Part D Coverage Restrictions
Posted on March 27, 2012 by B. Kingman
Your Pennsylvania Medicare Part D prescription plan may not cover all your drugs. Coverage restrictions which vary by plan may make it difficult or inconvenient to have some of your medications covered. It’s important to know the rules included in your plan and ask your doctor for assistance when necessary. Coverage restrictions can include:
- Quantity Limits
- Step Therapy
- Prior Authorization
These are all tools that Medicare Part D plans use to limit use of certain drugs.
If you receive a notice that a drug may not be covered contact your plan and find out the reason. Ask what you need to do in order to get your refills approved. This is the part that may make it difficult or inconvenient.
Contact your doctor and ask if there is another drug you could take for the same condition that may not have the coverage restriction. If there is and the drug is on your plan formulary this is the best solution.
If there is not, ask your doctor to help you meet the coverage restriction. This may include reducing the quantity in your prescription (quantity limits) trying other drugs first (step therapy) or having your doctor request special approval (prior authorization).
All Part D plans do not cover all drugs, or have known coverage restrictions which you should be aware of before signing up with one. Look for changes in plan rules each year during your open enrollment to avoid the complications caused by coverage restrictions and change plans if needed.
For a free review of your Pennsylvania Medicare Part D plan call our office at 1-800-649-9604.
Posted in Prescription Drugs | 0 Comment(s)
A Reverse Mortgage for Healthcare Expenses?
Posted on March 20, 2012 by B. Kingman
Reverse mortgages today are a safe way to access the equity in your home. They are backed by government guarantees and insurance to protect the consumer.
However, a reverse mortgage is a loan that comes at a high cost in fees. And while there are no monthly payments required during the time of the loan, interest accumulates and must be paid when the homeowner(s) moves.
Therefore a reverse mortgage is not for everyone over 62, the minimum age of eligibility, and most experts advise they should only be used as a last resort for allowing someone to stay in their home.
A typical situation is a homeowner who needs money for repairs or upkeep on their home or to pay real estate taxes.
Using the the money from a reverse mortgage to buy a new car, take a vacation or even pay for healthcare bills is not a wise idea because you are then paying interest on those expenses forever until you move.
Reverse mortgages are advertised as “tax free money” you’ve earned being a homeowner. Celebrity endorsements promote enjoying your golden years with this new pile of cash that’s your’s for the taking.
But many homeowners have ended up in trouble when the money from their reverse mortgage is all gone. You see one of the requirements of a reverse mortgage is that you continue to keep your home in good repair, continue to provide homeowner’s insurance and continue to pay your real estate taxes for as long as you live in your home. If you don’t do all of those you will be in default and could lose your home.
Posted in Retirement Living | 0 Comment(s)
New Medicare Taxes
Posted on March 16, 2012 by B. Kingman
High-income households will be paying more into Medicare as a result of the new health reform law.
For starters, the Medicare payroll tax is going up for individuals making more than $200,000 in wages, and couples making more than $250,000.
Under the new law, starting in 2013, high-income individuals will pay another 0.9 percentage points on earned income over $200,000 ($250,000 if married).
If he made $1 million, he will pay an additional $7,200.
In addition, high-income households would also be subject to a new 3.8% Medicare tax on investment income starting in 2013.
Here’s how the new tax on investment income would work: It will hit those people whose gross income (roughly speaking, wages plus investment income) exceeds the $200,000 threshold for individuals or $250,000 for couples.
Say you have $50,000 more in modified AGI than the threshold. If your investment income exceeds that amount, you would only owe the 3.8% tax on $50,000.
Deloitte notes that it’s possible that even if a person’s total income exceeds the income threshold, he may only be subject to the Medicare investment tax but not the increase in the Medicare payroll tax.
Raising the Medicare tax on wages will raise an estimated $87 billion over 10 years. But combined with a new Medicare tax on investment income, the revenue collected will jump to an estimated $210 billion, making it the biggest single revenue raiser to help pay for health reform.
Posted in Healthcare Reform | 0 Comment(s)
When Medicare Denies Your Claim
Posted on March 13, 2012 by B. Kingman
If you receive a bill from a doctor or other medical provider for a service they say was denied by Medicare you should review the Medicare Summary Notice (MSN) for that claim.
Summary Notices (your explanation of benefits) are mailed to you every three months, so you may need to call Medicare and ask them to send one for the date of service in question if you have not yet received it.
First however, find out if it is possible that there was a billing error. You may not need to file an appeal if the service was billed incorrectly. Medicare uses codes for processing medical claims. Each medical service is given a specific code and sometimes doctors’ offices or other providers accidentally use the wrong codes when submitting their claims to Medicare.
Then circle the service you want to appeal on your Medicare Summary Notice and include “Please Review” on the bottom and sign your name. Mail the signed original to Medicare with the statement from your provider to the address on the MSN. Keep a copy for your records. You may want to send it via certified mail or requesting a receipt.
Posted in Medicare | 0 Comment(s)
Does Medicare Cover The Shingles Vaccine?
Posted on July 20, 2011 by B. Kingman
Yes, Medicare does cover the shingles vaccine. However, unlike some other vaccines that are covered by Part B, the shingles vaccine is covered by Medicare Part D.
This is the same part of Medicare that you use when you buy prescription drugs at your pharmacy or through mail-order. People get Part D through either a private stand alone prescription drug plan (if they also have Original Medicare) or a Medicare Advantage plan that includes coverage for drugs (MA-PD). Your Part D plan will pay for the vaccination itself and for your doctor or other health care provider to give you the shot. However, you will need to make sure you follow your particular plan’s rules and networks in order for the vaccine to be covered.
You will pay the least for the shingles vaccine if you are:
- Vaccinated at a pharmacy that is in your drug plan’s network
- At a doctor’s office that can work with a pharmacy that will bill your Part D plan for the entire cost of the vaccination process, or
- At a doctor’s office that can bill your plan for the vaccine directly using a special computer billing system.
Before you get a shingles vaccine, it’s important that you check with your Part D plan’s coverage rules and see where you can get your vaccine so that it will be covered at the lowest cost.
Posted in Prescription Drugs | 0 Comment(s)
When To Sign Up For Medicare
Posted on July 15, 2011 by B. Kingman
It can be confusing to know IF and WHEN you need to sign up for Medicare. Here are three common situations:
1) In most cases, if you’re already receiving Social Security, you will automatically get Medicare Part A and Part B starting on the first day of the month you turn 65. You should receive your Medicare card in the mail 3 months before your 65th birthday.
2) If you are not getting Social Security benefits you will need to sign up for Medicare and should do so three months before your 65th birthday.
3) If you or your spouse will continue working and have group health coverage through an employer, contact your benefits administrator to find out how your insurance works with Medicare. It may be to your advantage to delay Part B enrollment. Be sure to follow Medicare’s rules carefully to avoid a late enrollment penalty.
Call Social Security at 1-800-772-1213 for more information about your Medicare eligibility or visit their website at www.SocialSecurity.gov/retirement.
Another great resource for folks who are new to Medicare is the book Medicare & You provided free by the Centers for Medicare & Medicaid Services.
Posted in Medicare | 0 Comment(s)
Medicare Supplement Policies are Guaranteed Renewable
Posted on June 3, 2011 by B. Kingman
One of the strongest benefits of individual Medicare Supplement policies is that they are guaranteed renewable. This means that as long as you continue to pay your premiums on time the insurance company cannot single you out and change your benefits or cancel your policy. Sometimes this is a concern of folks thinking if they file a large amount of claims their premium will skyrocket or the company will drop them.
Guarantee provisions are different with Medicare Advantage plans which only guarantee your coverage benefits and cost on a calendar year basis. Medicare Advantage plans can not only change your benefits and cost each year but they can also cancel your plan if they choose not to offer it in your county of residence. These changes are announced well in advance and there are provisions that allow you to obtain other coverage on a guaranteed issue basis, but it can be disruptive and inconvenient.
So if you are looking for long term guarantees with the peace of mind knowing your coverage will not change even if your health does, a Medicare Supplement is the type of coverage you will want to consider.
Posted in Medicare Supplement | 0 Comment(s)
Changing Medicare Supplement Plans
Posted on May 27, 2011 by B. Kingman
You can change Medicare Supplement policy any time of year. This is different from Medicare Advantage plans which can only be changed during a qualified enrollment period, most commonly at the end of the year.
Why would someone want to change to a different Medicare Supplement policy? Cost is the biggest reason. Medicare Supplement premiums increase over time based on your age and also based on the plan’s “loss ratio” also called “claims experience” which insurance companies monitor carefully. When the amount a plan is paying out in claims exceeds a certain percentage they will request permission from their state insurance department to increase the premium.
Some insurance company’s premiums increase more than others due to how well they manage their business along with other factors. If your premium seems to be increasing by a high amount each year you may want to shop and compare your coverage to what is available from other companies.
Medicare Supplement plans are standardized where plan-for-plan all insurance companies provide the same coverage. If you change insurance companies but keep the same plan your coverage will not change.
Keep in mind that most Medicare Supplement policies are medically underwritten so any current or past health conditions may affect your eligibility with a new company. But, if a new company issues you a policy all conditions are covered immediately.
Shop carefully and always use an agent who specializes in Medicare Supplements and represents multiple insurance carriers. Call Health Insurance Services, Inc. at 800-649-9604 if we can be of help.
Posted in Medicare Supplement | 0 Comment(s)
Free Guide to How Healthcare Reform Affects Seniors
Posted on May 25, 2011 by B. Kingman
This free guide from The Society of Certified Senior Advisors was created in order to answer some of the most often-asked questions about the new health care reform bill, titled the Patient Protection and Affordable Care Act, which was signed into law earlier this year. Each year the bill is slated to roll out new provisions that affect individuals, businesses, insurance companies, health care providers, and the government. This easy-to-read guide can help seniors and their families navigate the complexities of how healthcare reform affects seniors.
While it is possible that the bill will be modified over the years, whether by lawmakers or by the courts, it is important to understand the approaching provisions and what they mean for you. Many people will be affected in areas such as federal income taxes, adjustments in existing health care coverage, access to health care coverage, access to information, and requirements of employers.
The topics covered within include:
- How will my Medicare benefits change?
- What happens to my Medicare Part D coverage?
- How are my income taxes affected?
- What new assistance is available for long-term care?
- How are seniors protected against abuse under health care reform?
- Is there a timeline for when all of these take effect?
- Where can I go for more information?
Posted in Healthcare Reform | 0 Comment(s)
Where To Turn For Help With Prescription Costs
Posted on May 17, 2011 by B. Kingman
I remember back before 2006 when there was no insurance coverage for prescription drugs for people with Medicare. Today anyone who qualifies for Medicare Part A and or Part B can sign up for a Medicare Part D prescription plan to help cover the cost of their medication.
While Medicare Part D turned out to be extremely confusing to understand it can save most folks as much as half or more of the normal full cost of their medications. For that, Medicare beneficiaries should be thankful. And coverage is improving with the elimination of the ominous coverage gap, known as the “doughnut hole”, over the next several years.
But until that happens there are still many who struggle with their co-payments and out of pocket costs. So here are some tips on where Pennsylvania Medicare beneficiaries can turn for help with prescription costs.
If you are enrolled in a Medicare Part D plan, whether your coverage is included as part of a Medicare Advantage plan, or provided by a stand alone Part D plan, read and understand your prescription formulary guide and review it every year. The formulary guide lists the drugs that your plan covers and in which tier level they are included. The tier determines how much your co-payment will be. Plans can and do change their formularies and tier levels each year. So a drug that was a tier 1 last year could be a tier 2 this year.
Plans are required to send you an annual notice of change and new formulary guide each year which you should review to understand how your plan may be changing. Using the online tools provided by Medicare you can compare other plans that are available that may cost you less out of pocket. If you need help with this you can call 1-800-MEDICARE, or call our office for assistance at 1-800-649-9604. You can change plans each year during a qualified enrollment period.
Pennsylvania Medicare beneficiaries may be eligible for PACE or PACENet to help with their prescription drugs. Check out our resources page for more on the guidelines in this program.
If you served in any branch of the military you may be eligible for the VA drug benefit through the Veteran’s Administration.
Review your medications at least once a year with your doctor to see if any can be substituted with a generic or a therapeutic alternative.
Compare the cost of your generic drugs at several pharmacies. Not all have the same drugs on their popular $4 list. Be sure to include checking with wholesale club pharmacies which often have the best prices. You do not need to be a member of the club to use their pharmacy.
Check to see if your brand name drug manufacturers have a pharmaceutical assistance program. Most do and while they have income guidelines they are often more liberal than PACENet.
Ask your doctor for samples. I asked my doctor one time who they give out the free samples to and he said they give them to those who ask for them. And while samples don’t seem to be as available as they used to, it never hurts to ask.
Posted in Prescription Drugs | 0 Comment(s)
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