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FAQ

You’ve Got Questions - We’ve Got Answers

  • How do I qualify for Original Medicare?
    You need to be 65yo+, have a disability that qualifies you for Original Medicare or ESRD (End Stage Renal Disease)
  • How do I sign up for Original Medicare?
    IF you already receive your monthly social security benefits 24 months PRIOR to you turning age 65 or receive SSI for 24 months, you will be automatically signed up for Part A and Part B. However, IF you do not receive your monthly social security benefits, you will need to sign up manually for Part A and Part B. Please visit www.ssa.gov to sign up for Original Medicare AND to possibly receive “Extra Help” for your Part D prescription(s) along with your Part B monthly premium. If you need assistance while on the Social Security Administrative webpage, please contact us. We will be more than happy to answer questions and assist you during the process.
  • How much does Original Medicare cost?
    Part A (Hospital) does not cost most individuals going onto Medicare. However, if you have not worked 40 credit hours (10 years full-time in workforce), then you will have a monthly premium to pay. This monthly premium will depend upon how many full-time years you did work in the workforce. See www.medicare.gov for the monthly premium(s). Part B (Outpatient) in 2022 costs $170.10/month for everyone, however, if you receive “Extra Help”, you may have a reduced or no monthly premium. Beginning January 1, 2023 the NEW monthly Part B premium is lowering to $164.90/month
  • What is Original Medicare?
    Think of Original Medicare as a major medical comprehensive health 80/20 plan. Original Medicare is Part A (Hospital), Part B (Outpatient Medical) and Part D (Prescription Drugs) with Part D needing to be purchased separately from Part A and Part B.
  • How does Original Medicare work?
    Original Medicare pays 80% of approved medical expenses for Part A and Part B. Part A has an initial co-pay in 2023 $1,600.00 for the 1 st 60 days. If you are in the hospital longer than 60 days, you’re co-pay in 2023 $400.00/day for days 61-90 and $800.00/day co-pay for days 91+. When you are discharged or transferred to a Skilled Nursing Facility, the first 20 days are covered by Original Medicare. After 20 days, you will start accruing a co-pay $200.00/day for days 21-100. As for Part B, there is an Annual Deductible in 2023 $226.00 along with paying any excess charges that Original Medicare does not approve or cover after they pay 80% of the approved costs. Co-pays and deductibles change each year.
  • What can I do to protect myself from high out of pocket costs associated with Original Medicare?
    Depending upon your situation, you may have several options available to you. This includes Medicare Supplements, Prescription Drug Plan, Medicare Advantage with/without Prescription Drug Coverage, VA coverage, Medicaid (if you financially qualify), etc.
  • I’m on a fixed budget and am not able to afford the Part B monthly premium. Can I get help paying for it along with my monthly/90-day prescriptions?
    Yes. You can visit www.ssa.gov to apply for the “Extra Help”. “Extra Help” is designed to assist in reducing your out-of-pocket costs associated with your prescription drugs, monthly Part B premium and Prescription Drug Annual Deductible. Everyone’s situation is unique and will be determined by their financial situation.
  • I currently receive Medicare and Medicaid. I’m having issues with Medicare and Medicaid not coordinating my health benefits with each other. Is there anything that I can do to fix this?
    Yes. We offer Medicare Advantage Plans that coordinate the benefits between the two government health plans. There are a few insurance carriers that provide these benefits usually at no cost to you. Please ask us for further information and to discuss your situation.
  • I’m a U.S. Veteran. I currently receive Original Medicare and get my prescription drugs from my local VA office. Is there a health plan that will coordinate my benefits, help pay for my Part B premium and allow me more freedom to see any doctor or hospital in my area/region?"
    Yes. We have several Medicare Advantage Plans that are specifically designed for Veterans. They typically have no monthly premium with a portion of the Part B monthly premium being reimbursed per month. However, you MUST have Part A and Part B Original Medicare to qualify for a Medicare Advantage Plan.
  • I currently have diabetes, a heart issue, am on Original Medicare and a separate prescription drug plan. Is there anything out there that can provide me better coverage and not cost me an arm and leg?"
    Yes. We offer C-SNP (Chronic Special Needs Plans) Medicare Advantage Plans from several insurance carriers. To qualify, you need to have one or more of the following health conditions: diabetes, congestive heart failure or other heart issues.
  • What is Part D coverage?
    It’s part of Original Medicare that offers Prescription Drug Coverage that CMS has mandated anyone on Medicare to purchase whether they take/need prescription drugs. There is a Permanent Penalty if you choose not to take it.
  • How does Part D work?
    There is an Annual Deductible $505.00 in 2023 (changes every year) that must be met first before you begin paying co-pays. Usually, the Annual Deductible applies to Tiers 3, 4 and 5 by the majority of insurance carriers offering prescription drug coverage. Once the Annual Deductible is met, you will pay a co-pay and the insurance carrier pays the balance. Between the insurance carrier and your co-pays, this will equal the retail cost of each prescription drug(s) you are taking. Once you reach $4,460.00 in 2023 (changes every year), you begin the “Donut Hole” or “Gap”. While you are in the “Gap”, you will be paying 25% for generic prescriptions and 25% for brand prescriptions. Once you reach $7,400.00 (changes every year), you will then pay 5% or $4.15 generic or $10.35 for all other prescriptions.
  • I'm getting ready to retire soon from my employer. I currently have Medicare Part A and did not sign up for Part B and Part D when I became eligible because I had employer coverage. What is my next step?
    The very first thing you need to do is to sign up on Part B about 60 days BEFORE you officially retire. You will need to download Forms CMS-40B-E and CMS-L564-508 from Social Security website at www.ssa.gov, www.medicare.gov or you may contact me via email for the forms to be sent to you through a pdf file attachment. Form CMS-40B-E is to sign up for Part B and Form CMS-L564-508 is to verify that you had creditable health coverage prior to Medicare. This document also prevents you from receiving a permanent penalty on your Part B and Part D premiums once CMS verifies your previous employer coverage. Once you fill out the documents, please fax them to your local Social Security Office. It should take about 2 weeks to update in the Social Security system. After this is completed, please contact us to discuss your Medicare options that best suit your needs and budget.
  • I currently do not have any dental and/or vision insurance. How much does it cost?
    The monthly premium cost for dental and/or vision insurance will be dependent upon your zip code, and individual or family size. We offer several dental and vision plans that typically fit just about anyone’s monthly budget and cover their needs.
  • I have really bad teeth and need several major procedures done immediately on them (root canal, a couple of crowns and a dental implant). Is there a dental plan that will cover this and start immediately?"
    Yes. We offer dental PPO plans that are designed specifically for individuals/families that will need greater dental coverage for those major procedures with NO Waiting Periods, NO application fee, and Next Day Coverage. Please contact us for a quote.
  • I heard that life insurance is expensive to purchase. I currently do not have any. How much does it cost and how much can I get?
    Life insurance is typically based off your needs and budget. Whole life is generally slightly higher in monthly premium than term life. Whole life plans typically start from $5,000.00+ face amount whereas term life plans typically have a minimum of $50,000.00+ face amount to purchase.
  • When Can I sign up on health insurance?
    Every year during the Open Enrollment Period from November 1st to January 15th or when you have a Special Enrollment Period (marriage/divorce, have a child/adopt, move from one county to another or from one to state to another state and loss of health coverage)
  • How do I qualify for a Special Enrollment Period?
    Per healthcare.gov website, a Special Enrollment Period qualifications consists of any one of the following: marriage, divorce, having a baby, adopting, move from one county to another county (100 miles away), move from one state to another state, loss of health coverage i.e., Employer, Medicaid etc.
  • I qualify for a Special Enrollment Period. When do I need to decide on a health plan?
    Per healthcare.gov website, you have 60 days from the date you were either notified or the last day of coverage to decide before losing the opportunity to obtain health insurance until the next Open Enrollment Period (Nov 1st to Jan 15th). You may obtain private health insurance, go back onto your employer coverage or get a health plan from the health insurance marketplace. Please call us if you have any questions or need assistance.
  • I’m coming off Medicaid after having a baby. What are my options?
    Since you will be losing your Medicaid status, this qualifies you for a Special Enrollment Period. During this time, you may apply for health coverage via health marketplace, off exchange health plans, employer group health insurance, VA benefits (you need to be a U.S. Veteran to qualify) etc.
  • How do I know how much tax subsidy I will qualify for to help pay for my monthly premiums?
    The health marketplace uses the following information to determine how much tax subsidy an individual/family receives: number of people filed on your 1040 IRS taxes, sex, age, smoker/non-smoker, total household income, zip code, county and Federal Poverty Guideline Chart.
  • I’m offered health insurance through my employer, however, it’s not affordable for myself or my family. What are my options?
    You may purchase a Short-Term Medical plan (up to 3 years coverage available), an off-exchange health plan or go through the health insurance marketplace. However, if you decide to use the health marketplace, you may not qualify for a tax subsidy. Per healthcare.gov website, if your employer’s health plan is considered “affordable” (based on employee coverage premium IF employer offers family coverage, then it's based off of the family coverage premium in which monthly premiums cannot exceed 9.61% of your Total household income) OR meets the minimum standards (employer coverage pays 60%+ total costs of medical services and benefits include substantial coverage for doctors and inpatient hospital services), then you will not receive a tax subsidy. You may purchase a plan through the health marketplace at full cost. IF the employer's coverage premium is MORE than the 9.61% of your Total Household Income, then you WILL qualify for a tax subsidy through the health marketplace.
  • I’m an undocumented immigrant. Can I get health insurance through the health marketplace?
    Unfortunately, no. Per healthcare.gov, you would not be eligible for a health plan for yourself. However, you may be eligible to purchase an individual short-term medical plan or contact your local county hospital to see if you qualify for one of their health programs.
  • I’m getting ready to file my IRS taxes for the year with my accountant/tax specialist. They asked me for a copy of my 1095-A form. What is it and where can I find it?
    Form 1095-A is an IRS form that is specifically used for the health insurance marketplace for individuals/families that purchased a plan through them from the previous year. The health marketplace usually sends the forms out no later than January 31st every year. You may find a copy of it when you login to your marketplace account. Go into your Message area where you can download or print a copy of it. The IRS uses this form to help determine if you received too little or too much tax subsidy which may affect your tax refund. Please see your tax specialist/accountant for details.
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