enrollment application. P lasts… Your coverage begins… d to join a Medicare plan for the first time you receive notice of ment and continues months after the ceived. 10 Depends on the situation. oin a Medicare Part ne 30 (after you have July 1 of that year. enroll in a Medicare begins when you and continues for two The month following the month you applied. (SNP) or you lose SNP eligibility. P lasts… Your coverage begins… Medicare Advantage at any time to enroll in ble. condition and want to The first day of the month after you submit a completed application. ug coverage, so you will not face a premium penalty as long as you enroll in a
© 2018 Medicare Rights Center join a chronic care SN eligible, you can do so SEP ends when you jo or drug plan. Note: If y chronic condition, you join a different SNP th condition. You lose eligibility to continue getting coverage through your SNP. (SNPs must continue to cover you for at least one month if you become ineligible and for up to six months if it’s likely that you will requalify within six months.) You can join another Plan or Part D plan be you no longer qualify f ending either three mo continued period of en when you enroll in ano comes first. You’re enrolled in a chronic care SNP, but your provider fails to confirm that you have the chronic condition required for eligibility by the end of the first month of enrollment. You have an SEP to e Advantage Plan or a P begins the month the S that you don’t qualify a months after the mont when you enroll in ano Advantage Plan or Pa is earlier. 11. You experience contract violations (such as You have an SEP if… Your SEP Your Medicare Advantage Plan or Part D plan violated a material provision of your contract such as: Failing to provide you on a timely basis with benefits available under the plan; Failing to provide benefits in accordance with applicable quality standards; Giving misleading information in the private health or drug plan’s Your SEP to switch to Advantage Plan or Pa the regional CMS offic that a violation has oc an Medicare Advantag allows you to disenro either change to Origi another Medicare Adv You can switch to an Advantage Plan or Pa
NP for which you are o at any time. The oin the private health you have another get another SEP to at covers this other Medicare Advantage eginning the month for the SNP and onths after your nrollment ends or other plan, whichever The first day of the month after you submit a completed application. enroll in a Medicare Part D plan. The SEP SNP plan notifies you and ends two full th of notification or other Medicare art D plan, whichever The first day of the month after you submit a completed application. misleading marketing) or enrollment errors. P lasts… Your coverage begins… o another Medicare art D plan begins once ce has determined curred. (If you are in ge Plan, your SEP ll from your plan and inal Medicare or join vantage Plan) other Medicare art D plan during the The effective date of the new Medicare Advantage Plan or Part D plan will be the first of the month following the month the new private health or drug plan receives the completed application or up to three months after it receives the completed application. In some cases, CMS may process a retroactive disenrollment and/or retroactive enrollment in another Medicare Advantage
© 2018 Medicare Rights Center marketing to get you to enroll in the plan. last month of enrollme plan. If you do not choose a or drug plan immediat extended for 90 days f disenrollment in the pl A federal employee made a mistake in your enrollment or disenrollment in a Medicare Part D plan. You have one SEP to disenroll from a Medi begins the month of C lasts two additional mo CMS sanctions (finds fault with) a Medicare Advantage Plan or Part D plan and you disenroll in connection with that sanction. The length and start d join a new Medicare A Part D plan depends o CMS determines that your previous drug coverage did not adequately inform you of a loss of creditable coverage or that your drug coverage was not creditable. You have one SEP to from a Medicare Part the month of CMS app additional months. (In waive your premium p 12. Your Medicare Advantage Plan or Part D pla You have an SEP if… Your SEP Your Medicare Advantage Plan or Part D plan doesn’t renew its service. (Your Medicare Advantage Plan or Part D plan must notify you by October 1 if it won’t offer Medicare drug or health coverage next year, and it must continue to provide coverage through the end of the current calendar year.) Your SEP to switch to Advantage Plan or Pa December 8 of that ye day of February of the is in addition to the Fa period from October 1 7, when you can switc coverage and enroll o D drug coverage. Mid-year, your Medicare Advantage Plan or Part D plan closes or changes its contract with CMS so that you will be forced to disenroll from the plan. (Your Medicare Your SEP to switch to Advantage Plan or Pa months before the pro changes take place an
ent in your current another private health ely, your SEP is from the time of your an. or Part D plan. enroll in and/or care Part D plan that CMS approval and onths. Depends on the situation. ate of your SEP to Advantage Plan or on the situation. Depends on the situation. enroll in or disenroll D plan that begins proval and lasts two this case, CMS may penalties.) Depends on the situation. an no longer offers Medicare coverage. P lasts… Your coverage begins… o another Medicare art D plan lasts from ear through the last e next year. (This SEP all Open Enrollment 5 through December ch Medicare health r disenroll from Part Enrollments made from October 15 through December 31 are effective January 1. Enrollments made during January are effective February 1. Enrollments made in February are effective March 1. o another Medicare art D plan begins two oposed closing or nd ends one month You can ask that your new Medicare Advantage Plan or Part D plan coverage start the month after you get notice and up to two months after your old Medicare
© 2018 Medicare Rights Center Advantage Plan or Part D plan must notify you 60 days before the proposed date of termination or modification.) after they occur. CMS terminates your Medicare Advantage Plan’s or Part D plan’s contract because of misconduct or other problems. (Your plan must give you 30 days notice before the termination date.) Your SEP to switch to Advantage Plan or Pa month before the term lasts for two months a CMS decides to immediately terminate its contract with your Medicare Advantage Plan or Part D plan. CMS will notify you of your SEP. The terminamonth. 13. You disenroll from your Medicare Advantage Disenrollment Period (MADP). You have an SEP if… Your SEP You disenroll from your Medicare Advantage Plan during the Medicare Advantage Disenrollment Period (January 1 – February 14 of each year). You have an SEP to e stand-alone Part D dru disenroll from your Me Plan. You can disenro Advantage Plan by su disenrollment request in a stand-alone Part D Know that if you disen Medicare Advantage P MADP, you can only e Medicare with a stand You cannot switch you Advantage Plan.
Advantage Plan or Part D plan coverage ends. o another Medicare art D plan begins one mination occurs and afterward. You can choose to have your new Medicare Advantage Plan or Part D plan coverage begin up to three months after the month your old coverage ended. the termination and ation may be mid Depends on the situation. e Plan during the Medicare Advantage P lasts… Your coverage begins… enroll in a Medicare ug plan when you edicare Advantage oll from your Medicare bmitting a or by simply enrolling D drug plan. nroll from your Plan during the enroll in Original -alone Part D plan. ur Medicare The month following the month you submit an enrollment request to a new plan.
© 2018 Medicare Rights Center 14. You qualify for new Part D initial enrollment You have an SEP if… Your SEP You qualify for new Part D initial enrollment period to join a stand-alone Medicare Part D drug plan because you are a person with a disability who is turning 65. (Note: If you are already enrolled in a Medicare Part D plan and are paying a late premium penalty, the penalty will end when the enrollment period starts.) You have an SEP to d Medicare Advantage P does not include drug Original Medicare or to Advantage Plan that d coverage. You may al additional IEP to join a drug plan. The SEP be the additional Part D I Part D plan—usually t period including three turn 65, the month you three months after you 15. You want to enroll in a five-star Medicare Ad You have an SEP if… Your SEP You want to enroll in a Medicare Advantage or Part D plan that has an overall Plan Performance Rating of five stars and you’re otherwise eligible to enroll in the plan. (For example, you live in the plan’s service area.) Plan Performance Rat every fall and apply to calendar year. Your S Medicare Advantage o December 8 of the yea considered a five-star November 30 of the ye considered a five-star this SEP to change pla year. 16. You have been in a consistently low-perform You have an SEP if… Your SEP You have been in a consistently lowperforming plan, meaning that the plan has received an overall Medicare star rating of You have an SEP to e quality plan throughou should receive a notic
period when you turn 65. P lasts… Your coverage begins… disenroll from a Plan (that does or coverage) to join o enroll in a Medicare does not include drug so use your a stand-alone Part D egins and ends with EP to join a Medicare he seven month months before you u turn 65, and the u turn 65. If you are not already enrolled in a Part D plan, your coverage will usually start the month following the month you submit an enrollment request to a new plan. dvantage Plan or Part D plan. P lasts… Your coverage begins… tings are released o the following EP to join a five-star or Part D plan starts ar before the plan is plan. It lasts through ear the plan is plan. You can use ans one time per Enrollments December 8 through December 31 are effective January 1. Enrollments January 1 through November 30 are effective the month following the month you submit an enrollment request. ming Medicare Advantage or Part D plan. P lasts… Your coverage begins… enroll into a higher ut the year. You e from CMS in late The month following the month you submit an enrollment request to a new plan.
© 2018 Medicare Rights Center less than three stars for three consecutive years. October, saying that yperforming plan. You h that year, as well as th switch to a plan rated use this SEP, you mus MEDICARE directly. Note: This is separate SEP listed above. 17. Your Medicare Advantage stops contracting You have an SEP if… Your SEP Your Medicare Advantage Plan stops contracting with many providers in its network during the course of the calendar year and CMS determines these terminations are substantial. If the terminations are significant enough, you will have a one-time SEP to enroll in a different Medicare Advantage Plan (with or without Part D coverage) or switch to Original Medicare with or without a standalone Part D plan. Your plan will mail you a notice if CMS determines the terminations are substantial. From the month you g network change and tw after that. You should least 30 days in advan terminations and of yo new Medicare Advanta Original Medicare with You do not have a gua purchase a Medigap v 18. You experience an “exceptional circumstanc You have an SEP if… Your SEP If your circumstances do not fit into any of the other SEP categories, you have the right to ask CMS to grant you an SEP based on your particular exceptional circumstances.11 Depends on the SEP. 11 CMS can also grant “exceptional circumstance” SEPs to groups identified by a who were all misled about the plan’s offerings). Many of the SEPs mentioned in th
you are in a lowhave the remainder of he following year, to 3 stars or more. To st call 1-800- e from the five-star g with many of its providers. P lasts… Your coverage begins… get notified of the wo additional months be notified via mail at nce of the network our SEP to switch to a age Plan, or to join h a Part D plan. aranteed right to via this SEP. The month following the month you submit an enrollment request to a new plan. ce” P lasts… Your coverage begins… Depends upon the circumstances. common problem or characteristic (for example, members of a particular plan his chart were created as “exceptional circumstance” SEPs.
The Part B Special Enrollment Period © 2023 Medicare Rights Center Helpline: 800-333-4114 www.medicareinteractive.org Special Enrollment Periods (SEPs) are periods of time outside normal enrollment periods when you can enroll in health insurance. They are typically triggered by specific circumstances. The Part B SEP starts when you have coverage from current work (job-based insurance) and you are in your first month of eligibility for Part B. It ends eight months after you lose coverage from current employment because the employment or insurance ends. Using the Part B SEP also means you will not have to pay a Part B late enrollment penalty (LEP). Using the Part B SEP You can use the Part B SEP while you have job-based insurance, or for eight months after you no longer have job-based insurance (either from your job, your spouse’s job, or sometimes a family member’s job). In order to be eligible for it, you also must have been continuously covered by insurance from current work or by Medicare Part B since becoming eligible for Medicare (including the first month you became Medicare-eligible). If you have had more than eight consecutive months without coverage from either current work or Part B, you are not eligible for the Part B SEP. In most cases, you should enroll in Medicare before losing job-based insurance to avoid gaps in coverage. Remember, even if you use the SEP to avoid a late enrollment penalty, you may still be responsible for any health care costs you incur in the months after losing job-based coverage before your Medicare coverage takes effect. For help timing your Medicare enrollment to ensure it starts immediately after you no longer have job-based insurance, reach out to your human resources department one to two months in advance. If you do not meet the criteria listed above, you are not eligible for the SEP and may have to use the General Enrollment Period (GEP) to enroll in Medicare. • GEP takes place January 1 through March 31 of each year • When you enroll during the GEP, coverage begins the first of the month after you enroll. For example, if you enroll in January, your coverage begins February 1. • Enrolling during the GEP means you will have to pay a Part B LEP Note: If you qualify, you may also be able to enroll in Part B using either a Medicare Savings Program (MSP) or equitable relief. Both can also remove Part B late Remember: Job-based insurance is coverage you have based on your, your spouse’s, or in some cases a family member’s current employment. Retiree insurance and COBRA are not forms of job-based insurance.
© 2023 Medicare Rights Center Helpline: 800-333-4114 www.medicareinteractive.org enrollment penalties. How do I enroll in Part B through the SEP? 1. Contact the Social Security Administration (SSA) at 800-772-1213 and request forms. You will need the following forms from SSA • CMS 40B (Application for enrollment in Medicare) • CMS L564 (Request for employment information) You should fill out and sign CMS 40B. Ask the employer to complete CMS L564. These forms show SSA that you have been continuously covered by job-based insurance. Be aware that if you have had job-based insurance from multiple employers since you became eligible for Medicare, you should request additional copies of CMS L564 from SSA and ask each employer to complete the form. If a previous employer has gone out of business or you are otherwise unable to get them to fill out this form, contact the Medicare Rights Center at 800-333-4114 to learn about your options. 2. Submit all forms to SSA. Once you have gathered all needed documents, either go to your local Social Security office to drop off your application or send your application to their mailing address. To find your local Social Security office, visit https://www.ssa.gov/locator or call Social Security at 800-772-1213. Be sure to make copies of everything you submit. If you speak to an agent in person, they should give you a receipt indicating the date you submitted your application. After submission, you will receive a letter in the mail from SSA with your enrollment decision. If you are approved, your Medicare coverage will either be effective on the first of the month that you enrolled or on the first of the following month, depending on your situation. If you are denied enrollment, you have the right to appeal the decision. Note: If you request to use the Part B SEP while you have job-based insurance or within a month after you lose job-based insurance, you can delay your Part B start date up to three months.
© 2023 Medicare Rights Center Helpline: 800-333-4114 www.medicareinteractive.org Sample letter to SSA for Part B SEP [Date] Social Security Administration [Address of local office] Re: Medicare Part B Special Enrollment Period Beneficiary: [Name] SSN: [Social Security Number] To whom it may concern, I am submitting my application for enrollment into Medicare Part B and am requesting that my Part B benefit become effective on . Enclosed please find my completed Application for Enrollment into Medicare (CMS40B) and Request for Employment Information form (CMS-L564). I am eligible for a Special Enrollment Period (SEP) because I meet the following requirements: oI became eligible for Medicare on (month) , (year) due to [age/disability]. Since that time, I have never had more than eight consecutive months of lapses in coverage from either Medicare or from a group health plan based on [my/my spouse’s/my family member’s] current employment. In addition to meeting the above criteria: Check one: oI am currently covered by [my/my spouse’s/my family member’s] group health plan or large group health plan based on current employment oI am not currently covered by a group health plan or large group health plan based on current employment at this time. However, I was covered by [my/my spouse’s/my family member’s] employer group health plan based on current employment within the last eight months. I lost my employer group plan based on current employment on (month) (year) . According to Social Security’s Program Operations Manual section HI 00805.275 SEP Enrollments:
© 2023 Medicare Rights Center Helpline: 800-333-4114 www.medicareinteractive.org Beginning 3/95, individuals who are age 65 and over or disabled, can enroll (or reenroll) in SMI and/or Premium-HI: • during any month (including a partial month) in which he/she is enrolled in a GHP or LGHP (as defined in HI 00805.266A.) based on current employment status, or • in any of the 8 consecutive months following the last month during any part of which the individual was enrolled in the GHP based on current employment status. Additionally, HI 00805.275(G) states that lapses in Part B and/or GHP coverage from current employer do not disqualify me for a special enrollment period, as long as I did not have a lapse in coverage for more than 8 consecutive: The SEP provisions permit an 8-month period after the month GHP/LGHP coverage based on current employment status ends to enroll in SMI (or PremiumHI). Therefore, when employment or GHP/LGHP coverage ends, but before the 8-month period expires, a beneficiary is once again covered under a GHP or LGHP based on current employment status, the SEP is deemed not to have occurred. This protects the individual's rights to an SEP or to a subsequent SEP. Furthermore, according to POMS GN 03101.070, my request for an SEP into Medicare Part B is a request for an initial determination and is therefore subject to administrative and judicial review. Consequently, I will receive a formal decision letter from SSA that outlines my rights to appeal if I am denied enrollment into Medicare. Thank you in advance for your attention to this matter. Sincerely, [Your name] [Your title] Attachments: [List, if any]
Silver 94 (100%-150%) Silver 87 (>150%-200%) % FPL 0% 100% 138% 150% 200% 1 $0 $13,590 $20,121 $20,385 $27,180 $ 2 $0 $18,310 $27,214 $27,465 $36,620 $ 3 $0 $23,030 $34,307 $34,545 $46,060 $ 4 $0 $27,750 $41,400 $41,625 $55,500 $ 5 $0 $32,470 $48,494 $48,705 $64,940 $ 6 $0 $37,190 $55,587 $55,785 $74,380 $ 7 $0 $41,910 $62,680 $62,865 $83,820 $ 8 $0 $46,630 $69,773 $69,945 $93,260 $ add’l, add $0 $4,720 $7,094 $7,080 $9,440 $ Fed Medi-Cal for Adults Medi-Cal for Pregnant Wom Medi-Cal for Kids (0-18 Yrs.) Household Size Program Eligibility by Fede Your financial help and whether you qualify for various Cover based on the Federal Note: Most consumers up to 138% FPL will be eligible for Medi-Cal. If ineligible for Med financial help including: federal premium tax credit, Silver (94, 87, 73) plans and Zero C Silver 94, 87 and 73 plans provide lower deductibles, co-pays, and out-of-pocket maxim * Consumers at 400% FPL or higher may receive a federal premium tax credit to lower t second-lowest-cost Silver plan in their area. See the chart on page 2 for more informa American Indian / Alaska (1 SEE NOTE BELOW FOR INCOMES IN THIS RANGE
Silver 73 (>200%-250%) 213% 250% 266% 300% 322% 400%* $31,056 $33,975 $38,783 $40,770 $46,948 $54,360 $42,004 $45,775 $52,456 $54,930 $63,499 $73,240 $52,952 $57,575 $66,128 $69,090 $80,050 $92,120 $63,900 $69,375 $79,800 $83,250 $96,600 $111,000 $74,849 $81,175 $93,473 $97,410 $113,151 $129,880 $85,797 $92,975 $107,145 $111,570 $129,702 $148,760 $96,745 $104,775 $120,818 $125,730 $146,253 $167,640 $107,693 $116,575 $134,490 $139,890 $162,804 $186,520 $10,949 $11,800 $13,673 $14,160 $16,551 $18,880 deral Premium Tax Credit* Medi-Cal Access Program (for Pregnant Women) CCHIP (San Francisco, San Mateo, and Santa Clara county residents) men eral Poverty Level for 2023 ed California or Medi-Cal programs depends on your income, l Poverty Level (FPL). 3/2023 di-Cal, consumers may qualify for a Covered California health plan with Cost Sharing and Limited Cost Sharing AIAN plans. mum costs. their premium to a maximum of 8.5 percent of their income based on the ation. a Native (AIAN) Zero Cost Sharing 00%-300%) Tax credit continues beyond 400% AIAN Limited Cost Sharing (over 300%)
The unshaded column headings are associated with eligibility ranges for Covered California programs and financial help: Covered California uses FPL limits from the previous year to determine eligibility for its programs. Federal Premium Tax Credit 100%–400%+ FPL Silver 94 100%–150% FPL Silver 87 over 150%–200% FPL Silver 73 over 200%–250% FPL AIAN Zero Cost Sharing 100%–300% FPL AIAN Limited Cost Sharing over 300% FPL Covered California Programs Percentage of income paid for premium Based on second-lowest-cost Silver plan Household FPL Percentage 0-150% FPL 150-200% FPL 200-250% FPL 250-300% FPL 300-400% FPL 400+% FPL The cost of your Covered California premi Poverty Level percentage and the cost of t
The column headings shaded in purple are associated with eligibility ranges for Medi-Cal programs: Medi-Cal uses FPL limits for the current year, as calculated by the Department of Health Care Services, to determine eligibility for its programs. Medi-Cal for Adults up to 138% FPL Medi-Cal for Children up to 266% FPL Medi-Cal for Pregnant Women up to 213% FPL MCAP (for Pregnant Individuals) over 213%–322% FPL CCHIP (for Children in San Mateo, San Francisco, and Santa Clara counties) over 266%–322% FPL Medi-Cal Programs ms, based on household FPL n Percent of Income 0% household income 0-2% household income 2-4% household income 4-6% household income 6-8.5% household income 8.5% household income um is based on your household’s Federal the plans available where you live.
NOTES
* Income amounts reflect threshold without/with the $20 monthly income disrega ** Asset limits include amount without/with $1,500/person burial allowance. Income Levels Source: https://aspe.hhs.gov/poverty-guidelines Asset/Resource Levels: https://www.cms.gov/files/document/lis-memo.pdf Part D Cost-Sharing Source: https://www.cms.gov/files/document/2023-announ Full Low-Income Subsidy (LIS)/E Beneficiary Group Annual Income Eligibility Requirement Monthly Income Eligibility Requirement Asset E Requi Full-Benefits Duals: Institutionalized or receiving Home and Community-based Services Meet State Medicaid financial eligibility Meet State Medicaid financial eligibility Meet Stat financial e Full-Benefit Duals: income < 100% FPL Meet State Medicaid/MSP financial eligibility Meet State Medicaid/MSP financial eligibility Meet Stat Medicaid/ financial e Full-Benefit Duals: income > 100% FPL Meet State Medicaid/MSP financial eligibility Meet State Medicaid/MSP financial eligibility Meet Stat Medicaid/ financial e Non-duals: income < 135% FPL AND lower asset levels Single: $19,683/$19,923* Couple: $26,622/$26,862* Single: $1,640/$1660* Couple: $2,219/$2,239* Single: $9,090 /$1 Couple: $13,630/$ Partial Low-Income Subsidy (LIS)/ Beneficiary Group Income Eligibility Requirement Monthly Income Eligibility Requirement Asset E Requi Non duals with income < 135% FPL AND assets between lower and higher limits Single: $19,683/$19,923* Couple: $26,622/$26,862* Single: $1,640/$1660* Couple: $2,219/$2,239* Single: be $9,090 /$1 $15,160/$ Couple: b $13,630/$ $30,240/$ Non duals with income between 135-150% FPL Single: $21,870/$22,110* Couple: $29,580/$29,820* Single: $1,823/$1,843* Couple: $2,465/$2,485* Single: $15,160/$ Couple: $30,240/$
rd (annually = $240); income is rounded to the nearest whole dollar. ncement.pdf Updated January 2023 Extra Help (2023) - 48 STATES + DC Eligibility rement Need to apply for LIS? Monthly Premium Annual Deductible Copay/Coinsurance Plan’s Formulary Drugs e Medicaid eligibility No, receive it automatically No No None e MSP eligibility No, receive it automatically No No Copay: $1.45 generic /$4.30 brand Catastrophic Copay: $0 e MSP eligibility No, receive it automatically No No Copay: $4.15 generic/$10.35 brand Catastrophic Copay: $0 10,590** $16,630** No, if receiving SSI; otherwise, yes No No Copay: $4.15 generic/$10.35 brand Catastrophic Copay: $0 /Extra Help (2023) - 48 STATES + DC Eligibility rement Need to apply for LIS? Monthly Premium Annual Deductible Copay/Coinsurance Plan’s Formulary Drugs etween 10,590- $16,660** etween $16,630- $33,240** Yes No $104 Coinsurance: 15% Catastrophic Copay: $4.15 generic/$10.35 brand $16,660** $33,240** Yes Yes, Sliding scale $104 Coinsurance: 15% Catastrophic Copay: $4.15 generic/$10.35 brand
Below is my template for members that need to apply for Part A & Part B at the same time: ----------------------------------------------------------------------------------------------- Thanks again for taking the time to reply to my letter. It was great speaking to you. I wanted to follow up on our conversation and to give you clarity on when and how to apply for Medicare and the next steps. Step #1 is to have you apply for Medicare Parts A & B: (Since your bday is Feb, you’re currently in your enrollment window and your coverage under Medicare could start as soon as Feb 1st) You should enroll in Medicare Part A and Medicare Part B in the following ways: 1. You can contact the Social Security Administration to enroll, Call SS at 1-800-772-1213 OR 2. Go online to www.ssa.gov, Click on “Medicare Enrollment”, Then, click “Apply for Medicare Only” (see attached pdf) Keep in mind that you do not need to apply for Social Security benefits at the same time, you can choose to delay them until you’re ready. *As a reminder:* Part A is at no cost and covers Hospitalization (anything in-patient) Part B starts at $164.90/month and would cover Doctor visits (anything out-patient) – Attached is the IRMAA chart that reviews your income to determine your Part B & D costs. Step #2 is to select a secondary plan to fill in the gaps of Original Medicare, so this is what we spoke about: 1. OPTION 1 - Medicare Advantage Prescription Drug Plan (MAPD – HMO) AFFORDABILITY 1. This will take over your Medicare and keep you assigned to one group, like St. John’s. The MAPD Plan will include your drug coverage as well. This plan has $0 premium with low (to no) co-pays associated with treatments but will also throw in a bunch of extras, such as gym membership, Acupuncture, Vision, transportation, and even some over-the-counter benefit. 2. Attached is a sample of the Scan plan accepted at St. John’s and Dr. McGrath. 1. OPTION 2 – Medicare Supplement plus Prescription Drug Plan FLEXIBILITY 1. With the Medi-gap, or Medicare supplement, plan option you would keep your Medicare primary and the Medi-Gap will cover the gaps (including the giant 20% gap). This option has NO Medical Group, so you have the freedom to see any doctor and any specialist so long as they accept Medicare. In fact, it would be accepted nationwide. Based on your area and age, here is what I would recommend: Blue Shield Plan G Extra - Monthly premium is $135/month (this includes a $25/month discount for the first year) The rate increases after 12 months and will have a slight increase annually based on your age. There is only one annual deductible of $226 (in 2023) after which the Blue Shield Plan will cover you for all Medicare covered costs. Extra Benefits include: 1. Fitness through SilverSneakers – www.silversneakers.com to locate a facility that is part of the program 2. Teledoc services at $0 co-pay 3. $100 quarterly benefit to use for Over-the-Counter items through their catalogue (www.blueshieldca.com/medicareotc) 4. Vision discounts through VSP Vision. See attached Benefits. 5. Hearing benefits (see the benefit summary attached). 6. Foreign Travel Emergency coverage (limited) Blue Shield Plan G – without the extras would cost $121/month
Drug Plan would be separate coverage. The average premium on drug plan is around $30/month; however, once you have updated your medications list, we would get a more specific quote for your needs. Pros & Cons of Option #1: The major benefit is of course the monthly premium. Also, your care is coordinated with one group and one medical record system. This plan also throws in a bunch of added benefits. The major downfall is mainly that you are limited to just 1 medical group and would need to request referrals and wait on auth’s in order to see specialists. You would have emergency coverage out-of-area (including outside of CA), but non-emergency wouldn’t be covered. Pros & Cons of Option #2: The major benefit is having the freedom to choose whichever doctor, in any network, without having to wait for a referral. So you can see a pcp at Scripps, specialist at UCLA, and even get second opinions from a Dr in San Francisco and you’re still covered! You also have coverage nationwide. So if you decide to visit family a few months out of the year from another state, you’re covered! The negative about this option is obviously the higher and increase in annual premium. It also doesn’t include all the bells & whistles that an HMO plan would offer. There are 2 important periods I also wanted to mention to give you some additional peace of mind: 1. AEP – Annual Election Period – This takes place between Oct 15th and Dec 7th – during this period we review your drug plan benefits and what changes will be made for the following year. You can choose to stay with what you have or switch to a different plan if it would cover your medications better. Any change would start on Jan 1st of the following year. I meet or speak to each of my clients and do a complete review annually to make sure the plan they’re on is still the best suited for them. 2. California Birthday Rule – This is the exception that can be made when switching between supplement plans to save on cost. So each your during your birthday month you can switch from one like plan to another (or downgrade) without going through any underwriting. i.e. You could move from a G plan with Blue Shield to another G plan with a different carrier if it’s to save on cost. Above and beyond all the benefits and description above, the last benefit is ME . If I assist you with your enrollment on any of the above plans I would also become your broker. My commitment to you: As a dedicated Medicare Plan specialist I will be available all year long to service your Medicare needs. I will communicate with you any plan changes as I’m made aware of them. I get paid directly by the insurance companies, so I will never charge you for my services. This is A LOT of information to digest, please feel free to book an appointment in my live calendar via this link: www.calendly.com/simpler whenever you’d like to set aside time with me. As always, feel free to reach out if you have any questions.
Below is my template for members that need to apply for Part B if you already have Part A: ----------------------------------------------------------------------------------------------- Since you’re getting off group coverage, due to a loss of employment or group health coverage, you have 3 options to submit the enrollment request under their Special Enrollment Period. Step #1: You can do one of the following: 1. Apply Online: secure.ssa.gov/mpboa/medicare-part-b-online-application/ . In order to complete this process, your will need the following information: o Medicare number o Current address and phone number o Valid email address o Documentation verifying Group Health Plan coverage through yours/spouse employment IMPORTANT: o You will need to digitally sign the form to complete the application. o Within minutes of submitting the form an email will be sent from [email protected] requiring you to complete the process o If you do not receive the confirmation email within a few minutes of submitting the email address - check the Junk/spam folder (THE SIGNATURE IS NOT COMPLETE AND THE APPLICATION WILL NOT BE PROCESSED UNTIL THEY COMPLETE THE INSTRUCTIONS IN THE EMAIL) 2. FAX forms CMS-40B and CMS-L564 to your local social security office 3. Mail forms to local Social Security field office (see link above) Once you have both Part A & Part B – we will then need to select a secondary plan. *As a reminder:* Part A is at no cost and covers Hospitalization (anything in-patient) Part B starts at $164.90/month and would cover Doctor visits (anything out-patient). – Attached is the IRMAA chart that reviews your income to determine your Part B & D costs. Step #2 is to select a secondary plan to fill in the gaps of Original Medicare, so this is what we spoke about: 1. OPTION 1 - Medicare Advantage Prescription Drug Plan (MAPD – HMO) AFFORDABILITY o This will take over your Medicare and keep you assigned to one group, like St. John’s. The MAPD Plan will include your drug coverage as well. This plan has $0 premium with low (to no) co-pays associated with treatments but will also throw in a bunch of extras, such as gym membership, Acupuncture, Vision, transportation, and even some over-the-counter benefit. o Attached is a sample of the Scan plan accepted at St. John’s and Dr. McGrath. 1. OPTION 2 – Medicare Supplement plus Prescription Drug Plan FLEXIBILITY o With the Medi-gap, or Medicare supplement, plan option you would keep your Medicare primary and the Medi-Gap will cover the gaps (including the giant 20% gap). This option has NO Medical Group, so you have the freedom to see any doctor and any specialist so long as they accept Medicare. In fact, it would be accepted nationwide. Based on your area and age, here is what I would recommend: Blue Shield Plan G Extra - Monthly premium is $135/month (this includes a $25/month discount for the first year) The rate increases after 12 months and will have a slight increase annually based on your age. There is only one annual deductible of $226 (in 2023) after which the Blue Shield Plan will cover you for all Medicare covered costs. Extra Benefits include:
Fitness through SilverSneakers – www.silversneakers.com to locate a facility that is part of the program Teledoc services at $0 co-pay $100 quarterly benefit to use for Over-the-Counter items through their catalogue (www.blueshieldca.com/medicareotc) Vision discounts through VSP Vision. See attached Benefits. Hearing benefits (see the benefit summary attached). Foreign Travel Emergency coverage (limited) Blue Shield Plan G – without the extras would cost $121/month o Drug Plan would be separate coverage. The average premium on drug plan is around $30/month; however, once you have updated your medications list, we would get a more specific quote for your needs. Pros & Cons of Option #1: The major benefit is of course the monthly premium. Also, your care is coordinated with one group and one medical record system. This plan also throws in a bunch of added benefits. The major downfall is mainly that you are limited to just 1 medical group and would need to request referrals and wait on authorizations to see specialists. You would have emergency coverage out-of-area (including outside of CA), but non-emergency wouldn’t be covered. Pros & Cons of Option #2: The major benefit is having the freedom to choose whichever doctor, in any network, without having to wait for a referral. So you can see a primary doctor in Santa Monica, specialist in Los Angeles, and even get second opinions from a Dr in San Francisco and you’re still covered! You also have coverage nationwide. Your costs are also limited to your monthly premium and annual deductible, so you have predictable medical expenses. The negative about this option is obviously the higher monthly cost and increase in annual premium. There are 2 important periods I also wanted to mention to give you some additional peace of mind: 1. AEP – Annual Election Period – This takes place between Oct 15th and Dec 7th – during this period we review your drug plan benefits and what changes will be made for the following year. You can choose to stay with what you have or switch to a different plan if it would cover your medications better. Any change would start on Jan 1st of the following year. I meet or speak to each of my clients and do a complete review annually to make sure the plan they’re on is still the best suited for them. 2. California Birthday Rule – This is the exception that can be made when switching between supplement plans to save on cost. So each your during your birthday month you can switch from one like plan to another (or downgrade) without going through any underwriting. i.e. You could move from a G plan with Blue Shield to another G plan with a different carrier if it’s to save on cost. Above and beyond all the benefits and description above, the last benefit is ME . If I assist you with your enrollment, I also become your broker. My commitment to you: As a dedicated Medicare Plan specialist I will be available all year long to service your Medicare needs. I will communicate with you any plan changes as I’m made aware of them. I get paid directly by the insurance companies, so I will never charge you for my services. This is A LOT of information to digest, please feel free to book an appointment in my live calendar via this link: www.calendly.com/simpler whenever you’d like to set aside time with me. As always, feel free to reach out if you have any questions, I’m happy to help!
Below is my template for members that need to apply for Part A and DELAY Part B: ----------------------------------------------------------------------------------------------- As we discussed, since you are already on an employer plan, you do not need to take Medicare Part B when you turn 65. It would be best to apply for Medicare Part A ONLY and elect to delay Part B. So here’s my brief step-by-step; Also call Social Security for any assistance. Step #1 Apply for Medicare Part A: 1. Since your birthday is in August you will be able to apply for Medicare benefits beginning in May through the end of November 2023 to get this done. 2. You should enroll in Medicare Part A and DELAY Medicare Part B: o Online at https://www.ssa.gov/benefits/medicare/ (you will have to create an account with Social Security) or o By calling Social Security at 1-800-772-1213, Monday through Friday, from 7AM to 7PM. o When you get to the questions if you want to Apply for Part B Benefits, make sure to answer NO. 3. Keep in mind that you do not need to apply for Social Security benefits at the same time, you can choose to delay them until you’re ready. *As a reminder:* Part A is at no cost and covers Hospitalization (anything in-patient). Your group plan will remain primary. Step #2 Once you get off your employer plan you can then enroll in Part B with proof of creditable coverage. Attached are the 2 forms you would need: 1. CMS-40B – This is the form you would use to apply for Part B 2. CMS-L564E – This is the form your employer need to complete to show proof that you’ve had group coverage. Please feel free to reach out if you have any questions.
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