Some Medicare beneficiaries, those that are fairly new to the program, are not aware that if they do not agree with a payment decision or coverage decision made by a Medicare health plan or by Medicare, that they might file an appeal.
There are five levels involved in the appeals process and a beneficiary can proceed up a level if the appeal is denied at a lower level. In order to prepare for an appeal, make sure to gather any and all information from your physician or healthcare practitioner.
If you need a quick decision because your health is in jeopardy, you may request a quicker decision. If your doctor or your Medicare plan agrees, a decision must be delivered within 72 hours.
Always be aware of what Medicare covers and does not cover and what options are available to you if you disagree with decisions made that may affect your health.
Many Medicare beneficiaries do not realize that once they sign up for Medicare they are eligible to get a number of free preventive services. Additionally, for new beneficiaries, Medicare Part B offers a “Welcome to Medicare” preventive visit during the first 12 months of enrollment. During this visit, your doctor will review your medical history and provide you with information regarding any services you may need. Beneficiaries who have had Medicare Part B coverage for over 12 months qualify for an annual wellness visit to update or get a personal health care plan from your doctor.
Medicare also provides its beneficiaries with other free preventive services. Some of these services are listed below:
A cardio-vascular screening every five years
Annual mammograms
Annual flu shots
Annual screenings for prostate cancer
Annual screenings for cervical cancer
Annual screenings for colorectal cancer
When you sign up for Medicare, take the time to find out what it offers. Preventive services are important for all beneficiaries to take advantage of as theses benefits lead healthier lives. Always read your health care insurance policies and if you have questions, speak to a health care insurance expert agent.
While Medicare costs seem to always be increasing, the good news is that the coverage gap, part of Part D, is going down.
The coverage gap, also known as the “doughnut hole” is a temporary limit on what Part D, the drug plan, will cover for prescription drugs. In other words, the doughnut hole is defined as the period where you pay for your drugs out of pocket.
Not everyone will enter the doughnut hole. The doughnut hole begins only after you and your plan have spent a certain amount on covered drugs. In 2017, that doughnut hole or gap starts when total drug costs reach $3,700. If a beneficiary is in that hole, they get a 60 percent discount on brand-name drugs and a 49 percent federal government subsidy for generic medications.
In addition, there also is catastrophic coverage where the government starts picking up most drug costs when out-of-pocket expenses for a patient are over $4,950.
It is always a good idea to check into your health insurance options periodically. It is important for you to understand your coverage and how it changes.
There are a number of opportunities to enroll in Medicare. Being aware of all the possible enrollment periods can help you avoid penalties.
There are multiple enrollment windows in addition to the initial seven-month initial enrollment period. If you missed signing up for Part B during the initial enrollment window, you are not working or are not covered by a spouse’s health insurance through work, you may sign on for Part B during the general enrollment period from January 1 to March 31. If you sign up during that period, you coverage begins July 1. However, you will pay a life-penalty of 10 percent for each 12-month period you did not sign up for Part B.
If you are currently working and are covered by an employer’s plan, you may sign up later without penalty during a special eight month enrollment period applicable if you lose employer health care coverage. If this special enrollment period is missed, you need to enroll in the general enrollment phase.
The open enrollment period, from October 15 to December 7 every year, permits you to change Part D plans or Medicare Advantage for the next year. Note that you may now change Medicare Advantage plans outside of the open enrollment period if you choose a plan with a government awarded five-star quality rating.
Ideally, it is best to sign up for Medicare early, but you can certainly wait until your 65 birthday. It is important to remember though that signing up late may incur penalties that increase your monthly payments permanently.
If you already receive Social Security benefits, you are automatically enrolled in Parts A and B. You can opt out of Part B, since is has a monthly cost. However, if you choose to keep it, the premium cost will be deducted from your Social Security benefits.
If you are not on Social Security, you have to sign up for Parts A and B yourself. Starting three months before your 65 birthday, there is a seven-month period referred to as an initial enrollment window that begins. This window closes three months after your birth month. To make certain you get coverage for when you turn 65, you need to sign up in the first three months.
You may be able to delay signing up for Medicare is you are still working and your employer is providing health insurance or if you happen to be on a working spouse’s health insurance plan. If you lose coverage provided by an employer, you must sign up for Medicare within eight months to avoid serious penalties when you enroll.
Each year the government releases the costs for Medicare premiums for the coming year. While Part A, hospital insurance, is free for most people, the premiums for Part B — doctor visits, tests and procedures — and Part D, drug coverage, are paid for by the beneficiaries.
The amount payed in premiums is based on your income tax return from two years prior to the current fiscal year. There are five income thresholds on which premiums are calculated from. If your income is above a certain threshold then your Medicare premiums may also be higher. It is best to check annually, with a knowledgeable insurance agent, for any changes in the income thresholds. This is important to remember because if your increases you will likely pay more in premium for Parts B and D.
For example if your adjusted gross income as a single taxpayer, plus tax exempt interest, is over $85,000 or your income as a married couple and filing jointly is $170,000, Medicare premiums for Parts B and D can come with a surcharge.
In 2017, higher wage earners’ premiums range from $187.50 a month to $428.60 a month for Part B. For Part D coverage, high earners pay an extra charge from $13.30 to $76.20 in addition to regular premiums.
Since these numbers change based on the wages you earn and any changes in the health insurance coverage requirements, it is best to speak to a health insurance carrier to determine what you may be paying for premiums each year.
