Paul Barrett Insurance Services Blog
2020 defined standard Medicare Part D prescription drug plan coverage parametersHere are a few highlights of the defined standard Medicare Part D plan changes from 2019 to 2020. The chart below shows the changes in defined standard Medicare Part D design for plan years 2016, 2017, 2018, 2019 and 2020. The CMS "Part D Benefit Parameters for Defined Standard Benefit" is the minimum allowable Medicare Part D plan coverage. However, CMS does allow Medicare Part D plans to offer a variation on the defined standard benefits (for example, a Medicare Part D plan can offer a $0 Initial Deductible).
Medicare does a pretty good job of keeping people healthy. Upon initial enrollment in Part B, Medicare pays for an initial preventive physical examination in which doctor and patient review medical and social health history and discuss preventive services. Then annually thereafter, Medicare pays for an annual wellness visit where doctor and patient develop or update a personalized prevention plan and do a new health risk assessment. The initial exam must be done within the first 12 months of enrolling in Medicare Part B—so you might include this reminder in your checklist for retirees. But if they miss it, they can always catch up at their annual wellness visit.
There are specific protocols for the annual wellness visit. Some doctors follow them better than others (I speak from experience). The visit should include a general health risk assessment based on current health status and medical and family history, a review of drug and supplement use, measurements and tests the doctor deems necessary, and referrals to programs for smoking cessation and weight management, among others. There should also be a discussion of advance directives, including the types of decisions clients may need to make about end-of-life care and the forms that will allow a trusted person to make medical decisions on the client’s behalf. The medical group I go to has its own form and brings in a notary on Thursdays to make it easy for people to execute their forms and have them be included in their medical file. This is another thing to add to your checklist.
One of the main purposes of these free wellness visits is to establish a plan for health screenings and immunizations. These will be individualized for each client, of course, based on their own health risks. While Medicare pays for specific screenings at specific intervals, these can be accelerated if risks are higher. For example, Medicare will pay for a colonoscopy every 10 years for people not at high risk, or every two years for those at high risk.
A website called Better Health While Aging has come up with 26 recommended preventive health services for older adults which combines recommendations of the U.S. Preventive Services Task Force (USPSTF) with Medicare’s coverage of preventive health services. The USPSTF is an independent, volunteer panel of national experts in prevention and evidence-based medicine. They assign a letter grade (A, B, C, or D or an I statement) based on the strength of the evidence and balance of benefits and harms of a preventive service. For a preventive service to be recommended, there should be proof that providing the service results in improved health outcomes for most people. If a screening is not recommended it may be because research has not proven that detecting certain problems leads to better outcomes. For example, screening for prostate cancer by checking PSA levels in older men is no longer recommended because research found that overall screening didn’t save many lives, but did cause men to undergo many painful biopsies or treatment of small prostate cancers that probably would have never troubled them. And many preventive services become optional—or sometimes even recommended against—when people reach a certain age or state of poor health.
Preventive services fall into six areas. Many of them are included in Medicare’s annual wellness visit) For additional information about Medicare coverage for each item, click on the associated links.
Mental health, cognitive health, and substance use
Life Line Screening, which advertises itself as “America’s leading provider of quality health screenings.” This national company sets up in churches and school around the country and offers a number of tests designed to detect cardiovascular disease that are neither recommended by the USPSTF nor covered by Medicare. Their sales pitch is compelling—who wouldn’t want to know if a heart attack or stroke were just waiting to happen?—but there does not appear to be scientific evidence to support the tests, which can cost many hundreds of dollars. Tell your clients to save their money.
But do educate clients who are new to Medicare about the many screenings and preventive services that are now available to them. This is one of several benefits that came about as a result of the Affordable Care Act. Clients might as well take advantage of them.
References and further reading
Annual Wellness Visit
The Coverage Gap or Donut Hole (or Doughnut Hole) has caused a considerable amount of confusion for many people when they suddenly are required to pay a higher price (or before 2011, the full price) for their prescription medications. The following brief overview is based on the 2019 Medicare Standard Benefit Plan Model. Quick OverviewHere is a quick overview of the Donut Hole or Coverage Gap.
Are you considering Medicare Supplement insurance? Medicare Supplement plans, also called Medigap plans, can help pay for out-of-pocket costs for services covered by Original Medicare (Part A and B). It’s important to select a Medigap plan option that fits your health-care needs now and in the future because, depending on the timing of when you enroll, you might not be able to switch plans later.
There are 10 standardized Medigap plans available in every state (excluding Massachusetts, Minnesota, and Wisconsin, which all have their own versions). Each plan has a letter designation (Plan F, for example) and is sold by private insurance companies across the country. While the prices may vary across different insurers, the benefits of each Medigap plan are standardized across plans of the same letter. This means that coverage for Medigap Plan F, for example, will be the same regardless of the insurance provider.
Medicare Supplement Plans F, G, and N offer many of the same benefits, with a few differences, which this article will share.
Medicare Supplement Plan F Medigap Plan F is a popular choice that offers more coverage than any other Medicare Supplement plan. There is also a high-deductible Plan F that offers the same benefits as the standard Plan F, but requires you to pay a certain amount out of pocket before coverage starts.
Plan F benefits include:
Because Medigap Plan F offers the most benefits, it is usually the most expensive; however, this may not always be the case, and you should shop around to find the best plan option for you.
You may be able to find other Medigap plans with lower premiums than Plan F. But if you see your doctor a lot or face high out-of-pocket costs, Plan F generally gives you the most help with Original Medicare costs.
Medicare Supplement Plan G Medigap Plan G offers all of the benefits of Plan F, with the exception of the Part B deductible. If you choose Plan G, you’ll need to pay the standard annual Medicare Part B deductible ($185 in 2019) out of pocket.
It’s worth noting that both Plan F and Plan G cover Medicare Part B excess charges, and they are the only Medicare Supplement plans to do so. Excess charges are the difference in cost between what a non-participating doctor or health-care provider charges for a medical service and the Medicare-approved amount. If you see a non-participating provider, he or she is allowed to charge up to 15% above what Medicare has approved for a covered service, which you’ll normally be responsible for paying.
Medicare Supplement Plan N Medigap Plan N covers all the same benefits as Plan F with the exceptions of the:
What else do I need to know about Medigap Plan F, Plan G, and Plan N?If you’re thinking of signing up for Medigap insurance, a good time to enroll is during the Medicare Supplement Open Enrollment Period, which starts when you have Part B and are 65 or older. During this six-month period, you have a special right to join any Medigap plan offered by any insurance company in your service area with “guaranteed issue“; in other words, you can’t be turned down for health reasons or charged a higher premium if you have pre-existing conditions. After your Medigap Open Enrollment Period is over, it may be harder to enroll in a plan or switch plans if you don’t have guaranteed-issue rights. Medigap insurance companies can require medical underwriting or deny you coverage, especially if you have health problems.
Please note that a Medigap plan won’t work with a Medicare Advantage plan and can’t be used to pay for Medicare Part C costs. In most cases, you can’t be enrolled in both a Medicare Advantage plan and a Medigap plan, and it’s illegal for anyone to sell you a Medigap policy if they know you have a Medicare Advantage plan (unless you’re switching back to Original Medicare coverage). Also, Medigap plans don’t include prescription drug coverage, and if you’d like prescription drug benefits in addition to your Original Medicare coverage, you’ll need to enroll in a stand-alone Medicare Prescription Drug Plan.
If you’d like to find a Medigap plan option to supplement your Original Medicare coverage, or if you have questions about other Medicare plan options, you can:
Medicare Donut HoleThe Medicare Part D donut hole is just a term coined by ordinary people for the stage of Medicare Part D that is officially called the coverage gap. The reason they call it the Medicare donut hole is because it’s a hole in the middle of your drug coverage during a calendar year. There are NO Medicare Part D plans without the donut hole.
The Medicare Part D donut hole is a stage in every drug plan where your coinsurance for your medications is higher.
What is the Medicare Donut Hole?The Medicare Donut hole is a gap inside of your Part D plan. It is a period of the year when your medication costs can be higher.
Congress designed Part D so that it would provide coverage for the majority of your prescription drugs. However, a small percentage of people have medication costs that go well beyond average spending. Those people then share in a greater portion of the costs for their medications when they enter the coverage gap.
Medicare designed the gap to encourage beneficiaries, whenever possible, to seek generics or drug alternatives that are lower in cost. This helps Medicare to keep the total costs for the Part D program as low as possible.
How the Coverage Gap WorksThe coverage gap starts after the combined spending by you and your insurance company reaches a certain annual limit. Medicare sets this limit each year. In 2018, the gap begins when your drug cost reaches $3,750. Before your reach the gap, you will normally pay copays for each medication. After you reach the gap, you will pay a percentage of the cost of each medication. If the medication has a high retail price, this may mean your costs for the medication will increase while you are in the gap.
dicare Part D Plans without the donut hole do not exist. Some plans may offer Tier 1 or 2 generics in the gap, but those aren’t the drugs that make the donut hole expensive. It’s always best to use the Medicare Plan Finder Tool recommendation for the most cost effective plans.
Donut Hole ExpensesIn 2018, you pay 35% of the cost of your brand-name medications and 44% of generics once you reach the Medicare donut hole. So if a certain medication costs $100, and you were paying a Tier 3 copay of $30 before you reached the gap, the same medication will now cost you $35 when you are in the gap.
You will also have a discount on generic medications. Some plans will continue to offer you copays in the gap for generic medications as an added value for that plan.
Medicare continues to tally the spending between you and your insurance company while you are in the gap. If your total out of pocket drug expenses reach $5000 in 2018, then you exit the gap. You reach the fourth stage of Medicare Part D, called catastrophic coverage. At this stage, you will pay no more than 5% of the cost of your medications for the rest of the year. The insurance company picks up the rest.
Some medications fall outside of Part D altogether, and therefore do not get tallied toward the Medicare donut hole.
While the coverage gap can be painful, it’s important to remember that, just a few years ago, there was no prescription drug program for Medicare beneficiaries. Medicare Part D has greatly helped to reduce drug spending for millions of Medicare recipients.
Most Part D carriers negotiate discounted drug rates with pharmaceutical manufacturers, too. You get the benefit of these discounts just for being a plan member.
Common Questions about the Medicare Donut HoleHow do I know if I will reach the Medicare Donut Hole?Your Part D company sends out a statement, or explanation of benefits (called an EOB), each month. This statement tells you exactly how much you have already spent on covered medications and how many dollars are left before you reach the coverage gap. Likewise, after you reach the gap, your insurance company will continue to send you notices that track your gap spending. They will calculate how many dollars are left before you reach catastrophic coverage.
When does the Medicare Donut Hole End?The donut hole ends when you reach the catastrophic coverage limit for the year. In 2018, the donut hole will end when you reach $5000 out of pocket in one calendar year. That limit is not just what you have spent but also includes the amount of any discounts you received in the donut hole. So your out-of-pocket will be somewhat less than that.
So how do you get out of the donut hole? Unfortunately it’s by paying for medications through the donut hole until you reach catastrophic coverage level.
Do Medicare Advantage plans cover the Donut Hole?No. The Part D coverage inside of a Medicare Advantage plan works exactly the same way that standalone Part D plans works. Some Part D companies and Medicare Advantage companies might offer coverage of certain medications in the gap. However, this is almost always coverage of generic medications and rarely brand name medications. This doesn’t really help a great deal since the drugs that cost so much in the coverage gap are brand name drugs, usually not generics.
How Can I Avoid the Donut Hole?The best way to avoid the donut hole is to take generic medications whenever possible. You can also work with your doctor on reducing your drug spending. Show your doctor which drugs are costing you the most on your Part D plan, and see if he can recommend any cheaper alternatives. Some medications may not have a generic equivalent on the market yet, but there may be other similar medications that are cheaper that achieve a like result.
Exemptions from the Coverage GapSometimes people ask us if their Medigap plan will cover the coverage gap in their drug plan. The answer is no. Medigap plans help to pay for inpatient and outpatient services only. Drugs fall separately under Part D.
Every year we have clients ask us to help them find a Part D drug plan with no coverage gap. Such a plan does not currently exist in most states. The are no Medicare Part D plans without the donut hole. There is no separate insurance plan that you can buy to cover you in the Medicare donut hole either.
However, certain people with low incomes and limited assets may qualify for the low-income subsidy, called Extra Help for Part D. If you qualify, then Medicare will waive the gap for you. Also your ordinary copays on your prescriptions will decrease quite a bit. You can apply for the subsidy at your local Social Security office or online at their website.
Medicare Plan N Medicare Plan N has been popular since it was first introduced in 2010. Also called Medigap Plan N, this option was created for consumers who like the idea of paying a lower premium in exchange for taking on a small annual deductible and some copays.
All Medicare supplement Plan N policies are the same, no matter which insurance company you choose. You can find Plan N available in many states from various well-know insurance companies.
AHIP reported that Plan N enrollment grew by 33% between 2013 – 2014.
What Does Medicare Plan N Cover?This standardized Medicare supplement covers the 20% that Medicare Part B doesn’t. It also pays for your hospital deductible and all your hospital copays and coinsurance. You will pay your own excess charges, Part B deductible and some small copays at the doctor’s office and the emergency room.
*It's always a good idea to go over all the out of pocket risk with an agent before purchasing a policy.
What Does Plan N Cover at the Doctor’s Office?
First and foremost, your standard preventive care is covered entirely by Medicare. This includes services like screenings for cancer and diabetes and cardiovascular conditions. It also includes annual physicals, colonoscopies, vaccines and a variety of other normal tests. You will pay nothing for any of the standard Medicare preventive care services.
Your Medicare Supplement Plan N coverage will also includes visits to the doctor for injury and illnesses, durable medical equipment, ambulance, surgeries, home health, lab-work and other imaging tests, diabetes supplies, and many more services. The main thing to remember is that if Medicare Part A or B covers it, then your supplement will also cover it. Medicare pays 80%
If your doctor does not accept Medicare assignment, you will pay a 15% excess charge.
What Does Plan N Cover in the Hospital?Your Medicare Part A hospital benefits provide coverage for inpatient hospital services, skilled nursing, home health, hospice and blood transfusions. While you would normally owe a deductible for your hospital stay, your Medigap Plan will pay that for you.
Here’s a quick list of items covered in the hospital by Medicare Supplement Plan N:
Your Medigap Plan N CostsMedicare Supplement Plan N offers identical basic benefits like the more popular plan F, but you agree to pay a share of a few things that you wouldn’t pay on Plan F. First, you agree to pay the small annual Part B deductible ($183). You will also pay co-payments up to $20 for doctor appointments. Emergency room visits have a $50 copay.
Medicare Plan N EligibilityYou are eligible to enroll in Plan N as long as you have Medicare Parts A and B. You must also live in the plan’s service area. The best time to enroll in Medicare Plan N is during your Medigap open enrollment period. This six-month window starts with your Part B effective date. It’s your one chance to enroll in any Medigap plan without health underwriting. No insurance company can turn down your application due to health conditions.
If you’ve missed your one-time Medigap open enrollment period, you can still apply for a Medigap Plan N. We can explore the health questions on various company’s applications to see if you are able to pass.
Medigap Plan N Insurance CompaniesThough Medicare Plan N is one of the 10 federally standardized Medicare supplement options, each insurance company can choose whether to sell it or not. This policy is fairly easy to find since many carriers offer it.
Need Plan N quotes? Feel free to contact my office anytime, 631-805-5573 or shoot me and email request to Medicare@paulbinsurance.com
COPD is a an inflammation of the small airways(bronchioles) and tiny air sacs in the lungs. This causes narrowing of the airways and destruction of the air sacs making it difficult to exhale air out of the lungs. People complain of shortness of breath, chronic cough with mucus and wheezing. COPD is caused by long term exposure to irritating gases or particulate matter, most often from cigarette smoke. People with COPD are at greater risk of developing heart disease, lung cancer, and respiratory infections.
The two conditions that contribute most to COPD are chronic bronchitis and emphysema. Chronic bronchitis is an inflammation of the lining of the bronchioles. Most people will also have daily mucus production with chronic cough.
Emphysema is when the tiny air sacs (alveoli) at the end of the smallest airways are destroyed as a result of cigarette smoking.
Symptoms include shortness of breath, wheezing, chest tightness, chronic cough that produces mucus, blueness of the lips and fingertips(cyanosis), frequent respiratory infections, lack of energy, unintended weight loss(later in the disease), and swelling of ankles, feet and legs. At times, people with COPD may have an exacerbation- this is when the stable symptoms get markedly worse, most often due a respiratory infection. This requires medication and even hospitalization if severe.
Causes of COPD in the developed world center around cigarette smoking. In poorer parts of the world, COPD is most often caused by exposure to the fumes from burning poor quality fuel for cooking and heating in poorly ventilated homes. Between 20% and 30% of smokers will develop clinically apparent COPD. Other smokers will have some degree of
COPD, but it does not affect their daily lives.
The two large tubes that divide from the trachea are called bronchi. From these, many divisions occur leading to smaller and smaller tubes that end in clusters of tiny air sacs(alveoli).Think of how a tree divides into ever-smaller branches to visualize the tubes of the lung.The air sacs have blood capillaries in their walls and pick up oxygen and release carbon dioxide. The tubes and air sacs need to be elastic to allow this exchange of gases to take place. Emphysema causes them to lose their elasticity and overexpand causing air to be trapped during exhaling. This air-trapping doesn’t allow as much air to be inhaled because part of the air sacs are full of old air. The smallest airways also tend to collapse trapping even more air. If the cause isn’t stopped(smoking), eventually the person will not get enough oxygen into their bloodstream. Chronic bronchitis causes inflammation and narrowing of the small airways(bronchioles) causing obstruction to airflow. Increased mucus production causes further blockage to air, causing the chronic cough to try to clear it out.
There is one genetic cause of COPD. 1% of patients with COPD have alpha 1-antitrypsin protein deficiency. This protein is made in the liver and protects the lungs. It is most common in children and young adults.
The major risk factors for COPD are smoking, smoking with asthma, occupational exposure to certain irritants or gases, age, and genetics.
Complications of COPD most seriously affect the lungs. There is an increased risk of contracting respiratory tract infections. In the event that these patients get the flu or pneumonia, they must seek treatment immediately and may have serious breathing difficulty. Other complications include lung cancer, heart disease, and high blood pressure in arteries that supply the lungs.
The main diagnostic tool are pulmonary function tests. These tests show how the lungs are functioning. Spirometry consists of showing how much air the lungs can hold and how fast they can blow it out. This gives valuable information that can guide treatment.
The mainstay of treatment is to quit smoking. Medication that reduces inflammation can be administered by hand-held inhalers. Other inhaled medications help open narrowed airways. Inhaled steroids are very effective at reducing inflammation and don’t cause the same type of complications that oral steroids do. Some patients require extra oxygen to function and others can need a lung transplant
I hope this has given the readers an introduction to COPD and any questions will be gladly answered.
Keith M. Oshan, M.D.
4 Simple Steps to Understanding Medicare
Understanding Medicare is easier said than done. You get a big ‘old Medicare & You Handbook in the mail, full of terms you’ve never heard before. Then there are scores of insurance companies bombing your mailbox with a foot-high stack of mail every week.
If your desk is covered in Medicare mailers and you aren’t sure what to keep… this post is for you!
Are you supposed to read all that and have any idea what to do? How do you know which mail is ok to throw away?
Frankly, Medicare can intimidate most of us. Why? Well, most of us spend our lives working for an employer who selects our insurance for us. We go to an annual benefits meeting and sign up for the plan they’ve chosen for us.
A large majority of us have never had to choose from dozens of plan options like we are facing with Medicare. Then we hit 65, and we are clueless about Medicare.
Perhaps you are new to Medicare, and it will be your primary insurance. Perhaps you are working and not even sure if you need Medicare, but you want to make sure you don’t unknowingly get a late enrollment penalty.
If you feel lost – you are not alone ! This post will help you cut through the fluff. If you work through these 4 steps in order so that you learn the basics first. Then follow my tips at the end of this post and you will be able to toss those post cards booging down your kitchen table.
(No time to read this post right now? Or just want Medicare explained one-on-one? Feel free to visit my website or call me direct and I will provide you will all the free and accurate information you can handle.
#1 – Understanding Medicare Basics First We see too many people get confused early on. They try to jump right into figuring out Medigap plans and Medicare Advantage plans or how Medicare will coordinate with their employer coverage.
That’s putting the cart before the horse, so let’s set that aside for now. Before you worry about all that, I want you to first familiarize yourself with the Medicare basics. Your Original Medicare consists of Part A and Part B. These are provided to you by the federal government… in fact, you will enroll in these two parts (and only these two parts) through the Social Security office.
Your Original Medicare consists of Part A and Part B. These are provided to you by the federal government. In fact, you will enroll in these two parts (and only these two parts) through the Social Security office.
Anything in your mailbox that comes from the Social Security office or the Centers for Medicare & Medicaid Services is mail you want to keep.
The Parts of MedicareMedicare itself has PARTS (not plans).
Part A is your Hospital Coverage. This coverage pays for your room and board in the hospital or in a skilled nursing facility.
Part B is your Outpatient Coverage. This includes pretty much everything else: doctor visits, equipment, lab-work, surgeries, durable medical equipment, diagnostic tests, etc.
Part D is your drug coverage. This is a pharmacy card which will allow you to purchase your prescriptions at a much lower price than retail. It is insurance you buy for present AND future medication needs. It’s pretty important to have unless you can afford to pay for all your medications out of pocket. For more about drug coverage, read our post about Why you need part D.
You are eligible for these 3 parts of Medicare on the first day of the month in which you turn 65 (or earlier if you have qualified for Medicare due to disability).
Understanding Medicare just got a little easier! Now that you know these 3 basic parts, keep them in mind as we continue. We’ll refer back to them in the rest of the article to build upon what you have learned so far.
(We haven’t forgotten about Part C. We’ll have more on that in Step #4 because that Part is optional.)
#2 – Understanding Medicare Costs for these PartsAlright, so we know you are eligible for the 3 parts of Medicare at age 65. Now you’ll need to know what you can expect to pay for each of these parts. This is especially important if you are deciding whether to stay working past age 65 for an employer who offers health benefits or whether you will retire and go onto Medicare as your primary insurance.
Medicare Part A is free for most people, as long as you or a spouse have worked at least 10 years in the United States.
Costs for Part BMedicare Part B depends on your income. People new to Medicare in 2017 have a base rate of $134/month. However, people in higher income brackets will pay an “Income Adjustment.” Really that’s just a nifty term for explaining that people who earn higher incomes pay higher costs for Medicare.
Understanding Medicare Costs: Your Part B premium is based on your income from 2 years prior.
Social Security bases your income adjustment on your income as reported on your tax returns. They are usually looking at your income tax return from two years prior to now.
If your income has decreased since then, you can file a reconsideration request You’ll present proof of your lower income and ask Social Security to lower your Part B premium. They will reconsider your premium and notify you if it can be lowered.
Once Social Security has determined what you’ll pay based on your income, they will deduct your Part B premiums from your monthly income benefits. If you have delayed enrollment into your Social Security income benefits, then they will invoice you for Part B on a quarterly basis.
Later on, when you file to start your income benefits, they’ll switch over to the monthly deduction from your SS check.
Is Part B Necessary?Medicare Part B is an absolute must if Medicare will be your primary insurance at age 65. In fact, you can’t buy any supplemental insurance unless you first have both A & B.
However, if you actively work for a large employer (20+ employees), that will continue to be your primary insurance. Medicare will be secondary, so you can consider delaying Part B since your group insurance probably includes outpatient benefits already.
Costs for Part DUnderstanding Medicare Part D costs is a bit tricky because plans have varying premiums. Beneficiaries also might pay more due to their income, just as mentioned above in the Part B costs section.
Most states have around 30 different Part D plans to choose from. The national average Part D premium is currently around $34/month. That’s a good ballpark figure to use if you are just running some estimates today.
Part D plans have different drug formularies, so you’ll choose one that offers your medications at decent prices. The Medicare website has a handy plan finder tool to help you choose one that fits you.
Part D premiums get paid directly to the insurance carrier. However, you can request that Social Security deducts that monthly premium from your SS income check. If you owe an income adjustment for having a high income, this surcharge will be added to the monthly premium of your chosen Part D drug plan.
So we’ve learned that both Part B and Part D have a base premium, and also an income-related additional premium for people in higher income brackets.
#3 – Understanding Medicare Parts – What’s Covered and What’s NotBy this time you are wondering: exactly what am I paying for? What are my benefits?
Medicare covers most of your health care costs, but you are still responsible for your share. This includes things like deductibles and coinsurance and copays.
It’s quite similar to employer coverage you’ve had in the past. You paid your share of the monthly premium via paycheck deductions. That purchased the insurance coverage. Then when you used that insurance, you also paid your share of each medical service, right? You had co-pays at the doctor’s office. You probably also incurred a deductible if had surgery or hospital stay. It works the same with Medicare.
What Medicare Pays For:Part A pays for your first 60 days in the hospital. Your share of that cost is a hospital deductible, which is $1316 in 2017. After 60 days consecutive days in the hospital, Medicare pays a diminishing share of your benefits. You begin paying a larger share in the form of a daily hospital copay. This can be hundreds of dollars per day, so you need supplemental coverage to protect you from those expenses on Part A services.
This can be hundreds of dollars per day, so you need supplemental coverage to protect you from those expenses on Part A services.
After 60 days consecutive days in the hospital, Medicare pays a diminishing share of your benefits. You begin paying a larger share in the form of a daily hospital copay. This can be hundreds of dollars per day, so you need supplemental coverage to protect you from those expenses on Part A services.
Part B pays for your outpatient care. This includes things like doctor visits, lab-work, imaging tests, surgeries, durable medical equipment, and even things like chemotherapy, radiation, and dialysis. After a small deductible that you pay once per year ($183 in 2017), Part B will cover 80% of all of these services for you.
Your share is the other 20% of all of these services, with no cap. That can be quite a bit of money for some of the bigger ticket items like surgeries or cancer treatments. You’ll need supplemental coverage to protect you from high Part B expenses.
Part D helps to pay for retail prescription medications. By that, we mean medications that you yourself pick up at a local pharmacy or via the plan’s mail order.
You do NOT need any supplemental insurance for Part D. It has built-in co-pays for medications so that you don’t get smacked with paying 100% for necessary medications.
Now you’ve absorbed a lot of information so far, and we’ve got one step to still go over. (If you feel overwhelmed, just use the contact form on our homepage or give me a call directly 631-805-5573)
#4 — Understand Your Supplemental Coverage OptionsNow that we’ve outlined what Medicare pays for, and what your share is, we’ve discovered that some sort of supplemental insurance is necessary for you. This is MOST of what’s been filling up your mailbox: solicitations for supplemental insurance.
Once you decide between the two main types of coverage we are about to discuss, you’ll be able to toss out most of that stack of mail. There’s no need to keep mailers about Medicare Advantage plans if you determine that Medigap plans are a better fit for you, and vice versa.
Once you decide between the two main types of coverage we are about to discuss, you’ll be able to toss out most of that stack of mail. There’s no need to keep mailers about Medicare Advantage plans if you determine that Medigap plans are a better fit for you, and vice versa.
One of the great things about the Medicare insurance options is that there are plans available for any budget .
Medigap Plans (also called Medicare supplements)Medigap plans pay AFTER Medicare. They pay for the things that are normally your share. For example, all Medigap plans cover the 20% that we mentioned above. So Medicare will pay 80%, and your Medigap plan will then pay the other 20% of your Part B outpatient expenses (thank goodness)! Some Medigap plans also cover your Part A and B deductibles. You can choose your own Part D drug plan to go alongside this coverage.
Medigap plans also allow you freedom of choice in your medical care. You can see any physician or healthcare provider that participates in Medicare (nearly 900,000 providers across the nation). These plans cost more than Advantage plans because they are more comprehensive. They also give you more freedom in choosing your providers.
Medicare Advantage Plans (also called Part C)Understanding Medicare Advantage plans can be a bit confusing because the Medicare Advantage program is also called Part C of Medicare.
Medicare Advantage plans pay INSTEAD OF Medicare. These plans are optional. They were created to give a low-cost alternative to Medigap.
Advantage plans are private insurance plans with their own local network of providers, generally an HMO or PPO style plan. When you join an Advantage plan, you’ll see these providers in order to get the lowest copays.
You will pay co-pays for doctor visits, hospital stays, and any other Medicare-approved services. Medicare Advantage plans generally have lower premiums than Medigap plans. That’s because you agree to share in the costs by paying co-pays for services as you obtain them. (Whereas with a Medigap plan, you often will have NO copay, depending on the plan you choose.)
Most Medicare Advantage plans also include a rolled-in Part D drug benefit. This can be a benefit or a hindrance, depending on whether that rolled-in benefit includes the specific medications you need. Each type of plan has its advantages and disadvantages. You’ll want to be thinking about what things are most important to you.
In my local presentations and webinars for hospital groups and employers, I tell attendees to ask themselves filtering questions. Would a local network plan work for me or do I need wider access because I travel? Which plan would give me the most peace of mind? Am I okay with paying co-pays as I go along in order to get lower premiums up front?
These are the kinds of questions that will lead you to the right coverage.
So…back to that stack of mail, here are my best tips:
We’ll guide you through the next steps to enroll in the right parts of Medicare. We’ll also help you find the most suitable coverage for your needs and budget.
This is the second of a two part series on heart disease. The first article dealt with CAD(Coronary Artery Disease). This time the topic will be Congestive Heart Failure(CHF) and a basic explanation of the valves in the heart and how they can malfunction.
CHF happens when the heart can no longer effectively pump blood. Some causes of this can be CAD or HBP(high blood pressure).This occurs because these conditions leave the heart too weak or too stiff to function properly.There are some things a person suffering from CHF can do to improve their quality of life. Decreasing salt intake, start a gradual exercise program(walking), managing stress, and losing weight if obese.Unfortunately, not all causes of CHF respond to treatment. More on this later. The best way to prevent CHF is to control things that cause it, such as CAD, HBP, diabetes, or obesity.
CHF may be chronic, or have a very sudden, abrupt onset. Symptoms and signs may include some combination of these listed; shortness of breath(dyspnea) when you exert yourself or lie down, fatigue or weakness, swelling of legs, ankles, or feet, or irregular,rapid heart beat, reduced ability to exercise, persistent cough or wheezing with white or pinkish phlegm.
If you have chronic CHF and some of the above symptoms get markedly worse seek immediate help.
The heart can become stiff and fail without becoming weak. This is best demonstrated by heart failure caused by HBP. As the heart is asked to pump harder and harder against an increased resistance, at some point the muscle loses its ability to contract effectively and this results in failure.Heart failure can either be left-sided( left ventricular failure) or right-sided ( right ventricular failure). Usually both sides of the heart both fail.
Major causes include HBP, CAD,MI (heart attack), damaged heart valves, and damage to the muscle itself ( cardiomyopathy). Cardiomyopathy can be caused by some diseases, infections ( virus most common), alcohol abuse, and toxic drugs like cocaine or chemotherapy. In addition, there are congenital causes (defects you are born with), and conditions such as diabetes, HIV, elevated and depressed thyroid function, an abnormal buildup of protein or iron, and sleep apnea.Smoking and obesity are contributing factors that cause diseases or conditions that can bring on heart failure.
Complications that can occur with heart failure are related the cause and severity of the failure. Kidney damage and even failure can occur becauses as blood flow backs up in the kidneys, they lose the ability to function properly. Since the pressure within the heart itself rises, this puts a larger workload on the heart valves and can causes them to malfunction. Irregular heart rhythms can also happen with heart failure. The liver,as the kidneys, can be damaged by the backup of blood that causes increased pressure in the liver and scarring.
Some people's’ heart failure and symptoms can be improved with medication and lifestyle changes. Others , however, with severe and untreatable failure may a transplant or a left ventricular assist device.
A brief overview of heart valves will follow. Think of these structures as little doors that open and close and allow blood to flow in one direction only. The most important valves in the heart are the Aortic Valve ( AV) and the mitral valve (MV). There are other valves in the heart ,but they are much less involved in malfunctions.
There are two types of problems that affect the function of these valves. One is stenosis (narrowing), where blood flow is decreased. The other is regurgitation (backward blood flow) where more blood flows back into the right or left ventricles (lower chambers of the heart) and less flows out to the body. The fraction of blood being pumped out of the heart should be at least 50%. Multiple causes of valve problems are congenital ( born with) defects, infections, mechanical,and IV drug abuse. Valves can be surgically replaced, but can be risky in very sick patients. One great advance with aortic valve replacement is called TAVR. This stands for Transluminal Aortic Valve Replacement. This procedure can be done through an artery leading back to the aortic valve and removing and replacing it with a new one. It has allowed desperately ill patients a chance to lead very normal lives.
I hope these last two monthly articles on heart disease have been helpful. I know the amount of material is huge, but i have tried to simplify as much as possible. If any of you have more questions, you can reach me at The Long Islander website.
Keith M. Oshan, M.D.
This is the first part of a two part series on heart disease. We will first discuss Coronary Artery Disease ( CAD). Next month Congestive Heart Failure (CHF) will be presented. Causes, signs and symptoms, diagnosis, medical therapies, and procedures that restore blood flow to the heart will be examined. CAD occurs when the arteries that bring blood, O2 and nutrients become damaged. Cholesterol- containing deposits (plaques) and inflammation are the usual causes of CAD. Over time these plaques build up and cause narrowing of the arteries. This leads to decreased blood flow and, in some cases, symptoms such as chest pain (angina), shortness of breath, profuse sweating and fatigue. A complete blockage causes a myocardial infarction ( MI- heart attack). Some people can have no symptoms and suffer a major heart attack as the first awareness that they have heart disease. The damage to the coronary arteries is caused by smoking, HTN (high blood pressure), elevated cholesterol ( especially the bad kinds- LDL and VLDL ), diabetes ,and a sedentary lifestyle (couch potato). Once damage has occurred, fatty cholesterol-laden plaques accumulate at the site of injury (atherosclerosis) and cause various degrees of blockage.The blood platelets that clump at the site of injury can form a clot that further blocks the artery.
Risk factors include age, male sex (women over sixty-five have similar risk), smoking, elevated cholesterol, HTN, diabetes, obesity, sleep apnea, and family history. If a man has a father or brother with significant CAD, or MI under fifty-five he needs to undergo a full cardiac evaluation even without any signs or other risk factors. Sometimes these risk factors are additive. If you are obese,smoke,and have HTN, you are more at risk to be diabetic,and that raises your risk of CAD many fold. Complications of severe CAD and/or MI are angina, heart failure due to damaged heart muscle which is to weak to pump blood effectively, and abnormal heartbeats due to decreased blood flow to the heart’s electrical system.
Diagnosis includes an EKG (electrocardiogram), which can show patterns of decreased blood flow (ischemia) and previous heart attacks ( MI). Sometimes people have had heart attacks and don’t even know it!). A Holter monitor is a 24 hour recording of the EKG which can show heart changes during exertion or stress. It is the size of an iPod. A cardiac echocardiogram( a type of sonogram) can show the heart in real time motion and is used with an exercise stress test to detect signs of weakened heart motion. This can mean decreased blood flow and a poorly functioning heart. The gold standard of diagnosis is a cardiac catheterization. This procedure involves injecting a dye that is seen in real time showing if the coronary arteries are blocked or open. The dye is injected in vein in the arm or leg and circulates to the heart.
The treatment of CAD consists of lifestyle changes, medications,and possible medical procedures to restore the flow of blood to the heart. The most important lifestyle change involves quitting smoking. Smoking is responsible for CAD, lung cancer, COPD (emphysema), and decreased wound healing. Diet has serious consequences, but one should not go overboard with drastic changes. These are not sustainable in the long term. Plans like weight-watchers, which allow you to eat almost anything in moderation work best. The only food best avoided is most fast-food, since it is loaded with saturated fats and salt. Beginning a low impact exercise program of walking 30 minutes per day.Losing the weight will take stress off of the heart and decrease blood pressure and , sometimes, blood sugar as well. Any form of meditation will lower stress levels which is great for the heart.
Medications that lower cholesterol have greatly reduced the incidence of CAD. Drugs such as statins lower the LDL ( “bad cholesterol”)and raise the HDL (“good cholesterol”). This can decrease the size of plaques in the artery. A baby aspirin (81mg) can prevent platelets from sticking to damaged arteries causing clots that block blood flow. People need to discuss which drugs are right for them.
Procedures that restore blood flow through coronary arteries are used in the most severe blockages. This consists of passing a deflated balloon attached to a thin tube through the blockage and is then inflated to compress the blockage. Sometimes a stent is left in place releasing medication to keep the artery open. This is called angioplasty.
CAD is a condition with multiple causes and solutions. Even a bad family history can be significantly improved by early monitoring and timely intervention.
Keith M Oshan, MD