However, the Medicare AEP only lasts from October 15 through December 7 of each year. Some people may qualify for a Special Enrollment Period and may be able to change plans outside of the AEP, but for many, this will be the only time to change plans!
What you Should do During Medicare AEP
Even if you think you have the best Medicare plan in the world, here are a few things you should definitely do during or leading up to Medicare AEP (October 15 – December 7). If you need help with this, we advise giving us a call.
1. Check Eligibility for Savings.
Apply for LIS (Extra Help) prescription drug savings program) and other Medicare Savings Programs to see if you could be saving money. If you have low income, you may even want to try applying for Medicaid! The results could influence what coverage you are eligible for this AEP.
2.Analyze your Current Medicare Coverage.
Did you receive your ANOC (Annual Notice of Change), and is anything in your plan changing? These letters are usually sent and received every year at the beginning of September.
What insurance do you have now?
Do you have Original Medicare only, or do you have a private plan as well?
Do you have enough coverage?
Does your plan fit into your budget, or could you be saving more money?
Are all of your doctors and prescriptions covered by your current plan?
Ask yourself these questions and take notes, because there may be something better out there.
3.Notate your Life Changes.
Did you start seeing a new doctor this year, or do you have a problem with your current doctor? Not all plans accept the same doctors, so make sure you’re documenting your current physicians so you can easily confirm they are in network with any potential plans you’re considering for the new year.
Did you gain or lose a job, or suddenly develop financial stress? There are multiple ways to manage your Medicare based on a budget and a licensed agent can walk you through the options you may qualify for.
Were you diagnosed with a new health condition that requires expensive treatments? Some plans are specifically designed for certain chronic conditions.
Think about not only your past year but what you expect to happen over the next year. Think about what type of coverage you might need to get yourself through it all.
4.See What Medicare Plans are Available this Year.
Every year, new Medicare plans may come to the market, and old plans may change what they are offering. It’s important to look at the new information instead of just assuming that your old plan will stay the same. If your plan does change what they are offering, you will be notified – but it is important to look at other changes in your area as well.
Maybe there’s a great new doctor you’ve wanted to see, but she doesn’t accept your current plan! Or, maybe you suddenly have access to a plan with a five-star rating, when previously you only had access to four-star plans!
An important thing to note is that new benefits are not available to review and discuss each year until October 1st. You may need to speak with a licensed agent to ensure you’re reviewing the plans for the upcoming benefit year and not mistakenly comparing plan benefits that will ultimately be changing.
5.Schedule an Appointment with a Licensed Agent.
We know it’s nice to think that you can do it all yourself and that with the internet, you don’t need an insurance agent anymore! But, that’s not always true. The benefits of meeting with a licensed insurance agent are simple: it’s free, it’s easy, and it can’t hurt!
Our agents are licensed and represent a variety of different insurance companies, meaning they are not all biased towards one plan option.
Your plan won’t cost any more money whether you meet with an agent or not, so meeting an agent can only help you. A licensed agent can walk you through everything that is available in your local area and help you select the best option based on your needs. Plus, let us repeat – the meeting is free!
What you Should not do During AEP
We’re here to help, so we don’t want to only talk about the positives. Here are some things that you should NOT do during the Medicare AEP:
1. Don’t Jump into a new Medicare Plan Too Fast.
Do you understand how to choose a Medicare plan? Sometimes good deals are tempting, and it’s easy to jump into a shiny new plan because the costs are lower or there’s an added benefit. Make sure you’ve considered everything before you switch because it might not be easy to switch back. Make sure that your doctors work with the new plan, it covers your prescriptions, and there aren’t any hidden costs. Also, make sure the new benefit is something that will actually be useful to you!
2.Don’t Misunderstand Medigap.
Medigap, or Medicare Supplements work differently from Medicare Advantage and other types of Medicare plans. Technically, Medigap enrollment is not limited to the AEP. However, that does not mean that you should just change back and forth between different Medigap plans any time.
If you enroll in Medigap outside of your Initial Enrollment Period (when you first become eligible for and enroll in Medicare), you may be put through an underwriting process and may have higher fees based on your age and any preexisting conditions. Medicare Advantage and Part D plans do NOT take age and preexisting conditions into account, but Medigap plans if you wait too long to enroll.
3. Don’t Avoid Researching Medicare Plan Options.
If you already know the name of a carrier, you might be tempted to go straight to their website and enroll in a plan that looks good online. However, there may be more than one carrier offering plans in your area. So, how do you look at all of them easily?
Start by using a plan comparison tool, like our free Medicare Plan Finder. Then, once you’ve compared a few options, consider taking that research to a licensed agent who can talk to you about what you’re looking at and why the differences matter.
Ready for AEP?
To schedule an appointment with one of our licensed agents, call 833-438-3676 or click here. We can’t wait to help you get the coverage you deserve!
Does Medicare Cover Orthotics?
Medicare is a great resource for eligible beneficiaries to help pay for medical expenses. Orthopedic care can come with a hefty cost, and you may want to know, “Does Medicare cover orthotics”?
Yes, but only if your condition meets certain requirements and plan qualifications.
You can quickly and confidentially shop plans here.
When you have foot problems, it may seem like every little movement you make causes excruciating pain. Even standing still can be difficult. Orthotics can provide relief for people experiencing orthopedic problems such as osteoarthritis, foot pain, or back pain.
Does Medicare Cover Orthotic Shoes or Inserts?
Orthotic shoes are custom-fitted footwear designed to reduce the patient’s pain for a variety of health conditions including:
Metatarsalgia: chronic pain in the ball of the foot
Plantar fasciitis: chronic breakdown of soft tissue around the heel
Bunions: a painful, bony bump on the outside of the big toe
For the most part, Medicare does not cover orthopedic or inserts or shoes, however, Medicare will make exceptions for certain diabetic patients because of the poor circulation or neuropathy that goes with diabetes.
Medicare may cover the fit and cost of one pair of custom-fitted orthopedic shoes and inserts once per year for those patients.
How Much Does Medicare Pay for Orthotic Services?
Podiatrists are doctors who specialize in the feet and ankles, and they prescribe and design medically orthotic devices. Orthopedic devices as part of a leg brace fall under Medicare’s guidelines for durable medical equipment (DME).
In order for Medicare to cover orthotics, your doctor must first determine that orthopedic care is medically necessary. Medicare Part B may cover about 80 percent of the Medicare-approved cost, and you may have to pay the remaining co-insurance. The company that supplies your DME must be Medicare-approved.
Does Medicare Cover Orthotics for Plantar Fasciitis?
Plantar fasciitis, also called “Policeman’s Heel,” is an often self-treatable and diagnosable ailment involving inflamed tissue on the bottom of the foot. You may feel stabbing pain near your heel. It can usually be treated with physical therapy, shoe inserts, steroid injections, and surgery in some cases.
Podiatrists often prescribe treatment for plantar fasciitis. If your doctor is able to prove that it is medically necessary and the prescription is required, you may be able to get coverage at the Medicare-approved amount. Additionally, there may be some Medicare Advantage plans in your area that provide coverage for orthotics for plantar fasciitis.
Does Medicare Cover Orthotics for Weight Loss?
According to the Hospital for Special Surgery (HSS), orthotics can help ease the extra stress on the feet for overweight people. Medicare does not cover orthotics for people who are overweight just because they are overweight.
Medicare may cover weight loss services such as surgery and/or nutrition counseling for people who qualify. Some Medicare Advantage plans even cover fitness programs!
You may also be able to get over-the-counter benefits with some Medicare Advantage plans. So, even though you may not qualify for prescription orthotic coverage, you may be able to find coverage for over-the-counter products you can find at your local drugstore or mail-order pharmacy.
Does Medicare Cover Orthotics After Hip Replacement Surgery
Sometimes doctors prescribe hip braces as a part of hip replacement surgery recovery. However, hip braces oftentimes don’t include a foot orthotic device. Medicare may help pay for the hip brace as part of your DME coverage, but coverage may not include an orthotic device.
According to Dr. James P. Ioli, DPM, a podiatrist with the Harvard Medical School, you should have a physical therapist assess your “pelvic, hip, knee, ankle, and foot movement” to examine how your “soft tissue restrictions [muscle and cartilage stiffness]” and flexibility contributes to your pain. The physical therapist can address your pain and make recommendations to manage it.
Does Medicare Cover Transportation for Orthotics Appointments?
If you don’t need an ambulance, some Medicare Advantage plans cover non-emergency medical transportation to doctor’s appointments, to the hospital, and to the pharmacy. Contact your agent to learn more about Medicare Advantage supplemental benefits.
Does Medicare Cover Podiatry?
While Medicare will only cover orthotics if they’re part of a leg brace or for diabetes, Medicare will cover treatment for the following conditions:
Morton’s Neuroma is irritation of nerves in the toe. One common sign of Morton’s Neuroma is numbness, and podiatric treatment for Morton’s neuroma includes using a metatarsal pad, cortisone injections and surgery in some extreme cases.
Plantar Fasciitis is when the plantar fascia tears. The breakdown causes severe pain with standing and walking. Patients usually experience the most pain first thing in the morning because the calf and foot muscles tighten up overnight.
Plantar Fasciitis treatment includes physical therapy for proper stretching exercises, wearing a splint at night and cortisone injections. If pain becomes severe, a podiatrist might recommend surgery.
The pain and stiffness associated with bunions usually worsen gradually. Podiatrists normally start small with treatment and prescribe bunion pads, toe spacers or shoe inserts. If those items fail, the podiatrist may recommend surgery.
Stress fractures occur after repeated blows to an area cause tiny fractures. Common causes of stress fractures include walking, running, frequent jumping and playing sports.
Most stress fractures will heal on their own after the patient walks with crutches or uses a walking boot. In some severe cases, the fracture won’t heal because it’s in a complex foot bone, and surgery will be the only course of action to correct it.
Peripheral Neuropathy is caused by nerve damage. The damaged nerves are unable to send the proper messages from the central nervous system to the rest of the body.
Peripheral Neuropathy causes the patient to experience pain, burning sensations, numbness, tingling, and weakness. Common Peripheral Neuropathy causes include:
Peripheral Neuropathy has no cure, and treatment only relieves the patient’s symptoms. The most common treatment for neuropathic pain is prescription drugs, but also topical creams, gels, and patches. In some cases, a cortisone sympathetic nerve block can provide temporary pain relief.
Medicare will only cover your treatment if your podiatrist says it’s medically necessary. Medicare Part B may cover 80% of the Medicare-approved costs. You will be responsible for the Medicare Part B deductible in order for Medicare to cover podiatry.
Podiatric Care Not Covered by Medicare
Medicare does not cover routine podiatry services, because CMS doesn’t consider them to be medically necessary. Some of those treatments and services include:
Foot cleaning and soaking
Removing corns and calluses
Treatment for flat feet
Get Medicare Coverage for Orthotics and Podiatry Today
Medicare will only pay for limited podiatric services, and having the right coverage can make all the difference in your quality of care. The licensed agents at Medicare Plan Finder are highly trained and ready to help you find a plan to suit your budget and lifestyle. Call us at 833-431-1832 or contact us here today.
This post was originally published on May 28, 2019, and updated on December 11, 2019.
Medicare Part A and Part B form what is known as Original Medicare. Together, they provide a foundation of health benefits for millions of Americans and help defray much of the associated costs. However, not all health-related services and costs are covered with only Part A and Part B.
Without additional coverage, enrollees are not covered for some services, or they will have to pay out-of-pocket costs for several types of services.
Costs and coverage gaps can be minimized by adding several other types of Medicare plans, like Part C, Part D, and supplement plans.
Understanding what Original Medicare covers versus what enhanced coverage will provide, as well as what the associated costs are, is critical to managing your finances and healthcare issues as effectively as possible.
To understand what might be the best options for you, first, let’s take a quick look at what Original Medicare does and does not cover.
What Part A Covers
Part A, which is sometimes called Medicare hospital insurance, covers hospital costs and other related inpatient expenses. This includes hospice, skilled nursing facilities, and some home-based health circumstances.
Coverage includes a semi-private room, hospital meals, nursing services, intensive care, drugs and medical supplies used during your stay, lab tests, and x-rays, operating and recovery services, some blood transfusions, rehabilitation, and symptom management.
When you enter a nursing facility, you must require a level of care that can’t be provided at home or from your primary care doctor. Nursing care must be ordered by a doctor and be administered daily by a professional nurse or therapist.
Hospice care is covered when you agree that you are accepting palliative care instead of other Medicare-covered treatments. You agree you have been given six months or less to live, and you are only seeking assistance to live comfortably until you pass.
Hospice coverage does not include any treatment to cure your condition or your room and board. Your coverage does include some doctor and nursing services, medical equipment, prescription drugs for pain and discomfort, homemaker services, some therapy services, and counseling.
If you enter recovery during hospice and want to switch from hospice back to regular treatments, you can do that at any time without losing coverage.
When you’re housebound, or a doctor orders home health care for you, you may be covered by a combination of Part A and Part B benefits.
What Part B Covers
Part B covers a wide range of services.
Some of those include wellness and preventative services, some of which are covered 100%.
When you first enroll in Part B, you can make a “Welcome to Medicare” visit with your doctor for a comprehensive overview to discuss your specific healthcare needs and concerns. You are also covered for an Annual Wellness Visit that includes a full health risk assessment, a review of your current vital information (weight, blood pressure, BMI, etc.), mental health, and additional discussions about your current state of health and concerns.
You are also covered for some preventative vaccines. But not all vaccines are considered preventative and would not be covered under Part B, but may be covered under Part D.
You are also covered for preventative treatments related to high blood pressure, glaucoma, obesity, HIV, cardiovascular, and some cancers, among others.
Women are covered at 100% for pap smears, pelvic exams, and breast exams every two years.
Part B covers outpatient mental health services such as depression screenings, psychotherapy, psychiatric evaluations, some prescriptions, and partial hospitalization.
Lab tests and X-rays are covered when your doctor orders a test to help diagnose a condition or as part of your annual checkup. Medically necessary blood tests, urine tests, tissue lab work, and some screenings are also covered. X-rays are covered at 80% of the Medicare-approved amount. You are responsible for the other 20%.
Emergency transportation is covered if other transportation could put you in danger or you are having a medical emergency and need immediate assistance. Coverage only includes transportation to the nearest medical facility that can give you the type of help you need.
Transportation is covered at 80% of the Medicare-approved amount, and your Part B deductible will apply.
Durable medical equipment (DME) is covered, but for coverage to apply, a DME must be able to withstand repeated use for at least three years. It must also be usable at home and must be used for a medical purpose only. Medicare will cover 80% of the cost.
Some examples of DME include canes, crutches, hospital beds, infusion supplies, nebulizers, commode chairs, CPAP devices, and more.
Part B also covers some home health care, but only that which is relatively short-term and related to a limited period of recovery due to an illness, injury, or condition.
What Part A and Part B do not Cover
In most cases, Part A and Part B coverage will meet the vast majority of medical insurance needs. But there are also many things Original Medicare does not cover. You’ll have to pay these costs unless you get additional coverage.
Some things Part A and Part B do not cover include:
Hearing aids and related exams
Long-term custodial care
Most dental care and dentures (unless medically necessary)
Alternative medicine, such as homeopathy, acupuncture, and acupressure.
Elective and cosmetic surgery
Eye exams for prescription glasses and most contact lenses
Chiropractors are covered but only on a limited basis.
Routine foot care unless it is the result of diabetes, cancer, multiple sclerosis, inflammation due to blood clots, chronic kidney disease, malnutrition, or related conditions.
Most prescription drugs coverage
Medically unnecessary amenities such as private hospital rooms, private nurses, and personal care items that hospitals may provide (shower supplies, TV, etc.).
Custodial care includes daily activities such as bathing, grooming, dressing, meals, etc.
Part A only covers skilled nursing, but not long-term nursing, either at home or in a nursing facility.
Medical services, for the most part, outside of the United States and its territories are not covered as well. A Medicare Advantage plan is required for international coverage.
Part B also only covers drugs you can’t self-administer. You’re only covered if you must receive medications in a hospital, doctor’s office, or health clinic. Part D coverage extends to nonprescription drugs, and remedies are also not covered under Part B.
Do I Need Additional Health Insurance If I Have Medicare?
Medicare provides a very basic level of coverage. That’s why millions of Medicare beneficiaries choose to enroll in a variety of additional health plans to get extra benefits. These additional Medicare plans may also allow you to see additional healthcare providers, like dentists and specialists, without incurring astronomical costs.
These plans generally have low enough premiums that it is reasonable to pay a bit more each month for these additional benefits. In fact, some people might qualify for $0 premiums!
Adding a Medicare Advantage Plan (Part C)
Medicare Advantage plans, also called Medicare Part C plans, can lower your out-of-pocket costs and provide more coverage when bundled with Original Medicare.
You must be enrolled in both Part A and Part B before you can sign up for a Part C plan.
Some Part C plans also cover prescription drugs that you take at home. You will need to check each plan’s formulary to see if the specific drug you need is covered by a plan. Typically, Part C coverage also will provide routine dental care, vision care, hearing care and hearing aids, and fitness benefits such as Silver Sneakers or other types of exercise classes.
Part C plans come in many forms, but the most popular varieties are PPO plans and HMO plans. The difference between Medicare Advantage PPOs and HMOs is that HMOs come with very strict physician networks and you’ll have to select one primary care physician, while PPOs allow you the freedom of a wide network. While PPOs may seem like the obvious choice, that flexibility can come with a higher price tag – so choose carefully!
Because not all plans provide the same levels of coverage, you may pay a higher premium for more coverage.
The Medicare Advantage marketplace is highly competitive, and it can be confusing to determine which policy is the best one for you. Your best bet is to work with an experienced agent who can answer all of your questions and guide you along the way.
You can enroll in Medicare Advantage either when you initially sign up for Medicare, during the Annual Enrollment Period (October 15 through December 7), or in some cases during the Open Enrollment Period (January 1 through March 31).
$0 Premiums and Special Needs Plans
Some people may be eligible for a $0 premium Medicare Advantage plan.
There are three types of Special Needs Plans:
Chronic Special Needs Plans (CSNP) for people who have certain chronic conditions and need more coverage.
Institutional Special Needs Plans (ISNP) for people who have been living in an institution such as an inpatient medical facility for 90 days or more.
Dual Eligible Special Needs Plans (DSNP) are for people who are dual-eligible for both Medicare and Medicaid.
Adding a Medicare Prescription Drug Plan (Part D)
Prescription drug costs can be expensive, especially if you need highly specialized treatment or you’re on a fixed income. Adding a Medicare Part D prescription drug plan can be one of the smartest economic decisions you can make.
Just like with Part C plans, you’ll need to shop and compare Part D plans. A good place to start is to look at a possible plan’s formulary. This is the complete list of all prescriptions covered by that particular plan.
Match your existing and anticipated needs to the formulary for maximum savings.
Because formularies can change from year to year, also be sure to closely review your Annual Notice of Change every fall, to make sure your current coverage still best meets your needs.
You may still have some deductible and copayments to make, but typically you can save thousands of dollars depending on your situation.
Also, once you’ve paid a certain annual amount out of your own pocket, you are entitled to automatic catastrophic coverage. From that point on, your prescription drug costs are greatly reduced, and you’ll only pay a small copayment or coinsurance.
You may have heard of the “donut hole” with Part D coverage. This is the coverage gap that may require you to pay all drug costs yourself after Part D coverage has paid a certain amount for your prescription drugs. The good news is that federal healthcare legislation has been working to reduce the donut hole over several years, and in 2020, the gap is completely closed.
There are several times throughout the year you can sign up for Medicare prescription drug coverage. The first is during your Initial Enrollment Period. You can also enroll or make changes in your Part D plan during the Annual Enrollment Period that runs from October 15 through December 7 annually.
Additionally, a Special Enrollment Period occurs when you have a qualifying life event such as losing drug coverage or when you move from a particular plan’s area.
When you qualify for Medicare Extra Help you can also enroll in a Part D plan.
There are hundreds of private insurance companies offering Part D plans for Medicare beneficiaries – but they may not all be available in your area. It’s best to speak with an insurance agent to learn about all of the options available to you and to get guidance from a professional.
Adding a Medicare Supplement (Medigap) Plan
Medigap plans do what they sound like…they close the coverage gap in your existing Medicare Part A and Part B policies.
Medigap plans are also called Medicare Supplement plans. They are designed to cover your out-of-pocket Medicare Part A and Part B costs, including deductibles and copayments.
Medicare Supplement insurance plans are lettered A through N. Each lettered policy provides a different level of coverage offered by private companies contracted with Medicare. However, each Medigap plan with the same letter must offer the same core benefits, no matter which carrier you choose.
For example, if you choose Plan G to plug your coverage gap, the coverage will be the same no matter which insurer you pick.
Premium costs will differ, which is why you’ll need to shop around for the best insurance plans. Costs may also differ a bit because a carrier could offer services above the core benefits, or your location could cause a price fluctuation as well.
Plan C and Plan F are not accepting new members after January 1, 2020. If you’re already enrolled in one of these plans, you can keep your coverage.
If you apply during your IEP (beginning three months before you turn 65 and ending three months after) and you have Medicare Part B, you have “guaranteed issue rights.” You can’t be denied Medicare Supplement enrollment or charged more based on your age, health status, or pre-existing conditions.
However, if you do have pre-existing conditions, carriers can impose up to a six-month waiting period before your benefits begin.
Most Medigap plans do not offer dental, prescription drug, vision, or hearing coverage. You will need a Medicare Advantage plan if you want coverage for those services.
You can purchase Medigap during any time of the year, but your IEP is when a plan will
be the cheapest and easiest to enroll.
Can I Add a Medicare Supplement at Any Time?
Technically, yes! Medicare Supplement plans are a bit different from Medicare Advantage plans in that you can enroll at any time of year. However, when you enroll can make a big difference in what you pay. Unlike Medicare Advantage plans, Medicare Supplement insurance companies can charge you more based on preexisting health conditions if you wait too long to enroll. If you are enrolling in Medigap right when you become eligible or due to circumstances beyond your control, you won’t have to go through medical underwriting. However, if you wait until you’re older to enroll just because you weren’t sure, you could face higher premiums than expected.
Who Qualifies for Additional Medicare Benefits?
Anyone who is already enrolled in Medicare Part A and Medicare Part B can start looking at additional Medicare benefits (Medicare Advantage, Medicare Supplements, Part D). Keep in mind that Medicare guidelines stipulate that you cannot have Medicare Advantage and Medicare Supplements at the same time, and you cannot have Medicare Advantage and Part D at the same time.
Getting Help With Your Medicare costs
In some cases, you may be able to get help paying for your Medicare costs through a Medicare Savings Program (MSP).
Eligibility for MSPs is based on your income, assets, and current Medicare coverage. Most states use the Federal Poverty Level as a guideline. Income limits are based on this and can change annually.
Resources such as stocks, bonds, or money in checking or savings accounts are included. Your home, one car, furniture, personal and household items, life insurance with a cash value of less than $1,500, a burial plot, and up to $1,500 set aside for burial expenses are not included.
Limits and restrictions vary from state to state. To find out if you qualify, call your local Medicaid office or State Health Insurance Programs (SHIP). Alabama, Arizona, Connecticut, Delaware, DC, Mississippi, New York, and Vermont do not apply asset limits.
There are four MSPs, each with slightly different requirements and types of coverage for your health care costs.
Qualified Medicare Beneficiary Program (QMB)
The income limit for QMB in 2020 is $1,061/month for individuals and $1,430/month for married couples. The resource limit is $7,730 for individuals and $11,600 for married couples.
Helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance, and co-payments.
In 2019, gross monthly income limits were 100% of the Federal Poverty Level plus $20 (may vary depending on your state).
When you qualify for the QMB, you automatically qualify for Extra Help assistance to pay for prescription drug coverage.
Qualified Individual Program (QI)
The income limit for QI in 2020 is $1,426 for individuals and $1,923 for married couples. The resource limit in 2020 is $7,730 for individuals and $11,600 for married couples.
Helps pay Part B premiums if you have Part A and meet income and asset restrictions.
When you start receiving QI aid, you may be reimbursed for your Part B premiums for up to three months before your QI Program effective date.
QI assistance is awarded on a first-come, first-serve basis. Priority is given to people who got QI benefits the previous year.
You must also reapply every year.
QI benefits are not awarded to those who qualify for Medicaid.
Income limits are slightly higher in Alaska and Hawaii.
When you qualify for the QI Program, you automatically qualify for Extra Help assistance to pay for prescription drug coverage.
Specified Low-Income Medicare Beneficiary Program (SLMB)
The income limit for SLMB in 2020 is $1,269 for individuals and $1,711 for married couples. The resource limit in 2020 is $7,730 for individuals and $11,600 for married couples.
Administered by individual states. Helps pay Medicare Part B premiums for people who have Medicare Part A and meet income and asset limitations.
Receive reimbursement for up to three months of Part B premium payments from before your SLMB effective date.
Slightly higher income limits in Alaska and Hawaii.
When you qualify for the SLMB program, you automatically qualify for Extra Help assistance to pay for prescription drug coverage.
Qualified Disabled and Working Individuals Program (QDWI)
QDWI income limits in 2020 are $4,249/month for individuals and $5,722/month for married couples. The resource limits for QDWI in 2020 are $4,000 or less for individuals and $6,000 or less for married couples.
Helps pay Part A premiums.
You may be eligible for QDWI benefits if:
You’re a working disabled person under 65
You lost your premium-free Part A when you went back to work
You aren’t getting medical assistance from your state (mainly Medicaid)
Applying for Medicare Savings Programs
When you apply for MSPs, you will apply for all of the MSPs (QMB, QI, SLMB, QDWI) at the same time through your state Medicaid program. Each state has a different application process because MSPs are tied directly to state-funded Medicaid.
When you apply for health insurance assistance, you may need legal documentation such as your Social Security Administration card, your Medicare card, your birth certificate (or passport/green card), and proof of your address and income. If you have qualifying assets and resources, you may need proof for those as well (bank statements, life insurance policies, stocks, etc.).
After you file an MSP application, you should receive a “Notice of Action” within 45 days to tell you whether or not you have been approved.
If your application is approved, you will be automatically enrolled in the program that most aligns with your qualifications. Your benefits begin on the month indicated on your Notice of Action (usually the following month).
What is the Extra Help Program for Medicare?
The Extra Help program, also called “LIS” or Low-Income Subsidies, is a program that helps qualifying Medicare beneficiaries afford their Part D prescription drug costs.
About Extra Help/Low-Income Subsidies (LIS)
Extra Help provides prescription drug plan assistance such as costs for Part D premiums up to a state-specific benchmark amount, as well as deductibles, coinsurance, and co-payments.
Extra Help also eliminates Part D late enrollment penalties you would have incurred if you held off signing up for Part D.
If you qualify for QMB, SLMB, or QI, you also automatically qualify for Low-Income Subsidies (LIS). If you’re already enrolled in Medicaid, Supplemental Security Income (SSI), or a Medicare Savings Program (MSP), you automatically qualify for Extra Help even if you don’t meet Extra Help’s eligibility requirements. If you don’t get any of these benefits, you can apply for Extra Help through the Social Security Administration either online or with a printed application.
You can qualify for full or partial Extra Help depending on your income level and assets. If you are denied Extra Help assistance, you have the right to appeal the decision.
Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778)
Visit your local Social Security Office
What does Social Security Extra Help Pay For?
Extra Help can cover some of your prescription drug costs. The Medicare/Social Security Extra Help program is estimated to be worth about $5,000 per beneficiary. That’s because you could save about $5,000 in prescription drug costs by enrolling in Extra Help.
Medicare Costs in 2020
Let’s start with the Original Medicare program (parts A and B). If you qualify, you can get premium-free Part A Medicare. Most beneficiaries are still responsible for paying deductible and coinsurance costs.
You get free Part A premiums if you or your spouse worked and paid Medicare taxes for at least 40 quarters (10 years) during your working life, and you sign up for Part A during your IEP.
If you paid Medicare taxes for 30 to 39 quarters, your premium is $252 per month in 2020. If you worked and paid Medicare taxes for less than 30 quarters of your life, your premium will be $458 per month in 2020.
In 2020, the standard Part B premium is going up by about 7% to $144.60 due to increased program costs. The standard deductible is $198.
After you meet your deductible, you’ll pay 20% for most Medicare Part B services, other than preventative and wellness services.
If you have a high gross income, you could pay an Income-Related Monthly Adjustment Amount (IRMAA).
Now let’s look at costs for additional Medicare benefits.
Part D plan costs can range from $15 to $80 per month.
Two additional ways to save money on your prescription drugs are through mail-order deliveries and prescription savings cards. You can add to your monthly savings if you get in the habit of buying your prescription medications using these tools.
If you have Medicare but also have either Social Security benefits or Medicaid, your prescription coverage will still come from Medicare. You’ll need either Medicare Advantage with prescription coverage or a Part D plan.
Medigap plan costs vary from insurer to insurer but generally range from about $100 to $400 per month and will often depend on the carrier and the location.
Medigap providers typically use one of three methods to determine the pricing of their plans:
Community-rated: Everybody pays the same rate each month per location regardless of their age.
Issue-age-rated: You pay a premium based on the age you are when you sign up for the plan. The younger you are, the less you pay. Premiums may increase each year based on inflation, but they will increase as you age.
Attained-age-rated: Your premium is based on your age at the time you enroll, and it increases every year based on your age and inflation.
Understanding Medicare Part B – Coverage and Costs for 2020
What Is Medicare Part B?
Medicare is a federal government health insurance program for seniors 65 and older and others who meet qualifying conditions.
Medicare consists of four parts, labeled A, B, C, and D. Parts A and B make up the government-funded “Original Medicare” program. Part C refers to “Medicare Advantage” plans, which provide additional medical insurance. Part D refers to separate prescription drug Medicare plans.
Part A covers costs associated with hospitals and other inpatient services. It’s complemented by Part B, which covers outpatient services, preventative care, and durable medical devices.
Some people are automatically enrolled in Parts A and B while others must enroll on their own.
What is the difference between Part A and Part B Medicare?
Part A is often referred to as Medicare “hospital insurance,” while Part B Medicare coverage is often referred to as “medical insurance.” What this means is that while Part A can cover hospital stay charges, Part B can cover your doctor’s appointments and preventative care. If you had Part A only, you would have coverage for hospital care, but not any of your doctor’s appointments, so it’s important to enroll in both.
Medicare Part B Coverage
At this point, you’re probably wondering, “what does Part B of Medicare pay for?”
Medicare Part B covers ambulance services, doctor visits, preventative services, mental health, women’s health services (like mammograms), lab tests and X-rays, some medical equipment, and more. It does NOT cover hospital stays or most prescription drugs. The only time that Part B will cover drugs is if the drug is administered by a medical professional.
Medicare Part B Drugs
Here is a list of drugs covered by Medicare Part B:
Drugs used with durable medical equipment, like nebulizer supplies
Antigens, when prepared and administered by a doctor
Injectable osteoporosis drugs if medically necessary
Erythropoiesis-stimulating agents for those with ESRD or anemia related to other conditions
Oral ESRD drugs
Blood clotting factors for those with hemophilia
Other injectable and infused drugs when given by a medical professional
Preventative Services and the Annual Wellness Visit
Medicare Part B includes 100% coverage for several preventative services.
For example, when you first enroll in Part B, you can make a “Welcome to Medicare” appointment with your doctor. This will be a comprehensive overview conversation with your doctor about your healthcare needs and concerns.
You will also be eligible for an Annual Wellness Visit. This is more in-depth and includes a health risk assessment, a review of your and your family’s medical history, measurements (height, weight, BMI, blood pressure, etc.), mental health screenings, and a general conversation about your daily health concerns.
Also included under Part B at 100% coverage are your preventative vaccines, such as annual flu shots. However, some vaccines that are not considered preventative measures are not included under Part B coverage.
For example, the Shingles vaccine would be covered under Part D coverage instead of Part B.
Preventative services are also covered for:
high blood pressure
high blood sugar
smoking and alcohol cessation
Women are covered at 100% for pap smears, pelvic exams, and breast exams every two years. If you are diagnosed as at-risk for gynecological conditions, you may be able to receive screenings every year instead.
Medicare Part A covers inpatient mental health care. Part B covers outpatient mental health services, including:
No-cost yearly depression screenings
Both individual and group psychotherapy (including family counseling)
Psychiatric evaluations and diagnostic tests
Limited partial hospitalization
Partial hospitalization refers to psychiatric hospital treatments that don’t require an overnight stay. Items like meals, transportation, and support groups are not included.
You will only receive coverage when you see a doctor or specialist who accepts Medicare. You will be responsible for 20% of most of these services. There may be additional co-payments or coinsurance for partial hospitalization.
IMPORTANT: If you or a loved one is in immediate crisis, call the National Suicide Prevention Lifeline immediately at 1-800-273-8255 (TTY 1-800-799-4889). Help is available 24-7.
Laboratory Tests and X-Rays
When your doctor orders a lab test to help diagnose a condition or as part of your annual checkup, you are covered under Part B. Medically necessary blood tests and other diagnostics sent to a lab are covered.
They include blood work, urine tests, tissue lab work, and some screenings at no cost to you.
Blood for transfusions is handled differently. If you get a transfusion through a blood donation, you may not have to pay anything. Otherwise, you may have to pay 20% of the Medicare-approved amount.
X-rays are also covered but at 80% of the Medicare-approved amount. You are responsible for the other 20%.
Part B can cover emergency transportation if other transportation could put you in danger or you are having a medical emergency and need immediate assistance. It will only cover an ambulance ride to the nearest medical facility that can give you the type of care you need.
You cannot request to visit a hospital that is further away.
Air transportation is covered only if you need to get to a facility quickly and cannot do so by ground transportation (heavy traffic, inaccessible road conditions, etc.)
Transportation is covered at 80% of the Medicare-approved amount, and your Part B deductible will apply.
In some cases, Part B may cover non-emergency ambulance transportation if there is no other safe way for you to get to a hospital or other provider office for medically necessary services.
You will need to schedule your ambulance transportation in advance by reaching out to a non-emergency ambulance transportation company like ACC Medlink and Lifeguard.
The company you select may charge a fee and can contact Medicare to request authorization for coverage.
Durable Medical Equipment
Part B will only cover durable medical equipment.
For an item to be considered durable medical equipment (DME), it must be able to withstand repeated use for at least three years, must be usable at home, and must be used for a medical purpose only. Medicare will cover 80% of the cost.
In some cases, you may be able to choose whether you want to rent or purchase the equipment you need.
Some examples of DME include:
Blood sugar test strips and monitors/glucose control
Canes, crutches, scooters, walkers, and wheelchairs
Check with your doctor or Medicare to see if an item is considered a DME or not.
Part B covers some home health care, but only that which is relatively short-term and related to a limited period of recovery due to an illness, injury, or condition. Part B does not cover long-term care, either at home on in a nursing facility, that people may need due to frailty or because they need help with daily activities (bathing, grooming, eating, etc.)
What isn’t covered by Medicare Part B
Medicare Part A and Part B are structured to work together to provide maximum coverage at an affordable cost for most Americans.
In general terms, Part A covers in-hospital expenses, and Part B only covers outpatient expenses, durable medical equipment, and wellness activities.
Medicare does not cover anything not considered medically necessary. That includes elective and cosmetic surgery and several forms of alternative medicine such as homeopathy, acupuncture, and acupressure. Chiropractors are covered on a limited basis.
Other than flu and pneumonia shots, Medicare does not cover vaccinations and immunizations. The exception is if there is a health emergency, and vaccinations are required to stem the risk of infection through a contagious disease.
Part B also only covers drugs you can’t self-administer. Coverage is only provided if you receive medications in a hospital, doctor’s office, or health clinic. This is where Part D coverage can come in handy. All nonprescription drugs and remedies are also not covered under Part B.
General dental work is also not covered, unless it would need to be performed by a physician, meaning the treatment would be considered medical vs. dental
Part B also does not cover vision care, hearing aids, or contact lenses, except those required after cataract surgery. But if your eyes are affected by an illness or injury other than a routine loss of vision, you will be covered for ophthalmological services.
Routine foot care is also not covered unless a foot condition is the result of conditions such as diabetes, cancer, multiple sclerosis, inflammation due to blood clots, chronic kidney disease, malnutrition. Care must be diagnosed as medically necessary.
Except in rare circumstances, medical services outside of the United States and its territories are not covered as well. You will need to enroll in a Medicare Advantage plan for international coverage.
Medicare Part B costs in 2020/2021
Medicare premiums, copayments, and deductibles are adjusted annually according to the Social Security Act. What will Medicare Part B cost 2020 enrollees?
In 2020, the standard monthly premium is rising by about 7% due to increased program costs, up to $144.60. If you already get Social Security or Railroad Retirement benefits, your premium can be deducted from those. Social Security Medicare Part B payments will be automatic for most people.
The standard deductible is $198. After you pay your deductible, you’ll have to pay 20% for most Medicare Part B services, other than preventative and wellness services detailed above.
There is no income limit for Medicare Part B, but if you have a high gross income, you could be required to pay an Income-Related Monthly Adjustment Amount (IRMAA).
Some people may purchase a Part C plan that offers low deductibles and copays. You will pay a Part C premium, but you could wind up with more comprehensive coverage that will significantly augment existing Part A and B coverage and provide Part D prescription drug coverage as well.
Who qualifies for free Medicare B?
Unlike Medicare Part A, the amount of time you’ve worked does not affect your Part B premiums. Most people will have to pay a premium for Medicare Part B. To qualify for free Part B, you’ll have to qualify for one of the following programs:
If you are aging into the Medicare program, you should enroll in Part B any time between three months before your 65th birthday to three months after.
One question we hear a lot is, “I already have Part A, can I add Medicare Part B anytime?” Unfortunately, it’s not that simple. If you choose to forgo Medicare Part B when you first became eligible, you could face a late enrollment penalty fee later. Additionally, if you don’t enroll when you first become eligible, you’ll have to wait for the open enrollment period from January 1 through March 31 to enroll.
If you get Social Security or Railroad Retirement Board benefits for at least four months before your 65th birthday, you’ll automatically be enrolled in Part A and Part B coverage. Coverage starts the first day of the month you turn 65.
When you’re under 65, you have a disability, and you have been getting SSDI benefits for at least 24 months, you are automatically enrolled in Part A and Part B. If you suffer from Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease), you are automatically enrolled in Part A and Part B the month your disability benefits begin.
If you have been diagnosed with End-Stage Renal Disease (ESRD), you can enroll in Part A and Part B. To get full benefits that cover dialysis and kidney transplant benefits, you’ll need to be covered by both.
Check with Medicare.gov, because there are several stipulations regarding coverage for ESRD.
You can enroll in Part B during your Initial Enrollment Period (IEP), the General Enrollment Period (GEP), or during Special Enrollment Periods (SEP) if you qualify.
You can sign up for Part B benefits the following ways:
Call Social Security at 1-800-772-1213 (TTY: 1-800-325-0778).
If you worked for a railroad, call the Railroad Retirement Board at 1-877-772-5772.
Medicare Part B phone number: For questions about Medicare Part B billing, call 1-800-833-4455.
What happens if you don’t sign up for Medicare Part B?
While you are technically not required to sign up for Medicare Part B, you may face a late enrollment penalty fee if you wait too long to enroll. This will come in the form of a premium increase of as much as 10%.
Can I delay Medicare Part B coverage?
You can delay signing up for Part B coverage, but if you enroll at a later date, you may have to pay an enrollment penalty. This penalty will be in force for the entire time you have Part B coverage.
When you delay Part B coverage, it also means you can’t sign up for a Part C Medicare Advantage plan. One of the requirements for Part C is that you must currently be enrolled in Parts A and B.
Additionally, if you miss your initial enrollment period for enrolling in Part B, you’ll have to wait until the enrollment period from January 1 through March 31 to enroll.
Can I decline Medicare Part B coverage?
Is it mandatory to have Medicare Part B? No. But make sure you do your homework first and take into consideration your long-term health needs.
Although you have to pay a premium in many cases for Part B coverage, it still makes sense to enroll for a vast majority of people.
Is Medicare Better Than Individual Plans?
Is Medicare Better Than Individual Plans?
One survey about Medicare satisfaction vs. private insurance satisfaction found that people with Medicare were happier with their health plans than people with individual plans. Will you find the same to be true?
Types of Plans
As you turn 65 or otherwise become eligible for Medicare, you probably have a lot of questions. What’s going to change? Will I lose or gain new benefits? The good news is that signing up for Medicare does not necessarily mean giving up your plan flexibility or your favorite doctors. There are plenty of Medicare options available, and we’ll explain why it’s worth it to go ahead and get signed up as soon as you can.
You can purchase health insurance through your employer, as long as it meets the coverage limits set by the federal government. If you’re retiring but aren’t eligible for Medicare yet, you can use COBRA to hold you over. COBRA allows you to continue receiving your employer coverage for a short period of time (but your employer likely won’t help you pay for it except for in some unique cases).
You can also technically have Medicare and employer coverage at the same time, if you become eligible for Medicare while you are still employed. That might make sense for some people and not others.
You can purchase insurance from an exchange like Healthcare.gov, directly from your state, or directly from a health insurance company. Generally, purchasing private insurance is more expensive than employer coverage, and much more expensive than Medicare and Medicaid.
Veterans and veteran’s families may be eligible for free or low-cost healthcare through the Department of Veteran’s Affairs (VA). You or your spouse must have served for at least 24 continuous months or teh full length of time that you were called to serve for. You can also qualify if you were honorably discharged. To get TRICARE, you must already be enrolled in Medicare Part A and Medicare Part B. Click here to read more about coverage for veterans.
Medicaid is a federal health program. Each state has slightly different rules and each state has its own funding. The program can cover any person of any age with low income (according to the Federal Poverty Level and with some adjustments in each state). Most Medicaid beneficiaries will have either no or very small premiums. If you have a low monthly income AND are over 65, you may qualify for both Medicaid and Medicare! In that case, you can get what is called a “Dual-Eligible Special Needs Plan,” which is low-cost and tailored to your needs.
Original Medicare is a federally funded health program that can cover any adult over the age of 65 as well as some adults with disabilities, such as end-stage renal disease.
Most people with Medicare will start with parts A and B. Part A provides hospital coverage, and Medicare Part B provides medical coverage. Anyone who wants more coverage can opt to enroll in either a Medicare Advantage plan or a Medicare Supplement (also called Medigap) plan. Medicare Advantage is sometimes referred to as “Part C” because you have to have Part A and Part B first to enroll in it, and it can cover a lot of services that parts A and B do not.
Unless you enroll in a Medicare Advantage plan that includes prescription drug coverage, you’ll want to enroll in a separate drug plan. These plans are referred to as “Medicare Part D,” because they are completely separate from the other “parts.” Part D plans only cover prescription costs.
Some people may qualify for no or low-cost Medicare coverage, but others will have to pay premiums. Most people will not have to pay nearly as much for Medicare as they would with an individual or private health plan.
You may think that individual plans provide more coverage due to the higher premiums, but that is not always the case. All Medicare plans include preventative services. Plus, you can choose to enroll in Medicare Advantage, which is like a private plan for Medicare. With Medicare Advantage, you can roll all your benefits – medical, dental, vision, prescription drugs, and even fitness – into one convenient plan.
How is Medicare different from other health insurance?
Medicare is vastly different from other health insurance options for a lot of reasons, ranging from the way you pay for your coverage to when you can enroll.
For starters, the Medicare enrollment period is different from the ACA enrollment periods and your employer’s enrollment periods. The Medicare Annual Enrollment Period runs from October 15 through December 7, but be sure to not confuse it with the ACA Open Enrollment Period, which runs from November 1 through December 15 of each year.
Another thing that is different is that some people can have their Medicare Part A payments automatically deducted from their Social Security check.
Employer Health Insurance vs. Medicare
It’s hard to even compare Medicare vs. employer health plans because the only thing they have in common is that they provide health insurance. If you’re turning 65 or otherwise preparing to make the switch from your employer plan to Medicare, you should know the pros and cons of each option.
For starters, Original Medicare is the same for everybody. Technically, there are not separate plans to choose from within the government Medicare program. Once you’ve enrolled in Original Medicare, you can decide to add coverage through a private Medicare Advantage or Medicare Supplement plan. Some people may see this as a great thing because you can enroll right away without stressing about all your options. Others don’t like it, because one plan clearly cannot work for everybody. However, that’s what the private plans are for (and many of them are incredibly cheap compared to employer plans – some even have $0 premiums).
The advantage of private health insurance for Medicare (Medicare Advantage or Medicare Supplement) is that you can pick and choose which benefits are most important to you so that you aren’t paying for coverage that you don’t need. Plus, some people will qualify for Medicare Special Needs Plans which are specifically designed for people with special financial or medical needs and are usually relatively low-cost plans. Private Medicare plans can closely resemble individual marketplace plans or employer plans.
The disadvantages of private health insurance for Medicare-eligible people are that they sometimes have limited doctor networks and that some areas might have a limited number of plans to choose from. Typically, people who live in rural areas may have fewer plan options when it comes to private Medicare coverage.
Medicare vs. Medicaid
Both Medicare and Medicaid are government programs that are regulated by CMS (Centers for Medicare and Medicaid Services). They both provide health insurance for medically necessary services.
The main difference between Medicare and Medicaid is who qualifies. It is possible to qualify for both programs, but Medicaid qualifications are based on income while Medicare qualifications are based on age and disability. Another difference is that while the Medicare qualification rules are federal, Medicaid qualification rules can change slightly by state.
Medicare Versus Spouse Insurance
A lot of people who are newly qualified for Medicare wonder if it might be better to stay on their spouse’s insurance plan. The fact is, it depends on how good your spouse’s insurance is. However, if you do qualify for Medicare, Part A (the part that covers hospital costs) has a $0 premium for anyone who has worked and paid Medicare taxes for at least ten years. If you haven’t worked that long but your spouse has, you might still qualify. If that’s the case, there’s no reason not to go ahead and enroll in Medicare Part A as soon as you become eligible.
Additionally, if you wait too long to seek out further Medicare coverage, your costs may go up. You can be charged a penalty of up to 10% of your premium if you don’t enroll in Medicare Part B when you first become eligible. Plus, Medicare Supplement plans can charge more or deny coverage based on preexisting conditions if you wait too long to enroll. So if you think you might want to enroll in a Medicare Supplement plan, don’t wait too long to start looking.
Medicare vs Other Health Insurance: The Benefits
If you are eligible for Medicare coverage but considering alternative health insurance, you should start by learning what Medicare does and does not cover. Medicare Part A and Part B are the same for all who enroll. They cover preventative healthcare, like your annual wellness visits and flu shots at 100%.
Part A also covers 60 consecutive hospital days at 100%. After the 60th day, you’ll start to owe co-payments. Part B covers mental health, lab tests and X-rays, emergency transportation, and medical equipment.
Medicare A and B do not include prescription drug coverage, dental, vision, hearing, podiatry, or any service that is not deemed medically necessary either for treatment or prevention. For additional health coverage, millions of Medicare beneficiaries enroll in Medicare Advantage.
Since Medicare Advantage plans are owned by private companies, they can add in benefits like dental, vision, hearing, etc. – any of those extra benefits that you might be accustomed to from having private health insurance. Some Medicare Advantage plans also cover prescriptions. If you want prescription coverage but don’t care about all of the extra benefits, you can enroll in a stand-alone prescription drug plan instead. However, you cannot have both a Medicare Advantage plan and a Medicare prescription drug plan at the same time, so choose wisely.
Medicare vs Other Health Insurance: The Costs
The good news about Medicare is that as long as you or your spouse have worked and paid Medicare taxes for a certain number of years, your Part A Medicare costs will be low.
If you or your spouse has worked and paid Medicare taxes for at least 40 quarters, you’ll owe $0 in Part A premiums.
If you or your spouse has worked and paid Medicare taxes for 30-39 quarters, you’ll owe $252/month in 2020 in Part A premiums.
If you or your spouse has worked and paid Medicare taxes for less than 30 quarters, you’ll owe $458/month in 2020 in Part A premiums.
Part B premiums are standard for all Medicare beneficiaries. It can change each year, but the Part B monthly premium in 2020 is $144.60, and the deductible is $198. Most services that Part B covers are covered at 80%, so you may owe 20% coinsurance or doctor co-payments.
If you choose to enroll in a prescription drug plan, a Medicare Advantage plan, or a Medicare Supplement plan, you may face an additional premium.
Medicare vs. Private Insurance Costs
If you’re choosing between enrolling in Medicare Part B versus private insurance, remember that delaying your Part B enrollment can leave you with up to a 10% increase in your premium when you do decide to enroll.
If you decide to add on private Medicare insurance through a Medicare Advantage or Medigap plan, remember that you’ll still have to pay your Medicare Part A and B monthly premiums (unless you qualify for a savings program such as QMB). You cannot enroll in MEdicare Advantage without enrolling in Medicare parts A and B first.
Medicare Advantage and Medicare Supplement plans are completely separate and therefore come with separate bills. You’ll owe a premium (which in some cases can be $0), and you’ll likely have a deductible as well as co-payments for certain services.
Many private health insurance plans also have out-of-pocket maximums, which means that if you have a lot of health care costs, you can reach a point where you stop having to pay out-of-pocket for services. Those out-of-pocket expenses can really start to add up even with Medicare if you’re someone who needs a lot of medical care!
Why is Medicare cheaper than private insurance?
A lot of new Medicare beneficiaries do find that their Medicare costs are cheaper than what they were paying before they qualified. The biggest reason for that is the way Medicare is funded. While you or your spouse were working hard for all those years, you were paying Medicare taxes. Your low premiums today are because of all that hard work! Plus, the Medicare office does not incur nearly the same amount of administrative costs that many healthcare companies do.
Is it better to have Medicare or private insurance?
Is Medicare a good insurance option? Is private health insurance better? It depends on who you ask. This is a great question to ask an insurance agent who knows what sort of medical expenses you have and what your budget is.
The main difference you have to remember when you’re wondering if private insurance or Medicare is better is that private insurance gives you more plan options. To get a private Medicare Advantage plan, you’ll have to enroll in Medicare A and B, first. Then, you can choose if you want to personalize your coverage and add benefits by enrolling in additional medical insurance.
If you’re stuck between Medicare and keeping your employer plan, remember that you could face penalties if you don’t enroll in Medicare when you first become eligible – and nothing says you can’t keep both!
Is Medicare or private insurance better for people with dependents?
If you have dependents, Medicare isn’t going to help you. But that doesn’t mean you shouldn’t enroll. Medicare only provides individual coverage – there are no family plans or spouse Medicare plans. However, your Medicare Part A might be free. If that’s the case, you might want to consider enrolling in Medicare for yourself first, and then taking a look at options for your dependents.
If you have access to an employer plan, do the math to figure out if it may be more cost-effective for you to have your group vs. individual Medicare Advantage coverage. In some cases, it might even make sense for you to keep both. If your Medicare Advantage premium is low enough, you can keep that for yourself but also hang onto your group coverage for as long as you can to support your family. An insurance agent can help you figure out what’s best for you.
Can I drop my employer health insurance and go on Medicare?
If you become eligible for Medicare while still receiving employer health insurance, you can and should still enroll in Medicare to avoid penalty fees.
First, find out if you’re currently in one of the Medicare enrollment periods. Medicare open enrollment is different from your employer’s open enrollment period.
If you just became eligible, you’ll have a few months for your “Initial Enrollment Period.” If you’re aging into the program, this period begins three months before your 65 birthday and ends three months after. If you’ve already missed that period, don’t panic – you can enroll for the first time from January 1 through March 31 of each year.
Once you’re enrolled, the “Annual Enrollment Period,” is when you can add or make changes to your Medicare coverage. It runs from October 15 through December 7 of each year. This period is not for enrolling in Medicare for the first time – it’s only for adding or making changes to your private Medicare coverage.
According to Medicare.gov, some people will be automatically enrolled in Medicare Part A upon becoming eligible. If you are not automatically enrolled, you can apply for Medicare on the Social Security website.
How Medicare Works with Other Insurance
Millions of Medicare beneficiaries opt to enroll in Medicare Advantage or Medicare Supplements on top of their Medicare coverage. In these cases, the private insurance companies act as the “secondary payers.” Health benefits that Medicare does not cover will be automatically billed to the private company, but anything else will go to Medicare first. If you have both employer insurance and Medicare, Medicare might actually be the secondary payer. Check with your employer or your employer’s health insurance plan to be sure.
Both Medicare and private insurance coverage will have limitations – so having both is a great way to keep yourself and your families financially covered in case of a medical emergency.
How Medicare Plan Finder Can Help You
We specialize in Medicare and serving the underserved senior and Medicare-eligible population. Do you or a loved one need help selecting a Medicare plan that truly helps? Set up a free appointment with one of our licensed agents in your area to get bias-free assistance. Call us to set it up at 1-844-431-1832.
Spouse Medicare 101
Spouse Medicare 101
Medicare is different from other forms of insurance in a lot of ways. One of the biggest differences is that there are no family plans in Medicare. All Medicare coverage is individual-based.
However, even though Medicare and marriage are not directly related, your marital status can impact your Medicare costs in a few special ways.
Does Medicare Offer Spouse Coverage?
Medicare does not offer health coverage for spouses. You would have to be eligible on your own to qualify for Medicare – your spouse’s eligibility does not affect yours.
According to the rules set in place by the Centers for Medicare & Medicaid Services, marriage can affect your Medicare in the following ways:
Eligibility for Medicare cost savings can change due to your spouse’s income
Your Part D (prescription drug plan) premiums can be higher due to your spouse’s income
Premium-free Part A eligibility can be determined based on your spouse’s work history if they worked more than you.
So, can you get Medicare through your spouse? Not technically, no – but your marital status is not irrelevant.
Medicare if Spouse is Disabled
If one spouse is 65 and begins receiving Medicare and the other is not yet 65, there may be other ways to qualify. If you are diagnosed with ESRD or ALS or if you have been receiving SSDI (Social Security Disability Insurance) for at least two years, you can qualify for Medicare regardless of your age.
The good news is that if you do qualify for Medicare based on a disability, you may also qualify for a Medicare Special Needs Plan at a low cost.
Medicare Eligibility Requirements
The “main” Medicare program is called “Original Medicare.” You can qualify for Original Medicare by:
Unlike Medicaid, income does not impact Medicare eligibility. Additionally, unlike ACA plans, pre-existing conditions do not affect your Medicare costs or coverage. The only exception to this is in private Medigap (or Medicare Supplement) plans. If you do not enroll in a Medigap plan when you first become eligible for Medicare, you can be charged more based on your health history. Medigap plans are completely optional and are there for additional financial protection.
You can qualify for additional health and drug coverage through Medicare Advantage plans or Medicare prescription drug plans after you’ve enrolled in Original Medicare. Those plans cannot charge more based on your age or preexisting conditions.
Spouse Social Security Benefits
Even though the Social Security Administration manages Medicare enrollments, Social Security and Medicare are two vastly different things. There are a few differences in how your marital status affects your benefits.
For Social Security, your benefit is calculated based on your total household income according to your tax returns. That includes both your and your spouse’s income. Both you and your spouse can benefit from Social Security, even after one spouse has passed away.
Medicare does not work like that. Your marital status and income do not impact your eligibility, and there are no additional Medicare benefits given to a spouse after a Medicare beneficiary passes.
Medicare & Health Insurance Options for Spouse of a Medicare Recipient
If one spouse is ineligible for Medicare and needs to find a different health plan, don’t panic – there are plenty of options for health insurance for the spouse of a Medicare recipient. You might want to start by checking to see if that spouse is eligible for Medicaid based on your total household income. If the answer is no, you’ll want to start looking at individual health plans in your area, which you can do through healthcare.gov/.
If the Medicare spouse has insurance through an employer when they become eligible for Medicare, the non-Medicare eligible spouse can also try getting COBRA until they are also eligible for Medicare. COBRA allows an individual, couple, or family to continue health coverage after leaving a job. However, keep in mind that even if you’re able to keep your health plan through COBRA, your costs may go up because your employer won’t be sponsoring the plan for you anymore.
Can my Wife get Medicare at 62?
To get Medicare, you have to either be 65 or have a qualifying disability.
If your husband or wife is just a few years short of Medicare eligibility, they can select an ACA plan or enroll in a short-term health plan. Short-term medical insurance can be renewed for up to 36 months, so it’s a good option if you’re within 36 months of becoming eligible for Medicare. Since these plans are designed for such short periods of time, they tend to be a bit cheaper than long-term plans, like the ones offered by your employer or the ACA.
Can a Non-Working Spouse Qualify for Medicare?
People often wonder if Medicare is available for their non-working spouse. In short: yes, as long as they meet the age or disability requirements. However, your spouse’s costs may be different from yours. Your employment status does not determine your Medicare eligibility – but it can determine your Medicare costs as such:
If you or your spouse has worked and paid Medicare taxes for at least 40 quarters, you can qualify for premium-free Medicare Part A
If you or your spouse has worked and paid Medicare taxes for 30-39 quarters, you can qualify for a discounted Medicare Part A premium of $252/month in 2020
If you and your spouse have worked and paid Medicare taxes for less than 30 quarters (or have not worked at all), your Medicare Part A premium will be $458/month in 2020
Can my Wife get Medicare if she Never Worked?
Employment and marital status do not impact Medicare eligibility. Even someone who has never worked a day in their life can get Medicare, but their costs may be higher than someone who has been paying Medicare taxes.
Medicare vs. Medicaid
Unlike Medicare, your Medicaid coverage can be impacted by your marital status. While each state has somewhat different regulations, most of Medicaid eligibility is based on the Federal Poverty Line. Your income is calculated using your total household income, which is verified with your tax returns. Both your and your spouse’s income are included. That means that even if you qualify for Medicaid based on your income, you won’t be eligible if you and your spouse’s total income together is higher than your state’s limits.
How to Apply for Medicare Through a Spouse
You cannot apply for Medicare through your spouse. You’ll have to wait until you are eligible and then apply during your Initial Enrollment Period. If you qualify by turning 65, this period begins three months before your 65th birthday and ends three months after. If you miss that period, you can apply during the Open Enrollment Period from January 1 through March 31. To apply for Medicare online, visit the Social Security website, not medicare.gov.
How do I Apply for Spousal Medicare Benefits?
There are no spousal Medicare benefits – but you can apply for spousal Social Security benefits, here.
What is Not Covered Through Your Spouse’s Medicare?
Your spouse’s Medicare plan won’t provide health coverage for you. If you’re looking for Medicare for spouses, you’ll have to wait until the other spouse is eligible. Then, you can talk to an agent about finding separate plans that work for both of you and both fit into your household monthly budget.
Medicare Family Coverage
In general, Medicare is not available to non-qualifying spouses or dependants. However, if your child has a qualifying disability, they may be eligible for a Medicare plan of their own. Note that except for in the cases of ALS and ESRD, you will have to receive disability benefits for at least two years before you can enroll in Medicare.
How Does Getting Married Affect Medicare?
Getting married? Congrats! A new marriage often involves complicated discussions about finances, and you might be wondering, “will getting married affect my Medicare benefits?” The good news is that no, marriage does not affect your current Medicare benefits – but it CAN impact your eligibility for Medicare cost savings programs. For example, Medicare Savings Programs and Low-Income Subsidies for Medicare prescription coverage base eligibility on total household income. If your new spouse causes your household income to increase, you could become ineligible for these programs.
If you’re not yet 65, you might be wondering, “will I lose my disability Medicare if I get married?” No! Even if you are qualifying for Medicare based on disability and not age, your Medicare coverage won’t change based on your marital status.
Medicare Premium Payments: How Much Does Medicare cost for a Married Couple?
How much does a married couple pay for Medicare? Medicare is 100% individual, so each spouse will have to pay their own premium. There are no joint plans with joint costs.
Your Medicare Part A monthly premium will depend on your and your spouse’s work history and will range between $0 and $458 per month in 2020. Your Medicare Part B premium will be $144.60 in 2020 (unless you qualify for savings programs or have your premium covered by a Medigap plan). If you have Medicare Part D prescription drug coverage or either a Medicare Supplement or Medicare Advantage plan, you’ll pay a separate premium for those plans.
Do Husband and Wife pay Separate Medicare Premiums?
Yes – families and spouses cannot have joint Medicare plans. All premiums will be separate. Some people will have their premiums automatically deducted from their Social Security benefits.
While Medicare does not provide spousal benefits, there are some plans that offer household discounts for plan premiums. You should always confirm with your agent whether or not a household discount exists as some companies may have specific requirements regarding spousal discounts.
Medicare Extra Help and Income Limits
The one thing that marriage will affect when it comes to Medicare is whether or not you qualify for the Extra Help Program, otherwise known as Low-Income Subsidy (LIS). LIS exists to help people with limited income pay for their prescription drugs. Those who qualify for the program pay less in drug premiums, copayments, and coinsurances.
Single and married beneficiaries have different requirements for what constitutes a low-income level. For example, to qualify for LIS (a prescription drug savings program) in 2020, single beneficiaries must make less than approximately $19,000 per year, but married couples must make less than approximately $26,000 per year.
Even if you and your spouse have different Medicare plans, you can still share an agent! Sharing an agent will make your enrollment process easier and help you build a relationship with someone who knows everything about Medicare plan options and can help you find savings.
Do you have a licensed agent? Have more questions about spouse Medicare? Give us a call today to set up a free meeting. Our agents are licensed to sell several different insurance plans, so they can offer you an unbiased opinion and help you find the plan that truly works best for your needs. Call us at 1-844-431-1832.
Prescription Discount Cards 101
Do you have a high deductible or copayment for your prescription drugs? Did you get a new prescription that is not covered by your insurance? Well, great news! A discounted prescriptions network may help cover some of those costs.
What is a discounted prescriptions network?
A discounted prescriptions network provides prescription discount cards. These discount cards for prescriptions are available to everyone and can prove to be an easy way to save on your prescriptions.
Many top-rated prescription discount cards can be emailed or texted directly to you for immediate use.
You may be able to enjoy prescription savings in the long run by understanding the truth about these cards and knowing the best prescription discount cards available. Visit websites that offer the best prescription discount card reviews to choose the right one for your particular needs.
Your free prescription card could be a Walgreens prescription discount card, a GoodRX discount coupon, a SingleCare discount card, and so on.
Sometimes generic drugs provide the same value as the original drug at the lowest price. Brand name prescription drugs don’t cost more because they are better, but because companies have to pay for safety, effectiveness, animal, and clinical studies.
What is a pharmacy benefit manager?
A pharmacy benefit manager (PBM) is the middleman between the pharmaceutical company and the pharmacy. They negotiate drug pricing from the pharmaceutical company for the pharmacy.
This means that there may be a significant cost difference for the same drug in different stores and locations.
Pharmacies will negotiate prices depending on their customer base. If one pharmacy has many older adult customers, they may charge less for heart medication.
However, they might charge more for another drug that has a lower demand to make up the price difference. This is why comparing drug prices and utilizing prescription discount cards is important.
The Truth About Prescription Discount Cards
A prescription discount card can be useful to many people, but as Medicare scams continue to rise, it’s understandable why you may be hesitant to use them.
Some prescription discount cards can be misleading and claim higher savings. However, a large portion of free prescription discount cards are credible, can be used at thousands of pharmacies across the US, and don’t require your personal information.
Are prescription discount cards legitimate? A legitimate prescription drug discount card program has the following signs:
The website offers an easy pricing tool for brand and generic medications.
Pharmacies near you accept the card.
The website offers a home delivery option via a trusted website.
The discounted amounts are comparable to other discount program card program websites.
What are the best prescription discount cards?
Don’t confuse a health insurance card with prescription drug discount cards. A health insurance ID card is proof of insurance to use when you visit a health care provider, physician, or hospital while a drug card helps you fill a prescription at a discounted price.
Not all prescription discount cards are created equal.
Some prescriptions may be covered by one discounted prescription network and not the other. The best prescription discount card is the one — or combination of several cards — that can save you the most on the medications you take every day.
The amount of savings, number of eligible pharmacies, and number of prescriptions available will vary by the discounted prescriptions network. You may want to consider these cards:
With the GoodRx app, prescription drug price comparison is available right at your fingertips. GoodRx compares prices for every FDA-approved drug at more than 70,000 pharmacies across the US.
Coupons can be printed, emailed, or texted to you and all you need to do is show the pharmacist your coupon to save up to 80% on your prescriptions.
US Pharmacy Card
This card is completely free and does not require any personal information. The US Pharmacy Card is accepted at roughly 59,000 pharmacies nationwide. You can have your card printed, emailed, or texted to you. Fun fact: this card can also be used on prescriptions for your pets!
Discount Drug Network
The Discount Drug Network card can save you up to 85% on your prescriptions with or without insurance. The only personal information you need to supply is your name, email, and address.
Your free prescription discount card will be mailed to you. Plus, the drug pricing tool on their website makes comparing prices a breeze.
A SingleCare prescription discount card is a savings card honored by a network of pharmacies across the country. Choose a pharmacy near you and present your card to the pharmacist at the counter.
If one of the participating pharmacies is Walmart, then show your prescription discount card at Walmart. Or if one of the participating pharmacies is CVS, then show your prescription discount card at CVS.
How to Use Your Drug Discount Card
When you want your prescription filled, go to one of U.S. pharmacies contractually obligated to honor your card. Visit participating pharmacies, such as Walmart, CVS, Walgreens, or Rite Aid, to get your discount.
A drug discount card mobile app may also be available for iPhone and Android.
If you haven’t already, click here to download your free prescription discount card. Then you can browse local pharmacies’ prices for your prescribed medications.
Prescription Drug Price Finder
Once you’ve downloaded your discount card, click here. Then type in your prescribed drug. For our purposes, we’re using rosuvastatin (Crestor), which is one of the best-selling drugs in the United States. Then enter your zip code. We used 37209, which the zip code of our headquarters in Nashville, Tennessee.
Then select your dosage and amount. We chose 20 mg and 30 tablets.
According to GoodRx, the average price without insurance for a 30-day supply of 20 mg is $161.64 as of March 2020. As you can see, you will pay just $8.44 at Walmart for the same thing with your free prescription discount card.
*Prices may vary. Always check with your pharmacist to find out the exact discounted price of your prescription.
Prescription Discount Cards and Medicare
Medicare and prescription drug coverage can be confusing. Fortunately, a licensed agent can help explain your prescription coverage options. If you’re interested in arranging a no-cost, no-obligation appointment with an agent, fill out this form or call us at 844-431-1832.
This post was originally published on November 27, 2018, by Kelsey Davis. It was last updated on April 9, 2020, by Troy Frink.
Does Medicare Cover Chiropractic Care?
Many people visit the chiropractor to treat a variety of conditions including back pain and headaches. Chiropractic care may be an alternative to prescription drugs.
The idea is that chiropractic care will treat the root cause of the problem, rather than just treating the symptoms. If you have Medicare insurance, you may want to know, “Does Medicare cover chiropractic care?” Yes, but according to the official notice of Medicare coverage for chiropractic care, Medicare has non-covered, always-covered, and perhaps-covered categories.
So it is only applicable in limited circumstances when chiropractic care treatments meet specific rules.
Medicare Chiropractic Coverage
Medicare will not cover the X-rays, massage therapy, or acupuncture treatments your chiropractor may recommend. However, Medicare does cover chiropractic care (spinal manipulation) to correct subluxations, which describes the condition when one or more spinal vertebrae move out of position.
Original Medicare consists of hospital insurance (Part A) and medical insurance (Part B). Medicare Part B will help pay for chiropractic services if your doctor says they’re medically necessary.
If your chiropractor is Medicare-approved, Part B will pay for 80% of your adjustment. You will still owe 20% coinsurance, and the Part B deductible applies.
Original Medicare does not cover many services people want. Private insurance plans called Medicare Advantage (MA) plans can offer coverage for additional chiropractic services.
MA plans vary by location and carrier, and choosing a plan may seem overwhelming. A licensed agent with Medicare Plan Finder can help you find a health insurance plan in your area that fits your needs.
Here is how Medicare Part A, B, C, and D apply to Chiropractic coverage:
Medicare Part A will not cover a visit to a chiropractor because it only applies to hospital care. Chiropractic care is classified as a non-emergency medical service provided in a chiropractic doctor’s office.
Medicare Part B covers manipulation of the spine if a chiropractor believes treatment of a subluxation, which is a misalignment of the spine, to be medically necessary. Part B also provides coverage for physical therapy, since this is another outpatient treatment.
Medicare Part C, the Medicare Advantage plan part, will also cover medically necessary chiropractic services.
Medicare Part D, the Medicare prescription drug benefit, does not apply to chiropractic care at all because Chiropractors are not typically permitted to prescribe medicines legally.
How Many Chiropractic Treatments Does Medicare Cover?
Medicare provides five paid chiropractic visits annually. This can be arranged by your physician through either the Chronic Disease Management plan (CDM) or the Team Care Arrangement (TCA). Medicare chiropractic coverage will save you more than $250 in your healthcare costs.
How Much Does Chiropractic Care Cost With Medicare?
Medicare beneficiaries are United States residents enrolled in Medicare Part A or Part B benefits, or enrolled in both Part A and Part B. They are entitled to receive most medical services after paying their deductibles and a 20% coinsurance.
As a Medicare beneficiary, several factors affect the exact amount you pay with Medicare, for example:
Your health insurance plan
How much your chiropractor charges
Whether your doctor takes Medicare and accepts the assignment
The type of facility
The location of your test or service
What Leads to the Need for Chiropractic Adjustments?
Many common conditions can lead to spinal subluxations. For example, let’s say you bend over to pick something up, and when you stand up, your back doesn’t feel right. It hurts, feels tight, and you can’t stand up straight.
You visit your doctor right away, and your doctor determines that your spine is out of alignment. Your doctor might refer you to a chiropractor.
Before your chiropractor creates a treatment plan you will have X-rays and tests to assess your range of motion.
Improper lifting is one cause of spinal subluxations. Other common causes include:
A vertebra going out of place due to slips, trips or falls
The entire spine slipping out of place because of poor posture
Damage to intervertebral joints (joints between the vertebrae) resulting in joint swelling
For every inch that your head strays from its natural position, you put an extra 20-30 pounds of pressure on your neck (according to Rene Cailliet, MD, former Director of the Department of Physical Medicine and Rehabilitation at the University of Southern California).
While you sit, don’t slouch. Sit with a straight back and keep your head squarely above your shoulders. If you sit for an extended period of time, be sure to get up and walk around for a while. Develop healthy habits such as stretching your entire body every day.
Benefits of Chiropractic Care for Seniors and Medicare Eligibles
Even though Medicare does not cover chiropractic care unless it’s part of subluxation correction, you may still benefit from chiropractic care. Along with correcting subluxations, chiropractic care may provide relief from headaches, low back and neck pain, and sciatica.
Many people may not want to take prescription drugs for headache relief, and they may want to pursue an approach that doesn’t require an abundance of OTC meds either. Many studies suggest that chiropractic care helps treat both tension and migraine headaches.
Lower Back Pain
Chiropractic treatment may be a cost-effective approach to successfully treating lower back pain. Some patients may find that spinal manipulation is more effective for providing pain relief in the long term.
If your doctor recommends chiropractic care for your lower back pain, then it may be a viable option for relieving pain symptoms.
Sciatica refers to a pinched sciatic nerve. It usually starts with a herniated spinal disk. The pain runs from the base of the spine into your legs, and it can range from a mild ache to severe pain.
Your foot might also go numb or feel weak. According to the European Spine Journal, chiropractic adjustments may be more effective than corticosteroid treatment for sciatica.
Common Chiropractic Care Questions
What chiropractic codes does Medicare cover?
Here are the most common chiropractic codes:
CPT Code 98940 Chiropractic manipulative treatment (CMT); Spinal, 1-2 regions
CPT Code 98941 Chiropractic manipulative treatment (CMT); Spinal, 3-4 regions
CPT Code 98942 Chiropractic manipulative treatment (CMT); Spinal, 5 regions
Does Medicare cover chiropractic care in 2020?
Medicare chiropractic coverage in 2020 continues to cover the Medicare guidelines for chiropractic documentation.
Where can I find the latest Medicare fee schedule for 2020?
Medicare.gov is where you will find all the information you need about Medicare’s chiropractic coverage, including the latest Medicare chiropractic fee schedule.
Does AARP United Healthcare cover chiropractic?
Most plans in the AARP secondary Medicare insurance offer a chiropractic benefit.
Let Us Help You Find Medicare Coverage for Chiropractic Care
If you’re one of the many people who rely on chiropractic care for pain relief, you may want to consider a Medicare Advantage plan to help cover costs.
The licensed agents at Medicare Plan Finder are highly trained and they can help you find a MA plan in your area with additional chiropractic coverage. Call 833-438-3676 or contact us here to learn more.
This post was originally published on June 24, 2019, and updated on April 9, 2020.
Does Medicare Cover Cataract Surgery in 2021?
Surgeons perform more than 3.8 million cataract procedures every year in the United States. As you age, your risk of developing cataracts increases. Approximately half of all Americans will develop cataracts by age 75.
Before factoring in health care coverage, cataract surgery can cost $3,700 to $7,000 per eye. If you have one of the millions of cases of cataracts, you may wonder, “Does Medicare cover cataract surgery and implants?” Yes. Medicare covers these costs for qualified Medicare beneficiaries.
How Much Does Medicare Pay for Cataract Surgery?
Original Medicare (Part A or Part B) generally* does not include vision coverage. However, cataract surgery is an exception. Medicare Part B covers basic lens implants and cataract removal.
If your provider recommends an advanced lens implant, you may need to pay some or all of the additional costs. It’s essential to talk with your doctor to get a clear understanding of the necessary procedure.
*Medicare Part A may cover emergency services in a hospital.
Medicare Part D, which is the prescription drug plan, may cover any prescription medications you need after you have had your cataract surgery.
Incidentally, any medications you need before surgery, such as prescription eye drops, will be covered by Medicare Part B. Part B will also cover eyeglasses or a set of contact lenses for cataract surgery that implants monofocal intraocular lenses (IOL).
Since Part D has no deductibles, you may be responsible for a specified copayment amount that you must pay when you get your prescription drugs.
What Type of Cataract Surgery Does Medicare Cover?
Medicare covers two types of surgery: manual blade surgery and laser surgery.
Medicare will also pay for an intraocular lens (IOL), which corrects presbyopia or astigmatism, but only if these lenses should be replaced because of cataracts.
Does Medicare Pay for Laser Cataract Surgery?
Medicare coverage for cataract surgery doesn’t depend on the surgical method. Medicare will cover 80% of the cataract removal and basic lens whether the procedure is conventional or bladeless with a computer-controlled laser. Similar to conventional surgery, laser surgery requires you to pay the additional costs if you require an advanced lens.
Does Medicare Pay for Cataract Surgery With Astigmatism?
Since you can correct astigmatism with glasses, Medicare will only cover a cataract surgery with astigmatism if the cataract surgery itself is considered necessary. If this is the case, Medicare will pay for the cataract surgery.
Does Medicare Cover Glasses or Contacts?
For the most part, Medicare does not cover routine vision care, glasses, or contact lenses. However, Medicare can make an exception
You may be wondering, “How much does Medicare pay for glasses after cataract surgery?” After your surgery, Medicare will cover 80% of the costs for prescription glasses or contacts, but you must purchase them through a provider who accepts Medicare assignment.
You will be responsible for the remaining 20%. Some beneficiaries have trouble getting Medicare to cover the pair of glasses or contacts.
If you are denied coverage, you can appeal the decision and request that they are covered. If you already paid for them out of your own pocket, you can request reimbursement.
You and your health provider can write a letter to add to your appeal, just be sure to state that you had met the requirements for cataract surgery, so your glasses or contacts must be covered.
What Is the Average Cost of Cataract Surgery?
Cataract surgery can range from $3,800 to $7,000 per eye without a health insurance plan. For standard cataract surgery, the average cost is $3,700.
However, the average cost of astigmatism-correcting surgery is $5,000, and presbyopia-correcting is about $7,000.
What does Medicare pay toward cataract surgery? It depends on the Medicare plan you are enrolled in. If you are only enrolled in Original Medicare, you will need to pay a 20% coinsurance and your Medicare Part B deductible, which is $185 in 2019.
You may be able to get even more coverage through a Medicare Supplement plan (Medigap) or Medicare Advantage plan. Additionally, because cataracts cloud the eye lens, eye surgery is classified as a medical condition.
This means that Medicaid could also pay some of your cataract surgery costs.
How to Find a Cataract Surgeon Who Accepts Medicare
Ophthalmologists are eye doctors who specialize in vision correction and care. Many times your ophthalmologist will perform your cataract surgery.
Since not every ophthalmologist will accept Medicare Advantage and you may not want to go through the trouble of finding another healthcare provider, then ask your health insurance provider to give you a Medicare eye doctor list.
However, it may be a little more difficult to find a cataract surgeon who accepts Medicare in 2020 because the physician fee schedule has changed since last year. Eye surgeons have had to take a 15% cut in reimbursement compared to Medicare coverage for cataract surgery in 2019.
So another option is to use the Medicare.gov’s physician compare tool to help you find an eye surgeon who accepts Medicare.
Click here to get started. First you’ll come to the physician finder tool. Enter your zip code in the search bar beside the red arrow. We used 37209, which is our corporate offices’ zip code in Nashville, TN.
Then type “ophthalmology” in the search bar above the green arrow. Then click “Search” beside the yellow arrow.
Then you’ll come to a list of ophthalmologists who currently accept Medicare. Use the contact info to call different doctors to find the right fit.
Medicare Requirements for Cataract Surgery
Your vision must be 20/40 or worse to qualify for surgery. Your doctor will need to document that your vision is at this level or lower.
You also need to have difficulty completing daily living activities like reading, sewing, watching television, or driving.
It’s important to remember that the cloudiness in your eye is not directly correlated to the severeness of your cataracts. If you are unsure of your vision level or whether or not you qualify, visit your eye doctor.
Cataract Surgery and Medicare Supplements
Medicare Supplements work alongside Original Medicare and are a great way to add financial benefits to your current coverage. They can help cover your 20% coinsurance and your Medicare Part B deductible.
Plan F is currently the only plan that covers your Part B deductible.
However, Plan F was discontinued in 2020. If you enrolled in it before the start of 2020 you are locked into this plan and will maintain coverage. If you are interested in enrolling in Medicare Supplement Plans, fill out this form or give us a call at 1-855-783-1189 (TTY 711).
Cataract Surgery and Medicare Advantage
Medicare Advantage plans are required to cover, at a minimum, the same as Original Medicare. However, MA plans offer several additional benefits like prescription drug coverage, hearing and dental coverage, group fitness classes like SilverSneakers, and additional vision coverage.
Benefits will vary by plan but can include routine eye exams, eyeglasses, contacts, frames, and fittings. These benefits allow you to check your vision each year and update your prescription, lenses, and frames as needed.
If you are only enrolled in Original Medicare, you will need to pay for these expenses out of your own pocket.
What Are Cataracts?
Our eyes have a lens that works much like a camera. The lens bends light so you can see your surroundings.
A cataract makes that clear lens cloudy, and it can be more difficult to read or drive a car.
What Causes Cataracts?
Most of the time, cataracts develop with age, or when an injury changes your eye’s lens. As you age, the lens can become stiffer, thicker, and less transparent.
Sometimes genetic disorders, other eye conditions, medical conditions such as diabetes, or past eye surgery can contribute to cataract development. Other causes can be long-term steroid medication use.
According to the Mayo Clinic, signs and symptoms of cataracts can include:
Cloudy, blurry or dim vision
Increasing difficulty seeing at night
Sensitivity to light and glare
Need for brighter light for reading and other activities
Seeing “halos” around lights
Frequent changes in glasses or contact lens prescription
Fading or yellowing of colors
Double vision in one eye
How Do You Know If You Need Cataract Surgery?
Talk to your doctor if you experience any changes to your vision such as cloudiness or halos around lights. According to Harvard University, you should have an eye exam every year if you’re 65 or older.
Dr. Laura Fine, an ophthalmologist with Massachusetts General Hospital, says you don’t need cataract surgery until you think you need to see better.
Learn More About Medicare and Cataract Surgery
A licensed agent with Medicare Plan Finder may be able to find plans in your area that fit your budget and lifestyle needs.
Are you interested in learning about available plans in your area? Fill out this form or give us a call at 1-855-783-1189 (TTY 711) to schedule a no-cost, no obligation appointment with a licensed agent.
Does Medicare Cover Genetic Testing for Cancer?
Cancer is the leading cause of death worldwide and impacts millions of patients and families each year. Fortunately, genetic testing for cancer, which is growing in popularity, can be a great tool for understanding your risk of developing cancer.
Does insurance pay for genetic testing of cancer? Yes, but coverage determination depends on certain circumstances.
The American Cancer Society estimates that 1 in 3 people in the United States will develop cancer at some point in their life. Data and research show that cancer risk is highest for those between the ages of 65 to 74 years and accounts for the largest portion of new cancer cases found each year.
While you may have a smaller chance of developing cancer if you are under the age of 65, it is still a good idea to get tested as early as possible so that you can make smart decisions about health insurance and your future.
Is Cancer Hereditary?
About 10% of cancers occur in someone who has inherited gene mutations. Hereditary cancer syndromes are caused by mutations in certain genes passed from parents to children.
Researchers have found mutations in more than 50 hereditary cancer syndromes.
These mutations are found in the genetic code of DNA and are represented by the letters A, T, C, and G. These codes can be long – for example, the BRCA 1 code is over 10,000 letters long.
However, not every mistake in the “code” should raise concern for cancer.
Reasons to Consider Genetic Testing for Cancer
If you have an inherited gene mutation, that doesn’t necessarily mean you’ll get cancer. It only means that you’re at a higher risk of developing certain types of cancer.
If your personal history or family history of cancer suggests you are at risk, find out how genetic counseling and genetic testing can help you understand and manage your concerns.
The following populations should also ask for specific types of genetic testing:
Those whose family members have had gynecologic cancer should get tested for fallopian tube cancer. This very rare cancer only affects about 1,500 to 2,000 women worldwide and only about 300 to 400 women are diagnosed with it every year in the United States.
Certain factors may make it more likely that you and your family members can pass cancer on to your loved ones including:
Many cases of the same kind of cancer (especially if the type of cancer is rare) — like ovarian cancer caused by BRCA1 and BRCA2 gene mutations
Cancers that occur much sooner than usual – like breast cancer in a teenager
One person who has multiple types of cancer (like a man who has both colon and prostate cancer)
Cancers that occur in pairs of organs (both kidneys or both breasts, for example)
Siblings who have childhood cancers
Cancer that occurs in the opposite sex of the one usually affected (breast cancer in a man, for example)
Cancer that occurs in several generations (like in a grandmother, mother, and daughter)
Hereditary Genetic Testing for Cancer
The estimated number of new cancer cases in 2018 was 1,735,350. If you are curious about your risk of developing cancer, consider hereditary cancer testing.
Hereditary testing kits can help you understand any mutations you may have and allow you to better prepare for any issues that may arise in the future. Plus, knowing about an inherited mutation gives you the power to take the necessary steps to reduce your risk of cancer or to help detect it at an early stage.
Kits often include a saliva collection kit and a prepaid return label. The testing kits analyze over 30 genes that can contribute to the most common hereditary cancers.
A certified medical professional will review your sample and provide clear results of the absence or presence of any cancer-causing mutations. This information is personalized to you and provides information on how your genetic makeup can impact your family.
Medicare Cancer Test Kits
Fortunately, you can complete a cancer genetic test in the comfort of your own home. This can help alleviate any stress that may come from testing in a doctor’s office.
Most at-home test companies provide return labels so the entire process is convenient and stress-free. However, if you prefer to go into a doctor’s office for your genetic testing, that is also an option.
If you decide to use a Medicare cancer test kit to screen for covered screenings, be sure to follow the test’s directions to the letter. This helps ensure that your test results will be accurate.
Breast Cancer Genetic Testing & the BRCA Testing Cost
It is easy to learn your genetic risk of the most common hereditary cancers, including BRCA 1 and BRCA 2 genes. BRCA stands for BReast CAncer genes. BRCA 1 is on chromosome 17 and BRCA 2 is on chromosome 13.
All it takes is a small DNA sample through saliva.
Plus, the test can be conveniently mailed to you and completed in the comfort of your home. The cost of a hereditary cancer testing kit can range from $100 to $200.
There are multiple genetic testing companies, including Color and 23andMe, but not all are approved by the FDA.
Aging and Cancer
The risk of cancer increases with age, but it’s never too early to start screening. According to the Dana-Farber Cancer Institute, the average age for a breast cancer diagnosis is 61 years.
The average age for a prostate cancer diagnosis is 66 years.
There is no single explanation as to why age and cancer correlate, but researchers believe sunlight, radiation, environmental chemicals, and ingredients in our food are large factors.
Physical exercise, a healthy diet, and adequate sleep can help lower the risk of cancer as you age.
Medicare Coverage and Genetic Testing for Cancer
Medicare beneficiaries who need genetic counseling can get it covered under Medicare Part A and Part B only if it has been ordered by a physician before starting medication covered under Part D or if it is medically necessary in a skilled nursing facility.
Medicare covers certain genetic cancer tests if they’re medically necessary. In 2020, Medicare will cover genetic testing if:
You have recurring, relapsed, refractory, metastatic, or advanced stage III or IV cancer
You have not used the same genetic test for the same cancer diagnosis previously
You have decided to seek further cancer treatment such as chemotherapy and radiation
You have signs or symptoms of a cancer like colorectal cancer that can be clarified or verified with diagnostic testing
You have a first-degree relative who has a known mutation such as Lynch syndrome
Does Medicare Cover BRCA Testing?
How much does the BRCA test cost? The price ranges from $475 to $4,000. Fortunately, Medicare covers FDA-approved genetic testing for BRCA 1 and 2 for those with a personal or family history.
So, it covers hereditary breast, tubal, epithelial ovarian, or primary peritoneal cancer tests as well.
Does Medicare Cover Genetic Testing for Melanoma?
Medicare currently covers the Myriad Genetics myPath and Castle Biosciences DecisionDx genetic tests for melanoma.
Medicare also covers screenings for lung, breast, prostate, and cervical cancer. Screenings are used to detect potential disease and a diagnostic test establishes the presence or absence of the disease.
Does Medicare Cover Genetic Testing for Prostate Cancer?
Medicare covers prostate cancer screening for men over 50 every 12 months. If cancer is detected, Medicare Part B coverage includes a variety of options, including genetic testing to help physicians distinguish between an aggressive and a non-aggressive tumor.
This essential information helps physicians design an optimal treatment plan for their patients.
What Happens During a Genetic Test for Cancer?
A genetic test for cancer may provide some insight into your medical history and the possibility of passing mutated genes on to your loved ones.
Your doctor will first ask you questions about your personal and family medical history such as, “Have you or an immediate family member been diagnosed with cancer?” Based on your answers, your doctor may refer you to a genetic counselor. (A genetic counselor is someone who has advanced training in medical genetics and counseling.)
2. Informed Consent
Before your test, you must give informed consent, which means that you’re aware of and that you agree to the following items:
The genetic test’s purpose
The type and nature of the genetic condition being tested
Possible screening or treatment options depending on the test results
Further decisions you might need to make once the results are back
The possible consent to use the results for research purposes
Availability of counseling and support services
Your right to refuse testing
3. Collecting the Sample
Depending on the test, you may need to provide a saliva, blood, hair, cheek cells (usually a swab from inside your mouth), urine, or stool sample. Once your healthcare professional collects your sample, he or she will send it to the lab for testing.
4. Getting the Results
Once the results are in, your genetic counselor or healthcare provider will tell you about your test results and the next steps you should take.
Questions to Ask Yourself About Medicare DNA Cancer Screening
Does Medicare pay for DNA cancer screening? Yes, because the Centers for Medicare & Medicaid Services (CMS) covers a broad range of FDA approved diagnostic tests, CMS cancer screening is available to detect many types of DNA cancers.
However, as with any type of medical screening, you should know what you’re getting into before you take the test. Before you take a Medicare cancer swab test, ask yourself:
Is this test legitimate? Unfortunately, genetic kits including Medicare cancer swab tests are the latest trend in Medicare fraud, according to many state and federal agencies. Your doctor can tell you what type of test to buy.
Is this test FDA-approved? Medicare will only cover FDA-approved tests.
How will this information benefit future generations? You may not want to know if you have genetic mutations that could lead to cancer. However, that information could help your children and grandchildren. If you have gene mutations associated with cancer, you can have Medicare cancer screening. Many forms of cancer can be treated if they’re detected early.
We Can Help You Find the Best Medicare Plans for Cancer Patients
A Medicare Advantage (MA) plan is a great option if you are looking for additional benefits like genetic testing beyond BRCA 1 and 2 and myPath.
Some may even offer fitness classes like SilverSneakers®, which can help promote a healthy, physically active lifestyle and help lower your risk of cancer.
If you’re diagnosed with cancer, you may be eligible for a type of MA plan called a Chronic Special Needs Plan (C-SNP). These plans are specially designed for people with certain chronic illnesses and conditions. Your C-SNP will involve a network of healthcare providers that will coordinate your treatment plan with each other.
If you are interested in arranging a no-cost, no-obligation appointment with a licensed agent to discuss your options for MA plans including C-SNPs, call us at 833-438-3676 or fill out this form.
This post was originally published on November 29, 2018, by Kelsey Davis and updated on March 24, 2020, by Troy Frink.