The ABCD’s of Medicare – Basics of Medicare

by Jill Clifford

Medicare is a complex set of laws signed on July 30, 1965, by President Lyndon B.

Johnson, providing insurance coverage for people over sixty-five, those under sixty-five with

certain disabilities, people with Amyotrophic Lateral Sclerosis (Lou Gerhrig disease), and

anyone with end-stage renal disease. I am going to walk you through the history of this

complexity step by step. In the next article, I’ll discuss more details on available coverage,

enrollment options and requirements, premiums and penalties, and additional programs like

Medicaid and Extra Help.

Original Medicare provided only Part A (hospitalization, skilled nursing facilities, & blood)

and Part B (doctor services, outpatient hospital service, plus most other medical services that

Part A does not cover). The Omnibus Reconciliation Act of 1980 expanded home health

services and brought Medigap (Medicare supplement insurance), under federal oversight. In

1982, hospice was added to Part A.

In 2003, the Medicare Modernization Act (MMA-2003) signed by President George W. Bush, added Part C, which allowed private insurance companies to offer Medicare Advantage

plans, if approved by CMS (Center for Medicare and Medicaid Services), that combined Parts

A and B, and added prescription drug coverage for most plans. The MMA-2003 also specified

that as of January 1, 2006, all Medicare recipients were required to have credible prescription

drug coverage, then named Part D.

Therefore, as of 2006, all Medicare recipients are required to have Medicare Parts A, B,

and D, or credible insurance and prescription drug coverage as good as the standard

Medicare plan. Note that prescription drug discount or medical discount plans are not

considered credible coverage. Credible insurance can be employer insurance plans, Veteran

coverage like Tricare or VA benefits, or government or private pension plan insurance, or a

Part C Medicare Advantage plan. Tricare for Life and ChampVA also require enrollment in

Part B. Note that COBRA is not considered credible coverage. Also note that MMA-2003

specifies penalties for not enrolling in Part B or Part D when eligible, unless the individual has

other credible coverage.

The “Your Medicare Coverage Choices” diagram displays our current choices for Medicare

coverage. If we have other credible medical and prescription drug coverage, we may only

have Medicare Part A. Otherwise:

1. We can have original Medicare Parts A and B, to which we add a Part D plan (unless we

have other credible prescription drug coverage).

2. We can have original Medicare Parts A and B, plus Part D (unless we have other credible

prescription drug coverage) and add a Medigap policy.

3. We can have a Medicare Advantage plan (MAPD) with Part D included.

4. If we have other credible prescription drug coverage, we can have a Medicare Advantage

plan (MA) without prescription drug coverage. Those without prescription drug coverage are

often called “veteran plans,” as the people who enroll in them are most often veterans who

get their prescriptions from the Veterans Administration.

Diagram Reference:

Centers for Medicare and Medicaid Services, September 2016, Medicare and You: The official U.S. government Medicare handbook, U.S. Department of Health and Human Services.

The ABCD’s of Medicare – Medicare Supplements
by Jill Clifford

The ABCD’s of Medicare – Medicare Supplement Pros and Cons
by Jill Clifford

Today, we will cover some of Medicare Supplement (Medigap) plans, pros and cons, and decision points. With Medigap plans, the individual must have both Medicare Parts A and B. Although these plans are designed to cover most deductibles, coinsurance, and copayments of Medicare Parts A and B, they do not include prescription drug coverage. So, required credible prescription drug coverage must be obtained through a retirement plan, veteran benefits, or a stand-alone prescription drug plan.

In Medicare supplement plans, there is no standard coverage for hearing, vision, or dental. Hearing is only covered for balance problems, vision for eye infections or cataracts, and dental only in the case of accidents involving broken jaw, etc. While some Medicare Advantage, Part C plans offer these benefits, an individual cannot enroll into both a Medicare Advantage plan AND a supplement plan. Also, Medicare does not cover regular chiropractic visits, acupuncture, or most other alternative medical care.

Medigaps plans are either guaranteed issued (as when turning age 65) or they are underwritten. However,  nce enrolled in a Medicare supplement plan, an individual cannot be canceled or singled out for rate increases as a result of health problems and expenses, as long as they pay the plan and Part B premiums. Rate increases must be on the total class of covered individuals, such as by age. Smokers will always be subject to a higher rate than non-smokers.

There are numerous advantages to Medicare supplement plans:

* The plans are accepted by any provider who accepts Medicare, with no network restrictions, no needed referrals for specialists, and few limitations on the amount or frequency of medical care. However, except for Plans C and F, the Part B deductible must be paid ($226 in 2023).

* Most Medigap Plans G and N have some foreign travel emergency coverage, which is not covered under original Medicare. (Check the plan for details.)

* There are few limits on the maximum costs that are covered. For one, original Medicare will cover up to 150 hospital days for a single stay, using up the 60 lifetime reserve days. Most Medigaps will cover an additional 365 hospital days after the reserve days have been used. Skilled nursing coverage is limited to 100 days on both original Medicare and Medigap.

* There is a variety of plans (A through N) available with premium rates depending on the company and level of coverage. If an individual accepts more medical coinsurance risk, the premium cost can be less, for example taking a Plan N rather than a Plan G. There are many different companies offering Medigap plans, but remember CMS requires that these plans are standardized in their coverage. We need to ask: How strong is the company, and number of people currently covered? How supportive is their customer service? What is the initial enrollment premium? Are the rate increases standard year after year, like 3% per year, or sporadic and unpredictable? Is there a point at which the premium “freezes” and the individual pays that amount for coverage for the rest of their lives? How competitive are the premiums at higher ages? Are there added benefits, like a 24 hour nurse hotline, or gym or YMCA memberships? These

should all be considered before enrolling into a Medigap plan.

The ABCD’s of Medicare – Medicare Advantage Plans

by Jill Clifford

The ABCD’s of Medicare – Extra Help and Medicaid

by Jill Clifford

Today we’ll cover the Extra Help program for prescription drugs and Medicare Savings Program, also known as Medicaid. You or someone you know may be eligible.

Extra Help, administered through Social Security, could save thousands of dollars in prescription drug costs. Many eligible people may be unaware of these benefits or how to get them. To be eligible for the Extra Help, an individual or couple must be under the maximums for both assets and gross income. Assets include cash, bank and stock accounts, IRA’s, and real estate other than one’s primary home. Assets do not include the primary home, car, furniture, other personal belongings, or life insurance. Further, even if some Americans exceed income limits, they may still qualify if they are supporting other family members. Limitations:

Extra Help pays the premium of a stand-alone prescription drug plan, or the premium amount of prescription drug coverage in a Medicare Advantage Plan. It also reduces the cost of prescription drugs to no more that $4.15 for generic drugs and no more the $10.35 for all other Medicare Part D drugs. (Medicare Part B drugs are still 20% coinsurance under original Medicare, but may be covered differently under certain Medicare Advantage plans.)

To apply for the Extra Help program, you may call Social Security at 1-800-772- 1213 (TTY service at 1-800-325-0778), and they will send you a form called Social Security Administration Review of Your Eligibility for Extra Help (SSA-1026), or set up an appointment at the local Social Security Office, or apply online at

www.ssa.gov/extrahelp. After applying, you will receive a qualification letter. You may also have a telephone interview. If qualified, the benefits will be in effect on the first day of the qualifying month.

Medicaid is a Federal program, funded jointly by the Federal and state governments. In Washington, the Medicaid program is called “Apple Health.” To apply for Apple Health (Medicare Savings program), there are multiple ways. An individual may apply online at https://www.wahealthplanfinder.org/ or download an application form. Applications can be taken by phone at the Washington Healthplanfinder Customer

Support Center at 1-855-923-4633, or with local resources you can find on the Healthplanfinder site or by phoning the customer support center.

There are four levels of coverage under The Apple Health Medicare Savings programs, depending on the Federal Poverty Level (FPL), labeled QDWI, QI-1, SLMB, and QMB. All four include Extra Help if the assets limitation is met. However, the Apple

Health does not include assets, only income, in determining an individual's eligibility for coverage

The Qualified Disabled Working Individual(QDWI), Qualified Individual (QI-1) level and Specified Low. Income Medicare Beneficiary (SLMB) level all pay the Medicare Part B premium, which is $164.50a month in 2023. The Qualified Medicare Beneficiary (QMB) level includes payment of Part B premium and medical benefits, such as copayments or coinsurance on original Medicare and on Medicare Advantage plans.

Additionally QMB individuals can enroll in Special Needs Plans, which may provide extra benefits beyond original Medicare and Medicaid.

Apple Health maximum income for qualifying levels in 2023 (per https://www.hca.wa.gov/):

Maximums change each year, and may be otherwise adjusted. Maximums may be

higher under special circumstances, as when a single person or couple is caring for

dependent children or elderly person(s).

The ABCD’s of Medicare – Medicare Enrollment Periods

By Jill Clifford

Standard enrollment periods for Medicare and Medicare plans are Initial Enrollment Period (IEP), Annual Enrollment Period (AEP), Open Enrollment Period (OEP) for Medicare Advantage only, and the General Enrollment Period for Medicare Part B. There are also special enrollment periods (SEPs), allowing individuals to enroll into Medicare and Medicare plans, which we will cover in other articles.

For individuals turning 65 years old, Medicare normally sends their Medicare card and letter of eligibility around four months before the month they turn 65. Individuals are required to enroll in Medicare Part B, unless they have credible coverage as good as Medicare, like an employer’s plan. NOTE: Insurance under COBRA (Consolidated Omnibus Budget Reconciliation Act) is NOT considered credible coverage for Medicare. There is a 10% penalty assessed for every year that a person does not enroll in Part B when eligible, or have other credible coverage. A penalty is also assessed for not enrolling in Part D, whether a stand-alone prescription drug plan (PDP) or within a Medicare Advantage plan. NOTE: Veterans Administration (VA) medical benefits ARE NOT considered credible coverage for Medicare; Part B enrollment is not optional. However, VA prescription drug coverage IS considered credible for Medicare Part D.

The Initial Enrollment Period (IEP) is a seven month window to enroll in a Medicare plan, whether a stand-alone PDP, with or without a Medicare Supplement plan, or a Medicare Advantage plan. IEP is three months before the 65 th birthday, the month of the 65 th birthday, and three months following the 65 th birthday. Medicare is effective on the first day of the birthday month. Exception: if the 65th birthday falls on the first of the month, Medicare effective date is the first of the prior month. For example, if the 65 th birthday is October 1 st , Medicare is effective on September 1 st .

If covered under employer’s insurance, individuals may opt to decline Medicare Part B (medical benefits) before Part B is effective, and only keep Medicare Part A (hospitalization). There is no premium for Part A if an individual or spouse qualifies for Medicare. Premium for Medicare Part B is $164.90 per month in 2023, unless annual income exceeds $97,000 for an individual, or $194,000 for joint married. Above that, Medicare also charges IRMAA (Income- Related Monthly Adjusted Amount) for both Medicare Part B and Part D. Remember, however, enrollment in both Medicare Part B and D is required, unless there is other credible coverage. Individuals may apply for Part B premium payment by the state, if monthly income

is less than $1529, or $2060 for a couple.

If not enrolled in a Medicare plan during their IEP, individuals must wait until Annual Enrollment Period (AEP), October 15 through December 7 each year. AEP is also when individuals already on Medicare may change their Medicare plans. AEP enrollments are effective January 1, the following year.

Individuals on Medicare Advantage (MA) plans may change MA plans during Open Enrollment Period (OEP), January 1 through March 31. They may also choose to drop their plan, go back to original Medicare Parts A and B, and enroll into a prescription drug plan (PDP). OEP is not a period when individuals may change PDP plans, or initially enroll in either a PDP or MA.

If not enrolled in Medicare Part B when eligible, there is a General Enrollment Period from January 1 to March 31. There may be a late enrollment penalty, depending on whether or not the individual qualifies for a SEP, like losing employer coverage. Part B coverage will be effective the first day of the month after enrollment.

The ABCD’s of Medicare – Stop the Irritating Calls!

By Jill Clifford

Under the Electronic Code of Federal Regulations (e-CFR), Title 42, there is a section specifically addressing unsolicited calls to Medicare beneficiaries: “42 CFR § 423.2264 - Beneficiary contact.” They describe a beneficiary as a Medicare recipient or their caregiver(s). Contact is any outreach activities to these people by sponsors (companies) marketing Medicare plans, and their brokers and agents. Unsolicited contact is only allowed by conventional mail and other print media (for example, advertisements and direct mail) or

email (provided every email contains an opt-out option).

The law specifically prohibits the “use telephone solicitation (that is, cold calling), robocalls, text messages, or voicemail messages, including, but not limited to, the following:

(A) Calls based on referrals.

(B) Calls to former enrollees who have disenrolled or those in the process of

disenrolling.

(C) Calls to beneficiaries who attended a sales event, unless the beneficiary gave

express permission to be contacted.

(D) Calls to prospective enrollees to confirm receipt of mailed information.

So how do we stop the people who are violating these rules?

First, protect yourself by not engaging with unsolicited callers who want to talk with you about Medicare. DO NOT provide unsolicited callers with your name, your Medicare identification number or your Social Security number. Scammers could use this information to make changes to your plan without your knowledge.

Second, if you do get an unsolicited call about Medicare, ask the caller for their name, license number, and phone number. Tell the caller, you will call them right back if they will give you their number, then hang up. If that is refused, simply hang up.

Call 1-800-Medicare (1-800-633-2273) or Washington State Health Insurance Program (SHIP) at 1-800-562-6900 to report that you received an unsolicited call, giving them whatever information you have on the caller.

Agents who make unsolicited calls to Medicare beneficiaries can be fined per call, can be forced to do retraining, can lose their insurance company contracts, or lose their state insurance license.

If we do not take action against these rogue agents and brokers, we will continue to get unsolicited calls. So help yourself and everyone else who is receiving these irritating calls by taking action!

Medicare and Medicaid Resources

Listed below are Federal and Washington Resources, with Phone number and Website:

Social Security: 1-800-772-1213

TDD: 1-800-325-0778

Website: socialsecurity.gov

Kent Social Security Office: 1-866-931-7671

Address: 321 Ramsay Way, WA 98032

Extra Help (Prescription Drug) 1-800-772-1213

Website: ssa.gov/medicare/prescriptionhelp/

Medicare: 1-800-633-4227

Website: Medicare.gov

Medicaid: 1-877-267-2323

Website: Medicaid.gov

Auburn Community Services Office | DSHS: (877) 501-2233

TTY: (800) 833-6384

Website: WashingtonConnection.org

Address: 810 28th St NE Auburn, WA 98002

(For help with Medicaid, food stamps, cash assistance, transportation, etc.)

State Health Insurance Assistance Program (SHIP): 1-800-562-6900

TTY 1-360-586-0241

Website: shiphelp.org/about-medicare

Long Term Care System (ALTSA) : 1-855-567-0252

TTY/TDD 1-800-833-6384

Website: dshs.wa.gov/altsa/long-term-care-service

WA Association of Area Agency on Aging:

Seattle office: 206-684-0660

Address: 700 5 th Ave, #51, Seattle, WA 98104

Tacoma office: 253-780-4600

Address: 4301 S Pine St, Suite 446, Tacoma, WA 98409

Website: agingwashington.org

(For information help with long term care, elder abuse, Medicare, etc.)