Baby Boomers turning 65 in North Carolina have an abundance of choices with regard to their Medicare insurance. My customers who have been buying their own health insurance and don’t qualify for a government subsidy are thrilled to be able to choose from many policies that are much more affordable. Their challenge is sorting through these numerous policies and choosing what is right for their lifestyle, health needs and pocketbook. If you are uncertain which plan or plans are best for you, here is a step by step guide to ensure you make a wise decision: Read More

1. Often the method to make your first insurance payment (called the binder payment) for a Marketplace policy is different from the subsequent payments. This means you will receive an invoice every month unless you contact your insurance company and arrange for an automatic draft from your checking account, savings account, credit card or debit card.

2. Make sure you register on the website of your health insurance company.  Although you will have a customer service number, this will give you a chance to view your claims, pay your premiums, set yourself up on autopay and find in network providers.

3. Read your Marketplace Letter carefully. The Marketplacesometimes requires you to provide additional information several weeks after your policy begins. The type of information can be proof of your income, citizenship, identity or proof that you are in the U.S. legally. Even if you are paying your insurance premiums on time, the Marketplace will stop your government subsidy if you do not comply with their requests. This information can be uploaded to their website or mailed. If you mail it, make sure you follow their guidelines and include the barcode in Marketplace letter. Normally your insurance agent can upload your documents on your behalf.

4. When you apply for a government subsidy you provide an estimate of your Modified Adjusted Gross Income (MAGI). Your subsidy is based on your MAGI, age, zip code and household members. Every January the Marketplace will mail 1095 A forms to heads of households receiving a subsidy. The information on the 1095 Ais used to complete the 8962 form, which is used to reconcile the estimated income that you provided to the Marketplace with your actual income. If you don’t receive the 1095 A form, you can retrieve it at gov, call the Marketplace at 1 800 318 2596 or contact your agent. Even if you are only on a Marketplace policy for a short period you are required to complete this form. Failure to do this can prevent you from obtaining a subsidy in the future. 

5. If you have a change in circumstances such as a new job where you make a higher income or are offered health insurance, make sure you contact the Marketplace. A higher income needs to be reported because your new income could cause you to lose all or part of your subsidy. If your new job offers health insurance that is compliant with the Affordable Care Act,you are not allowed to receive subsidy unless your premium is considered unaffordable by the Marketplace.. Failure to comply with this policy could cause you to pay an IRS penalty.

6. Do not call your health insurance company to cancel your health insurance policy. Instead call the Marketplace at 1 800 318 2596. Once the Marketplace receives your request, they will contact your insurance company and cancel your policy. Since the Marketplace will cancel your policy the day you call, make sure you call the day your new health plan starts.

7. Changes such as your marriage status, dependents, a member becoming eligible for Medicare or address should be reported to the Marketplace immediately since these changes can affect the amount of your subsidy, policies available and your premium.

8. If you plan a trip outside of the United States, make sure your policy will provide the medical coverage you need. You may need to purchase Medical Trip Insurance.

9. To ensure you pay the lowest amount for your prescription drugsmake sure you use one of your plans preferred pharmacies or their preferred mail order.

10. If your doctor recommends you take a new drug that is not in the formulary of your current Plan,you can contact their customer service and request an exception. Also, you can shop around for the best price. Online applications like com, GoodRx.com and Singlecare.com often have coupons that offer significant savings. You may be able to get a lower cost through discounts at a local pharmacy, an on-line pharmacy like Amazon Pharmacy, Mark Cuban’s pharmacy, Costplusdrugs.com or Marley Drugs (https://www.marleydrug.com, 1 866-997-2871). From this website: www.needymeds.org, people often find huge savings on expensive drugs. This organization helps them connect with the manufacturers of expensive drugs to obtain them at no cost or a low cost. Their number is 1 800-503-6897. Another option is to order your drug from a Canadian pharmacy like Canadian Prescriptions Plus (1-866-779-7587, www.canadianprescriptionsplus.com).

11. Before Marketplace Open Enrollment, which is normally between November 1^st and January 15^th, you should receive a letter from the Marketplace and your insurance company. The Marketplace may have made changes that could affect your policy decision. Your insurance company may have a rate increase or changes in their provider network that may affect you positively or negatively. They may terminate your plan or no longer be participating in the Marketplace. If you have had changes in your health, income, medical providers or your prescription drugs, you may want to change to a different policy. Contact your insurance agent or the Marketplace if you need assistance updating our information.

All Medicare beneficiaries must be enrolled in both Medicare Part A and B before they are allowed to enroll in a Medicare Supplement or Advantage policy. The standard Part B premium amount in 2025 is $185. Most people pay the standard Part B premium amount. If your Modified Adjusted Gross Income (MAGI) as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount (IRMAA). IRMAA is an extra charge added to your premium. The chart below shows the extra amount you can expect to pay for Medicare Part B.

1.Make sure you have a current copy of  Medicare-and-You 2025. This handbook has details about what Medicare covers and provides websites and phone numbers where you can get additional information.

2.Remember that if Medicare does not pay for a medical procedure your Medicare Supplement will not pay for their share. If you are uncertain if a procedure is covered, you might find the answer in Medicare-and-You 2025. You can also call Medicare at 1 800 633 4227 and they are opened 24 hours per day, seven days per week.

3.During Open Enrollment, which is from October 15^th through December 7^th, you can change Medicare drug plans. Also during this period you can change from a Medicare Supplement to a Medicare Advantage plan. Unless you have creditable drug coverage from a previous employers or the VA, do not drop your Medicare Drug Policy without enrolling in a new one. Medicare Beneficiaries who have gaps in coverage normally pay a penalty when they enroll in a Medicare Drug plan in the future.

4. Medicare Prescription Drug plans often make changes to their formularies, deductibles, preferred pharmacies and other features from year to year. Also, often Medicare beneficiaries have changes in their medications. It is in your best interest to register on http://www.medicare.gov and store your prescription drugs as well as preferred pharmacies on their site. This will allow you to quickly check during Open Enrollment to see if you need to change to a different Medicare Prescription Drug plan.

5. If your doctor recommends you take a new drug that is not in the formulary of your current Medicare drug plan, you can contact their customer service and request an exception. Also, you can shop around for the best price. Online applications like Blink.com, GoodRx.com and Singlecare.com often have coupons that offer significant savings. You may be able to get a lower cost through discounts at a local pharmacy, an on-line pharmacy like Amazon Pharmacy, Mark Cuban’s pharmacy, Costplusdrugs.com or Marley Drugs (https://www.marleydrug.com, 1 866-997-2871). From this website: www.needymeds.org, people often find huge savings on expensive drugs. This organization helps them connect with the manufacturers of expensive drugs to obtain them at no cost or a low cost. Their number is 1 800-503-6897. Another option is to order your drug from a Canadian pharmacy like Canadian Prescriptions Plus (1-866-779-7587, www.canadianprescriptionsplus.com).

6.You can apply for a different Medicare Supplement at another insurance company any time of the year. Medicare beneficiaries sometimes do this when they find a company with a much lower premium. However, unless you have a guarantee issue because your current plan is being cancelled, you will have to go through medical underwriting. This means the insurance company will ask you medical questions, review your medical records and can decline you.

7. Even if you are enrolled in a Medicare Supplement that provides coverage in a foreign coverage, the coverage is limited and is not the same coverage that you have in the United States. Also, your Medicare Supplement will not pay its share until Medicare pays. Since a hospital in a foreign country is unlikely to file claim with Medicare, you may be required to pay your medical expenses and file a claim for reimbursement when you return home. It may be in your best interest to purchase trip insurance. 

1. Make sure you have a current copy of Medicare-and-You 2025. This handbook has details about what Medicare covers and provides website and phone numbers where you can get additional information.
2. The number for Medicare is 1 800 633 4227 and they are opened 24 hours per day, seven days per week.
3. During Medicare Open Enrollment, which is from October 15^th through December 7^th, you can change Medicare Advantage plans.
4. Another change you can make during Open Enrollment is from a Medicare Advantage to a Medicare Supplement plan. According to page 23 of Choosing-A-Medigap, you have a one-year Trial right for Medicare Advantage plans. This means that during the first year, you can return to Original Medicare and enroll in a Medicare Supplement without going through medical underwriting. When an applicant is required to go through medical underwriting the insurance company can decline them or charge them a higher premium. According to page 22 of Choosing-A-Medigap, you can also enroll in a Medicare Supplement without medical underwriting if your Medicare Advantage policy is terminated. You can enroll in a Medicare Supplement as early as 60 days before your coverage ends, but no later than 63 days after your coverage ends. After your one-year Trial Right, most Medicare Supplement insurance companies will require you to go through medical underwriting unless your Medicare Advantage policy has been and will be terminated. BlueCross BlueShield is exception to this. They have the Blue-to-Blue Rule which allows their Medicare Advantage Policy holders to switch to one of their Medicare Supplements during Annual Enrollment without medical underwriting.
5. During Medicare Advantage Open Enrollment, which is from January 1st through March 31st, you can switch to another Medicare Advantage policy. During this period you can only make one change.
6. To ensure you pay the lowest amount for your prescription drugs make sure you use one of your plans preferred pharmacies or their preferred mail order.
7. If your doctor recommends you take a new drug that is not in the formulary of your current Medicare Advantage plan, you can contact their customer service and request an exception. Also, you can shop around for the best price. Online applications like Blink.com, GoodRx.com and Singlecare.com often have coupons that offer significant savings. You may be able to get a lower cost through discounts at a local pharmacy, an on-line pharmacy like Amazon Pharmacy, Mark Cuban’s pharmacy, Costplusdrugs.com or Marley Drugs (https://www.marleydrug.com, 1 866-997-2871). From this website: www.needymeds.org, people often find huge savings on expensive drugs. This organization helps them connect with the manufacturers of expensive drugs to obtain them at no cost or a low cost. Their number is 1 800-503-6897. Another option is to order your drug from a Canadian pharmacy like Canadian Prescriptions Plus (1-866-779-7587, www.canadianprescriptionsplus.com).
8. If you are traveling outside of the United States, make sure your contact your Medicare Advantage insurance company to determine if your coverage will be sufficient. You may need to purchase travel insurance.
9. Unlike Medicare Supplements, Medicare Advantage plans are regional. If you move out of your plan’s service area you will have a Special Election Period which begins 1 month before your move and 2 months after the move to enroll in a new plan. Read More

If you have recently moved to the Raleigh Durham area and need assistance finding a Duke primary care or specialist doctor, the Duke Consultation and Referral Center can help. They are open Monday through Friday from 8:00 AM until 5 PM. Whether you or not they are Medicare eligible, my clients have found this number helpful. The Duke Referral Center has also help my customers whose doctors have retired or move to a new area find a new doctor.

Call 1-888-ASK-Duke (275-3853) to request an appointment or visit them on-line at dukehealth.org.

Topics Covered and Questions Answered:

• Explanation of the ACA (Affordable Care Act) provisions
• Update on the plans available in Raleigh, Durham and Chapel Hill area
• ACA Terminology
• How to choose a plan?
• Who is eligible for a government subsidy?
• How to apply for a government subsidy and what questions to expect?
• When you can apply for health insurance?
• What alternatives are available to ACA compliant policies?
• Who to call when you have health insurance complaints or to report fraud.

Read More

As I pointed out in my ObamaCare video, we are constantly bombarded with misinformation about the Affordable Care Act(ACA) or ObamaCare. Here are five more examples of these fallacies:

fallacy #1: “All health insurance must be purchased from the Marketplace. Read More

Unlike most people I enjoy going to the dentist. As a child I had a dentist who knew how to entertain his patients while performing dental procedures that were usually painless.  When my dentist retired his son took over the practice and continued the family tradition of making the patients feel at ease.  It’s good that I have always had access to exceptional dental care since I was not blessed with good teeth. My numerous childhood fillings resulted in a lot of crowns and root canals as an adult.

Fortunately my personal experience has helped me understand the important features of good dental plan and how to assist my clients in evaluating these plans. Here is my advice for buying dental insurance:

1. If you are leaving your current employer and have a dental plan that fits your needs, your best option might be to take the dental part of COBRA.  Even if you do not take the medical part of COBRA, you normally can accept the dental and stay on it for 18months.  The monthly premiums might be lower than your other options.  If you have a child who needs braces and your current plan offers Orthodontia, you should stay on this plan. Dental plans that individuals purchase do not include Orthodontia.
2. Although most dental plans cover 100% of two cleanings (preventative) per year, some will only cover one or require you to pay a co-pay or percentage. Make sure you understand what you will be required to pay for preventative.
3. Dental plans usually have  a 6 month waiting period before they cover basic services such as fillings, extractions, oral surgery and root canals. For major services such as crowns and bridges there is often a 12 month waiting period. When you leave a dental plan they provide a Certificate of Coverage showing the start and end dates of your dental coverage. Some dental plans will waive these waiting periods if you can provide a Certificate of Coverage showing that you have not had a break in dental coverage of more than 63 days during the past 18 months.
4. Check to see if your dentist is in the plan’s network and ask questions about how the plan will pay if you go outside of this network.  Since your dentist will probably not be able to perform all procedures such as root canals and oral surgeries, it is also important to know if specialists such as oral surgeons and endodontists are in the network in your area.
5. Understand the cancellation policies and initial enrollment fees of all the plans you consider.  Initial enrollment fees and a 12 month requirement to remain on the plan are not a problem if you are a retiree or self employed individual who expects to be on the dental plan for a long period.  However, if you are currently unemployed, but expect to be employed within a few months in a job that provides dental benefits this could be a problem.
6. When you do your cost comparison don’t just consider the monthly premiums. Also compare deductibles, yearly maximums and percentages that each plan pays for various procedures. Some plans will increase your yearly maximum if you remain on the policy a specific number of years.