How Does the Inflation Reduction Act Affect Medicare Drug Costs?

The Inflation Reduction Act of 2022 that was into law on August 16 by President Joe Biden was wide-ranging in scope, encompassing changes in everything from climate change, to IRS tax enforcement, to the corporate minimum tax rate. Of particular interest to Medicare beneficiares are the the Prescription Drug Provisions, which address prescription drug pricing.

How will the Inflation Reduction Act affect Medicare Beneficiaries?

In truth, the Prescription Drug Provisions portion of the Inflation Reduction Act only brings a few changes, but their ramifications should prove significant. Changes under the Act will impact prescription drug prices, out-of-pocket costs for prescription drugs, a monthly cap of $35 on insulin costs under Part D, and certain free vaccines. It’s easiest to look at the provisions as part of a timeline based on when the changes will be implemented:

2023

2024

  • Part D co-insurance costs eliminated after reaching out-of-pocket maximum. Once a Medicare beneficiary’s annual out-of-pocket expenses for covered drugs reach the out-of-pocket maximum, co-insurance costs go from 5% to zero. Currently, Part D beneficiaries have an out-of-pocket threshold of $7,050, and after that they must pay 5% of subsequent drug costs without limitation.

  • Increase in eligibility for Part D subsidy. Beneficiaries earning up to 150% of the Federal Poverty Level will be eligible for full benefits under the Part D subsidy.

2025

  • Out-of-pocket threshold lowered. The out-of-pocket threshold for Part D beneficiaries will be lowered from $7,050 to $2,000.

2026

  • Drug price negotiation. Medicare will be allowed to negotiate the prices of 10 high-cost Part D prescription drugs. Drugs open to negotiation will be high-cost drugs with long-time FDA approval that have no generic alternative. Currently, the 2003 Medicare Modernization Act that established Part D prohibits price negotiations for drugs offered under Medicare.

2027

  • Drug price negotiation - cont’d. Medicare can negotiate the prices of an additional 15 Part D high-cost prescription drugs.

2028

  • Drug price negotiation - cont’d. Medicare can negotiate the prices of an additional 15 Part B and Part D prescription drugs.

2029

  • Drug price negotiation - cont’d. Medicare can negotiate the prices of an additional 15 Part B and Part D prescription drugs.

Overall, the changes implemented by the the Prescription Drug Provisions portion of the Inflation Reduction Act will be welcome news to most Medicare beneficiaries. Additionally, the Congressional Budget Office projects that the changes will reduce the federal budget deficit by $288 billion over a next decade, many due to the cost savings brought by the drug price negotiation provision.

Dedicated Senior Medical Center Coming to Nashville

Nashville is about to get a new clinic to serve the under-served Medicare population: Dedicated Senior Medicare Centers is opening a facility in the Bordeaux area this fall.

It may sound like just another clever marketing strategy to say that Dedicated Senior Medical Centers puts patients first, but they have the track record to substantiate their claims.

Some stats regarding their primary and preventive health care for seniors:

  • Dedicated patients spend 38% fewer days in the hospital as well as fewer hospital, ER, and urgent care visits

  • Physicians at Dedicated only see from 350 to 450 patients per year versus a U.S. average of 2,300 patients being seen annually by a physician

  • In 2015, when patients were asked how likely they were to recommend the company to a friend or colleague, ChenMed’s (Dedicated’s parent company) score was 90%, which compares to an average score of 12% among health insurance companies and was a higher score than such well-regarded companies as Apple and Southwest Airlines

  • ChenMed was named To Newsweek's list of The Most Loved Workplaces for 2021 and placed first in the Healthcare category

  • Fortune magazine named ChenMed as one of their 2020 Change the World companies

The formula is fairly simple: Dedicated offers personalized primary care, smaller patient panels, and frequent physician team discussions. Physicians will see patients as often as necessary, and specialists are on site to provide coordinated team care.

Dedicated’s centers are located in urban areas with a high density of low-to-moderate-income seniors, and the new Nashville location will be in the Bordeaux neighborhood.

A full range of Primary and Preventive Care services will be offered, plus:

  • Onsite diagnostic testing, including, X-rays, labs, and testing

  • Medications supplied at site

  • Cardiology

  • Acupuncture

  • Nursing

  • Podiatry

  • Nursing services

  • Social workers, and door-to-doctor transportation.

Follow the progress on the new Nashville location here.

A New Marketplace Special Enrollment Period (SEP) Announced for Low-Income Consumers

The Centers for Medicare & Medicaid Services (CMS) made the announcement as part of the Biden Administration’s recent American Rescue Plan (ARP). This new SEP will allow more opportunities for lower-income consumers to enroll in Marketplace health care coverage during the year and benefit from the increased financial help to pay it. To be eligible, consumers must have an estimated annual household income at or below 150% Federal Poverty Level in their state and not be eligible for Medicaid/CHIP.

Eligibility requirements by state and household size for 2022 Marketplace applications can be found here.

Consumers will be able to access the low-income SEP now, and it is available to those who have applied for Marketplace coverage since Open Enrollment ended and who didn’t have access to another SEP from a recent life event, such as a loss of coverage or a move.

Medicare Advantage Plans - Are They Denying Necessary Care?

In recent days, a report has been released that found that Medicare Advantage plans sometimes deny or delay claims that should be paid and deny care that is medically necessary. We thought the news was pretty important and deserves attention. Please make sure to read to the end of this post to get my entire response. I don’t want you to think that I believe choosing Medicare Advantage is a bad idea.

The Claim

The startling report was compiled by the U.S. Health and Human Services Office of Inspector General and states that private, for-profit Medicare Advantage plans denied 18% of claims allowed under Medicare coverage rules and denied 13% of authorizations for medical services that Medicare would have allowed.

In order to estimate how often insurers denied requests that should have been covered, coding experts and physician reviewers analyzed a sample of about 250 care preauthorization denials by 15 of the largest Medicare Advantage plans over one week in June, 2019.

These private Medicare plans cover more than 28 million older and disabled Americans and are an increasingly popular option. By 2030, it is expected that over half of Medicare recipients will be enrolled in an Advantage plan, which means that it is crucial that Medicare beneficiaries enrolled in Advantage plans have access to medically necessary covered services.

Traditional Medicare has no maximum out-of-pocket limit, but Medicare Advantage plans do offer out-of-pocket maximums while also offering perks such as vision, dental, and hearing benefits, telemedicine, and gym memberships - all at a price comparable to original Medicare. Their popularity has resulted in Advantage plan enrollments more than doubling in the past decade.

How do Medicare Advantage plans offer more while not charging much more?

To keep costs down, private Advantage plans employ various insurance industry tactics such as restricting networks of doctors and other medical providers people can use, requiring prior authorization for some services, requiring referrals for specialists, and promoting a healthy lifestyle (such as the gym memberships).

However, the report claims the private insurers were keeping costs down by denying coverage or forcing the insured to pay for services their plans should cover. Often, denials were made because the insurance companies required more preauthorization from patients than Medicare required, such as requiring an X-ray before authorizing an MRI, or requiring more documents than were required by Medicare.

HHS recommendations for getting Medicare Advantage plans to approve more requests for coverage

In order to address the discrepancies, the Health and Human Services Inspector General recommended that the Centers for Medicare & Medicaid Services (CMS):

  • issue new guidance on the appropriate use of clinical criteria in medical necessity reviews;

  • update its audit protocols to address the issues identified in this report, such as use of clinical criteria and/or examining particular service types; and

  • direct Advantage plans to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors.

The Rebuttal

America’s Health Insurance Plans (AHIP) is a Washington-based group for health insurers that includes to 15 private Medicare Advantage plan insurers cited in the report. They took issue with the report:

  • AHIP claimed that the report’s stated denial rate of 13% was misleading and limited in scope by noting that the overwhelming majority (95%) of prior authorization requests in 2018 were approved.

  • they placed some of the blame on CMS by saying that more guidance was needed, stating that “The main concern about many of those cases was not that they were improper, but rather that more guidance from the government was needed on criteria that plans can use to make coverage determinations.”

  • finally, AHIP defended their preauthorization requirements by arguing that the extra measures can keep patients from getting dangerous, unnecessarily expensive or unnecessary care.

Our Conclusion

When public and private sectors intersect, there’s bound to be some conflict of objectives. Public entities such as CMS have the capacity to provide great services without the need for profitablity or efficiency, while private insurers make money by maximizing efficiences.

Advantage plans may be more strict on approving coverage, but they shouldn’t be denying necessary coverage. If you have ever had an employer PPO insurance plan, it undoubtedly required prior authorization for many procedures on a routine basis - that’s the nature of the industry.

An Observation

One of my policyholders recently called me about a denial from his Advantage plan. The good news is that we were able to work through the issue, and he received the care his doctor had recommended. The downside was the delayed response and the repeated phone calls he had to make on his own behalf. I’ve said it many times and will repeat here: you must be your own best advocate!

Another perspective is that Advantage plans, due to the fact that they are managed care, are incentivized to produce good health outcomes. Wouldn’t you rather have more professionals reviewing a complex case and trying to collaborate and solve it together, rather than trusting a fee-for-service system to deliver results?

Ultimately, I always defer to my policyholder on what they believe is best for their situation. I never try to convince someone that I know what’s best better than they do!

In summary, Medicare has been popular since it was introduced back in the 1960’s, and Advantage plans are gaining in popularity because they do bring excellent value to Medicare recipients. The report found some problems, but we believe improvements to the system will be made and Medicare Advantage plans will continue to be an attractive option for millions of Americans.

What to Know about Health Insurance when Moving to Another State

Let’s say you move from California to Tennessee, does your insurance move with you, or do you need new insurance?

Most individual health insurance is not transferable from one US state to another. Therefore, if you move to a new state, a part of the moving process needs to be obtaining health insurance in your new state of residence. This holds true whether you have individual/family coverage or Medicare (including Supplements, Advantage plans, and Prescription Drug plans).

Let’s explore both types of insurance.

It You’re Under 65 and Moving from One State to Another - Health Insurance for Individuals and Families

Employer-sponsored Plans

If your employer transfers you to another state and you’re covered by their health plan, you probably don’t need to worry because you can most likely stay on the same plan as long as the employer-sponsored plan has an adequate network in the new state. If the plan doesn’t have an adequate network, the employer will likely find you a new, accommodating plan in the new state.

However, if you have coverage through a non-Marketplace individual or family plan, you will need to check with your insurance plan to see if they have a good network in your new state and change plans if necessary.

Marketplace Plans

If you have a plan through the Marketplace, your move will require some action because Marketplace plans don’t transfer from one state to another.

First, report your move to the Marketplace as soon as possible in order to avoid a gap in coverage. For most states (including Tennessee), this can be done by going to https://www.healthcare.gov/login and entering your new state or residence. If your new state appears on this list, it means they have their own website where you’ll apply.

Normally, enrolling through the Marketplace can only be done during the annual Open Enrollment Period at the end of the year, but a move to a new state is known as a “qualifying life event,” which makes you eligible for a Special Enrollment Period (SEP). The special enrollment period allows you 60 days from the time of your move to enroll in a qualified health insurance plan through the federal marketplace, your new state’s exchange, or elsewhere. It is important to note that the SEP onlys exists if you had credible coverage in the state you left (defined as having minimum essential coverage for at least one of the 60 days preceding the move).

Medicare Coverage when Moving from One State to Another

Necessary actions for Medicare coverage when moving to a new state vary depending on the type of coverage.

Original Medicare

If you only have Original Medicare (Parts A and B), your benefits and coverage won’t be affected since Original Medicare is a federal healthcare program. Still, you need to contact the Social Security Administration about your change of address in order to continue getting important information from them.

Medicare Advantage

Since Medicare Advantage plans are managed by private companies, any move to a new state will trigger a Special Enrollment Period, during which time you can:

  • Switch to a new Medicare Advantage Plan or Medicare drug plan.

  • Return to Original Medicare (if you’re in a Medicare Advantage Plan and you move outside of that plan’s service area).

It is important to note that if you don’t enroll in a new Medicare Advantage Plan during the SEP, you’ll automatically be enrolled in Original Medicare once you’re disenrolled from your old Medicare Advantage Plan.

There are certain windows during which you can report your move. If you tell your plan before you move, the SEP begins the month before the month you move and continues for 60 days after you move. If you tell your plan after you move, the SEP begins the month you tell your plan and lasts for 60 days more.

Prescription Drug Plans

Much like an Advantage plan, Medicare Part D drug plans are sold by private insurers and are specific to each state, so your move will mean you will need to enroll in a new plan.

If you tell your plan before you move, your chance to switch plans begins the month before the month you move and continues for 2 full months after you move. If you tell your plan after you move, your chance to switch plans begins the month you tell your plan, plus 2 more full months.

Medicare Supplements

Since Medicare Supplements (also known as Medigap plans) are supplemental to Original Medicare and have the same carriers nationwide, in most cases you can keep your current coverage in your new state. Any provider who accepts original Medicare in your new state will accept your Medigap insurance, but make sure to inform your carrier 30 days before your move.

There are 2 exceptions:

  1. If you are moving into or out of Massachusetts, Minnesota, or Wisconsin. With Medigap, there are ten standard Supplement plans available in every state, designated by letters (A, B, C, D, F, G, K, L, M, and N), but the above states offer some different options.

  2. If you have a Medicare SELECT plan that limits your providers to certain hospitals; however, you would have guaranteed issue rights in this instance.

Moving will allow you the opportunity to shop for coverage from a different Medigap plan in your new state, but as always, don’t terminate your current supplement until the new one has been issued.

Health Plans Must Cover At-Home COVID-19 Tests

Beginning January 15, 2022, both health insurance companies and self-funded group health plans must cover over-the-counter (OTC) COVID-19 tests for members at no charge. The news was announced by the the Departments of Labor, Treasury and Health and Human Services on January 10 as part of the CARES Act.

Important details:

  • The free tests will continue through the end of the public health emergency.

  • The requirement currently applies to individual plans, both Marketplace and non-Marketplace, but does not apply to Medicare and Medicaid.

  • Self-funded group plans are required to cover the free tests.

  • Only FDA-approved tests with “OTC” listed in the attributes column are eligible for reimbursement. Click here for the full list. No doctors prescription is needed.

  • The limit for free tests varies depending on the insurance comany and could be as high as 8 per month for each family member. Check with your insurance company for details.

  • Reimbursement applies to OTC tests only. Tests that must be mailed to a lab for results aren’t covered, and tests must be for personal use only. Tests used for return-to-work testing or work-related testing required by an employer are not covered.

Some insurance companies may only require that a member present their ID card at a preferred pharmacy to receive a free test. Others will require that a member download a COVID-19 OTC At-Home Testing Reimbursement Form from their insurer, fill it out, and send it back with the original receipt and the UPC code from their test box.

For more information, check with your insurance company.

Medicare Costs Increase for 2022

Medicare costs for 2022 will go up substantially.

On November 12, 2021, the Centers for Medicare & Medicaid Services (CMS) announced that the Medicare Part B premium for outpatient care coverage will increase from $148.50 to $170.10 for 2022, a jump of 14.5%.

The deductible for Part B will increase 14.8% from $203 to $233 for 2022.

Medicare Part B premium, deductible, and coinsurance rates are set each year according to guidlines set by the Social Security Act. According to the CMS, the substantial increases for 2022 are due to various factors, including:

  • increased healthcare costs and greater utilization of the healthcare system, plus anticipated increases in the intensity of care provided.

  • An attempt to make up ground caused by Congressional action that only increased the Part B premium by $3 for 2021.

  • Additional contingency reserves due to the uncertainty regarding the potential use of the Alzheimer’s drug, Aduhelm™, by people with Medicare.

Below is a breakdown of costs associated with Medicare for 2022.

Medicare Advantage versus Original Medicare - Pros and Cons

Medicare was signed into law in 1965 after a national study showed that 56% of Americans over the age of 65 were not covered by health insurance. Medicare Advantage, also known as Part C and originally called Medicare+Choice, was created in 1997 as an alternative to Original Medicare.

As of 2021, nearly 63.8 million Americans had coverage through Medicare, and nearly 42% of those Medicare recipeints are enrolled in a Medicare Advantage plan. If current trends continue, it is estimated that over 50% of recipients will be enrolled in an Advantage plan by 2030.

What the pros and cons of each?

Original Medicare

Cons:

Pros:

  • Prescription drugs are not covered - unless a separate drug plan is purchased

  • Unless a Medicare Supplement is purchased, there are deductibles, copays, and coinsurance for things like doctors visits, ER visits, ambulance costs, hospital stays, and certain medical supplies.

  • Can choice any doctor or hospital that accepts Medicare

  • Don’t need a referral to see a specialist

  • Can go to any emergency room

  • If you’re super-healthy, Original Medicare costs nothing except for the Part B premium and the optional Part D premium

Medicare Advantage

Cons:

Pros:

  • Must use network providers

  • Referrals from primary care physician generally needed before seeing a specialist

  • Geographic limitations to coverage due to use of networks

  • Annual cap on out-of-pocket costs can be high - up to $11,300 in 2021

  • May not cost more - many plans are zero premium

  • Many plans include a prescription drug plan

  • Many more benefits available at no extra charge, such as eye exams and glasses, hearing aids, dental benefits, OTC drug benefits, transportation, gym membership

  • A focus on wellness

What’s the best choice for you?

The best choice for each beneficiary comes down to a variety of factors, such as general health condition and needs, if you will use the extra benefits offered by an Advantage plan, if you travel frequently outside of your network area, if you prefer managed care of an Advantage or would rather have flexibility of doctors, and if you are diagnosed with a chronic condition and want the predictability of costs that Original Medicare with a Supplment offers.

Why You Should Check Your Medicare Options During the Annual Enrollment Period

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The Annual Enrollment Period Medicare (AEP) runs from October 15th to December 7th, and it is the time every year when Medicare beneficiaries can make changes to their current coverage. Beneficiaries can switch from traditional Medicare to an Advantage plan or vice versa, or add, switch or drop a Part D drug plan. Plans and options change every year, so it’s important to review what’s best for you.

Unfortunately, most people don’t.

According to a just released study by the Kaiser Foundation, 71% of Medicare beneficiaries neglect to review their coverage options annually. According to Kaiser, “the average Medicare beneficiaries can choose among 33 Medicare Advantage plans and 30 Part D stand-alone prescription drug plans (PDPs).”

Costs and coverages between the plans can vary significatly, and the plans themselves change every year:

  • New players may enter the market.

  • Plans may be dropped, added, or changed as insurance companies try to optimize their product line.

  • Provider networks may change, which means your doctor may not be in network anymore.

  • Drug formularies may change, which means your current plan may not include all of your prescription drugs.

  • Also, your health needs may have changed since last year.

For the reasons stated above, the Centers for Medicare & Medicaid Services (CMS) recommends that beneficiaries review and compare Medicare plans each year. Medicare is complicated, and it’s hard to know if you’re choosing the option best for your needs. Feel free to contact me for an expert opinion.

Get an Online Insurance Quote

If you want to do a quick comparison yourself, you can see how your current plan compare compares to others by going here.

Get a Quick Individual or Family Health Insurance Quote Right Now, Online - and Nobody Will Call or Email You

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Just want a quote, without having to set an appointment or talk to anyone?

We can help. Just go here, enter some information, and get the best quotes from the insurance companies we represent. Then, you choose the plan that works best for you and enroll. It’s that easy!

Feel free to call/text (615-415-4424) or email (carol@ballengerbrokerage.com) if you have questions, but, otherwise, we won’t be bugging you.

P.S. - this link is for individual and family plans only. Please contact us if you need a Medicare Advantage, Medicare Supplement, or Part D drug plan.

CMS Extends Open Enrollment Period for Marketplace

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In an announcement dated September 17, 2021, the Centers for Medicare & Medicaid Services (CMS) announced that the Open Enrollment Period (OEP) for Marketplace would extended an extra 30 days. Consumers can now review and choose health plans beginning on November 1 and lasting until January 15, 2022. The move was made under President Biden’s directive as a way to use the Affordable Care Act to expand health insurance coverage to more Americans and make it easier and more affordable to obtain coverage.

“Health care is a basic human right, and the Biden-Harris Administration is committed to making health coverage more accessible than ever. With the Affordable Care Act and the American Rescue Plan, the President has brought affordable health coverage to millions—many of whom now have insurance for the first time.” - CMS Administrator Chiquita Brooks-LaSure.

Thanks to the American Rescue Plan signed by President Biden:

  • Premium tax credits are available to anyone paying more than 8.5% of their family’s household income towards their premiums at 8.5%, based on the cost of the benchmark plan.

  • Premiums after new savings will decrease, on average, by $50 per person per month or by $85 per policy per month.

  • Four out of five enrollees will be able to find a plan for $10 or less/month after premium tax credits, and over 50% will be able to find a Silver plan for $10 or less.

Want to see how much you and your family can save? Click one of the buttons below.

Should I Buy Medicare Insurance from Joe Namath?

Joe Namath was a great quarterback – a Hall of Fame quarterback, in fact, who won a national championship with Alabama and then went on to lead the New York Jets to an upset Super Bowl victory.

Does that make him a qualified expert on Medicare?

Not necessarily, but, judging by the commercials, he’s got the perfect product for anyone who’s over 65 and looking for Medicare answers.

Free Rides to Appointments!

Home Delivered Meals!

Private Home Aides!

All for nothing!

Could there be a catch? Could Joe be steering us wrong?

Let’s explore

Joe touts the Medical Coverage Helpline, which claims to be “Officially Authorized” by the Centers for Medicare and Medicaid Services. According to Medicare.gov, it’s considered fraud for a Medicare supplier to claim they represent Medicare or any branch of the federal government. Medicare Coverage Hotline is no more “Officially Authorized” by the Centers for Medicare and Medicaid Services than is any insurance agent licensed by an insurance company to sell Medicare Advantage plans, Prescription Drug plans, or Medicare Supplements. The red, white, and blue colors, and the American flag used in the Medicare Coverage Hotline logo are deceptive and may make the company look very official, but they are not a part of CMS. Bottom line: be skeptical of any company that stresses the “official” angle.

Joe says you’re entitled to free rides to appointments, home delivered meals, private home aides, etc. These sound like pretty nice perks, and many viewers will feel enlightened with the knowledge that they exist and can be had, just by signing up. The truth, though, is a little muddy. Joe’s selling Medicare Advantage plans, which are basically Original Medicare plans that are contracted out to private insurance companies. The private insurance companies are paid by CMS to offer the plans, which usually contain some benefits that Original Medicare does not offer, such as routine dental, hearing and vision care and prescription drug coverage. The free rides, etc,, are definitely a part of some plans, but are generally reserved for special-needs plans (such as low income), and they may not be offered in all areas. Every enrollee is not entititled to them. Bottom line: if it sounds too-good-to-be-true, be skeptical.

The Takeaway

The real truth about Medical Coverage Hotline can be found in the hard-to-read disclaimer at the end of the commercial:

“The Medicare Coverage Helpline is not affiliated with or acting on behalf of any government agency or program. The Medicare Coverage Hotline is a private for profit lead generation campaign and does not offer insurance and is not an insurance agency or broker. Your call is sold to a licensed insurance agent to give you information about your Medicare Advantage Plans. Prescription, dental and Vision benefits are not guaranteed, are only available in select plans and are not available in every state or ZIP code.”

The are many private insurance companies marketing many Medicare Advantage plans, and making a decision can be daunting for Medicare enrollees. Truthfully, the plans should probably be standardized a bit so that they are easier to understand. In light of all the choices, why let your choice of healthcare be handled by a high-volume call center such as Medicare Coverage Helpline? Don’t fall for a TV ad where everything sounds to good to be true. Instead, call a trusted local agent who offers many plans and can find the best one suited to your needs.

Joe Namath" by KoryeLogan is licensed under CC BY-SA 2.0

Medicare Annual Enrollment Period Checklist for Fall

The Annual Enrollment Period (AEP) for Medicare will begin on October 15 and last until December 7. It’s the time when a Medicare beneficiary can make changes to their current coverage.

Plans change every year, and the needs of beneficiaries also change. If you’re already enrolled with a Medicare plan, you will receive an Annual Notice of Change (ANoC) letter in September which will explain changes affecting your plan for the upcoming year.

Changes might include:

  • An increase in premium

  • Changes in benefits

  • Changes in member doctors

  • Changes in prescription drug formularies

Do you need to take action? Here’s some things to consider:

If you have a Medicare Advantage Plan - check the current list of member doctors, healthcare facilities, and medication coverage. The list gets updated every year, so you need to make sure it still works for you.

If you have an original Medicare and are interested in going to a Medicare Advantage Plan - AEP is the time when you can make the switch from one plan to another. Weigh the pros and cons and see what’s best for you. Need help? Contact me.

If you have a Part D Drug plan - you can switch from one Medicare Part D (prescription drug) plan to another during AEP. Prices, drugs covered, and pharmacies change annually, so compare plans and make sure your plan still works best for you.

What if you’re mostly happy with your plan, but want to make sure it still works for you?

First of all, good for you. It’s good you’re being proactive. You may be fine with what you have, but you might also be able to fine-tune your plan or refocus it for better coverage and cheaper prices. The Annual Enrollment Period (AEP) is the time to make changes.

Hope this helps. I represent many insurance companies, and I work hard to find the plan that works best for my clients. I also present all reasonable options so that you can be informed. If you have questions or want to review your plan, please let me know.

Post-Vaccine Information

After receiving your COVID vaccine, there are some expected side effects that will follow.

Similarly to any vaccine, the FDA approved COVID vaccine will likely result in side effects such as fatigue, body aches, headache, and fever. If you are experiencing these symptoms post vaccination, do not fret! This is your body’s natural response is to produce antibodies which will cause these effects- it means your immune system is working properly! You may not even experience side effects at all, but this does not mean that the vaccine isn’t taking effect- every body will react differently.

Some people have experienced the second dose having a much more intense effect than the first, this is also no reason to worry.

When to worry

The main risk of the vaccine (so far as we know) is an allergic reaction- anaphylactic shock in the most severe cases. However, the likeliness of an allergic reaction is very low and signs of this will typically show within thirty minutes of receiving the dose. Because of this, your provider will probably ask you to stay there for this half hour time window to monitor you for any unusual reactions.

If your symptoms last longer than 48 hours, contact your vaccination center ASAP.

American Rescue Plan: What Does it Mean for me?

On March 11, Biden signed the American Rescue Plan (ARP), designed to reduce health care costs and increase health insurance accessibility.

"Joe Biden" by Gage Skidmore is licensed under CC BY-SA 2.0

"Joe Biden" by Gage Skidmore is licensed under CC BY-SA 2.0

For those of you who purchase Marketplace health insurance through HealthCare.gov and get subsidies, you are likely eligible for increased tax credits that will reduce yours premium costs. The average monthly premium will be lowered by $50 per person or $85 per policy. Assuming you are eligible for subsidy, you will be offered at least a couple of plans that won’t cost more than 8.5% of your household income.

How do I take advantage of the increased health insurance subsidies in ARP?

Beginning on 4/1/2021, Marketplace consumers can take advantage of this and lower health related expenses by logging onto the healthcare.gov portal and updating their plan. Below I have provided a list of steps describing how to do this:

  1. After logging in, click on your existing application and take note of your current plan if you wish the re-enroll in the same one.

  2. You will then be redirected to a new page, where you’ll select ‘Report a life change’ and scroll down to select the corresponding green button.

  3. Choose “Report a change in my household’s income, size, address, or other information.”

  4. You will be taken to your existing application, where you should check that all information is up-to-date and correct any false information. Most information should not have to be changed.

  5. After re-submitting your application, browse the recommended plans and find the right one for you (I would be more than happy to help you decide- contact me if you would like to schedule an appointment!)

  6. Congratulations! You made it! Once you pay your next premium the change will be official.


ALERT: Beware of Fraudulent Coronavirus Vaccines

The Department of Health and Human Services (HHS) has recently issued a fraud alert addressing illegal schemes offering illegitimate COVID vaccines.

Following the release of the official COVID-19 vaccine, scammers have been targeting Medicare beneficiaries by offering a (fraudulent) vaccination in exchange for personal medical information. This information is used to commit medical identity fraud and/or falsely bill Federal healthcare programs.

These perpetrators typically find their victims through cold calling, social media, and door-to-door soliciting. NEVER accept medical care through any of these platforms!

INDICATORS OF POTENTIAL SCAMS:

  • Offers for early access vaccinations in return for a deposit or fee.

  • Demanding out-of-pocket payment.

  • Prompting you to put your name on the ‘waiting list’ for the vaccine.

  • Offers for additional medical testing or procedures during a vaccination appt.

  • Offers to sell/ship vaccines domestically or internationally for payment.

  • Unsolicited emails, calls, or personal contact from an unknown person claiming to be a medical professional, insurance company, or vaccination center requesting private information to evaluate eligibility for the vaccine.

  • Unverifiable FDA approval claims.

  • Advertisements/solicitations from unknown sources.

  • Individuals contacting you claiming to be a government-sanctioned messenger and insisting you receive a vaccination by federal orders.

ALWAYS ensure that you are receiving healthcare through a licensed professional. There is no telling the medical consequences a false vaccine will have on your health- not to mention your social security!

 

Think you’ve been scammed?

  1. Contact the insurance company members services to file a grievance.

  2. Find a verifiable vaccination center near you to receive the FDA approved vaccine.

  3. Contact me for additional questions or support at carol@ballengerbrokerage.com or by calling (615) 415-4424.

New to Tennessee?

Moving states may require you to enroll in a new insurance plan. I can help you find the right plan for you (and your family).

If you have coverage through the Marketplace, a change in residency between states will require you to update your policy.

Application Process

To begin the process, log onto healthcare.gov to file your new Marketplace application and update your profile with your new address. Please refer to this document for a step-by-step visual provided by the official site. Once you have confirmed that your new plan is in effect, go ahead and cancel your prior plan.

It is imperative that you notify Marketplace ASAP regarding your change in residency!

Failure to do so can result in a break of coverage and/or additional bills for an insurance plan that no longer covers you in your new address.

Part B in Depth

If you plan to work past age 65, you have a couple different options regarding Medicare part B.

Unlike Part A, Part B requires a monthly premium which is based on income. Depending on your circumstances, you may be able to delay enrollment in Medicare Part B if you so desire. However, in some cases your employer may insist otherwise. Below, I will dissect the different cases regarding Part B enrollment for those working past 65.

Must Enroll if…

  • Your employer has less than twenty employees.

  • You are receiving coverage via your spouse’s employer who requires all covered dependents to be enrolled upon reaching 65.

  • You are in an unmarried domestic partnership and receive coverage from your partner’s employer health insurance.

Consider Enrolling if…

  • Medicare is less expensive and/or offers better coverage than your current insurance.

  • You would like to keep your current insurance while still taking advantage of the benefits offered by Medicare.

  • You want to enroll in Medigap or a Medicare Advantage plan.

  • Medicare accepts your prescription drug plan.

Delayed Enrollment

  • If you decide you want to delay Part B enrollment, you will be granted an 8 month Special Enrollment Period (SEP).

  • This SEP will also allows you to enroll in Part C and/or Part D within the first two months of the eight; it is important to note that you will be charged a late fee if you surpass either of these deadlines.

COVID-19 Special Enrollment Period

Due to the ongoing pandemic, President Biden issued an executive order last week to open a new Special Enrollment Period (SEP) for enrollment in Marketplace insurance.

The ultimate goal of this order is to offer affordable and quality healthcare to families and individuals in the midst of the pandemic. It will take effect in all states covered by federally facilitated Marketplace insurance (yes, Tennessee is included!) The SEP is intended to offer additional time for uninsured or under-insured Americans to seek Marketplace coverage.

How do I know if I’m eligible?

To check the status of your eligibility, visit healthcare.gov.

I see that I am eligible, so what now?

Those who enroll under this SEP are allowed to select a plan with coverage which will take effect on the first of the month after enrollment. If you are currently enrolled, the SEP will allow you the unrestricted ability to exchange your current plan for one of equal or lesser coverage. However, those reapplying will be required to review their application and make any necessary changes or updates before submitting it. Following this, you will receive an updated eligibility result providing you with this SEP prior to enrollment.

FAQ

  • Will this SEP require any additional application questions or information (not included in typical SEP coverage)?

    • Nope! No need to provide additional information or documentation for this specific SEP.

  • Does this apply to Medicare beneficiaries?

    • No, this is relevant to individual and family plans regulated by Marketplace. Medicare has its own rules and guidelines.

  • How long will this SEP last?

    • February 15, 2021 through May 15, 2021, so don’t hesitate!

Still have questions? Contact me by email at carol@ballengerbrokerage.com or call me at (615) 415-4424.

So Which Plan is for Me?

Within the world of Medicare, there are two major choices: traditional/original Medicare and Medicare Advantage.

Original Medicare

  • With traditional Medicare, Parts A and B are included into your plan, however Part D is not.

  • If you would like a prescription drug plan (PDP), you must apply for this separately.

    • A Medicare supplement insurance (aka Medigap) is strongly advised for those who would like aid with out-of-pocket costs and do not have employer or union coverage.

  • Original Medicare will not cover the extra benefits Advantage offers, which often includes dental, vision, and hearing (DVH).

  • Paying for original Medicare, and supplement, and a Part D plan will generally cost more on a monthly basis, but this comes with the benefit of being covered by any hospital or provider across the United States that accepts Medicare.

Medicare Advantage

  • The Advantage plan (aka Part C) is an inclusive alternative to original Medicare, and typically bundles parts A, B, and D into one plan.

  • Beneficiaries will be offered the additional benefits not covered by traditional Medicare.

    • This includes dental, vision, hearing, etc.

  • Generally less expensive on a monthly basis, however the in-network providers are limited.

    • In the state of Tennessee, Advantage plans have networks such as PPOs, HMOs, EPOs, POSs, etc.

    • On the other hand, original Medicare doesn’t abide by networks and can be used by any Medicare accepting facility or provider across the United States.

When considering, ask yourself:

  • Do I want a prescription drug plan (Part D)?

  • How often would I utilize the additional benefits (DVH) offered with Advantage?

  • If I choose the Advantage plan, will my current providers be in-network? If I choose original, do all my providers accept Medicare coverage?

  • Would I prefer a lower premium and DVH benefits at the sacrifice of restricting my access to hospitals and providers?

Have further questions? I can help you! Click here at carol@ballengerbrokerage.com or call (615) 415-4424.