medicare

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2018 Medicare Part D

by Kristin P. Sinclair – A Accu Tax – October 9, 2018 – Rock Hill, SC

2018 Medicare Part D is PDP or Drug Coverage, and Medicare Part D has different stages. Some plans will have a deductible of $405.00 and then co-pays and co-insurance begins based upon your specific plan design, and cost sharing formulas. Some plans do not have a deductible to be met, and those plans could have a higher monthly premium or possibly some other format which helps to limit your exposure. But all Medicare Part D providers must meet specific guidelines and must have a plan that has been approved by Medicare. And must offer coverage for the 100 categories of medications that Medicare has determined that Medicare beneficiaries need to have coverage options for.

The initial Co-pays and co-insurance will apply until the true cost of medication covered by the Part D plan have reached $3,750.00 in 2018. Then the beneficiary goes into the next phase the Coverage Gap or Donut Hole. Your cost sharing then is a 65% discount off the cost of name-brand medication in the formulary. With your cost sharing you pay the other 35% for your medications while you are in the coverage gap. For generic drugs on the formulary you get a 56% discount of the price while in the donut whole, this means you pay the remaining 44% of the cost of your generic medication in the formulary while in the donut hole.

With your Medicare Part D Plan once your share of the out of pocket costs for the medications paid reaches, $5000.00 you enter the next stage which is called the Catastrophic Coverage Stage. In this stage, you will pay, $3.35 for generic drugs or 5% of the drug cost, and you will pay, $8.35 for name brand drugs or 5% of the drug costs on the monthly basis. Anyone who entered the catastrophic phase would see that phase throughout the balance of the annual period.

There are people who qualify for LIS or Low Income Subsidy and receive extra help from the government due to the limited amount of income and assets they have. Folks with LIS see different cost sharing levels than those who do not qualify for LIS benefits.

It is worth noting, that most Medicare Part D beneficiaries never leave the 1st stage or the co-pay stage during the annual period which occurs after any applicable deductible has been paid. Please also note that while those folks who do reach the gap or donut hole stage, those folks would pay 35% of the cost of your name brand medication while in the gap stage of coverage, the drug manufacture is also paying 35% of the cost of that same medication for your benefit. That additional amount the drug manufacture has been paying for you counts toward your out of pocket exposure, and can get you the Catastrophic stage sooner.

So Very Important – Your Formulary Choice
Why is it important to have your medication covered by your formulary for the annual period ? It is important so that you can minimize your out of pocket exposure when possible. If a medication is not covered by your formulary it is possible you could be responsible for all costs. An exception to your formulary could be agreed upon between your Medical care practitioner and your Medicare Part D provider. The exception requires your medical practitioner to provide supporting reason that an exception is a necessary option for your care and well being. Often the Medicare Part D Plan will want you to start with any available generic alternative at the more affordable rate. If necessary then to start a step by step method prior to using the more expensive medications exception. Once again your Doctor is going to be very involved in any request for an exception to a formulary.

These are good reasons to review your current medication(s) on an annual basis prior to the Annual Enrollment period of October 15th through Dec 7th. This is the time to choose the Medicare Part D Plan which best meets your medication needs for the up coming annual period. Your preferred pharmacy location should be convenient and included in your plan preferred pharmacy provider list. Since medications can change during the annual period, discuss your formulary with your health care practitioner(s). It is possible that an affordable alternative is already included in the formulary you have selected. Your Medicare Part D Plan is an important part of providing for your overall healthcare needs. Always take the time to choose wisely grasshopper!

Updated in Rock Hill SC
by Kristin P Sinclair (803)329-0615

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When is it Best to Buy a Medicare Supplement ?

by Kristin P. Sinclair – Rock Hill SC – October 9, 2018

The very best time to buy your Medicare supplement is during your Open Enrollment Period(OEP). Normally this period lasts for six months starting with the first day of the month you are 65 or older and are also enrolled in Medicare Part B. For those under age 65* there may be additional Open Enrollment Periods in certain states.

During your Open Enrollment Period an insurance company cannot refuse to sell you any Medicare Supplement Policy they offer; charge you a higher rate than that company might charge someone in good to excellent health; or make you wait for your coverage to begin. Please note that the insurance company may make you wait for up to six months for pre-existing condition coverage. That is a condition that you would have prior to your Medicare Supplement coverage starting. This period of time is called a pre-existing condition waiting period. After six months, your Medicare Supplement Policy will cover any pre-existing conditions.

If you make a change from one Medicare Supplement to another after becoming Medicare eligible, and you have not had a lapse in coverage with your prior provider; then you will have underwriting.   you can shorten, the period where a waiting period would be applicable. It is possible to shorten or eliminate any pre-existing condition waiting periods if you have Creditable Coverage before you apply.

An insurance company cannot subject you to any pre-existing condition waiting period if you have been covered by your employer health plan which is Creditable Coverage; if you are still working full time and opted to delay Part B until you have decided to move your coverage to include your Medicare Part B coverage, or if you have had at least six months of Creditable Coverage. Please note that you cannot have had a 63 day break in coverage between your Creditable Coverage and your Medicare Supplement coverage.

You need to include your letter of creditable coverage with your application unless you are new to Medicare Part B.

It is also important to keep in mind that your Medicare Supplement rights are based upon when you enroll in Medicare Part B. For those age 65 and older, your Medicare Supplement Open Enrollment Period begins when you enroll in Medicare Part B. This period cannot be change or repeated. Thus, if you have employer or union group health coverage that is as good or better than original medicare, then you may want to wait until later to enroll in Medicare Part B. Most group health coverage provides benefits similar to Medicare Part B; and also having Medicare Part B might be an unnecessary duplicate expense. Worse yet, your Medicare Supplement Open Enrollment Period might expire before you need it.

In summary, for those age 65 and over, when you are first eligible you have the right to buy any Medicare Supplement Policy offered in your state. This gives you more choices, and normally lower monthly premiums. So during the Open Enrollment Period, a person with health issues can buy a Medicare Supplement for the same lower prices as those with no health issues.

 

Kristin P. Sinclair (803)329-0615
Rock Hill SC

* For those under age 65 that have Medicare Coverage due to a disability, and suffer End-Stage Renal disease there may be limitations to their coverage options.

KPS: More information available at Medicare.gov

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Questions for Home Health Care Provider Interviews

by Donn J. Sinclair, MBA – October 3, 2018

When recovering from an injury or illness, your Medicare coverage and your Medigap or Medicare Supplement may pay some of the Home Health Care costs that you incur. When selecting a home care agency for you or a loved one, there are important questions to ask when interviewing home health care agencies.

  • Private duty home care – what year did the agency first offer that service ?
  • State licenses – are the agency staff and home health care agency properly licensed in your state ? More specifically, properly licensed to provide care level your physician ordered ?
  • Which home health care agency staff member coordinates with the patient’s physician to implement the physician developed plan of care ? The plan is evaluated and updated by the agency on what schedule ?
  • What daily notes are maintained to monitor the progress of the patient ?
  • Who and how is quality of care supervised and updated ? How frequent are unscheduled agency supervisory visits on the agency staff?
  • What are the home health care agency ongoing training mandates for their caregivers ? Who supervises the training ?
  • How and by whom are after normal business hour emergencies handled ?
  • Does the home health care agency have on staff nurses, social workers, physical therapists, and other qualified professionals available to provide needed in home care ? If not, with which providers does the home health care agency have an established working relationship ?
  • How do you obtain a written copy of the home health care agency’s privacy policy, ethics code, and mission statement ?
  • What screening techniques are used to screen caregivers ? Do these include reference checks, driving records, credit checks, and criminal background investigations ?
  • Are the home health care agency caregivers W-2 employees or W-9 subcontractors ? Are there any home health care agency incidents of failure to file payroll tax reports, or incidents where the agency failed to pay taxes on a timely basis ?

When it comes to selecting a home health care agency, you should follow the Boy Scouts motto “Be Prepared”. Make certain that you and your loved ones get the care they require and deserve. Also make certain that Medicare and your Medicare Supplement pay as they should for the care received.

 

Donn J. Sinclair, Winthrop MBA

in Charlotte NC and Rock Hill SC

October 3, 2018   (803)329-0609

 

DJS: More information is available at Medicare.gov

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Part B covers 2 types of services, and it’s great to have those protections

by Kristin P. Sinclair – A Accu Tax – August 15, 2018

Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.

Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment.

Learn More


Medicare and Yes, I Have Choices

by Kristin P. Sinclair – Charlotte NC – August 15 2018

Other items to include in your decision making when it comes time think about health care.
Which Health Care practitioners(s) you wish to offer your health care during the year. Does the provider accept Medicare, if yes, then they will accept your Medicare supplement as well.

Next question, when the health care provider accepts Medicare, do they accept the Medicare Advantage plan you are considering. Well, you need to verify that before you make you plan decision. Health Care providers have the option to either accept a Medicare Advance Plan as an insurance option, or possibly they could make a choice to not accept Medicare Advantage plans. Many Advantage Plans are Network Based.  Many Advantage Plans have a geographic area that offer the particular plan design. The Providers that accept the Medicare Advance Plan will usually be geographically accessible to that specific plans area.

Original Medicare is a Federal Program, Insurance products which work with the Original Medicare follow both Federal and State Guidelines.  Original Medicare will provide coverage with in the United States. Medicare Part A offers coverage to help with the costs for a Medically necessary  in patient hospital stay(s), with applicable Deductible and Co-Insurance cost sharing. When you select  a  Medicare Supplement plan, you are selecting a plan to help fills the gaps in Original Medicare.
Medicare Part B is the out patient care portion of medicare, Medicare Part B has an annual deductible and co-insurance cost sharing as well, the Medicare Supplement plan you select will offer coverage  to help fill gaps in the Original Medicare.

Helping to fill the gaps in the Original Medicare is going to reduce your out of pocket costs associated with health care.

Medicare Advantage Plan often you must use providers who accept your plan, and the plan could have limits on where you can travel and still have access to benefits if not in an emergency situation. And If you travel away from home for a period of greater than 2 months, you might need to change your plan, because of the amount of time you have chosen to be away from home.  Medicare Advantage plans have specific geographic regions, states, or counties that they offer coverage. MA will have annual contracts with Medicare, they must be as good as Original  Medicare and they will have Out of Pocket limits annually which can change per annual period.  Often the MAPD (Medicare Advantage Prescription Drugs) will be one policy choice for Hospital, Out patient and Drug plan coverage.

Stand Alone Prescription Drug plans are approved  Federally,  Center for Medicare Services, and  are State specific.  Stand Alone Medicare Part D covers the medications which are not administered under Medicare Part A or Medicare part B, Medicare Part D medications will usually be the medications you fill at your preferred local pharmacy or the mail order service your Part D provider has in place for your benefit as a potential cost saving opportunity when you seek a 90 mail order alternative. Using your plans  Preferred Mail order provider might offer you savings through out the Annual Period. A Medicare Part D plan will help round out your coverage when you select a Medicare Supplement.

From Oct 15th though Dec 7th each annual period you have what is called the annual Enrollment period, also called the Open Enrollment period. This is a time that you will review various Medicare Part plan and various Medicare Part C plans to decide what change you will make for the coming year. If a change is indicated.

However, Medicare Supplement or MediGap plans do not have the Annual Enrollment Period.
You can keep your plan as long a you pay your premiums. You have the opportunity to change your Medicare supplement plan any time of the year. As long as you can pass any underwriting requirement which might be applicable.

If you move to another state, you have guarantee issue rights so long as you make your change within 63 days of the change of residents.  Always keep a record of which plan you have and keep your letters you receive from your plan pertaining to your rights. Medicare has protections in place for your benefit.  We live in a mobile culture. It is great that we have the protections available to us, especially after our life time of work. We certainly deserve the protections that Medicare makes available to us.

 

Kristin P. Sinclair (803)329-0615
Charlotte NC, Rock Hill SC and Charleston SC
August 15 2018

* For those under age 65 that have Medicare Coverage due to a disability, and suffer End-Stage Renal disease there may be limitations to their coverage options.

KPS: More information available at Medicare.gov

 

 

 

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What Are Medicare Supplements ?

by Kristin P. Sinclair  – A Accu Tax  – September 12, 2018

Medicare Supplements are policies sold by private insurance companies. Medicare supplements are designed to help pay many of the health care cost not covered by Original Medicare.

Medicare Supplement plans are standardized. Meaning the basic plan design with a Letter Designation such as Plan F or High Deductible Plan F, Plan G,  Plan L or Plan N, has a standard set of benefits for that particular Letter used to describe what basic standard features are in the plan. Some companies will offer Value Added Benefits above and beyond the Supplemental Benefit.

Some companies will not have a plan which has added Value Added Benefits above and beyond the Supplement Benefit. Some companies will indeed have Value Added Benefits, so as a consumer you will want to ask your agent about things which you as a consumer are interested in to determine a plan which might be suitable for you needs.

 

Updated in Charlotte NC and Charleston SC

by Kristin P. Sinclair   A Accu Tax – Rock Hill SC

(803)329-0615   September 12, 2018

KPS: More information is also available at Medicare.gov

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Part B covers 2 types of services, and it’s great to have those protections

by Kristin P. Sinclair – A Accu Tax – August 15, 2018

Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.

Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment

Part B covers things like:

  • Clinical research
  • Ambulance services
  • Durable medical equipment (DME)
  • Mental health
  • Inpatient
  • Outpatient
  • Partial hospitalization
  • Getting a second opinion before surgery
  • Limited outpatient prescription drugs

2 ways to find out if Medicare covers what you need

  1. Talk to your doctor or other health care provider about why you need certain services or supplies. Ask if Medicare will cover them. You may need something that’s usually covered but your provider thinks that Medicare won’t cover it in your situation. If so, you’ll have to read and sign a notice. The notice says that you may have to pay for the item, service, or supply.
  2. Find out if Medicare covers your item, service, or supply.

Medicare coverage is based on 3 main factors

  1. Federal and state laws.
  2. National coverage decisions made by Medicare about whether something is covered.
  3. Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.

 

For more information, view the official medicare.gov website: https://www.medicare.gov/

Kristin P Sinclair

@Sinclair Financial Solutions

803-329-0615

August 15, 2018

Rock Hill, SC 29730