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Top 10 Medicare Questions & Misunderstandings

Top 10 Medicare Questions & Misunderstandings

"A smart man makes a mistake, learns from it, and never makes that mistake again. But a wise man finds a smart man and learns from him how to avoid the mistake altogether."

by Roy H. Williams

We are all bound to make mistakes. Let us be your "smart man" by giving you the opportunity to learn from others.

The most common question is: "Why?" Maybe you don't agree with the answer and you'd like to understand the reasoning behind it. Just when you think you understand Medicare, your world is turned upside down to hear about an exception to the rule. Our helpful hints will make you an efficient, knowledgeable superstar.​

Top 10 Medicare Questions & Misunderstandings

1. Is it an IEP or ICEP?

  • Per the CMS guidelines 30.2 - Initial Coverage Election Period (ICEP)
    • The ICEP is the period during which an individual newly eligible for Medicare Advantage may make an initial enrollment request to enroll in an MA plan. This period begins three months immediately before the individual's first entitlement to both Medicare Part A and Part B and ends on the later of:
      • The last day of the month preceding entitlement to both Part A and Part B, or;
    • ​The last day of the individual's Part B initial enrollment period.
  • ​The Initial Enrollment Period for Part B
    • The seven (7) month period that begins 3 months before the month an individual meets the eligibility requirements for Part B, and ends 3 months after the month of eligibility. See 42 CFR 407.14 for additional information.
  • ​Special circumstances:
    • If someone's Part A effective date is more than three months apart from their Part B effective date, the individual must apply for an Advantage plan with the same effective date as when their Part B became effective.
    • For example, if the Part A effective date was 1/1/15, and their Part B is now effective 2/1/16, they can only use the ICEP election for an Advantage plan effective 2/1/16. If they use the ICEP election for a 3/1/16 effective date, the application will be denied because it is outside of the eligibility window.
  • ​Prescription Drug Plan enrollment:
    • The individual was automatically enrolled in Part A when they turned 65. They continued to work a few years and are now retiring and enrolling into Part B. The Prescription Drug Plan IEP goes off the Part A. In this case, the IEP has expired.
    • However, you can use the Special Enrollment Period of losing employer coverage to give the individual 63 days to enroll into a Part D plan.

2. The agent issued a policy, but the client changed their mind and wants something different. What can be done?

  • Medigap: You may switch plans as long as you are within your 6 month enrollment window, even if the first application was processed. However, the client must call to cancel the unwanted policy.
  • Medicare Advantage/Prescription Drug Plan: You have a one-time ICEP. If CMS approved and/or processed the application most times you cannot switch plans unless you have a Special Enrollment Period or wait until the Annual Enrollment Period.

3. Do I need to enroll into Part A and Part B if I'm covered by Group Employer coverage?

  • Medicare is primary if your Group Employer coverage applies to less than 20 employees. If that is the case, then yes you would need to enroll into Medicare Part A and B to avoid penalty and gaps in coverage.
  • If you have over 20 employees then Medicare is secondary and Part B can be declined when you turn 65. You may re-enroll into Part B using a special enrollment period when you lose your Group coverage.
  • Always contact your Benefits Administrator to make sure you have "credible coverage" and for guidance on your specific enrollment situation.
  • Please review "Your Guide to Who Pays First" available on our website under the Medicare Tools page.

4. How will "blank" be covered under this policy?

  • You can find the Summary of Benefits and Evidence of Coverage for each carrier and all their plans on our website 24/7.
    • To research a specific coverage, pull up the Evidence of Coverage in PDF format. This gives you the ability to use the search tool by hitting "Control" and "F" on your keyboard. Simply type in the coverage you are looking for and it will find the details for you. Continue to hit "Enter" to find anywhere this coverage is mentioned in the EOC for that specific plan.
    • Helpful hint: Simplify your search using only a keyword for better results.
    • This feature can be used on any PDF document.

5. If a beneficiary is dual eligible, must I place them on a Special Needs Plan?

  • A SNP offers your client additional coverages that are sometimes not offered by Original Medicare, Medicaid and MA-PD.
    • Dentures, hearing aids, transportation, food assistance, etc
  • Do not lose the sale if the client's providers are not in-network. You can sign them up for a MA-PD where their providers are in-network.If they qualify for full Medical Assistance, the carrier will pay for their portion and the provider submits the co-pay amount to Medicaid.
  • Helpful hint: Medicaid never pays first.

6. What topics can I discuss on a one-on-one appointment versus a group meeting?

  • One-on-one appointment: you may discuss anything listed on the scope of appointment.
  • Group meeting: You may discuss other health related topics. Ex: Long Term Care
  • CMS guidelines require 48 hours before following up on any other line of business for cross selling purposes. However, you may leave materials for the beneficiary to read over at their leisure. URL has created a helpful document for you to gather information on cross selling opportunities while visiting with your clients.

7. What Medigap Plan letters can I sell during a guarantee issue right situation outside their initial enrollment?

  • You have the right to buy medigap plan A, B, C, F, K, or L that's sold by any insurance company in your state. Some carriers offer additional plan letters per their underwriting guidelines. Ex: Plan N
  • Please note these pay different commissions than your initial enrollment period
  • You can find further explanation on our quick reference guide posted under the Medicare Tools page on our website.

8. I have a Medicare Supplement plan and I'm moving to a different state. Does this give me a guarantee issue to buy a different Medicare Supplement plan?

  • Unfortunately, this does not give them a GI since the Medicare Supplement plan travels with them and they can use it at any doctor that accepts Medicare Assignment. Once you move, notify your insurance company as you may get rated up or down.

9. How do I narrow down which Medicare Supplement carrier to review with my client when the premiums are so close in price?

  • Rate history: Once you run the quote, on the left-hand side you will see Market Analytics, check this box to review the companies rate history.
  • Customer service: As an agent, you have the inside scoop on which carriers provide you with the best service. Be sure to relay that personal experience to the potential client.

10. What is the difference between PACE and PACENET?

  • PACE: pays the premium only to participating plans up to $39.45
  • PACENET: cardholders will pay $39.35 premium at the pharmacy each month. If you do not pick up prescriptions each month or the cost of the medication is less than the premium owed, the premium will continue to roll over month to month.
  • PACE/PACENET are "creditable coverage" and provides coverage during the donut hole/coverage gap.
  • PACE/PACENET have different maximum income limits to qualify.

The Health Insurance market will be forever changing. The biggest advice that we can give you is to use your resources. Do not assume what "makes sense" is correct. Please ask for help.It is easier to find an answer to a hard question than it is to fix an error on an application.

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Monday, 15 April 2024