Fibromyalgia, a medical illness that causes musculoskeletal pain throughout the body, affects approximately 4 million people in the United States. While it is not an age-related disease, the symptoms are more severe in seniors. It can cause severe pain and make daily tasks difficult. There is still a lot of mystery surrounding this condition, but there’s been a lot of headway in the diagnosis and treatment process. So, if you have fibromyalgia, you may be asking what treatments are available to you and whether Medicare will pay for them.
What is Fibromyalgia?
Fibromyalgia is a chronic (long-term) condition. It causes symptoms such as soreness, fatigue, muscle tenderness, and even difficulty sleeping. The condition is very complex and shows in a variety of ways, so much so that even healthcare specialists struggle to completely understand the disorder. This is because its symptoms all mimic symptoms of other illnesses and there is currently no definitive test to confirm a diagnosis. So, Fibromyalgia is often misdiagnosed for years before being found.
In the past, some doctors even questioned if fibromyalgia was real. This resulted in widespread “lazy” and “dramatic” stereotypes of those suffering from fibromyalgia. However, as the disease has been examined more thoroughly, some of the stigmas that once surrounded it have faded. Doctors have been able to find medication, therapy, and lifestyle changes that can all help you manage your symptoms and live a better life.
Fibromyalgia Symptoms
Fibromyalgia has a long list of symptoms including:
Fatigue
Trouble sleeping
Nonrestorative sleeping (sleep without feeling rested)
Headaches
Difficulty focusing (called Fibro Fog)
Dry eyes
Rash
Itching
Pain in the lower abdomen
Bladder problems
Depression
Anxiety
The most noticeable sign of fibromyalgia is pain. Most fibromyalgia patients have small tender spots around but not in the joints. When pressure is applied to these spots they can cause anything from a dull ache to severe pain. These areas, known as the 18 fibromyalgia trigger points, are symmetrical, appearing on both sides of your body with 9 spots on each side.
Since there is no specific test for fibromyalgia doctors used to diagnose fibromyalgia based on the above symptoms combined with pain in at least 11 of the 18 trigger points. However, the American College of Rheumatology (ACR) modified clinical practice recommendations and removed the minimum trigger point limit from the diagnosis criteria.
18 Trigger Points
Behind the Neck
Fibromyalgia patients frequently have two trigger points in the back of their neck where their skull meets the neck. Fibromyalgia may also cause a stiff neck, cramping, and limited range of motion. However, keep in mind that neck pain and stiffness is not limited to fibromyalgia. As we noted most symptoms will mimic other conditions. Neck pain can be caused by arthritis, trauma, over-exertion, bad posture, or even sleeping on it at an odd angle.
Front of Neck
The trigger points on the front of the neck are above the collarbone on either side of your larynx. Pain in the front of the neck can also be caused by arthritis, injury or swollen glands. So before diagnosing fibromyalgia, your doctor will most likely order blood tests to rule out any rheumatological causes first.
Shoulders
Shoulder trigger points are around midway between the edge of your shoulder and the bottom of the neck, where the supraspinatus muscles attach to the shoulder blades. People with fibromyalgia may suffer scorching or throbbing pain in this area, as well as shoulder stiffness, in addition to pain when pressure is applied. Tendonitis, rotator cuff tears, and adhesive capsulitis (commonly known as frozen shoulder) can all produce pain in the supraspinatus muscles, which form part of the rotator cuff.
Chest
Fibromyalgia pain spots on the chest are found near the second rib on either side of the sternum (also known as the breast bone). That sore point is felt at the costochondral junction, the cartilage that links the rib to the sternum, a few inches below the collarbone. Some fibromyalgia patients may feel significant pain that begins at the tender point and radiates over the chest, a condition known as costochondritis.
Upper Back
Fibromyalgia pain points in the upper back are positioned immediately below the shoulder blades, where the trapezius muscles meet the scapula. In addition to the tenderness, you may experience discomfort across the trapezius. In fact, a 2013 study found that people with fibromyalgia have much higher trapezius muscle tension when exposed to mental stress than others. A spinal disk condition, arthritis, or an injury can also all cause pain in that area.
Elbows
Tender spots on the forearms associated with fibromyalgia are right below the elbow crease toward the outside of the arm. These trigger spots might appear on either one or both elbows. Fibromyalgia is often linked to lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer’s elbow), both of which are forms of tendinitis. Both can result in discomfort and tingling down the forearm to the hands and fingers. Elbow discomfort can also be caused by injuries or illnesses unrelated to fibromyalgia, such as arthritis, gout, and lupus.
Lower Back
Lower back fibromyalgia pain sites are located towards the top of the buttocks, where the gluteus maximus and gluteus medius muscles connect. Fibromyalgia can also produce muscle pain, spasms, and stiffness across your entire back and buttocks. This type of pain is also common in people who do not have fibromyalgia. In the United States, one out of every four adults suffers from low back discomfort. It can be caused by problems with the vertebral disks, spinal misalignment, repeated stress injury, or an inflammatory condition.
Hips
The hip trigger points are located directly below the hip bone, roughly where the buttock muscles bend and connect the thigh muscles. In addition to the trigger points, people with fibromyalgia may have muscle soreness and limited range of motion in the hip area. Hip discomfort can be caused by osteoarthritis, muscular strains, and other injuries. When attempting to narrow down a diagnosis, X-rays and other imaging studies can sometimes rule out alternative illnesses. Imaging scans can assist distinguish between pain caused by joint degeneration, osteoarthritis, and myalgia (muscle pain).
Knees
Tender spots in the knee are found on the inside of the leg. The specific pain site lies directly above the side of the knee near the bottom of the vastus medialis muscle. Fibromyalgia-related knee pain may be accompanied by joint stiffness and cracking. Joint swelling, on the other hand, is not typical of fibromyalgia. If your knee is also swollen, it could be caused by another ailment such as knee osteoarthritis, a meniscus injury, bursitis, or an inflammatory disease.
Fibromyalgia Treatment
Unfortunately, there is currently no cure for fibromyalgia. Instead, medications, self-care practices, and lifestyle changes are used to reduce symptoms and improve quality of life.
Medications
Medications can help you sleep better and decrease pain. Pain relievers, anti-seizure medicines, and antidepressants are common fibromyalgia medications.
Pain Relievers
Fibromyalgia pain can be unpleasant and persistent enough to disrupt your everyday routine. If your discomfort is minor, you can take over-the-counter pain medicines such Tylenol, Aspirin, Motrin, or Aleve. These drugs can help you manage your disease by reducing your pain and discomfort. They may even help with your sleep.
Many of them also reduce inflammation. Inflammation is not a prominent symptom of fibromyalgia, although it may occur if you have a linked disorder such as rheumatoid arthritis (RA). Opioids have also been prescribed to treat fibromyalgia pain. However, research has revealed that they are ineffective over time. Furthermore, the dosage of narcotics is often increased rapidly, posing a health danger to those administered these prescriptions.
Anti Seizure Medication
Pregabalin (Lyrica), an anti seizure medication, was the first medication approved by the Food and Drug Administration (FDA) for fibromyalgia. It prevents nerve cells from delivering pain signals. Gabapentin (Neurontin) was developed to treat epilepsy, but it may also aid with fibromyalgia symptoms. Gabapentin is an off-label medicine that has not been approved by the FDA to treat fibromyalgia. Off-label drug use is when a medicine licensed by the FDA for one purpose is also used for a second, unapproved purpose.
A doctor can continue to prescribe the medicine for that unapproved purpose. This is due to the fact that the FDA regulates drug testing and ensures that the drug is safe to take but they don’t regulate what the drug can be used for. As a result, your doctor can prescribe a medicine in whatever way they believe is best for your treatment.
Antidepressants
Antidepressants such as duloxetine (Cymbalta) and milnacipran (Savella) are sometimes used to alleviate fibromyalgia pain and fatigue. These drugs may also assist to restore neurotransmitter balance and promote sleep. Both duloxetine and milnacipran have been approved by the FDA for the treatment of fibromyalgia.
Fibromyalgia Diet Changes
Some fibromyalgia patients claim to feel better when they follow a specific diet plan or avoid particular foods. There is no evidence that any specific diet changes will improve or cure fibromyalgia entirely but there are changes that are known to help some of the symptoms associated with fibromyalgia.
If you have fibromyalgia, aim to eat a well-balanced diet in general. Nutritious foods give you a steady amount of energy and help you keep your body healthy. They may also help to keep symptoms from worsening. Doing simple things like eating more fruit and lean proteins, and lowering sugar intake can all help balance your diet. Certain foods or substances, such as gluten or monosodium glutamate (MSG), may aggravate your symptoms. Keep a food diary to note what you eat and how you feel after each meal if this is the case. Share this journal with your doctor so they can assist you in determining which meals worsen your symptoms.
Natural Remedies
If drugs and dietary modifications do not completely improve your symptoms, you can explore other options. Many natural cures focus on stress reduction and pain relief, and they can help you feel better both psychologically and physically. They can be used alone or in conjunction with established medical treatments. Natural fibromyalgia treatments include:
Physical therapy
Acupuncture
Massage therapy
Meditation
Yoga
Tai Chi
General exercise
Therapy
Cognitive Behavioral Therapy
It’s worth noting that most alternative remedies for fibromyalgia haven’t been properly researched or confirmed to be effective. Before attempting some of these methods, consult with a healthcare practitioner about the advantages and dangers.
Medicare Coverage For Fibromyalgia
Medicare may cover some of the costs of your fibromyalgia treatment. Part B (Medical Insurance) can help pay the price of medical visits and diagnostic tests. If you are hospitalized for your disease, Medicare Part A may cover the costs of your hospital stay as well as any medicine you receive while in the hospital.
Part D, or prescription drug coverage, might help you save money on prescriptions you need. If you’ve been diagnosed with fibromyalgia in the last year and your current coverage isn’t meeting your needs, think about your alternatives during the Annual Election Period, which runs from October 15 to December 7. Pricing tiers will be established for each plan, based on generic, brand-name, and mail-order medications.
How EZ Can Help
If you need additional coverage, you can purchase an affordable Medicare Supplement Plan. Medicare Part B covers a lot, however it only covers 80% of your expenses, leaving you to pay the other 20% out of pocket. This can be rather costly, especially if you are on a fixed income, as many Medicare recipients are. However, by obtaining a Medicare Supplement Plan, you can save money on medical expenses while also receiving additional coverage.
There are ten Medicare Supplement Plans to choose from, each with its own set of coverage options and pricing. To save as much money as possible, it’s recommended looking into a Medicare Supplement Plan, so talk to an EZ agent about all of your alternatives. EZ’s agents work with the best insurance carriers in the country and can compare plans for you in minutes at no cost. Simply enter your zip code in the box below to get free instant quotes, or call 877-670-3602 to speak with an agent directly.
Even if you have Medicare Parts A and B coverage, you may still need extra coverage for your prescription drugs. So, like a lot of people with Medicare, you might be looking at Medicare Part D, especially Medicare Silverscript, which is the cheapest way to cover prescription drugs on the market. It’s not surprising that many Medicare recipients are choosing a Silverscript plan as a way to save money. Could one fit your needs?
Part D of Medicare is the plan for prescription drugs. Some of a Medicare recipient’s medicine costs are covered by these drug plans. Medication costs can add up quickly, and if you don’t have insurance, you may have to pay a lot out of pocket. Medicare Part D plans help pay for the prices of prescription drugs so that people who need them can get them.
Medicare is made up of different parts, or sections, that cover different types of health care. Part A and Part B are the parts of Original Medicare. Prescription drugs are not covered by either of these plans. On the other hand, there are Medicare Advantage Plans, also called Medicare Part C, that are given by private insurance companies. Some of these plans may cover Part D, but not all of them do. If someone with Original Medicare or a Medicare Advantage Plan without a Part D plan wants coverage for prescription drugs, they would need to sign up for a different Medicare Part D plan, like SilverScript.
SilverScript
SilverScript is a private insurance company that merged with Aetna in January of 2020 and offers Medicare Part D plans. It covers prescription drugs for people with Original Medicare. Coverage choices are available in all 50 states and Washington, D.C. People who are qualified for Medicare Part D can choose from three different plans from SilverScript. Each plan has a different fee and covers prescription drugs in a different way. To figure out which plan is best for you, you should make a list of the prescription drugs you take and compare it to the formularies of each plan.
Depending on the plan you choose and the medicines you need, SilverScript’s Medicare Part D plans offer a range of fees and copays that can fit almost any budget. Also, these plans cover you at thousands of pharmacies across the country. Even though the SilverScript formulary changes every year, this provider’s prescription drug plans offer full coverage and reasonable prices.
A formulary is a list of all the prescription drugs that a certain insurance will pay for. When looking for coverage for your prescription drugs, you should know what drugs you take and how the Medicare Part D plans in your area cover them. So, you can sign up for a plan that will cover your medicines. There are times when a Medicare Part D plan might not cover the medicine you need. There could be a formulaic option, though. Your doctor may think about a change if they think it would be a good idea. If not, you could ask for a list exception, which means that the plan may cover your drug if it is approved.
SilverScript may change its formularies from time to time, so it’s important to check your prescription drug benefits every year during the Annual Enrollment Period. This will make sure that you get the right coverage every year. There are five tiers of drugs, and each tier may have its own fees or copayments for coverage. Here’s how the tiers are broken up:
Tier 2 – Generic drugs that usually cost more than tier 1 drugs
Tier 3 – Preferred brand-name drugs with no generic version
Tier 4 – Less commonly prescribed non-preferred drugs
Tier 5 – Expensive specialty drugs that may require monitoring
In the formulary you will also see information about any restrictions or terms for coverage that apply to each drug. These rules are listed at the beginning of the formulary. They can include things like needing Aetna’s authorization first or limits on how many drugs can be covered at once. There’s a chance that a SilverScript formulary might be a little different based on where the plan is sold.
SilverScript Plans
There are three different SilverScript coverage choices for Medicare beneficiaries:
SilverScript SmartSaver
This choice is for people who are active, prefer generic drugs, and are generally healthy. It has the lowest national average of monthly premiums at $5.92. It includes $0 deductibles for Tier 1 drugs, and $505 deductible for Tiers 2-5. The copays for preferred pharmacies by tier are:
Tier 1 – $2 copay for 30-day prescriptions and $6 for 90-day prescriptions
Tier 2 – $15 for 30-days’ worth and $45 for 90-days
Tier 3 – 25% coinsurance
Tier 4 – 50% coinsurance
Tier 5 – 25% coinsurance for 30-day prescriptions
SilverScript Choice
This plan covers more than the SmartSaver plan, but it has a $505 deductible and a $33.60 monthly premium. If you qualify for the Extra Help program, you can get a $0 monthly premium instead. The copays for preferred pharmacies are:
Tier 1 – $2 copay for 30-day prescriptions and $6 for 90-day prescriptions
Tier 2 – $7 for 30-days’ worth and $21 for 90-days
Tier 3 – 17% coinsurance for a 30-day supply; 22% for 90
Tier 4 – 30%-40% coinsurance
Tier 5 – 25% coinsurance for 30-day prescriptions
SilverScript Plus
This plan has even better coverage than the first 2, with a $75.58 monthly fee, a $0 deductible on all tiers, and a coverage gap for Tier 1 and 2 drugs. I also has$0 copays on Tier 1 and 2 drugs for the other tiers the copays are:
Tier 3 – $47 copay for a 30 day supply; $141 for 90
Tier 4 – 50%-40% coinsurance for both supply amounts
Tier 5 – 33% coinsurance for 30-day prescriptions
What Pharmacies Accept SilverScript?
SilverScript lets you get your prescription drugs from thousands of pharmacies across the country. There are more than 65,000 pharmacies in the United States that are part of the SilverScript drugstore network. Your SilverScript Medicare Part D plan will be accepted at most chain pharmacies. But not all shops are in the “preferred category”. With a preferred pharmacy, you can get the drugs for the least amount of money. These pharmacies include:
Walmart
CVS
Wegmans
Kroger
Publix
Even though they cost a little more than preferred pharmacies, standard network pharmacies still offer service. These pharmacies include:
Walgreens (for most SilverScript plans)
Sam’s Club
There are also many local pharmacies that fall into either of those categories so be sure to check your plan for your area’s local pharmacies.
How To Choose
There are a few things to think about when choosing the right Part D plan, whether it’s SilverScript or any other plan, for you. The major things you should think about are cost, coverage, and how flexible the plan is. Cost is always a factor when choosing a Part D plan. Different plans come with different costs. Coverage gaps, fees, deductibles, copayments or coinsurance, and premiums all affect your overall cost. If you are in good health and prefer to take generic drugs, you may want to choose a plan with a lower premium and benefits for tier 1 or tier 2 drugs. You can choose a plan with a higher cost and more benefits to help with your health care needs if you need specific drugs, have serious health problems, or need more specific coverage.
You also need to know how much coverage you need. If you don’t need a lot of coverage, you may want to save money by getting a plan with less coverage. But if you need more coverage because of your health or for your own peace of mind, you may want to look into plans with more coverage that cost more. Choosing the best Part D plan will also depend on how flexible you are about the drugs and pharmacies you want to use. If you don’t mind taking generic or recommended generic drugs, you may have more plan choices. Also, if you are willing to get your drugs from different pharmacies you will have more plans to choose from. However, if you have specific drug plans or pharmacies in mind, you may need to look at better coverage plans to see what works best for you.
Call EZ
If you want to compare SilverScript drug plans, you should think about the prescription drugs you take and how much of them you take. You should also think about how much you are willing to pay for premiums and a yearly deductible. As we’ve already said, if the cost of your medicines is getting too high for you, a SilverScript plan could help you by putting all of your monthly costs into one payment.
You should also look into a Medicare Supplement Plan if you want to save even more money. There are 10 Medicare Supplement Plans to choose from, and each one has different rates and coverage choices. Talk to an EZ agent about all of your choices. The agents at EZ work with the best insurance companies in the country, and they can review plans for you for free in just a few minutes. Enter your zip code in the box below to get free instant quotes for plans that cover your present doctors, or call 877-670-3602 to talk to a licensed agent.
The Medicare Annual Enrollment Period (AEP) is a set period of time where you can change your Medicare benefits. Every year, the AEP lasts from October 15 to December 7. If you didn’t sign up for a Medicare Advantage plan or a Medicare prescription drug plan when you first became eligible for Medicare (during your Initial Enrollment Period), the AEP is usually your chance to do so, unless you apply for a Special Election Period (SEP). It also allows you to make any changes you need to tailor your Medicare coverage to your specific needs.
If you are eligible or already enrolled in any Medicare product you can use the AEP to move to a different Medicare plan, sign up for an entirely new plan, or drop out of a plan. This includes the ability to move from Original Medicare to Medicare Advantage, switch between different Medicare Advantage plans, and sign up for or change Medicare prescription drug coverage.
Your AEP Options
During the Medicare AEP, you can move from Original Medicare (Parts A and B) to Medicare Advantage (Part C), or vice versa, if you already have Medicare. However, if you want to switch, you may also have to make some other choices. Depending on what kind of plan you’re switching to and from, you’ll have to make different decisions.
In this case, you have Original Medicare and want to move to a Medicare Advantage plan. You may also have a separate Part D plan for prescription drugs. Most Medicare Advantage plans include everything that you need. They pay for your Medicare Part A and Part B benefits, as well as Part D prescription drugs and other health services and things that Original Medicare doesn’t cover. Some of these other things are dental, vision, and hearing care, as well as gym memberships. There is also an annual out-of-pocket limit on Medicare Advantage plans to keep you from paying too much.
During the AEP you can move from Original Medicare to a Medicare Advantage plan. Depending on the Medicare Advantage plan you choose, you may no longer need a separate Part D plan if you already have one. With Medicare Advantage, you usually don’t need a separate Part D prescription drug plan because drug coverage is built in.
If you switch to a Medicare Advantage plan, the plan will work with Medicare to move your benefits over. You don’t have to get in touch with Medicare on your own. On January 1, your new plan will start to cover you. If you have a stand-alone Part D prescription drug plan or another private Medicare plan, you’ll need to call the plan provider directly to drop out. Just call the number on the back of your member ID card. During the Medicare Advantage Open Enrollment Period, which runs from January 1 to March 31, you can choose a different Medicare Advantage plan or switch back to Original Medicare.
Medicare Advantage To Original Medicare
Original Medicare only has Part A (coverage for hospital stays) and Part B (coverage for medical care). It doesn’t give you some of the things your Medicare Advantage plan might have, like coverage for prescription drugs, dental, vision, or fitness. Original Medicare also doesn’t have an annual out-of-pocket cap, so there is no built-in financial protection.
If you still want these things, you will need to buy extra coverage. For example, if you want coverage for prescription drugs, you will now have to find a stand-alone Part D plan and sign up for it. If you decide you need more coverage, you will need to choose a Medicare Supplement Plan and sign up directly with the plan provider. To make the switch to Original Medicare, you will need to call your Medicare Advantage plan provider or Medicare directly.
Medicare advantage plans are pretty comprehensive, but there are still times you may want to switch to a different plan. Such as:
Moving to a plan that offers drug coverage
Moving to a plan without drug coverage
Switching to a plan that has dental or vision coverage
Aside from the AEP there are other times you can change your Medicare Advantage plan. During the Medicare Advantage open enrollment period, which runs from January 1 to March 31 every year, you can make changes to your plan at any time. The changes you make will go into action on the first of the month after you make them. You can also change your Medicare Advantage plan during a Special Enrollment Period if you have a big change in your life. Medicare may give you a special enrollment period if you move to a new place, if your coverage choices change, or if certain other things happen in your life.
You can apply for a Medicare Supplement Plan at any time of the year, not just during the AEP. However, unlike Part D and Medicare Advantage plans, Medicare Supplement Plans don’t have to offer a yearly enrollment period like Part D and Medicare Advantage plans do. If you apply for a Medicare Supplement Plan after your six-month initial enrollment time has ended, the insurer is likely to use a process called “medical underwriting” to decide if you are eligible and how much you will have to pay. Some states have passed laws that make it easier for seniors to switch from one Medicare Supplement Plan to another by applying birthday rules or guaranteed issue rights. Both allow a specific amount of time where you can change your Medicare Supplement Plan without going through underwriting.
Guaranteed Issue Rights
New York and Connecticut – Medicare Supplement Plans are guaranteed issue all year.
Massachusetts – There is a 2 month period every year between February and March where plans are guaranteed issue
Maine – Participants can move to a different Medicare Supplement plan with the same or less benefits at any time during the year, and all carriers must set aside one month each year when Medicare Supplement Plan A is guaranteed to be available to all participants.
Missouri – There is an Anniversary Guaranteed Issue Period. Anyone with a Medicare Supplement plan has 60 days around the anniversary of their plan each year to switch to the same plan from a different insurance company.
Birthday Rules
California – The rule goes into effect 30 days before their birthday and stays in place for 60 days after. During this time, customers in The Golden State can switch to any plan with the insurance company of their choice that has the same or less benefits.
Oregon – The birthday rule starts on your birthday and lasts for 30 days after that. This gives you 31 days to change plans. It works like California’s and lets customers switch to any insurance company or plan with the same or less benefits.
Idaho – This rule goes into effect on your birthday and lasts for 63 days. You will be able to sign up for any plan with the same or less benefits. Also, the plan could be with any provider.
Illinois – This birthday rule only applies to people who are 65 to 75 years old. During this time, you can switch plans with your current insurance company. But the benefits of your new plan can’t be better than those of your old plan. This open registration period starts on your birthday and goes on for 45 days.
Louisiana – The time for the birthday rule starts 30 days before your birthday and ends 63 days after it. So, you have 93 days to change the plan you have now. During this time, you can switch to a policy with the same or less benefits through your present provider.
Maryland – The birthday rule for Medicare Supplement starts on your birthday and ends 30 days after that. Giving residents 31 days to sign up for a plan with the same or less worth.
Nevada – For at least 61 days, you can make changes to your plan. This window opens on the first of your birthday month. You can switch carriers or plans during this time, but the benefits of the new plan must be the same or less than what you get from your present plan.
Oklahoma – The 60-day window for the birthday rule starts on your birthday. During the 60 days, you can change your plan or provider. However, you can only switch to a plan with the same or less value than the one you have now.
Need Help?
Medicare is great, but sometimes it can be hard to understand. Even after you sign up during the AEP, you’ll still have to make some decisions about your health care. Don’t worry about asking questions. Talk to an EZ person who can tell you what you need to do to sign up and explain everything to you. EZ can help you sign up, buy a Medicare Supplement Plan, or just think about your choices. Our insurance brokers work with the best firms in the country. You can get a free review of all the plans in your area from them. We’ll talk with you about your medical and financial needs and help you find a plan that meets them all. Call one of our certified agents at 877-670-3602 to get started.
Does Medicare cover assisted living? The simple answer is no. Medicare does not fund assisted living, which provides housing and custodial services including laundry, cooking, medication management, and other daily living activities for older people or those with disabilities eligible for Medicare. However, it will cover some services such as skilled nursing facilities and some home health care services.
As you get older, you may need help doing things like taking a shower or getting ready. A study showed that 1 in 5 people over the age of 85 in the U.S. need or get extra help with everyday chores. If you find it hard to live on your own, you might want to look into an assisted living center. Different from nursing homes, these facilities give older people the personalized care they need and let them keep their own living area. If you have Medicare, it’s important to know what your plan covers and how much money you may have to pay out of pocket.
What Is Assisted Living?
Assisted living is a place to live for older people or people with disabilities, such as amyotrophic lateral sclerosis (ALS) or end stage renal disease(ESRD), who need help with some daily tasks and access to medical care when they need it. People in this situation or their families may choose assisted living homes so that they can get help from professionals. People who live in assisted living may need ongoing medical care and skilled nursing services.
Assisted living is a step below a nursing home or skilled nursing facility in terms of the amount of care it offers. State rules, which vary from state to state, govern them. Assisted living usually gives people more freedom and costs less than care in a nursing home, but it is more expensive than a place for independent living. Assisted living is more like a home than a hospital, while a nursing home is more like a hospital. People who can’t live on their own but want to keep as much freedom as possible can benefit from assisted living.
The Difference Between Assisted Living and Skilled Nursing
Assisted living communities are more like homes, whereas skilled nursing facilities and nursing homes are more clinical like hospitals. Skilled nursing facilities provide a higher level of medical care and, in some cases, may be covered by Medicare. Most assisted living communities focus on giving personal care rather than medical care like helping you bathe, eat, and get dressed.
As long-term care assisted living centers are not covered by Medicare because they are considered custodial care, but Medicare will pay for any health care costs that add up while the person is living in an assisted living home. These health care bills that can be covered include things like medicine and medical equipment. Most of the time, Medicare will only fully pay for skilled medical care or short stays in a skilled nursing facility. Hospital insurance is covered by Part A of Medicare. For example, if you need care while healing from surgery and it’s not the only thing you need, it will be covered.
In some cases, the same company might run both an assisted living community and skilled nursing facility in the same building or on the same property. How Medicare pays for your care depends on what kind of care you are receiving in one of the hybrid facilities and if you meet certain criteria.
Skilled Nursing Criteria
For Medicare to cover skilled nursing care:
You must have just come out of a hospital stay of at least 3 days and still have covered hospital days left in your benefit period.
Your doctor has to prescribe this level of care.
The reason you are in skilled nursing is because of the same condition you were in the hospital for or the condition stems from being in the hospital, such as you picked up an infection while in the hospital.
The skilled nursing care has to be considered medically necessary.
If you meet all of these criteria, Medicare will fully cover your first 20 days of residential care. From days 21 to 100, you would have to pay up to $200 a day in coinsurance. If you have Medicare Supplement, your share of the costs could be covered for up to 100 days instead of 20. Either way Medicare will not cover any part of this care after 100 days.
Will Medicare Advantage Cover Assisted Living?
Medicare Advantage has to cover at least as much as Original Medicare. However, Medicare Advantage is bought through private health insurance companies so any extra policy benefits will vary. Some Medicare Advantage plans do include benefits for home care services, but they don’t usually cover assisted living or other long-term custodial care. However, if you move to an assisted living community, Medicare Advantage will continue to pay for eligible medical costs like medications, surgeries, and appointments, just as it would if you were living at home.
Cost Of Assisted Living
In 2023, the average cost of living in an assisted living home is $4,774 per month or $57,288 for the year. The total cost of assisted living can be different based on the following:
How many hours of care you need, such as 24/7 or just a few hours a day.
What time of day you need care
Where the assisted living community is located
Which facility you choose
If you need additional services depending on your health
Generally, assisted living communities have varying levels of care. The more independent you are and the less care you need the cheaper it will be. Depending on the facility here are the costs associated with assisted living communities:
Rent
Medication management, or nursing care services
Special meal plans
Transportation
Events or activities
Move-in fees
Housekeeping
Laundry services
Unless you have long-term care insurance, you will have to pay for all of the costs of assisted living out-of-pocket. If you have long-term care insurance your policy may cover some assisted living costs if you meet certain requirements. Additionally, if you have access to Veterans Affairs benefits, check your plan to see if long term custodial care is covered and for how long.
Other Care Options
Medicare Part A pays for skilled nursing care, but only under certain circumstances and for a short time. With a few cases, it must be given less than seven days a week or less than eight hours a day for no more than 21 days. Some of the other types of care that Medicare might pay for are:
Home Care – Such as part-time or occasional help from a home health worker. Medicare does not, however, pay for care at home 24 hours a day, 7 days a week. It also doesn’t pay for maid or custodial services like cleaning, bathing, or putting on clothes if those are the only things you need.
Hospice or respite care – Both of which Medicare pays for. Hospice cares for and supports people who are nearing the end of their lives. Respite care is a short stay in a hospital for hospice patients that gives their nurses a break.
PACE – Also known as programs of all inclusive care for the elderly. It is a Medicare/Medicaid program that helps people get the health care they need in their own communities so they don’t have to go to a care center. It pays for prescription drugs, doctor visits, help getting to and from the doctor’s office, home care, and if needed, stays in a nursing home.
Working With EZ
As you get older, you need to be able to take care of yourself. An assisted living center may be a good choice if you need extra help with everyday tasks. The cost of assisted living varies on many things, like the type of care you get, how long you need care, and where you live. Original Medicare and Medigap (supplemental insurance) does not pay for personal care in an assisted living facility, but they may pay for other medically required services. A Medicare Advantage plan may cover more services, such as personal care, than a regular Medicare plan.
Since Medicare won’t usually cover the costs, you should think ahead and find other ways to pay for assisted living. Medicare is great, but sometimes it can be hard to understand. After you sign up, you’ll still have to make some decisions about your health care. Don’t worry about asking questions. Talk to an EZ person who can tell you what you need to do and explain everything to you. EZ can help you sign up, buy a Medicare Supplement Plan, or just think about your choices. Our insurance brokers work with the best firms in the country. You can get a free review of all the plans in your area from them. We’ll talk with you about your medical and financial needs and help you find a plan that meets them all. Call one of our certified agents at 877-670-3602 to get started.
Original Medicare does not have an annual limit on out-of-pocket costs, and 4.5 million Medicare recipients are expected to spend more than $5,000 each on out-of-pocket health care costs in 2023. This lack of financial protection, combined with the fact that Original Medicare doesn’t cover all medical costs, has led to a lot of people buying Medicare Supplement Plans. This is because Medicare Supplement Plans fill in those gaps in coverage and financial protection. But how do private health insurance companies determine your premium? Insurance companies who offer Medicare Supplement Plans use three different pricing methods: attained-age, issue-age, and community-rated. Knowing how these prices work, can help you compare Medicare Supplement Plans and find the one that works best for you.
The Pricing Methods
The method a company uses for pricing has a significant impact on the overall cost of a policy. These 3 ratings are each based on different factors. First, we have attained age rating, which is based on the age you are when you sign up for your plan and will increase as you age. Next is issue-age rating, this method also uses your age when you enroll to determine your premium, but it will not increase as you get older. Finally, there is community-rated, which isn’t based on your age but instead is based on where you live. Below we’ve detailed each of these plans and how they work.
Community Rating
The costs of community-rated Medicare Supplement plans depend on where you live. No matter someone’s age, everyone pays the same premium for the same Medicare Supplement plan within their region, which is decided by the insurance company it can be by city or county. So, if you and your neighbor buy the same Medicare Supplement plan, your monthly premium will be the same even if you are 70 and your neighbor is 80.
Only a few states offer Medicare Supplement plans that are rated by the community. Maine, Vermont, Massachusetts, Connecticut, New York, Arkansas, Minnesota, and Washington are some of these states. States that don’t offer community-rated plans may charge you a higher premium based on your age, depending on whether they offer attained-age or issue-age-rated plans at enrollment. Most of the time, community-rated plans have the least expensive premiums, but rates may be different depending on where you live, whether you live in a city or a rural area, among other things.
What States Have Community-Rated Medicare Supplement Plans?
In these eight states, the monthly premiums for Medicare Supplement policies must be based on the community rating:
Arkansas
Connecticut
Massachusetts
Maine
Minnesota
New York
Vermont
Washington
Issue Age Rating
The premiums for issue-age-rated plans are based on how old you are when you sign up for coverage, similarly to attained age but they do not incrementally increase with age. For example, if you sign up for a plan at 65 your initial premiums will be less than if you signed up at 75. Most of the time, issue age plans also raise rates every year, but the rate increases are not based on your age like attained-age premiums are. Instead, they raise based on inflation and other factors that affect health costs.
If you sign up for this type of plan when you first become eligible to buy a Medicare Supplement plan, it costs less in the long run than plans for people who are older. But you should be aware that issue-age-rated plans start with higher premiums than attained-age-rated plans.
The issue-age method is used to rate Medicare Supplement insurance policies in the following states:
In these states, however, carriers may opt to use community ratings instead through an appeals process.
Attained Age Rating
Most of the time, Medicare Supplement insurance companies use attained-age rating models. The age when you sign up for the plan is used to figure out how much your premiums will cost. The younger you are when you enroll the lower your premiums will be. But these premiums are not locked in for life, as you age they will increase. For example, if you’re 65 years old, the premium for a certain Medicare Supplement plan might be $130, but if you’re 75, the same plan might cost $170. Generally, rates go up by a small amount each year or at a designated time. These rate increases are generally decided by state health insurance agencies.
Some states, like Massachusetts, Minnesota, and Wisconsin, have different rules for coverage as well as different Medicare Supplement Plans available. While those states have different plans they do all offer the same benefits they just operate in slightly different ways and have different names. If you live in one of these states, you can look at our state-by-state Medicare Supplement guide to find out exactly how your plans will be priced.
States that Offer Attained-Age Medicare Supplement Plans
No state requires carriers to offer Attained-Age Medicare Supplement plans. However, any state that is not required to specifically use a certain method is allowed to offer attained-age plans. There are many states that offer this pricing method but they can also offer any of the other methods as well. These states are:
Choosing Between Attained Age, Issue Age, and Community Rating
When choosing between attained-age, issue-age, or community-rated plans, there are a few things to think about, such as:
Your medical needs as a whole
Costs and benefits of the plan
Your age
The plan provider’s reputation
Premium cost rate projections
Different states have different levels of protection for Medicare recipients who want a Medicare Supplement plan. One such right to be on the lookout for is ‘guaranteed issue’ protections. With these rights, a Medicare Supplement insurance company can’t turn you down if you meet certain requirements. Such as, you suddenly lost a group health plan that covered your Medicare cost-sharing, You disenrolled from Medicare Advantage within 12 months of enrolling, or if your previous insurer no longer offers your Medicare Supplement Plan or commits fraud. They also promise to cover pre-existing conditions and won’t raise your premiums too much because of your health.
The easiest time to join a Medicare Supplement plan is during your six-month Medicare Supplement Open Enrollment Period, which starts when you sign up for Medicare Part B. After this initial enrollment period, Medicare Supplement plan providers can turn you down for coverage if you already have a health problem.
For example, if you drop your Medicare Supplement attained-age-rated coverage because it’s too expensive, you might not be able to buy another Medicare Supplement plan unless your state has continuous guaranteed issue rights or you meet other requirements. The states that have continuous guaranteed issue rights are Connecticut, Maine, Massachusetts, and New York. Continuous guaranteed issue rights mean that all Medicare Supplement providers must sell policies at least once a month or all year long.
Before you sign up for a Medicare Supplement plan, it’s important to know the rating category so you can figure out how much your long-term premiums will cost.
What Else Affects Medicare Supplement Plan Costs?
Medicare Supplement premium prices can be affected by a number of other things. Rates can be affected by things such as the rate of inflation, the state you live in, the cost of health care, and your lifestyle. Lifestyle factors can include choices like smoking or drinking.
The plan benefits that you want to include will also affect the price of your plan. The cost of the plan will be higher if it has more benefits. Your premiums will be less if you choose a plan with a higher deductible. In order to choose the best plan, you should carefully look at your health care needs and how much each plan will cost in the long run.
How To Lower Medicare Supplement Plan Costs
There are other ways to lower your Medicare Supplement premiums besides researching your options and comparing different insurance companies, such as:
High deductible plans – This could be a good choice if you are in good health and think you could pay more for the few claims you make.
Getting a plan for your partner – Some companies give a Medicare Supplement Household Discount to couples who both buy Medicare Supplement policies from them.
Bundling – Companies may lower the cost of your Medicare Supplement premiums if you buy another type of insurance from them, like life insurance.
It’s important to understand your pricing plan, whether you’re signing up for Medicare Supplement for the first time or you already have a policy. As a customer, if you know how companies charge for their services, you can make better decisions about what to buy. Be sure to do your research, and you might be surprised by how much you can save.
Working With EZ
If you are in the market for a Medicare Supplement Plan, one of the most important things you can do is compare the various plans’ premiums and benefits. This can require a significant amount of research, which can take a notable amount of time because you will need to call a number of different insurance companies in order to get quotes.
However, if you collaborate with an EZ agent, you can reduce the amount of time it takes to compare prices by 50%. When you work with a licensed agent, you gain access to a centralized resource where you can compare the Medicare Supplement Plan offerings of multiple insurance companies.
In addition to providing you with price comparisons, your agent can also explain the distinctions between the various plans. Your insurance agent will be able to assist you in comparing the out-of-pocket costs to the monthly premiums so that you can select the strategy that will save you the most money in the long run. Give us a call at 877-670-3602 to get started with your search for a Medicare Supplement Plan.
If you are a Medicare recipient or are about to become one, you may have noticed that Original Medicare (Parts A and B) does not cover all of your medical costs. Therefore, you will likely need a Medicare Supplement Plan to help cover out-of-pocket expenses. The good news is, you have plenty to choose from, there are 10 different plans available all with different levels of coverage. However, Plan G and Plan N are currently the most popular. Choosing between these two plans can be hard because they do have a lot in common, in fact they have more similarities than differences. It is essential to understand what each plan covers. Being misinformed can leave you with extra unnecessary out-of-pocket costs. So, let’s compare these plans so you can get an idea of which one fits you better.
What Both Plans Cover
Medicare Part A deductible– In 2023, if you are hospitalized for inpatient care, you have to pay the Part A deductible of $1,600 per each 60-day benefit period. The Benefits period restarts after you have been out of the hospital for 60 consecutive days. This is not an annual deductible, you could end up paying this deductible more than once in a single year. Having these plans cover this deductible means it’s not coming out of your pocket.
Part A hospital care and coinsurance – Part A partially covers hospice care leaving you copays or coinsurance. Certain prescription drugs will also have a copayment. However, you will be responsible for all of these copayments without a Medicare Supplement Plan that covers them.
Part B coinsurance – Medicare Part B requires a coinsurance payment for each covered service. Meaning Part B will pay 80% of the Medicare-approved amount for each covered service. Leaving you to pay the remaining 20% as your coinsurance payment (after you meet your annual Part B deductible). Plans N and G will both cover 100% of the Part B coinsurance.
Blood – If you need a blood transfusion for any reason, Original Medicare will only start covering the pints of blood after you have already paid for the first 3. Plans G and N will cover those first 3 pints for you so you’ll never have to pay for blood.
Skilled Nursing Facility Care – Medicare Part A will require you to pay a daily coinsurance if you are admitted for more than 20 days. As of 2023, your coinsurance could reach up to $200 a day. Thankfully, Plans G and N cover this coinsurance entirely.
Foreign Travel Emergencies – Typically, Original Medicare does not cover any medical care that you receive outside of the U.S. Plans G and N will both cover 80% of the costs of qualifying emergency medical care if you need it outside of the country.
What Neither of Them Cover
The only benefit that both of these plans will not cover is the Part B deductible. This is because of the Medicare Access and CHIP Reauthorization Act, or MACRA. This law altered Medicare with a modification to regulations that say plans are not allowed to offer any first-dollar coverage. This is also why Plans C and F are no longer available to new Medicare beneficiaries because both plans offered the Part B deductible coverage.
The Coverage Differences
Now that we know what benefits these plans both have in common, let’s look at the differences between them.
Benefits
Doctor Visit Copays – While Plan G will cover 100% of doctor visit copays, Plan N will not. With Plan N you will still have a $20 copay for each doctor’s visit. Therefore, if you visit your doctor fairly often this could really add up over the course of the year.
Emergency Room Copay – First, keep in mind that visiting the emergency room and being admitted are two different things. Just coming to the emergency room and then being released will cost you a $50 copay with Plan N. However, with Plan G there are no additional costs or copays for an emergency room visit.
Medicare Part B excess charges – Doctors and other healthcare providers can sign an agreement to accept “Medicare Assignment”. Which is essentially a fee schedule between Medicare and the provider saying that Medicare believes services should cost a specific amount and the doctor agrees to accept those prices. If the healthcare provider does not sign this agreement then they are allowed to charge up to 15% more than the Medicare-approved amount. That 15% is what is known as the Part B excess charge. Excess charges are one of the most significant coverage differences between Plan N and G as it could leave you with significantly higher medical expenses if it’s not covered. Plan G covers 100% of these excess charges whereas Plan N doesn’t cover them at all.
Costs
Cost is another difference, obviously even though the coverage differences are slight any plan with more benefits will be more expensive even if it’s only by a small margin. The price of Medicare Supplement Plans vary based on your location, age, and smoking status. In areas with higher costs of living, monthly premiums are generally more expensive. In general, Medicare Supplement Plans are priced in three ways: community-rated, issue-age-rated, and attained-age-rated.
Community-rated
Everyone, regardless of age, who has the same Medicare Supplement Plan pays the same monthly premium under this pricing structure. Your premiums may increase due to inflation and other factors but never due to your age.
Issued-age-rated
With this structure, your Medicare Supplement Plan premium is baked on your age at the time you purchase it. The younger you are the lower your premiums will be, and they will not increase with your age. Just like with community-rated, these plans will only ever become more expensive due to inflation and other outside factors but not your age.
Attained-age-rated
This type of pricing will calculate your premium based on your current age and does increase as you get older. Your premiums will be lower when you’re younger, but will steadily rise with your age. Increases can also happen due to inflation and other factors as well as your age.
Having Said that Plan G premiums range between $100 and $300 on average. Now, if you’re interested in a Plan G plan but the premium is a bit too expensive there is an alternative. Plan G also has a high-deductible version that offers all the same benefits with a lower premium. In exchange for the lower monthly cost you have to meet a higher deductible than you would with the standard Plan G. As for Plan N the average premium is between $120 and $180 as of 2023. When you factor in all the variables that can affect your premium Plan N can cost as low as $70 or be as expensive as $400.
So Which One Is Better?
The answer to this all depends on you. But in our opinion Plan G is the most valuable. Compared to Plan N, it provides the most coverage and saves you a significant amount of money. However, if you don’t need to visit your doctor frequently, you may easily be better off with Plan N. Overall if you’re a healthy person on a tight budget Plan N does have fantastic benefits. Although, even if you only visit the doctor a few times a year, Plan G does offer that extra bit of protection for only a little bit more money. With Plan G the only out-of-pocket Medicare cost you have to worry about is the $226(2023) Part B deductible.
How To Enroll
The best time for you to enroll is during your Medicare Supplement Open Enrollment Period. This is because if you enroll during this time you automatically receive guaranteed issue rights. Meaning you can’t be denied coverage or charged more due to your health or any pre-existing conditions. You only get one Medicare Supplement Plan Open Enrollment Period, so it is important to make use of it while you have it. The Medicare Supplement OEP begins once you turn 65 and enroll in both Medicare Part A and Part B; it continues for 6 months.
Need Some Help?
Financial planning and figuring out which benefits you need and don’t need can be time-consuming and frustrating. That’s what EZ.Insure is here for. A Medicare agent can do all of that research and compare plans for you. As well as take the time to get to know your budget and explain everything that will affect you personally. This means you’ll have professional help ensuring you get the best coverage. EZ.Insure provides you with your own personal agent. You’ll never have to worry about bouncing from agent to agent, yours will always be there to answer your questions, compare plans, and enroll you all for no extra cost. They can even help you after you’ve enrolled by reviewing your coverage annually or helping submit claims. To get started with your agent today simply enter your zip code in the bar below or give us a call at 877-670-3602.
Knees
The answer to this all depends on you. But in our opinion Plan G is the most valuable. Compared to Plan N, it provides the most coverage and saves you a significant amount of money. However, if you don’t need to visit your doctor frequently, you may easily be better off with Plan N. Overall if you’re a healthy person on a tight budget Plan N does have fantastic benefits. Although, even if you only visit the doctor a few times a year, Plan G does offer that extra bit of protection for only a little bit more money. With Plan G the only out-of-pocket Medicare cost you have to worry about is the $226(2023) Part B deductible.