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Re: [IP] Re: Medicare enrollment



 Pam, it was great to read your explanations and it is so admirable that you
work with SHIP. In the past a SHIP representative helped me with appeals and
with her help my claims were 100% granted.

Sent from my iPhone
Phyllis 

 > On Jan 30, 2018, at 7:40 PM, Pam Brown
<email @ redacted> wrote:
> 
> I'll try to address all the Medicare questions at once (I work in a SHIP
 > program, which are volunteer-based programs sponsored by the federal and
state
> governments that help people with Medicare). First, as some of you already
> pointed out, there are two routes to getting your Medicare. The first is
> Original Medicare Parts A and B with an optional supplemental plan (Medigap)
> and an optional stand-alone Part D prescription drug plan. This is fee for
> service coverage and the insurer for Parts A and B services is the government
> (CMS). They process the claims and pay the bills. Supplemental plans and drug
> plans are sold by private insurers. Supplements in most states are
> standardized with letters A through N and are almost always portable and can
> be used anywhere in the country. For example a Plan N purchased anywhere from
> any insurer has to offer the exact same benefits as any other Plan N. There
 > are no networks or referrals needed with this Original Medicare route. As
long
> as a provider takes Medicare, they have to also take all official Medigap
> supplement plans.
> You have certain times when you're guaranteed the ability to get one of these
> Medigap plans without health screening. One such time is within six months of
> starting Medicare Part B for the first time. There are certain other times,
> depending on your state. There are federal "guaranteed issue" rights and then
> certain states also have their own additional rights. If you don't get a
> Medigap under one of these rights, you could be denied, charged more based on
> your condition, or have waiting periods for pre-existing conditions. Under
> this Original Medicare path, Medicare Part B typically pays 80% after a
> deductible, and you pay the other 20% unless you have a supplement, in which
> case it pays the 20%.B 
> DME and drugs used in conjunction with DME are covered under Part B, hence
> insulin when used in a pump is Part B. If you have a supplement or other
> secondary coverage that pays the 20%, you'll owe nothing. As far as I know,
> there is no formulary for insulin under Part B. The key is that it has to be
> medically necessary and the prescription has to specify that the insulin is
 > used in a pump. I know that all the national chains such as CVS, Walgreens
and
> Rite-Aid have national Part B billing staff who can help any local branch
> store bill it the proper way.
> 
 > Instead of an official Medigap supplement you can also have secondary
coverage
> through an employer or retiree plan, COBRA, Tricare for Life, etc. That
 > coverage may pay for things that Medicare doesn't, like dental, or it could
be
 > worse than getting a Medigap and separate drug plan because it might have
high
> deductibles, etc. It may or may not have what is known as creditable
 > prescription coverage. If it does you do not need a Part D plan. If you do
not
> have creditable coverage then if you don't get Part D when you're first
 > supposed to, you will have to wait until the following year and pay a
lifetime
> penalty.
> Part D has the infamous donut hole, although that's supposed to be gone by
> 2020 under the ACA. Stand-alone Part D plans vary by state or even by
> County.B  There is a big range of Part D plans. For instance, here there are
> 25 plans with monthly premiums ranging from $18/mo to $170/mo. They all have
> different formularies and categorize the drugs into different tiers. There is
> no standardization amongst plans as far as what tier a given drug is. If you
 > take any meds at all that are Part D meds, then the best way to pick a plan
is
> to enter your specific drugs, dosages, frequencies, etc., into the Planfinder
> tool on medicare.gov. It will analyze the results and tell you what plan is
> the overall lowest cost for you. It factors in premiums as well as copays,
> etc.
> 
> Alternatively to the above, you can assign your Medicare over to a private
> Medicare Advantage plan. These encompass Parts A and B (you still have to pay
 > the same premiums for Part B) and usually also include Part D bundled into
it.
> These are typically managed care plans such as HMOs and PPOs, meaning they
> have geographically-limited provider networks, require authorizations, etc.
 > Advantage plans have to offer equivalent benefits to Parts A and B of
original
> Medicare, but can set their own deductibles and copays. These plans also have
> to follow the Part D rules and they too have their own drug formularies, the
 > donut hole, etc. You can also see the results for your drugs under these
plans
> on the same medicare.gov tool. For Part B drugs such as insulin in a pump,
> many of the Advantage plans charge the 20% as if you were under Original
> Medicare without a Medigap supplement. That's also often true for DME such as
> pump supplies. That's why for many pumpers it's often better to go the
> Original Medicare and Supplement path and pay nothing for your insulin or
> supplies. Also, Advantage plans are highly specific, often limited just to a
> single county, so you have to check carefully and see what your options are
> and what the details of each plan in your area are.
> I hope this helps. I'm happy to answer any questions. Pam
> .
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