Medicare is an essential program for seniors over 65, however, many of its benefits are underutilized or misunderstood. Consider the annual “wellness” visit. During which a physician will assess your health risks, take your blood pressure and other routine measurements, test for cognitive impairment, and provide personalized health advice. It’s Free! Nonetheless, a surprising number of people do not take advantage of this benefit. This isn’t the only benefit that has gone under the radar. Many healthy seniors ignore a variety of free preventive services, ranging from bone density screening to cancer detection. Other benefits such as home health care, are also frequently unused due to their strict eligibility requirements. Below you’ll find all the ways to make sure you’re using all of your benefits and getting your money’s worth.
Choose The Right Doctor
It is important to choose a doctor who accepts Medicare assignments in order to save money. If a doctor accepts a Medicare assignment, they accept Medicare-approved amounts as full payment, and you cannot be charged more. Most physicians who treat Medicare patients will accept Medicare assignments. Providers who don’t participate fall into two categories:
Non participating providers – These providers can charge up to 15% more than the Medicare approved amount for covered services and leave you responsible for the additional costs
Opt-out providers – These providers can charge whatever they want which is outlined in a private contract with the patient.
To locate physicians in your area who accept assignment, visit Medicare.gov to find doctors and other health professionals section. The search tool displays which physicians accept Medicare payments.
If you have a Medicare Advantage plan, check your plan’s provider directory or website to ensure you’re choosing doctors in the network. Keeping in mind that doctors may be added or removed at any time. Generally, you will pay more to see non-network providers. Make sure that you research different doctors. Confirm that they accept Medicare and are willing to educate you on what is and is not covered so that you are not overcharged.
Understand Your Policy
Medicare provides coverage for skilled services such as nursing, speech therapy, and physical therapy, but there are eligibility requirements. To qualify for these services, you must be homebound. Meaning you are unable to leave your home without assistance or because of a medical condition. Many seniors mistakenly believe that they are covered for these services, only to receive a hefty bill in the end. Before assuming something is covered, carefully read your policy’s guidelines.
Look Into Medicare Advantage
Medicare Advantage plans are offered by private insurance companies and offer the convenience of having Part A, Part B, and Part D services all bundled into one plan. Whereas traditional Medicare has you sign up for each plan individually. Medicare advantage plans may also include coverage for routine dental, vision, and hearing exams. Which are not available under Original Medicare. However, the biggest benefit of Medicare Advantage is the annual out-of-pocket maximums for seniors excluding
prescription drug plans. Which as of 2023 is $8,300. With Original Medicare, there are no annual out-of-pocket maximums.
However, you should also be aware of the disadvantages of Medicare Advantage. Original Medicare is widely accepted by physicians and hospitals all over the country. Whereas a Medicare Advantage plan will have a smaller network of providers. So, it’s possible that your doctor isn’t in their network. Next, you may be required to get a referral before seeing a specialist. Which is not the case for Original Medicare enrollees. There are also certain covered services that Parts A and B that may have a high copayment under a Medicare Advantage plan. Meaning you would have higher out-of-pocket costs with Medicare Advantage than you would with Original Medicare.
If you have a chronic or serious health condition and will likely visit the doctor frequently, you may want to consider a Medicare Supplement Plan. Medicare covers the majority of eligible medical expenses for seniors, but you are still responsible for 20%-25% of the total cost of care. Medicare Supplement Plans were designed to help cover a substantial portion of the medical expenses that come from having Medicare Part A and B, that you would otherwise be responsible for.
As with Part D, private insurers offer Medicare Supplement Plans and with Part D, there are a variety of plans to choose from. So you should shop around carefully to find the plan that fits you best. While yes, Medicare Supplement Plans do have premiums and can increase your monthly expenses, the additional coverage could give you peace of mind and eliminate some of the uncertainty that comes with your out-of-pocket Medicare costs.
Save On Medications
Even if you have Medicare Part D prescription drug coverage, your out-of-pocket costs can be astronomical, in part because Part D does not have a limit for out-of-pocket expenses. After you reach the catastrophic coverage threshold of $7,400 (as of 2023), the majority of people will continue to have to pay 5% of the cost of covered drugs. In certain instances, you can reduce drug costs by forgoing your Part D plan and paying cash. Big-box stores such as Costco and Target offer a variety of generic prescriptions for much cheaper, whereas many Part D plans have a high standard copay to fill a prescription. The only problem with paying in cash and not using your coverage is that the expense won’t count towards your deductible.
If you stick with your Medicare Part D plan’s list of “preferred” pharmacies you will typically pay less for your prescriptions. Also most Part D plans separate their drug formularies (list of covered drugs) into 5 tiers: preferred generic, generic, preferred brands, non preferred, and specialty. With preferred generics being the lowest cost-sharing tier and the most affordable for enrollees. If you find a drug that is approved for your condition on a lower tier than the one you currently take, ask your doctor if you can switch to the more affordable one.
Review Your Quarterly Summary
Your quarterly Medicare summary displays services and supplies for which Medicare was billed. This summary will also indicate whether or not any claims have been denied; if so it is important to contact the provider of the denied claim. If you believe the claim is unjust, you can appeal the claim denial by following the instructions on the summary’s final page. When admitted to the hospital, for instance, you will receive a notice outlining your Medicare rights. You may request an appeal of the decision and a review of your case if you believe you were discharged prematurely.
Use Your Preventative Care
Many Medicare recipients don’t realize that there is a long list of services that they can get for free. Medicare provides numerous screenings and annual wellness visits at no cost to you. These free preventative measures are important for detecting serious illnesses early. The screenings may include depression, cardiovascular disease, and other conditions. There are free counseling sessions for tobacco and alcohol abuse, as well as free vaccinations for flu and pneumonia. Additionally, you are eligible for a free “welcome to Medicare” preventive visit within the first 12 months of receiving Medicare Part B. During this initial appointment, you can also receive free assistance planning for end-of-life care. And your physician can help you draft an advance directive that outlines all of your wishes.
Utilizing these freebies can aid doctors in detecting major health problems before they worsen, thereby preserving your health. You might also have access to free wellness benefits if you have a Medicare Advantage plan. Some Advantage plans, for instance, include SilverSneakers membership at no extra charge. This program provides a basic gym membership and access to senior-specific group exercise classes.
Plan Yearly Expenses With The Out-Of-Pocket Maximum In Mind
Individuals’ Medicare costs can vary widely based on their circumstances and the type of coverage they have. Original Medicare typically covers 80% of a beneficiary’s Part A and Part B expenses. Such as doctor visits, hospital stays, and lab work. Individuals are responsible for remaining 20% of out-of-pocket costs, with no annual cap. Medicare Advantage plans offer predictable copayments and an annual limit on out-of-pocket costs. Once you reach your plan’s out-of-pocket maximum, all Medicare-covered services for the remainder of the year are covered in full. This cap can provide peace of mind if you have a sudden illness or are preparing for a major medical procedure.
Shop Around Every Year
Original Medicare, which includes Part A (hospital insurance) and Part B (medical insurance), is relatively simple. There is no need to shop around for Parts A or B because they come in a universal package. Where you should shop around is your Medicare Part D plan and your Medicare Supplement Plans. Medicare contracts with private insurance companies that offer Part D and Medicare Supplement Plans to provide seniors with a variety of coverage options. Moreover, these coverage options and their costs can change from year to year. This means that the plan you have this year might not be the best for you next year. The worst thing you can do is automatically enroll in your previous year’s plan without comparing options. This could result in higher out-of-pocket costs and for Part D could mean less coverage for prescription medications.
Get Help From EZ
If you’re looking for a Medicare Supplement Plan or Medicare Advantage Plan, you must compare the costs and benefits of each. This requires extensive research. Which can be time-consuming, as you will need to contact multiple insurance companies to obtain rate quotes. However, if you work with one of EZ’s agents, you can compare prices in half the time. Working with a licensed agent provides you with access to a variety of carriers and plans.
In addition to providing price comparisons, your agent can explain the differences between each plan. And explain the differences between each plan. In addition, your agent can assist you in determining which plan will be the most cost-effective for you in the long run by comparing out-of-pocket costs and premium costs. Call us today at 877-670-3601 or enter your zip code in the bar below to begin comparing.
As of June 17, the Affordable Care Act (ACA), also known as Obamacare, is still intact, and the long, drawn-out fights over the legislation seem to be at an end. The ACA survived its third major Supreme Court challenge with a 7-2 decision in its favor, meaning the comprehensive health care reform law will continue to provide health insurance to millions of Americans. Republican lawmakers have decided to no longer focus on repealing the law, despite election promises to end Obamacare.
In 2018, the Texas State Attorney General filed a lawsuit to have Obamacare repealed.
After former President Trump’s administration successfully challenged the individual mandate in 2017, which had meant that Americans were required to have health insurance or face a tax penalty, Texas State Attorney General Ken Paxton, a Republican, filed a lawsuit claiming that Obamacare itself was unconstitutional. His argument was that, without the tax penalty, the coverage requirement is unconstitutional, thus making the whole law unconstitutional. This battle has been going on since 2018, and the Supreme Court has finally had the chance to review the case.
Why The Lawsuit Was Dismissed
The case was decided on a technicality, with 7 justices agreeing that the challengers of the 2010 law did not have the legal right to bring the case, because the plaintiffs did not experience any harm that would give them standing to challenge the law. They did not weigh in on the constitutionality of the law.
The majority opinion stated, “Plaintiffs do not have standing to challenge [the law’s] minimum essential coverage provision because they have not shown a past or future injury fairly traceable to defendants’ conduct enforcing the specific statutory provision they attack as unconstitutional… To have standing, a plaintiff must ‘allege personal injury fairly traceable to the defendant’s allegedly unlawful conduct and likely to be redressed by the requested relief’… No plaintiff has shown such an injury ‘fairly traceable’ to the ‘allegedly unlawful conduct’ challenged here.”
Getting rid of Obamacare would have resulted in millions of Americans losing health insurance, and would have left many without the opportunity to get any; there are currently three dozen states who have opted not to establish a state exchange, so all of their residents’ only option has been to purchase an Obamacare plan. Getting rid of the law would have denied affordable health care plans to Americans whose states have refused to participate in offering exchanges.
“Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them,” Chief Justice John Roberts wrote in the majority opinion.
The Future Of Obamacare
More than 25 million Americans have health insurance coverage through the ACA, and recent polling suggests that more Americans support Obamacare than oppose it. This ruling was a major win for Obamacare, and opens the door for Democratic lawmakers to extend the newly expanded subsidies for the foreseeable future, instead of allowing them to expire at the end of 2022.
“It’s our chance now to really build [on Obamacare], now that [opponents of the law have had] three strikes and…are out,” said Xavier Becerra, the secretary of Health and Human Services, and the former Attorney General of California, who stepped in with other Democratic-led states to defend the law when the Trump administration would not. “Now we know we survive, and now we build.”
Some Democratic lawmakers have taken this win as a way to push forward with universal health care coverage, but Medicare for All still faces a lot of opposition, and President Biden himself campaigned on building up Obamacare rather than pursuing a universal health care model. For now, the main focus of lawmakers is trying to make sure that Obamacare serves all Americans well.
“We’re at a moment when insurers are no longer running away from the exchanges and there’s relative stability in the individual market — and this is a moment that insurance regulators and policymakers should be asking how do your marketplace plans work better for consumers?” said Kevin Lucia, a former Obama administration health official who worked on the law’s implementation.Former President Obama agrees, saying in a tweet, “Now we need to build on the Affordable Care Act and continue to strengthen and expand it. That’s what @POTUS Biden has done through the American Rescue Plan, giving more families the peace of mind they deserve.”
2020 will bring more health insurance options for people in counties that have previously had few choices. This fall open enrollment period, people shopping in the ACA Marketplace will find about 60% of insurers adding more plans. This is great news for people who have had limited options, especially those who only had plans from a single insurance company available to them. What’s even better is that 46% of insurers say they plan to either lower their premium rates or keep them the same as last year.
Many insurers abandoned certain areas of the country leaving people with less options.
The Fleeing Insurers
Prior to 2018, many health insurance companies were choosing not to participate in the federal health insurance marketplace, leaving people with few options. Many abandoned certain areas of the country because it was costing them too much to cover the poorer, sicker people who were able to get healthcare plans under the rules of the ACA. Because there was so much more demand than supply, premiums were constantly rising, making it harder for people to get insurance even when they could find a plan in their area.
Resurgence Of Insurers
After seven years of instability and decreasing involvement, some insurers began slowly re-entering the Marketplace in 2018. Oscar Health was one of the first to increase the plans they were offering in the Marketplace for 2019. Following Oscar Health was Bright Health, who expanded on venture-funded Medicare Advantage plans. Cigna joined them soon after.
“Stability has not been a major theme in the story of the Affordable Care Act marketplace, but since 2018, premium growth has slowed and issuer participation has increased,” RWJF summarized in a statement. “While enrollment has trended down somewhat in recent years, health plans seem newly interested in participating.”
The Expansion
Centene, Oscar, and Bright Health will be expanding into counties where they weren’t previously offering plans. Blue plans, Cigna, and Anthem are also choosing to expand into new areas.
Oscar will expand to cover individuals and families in six new states and a total of 12 new markets. For its individual markets, Oscar will be expanding into Florida, offering plans in Miami, Tampa, Ocala and Daytona. Oscar will also offer plans for the first time in Philadelphia, Denver, Richmond, Atlanta, and the Kansas City metropolitan area across Missouri and Kansas. In Texas, Oscar will begin with Houston and expand the plan options currently offered in Dallas-Fort Worth. Oscar will also expand to serve several counties in Western Michigan.
Bright Health will double their expansion of Medicare Advantage plans into 13 new markets across six states. The states include Florida, Illinois, Nebraska, Ohio, South Carolina, and Tennessee. Last year, Bright Health grew to include products in Arizona, New York, Ohio, and Tennessee.
Centene plans on expanding into ten markets, including Arizona, Florida, Georgia, Kansas, North Carolina, Ohio, South Carolina, Tennessee, Texas, and Washington.
Cigna announced they will be expanding in the federal health insurance marketplace, specifically 19 new markets (counties) in 10 states: Arizona, Colorado, Florida, Illinois, Kansas, Missouri, North Carolina, Tennessee, Utah and Virginia.They are offering $0 preventive care, free telehealth services, and low-cost options for chronic disease management. This is a pretty big deal for people that couldn’t receive this kind of care or could not afford it.
“More people who purchase health care coverage on the exchange now will have access to Cigna’s broad range of products and services that makes quality health care more accessible and affordable,” said Brian Evanko, president of Cigna’s government business. “We’ve learned from our thoughtful approach and continuous presence on the exchange how to deliver a great product with a simplified customer experience. We are proud to be able to deliver our exceptional offering to even more people throughout the U.S.”
If you would like to learn more about the new insurers in your area and what plans they are offering, EZ will help guide you through the process. We will provide you with a personal agent that will go over all the information, and compare plans so you can find a plan that meets your financial and healthcare needs for free. To see prices and shop for plans, enter your zip code in the bar above, or speak with an agent directly by calling 888-350-1890.
Just before Christmas, a federal Texas judge, Reed O’Connor, ruled that the entire Affordable Care Act, also known as Obamacare, was unconstitutional. This all began December 2017, when President Trump eliminated the individual mandate from Obamacare. The individual mandate was the penalty people had to pay during tax season if they did not get health insurance for the year. When the mandate was officially gone, many states decided to take action against the ACA, filing a lawsuit deeming the ACA unconstitutional. Texas is the first state to rule against the ACA’s validity. Obamacare may now face some challenges. However, as of now the ACA open enrollment will still take place for 2019, and people will still get coverage.
Texas judge ruled Obamcare (ACA) unconstitutional, making it invalid.
If the ACA is completely dismantled, then this means that other provisions would go away as well. This includes pre-existing conditions, young adults staying on their parents’ insurance until the age of 26, and the coverage of “essential benefits” such as mental health, prescription drugs, and maternity.
The ACA Holds Up For Now
In response to the judgement from O’Connor, Obama wrote “it’s so important for you to know that last night’s ruling changes nothing for now. As this decision makes its way through the courts, which will take months, if not years, the law remains in place and will likely stay that way. Open enrollment is proceeding as planned today. And a good way to show that you’re tired of people trying to take away your health care is to go get covered! A lot of good people are fighting to ensure that nothing about your care will change. The ACA protects your pre-existing conditions, no matter how you get your insurance. Young people can stay on their parents’ plans until they’re 26. Preventive care like checkups, mammograms, and contraceptive care are still covered. Mental health care is still covered. Women can’t be charged more just for being a woman. All of that is guaranteed by the ACA as long as it’s the law.”
Trump on the other hand was happy of the judgement stating in a tweet, “It was a big, big victory by a highly respected judge, highly, highly respected in Texas, and on the assumption that the Supreme Court upholds, we will get great, great health care for our people. We’ll have to sit down with the Democrats to do it, but I’m sure they want to do it also.”
As of now, Obamcare will be available for 2019. The future of the ACA is unkown, especially not until 2020 after the high court hears Texas’ case.
What The Future Holds
While legal experts predict that the decision will be overturned by the high court, it will not be likely to take place until 2020. Until then, the ACA law is not yet invalidated, even though enrollment has taken a hit. Enrollment is down by 12% compared to the previous year. The ACA has withheld a lot over the years, and only time will tell it’s future, but as for now, it is here to stay.
Over the years, President Trump has been slowly picking away at Obamacare, also known as the Affordable Care Act. But there has been one section of the ACA that he intends to keep, which is the pre-existing conditions clause. Trump recently stated he was going to “totally protect people with pre-existing conditions.” Despite the Trump Administration putting the provision in jeopardy, Trump is stating he backs it and that Democrats do not.
Trump promises to protect and cover pre-existing conditions, even after the ACA is gone.
The controversy all began when Trump was running for presidency. One of his promises was to get rid of Obamacare, and so far he has kept that promise. Over the years, he has gotten rid of the individual mandate. This mandate stated that people must get health insurance or they will face a penalty. Due to getting rid of this mandate, many states have challenged the ACA’s constitutionality in a lawsuit this past February. These states are saying that since the mandate is unconstitutional, then the entire health care is also.
The Promise
Throughout the dismantling of the ACA, Trump is fighting to protect people with pre-existing conditions. He wants to make sure that they are still able to get health insurance, and will not be rejected or pay more because of the conditions. This is all came about as midterm elections were approaching, and he was urging people to vote Republican. In his tweet he stated that Republicans will back those with pre-existing conditions, and that Democrats will not, so “vote Republican.”
Trump administration officials said they will allow states to use federal subsidies to pay for health plans that don’t cover pre-existing conditions. Republicans all over the U.S. back what Trump has said about pre-existing conditions.
Make sure you plan ahead so that you are covered. Look into a short-term plan, and if it will work for you.
However, there are many doubts if this will actually hold true. A lot of people are skeptical about the pre-existing provision, especially after the midterm elections. Many see this as an attempt to get people to support Trump. The fact is that premiums may be high for those with pre-existing conditions, and not necessarily protect them.
Short-term plans are being expanded in hopes that people will go for them, which does not offer comprehensive plans. This means they may not necessarily cover pre-existing conditions. But if Trump does truly stand behind protecting pre-existing conditions, he can take some steps to ensure it will be be protected, which we have yet to see.
Once the lawsuit between the states and the government to get rid of the ACA is over, only then will we know what will happen with pre-existing conditions. This can cost a lot of people looking for health insurance a lot of money, and even possibly be denied coverage.
Since President Trump and the Department of Health and Human Services cut cost-sharing reductions in October, some states have brought a lawsuit against the government. The lawsuit centers on the loss of federal funding, which jeopardizes basic health programs.
The Basic Health Program offers an alternative coverage plan for people with household incomes between 133 and 200 percent of the federal poverty level. The ACA included this as an option to make coverage more affordable. New York and Minnesota were the two states in which these programs were offered in order to provide a “standard plan” for those who didn’t qualify for employer coverage or other government programs. It is estimated that they offer comprehensive coverage for more than 800,000 low-income people.
The attorneys general of New York and Minnesota filed the suit against the government for over $1 billion a year lost from funding the basic health programs. The two states estimate that New York will get about $1 billion less funding in 2018 to run its Essential Plan, and Minnesota will get about $130 million less to run MinnesotaCare.
“The abrupt decision to cut these vital funds is a cruel and reckless assault on New York’s families — and we will not allow it,” state Attorney General Eric Schneiderman said in a statement trumpeting the suit. “I won’t stand by as the federal government continues to renege on its most basic obligations in a transparent attempt to dismantle the Affordable Care Act.”
“For each dollar Minnesota sends to Washington, D.C., we get just 53 cents back,” Minnesota Attorney General Lori Swanson said in a statement. “This lawsuit seeks to avoid Minnesota losing hundreds of millions of dollars of payments in the coming years.”
The administration told the states it would stop paying the “cost-sharing reductions component” of the basic health program funding, but continue to pay premium tax credits.
The two states have submitted proposals to restore the funding, but the Department of Health and Human Services failed to answer, and never considered the proposals. Because of this, the two states are asking a judge to intervene in order to force the government to pay the full federal funding.
The fear amongst the two states is that if the federal funding is not restored, and then costs will rise and coverage will shrink. “It could trigger major changes to the eligibility structure, the benefits or increases in premiums,” says Maureen O’Connell, president of Health Access MN, which helps people enroll in marketplace coverage.
cost-sharing reductions in October, some states have brought a lawsuit against the government. The lawsuit centers on the loss of federal funding, which jeopardizes basic health programs.
“For each dollar Minnesota sends to Washington, D.C., we get just 53 cents back,” Minnesota Attorney General Lori Swanson said in a statement. “This lawsuit seeks to avoid Minnesota losing hundreds of millions of dollars of payments in the coming years.”