Mark Maliwauki, Medicare Insurance Broker

Answer: You can sign up for Medicare 3 months before your birth month.

I encourage my clients to sign up for both Part A & Part B to avoid future penalties for enrolling late.

Answer: They mix up Medicare with Social Security. These are separate. Medicare is only health insurance and although most qualify, there is a standard number of hours worked or “credits” that must be achieved to get Medicare.

Answer: Planning for the unknown is what insurance is all about. Risk should be considered and addressed. Financial futures are severely impacted when the right amount of insurance is not taken out.

Answer: Because it is a cap on all prescriptions for a given year. Once the $2000 cap is achieved, all prescriptions are $0 for the remainder of the year.

Answer: You certainly could be. You must be able to either prove you have medical and prescription drug coverage or get bothPart A and B and a drug plan Part D

Answer: You will have 63 days from your last coverage date to enroll in a qualified Medicare plan. This can be a Medicare Supplement or Medicare Advantage plan or Original Medicare with a drug plan.

Answer: It has the opportunity to change it dramatically. AI integration, getting rid of fraud and waste once and for all will allow Medicare benefits to truly change lives.

Answer: It will save some Seniors who are paying a lot for Rx. The challenge is that it is unfair to assume Medicare carriers can pick up the slack. Drug prices must come down so significant pressure must be put on all Rx companies.

Answer: They can supplement depending on the availability of your Rx and a plan in a given plan area. Discount cards are another option when regular Rx plan options are not available.

Answer: Yes. Losing employer coverage qualifies as a special enrollment period. You have 63 days to get your new coverage in place.

Answer: Original Medicare Part A and Part B would be very costly in the event of a serious or catastrophic accident or injury. You would pay 20% out of pocket for all expenses incurred. A Medicare Advantage plan has a Maximum Out of Pocket that limits your liability and caps your costs.

Answer: The latest information we have comes from 2023. It states that the United States spent $4.9 trillion on healthcare, which translates to $14,570 per person. This amount represents a significant portion of the nation's Gross Domestic Product (GDP), accounting for 17.6%

Answer: The increased scrutiny and auditing of Medicare Advantage (MA) plans, especially through Risk-Adjustment Data Validation (RADV) audits, is likely to impact nursing home coverage in several ways. Specifically, tighter scrutiny and potential cost containment efforts within MA plans could lead to:

Reduced Payments:

MA plans may reduce payments to nursing homes to offset potential overpayments identified during audits or to balance budgets.

More Denials and Appeals:

As MA plans face pressure to control costs and maintain compliance, they may be more likely to deny or delay coverage for nursing home stays, leading to increased appeals from beneficiaries and providers.

Pressure on Nursing Home Contracts:

Contract negotiations between MA plans and nursing homes may become more challenging, with nursing homes potentially facing unfavorable terms to ensure continued coverage.

Shifting of Costs:

To manage their budgets, MA plans may increase premiums or reduce other benefits, potentially shifting the burden of care to beneficiaries.

Potential Impact on Access:

The combination of reduced payments, more denials, and potential cost-shifting could lead to reduced access to quality nursing home care for some beneficiaries, particularly in rural areas or those with complex medical needs.

Answer: No. But a good Medicare agent always goes through the various options and why they are different. That way you are educated on exactly what the differences are why a Supplement makes more sense for you vs a Medicare Advantage plan or vice versa,

Answer: Medicare Part D will cost you an extra premium and it would be paired with a Medicare Supplement as they don't come with an Rx plan.

Medicare Advantage plans with the exception of specific veteran's plans come with Rx built in and there is no additional cost for the coverage.

Answer: It is the doctor's choice to go out of network. There are various reasons for it but unfortunately, it seems to always come at the time you really need their services and you are no longer covered as they are out of network.

Answer: They certainly can be. Medicare plans are based on the county you live in and the benefits associated with the plan are normally driven around the # of members or potential members in that county.

Answer: You would simply need to call your HMO and find out. It is likely that you will pay out of network charges if you choose to get care outside of your HMO network although there can be exceptions made if you are specifically referred to a Dr outside of the network.

Answer: You can go to Medicare.gov, type in your zip code to find the available plans in your county and then type in the Rx you are looking to source.

Answer: Contact SSA.gov to get enrolled in Medicare. If you will not be staying on group coverage you will need to sign up for both Medicare A & B.

You have until 3 months after your birth month to get enrolled without a penalty.

Answer: Mental health services usually have a copay depending on the plan so you would want to do a plan comparison to see which one is the least expensive. It can be up to $40-50.

Since the Covid-19 plandemic, telehealth services have been covered 100%

Answer: Original Medicare is a 20% out of pocket for all services.

A Medicare Advantage or Part C plan has an inpatient hospital deductible of $x per day for 1-6 days typically. That is your responsibility with your Medicare Advantage plan.

To summarize:

You would not pay both of these charges. If you have Part A only would you pay the $1676 deductible (or 20%) and with the Medicare Advantage Part C plan you would pay the $350 per days 1-5 deductible and after that, you would not have any additional inpatient hospital charges.

Answer: Yes. Colonoscopies are preventative and therefore covered at 100%.

You could always check on Medicare.gov as a back up to confirm.

Answer: Anything outside of seeing your Primary Care doctor i.e. a specialist of any kind is going to cost you a copay.

Answer: When the client doesn't have their Medicare Card or VA Benefits cards with them to enroll. It would be much better if all Medicare agents had access to a system that contains this information and is available to get via username and password security.

Answer: Any Medicare agent (including myself) is equipped and trained to help you navigate the maze and breakdown the acronyms that make up Medicare. 208.598.0520

Answer: Ask them to get in-network, find out what your out of network charges will be compared to in network charges, negotiate with the hospital for a cash price, enroll into a different plan that is in network when you are able to do so.

Answer: Once your income reduces, get with SSA and let them know so the IRMAA premium or "tax" can be reduced or eliminated

Answer: I wouldn't necessarily say they are over hyped but many people never even use the OTC or Over the Counter dollars each quarter. It is a nice benefit but depending on the plan you have, the items could be more expensive than they would be if you were able to just pick them up at the pharmacy or grocery store.

Outside of that, there are benefits for vision, hearing and dental that are included in the plan coverage which if they weren't, you would have to have a separate policy for or pay out of pocket anyway. Some coverage is better than no coverage.

Answer: It all depends on your needs and financial situation. Med Supps definitely have a place in the Medicare plan space and you need to consider all plans available so you choose the best option for you.

Answer: Medicare provides 60 lifetime reserve days of inpatient hospital coverage, which can be used after a beneficiary has exhausted their standard 90 days of coverage within a benefit period. These reserve days are used only once and can be used at any point during a beneficiary's lifetime to extend their hospital stay.

Answer: It needs a serious look. You can't have an organization that big and not have regular reviews of performance and outcomes. It should have a major review at the end of every Medicare enrollment year.

Answer: I look forward to breaking things down so the information is understandable and helping my clients choose the best option for them at the present and immediate future time. I enjoy helping them solve the challenges associated with Medicare plans and coverages so that they know what they have and how their plan truly benefits them.

Answer: According to Medicare.gov the "source of truth" for all things Medicare:

Medicare Part A (Hospital Insurance) usually covers inpatient hospital care if you meet both of these conditions:

You’re admitted to the hospital as an inpatient after an official doctor’s order, which says you need inpatient hospital care to treat your illness or injury.

The hospital accepts Medicare.

It does not cover hospital submissions that are for emergency needs.

Answer: Yes, Medicare will cover home healthcare assistance under certain conditions. Both Original Medicare (Parts A and B) and Medicare Advantage (Part C) can provide coverage for home health services. However, it's crucial to understand that not all home healthcare is covered, and there are specific requirements and exclusions. 

Here's a breakdown of how Medicare and home health care work:

1. Medicare Parts A and B Coverage:

    •    Part A:

Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. 

    •    Part B:

Covers certain doctors' services, outpatient care, medical supplies, and preventive services. It also covers eligible home health services. 

    •    Home health under Part B:

Requires you to be "homebound" and need skilled care (e.g., nursing, therapy). A doctor must certify that you are homebound and that you need these services. 

    •    Home health under Part A:

May be covered after a hospital stay or skilled nursing facility stay, but only for a limited period. 

2. Medicare Advantage (Part C) and Home Health:

    •    Medicare Advantage plans are private health plans that offer the same benefits as Original Medicare, plus extra benefits, such as home health care.

    •    Some plans may offer more comprehensive coverage for home health than Original Medicare. 

3. Covered Services:

    •    Skilled nursing care (e.g., medication management, wound care).

    •    Physical, occupational, and speech therapy.

    •    Medical social services.

    •    Home health aides (if receiving skilled nursing or therapy).

    •    Durable medical equipment (DME) and medical supplies. 

4. Services Excluded from Coverage:

    •    Custodial care: Generally, Medicare does not cover services that are not medically necessary, such as help with personal care or homemaker services.

    •    Home meal delivery: Medicare typically does not cover home meal delivery services.

    •    Skilled nursing is limited

Answer: This is a very good explanation from the source of truth ie; Medicare.gov on what Medicare's role is in covering long term care.

https://www.medicare.gov/coverage/long-term-care

Answer: Doctors often disapprove of Medicare Advantage plans due to issues with pre-authorization requirements, frequent claim denials, complex administrative processes, and reduced reimbursement rates. These challenges can lead to increased administrative burdens for doctors, impacting patient care and potentially leading to burnout.

There are explanations for all of these that would counter the Doctors dislike. A big one is PA and claim denials. Both of these have been around long before MA plans. PAs are helpful for all involved. Claim denials more often than not are the result of a miscoded procedure at the provider (doctor, hospital) level.

Answer: Original Medicare has no Rx, dental, vision, hearing or OTC benefits. You would need separate policies to have them and the Part D or Rx plan is mandatory or your will be fined for life.

It also doesn't pay for copays and deductibles. And, of any expenses you incur, you will owe 20%.

A Part C or MAP+D plan comes with all of the benefits or 90% of the benefits above (depending on the plan and service area) and has a MOOP (Maximum out of pocket) so you know that the most you will ever pay vs the 20% of Original Medicare is a set amount. Then, you are covered 100% for the remainder of the year.

That safety net and the fact that MAP+D (Part C) plans are very affordable is really what you have to consider.

Answer: If you are 65 you will have to go on Medicare. You have 63 days to get on Original Medicare A&B or chose a Medicare Supplement or Medicare Advantage plan.

Answer: If you already have a Red White and Blue Medicare card with Part A and Part B, you do not need to sign up for Medicare again when you reach 65. You will have been awarded Medicare early because of your disability most likely.

Answer: Medicare.gov is the source of truth (or should be) for these types of inquiries:

https://www.medicare.gov/coverage/mammograms

Answer: There is no such thing as a perfect Medicare plan. There is no such thing as a free lunch.

Medical services cost money and from year to year sometimes month to month the needs of people change and the only thing you can do is match your current and / or short term needs with the best plan to meet those needs that is available right now.

You will always have to put some skin in the game. I firmly believe the future of Medicare and Medicaid is going to include more cost share from the member. Premiums, copays et al will have to go up.

Answer: Apply for State Medicaid.

Partial Medicaid also known as Medicare Savings Program can help pay your Medicare Part A&B premiums, other plan premiums (if you have a Medicare Advantage plan), copays and coinsurance. This particular MSP is also called QMB or Qualified Medicare Beneficiary.