UNLOCK THE MEDICARE PUZZLE* 

 Are you turning 65 or receiving benefits now? 

Do you know how the Medicare alphabet works, your choices and your rights? Do you know about the complex enrollment rules that could cost you money?

When you turn age 65, there is only one "Original Medicare" to initially enroll in and you need to think about two simple things: enrolling in Part A (hospital coverage) which is normally premium free and consider enrolling in voluntary Part B (doctor and medical coverage) which has a monthly premium. Note: High adjusted gross income will have an assessment in addition to the normal monthly premium.

Part B: if you plan to continue employment past age 65, have a creditable company health plan or your spouse's employer plan is able to provide you with creditable (equal or better than "Original Medicare") health coverage, you may elect not to enroll in Part B until you no longer have such coverage which could save you the Part B premium expense. Be aware, however, that after age 65, if you do not have creditable health coverage and you have not enrolled in Part B, there is an annual 10% penalty for each full twelve (12) months that you could have had Part B until the time you elect to enroll in Part B, at which time, this penalty will be included in the premium for the remainder of your Medicare life.

Original Medicare: Part B has an annual deductible and then generally pays 80% of medically approved expenses with your cost sharing at 20%. You may go to any certified facility or doctor accepting Medicare. You also have another option called Part C (Medicare Advantage Plans) operated by private companies and approved by Medicare. These plans are an alternative to "Original Medicare" Part A and Part B and generally have low or no premiums (you must, however, continue to pay your Part B).

Part C: the Medicare Advantage Plans have co-pays and co-insurance. These plans consist of organizations like: HMO's (Health Maintenance Organizations) where you must visit a primary physician in the network to receive any specialist referrals within the network and PPO's (Preferred Provider Organizations) where you are not required to visit a primary care physician in order to see any specialist within or outside of the network.

Some of the Medicare Advantage Plans offer an annual out-of-pocket limit that protects you from exceptional circumstances of unplanned hospital and medical costs compared to "Original Medicare" that has no out-of-pocket limits.

MSA: stands for Medical Savings Account. MSAs are one type of Medicare Advantage plan that combines a high-deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.

Each member in the same region receives the same deposit amount; your health or age won't affect the amount.

Although the IRS considers the MSA a "trust" or "custodial" account, this doesn't mean someone else is in control. You own the money, and it is yours to use as you wish and at your direction.

Part D: the Prescription Drug Plans (PDP's) are voluntary and help with your present or future prescription medication needs. PDP's are basically offered in two forms: 1) a stand-alone program where you can enroll with a monthly premium: 2) integrated with some Part C Advantage Plans that may not have premiums or annual deductibles. Note: High adjusted gross income beneficiaries will have an assessment in addition to the monthly premium.

Several thought considerations are required for selection of a Part D plan: 1) number of prescription drugs taken and the availability that you desire 2) the premium 3) the deductible. 

Medigap Policies: are provided by private insurance companies. Medigap policies only work with "Original Medicare" and can cover much of the 20% cost sharing you would have to pay with "Original Medicare". There are presently eleven Medigap policy plans (A,B,C,D,F,G,K,L,M and N). Plan A is the basic plan and as you go up the alphabet each plan provides more benefits and increased premiums.

Note: each plan level is identical for all insurance companies except for the premium. Medigap policies offer great coverage, however, you can enroll and receive guaranteed acceptance for only six months after you have started your Part B. Later you would be able to enroll in a Medigap Policy, but with underwriting your premium could be rated higher or you could be declined.

What is the Medicare Annual Election Period?

The Annual Election Period (AEP) is October 15th thru December 7th which allows people to join, change or drop a Part C Medicare Advantage plan or Part D prescription drug plan. Any new changes become effective January 1 in the new plan year.

Enrollment in Hospital Part A and Medical Part B are required prior to the annual enrollment period.

For example:

• If you did not enroll in a Part C Medicare Advantage plan or stand-alone Part D prescription drug plan during your initial enrollment period or a special enrollment period, you may enroll in a Part C Medicare Advantage plan or stand-alone Part D prescription drug plan during the AEP for the new plan year.
• If you review the "Annual Notice of Change" that is received in late September and note any changes in benefits, networks, prescription formularies, etc., you may elect a new Part C Medicare Advantage plan or Part D stand-alone prescription drug plan during the AEP for the new plan year.
• If you disenrolled from a Part C Medicare Advantage plan and returned to Original Medicare, you can enroll in a Part D stand-alone prescription drug plan and you may elect to apply for a Medicare Medigap policy. 

You may make more than one election during the AEP. Your final election during that period is the one that counts. The last election (or only election) made during the AEP will be effective January 1 of the following plan year.

Please contact EHB Insurance Group to review and begin the enrollment and/or application process early so that your elections will start on January 1. 

NOTE: Enrollment for present Medicare beneficiaries cannot be accepted until October 15 for the AEP. 

What is the Medicare Open Election Period?

January 1st thru March 31st is the Open Election Period (OEP). If you are in a Part C Medicare Advantage Plan, you have one opportunity to change or leave your plan and switch to Original Medicare during this period. If you leave your Part C Acvantage plan and return to Original Medicare, you can also join a Part D Prescription Drug Plan (PDP) and your coverage will begin the first day of the month after the plan receives your enrollment forms. 

Part D Prescription Drug Plans

There are several important values to consider in selecting a prescription drug plan (PDP):

• How many prescriptions are taken on a regular basis?
• Is selecting the lowest premium the best choice?
• Can a deductible versus no deductible save money?
• What is the co-pay and price or tier placement of drugs from one company to another?
• Will prescription needs reach the "donut hole" gap?
• Are there any restrictions to consider?

Even though these are only a few items of consideration when evaluating what prescription drug plan is right for you, it is best to consult with EHB Insurance Group, a Medicare insurance professional, who can answer all your questions before making a choice.

 *EHB Insurance Group is an independent insurance broker and not affiliated with the United States federal government Medicare program.

ABC's of Medicare Educational Seminars 

These seminars began in the Arizona counties of Coconino and Yavapai October 2009 and successfully continued for ten years, including as requested in other Arizona counties.

As of January 2019, we began to offer in place of these in-person seminars the convenience [as has and continues to be offered in multiple states] of FREE personal telephone chats and computer screen-sharing appointments to include real-time, online insurance plan applications.

Please call or contact us to schedule a personal telephone chat, local in-person appointment or a presentation for your group. 

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                      MEDICARE PORTFOLIO*

Medigap Policies:

Aetna, Anthem, BCBS of AZ, Guaranteed Trust, Humana, Manhattan Life, Mutual of Omaha Insurance, United Healthcare. 

Advantage Part C Plans:

Aetna, Anthem, BCBS of AZ, Centene, Cigna, Devoted, Humana, United Healthcare.

*This is a sample list of some insurance company plans presently represented by EHB Insurance Group in multiple states.

As of October 1, 2022, Medicare has created a call recording mandate and the following statement:

"We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-Medicare to get information on all of your options."

ANNUAL DRUG PLAN LIST CHANGES

Beginning January 1, some of the medicines that are covered in prescription drug plans may change.

Some medicines will have new requirements and specific regulations may apply. These requirements include:

Prior Authorization: Before the pharmacy fills or refills a prescription, the doctor must contact the insurance company for approval of any medicine that requires prior authorization.

Plan benefits will not cover any medicine without prior authorization, and the Medicare beneficiary/patient is obligated to pay the entire cost of the medicine without approval.

Step Therapy: Sometimes there is more than only one medicine that works to treat a health condition, may cost less and work just as well.

Before a prescription is filled for a medicine that costs more, the Medicare beneficiary/patient may be asked by the insurance company to try at least one other medicine first. 

If the doctor thinks the other medicine isn’t right for them, the Medicare beneficiary/patient will need to request approval from the insurance company to use the medicine that costs more.

The plan benefits will not cover any medicine without approval and the Medicare beneficiary/patient is obligated to pay the enrire cost of the medicine if they decide not to purchase the prescription.

Quantity Limits: A Medicare beneficiary/patient has a limit on the amount of some medicines they can have filled or refilled during a period of time.

These limits can be placed on some drugs because of safety concerns and help prevent misuse of these drugs. If the prescription is over the limit, there are two choices: 

- the allowed amount of medicine is covered by the plan benefits and the over-the-limit amount must be paid out-of -pocket.

or

- if the doctor thinks more medicine is needed, they can ask for approval from the insurance company for the amount of medicine over the limit.

Tier Changes: The medicines are grouped into different tiers. For each tier, the Medicare beneficiary/patient will pay a different amount.

If the prescription is filled or refilled and is moving to a different tier, the Medicare beneficiary/patient may need to pay more or less.

Not Covered: Starting January 1, some medicines may no longer be available on some drug or formulary lists.

If a prescription is filled or refilled for any medicine that is not covered under a benefit plan, the Medicare beneficiary/patient will be obligated to pay the full cost of the prescription or the doctor can ask the insurance company to make an exception. 

The doctor can ask the insurance company to make an exception to cover a medicine if it’s not on the drug or formulary list.

Why insurance companies make these changes:

Insurance companies review and update their drug or formulary lists to help ensure safety and offer cost-effective choices for drug benefits.

Updates to the drug or formulary lists can happen when medicines have changes in dosage and prescriber guidelines.

The selection of available medicines may also change. This can happen when a drug is removed from the market by the Food and Drug Administration (FDA) or a drug manufacturer, or a new drug becomes available and is added to the drug list.

What you can do:

After October 15, contact us to review the latest drug lists and changes for the new plan year and/or if you have any questions. 

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Medicare Premiums for Higher Income Beneficiaries

These charts show the Part B and Part D monthly premium amounts based on income. The amounts change each year and there may be a late-enrollment penalty.

CHART 1

 2023 Part B and Part D Monthly Premiums

Beneficiaries who file an individual tax return with income of $97,000 or less (single) or $194,000 or less (couple)

2023 Part B monthly premium is: $164.90.

2023 Part D monthly premium is your plan premium.

Beneficiaries who file an individual tax return with income of $97,000-$123,000 (single) or $194,000-$246,000 (couple)

2023 Part B monthly premium is: $230.80.  

2023 Part D monthly premium is your plan premium plus $12.20.

Beneficiaries who file an individual tax return with income of $123,000-$153,000 (single) or $246,000-$306,000 (couple)

2023 Part B monthly premium is: $329.70. 

2023 Part D monthly premium is your plan premium plus $31.50.

Beneficiaries who file an individual tax return with income of $153,000-$183,000 (single) or $306,000-$366,000 (couple)

2023 Part B monthly premium is: $428.60.

2023 Part D monthly premium is your plan premium plus $50.70.

Beneficiaries who file an individual tax return with income above $183,000 up to $500,000 (single) or $366,000 up to $750,000 (couple)

2023 Part B monthly premium is: $527.50.

2023 Part D monthly premium is your plan premium plus $70.00.

Beneficiaries who file an individual tax return with income above $500,000 (single) or $750,000 (couple)

2023 Part B monthly premium is: $560.50.

2023 Part D monthly premium is your plan premium plus $76.40.

CHART 2

 2023 Part B and Part D Monthly Premiums

Beneficiaries who are married but file a separate tax return from their spouse and lived with his or her spouse at some time during the taxable year with an income of $91,000 or less

2023 Part B monthly premium is: $164.90. 

2023 Part D monthly premium is your plan premium.

Beneficiaries who are married but file a separate tax return from his or her spouse with an income of $97,000-$403,000

2023 Part B monthly premium is: $527.50. 

2023 Part D monthly premium is your plan premium plus $70.00.

Beneficiaries who are married but file a separate tax return from his or her spouse with an income above $403,000

2023 Part B monthly premium is: $560.50. 

2023 Part D monthly premium is your plan premium plus $76.40.

IRMAA - Income Related Monthly Adjustment Amount