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Raleigh, NC 27615

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Medicare is a medical insurance plan offered by the federal government to people who are 65 years of age and older; for some disabled people who are younger than 65; and, for anyone who has End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).  Medicare is administered by the Centers for Medicare and Medicaid Services, (CMS) and is the nation's largest health insurance program, covering nearly 40 million Americans.

Medicare is made up of two main parts:


Part A (Hospital Insurance)

This part is usually without cost to the insured, who qualifies by working and paying into Medicare for at least 10 years during their career, or though a spouse who qualifies.

Part B (Medical Insurance-or doctor coverage)

This part carries a cost which is typically deducted from the insured's Social Security Benefits, but can be billed in quarterly payments with some restrictions.

There is a supplemental part that some people choose to add to their A & B Coverage:

Part D (prescription drug benefit)

This government regulated part is electively purchased directly from a private insurance company at a cost to the insured, since the government plans, A & B, do not cover prescription drug costs.

There are other private Medicare substitution options available in some locations that combine parts A, B, and sometimes D into a single plan that is underwritten and administered by private insurance companies, but is monitored and highly regulated by CMS.

Part C (Medicare Advantage Plans)

Availability of these plans vary widely from county to county, and they range from no cost to low costs premiums, and typically require utilization of a defined network of doctors to receive benefits, and include different co-pays for each service. Qualification for Part C requires previous enrollment in Parts A & B.  Medicare Advantage plans often require little or no underwriting when purchased during the annual Open Enrollment Period during November 15- December 31.

Enrollment in Medicare

When you first qualify for Medicare due to age, you must enroll in Part A (and can choose to enroll in part B), any time during the three months prior to your 65th birthday, the month in which you turn 65, and for the three months after your 65th birthday. This seven month window is your Initial Enrollment Period.  If you choose not to, or fail to enroll in Part B during your Initial Enrollment Period, you can elect to enroll later during one of the General Enrollment Periods, which occurs each year between January 1 and March 31, but you may have to pay a 10% penalty in the form of higher premiums for Part B for late enrollment.  You can also change your Part D plan, or switch between Part C and Parts A & B during this open enrollment period.  Enrollment in Medicare can be made by calling Social Security at 1-800-772-1213 or by visiting any local Social Security Office.

If you are not planning to retire at age 65 or you are still not eligible for Social Security benefits at age 65, you can and should still enroll in Medicare Part A during your Initial Enrollment Period, even if you have ongoing group health coverage.  If you are still working and have a group plan in place, you can delay enrollment in Part B, since you will have an 8 month Special Enrollment Period when you can later enroll in Part B, penalty free, after your group coverage ends, or you leave the company.  When you have group coverage and Medicare at the same time, the group coverage is considered primary and Medicare becomes the secondary insurance.

Medicare Benefits


It is important to understand that Medicare does not fully cover your medical expenses.  While Congress is regularly making changes to Medicare benefits, the result is that there are deductibles and co-insurance on all services you receive that place a lot of the cost of doctor and hospital expense on you, the insured.  These limitations in what Medicare pays could cost you thousands of dollars out-of-pocket in the event of a hospital stay or some expensive medical procedure.  Therefore, many people privately seek supplemental insurance to add to their Medicare benefits, often called Med-supp or Medi-gap coverage.  Depending upon how much premium you are willing to pay, you could get a Med-supp plan that will cover all of the gaps in Medicare coverage so that you will not have to pay any out-of-pocket expense. Even so, Medicare Parts A & B do not provide payment for prescription drugs, so additional prescription drug plans can be purchased individually and usually carry tiered co-pays for each drug filled.

While Medicare is a health insurance plan provided by the government, it is not a long term care policy, even though it has limited benefits for nursing home care, or in some cases, home health care.  Medicare will only pay for approved skilled nursing care for 20 days in full and then only for a maximum of 100 days, with a large daily co-pay required for days 21-100, and subject to the following conditions:

  • Nursing home stay MUST be preceded with at least a 3 day hospital stay within the previous 30 days
  • Patient must be recovering or in an improving level of health or Medicare coverage for nursing care will end, i.e. Medicare will not cover convalescent care but only re-habilitation received in a nursing center.
  • Facility must be Medicare approved.

Medicare Covered Expense


All claims you make under Medicare are subject to the scrutiny and approval of each charge as to whether or not it is a Medicare covered expense. In addition to excluding certain services and charges as not being covered by Medicare, CMS has a detailed dollar amount it will pay for each and every covered service, device, procedure, or other medical treatment.  Doctors and facilities usually agree to take this Medicare approved amount as payment in full for their services, or they typically will choose not take patients who are on Medicare.  Occasionally, however, you could receive services and treatment where a non-Medicare doctor or facility will render services for the Medicare approved amount, but will also bill you or your supplemental insurance for the excess amount of their normal charge.  Since not all supplemental plans cover this excess amount, it is important to ask your medical provider if they accept Medicare approved charges as payment in full, or consider purchasing a Med-Supp plan that will pay all excess charges.











Medicare Supplement Insurance


The supplemental insurance that fills the gaps in what Medicare covers is called Med-supp, or Medi-gap insurance because it will pay some amount of the deductibles and co-insurances Medicare leaves for the insured, depending upon the supplemental plan chosen and the amount of premium an insured is willing to pay.  The level of premiums for each plan will reflect the amount of Medicare "gap" that is filled, but in this case, Plan F, the most comprehensive Med-supp plan that is available, will completely plug all Medicare gaps.  What this means is that for those senior who can afford the monthly premium, with this plan an insured can know, with certainty, that all of their hospital and doctor expenses will be fully covered.

All of these supplemental plans are regulated and controlled by the government and are identified with a letter name from Plan A to Plan N.  There are presently only about 11 plans available, but this list changes periodically.  The benefits of each plan with the same letter name will include EXACTLY the same benefits no matter which insurance carrier is offering it.  This strict government regulation simplifies shopping for Med-supp plans, since, once you decide on a plan, you simply need to compare prices, because all of the other details will be the same.  While the benefits within each plan are required to be the same no matter which company is providing them, the pricing can vary from company to company and it is NOT required that every company sell every plan, and often companies will only offer a limited number of the plans that the government has approved.

The current configuration of Med-supp plans do not include any prescription drug benefits, (unless you still have one of the old plans that once did) so in order to completely fill all the gaps in your exposure to potential medical expense, a separate stand alone Part D (prescription drug) plan must be purchased in addition to a Med-supp plan.

Some post-retirement company health plans are designed specifically for the business that is offering their retired employees that benefit, and may contain some combination of benefits that fall outside of this government regulated structure of supplemental plans.  Many times these company plans are very rich and if they are offered at no cost, they give the retiree a great benefit for their years of service to that company.  If you are eligible for a company based retirement health plan, but you must pay premium to continue to receive it, it would be prudent to have a knowledgeable health insurance professional review the cost effectiveness of your company plan compared to what is available individually through the use of Medicare supplemental insurance.

Finding a good supplemental health plan to work with your Medicare benefits is important, and getting qualified help is essential.  Let one of the agents at Blue Atlantic Insurance Group assist you through this confusing process by showing you some of the best companies with the best pricing for Med-supp plans currently available.

Medicare Advantage Plans


When premium cost is an issue, if it is available in your area, a Med Advantage plan may be a good solution. There are limitations on when you can enroll, and even more restrictions on how or when you can switch from other types of Medicare or make changes in your prescription and Med-supp plans.  Contact Blue Atlantic Insurance Group and we will put one of our Med Advantage experts in touch with you to discuss your options.

Prescription Drug Plans


Medicare Part D is often bundled with Med Advantage plans, but must be purchased separately with Med-supp coverage or added to Med Advantage plans that do not include it as part of the coverage.  This extra premium is usually affordable for the level of benefit most seniors receive and will help to control prescription drug cost in a given year.

About the Donut Hole

Buried in every individual prescription drug plan is another "gap" in coverage which is defined as a dollar amount of prescription drug expense after which there is no coverage until you then exceed another higher amount, after which you once again get full coverage.  These figures changes from year to year, but if you have nearly $3,000 in prescription drug expenses, (not the sum of your co pays but the accumulation of the full reimbursed cost of each prescription filled), you will likely reach this "donut hole" and you will have to pay about $1700 in out-of-pocket prescription drug expenses before you emerge from the other side of the donut hole. Presently, there is no coverage allowed in private plans for this donut hole gap, but some custom company retirement plans may have full coverage that pays benefits and eliminates the donut hole.






Why You Should Call Blue Atlantic Insurance Group about your Medicare Benefits

Whether you are about to enroll in Medicare for the first time, have been on Medicare for a number of years, are wondering if you need Medicare supplemental insurance, prescription drug insurance, or a Med Advantage plan; or, you want to review supplemental insurance you already have, don't go it alone.  You can find lots of information on the internet, but unless you know how to interpret it, it will only confuse you and make you less certain that you are getting the maximum benefits which you are entitled to receive.  If your present insurance agent is not an expert in Medicare, you may get well meaning, but bad advice.  Many insurance agents who represent themselves as Medicare specialists, only represent one insurance company and will recommend their company products, whether they suit your needs and budget, or not.

Here at Blue Atlantic Insurance Group, we search the market to find the best companies with the best rates to offer our clients.  Because of this independent status, we are not loyal to a few insurance carriers; we are loyal to YOU, our client.  Meet with one of our professional, knowledgeable agents and ask them all  your Medicare questions, and you will find, as all of our other clients already do, that at Blue Atlantic Insurance Group, we are not just insurance experts; we are your neighbors and friends.

We are Blue Atlantic Insurance Group.

Call us Today! 919-612-7450