Original Medicare Rehabilitation

Rehab, or Inpatient Rehabilitation Care, is part of Medicare Part A or “Hospital Insurance.” To learn more about what Part A covers, click here.

Rehab administered in an outpatient setting or by doctors / medical providers can be covered by Part B when considered necessary by Medicare Standards. One example of a covered program is Cardiac Rehabilitation Programs.

“Medically Necessary”

Original Medicare will pay for part of your rehab in most cases if your care is considered “medically necessary” by CMS (Center for Medicare and Medicaid Services) standards.

According to CMS, medically necessary rehabilitation requires:

• certification by a doctor that you have a medical condition that requires rehab
• continued professional medical supervision
• coordinated care from doctors and therapists

How Many Days does Medicare Pay for Rehab?

If you only have Original Medicare, you will have costs associated with rehab for each benefit period.

• For the first sixty days, a deductible will apply (in 2020, $1,364).
• After that, a $341 coinsurance will apply to days 61-90, and $682 coinsurance from day 91 and beyond.
• Finally, if you are going beyond 91 days in rehab, you will only have 60 more “lifetime reserve days” for coverage. What this means is that Medicare will only cover 60 rehab days total in your lifetime after you hit the 90 benefit period limit. These lifetime days do not start over each year. As a result, if you run out of lifetime reserve days, you will be paying 100% of all costs for rehab when you run out.

For more information on inpatient rehab, please visit this medicare.gov page.

Medicare Supplements (Medigap)

Medicare Supplements are designed to pick up the costs that Original Medicare does not cover (such as deductibles, coinsurance and co-pays.)

Click here to read more about Medicare Supplements.

There are some Medicare Supplements that pick up just about all costs that Medicare does not pay. (As long as they are “covered services.”) You can consult this chart to see what plan pays what.

Medicare Plan F and Plan G offer the most extensive coverage and among the most popular plans.

• Click here to learn more about Medigap Plan F
• Click here to learn more about Medigap Plan G

Medicare Advantage Rehab Coverage

Private insurance companies run Medicare Advantage plans. They are designed to “replace” Original Medicare. They cover at least what Original Medicare covers plus they offer additional coverage and extra benefits and services to their beneficiaries.

• You can learn more about Medicare Advantage here.
• In addition, you can learn about the differences between Medicare Advantage and Medigap Plans here.

Each Medicare Advantage Plan will be different in regard to their Medicare rehab coverage. However, they most often offer additional coverage or a different structure as to how they cover rehab days – both inpatient and outpatient.

Additionally, all Medicare Advantage Plans (also called MA / MAPD plans) are required to have a “max-out-of-pocket” limit for each annual benefit period. This means that you will not pay more than that predetermined amount each year for your covered health services.

Now that we have looked at the various plans and how long they cover rehab, let’s look at a few specific examples that Medicare addresses.

Does Medicare Pay for Physical Therapy?

Sometimes, when people ask if Medicare pays for rehab, they are referring to outpatient physical therapy.

Medicare covers some costs for outpatient physical therapy when it is considered “medically necessary” as we defined earlier in this article.

Medicare Part B helps pay for physical therapy, and if you only have Original Medicare, you will pay 20% of your medical costs.

How Long Does Medicare Pay for Physical Therapy?

According to CMS, “Medicare law no longer limits how much it pays for your medically necessary outpatient therapy services in one calendar year.”

Finally, always remember to make sure that your physical therapy is considered both medically necessary and a Medicare covered service. If it is not, you may end up paying for all of it.

How Long Does Medicare Pay for Cardiac Rehab?

If you have recently had a heart attack or some other cardiac event (see here for more information on what “events“ CMS covers), Medicare will cover most costs for Cardiac rehabilitation programs. These programs usually are covered for as long as they are needed.

Medicare covered costs can include both regular cardiac rehab and “Intensive Cardiac Rehabilitation” Programs (ICR).

According to CMS, programs can address exercise, education and counseling in some form, and can either be held in an outpatient hospital setting or at a doctor’s office.

In regards to costs, just remember…

• Original Medicare will cover 80% of approved medical bill amounts under Part B. (Part B deductibles may apply).
• If you have a Medigap Plan (aka Medicare Supplement) then that plan will pick up additional costs according to your plan’s letter specifications. (See the Medigap chart above or visit our Medigap Page for more information.)
• Or, if you have a Medicare Advantage Plan, your plan will list out how it covers cardiac rehab costs and what your copayments will be, if any.

How Long Will Medicare Pay for Nursing Home Rehab?

If you need rehab that extends beyond a stay as an inpatient at a regular hospital, your doctors may transfer you to a “Long-Term Care Hospital” (LTCH). Long-Term Care Hospital stays are different than living in a Long-Term Care facility (also called a nursing home). They are still considered a hospital setting, so they are covered by Medicare Part A.

Under Original Medicare, your coverage lengths and payment amounts are the same as the inpatient rehab amounts we detailed out above in the section, “How Many Days does Medicare Pay for Rehab?.” Or, you can find them on the government website here.

However, your benefit period does not start over if you are transferred from one hospital to another (including a LTCH). So, you will not have to pay another deductible.

Conclusions

We understand that Medicare rules and costs are often confusing. This is especially true when you are confronted with rehab options. Your coverage lengths and costs will often be different depending on how you have your Medicare coverage set-up.

If you need more help in answering questions regarding your specific plan, you can reach out to your insurance agent or plan directly. If you are looking for an agent, you can contact us for help.

The post How Long Does Medicare Pay for Rehab? appeared first on Medicare Life Health.

When does Medicare pay for stem cell therapy? The answer is: in a limited amount of cases.

Stem cell therapy is still controversial and expensive. Moreover, there are limited amounts of studies available on specific therapies and procedures. As a result, Medicare’s coverage of stem cell therapies, including transplants, is minimal.

If you have a sick loved one, or if you yourself are sick, it makes sense to want to research every option available for quick healing. During your search, you may run into “stem cell therapy” as a treatment option. Sometimes, stem cell news can bring up confusing and conflicting stories. Let’s start with the basics of stem cell therapy and then discover what Medicare covers for treatments.

What is a Stem Cell?

To start, according to the Mayo Clinic, a stem cell is a “master cell” that forms a base for the creation of all the body’s other cells. (For example, brain cells, organ cells, blood cells or bone cells.) That is a simple way to look at a complex body function.

However, the main take away is, stem cells are the ONLY cells that naturally have the ability to generate new cells.

Because of their generative ability, the study of stem cells holds great possibilities for healing diseases. As a result, researchers call stem cell therapy “the next chapter” in healing our organs, blood and tissues. Effectively, reducing the need for organ transplants.

What is Stem Cell Therapy?

Doctors and researchers are creating and studying new procedures every year that will help heal organs, but the science is still new, and the verified and approved procedures and treatments are few and expensive.

Stem Cell Therapy is also called regenerative medicine. According to the Mayo Clinic it, “promotes the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives.”

Stem Cell Therapy is a fascinating subject for anyone needing an organ transplant or experiencing organ dysfunction / organ failure. Organ donors are few and transplant lists are long. The possibility of stem cell therapy being able to be a solution is promising and exciting.

In addition, there is also hope that stem cells will be able to offer treatments in spinal cord injuries, diabetes, Parkinson’s, and heart disease.

However, not only is research expensive, it is also controversial.

So, What is the Controversy Behind Stem Cell Therapy?

The controversy behind stem cell therapy lies within where the studied stem cells are harvested. You can get stem cells from embryos, adult tissues, or even, as more recently discovered, in amniotic fluid as well as umbilical cord blood.

However, the best, more versatile stem cells are embryonic stem cells. Not only do these cells have more regenerative potential, but they also are not changed or affected by any environmental factors (like adult cells would be.)

Harvesting stem cells leads to strong ethical debates on “personhood” and whether or not researchers should be using embryos for stem cells. You can read more on that debate here.

What Does Medicare Cover for Stem Cell Therapy?

As mentioned, because the science is new and studies on procedures and their affects are limited, Medicare has a very limited coverage of Stem Cell Therapies. The CMS (Centers for Medicare and Medicaid Services) closely follow the recommendations of the FDA (Federal Drug Administration) on what procedures are considered necessary and effective.

According to the CMS, Medicare Part A covers stem cell transplants under “certain conditions”. (Part A is also responsible for transplant coverage.) Usually, these conditions start with having you try other Medicare-approved options first if stem cell therapy is not the charted first course of action.

First, know that coverage can be different in each state. However, when procedures are standardized, CMS will release new information on what is Medicare-approved nationally.

Examples of Medicare-Approved Stem Cell Therapies

The CMS has a page on “Coverage with Evidence Development,” and on this page you can find new information on coverage and research. For example, on this page, you can see information on “Allogeneic Hematopoietic Stem Cell Transplant for Multiple Myeloma.” In regards to this specific disease, stem cell therapy was approved by CMS for Medicare coverage in this specific way:

“CMS will cover items and services necessary for research under §1862(a)(1)(E) for a allogeneic hematopoietic stem cell transplant (HSCT) for certain Medicare beneficiaries with multiple myeloma (MM) using the Coverage with Evidence Development (CED) paradigm. “

https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/allo-MM

You will also find additional information on the CMS website for the following stem cell therapies:

• Allogeneic Hematopoietic Stem Cell Transplant for MDS
• Allogeneic Hematopoietic Stem Cell Transplant for Multiple Myeloma
• Allogeneic Hematopoietic Stem Cell Transplant for Myelofibrosis
• Allogeneic Hematopoietic Stem Cell Transplant for Sickle Cell Disease

Another example, is AuSCT or Stem Cell Therapy/Transplantation for Amyloidosis

According to CMS, AuSCT can treat AL Amyloidosis, a “rare blood disorder” affecting your heart, kidneys, nervous and gastrointestinal systems.

In this transplantation, stem cells are retrieved from a patient’s bone marrow or blood, stored, and then transplanted back into the patient following high dose chemotherapy used to treat various cancers.

Read more here.

National Coverage Listings are Not All-Inclusive

Of course, that list does not cover all the potential uses for stem cell therapy, but it is a place to start. Additionally, since each state’s Medicare coverage can be different, your medical providers and doctors are good places to go for Medicare coverage questions.

Where Can You Receive Medicare Covered Stem Cell Treatments?

Very few medical facilities have the equipment or expertise for specific stem cell therapies. For this reason, approved stem cell transplants (and cornea transplants) are not limited to just Medicare-approved facilities.

This flexibility can be good news for Medicare beneficiaries looking to schedule these unique procedures. On the other hand, according to Medicare.gov, all other transplants, must be done at Medicare-approved centers and facilities.

Does Medicare Cover Stem Cell Therapy for Knees?

One popular use for stem cell therapy is repairing injured knees. Unfortunately, it is not covered by Medicare at this time. In addition, stem cell therapy is not Medicare-approved for other stem cell treatments for arthritis and joint connection issues (i.e. tears and pain in ligaments and tissues).

You can certainly go outside of your Medicare coverage to have these treatments done, but be careful of clinics using non-FDA-approved techniques and making unsubstantiated claims. You can read the FDA’s warning here.

Conclusions

In Summary, if you are wondering “is stem cell therapy covered by Medicare?”

• Your best first step is to consult with your doctor and medical providers to get information on what specific therapies would be applicable to your unique situation.
• Then, specifically ask them about stem cell therapies available.
• Remember, each area of the country might have different rules and treatments available.

The post Does Medicare Pay for Stem Cell Therapy? appeared first on Medicare Life Health.

Attained Age vs Issue Age

Medicare Supplement Insurance Companies all price their plans differently. One of the biggest differences between plan prices is whether or not an insurance company uses attained age vs issue age to price their Medigap plans.

Background Information: What is a Medicare Supplement?

Medicare Supplement plans, also called Medigap Plans since they cover the gaps in Original Medicare coverage, are issued by private insurance companies.

Click here to read a simple, but comprehensive introduction to Medicare Supplement (aka Medigap) Plans.

Standard Coverages from Each Medicare Supplement Plan

The government tells each company what should be included/covered in each Medigap Letter Plan. As a result, they are standard in coverage. However, the insurance companies can price each plan differently, and each company does so according to its needs in each market (part of the country) they sell in.

Medigap Costs & Pricing Considerations

The way each private insurance company prices its plans has an effect on what the plan will cost you now, and then again down the road as premiums are re-evaluated each year.

Medigap Plans do tend to increase in price each year (some more than others if new people cannot enroll in them, such as Plan F or C).

Shop Your Plan, While You are Healthy

As a result, it is a good idea to shop your Medigap Plan year to year if you are still healthy enough to get medically underwritten into a new plan. (What this means is, switching Medigap plans, when you are not guaranteed to be issued one, is dependent on you being healthy enough for an insurance company to accept you into the new plan.)

• Call an Independent Insurance Agent to see what options are available to you in your area. (Ask about Plan G.)
  
• Call Carly, your Medicare Author and Independent Agent if you life in Nebraska or Iowa. Or if you live elsewhere, find an agent here.

Attained Age vs Issue Age vs Community Rated Pricing

Remember, when you are comparing private insurance companies plans, pricing is the only difference between letter plans. The coverage is the same for each letter plan, and set by the government, so pricing is your biggest consideration.

Additionally, you need to consider HOW the plan is priced, not just WHAT each plan costs. The way each plan is priced will affect how the price changes year-to-year.

There are three ways that insurance companies can price their Medigap Plans: Attained Age, Issue Age, and Community Rated Pricing.

Attained Age Pricing of Medigap (Medicare Supplement) Insurance Plans

Attained Age Plans are priced (or rated) based on your current age.

Medigap plans that use this pricing are based on your attained age. Your plan price rises as you get older. Premiums might start lower for younger beneficiaries on these plans, but when they hit certain ages set by the plan, their premiums will increase.

Attained age plans can also go up because of other factors (such as inflation or company actuarial assessments.)

Issue Age Pricing of Medigap Plans

Issue Age Rated Policies (or “entry age-rated”) have premiums based on the age you are when you purchase your plan. Or, as CMS puts it, when you are “issued” the plan. For example, when buying a new plan, a 70-year-old beneficiary will pay more for the same plans as a 65-year-old beneficiary.

This means that the younger you are when you buy this kind of policy, the less you will pay for it. In addition, the policy will not go up in price as you age, because of your age. It may go up for other reasons, but not because of your age.

Community Rated Pricing of Medigap Plans

The CMS (Centers for Medicare and Medicaid Services) and private insurance companies sometimes call Community Rated Plans “no-age-rated” plans, as their pricing has nothing to do with the age of their beneficiaries.

The price of the plan is not dependent on your age. If the plan goes up, it is not because your age went up. The increase in price may have been dependent on other factors (such as inflation).

Other Pricing Considerations

Insurance companies have other ways to raise or lower their Medigap Plan prices. According to CMS, these include:

• Plan discounts like household discounts, smokers ratings, or payment processing discounts.

• Discounts for people that apply through medical underwriting versus being a guarenteed issue.

• Using “Medicare Select” network providers in certain types of plans.

• Choosing “high-deductible” versions of specific Medigap letter plans.

Conclusions and Actions

In conclusion, since each private insurance company can price their plans differently, it is important to ask how your current supplement is priced or supplements you are considering are priced.

The pricing structure affects not only what you are paying now for your Medigap plan, but what you will also be paying in future years.

Again, call Carly, your Medicare Author and Independent Insurance Agent if you life in Nebraska or Iowa. Or if you live elsewhere, find an agent here.

Further Reading

• Read this article, if you need guidance on deciding what Medicare Plan type is right for you.

• Start here, if you need to learn the basics of Medicare, who can get it, and what it covers.

• Need to know how to apply for Original Medicare? Read this.

• Need Part D Coverage Information? Read this article on Prescription Drugs Coverage.

• Finally, start with this article, if you want to read the differences between the two paths of Medicare: Medicare Advantage vs Medigap.

The post Attained Age vs Issue Age appeared first on Medicare Life Health.

Medicare Easy Pay is the automatic payment system set up by CMS to pay your Medicare Premiums.

CMS (The Centers for Medicare & Medicaid Services) offers Medicare Easy Pay for Part A and Part B Premium Payments from a checking account or a savings account. (Most people get Part A at no cost, so people typically use Easy Pay for just Part B premiums.)

If you sign-up for Easy Pay, then your premiums will be automatically deducted from the account you specify.

How Do You Sign-up for Medicare Easy Pay?

Well, I wish I could send you straight to a website with a secure enrollment option, all done online. However, it does not exist at this time. Instead, you will have to fill out a paper enrollment form and mail it in.

Enroll By Mail

Mail a completed Authorization Agreement for Pre-authorized Payments form [PDF, 117 KB] (SF-5510) to:

Medicare Premium Collection Center
PO Box 979098
St. Louis, MO  63197-9000

From Medicare.gov

In addition, if you are already signed-up for Easy Pay, but you want to make a change, this is also the address you will send the same form into. Just add the changes you want to make on that same form you would send in for new Easy Pay Enrollment.

Enroll in Person

Alternatively, you can also go to your local Medicare / Social Security office and make an appointment to submit your information through the office.

Railroad Benefits Differences

If you are with the Railroad, your options are different. You will need to send your payments in by mail, or set-up a “bill-pay” option with your bank for them to monthly mail the money into this address:

RRB, Medicare Premium Payments
PO Box 979024
St. Louis, MO 63197-9000

If you are retiring with Railroad Retirement, please read our about your benefits and choices with Medicare here.

How Does Medicare Easy Pay Work?

After you sign-up for Medicare Easy Pay by sending in your enrollment application, then the Center for Medicare and Medicaid Services (CMS) will take 6 – 8 weeks to process your application.

Remember, it is important to pay any billed premiums in the mean time.

Then, when you are set-up, CMS will monthly send you a Monthly Statement, called a “Medicare Premium Bill.” However, this is just for your reference, and you will not have to pay it when you are set-up for Easy Pay as it will be deducted from your account monthly now. CMS has a diagram to help you read this document here.

Medicare.gov also states that premiums typically come out of your checking or savings account around the 20th of the month.

Further Reading

Finally, to learn more about Medicare Insurance, here are some of our most useful articles:

• What is Medicare Advantage?

• Medigap vs Medicare Advantage

• What are Medicare Supplements?

• What are the 2020 Changes for Medicare and 2020 Part B Premiums

• How to Choose a Medicare Plan?

• What is Medicare Part D – Prescription Drug Plans?

The post Medicare Easy Pay appeared first on Medicare Life Health.

The Medicare and Medicaid Difference Guide helps you understanding both services, so you can make the best decisions for yourself and your loved ones.

The United States has two separate national health care systems: Medicare and Medicaid. The government created the two programs for two different kinds of people. However, they often overlap. Let’s look at both programs, including their similarities and difference. We will also look at who needs or qualifies for each program.

Let’s Start with Medicare vs Medicaid.

What is Medicare?

Medicare is the U.S. national health care program that provides seniors age 65 and older, and some disabled people, with health insurance.

The U.S. government started the program in 1966. The Centers for Medicare and Medicaid Services runs these programs. Medicare also covers people with end stage renal disease and amyotrophic lateral sclerosis.

Medicare does not cover all of the costs associated with health care. As a result, people with Medicare will also use a Medicare Supplement Insurance Plan (Medigap Plan) or a Medicare Advantage Insurance Plan to round out their care coverage.

Please read our Ultimate Guide article on “What is Medicare.“

What is Medicaid?

Medicaid is the United States National Health Care System that provides health coverage to over 64.7 Million People.

The program was created for people with low-incomes that cannot afford, or do not have access to, private healthcare insurance.

How are the programs similar?

The programs are both National Health Care Systems. In fact, they are the only two nationalized heath care systems the United States has. Many other countries around the world have much more extensive national coverage for their citizens. The U.S. has a limited program for specific age, income, and health groups, and the rest of the country relies on private health insurance.

In addition, both programs cover specific hospital services, doctor services, and other health care related services.

Medicare has four parts. First, Medicare Part A, also known as “Hospital Insurance,” helps with coverage regarding: inpatient care, home health care, nursing facilities, and hospice.

Second, there is Medicare Part B, also known as “Medical Insurance.” Part B helps with coverage related to doctor and other provider services, including: doctors visits, health care providers, outpatient, prevention services, and medical equipment. Medicare Beneficiaries pay for Part B.

Finally, Medicare has a Prescription Drug Program that is administered by private insurance carriers. Click here to lean more about What Medicare Covers and Medicare Parts A, B, C and D are.

Both Medicaid and Medicare Advantage Plans can be set up as managed care plans with networks of doctors and hospitals members have access to. If you would like to learn more about how these networks work, please read, HMO vs PPO – Which is Better?

How are the programs different?

One of the biggest differences between the two programs is who runs them. Medicare is run on a national level, by the Federal government. On the other hand, Medicaid is run by each state individually.

Of course, the biggest difference is the the different populations the programs serve:

• Medicare – For Seniors over age 65, and some disabled people
• Medicaid – For people with low income and few resources

Medicare and Medicaid Differences in Beneficiaries – Who Gets What Program?

The U.S. government created Medicare and Medicaid to take care of different “vulnerable” populations – the poor, the disabled, and the elderly. Let’s look at each program and population.

Who should get Medicare?

Anyone who is a citizen or qualified resident of the U.S. can enroll in Medicare when they turn 65 years old. There is a seven month window of time starting three months before turning 65, the month of your birthday, and then three months after your birthday month.

How do I Sign-up for Medicare?

First, you may be automatically signed-up if you are already receiving Social Security (SS) or Railroad Retirement (RRB).

Second, if you are not already receiving SS or RRB benefits, you must sign up for it when you turn 65 years old.

Conversely, if you are not ready for Medicare when you turn 65, you must notify the government that you want to delay your benefits. If you do delay, it must be because you have credible coverage in place. An example of this would be an employer plan.

Click here to read more about Medicare, including where to go to enroll.

From Our Article What is Medicare? A Guide to All Medicare Basics

Supplemental Medicare Insurance Options

Medicare picks up about 80% of the health care costs for its beneficiaries. For the other 20%, seniors turn to either Medicare Supplements (aka Medigap Plans) or Medicare Advantage Plans. Click here to read our article on Medicare Advantage vs. Medigap, or see the informational articles below.

Who should get Medicaid?

Medicaid is for people with limited income and resources. Medicaid is run on a state level, not on a federal level. As a result, in order to qualify for Medicaid, you will need to determine what your state defines as a qualifying income level.

How Do You Enroll in Medicaid?

Again, since Medicaid is run by State Governments, you will need to contact your state’s agency to start see if you qualify to enroll.

You can find a list of State Agencies here on the Medicaid.gov website.

Who Can Get Both Medicare and Medicaid?

People of any age who have certain qualified disabilities and people over 65, who are also below their states Medicaid income levels, can qualify for both Medicare and Medicaid.

For example, Henry is a 55 year-old disabled man who is also unemployed and living below the poverty level set by his state. Consequently, he would most likely qualify for both Medicaid (because of his income level) and Medicare (because of his qualified disability).

People that qualify for both programs are called “Dual Eligible.”

Who Can Help?

Navigating one (let alone both) of these systems can be confusing. But there is help available.

• If you need help with Medicaid or need to enroll in Medicaid only, then contact your state agency directly.

• If you need help enrolling in Medicare, then you can contact CMS and Social Security in the following ways:
  • BY PHONE: If you need to sign-up for Medicare, you can call Social Security at 1-800-772-1213.
  • ONLINE: Additionally, you can also visit CMS online at ssa.gov/benefits/medicare if you need to sign yourself up.
  • RAILROAD: Finally, if you are on Railroad Retirement Benefits, you will need to notify the local Railroad Board (RRB) office before you turn 65 that you would like to sign-up for Medicare. You can sign-up 3 months before you turn 65 even if you are not planning on retiring at 65. You can read more about Railroad requirements in our article here.

• Finally, if you need help finding a Medicare Supplement or Medicare Insurance Plan, or if you are dual eligible for both Medicare and Medicaid, then please contact an Insurance Agent. An Independent Medicare Insurance Agent will help you explore your options, and help you make the right choice for your unique situation.
  • You can contact your author Carly Cummings here, for assistance if you live in Nebraska or Iowa.
  • Or, if you live in all other 48 states, you can find an agent in your area here.

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The post Medicare and Medicaid Difference Guide appeared first on Medicare Life Health.

The Medicare Donut Hole (or Doughnut Hole) is a coverage gap in the Part D Prescription Drug Plan where beneficiaries could pay more for their drugs.

The Center for Medicare and Medicaid Services (CMS) calls the coverage gap a “temporary limit” on what their drug plan will cover.

Why Did My Drugs Get More Expensive this Month?

During Medicare’s Annual Enrollment Period (AEP) this year I was stationed at a pharmacy a few hours a week to answer people’s questions.

One gentleman came up to me and said, “The Pharmacist sent me over to you to ask you: Why did my drugs cost more this month? I get the same drugs each month, but this month, they cost me more!”

Yes sir, you have reached the Medicare Donut Hole in your Part D Prescription Drug Coverage. It was November, and this gentleman had been able to make it his other five years on Medicare without reaching the coverage gap.

However, this year, his drug costs were a little higher, and he hit the gap before the end of the year.

Will I hit the Coverage Gap?

The price changes in the coverage gap can be a shock if you have not experienced it before. So, let’s go over a little more information to prepare you for what might come.

When Does the Donut Hole Begin?

In 2020, the Part D Coverage Gap begins when you and your plan have spent $4,020 on prescription drugs. (In 2019, it was $3,820.) Thus, if you only spend $1,000 a year on drugs, the donut hole will not affect you.

When Does the Donut Hole End?

In addition, you may be wondering, when does medicare donut hole end? It ends once you and your drug plan have spent $6,350 in 2020 ($5,100 in 2019). You are then out of the coverage gap and have entered into Catastrophic Coverage.

During Catastrophic Coverage you will pay a much smaller amount of money for your drugs. This includes smaller co-insurances and smaller co-payments for the rest of the calendar year.

What am I Paying in the Coverage Gap (Medicare Doughnut Hole)?

As of 2020, Medicare will pay for 75% of BOTH brand name and generic drugs in the coverage gap. As a result, you will pay 25% of the cost of your drugs in the coverage gap.

There are some Medicare drug plans that includes coverage in the gap. According to CMS, ” you may get a discount after your plan’s coverage has been applied to the drug’s price. The discount for brand-name drugs will apply to the remaining amount that you owe.” You will need to speak to your plan to learn more.

What Costs Counts Towards the Coverage Gap?

Here are the costs that apply to your out-of-pocket expenses:

• First, Your Annual Drug Plan Deductible
• Second, Your Co-insurance and Co-Payments
• Third, Your Discount on Brand-name Drugs in the Donut Hole Coverage Gap
• Finally, Your Costs in the Coverage Gap

Here is what does not apply:

• Your Plan Premiums
• Any Pharmacy Dispensing Fees
• Any Drugs Not-Covered by Medicare Part D

Need More Information on Part D Drug Coverage?

• Start with our Simple Introduction to Part D Coverage here.

• Read about late fees and penalties that may apply to Part D here.

• Need to Switch your Drug Plan? You can do this during Annual Enrollment Period (AEP) each year.

• Or, just start at the beginning, with “What is Medicare?” to get an overview of the Medicare Program.

For Part D Sign-up Assistance

• Finally, if you are just aging into Medicare and need a Drug Plan.
  • Contact us here if you live in Nebraska or Iowa.
  • Or, find an agent here for other states.

The post What is the Medicare Donut Hole? appeared first on Medicare Life Health.

The 2021 changes for Medicare were released this month. The 2021 Part B Deductible is just one of the increases you will see.

The Centers for Medicare & Medicaid Services (CMS) released their updates for the coming year in a press release. Let’s look at what is changing.

Part B Deductible for 2020

• In 2021, the Medicare Part B Deductible will be $203.
• In contrast, the deductible was 198 for 2020.
• This is an increase of $5.

Part B Premiums for 2021

• In 2021, the Medicare Part B Monthly Premium will be $148.50
• In 2020, the Medicare Part B Monthly Premium was $144.60.
• The premium was 135.50 for 2019.

Why are the Part B Deductible and Premiums Increasing in 2021?

The CMS adjusts the deductibles yearly, in accordance to the Social Security Act. Moreover, the increase reflects national healthcare trends.

In addition, the CMS has stated that the rate hike is mostly due to the increased use and cost of physician- administered drugs. Part B covers Physician-administered drugs.

What Part B Covers

As a reminder, Medicare Part B covers:

• Physician and Provider Services
• Outpatient Services
• Home Health Services
• Durable Medical Equipment
• Other non-hospital health services

To learn even more about the parts of Medicare and what they cover, you can see our infographic and discussion here.

Who Pays the Part B Deductible?

• If you have Original Medicare only, you will pay the Part B Deductible.
• In addition, if you have a Medicare Supplement that does not cover the Part B Deductible, you will pay it.
• Some Medicare Advantage Plans have you cover the Part B deductible. This will be stated in your Summary of Benefits. However, 2020 plans have already been released, so deductibles are already set for the new year and will not be affected by this increase.

As of 2020, new beneficiaries to Medicare will not be able to choose a Medicare Supplement Letter Plan that covers the Part B Deductible. For example, Plan F covers the deductible, so seniors new to Medicare in 2020 and beyond will not be able to pick Plan F. Seniors that are already on these letter plans can keep them. Read more about this topic here.

Will the Changes Affect Part C or Part D costs?

No, these deductible and premium increases will not affect Part D Drug Plans or Part C Medicare Advantage Plans. The premium costs and the deductibles have already been set for the coming year. As a result, they are not affected.

According to the CMS press release,

As previously announced, as a result of CMS actions to drive competition, on average for 2020, Medicare Advantage premiums are expected to decline by 23 percent from 2018, and will be the lowest in the last thirteen years while plan choices, benefits and enrollment continue to increase. Premiums and deductibles for Medicare Advantage and Medicare Part D Prescription Drug plans are already finalized and are unaffected by this announcement.

CMS Press Release, Nov 2019

That is extra good news for those on Medicare Advantage Plans that have their deductibles satisfied with their plan. Some Medicare Advantage plans have a zero dollar deductible for their whole plan. These plans bundle Parts A & B and have the option of including the Part B Original Medicare deductible or covering it themselves.

Income Adjustments to Part B Premiums

There are no income related adjustments to the Part B Medicare Deductible. However, there are income related adjustments to your Part B Premiums.

• First, the standard 2020 Part B premium of $144.60 applies to those with income less than or equal to $87,000 a year ($174,000 joint income).
• Second, if you claim income between $87,000 and $109,000 ($174k-$218k joint), you will pay $202.40 a month.
• Third, if you claim income between $109,000 and $136,000 ($218k – $272k joint), you pay $289.20.
• Fourth, if you claim income between $136,000 and $163,000 ($272k – $326k joint), you pay $376.00.
• Fifth, if you claim income between $163,000 and $500,000 ($326k – $750k joint), you pay $462.70.
• Finally, if you have income greather than or equal to $500,000 ($750k+ joint), then you pay 491.60.
• Click here if you need to see a table for premiums for spouses that file separate returns.

Are there Changes to Part A?

Yes, there are also changes to Medicare Part A. If you have a Medicare Supplement Plan, depending on which Letter plan you have, your supplement will continue to pick up these costs.

If you have a Medicare Advantage Plan, your plans benefits will still apply to you instead of the Original Medicare benefit structure. 2020 plans have already been released, so you will not be affected by these changes.

However, if you have Original Medicare only, you will want to take a look at the Part A changes that affect you here.

Further Reading

If you would like to learn more about Medicare we Suggest the following articles:

This Tool Kit answers your questions regarding Medicare Information, Medicare Supplements, Medicare Advantage, and Prescription Drug Plans. Discover what products are right for you and how to sign-up for them. 

Medicare 101

Read about basic Medicare Information. What is Medicare Part A? Part B? Get answers to your basic Medicare questions.

Medicare Supplements

What is a Medicare Supplement and how do I choose the best one for me? 

Medicare Advantage

What is Medicare Advantage and when is it, and what plans are, best for my situation?

Prescription Drug Plans

When do I need a drug plan and what do I need to look for in a good plan?

Medicare Advantage vs Medicare Supplements

What plan type is best for my situation and what do I need to consider when choosing.

Most Asked Medicare ?s

Answers to your questions and answers to questions you should be asking.

The post 2020 Part B Deductible / 2021 Part B Deductible appeared first on Medicare Life Health.