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Lawley Medicare Solutions Learning Center:

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Question:  I have Medicare insurance with a Medigap Plan, as well as a standalone Prescription Drug Plan. I am preparing to travel out-of-state, do all physicians accept Medicare insurance?

Answer: Medicare Part A (which covers hospitalization) and Medicare Part B (which provides medical coverage) has been available since 1965. Healthcare has changed a lot since that time including the addition of Medicare Part D (Prescription Drug coverage) which began in 2006. Many assume that all physicians and hospitals accept participate in Medicare insurance, but that is not true. Medicare insurance is probably the most widely accepted insurance product on the market today, but there are still physicians who do not accept Medicare insurance.

More than 95% of physicians within the United States participate in Medicare insurance. When physicians “participate” with Medicare, they must always accept Medicare “assignment.” This means that they must accept as payment what Medicare allows for as payment for that procedure, office visit, etc. This assignment (payment) is often significantly less than the amount they would bill for that service. Medicare insurance pays the physician directly at 80% of the assigned value of the visit. The 20% left over is billed to you or your secondary insurance. For example, if you see your physician for an office visit which costs $175, Medicare insurance would approve the assignment for this visit at $100, so Medicare insurance would pay $80. You or your secondary coverage would be required to pay the remaining 20%, which in this case, would be $20.

When physicians are “non-participating” providers, they don’t routinely take assignment. These physicians can bill Medicare insurance, but don’t accept what Medicare “assigns” as full payment. This group of physicians will require that you pay more than the Medicare-approved amount. These non-participating physicians can only bill their patients up to 15% above the Medicare insurance assignment amount nationally for their services. In New York State, this additional amount can only be 5% above Medicare insurance assignment. For example, you see your non-participating physician and he bills $175 for the visit. Medicare assignment is $100, so Medicare pays $80. The physician would then expect you or your secondary coverage to pay $25 in New York State, and $35 in most other states. These non-participating physicians can also request full payment up-front for services, and Medicare would then reimburse you with a check for $80.

The third group of physicians are those providers who have “opted out” of Medicare insurance altogether. They cannot bill Medicare insurance for any services (except in some cases of emergencies). This group of physicians are required to inform you of this opt-out in advance, and you are required to sign a written agreement up front, before being seen. This group of physicians can charge whatever they want for services rendered. A common situation for this type of practitioner is Chiropractors – many Chiropractors give you a per-visit charge and do not bill any insurance.

Most physicians in the United States USA participate in Medicare insurance. In the western New York area, it would be difficult to find a non-participating physician l Federal Medicare does not require permissions or referrals for healthcare. So, as you travel around the United States, you can use your Federal Original Medicare insurance card (with few exceptions) anywhere you wish.

It is important to remember that participating in Medicare insurance does NOT indicate participating in the many hundreds of alternative insurance products available such as Medicare Advantage Plans. These plans have their own network of providers and hospitals based on their type of coverage, Preferred Provider Organization (PPO) and Health Maintenance Organization (HMO). This is important to consider when you evaluating your insurance each year, particularly for Medicare Advantage Plans.

If you travel outside of New York State, your Federal Medicare and Medicare Supplement Plan (Medigap) are useful nationally. These products rarely require prior approval or referrals for services. If and when you need care while traveling, your coverage should be completely portable and comprehensive.

When determining if a physician accepts your Medicare insurance plan, show the providers your insurance cards, using the terms Medicare and Medicare Supplement (Medigap) coverage. If you only ask the provider, “Do you take [the insurance carrier name, ex Independent Health]?” then you may not get a correct answer. Be very specific about the insurance product you have when speaking with your providers.

Safe Travels!

 

Read all Inside Medicare articles HERE.

 

LAWLEY HAS A TEAM DEDICATED TO MEDICARE INSURANCE!

Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur.

For questions, concerns, or to reach Lawley Medicare Solutions, fill out the contact form below or call 716.849.1540.

Lawley Medicare Solutions Learning Center:

Ask Janell!

 

QUESTION: I have used the same pharmacy for years, but my insurance is encouraging me to use a different pharmacy and mail order. Do I have to switch pharmacies?

 

ANSWER: Each year, insurance companies adjust their coverage, including pharmacy contracts. You may have decided to keep the same insurance product, but that does not mean your 2024 coverage is the same as it was last year.

During the Annual Open Enrollment period (October 15 to December 7), you have an opportunity to review your current insurance plan and decide on coverage for the coming year.

Open enrollment allows you to evaluate the insurance products available to help control costs. That evaluation process then requires a decision to change or not to change to save that money. Only you can decide when and how much change makes the savings worthwhile.

Many insurance companies own their own pharmacy or have a mail order option they strongly encourage enrollees to use. Those pharmacy options give you the lowest price on your medications.

The pharmacy list usually has two levels; standard & preferred. In 2024, there are plans that do not give you any prescription drug coverage at some pharmacy locations. So, pharmacy choice is always an important variable to include in your insurance plan selection.

When your pharmacy is a “Preferred Pharmacy,” you get lower pricing. When your pharmacy is a “Standard Pharmacy,” the pricing will be higher for you on each and every prescription. When your pharmacy is “Out of Network,” your prescription drug plan will not help you pay for any of the medications purchased there.

Are you willing to switch pharmacies? That is up to you. It is not that hard to do, but many of us choose our pharmacy because it is convenient, we like the people who work there, or it is close to where we work or live. If you have to drive across town to save some money, will you be happy with that choice? How often do you have to drive there? Will you be saving money if it is out of your way?

The negotiated cost of your medications can also be very different from pharmacy to pharmacy with the same insurance product. If your negotiated cost is higher for your medication, you could hit the coverage gap – aka the “Donut Hole” – sooner, causing your costs to increase significantly throughout the year.

You may want to consider mail order medications. This would mean your medications are delivered to where you get your mail. This can be arranged through a local pharmacy, like Wegman’s Home Delivery, which ships out of Buffalo. It could also be a national provider that your insurance company recommends. This information is included from the Evidence of Coverage for 2024, which you received at the beginning of the year. The mail order options could be a convenient way for you to get 90 day supplies of your regular medications.

Note that you can choose to receive some medications by mail and some medications at the local pharmacy you choose. It doesn’t have to be an all or nothing choice.

Talk to your pharmacist and see what they know. Some pharmacists are very familiar with insurance policies and may be able to explain some of the changes. Sometimes they don’t know the changes until they fill your prescriptions. You can review the material your insurance company sends to you for clarifications to the new rules. You can also contact your insurance company to ask these questions or for clarifications.

The www.medicare.gov website is designed to help you through this research. The information on the website is very useful. If you don’t use a computer, maybe someone in your family could work with you on this.

The 1-800-MEDICARE call center staff can also help you evaluate this information. As you mentioned, your current plan has sent you information on pharmacy changes and co-pay structures as well. So, review that material and use the resources to research the options. This research into the pharmacy options available could save you a significant amount of money this year and beyond.

 

Read all Inside Medicare articles HERE.

 

LAWLEY HAS A TEAM DEDICATED TO MEDICARE INSURANCE!

Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur.

For questions, concerns, or to reach Lawley Medicare Solutions, fill out the contact form below or call 716.849.1540.

Lawley Medicare Solutions Learning Center:

Ask Janell!

 

QUESTION: I feel like every time I answer the phone there is someone calling me about Medicare Insurance. Why do I receive so many calls?

 

ANSWER: This is such a great question and I hear it so often. Medicare, also known as Centers for Medicare and Medicaid Services (CMS) rarely, if ever, calls anyone on Medicare insurance.

This clarification is important for two crucial reasons:

1. Every time you answer one of those calls you risk being switched to an insurance product you may not want and you may not understand.
2. Sometimes those calls could be coming from someone committing Medicare fraud.

In both situations, the caller is trying to get YOU to say “Yes” at some point in the conversation, and obtain your Medicare ID number.

Not too long ago, your Medicare ID number was your Social Security number. In 2018, CMS began mailing everyone with Medicare insurance an ID card with a ID number unique to you, which is a combination of letters and numbers. This unique ID number helps to prevent some of the identity theft we were seeing.

People who want to commit fraud still want to get that ID number from you. All of your providers need that ID number to bill Medicare for your appointments and treatments. Those hoping to defraud Medicare also need that ID number from you.

Other individuals who aren’t looking to defraud Medicare, but alternatively enroll you into different insurance, also need that Medicare ID number. If/when you decide to change your insurance during the annual open enrollment period each year (October 15 to December 7) you will need your Medicare ID number to make that change.

There may be other opportunities to change your Medicare insurance during the rest of the year, and we call these Special Enrollment Periods (SEP’s). That is why those brokers want your Medicare ID number almost all year long. Many insurance brokers get a commission or get paid for enrolling individuals into the insurance products they are affiliated with.

Most of these types of calls you receive are not local people, they are calling from other parts of the country or other countries with the sole goal of getting that Medicare ID so they can use it as they choose for fraud or to switch you insurance from the product you currently have to something that pays them a commission for making the switch. If you receive a call from someone you don’t know or who you have not talked with previously, you shouldn’t answer that call.

Your primary way of protecting yourself is: DON’T answer the phone from unknown numbers. Let it go to voicemail and then only call when you know it’s a legitimate call.

If you do answer the phone from an unknown number, remember, they want you to say “Yes.” When you say “Yes” in response to ANYTHING, they can fraudulently use this word to enroll you into different products, or purchase something you don’t need or want. So, when they say “Hello, is this John Doe?” DON’T answer “Yes” – instead ask “Who is calling?”

Another way to protect yourself is to review your mail and your explanation of benefits (EOB) from your insurance company for treatments, doctor visits, and medications. Look them over to see if they are all valid dates and procedures. Be thorough in reviewing your EOB, including insurance carriers and the pharmacy, the items billed, and medications filled at the pharmacy or mail order. Sometimes those EOB’s are not for anything you had done, and that is fraud.

If you are concerned about a procedure, product or medication, I encourage individuals to call the provider first to clarify the bill. If you don’t receive satisfying information, feel free to contact Medicare (1-800-MEDICARE).

If you get a new insurance card in the mail and don’t know why, you could call the company to see what is happening. You also could call Medicare to ask when and why your insurance was changed (1-800-MEDICARE).

The number they use for both Medicare and Medicaid fraud is (877-678-4697). If we are diligent in our efforts to protect against fraud, our Medicare dollars will be put to more productive use, covering your medical costs.

CMS is working hard to keep Medicare a reliable, successful, and financially solvent insurance product available to those Americans who have Medicare coverage. Your diligence in reviewing your Medicare Explanation of Benefits and protecting your Medicare ID number will help them with this job.

Read all Inside Medicare articles HERE.

 

LAWLEY HAS A TEAM DEDICATED TO MEDICARE INSURANCE!

Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur.

For questions, concerns, or to reach Lawley Medicare Solutions, fill out the contact form below or call 716.849.1540.

Lawley Medicare Solutions Learning Center:

Ask Janell!

 

QUESTION: I am preparing to retire at the end of the school year. My insurance covers both myself and my spouse. My spouse may be eligible for Medicare, but he will still have the retiree health coverage. What else might he need to do?

 

ANSWER: Congratulations on your retirement!

In this situation, you and your spouse have slightly different options. You both can keep the retiree health insurance, but your spouse has an extra step.

When an individual is eligible for Medicare (like when they turn 65 years old or certain other situations involving disability) and their health insurance is a retiree benefit, they MUST sign up for Medicare Part A & B, also known as “Original Medicare.”

If your spouse is collecting Social Security (SSI), they already have Medicare Part A. Whenever a Medicare-eligible individual collects SSI, they are automatically signed up for Medicare Part A – so they may not realize it, but they have Part A. You cannot decline Medicare Part A if you collect SSI. If this is your spouse’s situation, then they must sign up for Medicare Part B.

If your spouse is not collecting SS benefits they need to contact the Social Security Administration (SSA) to request that their Medicare Part A be started. This can be done by logging onto the www.SSA.gov website and creating a login and password. Once completed, your spouse can sign up for Medicare Part A relatively easily. Creating the login and password will be more complex than most websites, but that added security is important to your financial security. If they don’t want to use the website, you can call or go to the local SSA office to sign up for Medicare Part A only. This can take a bit of time, so don’t put this off or delay getting started.

The process for signing up for Medicare Part B involves two forms, the CMS 40B and the CMS L564. The CMS 40B is for your spouse to complete, and it is simply a request to start Medicare Part B. It does ask for the Medicare ID number, and if your spouse doesn’t know what that is, he could call the SSA or go to his local SSA office to get that number. When completing this form, he should also indicate when he wants the Medicare Part B to begin. Medicare always starts the first of the month, so it could be July 1, or August 1 or September 1, depending on his retirement date. He would not want a gap in coverage.

The second form, CMS L564 is completed by the employer that provided the health insurance you have. On this form, your spouse only completes the boxes 4, 5, 6 & 7. You can then take the form the employer who provided the health insurance. Their Human Resource staff will complete the remainder of the form.

Once completed, both forms CMS 40B and CMS L564 are delivered to the SSA office for processing. This is how to get the Medicare Part B started in a timely manner. You can turn these forms in up to 90 days prior to needing the coverage, but time is ticking away, so don’t delay.

SSA staff will process these forms, call you with any questions, and then issue your spouse a new Medicare card. This new card will now list both Medicare Part A & B. It is important to keep all Medicare cards and anything with your Medicare number on it safe and private.

Your spouse will also have retiree health insurance options that could be different from your options. That is important to evaluate. Up to this point you have both had the same insurance product that was tied to your employment. Your retiree health benefits can continue, but your options (with and without Medicare) are different. Now you could have different insurance products because you are retired and the choices are different.

Again, Congratulations on your retirement. New adventures await both of you, as you step into the next exciting phase of your life!

Read all Inside Medicare articles HERE.

 

LAWLEY HAS A TEAM DEDICATED TO MEDICARE INSURANCE!

Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur.

For questions, concerns, or to reach Lawley Medicare Solutions, fill out the contact form below or call 716.849.1540.