Costs in the Coverage Gap

Most Medicare Prescription Drug Plans have a coverage gap (also called the “donut hole”). This means there’s a temporary limit on what the drug plan will cover for drugs.

Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2015, once you and your plan have spent $2,960 on covered drugs (the combined amount plus your deductible), you’re in the coverage gap. In 2016, once you and your plan have spent $3,310 on covered drugs, you’re in the coverage gap. This amount may change each year. Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap.

Once you reach the coverage gap in 2015, you’ll pay 45% of the plan’s cost for covered brand-name prescription drugs. You get these savings if you buy your prescriptions at a pharmacy or order them through the mail. The discount will come off of the price that your plans has set with the pharmacy for that specific drug.

Although you’ll only pay 45% of the price for the brand-name drug in 2015, 95% of the price—what you pay plus the 50% manufacturer discount payment—will count as out-of-pocket costs which will help you get out of the coverage gap. What the drug plan pays toward the drug cost (5% of the price) and what the drug plan pays toward the dispensing fee (55% of the fee) aren’t counted toward your out-of-pocket spending.

Example: Mrs. Anderson reaches the coverage gap in her Medicare drug plan. She goes to her pharmacy to fill a prescription for a covered brand-name drug. The price for the drug is $60, and there’s a $2 dispensing fee that gets added to the cost. Mrs. Anderson will pay 45% of the plan’s cost for the drug ($60 x .45 = $27) plus 45% of the cost of the dispensing fee ($2 x .45 = $0.90), or a total of $27.90, for her prescription. $57.90 will be counted as out-of-pocket spending and will help Mrs. Anderson get out of the coverage gap because both the amount that Mrs. Anderson pays ($27.90) plus the manufacturer discount payment ($30.00) count as out-of-pocket spending. The remaining $4.10, which is 5% of the drug cost and 55% of the dispensing fee paid by the drug plan, isn’t counted toward Mrs. Anderson’s out-of-pocket spending.

In 2015, Medicare will pay 35% of the price for generic drugs during the coverage gap. You’ll pay the remaining 65% of the price. What you pay for generic drugs during the coverage gap will decrease each year until it reaches 25% in 2020. The coverage for generic drugs works differently from the discount for brand-name drugs. For generic drugs, only the amount you pay will count toward getting you out of the coverage gap.

Example: Mr. Evans reaches the coverage gap in his Medicare drug plan. He goes to his pharmacy to fill a prescription for a covered generic drug. The price for the drug is $20, and there’s a $2 dispensing fee that gets added to the cost. Mr. Evans will pay 65% of the plan’s cost for the drug and dispensing fee ($22 x .65 = $14.30). The $14.30 amount he pays will be counted as out-of-pocket spending to help him get out of the coverage gap.
If you have a Medicare drug plan that already includes coverage in the gap, you may get a discount after your plan’s coverage has been applied to the price of the drug. The discount for brand-name drugs will apply to the remaining amount that you owe.
Items that count towards the coverage gap: Your yearly deductible, coinsurance, and copayments, the discount you get on brand-name drugs in the coverage gap and what you pay in the coverage gap
Items that don’t count towards the coverage gap: The drug plan premium, pharmacy dispensing fee and what you pay for drugs that aren’t covered.

 

How to Appeal a Medicare Decision – Redlands CA, Yucaipa CA

Hello!

I hope all is well with you. Below in the article is some useful information for you or someone you know that is on Medicare.

Have you ever had these questions come up?

How do I Appeal a Medicare Decision?

When can I appeal a payment or coverage decision?

What happens if I decide to file an appeal?

What’s the first step of filing an appeal?

If so this article has the answers for you.  And if you haven’t this could be valuable information for the future.

Have a wonderful day!

George Litchfield
Medicare Plan Specialist
Lic#OB56846
GeorgeLitchfield.com

Call me today at 888-891-5557

 

 

Medicare - Redlands CA - George LitchfieldAn appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. That decision can be made by Medicare or by the private Medicare-approved health plan that administers your Medicare Advantage (MA/MAPD) plan, prescription drug plan (PDP) or special needs plan (SNP).

When can I appeal a payment or coverage decision?

You can file an appeal if Medicare or your plan denies one of the following:

  • Your request for a health care service, supply, item or prescription that you think you should be able to get.
  • Your request for payment for health care service, supply, item or a prescription drug you already got.
  • Your request to change the amount you must pay for a health care service, supply, item, or prescription drug.

You can also appeal if Medicare or your plan stops providing or paying for all or part of an item or service you think you still need.

What happens if I decide to file an appeal?

If you decide to appeal, first ask your doctor, health care provider or supplier for any information that may help your case. See your plan materials, or contact your plan for details about your appeal rights. Medicare and all companies that provide Medicare plans are required to help you file an appeal.

The appeals process for all types of Medicare plans has five levels. At each level, a decision about your appeal is made and communicated to you in a letter. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you’ll be given instructions in the decision letter on how to move to the next level of appeal.

What’s the first step of filing an appeal?

Although we won’t go through all five steps of an appeal process, we can describe the first step. How you file an appeal depends on the type of Medicare coverage you have. But no matter what type of Medicare plan you have, at any step of the appeals process, you can—and may want to—ask your doctor, health care provider or supplier for any information that may help your case, or other help.

Original Medicare

If you’re on Original Medicare, then every three months you’re mailed a Medicare Summary Notice, or “MSN.” An MSN shows all services or supplies that health care providers and suppliers billed to Medicare for your care during the three-month period. It shows what Medicare paid, and what you may owe the provider. You can also view your MSNs electronically on MyMedicare.gov.

Your first step is to find the MSN that shows the service or supply you’re appealing. You then have two options to file the appeal:

1. Fill out a Redetermination Request Form (PDF). Send it to the Medicare contractor at the address listed in the “Appeals Information” section of your MSN. Or, you can…

2. Follow the instructions on the back of your MSN, and send the request for an appeal without the Redetermination Request Form. You provide the same types of information as what’s asked for on the form, and send it to the Medicare contractor listed.

Generally, you get a decision from your Medicare contractor within 60 days after they get your request. The decision is called a “Medicare Redetermination Notice,” and it can come as a separate notice or as part of your MSN.

Medicare Advantage Plan (Part C)

You have the right to ask the company that administers your Medicare Advantage plan to pay for, or cover, health care services or items you believe should be covered. This request for services or supplies is called an “organization determination.” You can either ask for a determination yourself, or have your doctor or someone representing you ask for one.

Organization determinations typically take 14 days. If you or your doctor thinks your health could be harmed by waiting that long, you can ask for an “expedited” or fast determination. Then your health plan has 72 hours to give you a decision.

Your plan can approve your request, or partially or fully deny it. Your plan will send you a written notice explaining why, and give you information on how to file an appeal. This process may vary depending on your plan, so follow the instructions provided. However, regardless of your plan, you are allowed to ask for a copy of your file containing medical and other case information.

Medicare Prescription Drug Plan (Part D)

Appealing a decision for a Part D plan typically means working with your plan to get coverage for a prescription drug that you feel you need. As with a Medicare Advantage plan, this usually involves either you or your doctor (or representative) working directly with the company that administers your Part D plan.

Prescription drug coverage relates primarily to your plan’s formulary, or drug list. For more information, see the previous Medicare Made Clear blog post Medicare won’t cover a prescription I need—what now?.

Medicare Special Needs Plan (SNP)

Your Medicare SNP needs to tell you in writing how to file an appeal. After you file an appeal, the plan reviews its original decision. If your plan doesn’t decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan.

–This information was provided by Medicare Made Clear

Georgelitchfield

 

 

GeorgeLitchfield.com – If you or someone in your family is 65 or older and is in need of a Medicare Supplemental Plan or already has a plan, but wants to make sure that it is the right plan please give us a call (888)891-5557 or go to our website GeorgeLitchfield.com  and we will give you a quote and help you keep money in your pocket.

 

New Medicare Guides Provide Latest Information

babyboomersIt’s a new year, and that often means a few changes in Medicare. Changes may include new covered services, adjustments to out-of-pocket costs and more.

Medicare Made Clear offers two educational guides that may help you get up to speed on Medicare for 2013. Both are available to download free.

This is a comprehensive introduction to Medicare. It begins with a simple explanation of ten key facts for understanding the program. It goes on to talk about enrollment and the two ways you can get Medicare—through Original Medicare run by the federal government or through a private Medicare Advantage plan.

Once you’re through the basics, the Show Me Guide explains the parts of Medicare, what each covers and your cost-sharing responsibilities. Examples, colorful graphics and clear answers to common questions help make the information come to life. There’s even a decision road map to help you think through your Medicare needs and find a plan that works for you. The guide ends with a list of resources and a Medicare glossary.

This guide may help give you a solid foundation for understanding Medicare and your choices. It’s a great reference to keep in your Medicare file.

Some people like to get right to the point. They don’t need to know the details right away. They would rather get an overview and have the choice to go deeper. If you are one of these people, then the Getting Started With Medicare guide may be for you.

This guide covers the basics about Parts A, B, C and D as well as supplement insurance—one page for each. It provides a list of questions that may help you understand your coverage needs and make a confident choice. Then it gives you a worksheet to help you find and compare the plans you are interested in side by side.

Getting Started With Medicare is a hands-on tool. It walks you through the steps you can take to help find the plan that’s right for you.

–This information was provided by Medicare Made Clear

GeorgeLitchfield.com– If you or someone in your family is 65 or older and is in need of a Medicare Supplemental Plan or already has a plan, but wants to make sure that it is the right plan please give us a call (888)891-5557 or go to our website GeorgeLitchfield.com and we will give you a quote and help you keep money in your pocket.

Find the RIGHT Medicare Insurance for Your Needs!

Find the RIGHT Medicare Insurance for Your Needs!

  • Are you new to Medicare?
  • Do you want to save money on your Medicare insurance?
  • Do you want objective information on your Medicare insurance options?

The Litchfield Agency provides expert, unbiased guidance in selecting and enrolling in the Medicare insurance that’s right for you.

We work with many insurance companies to help you choose the right plan and avoid unexpected costs or denial of coverage.

George Litchfield
Turning65-NewtoMedicare.com

Turning65-newtomedicare.com – Are you a senior age 65+ looking for Medicare Supplemental Insurance? Call 909-790-7748 or 888-891-5557

Find the RIGHT Medicare Insurance for Your Needs!

Find the RIGHT Medicare Insurance for Your Needs!

  • Are you new to Medicare?
  • Do you want to save money on your Medicare insurance?
  • Do you want objective information on your Medicare insurance options?

The Litchfield Agency provides expert, unbiased guidance in selecting and enrolling in the Medicare insurance that’s right for you.

We work with many insurance companies to help you choose the right plan and avoid unexpected costs or denial of coverage.

 

Have a great weekend!
George Litchfield
Turning65-NewtoMedicare.com – Turning 65 ? Looking for reliable Medicare Insurance? or Looking to get better rates. The Litchfield Insurance Agency assists the Beaver Medical Group in Redlands. Whether it be Medicare, Health, Life. We will find the right plan for you. Serving Redlands, Banning, Yucaipa and the Inland Empire.

The Litchfield Agency’s Guide to Medicare Insurance Options

The Litchfield Agency’s Guide to Medicare Insurance Options

If you are just turning 65, and are newly eligible for Medicare, you are entering a brand-new world of health insurance options.

For most people, the insurance coverage available as a Medicare beneficiary is less expensive and/or more complete than what they were on before.  Some retirees have their coverage completely covered by their former employer, with no premium to pay; Veterans also have inexpensive (if inconvenient) coverage.  Most people though are best served by enrolling in either Medicare Supplement insurance or a Medicare Advantage plan.

There are two main types of Medicare insurance: Medicare Supplement plans, and Medicare Advantage plans.

Medicare Supplement insurance– long considered the best coverage available, this coverage covers the gaps that Original Medicare (having parts A and B only) leaves open.  It provides tremendous flexibility with regards to physician and provider choice.  Its “pay-once” structure, meaning you pay the monthly premium and nothing as you use most services, makes it very easy to use and virtually hassle-free.  Has to be combined with a stand-alone “drug-only” Medicare Part D plan for prescriptions.  Purchased mainly by those just turning 65, this is difficult to obtain after your first year of Medicare eligibility.

Medicare Advantage insurance– these plans vary tremendously in terms of coverage and healthcare provider restrictions.  They  represent more of a “pay-as-you-go” approach to healthcare, with very low premiums and moderate co-payments as you use services.  These plans often include drug coverage, and sometimes include annual caps on your out-of-pocket costs.

Neither option is “best”- the choice of which type of plan is really up to an individual.  We have helped seniors enroll in Medicare Supplement, Private Fee for Service, PPO, HMO and “drug-only” Medicare prescription drug plans.  Because of our independent nature, we are uniquely positions to discuss a variety of options and find one that is appropriate.

–George Litchfield
Turning65-NewtoMedicare.com


 http://www.turning65-newtomedicare.com – Turning 65 ? Looking for reliable Medicare Insurance? or Looking to get better rates. The Litchfield Insurance Agency assists the Beaver Medical Group in Redlands. Whether it be Medicare, Health, Life. Call 888-891-5557 and we will find the right plan for you. Serving Redlands, Banning, Yucaipa and the Inland Empire.

Need help? Call Toll-Free 1-888-891-5557  for a licensed representative.

Video – Understanding Medicare Advantage Plans

Save With Your Medicare Plan


http://www.turning65-newtomedicare.com – Turning 65 ? Looking for reliable Medicare Insurance? or Looking to get better rates. The Litchfield Insurance Agency assists the Beaver Medical Group in Redlands. Whether it be Medicare, Health, Life. We will find the right plan for you. Serving Redlands, Banning, Yucaipa and the Inland Empire.

Getting Ready for Medicare – 3 Important Steps

If you’re new to Medicare, you may be wondering about all the different plan choices available to you. You also may be feeling a little overwhelmed by all of the information. If so, don’t worry. A lot of people have found themselves in your shoes.

Here are a few steps to help you begin to prepare for Medicare.

  1.      Know Your Enrollment Dates

You don’t want to miss your Initial Enrollment Period (IEP). Your IEP begins three months before the month you turn 65, runs through your birth month and ends three months after your birth month. If you are eligible for Medicare due to disability, your IEP begins 24 months after you first become eligible for Social Security benefits. If you don’t sign up during your IEP, you may face increased premiums later on. Most people receive notification of their eligibility well before their IEP.

2.      Understand Your Needs

Take time to consider your health care needs and preferences. Here are some questions to help guide your thinking:

  • How much did you spend on health care last year? Do you expect similar costs this year?
  • Are you eligible for any health care coverage other than Medicare, through your or your spouse’s employer, for example?
  • Which prescription drugs do you take regularly? How much do you spend on your prescriptions?
  • Are you in good health generally? Do you have a chronic condition such as diabetes, heart disease or asthma?
  • Which doctors and hospitals do you use? Are you willing to change doctors to save on health care costs?
  • How much do you travel, and where? Do you need coverage for traveling out of state or overseas?

3.      Learn About the Parts of Medicare

Based on your answers to the questions in #2 above, you can start to consider your coverage choices. It can be confusing at first, because Medicare has several parts that provide different types of coverage. Here’s a quick run-down.

  • Original Medicare is a government-sponsored program consisting of Part A (hospital coverage) and Part B (doctor visits and outpatient care). It doesn’t include coverage for most prescription drugs. If you’re receiving Social Security benefits, you’re automatically enrolled in Part A and Part B. At the time of enrollment, you can decide to accept or reject one or both at that time.
  • Medicare Advantage plans (also called “Medicare Part C”) are provided by private insurance companies contracted by Medicare. These plans offer all of the benefits included with Original Medicare, along with additional benefits, which vary depending on the plan. Most Medicare Advantage plans include prescription drug coverage as well. If you choose a Medicare Advantage plan, you have to be enrolled in Medicare Parts A and B, but your benefits are administered by the plan instead of by Medicare.
  • Medicare Part D plans are provided by private insurance companies to help with the cost of prescription drugs. You can get coverage through a standalone prescription drug plan or as part of a Medicare Advantage plan. If you choose Original Medicare and want prescription drug coverage, you’ll need to purchase a standalone Part D plan. Also, you must have both Parts A and B to be eligible for a Part D plan.
  • Medicare supplement insurance, sometimes known as “Medigap,” works with Original Medicare (and not Medicare Advantage plans) to help pay some of the costs that Original Medicare doesn’t cover. Medicare supplement insurance plans are sold by private insurance companies. Whether or not you buy a plan is up to you.

–This information was provided by Medicare Made Clear

For more information visit http://www.turning65-newtomedicare.com or call 888-891-5557

Turning 65 ? Looking for reliable Medicare Insurance? or Looking to get better rates. The Litchfield Insurance Agency assists the Beaver Medical Group in Redlands. Whether it be Medicare, Health, Life. We will find the right plan for you. Serving Redlands, Banning, Yucaipa and the Inland Empire.