What they aren’t telling you about SilverSneakers

By | General Information, Medicare Advantage | No Comments

Have you seen the TV advertisements for Medicare program that includes SilverSneakers benefits?

Over the past few week’s during Medicare’s Open Enrollment period I’ve seen at least 1 television advertisement a night talking about these programs.

And they look very attractive providing both health insurance and free gym memberships. Right?

For those of you not familiar, SilverSneakers is a program offered with certain Medicare Advantage plans that provides free memberships to participating gyms across the country.

I remember a few months after I joined the Medicare Coach a new client came in and said “I was talking to my friend the other day and she has a Medicare plan that pays for her gym membership. I want that plan too so I can save some money.”

At the Medicare Coach our clients ultimately make their decision, but we have an obligation to share the pros and cons of different Medicare options to ensure they are making well informed decision. For this client, moving to a plan offering a gym membership with would mean leaving her Original Medicare plan and joining a Medicare Advantage plan.

I told the client “I’m happy to move you to a plan that will pay for your gym membership, but I want to make sure you understand what you are giving up by making the switch. By joining that Medicare Advantage plan, you are giving up being able to use your health insurance at some of the doctors your friends have seen when they received their cancer diagnosis, such as Mayo Clinic and MD Anderson. Is saving $75/month on a gym membership worth giving up access to some of the best health care in the country?”

Based on this she decided it was best to stay with her Original Medicare plan instead of switching to a plan offering SilverSneakers.

Very frequently we hear from people who want the SilverSneakers program they see on TV, but once we explain the plan they usually realize they are better off on an Original Medicare plan.

Also, please keep in mind that insurance companies and Medicare brokers love to sell these SilverSneaker Medicare Advantage plans because they are among the most profitable and pay some of the highest commissions.

I share this with you because the number 1 reason people regret their Medicare decision is because they didn’t fully understand the pros and cons of the Medicare program they picked.

While most of our clients pick Original Medicare, some of our clients are better fit for a Medicare Advantage plan with SilverSneakers benefits.

So before you make your Medicare decision please understand the pros and cons of the plan you are considering.

Click here to learn more about the key differences between the Medicare programs: Original Medicare and Medicare Advantage. This will help you get a high-level look at the programs to help decide which is best for you.

Again, for some people a program with “SilverSneakers” may be the best option, but please don’t make your decision solely on this gym benefit.

How to Pick A Supplement Plan

By | General Information

I’ve received many questions lately about choosing your supplement plan. So today I want to quickly go over what supplemental plans are and what you should consider with comparing plans.

Supplement medical insurance (also called Medigap) is a policy that pays for some health care costs (GAPS) that Original Medicare doesn’t cover like copayments, coinsurance, and deductibles. Medicare usually pays 80% of the approved charges and you’re responsible for the remaining 20%.

Insurance companies may charge different premiums for the EXACT same supplement coverage. Please know that the benefits are the same in whatever plan or insurance company you choose. But, the premiums vary widely and the service you receive may differ.

When you look at supplement plans you should first pick the letter of the plan that works best for you, then decide which company to go with based on the premium price and history of rate hikes.

Choosing the right supplement plan will be your most difficult decision because you could spend thousands of unnecessary dollars over your lifetime unless you know what to look for in a plan.

Medicare Vision and Hearing Coverage

By | Dental, General Information, Medicare Advantage

Is having health insurance to cover your hearing and vision important to you?

If so you are one of the many.

I frequently hear people who greatly value this coverage and want to ensure their Medicare plan includes these two benefits.

This is why so many take into account hearing and vision benefits as we make our Medicare decision.

But making a Medicare decision based on vision and hearing benefits can be very difficult.

So, please be careful.

The advertising on this topic can be misleading and can take you down a path where you may make make a Medicare decision you later regret.

Today I want to share two key points to keep in mind as you make your Medicare decision. A decision that keeps in mind your vision and hearing benefits while also ensuring you aren’t sabotaging your other health care benefits.

  1. Both Medicare programs Original Medicare and Medicare Advantage cover medically necessary vision and hearing. I will spend an entire blog going into more detail on what specifically covers under “medically necessary”. It will cover hearing and vision related health care such as cataract surgery and cochlear implants.
  2. Some Medicare Advantage plans charge extra for vision and hearing coverage and limit the amount of money that can go towards these services. Make sure you understand the rules of the plans as you make your decision.

What this means is that while many Medicare Advantage plans advertise, it may or may not be worth giving up the Original Medicare benefits.

There are many important factors that go into your Medicare decision, so please make sure you look at all of them before you finalize which Medicare program you want to go with.

Medicare Open Enrollment 2018

By | Medicare Open Enrollment

It’s that time of year again.

With Medicare’s Annual Election Period (also know as Open Enrollment) starting in just a few days, I want to share some key things to be aware of so you don’t get surprised with a high prescription bill in 2018

Open Enrollment is a period that runs from October 15th to December 7th . During this time you have the opportunity to change your coverage for the new year.

And even more important, this is when the details for 2018 prescription plans are released. Therefore, the plan you had this year might not be the best for you in 2018. Your co-pays and deductibles may increase and your pharmacy may no longer be included in the plan’s network.

I’ve saved hundreds of dollars by changing prescription plans four times during the past seven years.

Those who don’t review every year are leaving millions of dollars on the table in over payments.

During open enrollment:

  • Determine which pharmacy you prefer and find out if your pharmacy is still in your plan’s network.
  • Make sure the medications you take are covered under your current plan.
  • Once you select your plan, visit with your pharmacist about the plan before December 7th. It is critical to double check directly with your pharmacy that they will accept the new plan and that they can obtain all the medications you need. Even if you enrolled in a plan, you can change plans before the deadline, and Medicare will accept the last plan you submit

I can not emphasize enough importance of reviewing your prescription plan.

Danielle today was about to find a 2018 prescription plan for a client that will save him $8,000 and another client $11,000.  We expect over 60% of our clients to switch prescription plans so save money in the new year.

Don’t miss your Open Enrollment window


PS: We offer a one-on-one service where we will do your Open Enrollment review for you. In this review we will find you a 2018 prescription plan that will cover your medications at the lowest cost. Please email me at larry@mymedicarecoach.com to learn more about this service

How Do I Know if My Doctor Accepts Medicare?

By | General Information

If you are enrolled in Original Medicare, Part A and Part B, you can choose any doctor who accepts Medicare assignment (the maximum amount allowed for charges under the Medicare payment rules).

You can call the doctor and ask or use Medicare gov’s Physician Compare tool. The finder tool lets you search through a list of physicians in your area to see which ones accept Medicare.

A beneficiary enrolled in a private Medicare Advantage program is faced with more research before knowing which doctors will accept your plan because it will depend on the type of plan you are enrolled in.

It’s important to understand the differences between the types of Medicare Advantage plans.

An HMO (Health Maintenance Organization) plan allows you to see your doctor if he or she is already participating in the plan.

PPO (Preferred Provider Organization) plans cover both in and out of network providers so you can choose any doctor that accepts Medicare assignment.

PFFS (Private Fee-for-Service) plans determine how much the plan will pay providers and how much you must pay to get care. Your doctor must accept the plan’s payment terms and agree to treat you. If your doctor does not agree to those terms, then the PFFS plan will not cover any services performed by your doctor.

SNP (Special Needs Plans) cover Medicare beneficiaries living in institutions who are dual-eligible for Medicaid and Medicare and those with chronic conditions like diabetes or End Stage Renal Disease (ESRD).

HMO-POS (Health Maintenance Organization-Point of Service) plans cover both in and out-of-network services, but at different rates. You pay less out-of-pocket when you use in-network doctors, labs, hospitals, and other health providers.

MSA (Medical Savings Account) plans include both a high deductible and a bank account to help you pay the deductible. The amount deposited into your account varies from plan to plan. The money is tax-free if you use it on IRS-qualified medical expenses, which include the health plan’s deductible.

The best way to determine if you doctor accepts your Medicare plan is to call before the appointment. You can also go to the Medicare.gov website and find and compare doctors, hospitals and other providers.

Why Pat didn’t join Medicare at 65

By | Uncategorized

This week I’m sharing part of a recent interview I did with my friend and colleague Pat.

Pat decided not to enroll in Medicare at 65, and in this video we talk about why that makes sense for him (and may make sense for you too).

Click the “Play” button below to watch this week’s blog


What You should know when comparing Original Medicare and Medicare Advantage?

By | Uncategorized

Eligible Medicare beneficiaries continue to be confused on the differences between the Federal (Original) Medicare and the (Private) Medicare Advantage programs. The programs differ in these three basic ways: Delivery, Ideology and Equity.

Let’s begin with delivery. Original Medicare was designed to deliver coverage for all beneficiaries nationwide who could receive their care by all physicians and hospitals who accept Medicare.

Medicare Advantage was approved by Congress in 2003 but private insurers primarily use limited provider networks to contract the most favorable rates leaving out many rural areas in the country.

Original Medicare combines the Federal red, white and blue Medicare card for doctors and hospitals along with private supplemental insurance to pay the 20 percent Medicare does not pay. The beneficiary then buys a standalone prescription plan from a private insurer.

Enrollees in a private Medicare Advantage plan must enroll in Medicare A (Hospital) and B (Doctors) but provide their beneficiaries with one private company insurance card. In most cases the one card is used for all care providers including prescriptions. No supplement insurance may be purchased.

Ideology favoring market solutions for health care financing is driving the Medicare Advantage program by enough members of Congress who approve excess tax payer funding to help the private market attract new members with extra benefits like dental, vision and hearing even though the administrative costs are much higher than Original Medicare.

Now more than 30 percent of Medicare beneficiaries are enrolled in Medicare Advantage and the goal by insurance companies is to increase this number to 50 percent over the next ten years.

But what about equity for the 70 percent of Medicare beneficiaries who don’t get the extras that the Federal government is paying for? Let’s just review quickly what accounts for the positives and negatives of each program before you make your decision.

Original Medicare

You are required to enroll and pay for Medicare Part A and B
Plan is stable from year to year
Plan is accepted by nearly all doctors and health care facilities in the US
No need for referrals or prior authorization
Maximum out of pocket with supplement plan (none with C-F)
Coinsurance where Medicare pay 80% of expense and you (or your supplement plan) pays the other 20%
Radiation therapy follows 80/20 rule. No out of pocket with supplemental plans
Chemotherapy follows 80/20 rule. No out of pocket with supplemental plans
Includes medically necessary vision only (i.e. Cataract treatment)
Requires a 3 night hospital stay to receive skilled care.
Standard Affordable Care Act Preventative Services
Because you buy a separate prescription plan, you have the option to change prescrription plan every year to get best price
The federal government manages and regulates

Medicare Advantage

You are required to enroll and pay for Medicare Part A and B
Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year.
Plans accepted only at in network doctors and hospitals. (Acts like HMO, PPO, or PFFS)
Plans require prior approval
Out of pcoket up to $6,700
Co-pays for your treatment where rates vary by plan
Radiation therapy you pay 20%
ChemotherapyYou pay 20%
Includes vision, dental, and hearing. And many times gym memberships
Not requiring a three night stay in the hospital to receive skilled care
Standard Affordable Care Act Preventative Services
Most come with a set prescriptin plan and no room to change based on your medications
Private health insurance companies sell Medicare Advantage plans. The federal government regulates them.

The primary benefit differences are minimal except for the extras like vision, dental and hearing benefits included in many Advantage plans. Not requiring a three night stay in the hospital to receive skilled care is also a positive. Original Medicare requires a 3 night hospital stay to receive skilled care.

It still boils down to your personal preference. If you want to choose your own doctor and specialists and use your plan anywhere in the US where Medicare is accepted, then Original Medicare is for you.

If you live in a large metro area or state where Medicare Advantage is accepted by a wide range of specialists, doctors and quality care hospitals, then Advantage could be best. Just be sure to get all the facts before you make that decision.

What will Medicare cost me?

By | General Information

Did you know that you will be required to pay a fee for most, if not all, parts of Medicare?

Many people assume that Medicare is free because you have paid into “Medicare” through taxes for most of your life…but that assumption is not correct.

Today I want to clarify how Medicare is financed and what we, as Medicare beneficiaries, pay for when it comes to our Medicare coverage.

According to a July 18, 2017 report from The Henry J. Kaiser Family Foundation, in 2016 Medicare was funded primarily from three sources: general revenues (45 percent), payroll taxes (36 percent), and beneficiary premiums (13 percent).

Part A (Hospital) is financed primarily through a 2.9 percent tax on earnings paid by employers and employees (1.45 percent each) (accounting for 88 percent of Part A revenue.) Higher-income taxpayers (more than $200,000/individual and $250,000/couple) pay a higher payroll tax on earnings (2.35 percent).

Most of us won’t pay any extra fees for Medicare Part A once we join Medicare.

Part B is financed through general revenues (75 percent), beneficiary premiums (23 percent), and interest and other sources (2 percent).

Most of us will pay $134/month for Medicare Part B once we join Medicare.  There are two unique aspects of the Part B fee

  1. This rate is subject to change every year and likely will change each year
  2. The rate varies on your situation.  For example, if you are claiming Social Security you likely pay less than $134 and if you have a higher income (more than $85,000/individual or $170,000/couple) you will pay more than $134.

In addition to the standard payments above, we likely have additional payments based on which of the two Medicare programs we pick: Original Medicare or Medicare Advantage.

If you pick Medicare Advantage, you will enroll in Part C. Part C comes with a wide range of premiums, deductibles and out-of-pockets depending on the plan you pick.

If you pick Original Medicare you will enroll in prescription plan (Part D) and we recommend you get supplement plan which helps pay some of the health care costs that Original doesn’t cover, like copayments, coinsurance, and deductibles.

There are many parts to Medicare that will determine how much you will pay on a monthly basis for coverage, but most of our clients have monthly Medicare payments range from $150 to $200.

I hope these Medicare explanations will help you understand how Medicare is financed and what you can expect to pay.

What to Look For When Comparing Costs of Original Medicare with Medicare Advantage?

By | General Information, Medicare Advantage

One of the most common questions people ask me when making their decision is “What is the difference in the two Medicare programs: Original Medicare and Medicare Advantage?”

Original Medicare has one plan accepted by most health care providers in the United States while private Medicare Advantage has many different plans accepted by fewer providers on a case by case basis.

But what about the cost?  Cost can determine which plan to pick, but when comparing costs between these two programs please be careful.

When comparing costs, both programs require you to enroll in Medicare A (Hospital), and Medicare B (Doctors) with Part B premiums ranging from $134 per month all the way up to $429 depending on your income.

If you select Part C Medicare Advantage (MA), in addition to paying the Part B premium, you will pay any MA premiums, along with co-pays and deductibles.

Out of pocket costs in a MA plan can be high. In 2017, the average out-of-pocket limit in a MA plan is expected to be about $5,332 with a maximum out-of-pocket limit of $6,700. So while these plans may have low premiums, you can expect to pay more on the back end.

Although, it is often noted that Medicare Advantage plans have a maximum limit of out-of-pocket spending and Original Medicare does not, you can accomplish the same result of limiting your exposure with a supplement plan that picks up the difference of what Medicare does not pay, including the Medicare annual deductible.

If you don’t pick Part C Medicare Advantage, you will pick a Part D prescription plan and a supplement plan.

Original Medicare doesn’t have a maximum out-of-pocket cost.  Therefore out-of-pocket costs in Original Medicare plan depend on the supplement plan you pick.

Here’s the bottom line.

With Original Medicare you can keep the doctors and hospitals you know and trust, and have the freedom to use any doctors, medical centers and hospitals in the U.S. that accept Medicare.

What’s the benefit of having a free gym club membership with Medicare Advantage if the plan refuses to pay for your cancer treatment at M.D. Anderson clinic because the lifesaving care recommended by your doctor is not covered in your MA plan’s network?

Original Medicare has stability while MA plans don’t necessarily. Each year the insurance company who offers MA plans can choose whether they want to stay in Medicare or not.

They can also change costs and benefits each calendar year. Under the Affordable Care Act, there was a significant reduction in the way the MA plans are paid which could have an impact with increased costs that beneficiaries may pay in the future.

Original Medicare will always be there for you and your basic plan won’t be dropped or changed.

With Original Medicare, you avoid the hassle factor of having to research other plans every calendar year. If you have a MA plan, you will be required to look for changes in your existing plan. Changes could include increases in cost sharing, premiums and removal of certain medications you currently take from the insurance company’s formulary list.

If you still want to compare premium costs of a Medicare Advantage plan with Original Medicare, I can get you an Original Medicare plan, with a low supplement insurance premium of $35 per month along with a Part D prescription plan of $18 and a maximum out of pocket expense of $2200, compared to a MA maximum out of pocket expense of $6,700.

And best of all, you’ll be in control of your health care choices.

Medicare’s Special Enrollment Periods

By | General Information, Medicare Open Enrollment

When you are first eligible for Medicare you have a 7-month Initial Enrollment Period (IEP) to sign up for Part A and/or Part B. The (IEP) begins 3 months before the month you turn age 65 including the month you turn 65 and ends 3 months after the month you turn 65.

But today more and more of us are delaying our Medicare enrollment past our IEP.

You may decide not sign up  during your Initial Enrollment Period because you are eligible to remain on your group health insurance plan or spouse’s plan at work.


Once your Initial Enrollment Period ends and you remain on a group medical insurance plan, you will be eligible to sign up for Medicare any time in the future under the Special Enrollment Period (SEP) rules.

You qualify for the SEP rule if you’re covered under a group health plan based on current employment.

Your 8-month SEP window to sign up for Part A and/or Part B starts at one of these times (whichever happens first):

  • The month after the employment ends.
  • The month after group health plan insurance based on current employment ends.
  • If you are a volunteer, serving in a foreign country.

Often times the SEP rule is not taken into consideration and the Medicare beneficiary assumes there is a penalty if one does not enroll in Part B when first eligible. If you follow the SEP enrollment criteria above, there is no penalty.

Note: COBRA and retiree health plans aren’t considered coverage based on current employment. You are not eligible for a Special Enrollment Period when that coverage ends.

If you do remain on a  group health insurance plan when you are first eligible for Medicare, make sure you check with your human resource person to see if the group prescription coverage is “Creditable” meaning as good as or better than what Medicare Part D prescription coverage offers.

If it’s not “Creditable” you may want to sign up for a Medicare Part D plan and still remain on the group insurance. In this case you would need to sign up for Part A only to get on the Medicare drug plan and avoid future penalties.

So if you don’t join Medicare at 65, there are other times you can enroll in Medicare under SEPs.  Ensure you identify your SEP and get the proper paperwork from you employer.  This paperwork will prove you are eligible to join Medicare and prove you don’t need to pay penalties.

To learn more about whether or not you need to join Medicare, CLICK HERE read my recent blog “The #1 Reason You Don’t Need to Join Medicare”