Category: Medicare

Schedule Your Annual Enrollment Appointment Today To Enroll!

Get ready for a game-changer in managing your healthcare costs! Starting January 1, 2025, Medicare Part D is rolling out an exciting new program under the Inflation Reduction Act. The Medicare Prescription Payment Plan will revolutionize how you pay for your prescription drugs by allowing you to spread out your out-of-pocket costs over the year.

Inflation Reduction Act 2025 Changes:

• $2,000 Yearly Cap: A new $2,000 yearly cap on Medicare prescription drug costs.
• Price Negotiations: Medicare can now negotiate drug prices directly.
• Improved Access and Cost Caps: Improved access to biosimilars and a $35/month cost-sharing cap on insulin in durable medical equipment pumps.

What’s in Store for You:

• Monthly Payment Magic: Say goodbye to unpredictable costs! All Medicare Part D plans will now offer capped monthly payments for prescription drugs, making it easier than ever to budget and manage your healthcare expenses.
• Who’s In?: If you’re enrolled in Medicare Part D, including those receiving Extra Help, you’re eligible to benefit from this groundbreaking payment plan. Those with higher cost-sharing, especially for brand-name or non-preferred drugs, will find this program particularly helpful.
• Opting In Is a Breeze: During the Annual Enrollment Period (AEP) starting in October 2024, you can opt into this program as you enroll or renew your Part D coverage. Already enrolled? No worries! You can jump on board at any time during the plan year by reaching out to your Part D sponsor.

Key Features to Remember:

• Applies to both standalone Medicare prescription drug plans and Medicare Advantage plans with drug coverage.
• This program doesn’t reduce your total prescription drug costs but makes them way more manageable.
• Your Part D sponsor is committed to processing your election requests promptly.
• If you’ve been hit hard with high cost-sharing early in the year, this program could be a game-changer for your budget.

As you prepare for the upcoming changes, it’s important to stay informed and make decisions that align with your healthcare needs and budget. Consider discussing this new payment plan with me during your AEP appointment to see how it fits into your overall healthcare strategy. With the Medicare Prescription Payment Plan, managing your prescription drug costs has never been easier.

REMINDER! Schedule Your Annual Enrollment Period (AEP) Appointment Today!

Don’t wait until the last minute! Schedule your AEP appointment now to get a full coverage review to ensure your 2025 health care needs are in place, and receive assistance in opting into this new prescription payment plan program.

Fill out the 2025 Insurance Updates Form prior to your appointment to streamline the process and make the most of your enrollment period.

To schedule your appointment please contact our office today. We look forward to assisting you with your 2025 healthcare needs!

Answers to Your Most Common Questions

Summer is the perfect time for seniors to embark on new adventures, whether exploring national parks across the U.S. or visiting exotic destinations abroad. As you plan your travels, understanding how your Medicare coverage works away from home is crucial. Here, we address the most frequently asked questions about Medicare and travel, ensuring you’re well-prepared for any health-related needs during your summer journeys.

Coverage Outside the U.S.: Does Medicare Cover Medical Care While I’m Traveling Abroad?

A: Original Medicare generally does not cover healthcare services outside the U.S., except in limited situations such as emergencies in Canada or when traveling through Canada on your way to Alaska from another U.S. state.

Medicare Advantage Plans: What About Travel Coverage?

A: Some Medicare Advantage plans offer travel benefits that extend beyond emergency and urgent care. These benefits can include coverage for routine health care services whether you are vacationing within the U.S. or abroad. It’s essential to consider that coverage details, rules, and limitations can vary significantly between plans. When selecting a Medicare Advantage plan, ensure it meets your travel needs by asking:

• What emergency or routine health care services are covered if I vacation in the U.S. or out of the country?
• Do I have to seek services with specific providers?
• How long can I be away from home and still receive coverage?
• Will this plan cover both domestic and international travel?

Prescription Drugs Abroad: Does Medicare Cover Them?

A: Medicare Part D does not cover drugs purchased outside the U.S., but certain travel-related vaccines might be covered.  Medicare Advantage plans do no cover prescription medicines or routine health care services overseas. This means you might be paying 100% of the costs of care.

Using Medigap Policies for Travel: What Do You Need to Know?

A: Medigap (Medicare Supplement Insurance) policies provide emergency health coverage for the first 60 days of your trip outside the U.S. During this period, the policy typically covers 80% of the costs for medically necessary emergency care, as defined by Medicare. It’s important to note that Medigap plans are not designed to cover non-emergency medical services or surgeries abroad. Instead, they aim to stabilize your condition for transport back to the U.S.

Can I Use Telehealth Services While Traveling?

A: Some Medicare Advantage plans offer telehealth services that allow you to consult with healthcare providers remotely. Check with your plan to see if telehealth services are available while you’re traveling within the U.S. or abroad.

What Should I Do If I Need Medical Care While Traveling Abroad?

A: If you need medical care outside the U.S., you generally need to pay for the services upfront. Foreign hospitals are not required to file Medicare claims for your travel medical costs. You’ll need to submit an itemized bill to Medicare for your doctor, inpatient, and ambulance services if you’re admitted to a foreign hospital under specific circumstances and the hospital does not file Medicare claims for you.

Travel Insurance Options: Should You Consider Additional Coverage?

A: Due to limited Medicare travel coverage, many seniors opt for supplemental travel insurance. Review policy terms carefully.

Cruise Ship Coverage: What’s Covered by Medicare?

A: Original Medicare (Parts A and B) and Medicare Advantage Plans may cover medically necessary health care services on a cruise ship if the ship is in U.S. territorial waters or within six hours of a U.S. port when the services are received. 

Does Medicare Cover Emergency Air Transportation Back to the U.S.?

A: Medicare generally does not cover emergency air transportation (medical evacuation) from a foreign country to the U.S., except in very limited circumstances where the transportation is considered medically necessary and is provided as part of an inpatient hospital stay that Medicare covers.

Planning Ahead for Emergencies: What Should I Include in My Medical Travel Kit?

A: When traveling, it’s essential to pack a medical travel kit with essentials like medications, copies of insurance cards, emergency contacts, and a list of allergies. Being prepared can help ensure you’re ready for any unexpected health situations that may arise during your trip.

As you plan your travels, it’s important to keep in mind how your Medicare coverage works outside of your home area. Always check with your plan beforehand to understand what’s covered and consider additional travel insurance for added peace of mind. Being prepared ensures you can focus on enjoying your trip without worrying about unexpected medical costs.

If you’d like to review your plan before your next travel, please contact our office today at (631) 738-6760 and we would be happy to assist you in ensuring you fully understand your coverage before you set sail onto your next adventure!

Bon Voyage!

As we soak up the sun this summer, it’s essential to balance enjoyment with skin protection, especially for seniors who face increased risks of skin cancer. Did you know that UV rays from the sun are the primary cause of skin cancer? But fear not! With practical tips and understanding Medicare coverage, you can stay safe and enjoy sunny days responsibly.

Protecting Your Skin: Practical Tips

1. Seek Shade Strategically During peak sun hours (10 a.m. to 4 p.m.), find shade under an umbrella, sunshade, or in shaded areas to reduce UV exposure. It’s your personal oasis from the summer heat.
2. Fashionable Sun Protection Stay stylish and sun-safe with loose, breathable clothing, a wide-brimmed hat, and UV-blocking sunglasses. Protect yourself from head to toe while looking your best.
3. Sunscreen: Your Skin’s Superhero Always apply broad-spectrum sunscreen with SPF 30 or higher. Reapply every two hours (more frequently if swimming) and opt for waterproof formulas for continuous protection.
4. Embrace Vitamin D Wisely Maintain strong bones with vitamin D-rich foods like salmon and dairy products. Consult your doctor about supplements for additional options beyond sun exposure.
5. Review Your Medications Certain medications can increase skin sensitivity to sunlight. Discuss your prescriptions with your healthcare provider to stay informed and protected.
6. Stay Cool and Hydrated Beat the heat by staying hydrated and wearing lightweight, breathable fabrics. Moisturize regularly to keep your skin healthy and hydrated.

Early Detection Saves Lives

Monitor your skin for changes such as unusual moles or patches. Promptly notify your doctor if you notice anything concerning – early detection is crucial for effective treatment.

Understanding Medicare Coverage for Skin Cancer

The senior population faces significant risks from skin cancer, with over 40% of melanoma cases in the U.S. occurring in those aged 65 and older. Here’s how Medicare supports your skin health:

1. Medicare Part B Coverage
   • Routine skin cancer screenings are not covered for asymptomatic individuals under Medicare Part B.
   • Medicare Part B covers doctor examinations if you notice changes in moles or skin growths. If further evaluation is needed, Medicare may extend coverage for specialist referrals.
2. Coverage for Treatment
   • Medicare Part A and Part B cover outpatient treatments for skin cancer after meeting deductibles. Hospitalization costs are covered under Part A after its deductible is met.
3. Annual Wellness Visits
   • Medicare Part B offers annual wellness visits, providing an opportunity to discuss skin health concerns with your doctor. The visit is covered without applying the Part B deductible.
4. Medicare Advantage and Prescription Coverage
   • Medicare Advantage plans cover the same benefits as Original Medicare (Part A and B) and may offer additional coverage options.
   • Medicare Part D plans cover prescription drugs used for skin cancer treatment, expanding coverage beyond Original Medicare’s limitations.

Whether you’re considering Medicare Advantage or need comprehensive coverage insights, exploring your options ensures you receive the best care for your skin health needs. Stay informed, stay protected, and enjoy the sunshine responsibly this summer!

If you have further questions about your Medicare coverage, or would like to schedule a plan review, please contact our customer support services.

During Nursing Home Week

As we observe Nursing Home Week, we want to take a moment to acknowledge the dedicated nurses, caregivers, and staff who provide round-the-clock care to our loved ones. This week serves as a reminder of the commitment to ensuring the well-being and comfort of our elderly population. For seniors and their families, understanding how Medicare intertwines with nursing care is crucial for planning and ensuring access to the necessary services.

Medical Coverage for Nursing Home Care

Nursing homes provide a variety of services and personal care assistance. Medicare coverage for nursing homes, however, varies depending on factors like the specific facility, required services, and duration of stay.

Medicare coverage depends on:

• State and federal laws.
• National coverage decisions made by Medicare.
• Local coverage decisions made by companies.

Medicare Part A Skilled Nursing Facility (SNF) Care:

extends coverage for skilled nursing facility (SNF) care under specific conditions. This encompasses a spectrum of services for a limited time, including the following:

• Hospital inpatient care.
• Skilled nursing facility care.
• Nursing home care.
• Hospice.
• Home health care.

To qualify for Medicare-covered SNF care, a beneficiary must have undergone hospitalization for a minimum of three consecutive days and necessitate skilled care or rehabilitation services that can only be administered within the confines of a skilled nursing facility. 

*Note that a patient must check in to a skilled nursing facility within 30 days of leaving the hospital. On top of that, it must be for the same illness or condition related to the hospital stay.

Duration of Medicare-Covered SNF Care:

• Medicare encompasses coverage for up to 100 days of SNF care per benefit period. Nonetheless, coverage extending beyond 20 days mandates the beneficiary to bear a daily coinsurance amount.
• It’s incumbent upon individuals to familiarize themselves with the criteria governing continued Medicare coverage in an SNF setting, along with the prospective out-of-pocket expenses entailed.

Medicare Advantage Plans (Part C) and Nursing Care:

• Certain beneficiaries may be enrolled in Medicare Advantage (Part C) plans, which are dispensed by private insurance entities sanctioned by Medicare. These plans frequently encompass coverage for skilled nursing care, albeit the specifics may vary.
• Beneficiaries enrolled within Medicare Advantage plans should meticulously scrutinize their plan’s coverage nuances, inclusive of any stipulations or prerequisites concerning nursing care.

Long-Term Care and Medicare:

• It’s imperative to discern that Medicare typically refrains from extending coverage for long-term care in nursing homes for protracted durations. Long-term care requisites, such as assistance with activities of daily living (ADLs) or custodial care, are generally excluded from Medicare coverage.
• Individuals may find themselves compelled to explore alternative avenues, such as long-term care insurance, In-Home Health Care, or Medicaid, to defray the costs associated with prolonged nursing home stays.

In-Home Health Care: A Viable Alternative: In-home health care provides a valuable alternative for individuals requiring assistance with daily activities after a hospital stay.  This option allows individuals to receive care in the comfort of their own homes, maintaining a sense of independence and familiarity. In-home health care services can include:

• Meal planning/preparation
• Assistance with dressing, bathing, toileting
• Light housekeeping
• Accompany to doctor’s visits and other appointments

In-home health care plans are available at various levels and do not have age requirements or underwriting, making them an affordable option for seniors and their families. This option is especially beneficial after a hospital stay when care is needed but does not meet the requirements for nursing facility coverage under Medicare. 

Medicare coverage in nursing homes is a vital resource for elderly and disabled individuals in need of skilled nursing care. While it comes with limitations and eligibility requirements, it serves as a crucial safety net for those who might otherwise struggle to afford necessary care. Knowing and exploring your options to receiving care can greatly impact your quality of life and peace of mind.

If you would like more information and guidance on your Medicare coverage, skilled nursing facility benefits, or in-home health care plans, please don’t hesitate to contact our office today at (631) 476-4015 or email us at mlegaspi@imperial-coverage.com.

Get ready for a game-changer in managing your healthcare costs! Starting January 1, 2025, Medicare Part D is rolling out an exciting new program under the Inflation Reduction Act. The Medicare Prescription Payment Plan will revolutionize how you pay for your prescription drugs by allowing you to spread out your out-of-pocket costs over the year.

What’s in Store for You:

1. Monthly Payment Magic: Say goodbye to unpredictable costs! All Medicare Part D plans will now offer capped monthly payments for prescription drugs, making it easier than ever to budget and manage your healthcare expenses.
2. Who’s In?: If you’re enrolled in Medicare Part D, including those receiving Extra Help, you’re eligible to benefit from this groundbreaking payment plan. Those with higher cost-sharing, especially for brand-name or non-preferred drugs, will find this program particularly helpful.
3. Opting In Is a Breeze: During the Annual Enrollment Period (AEP) starting in October 2024, you can opt into this program as you enroll or renew your Part D coverage. Already enrolled? No worries! You can jump on board at any time during the plan year by reaching out to your Part D sponsor.

Key Features to Remember:

• This program doesn’t reduce your total prescription drug costs but makes them way more manageable.
• Your Part D sponsor is committed to processing your election requests promptly.
• If you’ve been hit hard with high cost-sharing early in the year, this program could be a game-changer for your budget.

As you prepare for the upcoming changes, it’s important to stay informed and make decisions that align with your healthcare needs and budget. Consider discussing this new payment plan with your Medicare Broker to see how it fits into your overall healthcare strategy. With the Medicare Prescription Payment Plan, managing your prescription drug costs has never been easier.
To learn more, or get assistance in enrolling to this new program, contact our customer support services today.
To learn more, or get enrollment assistance, please contact our office today at (631) 476-4015.

Exploring the 3 Ways You May Qualify

Medicare offers Special Enrollment Periods (SEPs) that allow individuals to enroll in or switch Medicare plans outside of the standard enrollment periods. These SEPs are crucial for individuals who experience certain life events or qualify for specific circumstances. Let’s explore what qualifies you for a SEP and how you can take advantage of them.

Qualifying for a Special Enrollment Period

There are three main reasons why you may qualify for a Special Enrollment Period:

1. Qualifying Life Events (QLEs): If you experience a QLE, such as moving to a new area, losing health coverage, or other life-changing events, you may be eligible for a SEP.
2. 5-Star Special Enrollment Period: Medicare rates plans on a scale of 1 to 5 stars, with 5 stars being the highest rating. If a 5-star plan becomes available in your area, you can switch to it during a SEP.
3. Working Past Age 65: If you delayed enrolling in Medicare because you had employer-based coverage, you have an 8-month SEP to enroll in Medicare once that coverage ends.

Qualifying Life Events and Special Enrollment Periods

If you have Medicare and experience a QLE, you may qualify for a SEP to change your Medicare Advantage or Prescription Drug Plan. These events include:

• Changing your primary residence
• Losing your health insurance
• Being eligible for other health insurance

*Each QLE has a specific timeframe within which you must act to qualify for a SEP. For example, if you move, your SEP is typically 60 days after your move.

5-Star Medicare Special Enrollment Period

If a 5-star Medicare plan becomes available in your area, you can switch to it during the 5-star SEP, which runs from December 8 to November 30 of the following year. It’s important to compare plans to ensure the new plan meets your needs.

Enrollment in Medicaid or Extra Help

Most people with Medicare can only make changes to their drug coverage at certain times of the year. If you have Medicaid or receive Extra Help, you may be able to make changes to your coverage one time during each of these periods:

• January – March
• April – June
• July – September

If you lose benefits from Medicaid or Extra Help, you will have a one-time opportunity to adjust your Medicare Advantage enrollment.

Disenrollment from your initial Medicare Advantage plan

If you initially enrolled in a Medicare Advantage plan upon becoming eligible for Medicare, you have a 12-month window to disenroll from the plan and return to Original Medicare.

If you previously dropped a Medicare Supplement Insurance plan to join a Medicare Advantage plan but now want to switch back, you also have a 12-month period to do so (as long as this was your first enrollment in a Medicare Advantage plan).

Working Past Age 65 and the Special Enrollment Period for Medicare Part B

If you or your spouse work past the age of 65 and delay enrolling in Medicare, you have an 8-month SEP to enroll in Medicare Part B once you retire or lose employer coverage. This helps you avoid late penalties.

Avoiding Gaps in Coverage and Part D Late Enrollment Penalties

To avoid gaps in coverage, enroll in Medicare before you lose employer-based coverage. If you anticipate retiring, contact your employer’s human resources department one or two months in advance to time your Medicare enrollment correctly.

Understanding Medicare Special Enrollment Periods is crucial for individuals to make informed decisions about their healthcare coverage. Whether you’re experiencing a QLE, have access to a 5-star plan, or are working past age 65, knowing your options and timing is key to maximizing your Medicare benefits.

If you would like more information on the SEP, or to find out if you may qualify, please contact our office today and we would be happy to assist you.

Let’s show our HEART a little more Love!  Cardiac health is a vital aspect of overall well-being, and Cardiac Rehab Week serves as a poignant reminder of the importance of maintaining a healthy heart. This annual celebration not only highlights the significance of cardiac rehabilitation but also emphasizes the important role your Medicare coverage can play at maintaining heart health. Join us as we explore Cardiac Rehab therapy and ‘heart healthy’ benefits under Medicare, and tips on how to show your heart a little extra love through a healthier lifestyle.

Understanding Cardiac Rehab Week

Cardiac Rehab Week, observed annually, aims to raise awareness about cardiac rehabilitation and its positive impact on individuals recovering from heart-related conditions. Did you know that cardiac rehabilitation can reduce the risk of death from heart disease by up to 25%?  It also provides an opportunity to acknowledge the efforts of healthcare professionals, support systems, and patients who contribute to the success of cardiac rehabilitation programs.

Medicare’s Role in Supporting Cardiac Health:

• Medicare covers cardiac rehabilitation programs for eligible beneficiaries.
• Cardiovascular Disease Screenings Coverage
• Cardiovascular Disease Treatment Coverage
• Cardiovascular behavioral therapy (Medicare Part B)
• Medical Equipment: Medicare may cover durable medical equipment like blood pressure monitors or cardiac monitors prescribed by your doctor.
• Medications: Medicare Part D provides coverage for medications prescribed to manage heart conditions, such as high blood pressure or cholesterol.

Your costs in Original Medicare: You pay nothing for the tests if your doctor or other health care provider accepts the assignment.

Costs under Medicare for cardiac rehab vary depending on the location and will include the Part B deductible.  The costs under Medicare often depend upon where you are participating in cardiac rehab. The Part B deductible will apply.

What Diagnosis Qualifies for Cardiac Rehab?

Medicare will cover the costs of cardiac rehabilitation, providing you have a certain medical diagnosis. These include:

• Having had a heart attack in the past 12 months.
• History of coronary artery bypass surgery
• Currently stable angina (chest pain)
• History of a heart valve repair or replacement
• History of coronary angioplasty to open a blocked artery or place a stent
• History of a heart or heart-lung transplant
• Stable, chronic heart failure

Heart-Healthy Lifestyle Choices for Seniors:

Tips on how to show your HEART a little extra LOVE!

According to a recent 2024 study by the American Heart Association, the average age at first heart attack is 65.6 years for males and 72.0 years for females. This highlights the critical importance of maintaining heart health as we age

By taking advantage of Medicare’s coverage for cardiovascular screenings and wellness visits, along with adopting heart-healthy lifestyle choices, we can empower ourselves to lead healthier, happier lives.

Let’s continue to prioritize our heart health, not just during this special week, but every day of the year. Together, we can make a difference in our cardiovascular health and inspire others to do the same. Here’s to strong hearts and healthier tomorrows!

To learn more about your Medicare benefits, please contact our office today and we would be happy to schedule a plan review with you to ensure you are getting the most out of your benefits! You can also visit our website to schedule an appointment with us.

Get the most of your coverage so you can LIVE YOUR BEST LIFE!

When it comes to Medicare, there’s more than meets the eye. In this blog, we’ll explore 15 lesser-known services covered by Original Medicare, with a focus on Original Medicare Part B. Whether you’re a new beneficiary or a seasoned one, understanding these services can help you make the most of your coverage.

1. Welcome to Medicare Preventive Visit
   • Upon enrolling in Medicare, you’re entitled to a Welcome to Medicare visit. This comprehensive checkup with your Medicare-covered primary care physician establishes a baseline for your health and sets the stage for your upcoming health management plan.
2. Yearly Wellness Visits
   • In addition to the initial visit, Medicare covers an annual wellness visit with your primary care physician. This dedicated checkup ensures that your overall health is on track and allows for a review of your care plan.
3. Counseling to Quit Smoking
   • If you’re looking to quit smoking, Medicare has your back. Coverage includes up to eight face-to-face counseling sessions per year with a healthcare provider to support your journey to a tobacco-free life.
4. Flu Shots
   • Protect yourself from the flu with Medicare-covered flu shots, available at your doctor’s office or local pharmacy. Combined with good hygiene practices, flu shots are a powerful defense against influenza.
5. Nutrition Therapy Services
   • For those with qualifying conditions like diabetes or kidney disease, Medicare may cover nutrition therapy services. This includes assessments and individual and/or group nutritional therapy services.
6. Alcohol Misuse Screening & Counseling
   • Address alcohol misuse with Medicare’s coverage for annual screenings. If necessary, you can receive up to four face-to-face counseling sessions per year to help you manage your alcohol usage.

Note: You must get the counseling in a primary care setting. For example, like a doctor’s office.

7. COVID-19 Vaccination and Boosters
   • Stay protected from COVID-19 with Medicare-covered vaccinations and boosters. Accessible at your doctor’s office or local pharmacy, getting vaccinated not only safeguards you but also contributes to community health.
8. COVID-19 Tests (Including Antibody Tests)
   • Medicare covers all types of COVID-19 tests, ensuring you can get tested if you feel unwell. This includes at-home rapid tests and antibody tests to assess your potential immunity.
9. COVID-19 Monoclonal Antibody Treatments
   • If you test positive for COVID-19 with mild to moderate symptoms, Medicare covers monoclonal antibody treatments to help fight the virus and avoid hospitalization.
10. Obesity Screening & Counseling
    • Medicare Part B covers obesity screenings and counseling for individuals with a BMI of 30 or more. Work with your healthcare provider to focus on diet and exercise for a healthier lifestyle.

11. Gender-Specific Cancer Screenings
    • Medicare covers specific cancer screenings for both men and women, including prostate cancer screenings for men and mammograms/Pap smears for women.
12. Diabetes Self-Management Training
    • Newly diagnosed with diabetes? Medicare offers coverage for diabetes self-management training to help you cope with and manage your condition effectively. Medicare may cover up to 10 hours of this initial training – 1 hour of individual training and 9 hours of group training.
13. Special Footwear for Diabetes
    • For those with diabetes, Medicare may cover therapeutic shoes and inserts prescribed by an approved podiatrist to address foot neuropathy.
14. Colorectal Cancer Screenings
    • Medicare covers various diagnostic screenings for colorectal cancer, including stool DNA tests and colonoscopies. Regular screenings are essential for early detection.
15. Depression Screenings
    • Seniors can benefit from Medicare’s yearly depression screenings at no cost. If needed, referrals to mental health professionals or prescription options may be recommended.

Understanding your Medicare coverage is crucial for managing your health. These 15 covered services ensure that you receive the necessary screenings, tests, and support for a healthier and happier life. If you have questions about your coverage or want to explore additional options, feel free to reach out to our office at (631) 476-4015.

Choosing the right health plan shouldn’t be complicated. In this blog, we’ll explain the main differences between them, providing insights to help you make informed decisions. Think of this as your handy guide, with essential questions to make your healthcare choices easier and help you confidently pick between HMOs and PPOs.

HMO vs. PPO: What You Need to Know

HMOs are known for being cost-effective with designated provider networks, while PPOs offer more flexibility at a higher cost, allowing you to access out-of-network care. Your choice between the two ultimately depends on your preferences regarding costs and restrictions.

Understanding HMOs:

Health Maintenance Organization (HMO) plans typically consist of an approved network of healthcare providers. In most cases, your medical care is covered only if you visit a provider within the plan network. Going outside this network might mean paying the full cost of services, except in emergencies.

Understanding PPOs:

Preferred Provider Organization (PPO) plans provide you with the flexibility to choose your healthcare provider. Like HMOs, PPOs establish a provider network, usually resulting in lower out-of-pocket expenses when staying within the network. However, partial coverage for out-of-network care is possible, with higher anticipated costs for services beyond the designated network.

Commonalities Between HMOs and PPOs:

Despite their differences, both HMO and PPO Medicare Advantage plans share common ground. They offer the same coverage as Medicare Part A (hospital insurance) and Part B (medical insurance) in a unified plan.

Many Medicare HMO and Medicare PPO plans also include additional benefits beyond what Original Medicare covers.

Key Questions to Consider when choosing between an HMO plan and a PPO plan:

1. Provider Accessibility:
   • HMO: Do you prefer a plan with a specific network of approved providers?
   • PPO: Is having the flexibility to choose your healthcare provider important to you?
2. Cost Considerations:
   • HMO: Are you looking for a cost-effective plan with potentially lower out-of-pocket expenses within the network?
   • PPO: Can you afford the higher cost for the flexibility to access both in-network and out-of-network care?
3. Primary Care Physician Preference:
   • HMO: Do you value having a primary care physician coordinate your care within a network?
   • PPO: Is having the freedom to choose specialists without referrals more appealing to you?
4. Network Restrictions:
   • HMO: Can you commit to receiving most, if not all, of your care within the plan’s network?
   • PPO: Are you willing to pay higher costs for the flexibility to see providers outside the designated network?
5. Coverage Beyond Medicare Parts A & B:
   • HMO and PPO: Are you interested in additional benefits beyond what Original Medicare covers, offered by both plan types?
6. Coordinated Care Preference:
   • HMO: Do you appreciate a team approach to your care within a coordinated network?
   • PPO: Does the idea of having more individual control over your healthcare decisions appeal to you?
7. Freedom of Choice:
   • HMO: Is having a more structured healthcare experience with a designated network preferable?
   • PPO: Do you value the freedom to seek care from any healthcare provider without network restrictions?
8. Personal Healthcare Needs:
   • HMO and PPO: When deciding, consider your specific health requirements, provider preferences, and overall comfort level with each plan’s features.
9. Customer Service and Support:
   • HMO and PPO: What is the quality of customer service for each plan, and how responsive are they to your inquiries?
10. Travel Considerations:
    • HMO: How does the plan handle healthcare needs when you’re outside the plan’s service area?
    • PPO: Are there additional benefits or coverage when seeking care outside the designated network, especially during travel?

Choosing between an HMO and a PPO requires considering key aspects. By asking these questions, you can pinpoint what matters most to you in terms of cost, flexibility, and healthcare preferences. Your ideal plan is the one that aligns with your lifestyle and budget.

To help you weigh the pros and cons and make a confident decision, download this FREE HMO vs PPO Guide.

Your health coverage should cater to your needs, ensuring you receive the best care for your unique situation.

If you would like additional assistance with plan comparisons, please contact our office today and we would be happy to schedule a review to ensure your Medicare needs are properly in place for 2024.

Resources:

Medicare.gov

www.uhc.com/news-articles/medicare-articles/the-difference-between-medicare-hmo-and-ppo-plans

If you’re new to Medicare, understanding the various enrollment periods can be a bit overwhelming. With the Annual Enrollment Period (AEP) coming to a close, two crucial enrollment periods are just around the corner: the General Enrollment Period (GEP) and the Medicare Advantage Open Enrollment Period (MAOEP).

Both run simultaneously from January 1^st to March 31^st.

First, some background. When you are new to Medicare, you have an Initial Enrollment Period (IEP) that runs for a total of 7 months: 3 months before the month you turn 65, the month you turn 65 and the 3 months following that month.

Example: If your birthday is December 3rd, your IEP starts on September 1st and ends on March 31st.

This is the best time to enroll in Original Medicare (Parts A and B together) because you’ll avoid potential penalty fees and delays in healthcare coverage.

However, if you happen to miss your Initial Enrollment Period (IEP), don’t worry. You get another chance each year during the General Enrollment Period (GEP) to sign up for Medicare Part A and/or Part B. During the GEP, you can only enroll in Medicare Part A and/or Part B.

During this time, you cannot:

• Enroll in a prescription drug plan (Part D)
• Buy a Medicare Advantage plan (Part C)
• Change any existing coverage you might have (like going from one Advantage plan to another or dropping Part D)
• Make any other changes to your coverage

Penalties for Signing Up Late

If you sign up for Parts A and/or B during the General Enrollment Period, you might have to pay extra on your usual premiums – that’s the penalty for signing up late. That’s why it’s a good idea to enroll during your Initial Enrollment Period (IEP).

• Part A Late Enrollment:

If you need to purchase Part A and miss your first Medicare eligibility chance, your monthly premium may increase by 10%. The penalty lasts for twice the number of years you delayed. For example, if you wait 2 years to sign up, you’ll pay a higher premium for 4 years. Special Enrollment Periods may exempt you from penalties – check your eligibility.

• Part B Late Enrollment:

You usually won’t face a Part B penalty with a Special Enrollment Period. Expect an extra 10% for each year you could have enrolled but didn’t. Your income may also affect your premium. Learn more about Special Enrollment Periods for your options here: Special Enrollment Periods | Medicare

During the GEP, there is another period called the Medicare Advantage Open Enrollment Period (MAOEP). The main difference between Medicare Advantage Open Enrollment and General Open Enrollment is who can use each one and what changes you can make.

The Medicare Advantage Open Enrollment Period (MAOEP) lets you:

1. Change Medicare Advantage Plans: You must be already enrolled into a Medicare Advantage plan. If both Medicare Advantage plans are offered in your area, you may change from one to another.
2. Go Back to Original Medicare: You can drop your Medicare Advantage plan and return to Original Medicare (Parts A and B), with a Part D prescription drug plan. You also have the option to add a Medicare Supplement (Medigap) policy. However, this is not a guaranteed issue. You will most likely have to go through Medical Underwriting.

During this time, You cannot:

• Enroll in Medicare Advantage for the first time if you are currently on Part A and Part B (Original Medicare).

Understanding and navigating these enrollment periods is crucial for ensuring that you have the right Medicare coverage. If you have any questions or need more information on changing your plan, feel free to reach out to our office today at  (631) 476-4015 and we would be happy to assist you.