2020’s out-of-pocket limit for Medigap Plan K: $5,880.
The 2019 out-of-pocket limit for Medicare Supplement Plan K is $5,560.
2020’s out-of-pocket limit for Medigap Plan L: $2,940.
The 2019 out-of-pocket limit for Medicare Supplement Plan L is: $2,780.
How Does This Coinsurance Apply?
You don’t owe coinsurance on the full cost of medical services with Plan K or Plan L.
Only the portion of your out-of-pocket costs that are not covered by Medicare Part A and Part B is shared with your Medicare Supplement plan.
With Medicare Supplement Plan K, you’re responsible for 50 percent coinsurance. With Medicare Supplement Plan K, you’re responsible for 25 percent coinsurance.
The out-of-pocket limits for these plans change annually. Changes are based on inflation estimates from the Centers for Medicare and Medicaid Services (CMS). Your coinsurance percentage on these plans does not change.
Medicare Coverage Without Coinsurance
While other Medicare Supplement plans don’t charge coinsurance, they typically have more expensive monthly premiums.
If you’re considering Medicare Supplement Plan K or Plan L, you like to actively manage your expenses. You may also enjoy Medicare Supplement Plan N. Plan N has copayments the range from $20 to $50 per medical visit, but no coinsurance.
Medicare Advantage plans are private Medicare replacements with their own fee structures and doctor networks. These plans have an annual out-of-pocket limit of their own.
The Medicare Part B premium cost of $135.50 per month will increase to $144.60 per month in 2020. That’s a nearly 7-percent increase if you’re paying the standard premium.
As always, if your income decreases, your premium may even be reduced. Things get a little more complicated if you fall under one of the following special situations:
Is Your Part B Premium Automatically Deducted from Your Social Security? By law, Medicare cannot cause you to receive less in Social Security benefits than you did last year. However, Social Security benefits are expected to increase slightly in 2020, and so your increased Social Security payments will likely go towards your Part B premium.
Are You Receiving Aid to Pay for Part B? You’ll have to check with your aid provider if your Medicare Part B premium is paid for with government or non-profit help, but the new year shouldn’t cause a significant change in your benefits.
Is Your Medicare Part B Premium More Than $144.60 Per Month? The income-related monthly adjustment amount (or IRMAA) requires high earners to pay more than the standard Medicare Part B premium cost of $144.60 per month.
High-income surcharges are based on your tax return from two years ago. Taxpayers who reported income of over $87,000 (or $174,000 if filing jointly) in 2018 may see premium increases of $57.80 or more per month.
The IRMAA cutoff began at a much higher level until 2018. Over the past three years, the surcharge has been applied to more people.
If your 2018 tax return no longer reflects your current living situation, you can contact Social Security to ask for a lower premium.
Are You Enrolled in Medicare Advantage (Part C)? Although each Medicare Advantage plan is different, the government believes that monthly Medicare Advantage premiums will drop to $23 per month in 2020.
Between 2011 and 2018, there was an additional Medicare holiday to consider. From January 1 through February 14, the Medicare Advantage Disenrollment Period (MADP) gave you one more chance to leave your Medicare Advantage (Part C) plan.
The Medicare Advantage Disenrollment Period will NOT return after 2018.
You couldn’t join Part C via Original Medicare during that time.
When you left a Medicare Advantage plan during your Disenrollment Period, your Part C plan would last through the end of the month. For instance: if you requested to leave your Medicare Advantage plan on January 27, your last day on the plan would be January 31.
Extra Part A & B Coverage After Your MADP: You could add a Medicare Supplement plan (which pays your out-of-pocket costs) to your Original Medicare if you used the Medicare Advantage Disenrollment Period.
Standalone Medicare Part D After Your MADP: If you used the Disenrollment Period to leave a Medicare Advantage plan, then you could join a standalone Medicare Part D RX drug plan during this time (through February 14). This was available to you even if your coverage didn’t include Part D before you left.
At the Hospital: If you end up at the hospital without health insurance, doctors and medical professionals are required to treat you no matter what. They won’t deny you as a patient in need. This is because the Emergency Medical Treatment And Labor Act or EMTALA “[ensures] that any individual with an emergency medical condition, regardless of the individual’s insurance coverage, is not denied essential lifesaving services.”
However, if you don’t have health insurance, you’ll still pay medical bills for services. These treatment costs increase exponentially without coverage.
Who Pays for Medical Bills: Depending on your plan, your health insurance pays for a portion of medical services, including doctor’s visits, prescription drugs, and emergency room trips. You’ll pay the rest of the amount in the form of a copayment or coinsurance. However, without coverage, you’ll be paying the entire bill from the hospital. Each hospital sets their own prices for different services.
Negotiate Your Hospital Bills: Hospitals may offer uninsured individuals discount plans so you can pay in specific periods of time. Installments will likely be split up over the course of the year (one bill each month), so you can regularly pay off your treatment costs.
You can also search for hospital programs called “charity care” that assist you financially. If you qualify for this service, the amount owed will be adjusted to your ability. Even applying for charity care may halt any bill collectors.
Visit an Urgent Care Center: If you’re not experiencing a true emergency, you should see if an urgent care center is nearby. Medical professionals at urgent care can help you treat your illness or injury. These services can cost less than a trip to the ER, although you may have to pay in advance if you don’t have health insurance.
Covering Your Visit With Health Insurance: While the number of people with health insurance has increased in recent years, some people continue to live without health coverage. The individual mandate was passed as a part of the Affordable Care Act, requiring Americans to sign up for health insurance or pay a tax penalty. This financial incentive led many to compare and choose a health plan that best suited their needs.
Signing up for health insurance during the Open Enrollment Period helps you avoid these scary scenarios – you’ll worry less about financial matters if you find yourself in the ER when you’re covered.
Hospice care gives comprehensive end-of-life support to those who have 6 months or less to live. Hospice providers focus on making you comfortable during a terminal illness.
Hospice is generally thought of as an inpatient service – whether in a dedicated facility or part of a hospital – although in-home hospice care is common. Hospice providers may help you, your family, and your caregiver.
Private Health Insurance: Most health insurance plans – including Obamacare and employer plans – will cover hospice care nearly in full. Your hospice stay will likely come with a dedicated caregiver, any medical equipment you need, and emotional support. When in hospice, your plan can pay for non-medical benefits like food or music therapy.
Your health insurance may want a doctor to verify that your condition is terminal before agreeing to pay for hospice. Your health insurance may ask you to stop receiving curative treatments for your medical condition.
Medicare and Hospices: Medicare accounts for most U.S. hospice spending. Your mandatory Medicare Part A covers most hospice costs.
All Medicare Supplement plans cover your copayments for hospice pain and symptom management prescriptions; and will also take care of your 5 percent copayment for inpatient respite care, which gives time off for you and your primary caregiver if you’re faced with a life-limiting disease.
Since Medicare Part A covers hospices, optional Medicare Advantage plans (which replace your Original Medicare) take care of hospices as well.
Short-Term Health Insurance: These plans rarely interact with hospice care, since temporary insurance plans may not accept new members with chronic or terminal illnesses. It’s possible that you could qualify for hospice care while on short-term insurance if you’re in a serious accident.
All short-term plans are different. While some plans might not cover hospice care, other plans will treat it like any other benefit. Once you qualify for hospice, a short-term plan could pay for your hospice care in full if you’ve met your deductible and out-of-pocket maximum.
Medicaid: In most states, Medicaid will cover hospice care almost in full. Medicaid’s hospice benefits are similar to Medicare.
TRICARE and VA : Veterans’ programs pay for hospice care in the United States and its territories.
Other Insurance Products: Many independent insurance agents sell long-term care insurance, a type of benefit that pays for assisted living needs. Some life insurance plans also include a living benefit rider, which gives you an advance life insurance payment.
Walking aids, such as walkers, canes, scooters, and wheelchairs, help you perform daily tasks if you have a mobility impairment. Doctors can prescribe walking equipment if you need extra assistance to move around.
Today, suppliers offer a wide variety of walking aids to alleviate your pain or adapt to your specific needs. Some devices can also serve as rehabilitative equipment that can strengthen your ability to move unassisted.
Depending on the walking device, prices can vary. Out-of-pocket expenses can range anywhere from $20 to $5,000 or more. Once you are prescribed equipment at your doctor’s office, urgent care, or hospital, your health plan can help cover costs so you can quickly get around.
Health Insurance and Walking Aids
A prescribed walking device may be covered depending on your health plan as a form of durable medical equipment, or DME. Examples of DME include:
In order for your health insurer to cover costs for a walking aid, you will need a doctor’s prescription. That prescription helps your insurer verify your walking aid is “medically necessary”, since health insurers can’t pay for cosmetic items. If your plan does provide DME coverage, you’ll only pay for a small portion for the equipment, also known as your copayment or coinsurance.
Before purchasing medical devices, check that your equipment supplier participates in your health insurance plan. If they are in-network, you can save on out-of-pocket costs. Depending on your illness or injury, you may be able to rent medical supplies. Otherwise, you’ll be asked to purchase your equipment on your own.
Because health insurance companies aren’t required to cover certain medical supplies under the Affordable Care Act, costs vary from case to case. You can look at your expected copay or coinsurance and decide whether or not to use your insurance. However if you choose to purchase a walking device without going through your insurer, it’s up to you to pay for expenses.
Depending on your health status and ability to walk, your doctor can recommend different walking aids. He or she will assess your needs and can provide you with resources to help you adjust to your new tools. By learning more about financial costs, you can quickly understand your share of costs as you plan for the future.
Accountable Care Organizations, or ACOs, are programs that work to provide higher quality care to Medicare enrollees. They consolidate all of the roles that treat patients – health insurance providers, doctors, and hospitals – to focus on primary care.
There are many benefits for patients who participate in Accountable Care Organizations. Firstly, your Medicare benefits will stay the same. Your payments won’t increase and you’ll receive any and all treatments that you require. You can also choose your preferred physician or hospital that accepts Medicare. ACOs allow you, the patient, to continue making important decisions regarding your health.
As individuals become older, they often require more care due to the increased risk for certain illnesses. By collaboratively keeping an eye on patients, health professionals in ACOs can detect and treat diseases earlier, leading to a healthier population.
ACOs are assigned Medicare enrollees at specific locations throughout the United States. There are a few criteria that patients with Medicare have to meet to participate in an ACO:
You must be enrolled in Medicare,
You must have a primary care service with a physician at an ACO,
You must live in the United States or U.S. territories and possessions.
Once you have received at least one primary care service within the ACO, you will be assigned as a participating beneficiary.
How ACOs Have Improved the Healthcare System
Former Secretary of the Department of Health and Human Services, Kathleen Sebelius, has stated that “Accountable Care Organizations will improve coordination and communication among doctors and hospitals, improve the quality of the care their patients receive, and help lower costs.” Since 2010, ACOs have continued to seek the best treatments for Medicare enrollees to avoid medical delays.
If people with Medicare routinely visit a primary care physician, they can avoid costly trips to the emergency room – this is the thought behind the implementation of ACOs. ACOs have also saved money for the Medicare program. By preventing accidents and other illnesses, ACOs have changed the delivery of healthcare to individuals with Medicare.
ACOs were created as a senior-focused part of the Affordable Care Act, (or “Obamacare”). They work by taking responsibility for Medicare patients’ cost and quality of care experience.
Accountable Care Organizations use a “Shared Saving Program” as their payment model to promote efficiency within the healthcare system. Payments to ACOs are directly related to quality, with the overall goal to reduce costs for the government.
ACOs track their performance through data to measure the providers’ success with patients. By helping Medicare enrollees maintain their health, they can share the savings from Medicare. The bottom line is: the better care ACOs provide for patients, the more money they make.
ACO Locations in the United States
As of January 2018, there are 561 Accountable Care Organizations participating in the Shared Saving Program. This number has continued to increase since the ACO’s beginnings in 2010, integrating in the healthcare system to operate smoothly. There are ACOs in almost every state, including the District of Columbia.
The Future of ACOs
Passed in February 2018, the CHRONIC Care Act will increase government support for ACOs. Programs will now be able to incentivize chronically ill patients to seek primary care by offering up to $20 per visit. This means you’ll be paid to seek care from physicians.
Since 2012, the number of individuals assigned to ACOs has more than tripled. Healthcare professionals and government officials have noted how this improved efficiency in ACOs. ACOs have sustainably helped individuals with disease management and preventive care, while saving costs on long-term medical expenses.
If you are not a U.S. citizen, you may be eligible for Medicaid. But you have to meet certain requirements before receiving any benefits. First, you must be a qualified immigrant. Second, you will have to wait five years before you can apply. Exceptions exist as well.
Immigrant paroled into the U.S. for at least one year,
Immigrant granted conditional entry into the U.S. before 1980,
Victim of trafficking, including spouses, children, siblings, or parents,
Battered non-citizen, including spouses, children, or parents, or
Veteran and active member of the military, including spouses and children
The Five-Year Waiting Period If you fit the federal definition of qualified, you will have to wait five years in order to apply for and receive coverage from Medicaid. However, some groups are exempt.
Among those who wait are lawful permanent residents, immigrants paroled into the U.S. for at least a year and immigrants granted conditional entry before 1980.
Among those who do not have to wait are asylees, refugees, Cuban/Haitian entrants, victims of tracking, battered noncitizens, and veterans and active members of the military.
Undocumented immigrants are not eligible to enroll in Medicaid.
Meeting Medicaid Requirements
If you are a qualified immigrant, you must also meet your state’s eligibility requirements on income and household size for Medicaid. Depending on the state you live in, you can follow the income guideline, which includes the number of individuals in your family/household.
Taking the Next Steps
It’s important to double check your immigration status as well as your qualifications to see if you are eligible for Medicaid. Researching the basics on Medicaid can help you in the process of finding coverage as a non-citizen. Plans under Medicaid can vary depending on the state but most should cover certain essential services.
You can apply for Medicaid at any point of the year. If you meet the income and residency requirements for your state, you may be able to receive coverage. Medicaid is extraordinarily helpful if you are eligible to enroll. Since 2013, there has been an 18.6 percent increase in Medicaid enrollees and this number is only increasing.
Yes, college students can receive health insurance and are encouraged by their schools to be enrolled in a plan. Being insured will bring you relief during your time at college.
Searching on your school’s health services website will lead you to specific requirements and policies regarding insurance for students. Your location and ability to pay for insurance can both play important roles when choosing a plan.
Depending on your personal and financial circumstances, here are a few health insurance options for incoming or current college students:
Enroll in your university’s comprehensive student health plan.
Many schools offer health plans for students to enroll in, at lower prices than you could get on your own. Some plans, but not all, come with dental and vision coverage. For students receiving financial aid, monthly premium costs may be subsidized.
Apply for state or federal programs, such as Medicaid.
Older or independent students may qualify for programs like Medicaid that are funded by the government. It may be difficult to find coverage through these programs, as they are often limited to a select group of individuals.
Consider short-term health insurance.
Short-term health insurance can be a surprisingly affordable option for students who need insurance coverage on a temporary basis. These plans can last anywhere from 30 to to 90 days. For students in-between school plans, short-term health insurance can be the perfect fit.
Students should look into a health insurance plan that meets their individual needs, as well as their college’s standards, with a close eye. By enrolling in a plan, you’ll enjoy your time in school without worrying about whether or not you’re covered.
It is crucial that you understand what those conditions and time periods are to ensure that your stay in a SNF is Medicare-covered. You’ll also want to know what costs you may still incur as a Medicare beneficiary that needs care offered by a SNF.
What Services Does Medicare Part A Cover in a Skilled Nursing Facility?
Medicare covers most aspects of a stay in a skilled nursing facility if you meet the above criteria. A list of Medicare-covered services includes:
Skilled nursing care
A semi-private room
Physical and/or occupational therapy
Speech-language pathology services
Medical equipment and supplies
Ambulance transportation, if medically necessary, to the nearest provider of needed services not offered at your SNF.
Supplemental Coverage Makes Skilled Nursing Facility Admissions Much Easier
Important to note: the costs below pertain to someone who has coverage through Medicare Part A only. If you have additional supplemental coverage through a Medigap plan, most plans cover the SNF daily coinsurance amounts that you incur on days 21-100. If you have a Medicare Advantage plan, your coverage and costs may vary from what is offered under traditional Medicare, and you should review your plan’s unique “Summary of Benefits” to determine what coverage it offers.
Medicare Part A Skilled Nursing Facility Coverage Criteria
You are covered by Medicare Part A if your stay in a SNF meets the following conditions:
You are enrolled in Medicare Part A and have days remaining in your “benefit period”. A benefit period begins the day you are admitted to a hospital or a SNF. It ends when you have not received hospital or SNF care for 60 days in a row. After that 60-day period ends, if you were to have to go back to a hospital or SNF, a new benefit period would start,
Your stay in a SNF must be preceded by a qualifying hospital stay (3 or more days as an inpatient), must start within 30 days of leaving the hospital and must be for the same condition(s) for which you were hospitalized,
Your doctor must believe you need the daily skilled care provided by a SNF, and
Your reason for needing skilled care in a SNF must be related to the qualifying hospital stay or be the result of a condition that started while you were hospitalized or getting care in a SNF.
If you meet the above criteria, your stay in a SNF would be Medicare-covered.
What Are Your Costs for a Medicare-Covered Stay in a Skilled Nursing Facility in 2020?
Medicare Part A provides coverage for a Medicare-covered skilled nursing facility stay. However, this does not mean that you are covered at 100% for all costs indefinitely. As with other parts of Medicare and other services, there are some out-of-pocket costs.
For days 1-20 of a Medicare-covered SNF stay, Medicare covers the full amount of the stay with no out-of-pocket costs to the Medicare beneficiary.
After day 20, for days 21-100, you would be responsible for a daily coinsurance amount of $176 per day.
After day 100, there is no Medicare coverage for a SNF and you would be responsible for all costs.
If you have a break in SNF care that lasts 60 days or more, your benefit period would reset. This means that Medicare coverage for SNF benefits is reset, and the maximum coverage available would be 100 days for a new stay in a SNF.
Medicare Part A is the part of Medicare that covers inpatient hospital benefits, skilled nursing facility care, hospice care, and home health care. For most people, there is no premium associated with Medicare Part A, and you are automatically enrolled in Part A upon reaching age 65 or through Medicare disability. For this reason, since there is not a premium for it, there is not typically a justification for cancelling or waiving Part A.
That said, you do have the option of not participating in Medicare Part A if you don’t want to do so. There is no penalty for choosing this as long as you are covered by other coverage, such as coverage through an employer or former employer. However, it is important to note that Medicare and Social Security are connected. So, if you waive Part A, you also cannot participate in Social Security, and if you have already received Social Security benefits, you will have to re-pay any benefits you have already received.
Who May Want to Consider Cancelling or Waiving Medicare Part A?
There are some unique situations which may cause you to consider cancelling or waiving Medicare Part A, including:
You are not entitled to premium-free Part A – If you have not qualified for premium-free Part A through you or your spouse’s payroll taxes (40 quarters total), you will have to pay a premium for Medicare Part A. In this case, if you are covered by other insurance, you may elect to delay or waive Part A. It is important to note, however, that doing so may cause a delay and late enrollment penalty at a later time when you do enroll in Part A.
You have a high-deductible health plan and an Health Savings Account (HSA) from an employer with more than 20 employees – If you are in a high-deductible health plan and have an HSA, you may elect to delay, cancel or waive Part A. Enrollment into any part of Medicare, including Part A, prohibits you from continuing to contribute to your HSA.
What About Medicare Part B?
Medicare Part B DOES have a premium ($144.60 for 2020, an increase of $9.10 from $135.50 in 2019). Therefore, choosing whether to delay enrollment into Part B is the more pertinent question for most people. Medicare does have late enrollment penalties that apply if you are not currently covered by a credible group health plan, so you should make yourself aware of those penalties before making this decision.
However, if you do have group coverage that is primary to Medicare (more than 20 employees), delaying Medicare Part B may make sense, and you will be exempt from the Medicare late enrollment penalty for Part B as long as you start Part B within 8 months of losing that group coverage.
Health insurance and Medicare plans that you buy on your own usually run on a calendar year schedule – January 1 to December 31. That’s all 365 days.
This is helpful to know when you’re figuring out how much you’ve spent towards your deductible or your out-of-pocket maximum. However, plans don’t have to last for 365 days if you bought them in the middle of the year.
Health insurance and Medicare plans generally make changes to covered benefits, deductibles, co-payments, and monthly premiums at the start of each calendar year.
Keeping and Leaving Health Insurance: When you buy a health insurance plan at the end of the year, make sure that you’re signing up for the correct year. For instance, plans for 2019 will be available at the end of 2018. But even if you purchase a 2019 plan in 2018, that plan won’t start until January 1.
You can also join new health insurance plans each year. Since 2014, insurance companies must cover you if you’re sick, and they can’t charge you extra for being sick.
When Does My Health Insurance Plan End? Technically, your health insurance continues each year if you decide to remain on your plan. Health plans can last for multiple years even if they look different from year to year. For instance, your member ID may remain the same each year.
If You Got Health Insurance in the Middle of the Year: Your plan’s year will still end on December 31. Since you pay for health insurance each month instead of a once per year payment, your cost to stay on the plan will be the same.
However, your plan’s benefits, deductibles and out-of-pocket maximums will be the same as if you had bought your health insurance plan at the beginning of the year. This means that you’ll have less time to use the benefits of your plan. For example, instead of having 12 months to reach a $1,000 deductible, your deductible will reset at the beginning of the new year.
If You Got Health Insurance From Your Employer: If you got health insurance through your workplace, your plan year may be on a different schedule. The plan will not be able to kick you off as an individual, although your employer can change health insurance companies, or you can ask to leave the plan. Changes to employer-sponsored plans will usually take effect on January 1.
If You’re Leaving Your Employer’s Health Plan: You can continue on your employer’s health plan (or your spouse’s health plan, if you’re no longer eligible) using an option called COBRA. With COBRA, you’ll be able to continue the plan on your own for up to 36 months. However, you’ll have to pay the full cost of the plan.
What About Temporary Health Insurance? Also known as short-term health insurance plans, these policies can start any time but only last for a maximum of 90 days. Your ability to renew short-term coverage depends on your health status and your state. These plans cover healthy people in case of emergencies, or a break in their traditional “major medical” health insurance coverage. Temporary health insurance plans do not count as health insurance for Obamacare tax purposes.
What About My Medicare Supplement, Part C, or Part D Plan? Medicare plan years generally keep to the same schedule as health insurance plans for people under the age of 65. However, the guidelines for enrollment and plan renewal are different, depending on what coverage you have. Learn more on our Medicare info webpages.
Your temporary (or “short-term”) health insurance coverage might continue if you’re hospitalized when your plan expires. To find out if it applies to your plan, you’ll want to look for the “continuation of coverage” or “extension of benefits” provision in your plan’s policy.
Finding Your Policy: To find out if your short-term plan allows you to stay covered if you’re in the hospital when it expires, look at your insurance contract (this contract is also known as your plan’s certificate of insurance).
You will receive the contract each time you sign up for or renew your coverage. Search the contract for “total disability”, “continuation of coverage” or “extension of benefits”.
Total Disability: You can’t be expected to perform work while you’re in the hospital. This means that you are considered “totally disabled” for insurance purposes at the time.
What the Provision Means: Since you’re totally disabled in the hospital, benefits that would have otherwise been paid by your short-term insurance plan might still be covered while you’re in the hospital. Coverage typically stops after you leave the hospital, or once a set period of time ends (whichever is sooner).
You will likely still lose coverage once you’re discharged from the hospital. However, a continuation of coverage clause might stop the plan from ending during the middle of your stay.
How to Get Coverage Once Your Short-Term Plan Expires: Your temporary health insurance won’t be renewed if you’re hospitalized when it expires. Even so, there may still be easy coverage available to you. In some states, total disability can qualify you for Medicaid. Qualified patients can apply for and enroll in Medicaid at any time, including from the hospital.
Additionally, if you are rejected from Medicaid, then you may be able to enroll in an Affordable Care Act plan. Normally these plans are only available during certain times of the year.
What Is Short-Term Health Insurance? Temporary health insurance plans have many differences from Obamacare and most other health insurance. You can join a temporary plan at any time. Plans last for a maximum of 90 days (but many insurance carriers allow you to re-apply every 90 days, depending on state regulations). These plans have low monthly costs, and in some cases, high deductibles. You will have to pay a tax penalty if you rely on them for health insurance for more than 90 days, as they don’t guarantee coverage for all of the Affordable Care Act’s essential health benefits. If you’re not familiar with short-term health insurance, learn more to see if this limited plan type is right for you.
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Since 2006, we’ve been a leading search, comparison and recommendation tool for people of all ages who buy their own health insurance.
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To sign up for health insurance using HealthCare.com, you’ll enroll the way you choose – by phone, by web form, or by filling out a form to be contacted later by an insurance agent. For more information, read our guide to buying individual health insurance.
What if I Had Health Insurance for Some Months But not Others?
The penalty will decrease if you had qualifying health insurance in some months. For example, if you only had health insurance from August through December 2017, then your penalty would be reduced by 50 percent – for a minimum of $347.50, depending on your income.
If you went without health insurance for less than 3 months, then you’re “exempt”, meaning that you don’t have to pay a penalty. This Get Out of Jail Free Card doesn’t work if you go without health insurance for 3 months or more. If you spent that much time without health insurance, then you’ll be penalized for missing every month.
How Will I Know How Many Months I Had Health Insurance For?
Your insurance company will mail a 1095 form to your address. This form will tell you which months you were insured.
The form is usually sent to jog your memory. Most people don’t have to send it to the IRS.
Should I Prepare for a 2018 Penalty?
The penalty will be the same for 2018, before ending in 2019.
Your health insurance subsidy is based on your income for the current year. When asked about income, don’t use your information from last year.
Since the year isn’t over yet, this is always an estimate of your annual income. You’ll have to make your best guess as to how much you’ll make in the current year. If you’re having trouble, multiply your monthly income by twelve.
Don’t just put down last year’s income. However, that number could help you figure out what you’ll make this year.
What Is a Health Insurance Premium Subsidy?
You can get a huge discount on monthly premiums when you buy Affordable Care Act insurance on your own. This discount is based on your income. It’s called a premium subsidy, or a premium tax credit.
Premiums are the monthly payments you make to stay on an insurance plan. Subsidies are discount payments to you. In this case, the subsidies go directly to your health insurance plan, so that you pay lower premiums.
Where Do You Enter Your Income for Health Insurance?
To calculate your discount, HealthCare.com will ask for your income. (You may read this as annual household income, modified adjusted gross income, or yearly income – they’re all very similar.)
Your discount will be the same across all plans, even though their monthly premiums are different.
Some “silver” plans may include additional services for people who receive premium subsidies.
Your premium subsidy is processed automatically. You don’t have to do the math or fill out paperwork to get it every month. It’s a popular feature that’s a part of all subsidy-eligible health plans.
What if My Estimated Income Is Wrong?
It’s OK if your estimated income is a little off! When you file taxes next year, you’ll square up with the government.
If you underestimated your income, you’ll have to pay back a portion of the difference. The government calls this a “clawback”. Depending on your actual income, you likely won’t be responsible for paying the full difference.
If you overestimated your income, you’ll receive the subsidy that you didn’t get before.
Where Can I Calculate My Subsidy?
HealthCare.com has you covered. Our tool below will figure out your subsidy in under 2 minutes.
You don’t have to add your children to your existing healthcare plan. However, in most circumstances, it should be easy to keep your children on your existing plan through their 26th birthday.
You Can Always Add Children During An Enrollment Period: Young people can join their parent’s Affordable Care Act-compatible plan until they turn 26 years old. Their parent can add them to new or existing coverage during the annual Open Enrollment Period, or during a Special Enrollment Period.
Those under the age of 26 are eligible to join their parent’s insurance in any circumstance. You can add your child to your plan whether or not they’re in school, or employed, or living at home, or parenting, or married.
Adding A Child To Your Plan: Putting a young person on your health plan is easy to do. Just contact your insurance provider, and have your child’s information at hand. Your premiums will probably increase, but it may be less expensive for your child than if they had bought healthcare on their own.
Other Options Are Available: An independent young person can also explore other healthcare options on their own. If your daughter was not listed as a dependent on your tax return, she could qualify on her own for Medicaid or high Obamacare premium subsidies. There’s also no rule against her getting insurance coverage through her own employer.
A younger child could qualify for state-run child health programs. Joining an existing health insurance plan is not always the best choice for your child.
Medicare Supplement high-deductible Plan F is considered a cheaper alternative to a regular Plan F plan – featuring lower monthly premiums in exchange for having to deal with a higher deductible. This deductible level changes from year to year. For 2018, the Medicare Supplement high-deductible Plan F comes with a deductible of $2,240. This deductible amount changes every year, no matter when you first bought your plan.
The $2,240 deductible is an increase of $40 from 2017. Last year, the deductible level was $2,200. The 2018 deductible limit for high-deductible Plan J is also $2,240.
The 2018 Plan F deductible only applies to the high-deductible versions of each plan. Beneficiaries who are enrolled in a standard Plan F and Plan J do not have a deductible.
Why Did the Deductible Change? Medicare Supplement rules are set by federal regulations. The deductible number for high-deductible Plan F and Plan J rises in accordance with the August Consumer Price Index each year.
Note that all plans of the same type (for instance, each and every Plan A option available on the market) have the exact same deductibles and benefits, no matter which company you buy your plan from.
We present health insurance and Medicare coverage options to our visitors (either plans themselves or third-party websites). We then match users to independent, licensed health insurance agents who will help you finish signing up.
We consider this to be an ad-driven business model, similar to Kayak.com or Trivago in online travel. HealthCare.com may earn revenue for leads, clicks, calls and applications generated, and may be compensated by its advertisers for sponsored products and services.
HealthCare.com allows you to shop across plans, which includes both ACA marketplace and non-marketplace plans. In addition, we also show you coverage options outside of Obamacare, along with coverage options for seniors over age 65.
We understand if you prefer to go to Healthcare.gov or your state’s exchange to buy coverage. Just know that it’s not your only option.
We’re proud of HealthCare.com’s comparison experience, guided flow, timely advice and easy-to-understand definitions. We’re also proud of the breadth of options we can show you, along with our ability to connect you with our online and phone-based insurance partners who can sell you the same plans sold on the exchanges.
In terms of buying from the insurance company directly, you’re not going to get any price advantage. Most insurance companies sell their coverage through third-party sites, so why not shop around on our comparison site if the price is the same everywhere?
We have worked hard to establish relationships with the best data sources around. Rates and plans come from the insurance companies themselves, who have approved the plan inventory we display before we publish them. That said, you’ll need to confirm the final pricing with whichever provider you choose to buy from. Keep in mind that the rates are dependent on the accuracy of the quote information you provide them.
That said, not every type of disability lets you enroll in Medicare. You can only join Medicare due to a disability if you receive payments from the Social Security Disability Insurance (SSDI) program. SSDI has its own requirements for acceptance.
You can enroll in Medicare before the age of 65 if:
If you receive SSDI payments (which you must have received for 24 months);
If you were diagnosed with ALS (you can enroll immediately once you receive your first SSDI payment; OR
If you were diagnosed with end-stage renal disease or ESRD (your enrollment depends on the type of treatment you receive).
Things that won’t make automatically you eligible for Medicare before 65:
If you deal with any other kind of serious health problem;
If you receive worker’s compensation; OR
If you have a diagnosis for another disability not included in the previous section.
To qualify for disability and Medicare coverage, you or your spouse must also receive Social Security benefits, or have paid Social Security taxes for about 10 years (or the equivalent Railroad Retirement Board or government employee benefit – the rules have changed several times over the past few decades).
Medicare Disability Enrollments Are Common: Medicare is generally thought of as health insurance for those over the age of 65, but 16 percent of Medicare beneficiaries enrolled earlier due to a disability.
Medicare Differences on Disability: Your Original Medicare (Parts A & B) benefits will be the same as if you had aged into Medicare. However, it will be more difficult for younger enrollees to get private supplementary coverage until they turn 65.
Medicare beneficiaries who are eligible due to disability can generally get Part D prescription drug plans. Each state has different rules about whether and how Medicare Supplement plans should serve disabled enrollees. You could also lose Medicare coverage if you’re no longer disabled.
Medicare Alternatives: Medicaid, which is comprehensive and free, is a much easier way to get healthcare if you’re disabled or out of work. While you generally have to renew Medicaid coverage each year, you can enroll very quickly. If you receive Supplemental Security Income (SSI) or have limited income, you may also qualify for Medicaid.
Taking the Next Steps
Learn more about Medicare coverage at HealthCare.com. Some Medicare Supplement plans may also provide coverage for those under 65 and dealing with a disability.
Contact Your Insurer Directly: Looking for your 1095 tax form? Contact your insurer directly to get your copy of Form 1095 – ONLY your insurer will have access to your it and can provide you with a copy.
Click here if you purchased your plan via healthcare.gov.
If you get healthcare from your employer, contact your company’s benefits department.
If you found your coverage through our plan comparison tool, you’ll still need to contact your insurer; we don’t have access to anyone’s 1095 tax form.
How Can I Find My Insurer? Call the main number on the back of your insurance card. If you can’t find your insurance card, use a search engine to reach your insurance company. Even if you’re no longer enrolled, your insurance provider still has to promptly mail your Form 1095 if you request it.
What Is Form 1095? It is a letter from your insurance provider that lists each month you had health insurance. You generally needed to have coverage for 9 months to avoid a tax penalty. That was only applicable up until the 2018 plan year. Form 1095 serves as proof for tax purposes.
It may also include the information that you’ll need to file for health tax credits, which can be a huge help to you.
Do I Need Form 1095 to Pay My Taxes? Your document may be called Form 1095-A, 1095-B, or 1095-C, depending on what type of health insurance you had last year.
If you expect a 1095-A, you will need the form before you finish your taxes. People who receive health insurance subsidies generally get Form 1095-A.
How Many Forms Should I Expect? You’ll receive a Form 1095 from each health plan you had over the past calendar year.
You won’t receive one if you didn’t have health insurance during the previous year since the form comes from your insurance carrier.
What If I Had A Short-Term Plan? Short-term plans, also known as temporary health insurance, cannot send you Form 1095. These are plans specially designed to be temporary – they’re not the same thing as having comprehensive health insurance for a limited period. These plans do not count as health insurance under the Affordable Care Act.
How Long Should It Take to Get My Form 1095? Since your taxes are due on April 15, you should generally expect to receive it by March.
HealthCare.com CANNOT Provide Your Form 1095 – Calling HealthCare.com will only make it harder to get it. HealthCare.com connects you to health insurance brokers, who are unable to transfer you to health insurance customer service. Our partners would not know whether or not you had health insurance last year. Our partners do not have the information required to provide you with Form 1095.
What other forms may I need?
Did you receive a premium tax credit? If so, then you may need to fill out Form 8962. This applies if you signed up for a health insurance plan through the Marketplace and received a subsidy. You have to reconcile what your actual income versus the estimated income used when you applied for insurance coverage. This affects the amount of your tax credit.
Do you need to file for an exemption? If so, then you need to fill out Form 8965. This applies if you file for an exemption for not having an insurance policy that met minimum essential coverage. Such plans cover at least 60 percent of average medical costs and provide 10 essential health benefits, including preventative care, ambulatory and pediatric services. This applies only up to the 2018 tax year. The Tax Cuts and Jobs Act of 2017 eliminated the penalty and the need for taxpayers to file Form 8965 with their tax return.
Medicare Part D provides coverage for a range of diabetes supplies, including insulin. The supplemental prescription drug coverage which Part D provides is critical to have if you’re a Medicare beneficiary who uses injectable insulin to manage diabetes.
With the exception of insulin pumps, which are covered as durable medical equipment under Medicare Part B, all supplies used to deliver insulin, such as syringes, needles, alcohol swabs, gauze pads, and insulin pens, are covered by Part D drug plans. However, the supplies covered under Part D include only the devices and supplies that are necessary to take insulin. Other supplies used to manage and control diabetes, such as blood sugar testing strips, will fall under the coverage of Medicare Part B.
It’s not uncommon for diabetes patients requiring insulin to end up in the Medicare coverage gap known as the “donut hole,” where they’re responsible for paying a larger percentage of the cost for insulin. When this happens, a diabetic patient’s out-of-pocket costs at the pharmacy will increase dramatically, so it’s very important for these patients to budget for its increasing cost.
Medicare Part A counts as minimum essential coverage. Under the Affordable Care Act, all taxpayers need to be enrolled in a plan that qualifies as minimum essential coverage (MEC). Such plans cover at least 60 percent of average medical costs and provide 10 essential health benefits, including preventative care, ambulatory and pediatric services.
If you’re a Medicare beneficiary, you almost certainly have minimum essential coverage. If you didn’t have MEC, you’d still owe a tax penalty of $695 or 2 percent of your income – whichever is higher – for being uninsured.
Even after you turn 65, you’re still responsible for maintaining minimum essential coverage. Having MEC is like buying car insurance. Even if your coverage is limited, you’ll have protection for basic and common needs.
Medicare Coverage Meets Minimum Essential Coverage in These Situations
You meet the MEC requirement if you have any of the following:
Medicare Advantage, Medicare SELECT, or another specialty Medicare plan like PACE (all of which must cover everything in Medicare Part A).
If Medicare is the secondary payer for your health claims because your primary payer is a private insurance plan, VA care, retiree insurance, or a COBRA plan, then you also have minimum essential coverage. If your plan qualified as minimum essential coverage before you enrolled in Medicare, it will continue to count as such.
If you only have Medicare Part B, then you do not have minimum essential coverage from Medicare.
With POS (Point of Service) plan coverage, health insurance policyholders receive care at a lower cost when they receive care from in-network doctors, though this type of plan also includes coverage for out-of-network care (with a referral).
POS plans require policyholders to elect a primary care physician (PCP) and they must obtain a referral from their PCP before seeing a specialist – even if that specialist is in-network. In essence, POS plans offer lower medical costs in exchange for a more limited choice of providers. It’s important to note while POS plans may provide partial out-of-network coverage, it is the patient’s responsibility to pay bills and fill out necessary claim forms in order to be reimbursed for the out-of-network care they receive.
An EPO health plan is an “Exclusive Provider Organization” plan. With an EPO (Exclusive Provider Organization) healthcare plan, your care is covered when you see a doctor in the network. If you get care from doctors or hospitals outside the network, it won’t be covered; EPOs lack out-of-network benefits. In addition, EPO plans do not require referrals in order to see a specialist.
EPOs are often described as a kind of hybrid between HMOs (Health Maintenance Organization) and PPOs (Preferred Provider Organization). Like an HMO, EPO plans do not cover care received from out-of-network providers. And similar to a PPO, EPO plans do not require that you get a referral from your primary care physician in order to see a specialist. You can make appointments directly with a specialist without having to see your primary care physician first.
EPO plans tend to be cheaper than other plan types, but they also limit policyholders to a smaller network of doctors and healthcare providers.
Within the context of healthcare, “out-of-pocket” often refers to out-of-pocket costs – specifically, medical expenses which you pay by yourself, instead of expenses where your insurance foots the bill.
Medical services that are covered by your insurance plan can still have an out-of-pocket component. Out-of-pocket costs include copayments, deductibles, and coinsurance for covered health services. For instance, Affordable Care Act health insurance plans are categorized by metal levels, going from bronze to platinum, in which you’ll pay from 10 percent to 40 percent of your costs out-of-pocket.
If your insurance plan doesn’t cover a certain doctor or service, you’d be paying for it entirely out-of-pocket – that is, all by yourself.
Most types of health insurance include an annual out-of-pocket maximum, or an amount after which you don’t have to pay for anything else out-of-pocket for covered costs, once you’ve reached that spending amount. This out-of-pocket maximum may or may not include deductibles or premiums when calculated.
A Preferred Provider Organization (PPO) is a type of health insurance plan where an insurance company makes arrangements with provider groups, care specialists, hospitals, and other sources of healthcare to form the plans network.
If you have a PPO plan, you can visit any provider in your plan’s network at a significantly discounted “in-network” rate.
More Choice & Flexibility
PPOs are attractive for many Americans, since these plans also cover medical costs outside of their provider networks. You generally don’t need a doctor’s referral from your primary care physician (PCP) to see medical specialists who are part of your PPO. PPO plans may let you choose a primary care provider, but you probably won’t have to do so.
If you visit a doctor, stay at a hospital, or use services that are part of the PPO, you will be considered to have used services that are in-network – therefore incurring no penalties for out-of-network providers. You can also see medical professionals outside of your PPO plan’s network. Your PPO may have an entirely separate deductible and out-of-pocket maximum for out-of-network medical professionals.
Because of the greater flexibility afforded to policyholders, PPOs tend to be more expensive than an HMO. And even though you’re allowed to go out-of-network under a PPO, you’ll be responsible for a greater share the costs, which are likely to be higher than if you had stayed in-network.
You can browse HealthCare.com with confidence, knowing that you understand the differences between insurance plans available in your area. Use our intelligent plan selection tool to choose an PPO if you prefer, or request a PPO on the phone from one of our affiliated brokers.
While doctors and hospitals don’t report debts to consumer credit bureaus, it’s fairly common for healthcare providers to turn over an unpaid debt to third-party collection agencies who will share this information. When this happens, your failure to pay a bill will affect one of the most important factors in determining your credit score: your payment history.
Medical Bills on Credit Report in Practice
Let’s say you have yet to pay the bill from your most recent visit to the dermatologist. If the bill remains unpaid for long enough, your doctor may turn over your unpaid debt to a collections agency; in all likelihood, a collector will then contact you in an effort to get you to pay up. At this point, your credit report may indicate your unpaid bill as having gone to collections.
The extent to which medical debt can affect your credit score depends on the type of scoring model used by a potential creditor to check your creditworthiness. FICO 8, the scoring model which many lenders rely on, records all collections, regardless of whether the charges were eventually paid. That is to say, even if you eventually paid off your debt, your credit report may reflect that the bill you paid off went to collections. Collections accounts can take up to seven years to drop off your credit report, although the impact on your credit score will lessen over time. FICO 9, which is the newest scoring model, puts less weight upon medical debt but is not as widely used as FICO 8.
As of September 15, 2017, the three major credit reporting agencies – Equifax, Experian, and TransUnion – must allow a 180-day waiting period to elapse adding unpaid medical debts to people’s credit reports. The waiting period affords patients/policyholders some time to resolve outstanding medical bills with their healthcare and insurance providers.
Well, Medicare IS health insurance. You’ll pay monthly Medicare premiums and present your Medicare card to the doctor to pay for services, just like you would with other health insurance. There are, though, several cases where you can have both private insurance and Medicare at the same time.
If You Have Employer-Sponsored Private Insurance and Medicare: Whether you get insurance through your own employer or that of a spouse or family member, your main concern will be to determine whether or not it pays for claims before Medicare does (as a “primary payer”) or after Medicare (as a “secondary payer”). This depends on the size of the employer that you receive coverage from.
Your employer coverage will be primary if:
Your employer has 20 people or more, and you’re over 65 years old OR
Your employer has 100 people or more, and you qualify for Medicare due to a disability.
Your employer coverage will be secondary – meaning that Medicare will have to pay most of your claims first – if:
Your employer has fewer than 20 people and you’re over 65 years old OR
Your employer has fewer than 100 people, and you qualify for Medicare due to a disability.
It’s important to check with your insurance administrator to make sure that they coordinate appropriately with your Medicare coverage. You may be responsible for overpayments or penalties if your primary insurance isn’t synced with your Medicare correctly. It’s difficult to coordinate this and may make it harder to get supplementary coverage later on, but you may want to keep employer insurance for cost savings or for the sake of your spouse.
If You Have VA Coverage: Although you don’t need to enroll in Medicare Part B, the VA recommends that you do. This will expand the range of emergency care and outpatient doctors that you can visit.
If You Have COBRA or Retiree Insurance: Your coverage won’t end automatically once you’re eligible. If you hold onto it, you won’t be eligible for a penalty-free Medicare enrollment period once your coverage does end.
If You Have an Individual Health Insurance Plan: It’s generally against the law for insurers to sell Medicare beneficiaries a new individual health insurance plan (these are sometimes called “Obamacare”, “major medical”, “qualified”, or “Marketplace” plans). If you currently have this coverage, you’ll lose eligibility for tax credits that you’d otherwise receive for having private insurance, and your insurance might decline to pay simply because Medicare could have paid.
You’ll still be responsible for a small portion of your medical bills when you have Medicare. You’ll probably want additional coverage that pays the medical bills that Medicare leaves to you.
86 percent of Medicare enrollees enter into certain types of supplementary coverage that coordinate with Medicare. These plans take care of potentially costly coverage gaps in your Medicare coverage, like coinsurance, at a fraction of the out-of-pocket rate:
Medicare Supplement plans (also known as “Medigap”) are available in every state. There are 10 different types of plans, each with different levels of coverage to pay for your excess Medicare costs.
Medicare Advantage plans (also known as “Part C”) replace your Part A & Part B coverage. Instead of getting Medicare through the government, you’ll go through a private insurer who may offer you extra benefits and smaller doctor networks. Part C plans also limit your yearly out-of-pocket costs.
Medicare Part D plans pay for prescription drugs. Part D coverage might be included with Medicare Advantage plans, but Medigap and Original Medicare beneficiaries will sign up separately.
There are also three major services that aren’t covered by Medicare: hearing aids, dental work, and vision care. If you’re a Medicare beneficiary, you can:
Pay for these services on your own;
Enroll in separate vision, dental, or hearing insurance; or
Join a Medicare Advantage plan that covers these services.
In a few very unusual circumstances, you can switch from Medicare to individual health insurance. However, this isn’t cost-effective for most people.
Taking the Next Steps
Once you determine which type of supplementary Medicare coverage is right for you, HealthCare.com’s innovative comparison tool can help you find the policy that fits you best. Both Medicare Supplement and Medicare Advantage plans are widely available.
It’s unlikely that you’ll find short-term insurance that covers pre-existing conditions. Generally, your individual claims will be denied if they resulted from a pre-existing medical condition. Short-term insurers can even outright decline to insure you due to your medical history or current health status.
Many Conditions Are Excluded from Short-Term Insurance Coverage
Some pre-existing conditions are chronic conditions, including:
Chronic obstructive pulmonary disease,
Congestive heart failure,
High cholesterol, and
High blood pressure.
The length of time that short-term policies “look back” on pre-existing conditions varies by state, ranging from the previous six months to five years. If you’d like to purchase another short-term policy after the first policy expires, your new plan may not cover conditions that developed during the term of your first policy.
You’ll be able to ask your insurance company what is covered before buying a plan.
Short Term Plans Cover Limited Benefits
Ongoing Health Problems Are Not Covered: Since short-term health policies are designed to take care of immediate health needs, they are unsuitable for long-term maintenance of health issues. Short-term plans rarely cover medical devices, dental care, or vision care. Prescription costs are typically the planholder’s responsibility outside of a hospital setting as well.
You Will Get Emergency Care: Peace of mind from unexpected medical costs is a major benefit of short-term coverage. If you’re seriously ill or injured, short term insurance will cover the costs of your hospital visit. Short-term policies also cover follow-up care for acute medical issues until your coverage ends.
You Can See A Primary Care Doctor: Nearly all doctors accept short term insurance. You will receive a welcome letter, insurance card, and other familiar benefits when you enroll. Although you have to pay for care on your own before hitting your deductible, the costs for a visit once you do reach your deductible are generally low. Some plans also include a checkup, free of charge.
You Can See a Specialist: Specialized doctors (such as a dermatologist, orthopedist, or neurologist) are frequently covered by short term plans. Medical imaging (like x-rays) and mental health care are also common short-term benefits. Short term plans often bundle in additional benefits such as life insurance or prescription drug discounts as well.
Insurance premiums are one of many items that qualify for the medical expense deduction. Since it’s not mandatory to enroll in Part B, you can be rewarded for choosing to pay this medical expense.
You can only benefit from the medical expense deduction by following specific rules. You’ll need to file your taxes in a certain way, itemizing your deductions instead of choosing the standard deduction. Additionally, your medical expense deductions only begin to count after they surpass 10 percent of your Adjusted Gross Income. Adjusted Gross Income, or AGI, is your total pre-tax income before certain non-itemized deductions such as health savings account spending.
Depending on the circumstances, you may be better served by not deducting medical expenses. You may only want to deduct medical expenses in one year, and not another.
However, if you’re actively self-employed, you can deduct your entire health insurance premium. You’ll have the opportunity to do so even if you don’t itemize your deductions. This deduction will be entered on your Form-1040, and not shunted along with your other medical deductions on a Form 1040-A.
A tax deduction – like the well-known medical expense deduction – won’t exactly pay your taxes directly. Instead, tax deductions reduce the amount of money that you have to pay taxes on. Choosing to take the medical expense deduction gives you a write-off that will ultimately reduce, but not erase, the taxes that you owe.
Taking the Next Steps
Keep collecting bills or receipts for your medical expenses. You can see if you’ll want to aim for a medical expense deduction by reviewing your spending and income for the current year. More importantly: this is not tax advice – speak with a qualified tax professional to learn more.
In order to find out if a specific drug is covered by your insurance plan, you’ll need to review your insurance provider’s drug formulary (the list of prescription medications covered by your health insurance plan). Your insurance provider’s formulary is a “preferred drug list” of all the medications they cover. A formulary will also list the maximum dose and quantity of each drug that can be prescribed and covered, and will note any prior approvals you require to get certain drugs.
Some drugs on your plan’s formulary may be covered automatically with a doctor’s prescription; other medications may require a prior authorization from your doctor, or may be covered only after you’ve tried a different, preferred drug first. If you buy a prescription drug that is not included in your plan’s formulary, that drug will be more expensive, as your health insurance may not cover any of the cost.
How to Find Your Plan’s Drug Formulary
To access your insurance plan’s drug formulary:
Visit your insurance provider’s website,
Call your insurance provider at the phone number listed on the back of your insurance card, and ask for a hard copy of your plan’s formulary, OR
Look through the information you received when you compared or first signed up for your plan.
If you have a specific question about your formulary, such as what tier a particular drug is in, or whether a medication requires prior authorization, your insurance company’s customer service representative may be able to help you over the phone.
Formulary Drug Tiers
Most formularies organize the drugs they cover into a hierarchy of separate “tiers,” which are classified by cost. Drug tiers convey to policyholders how much a specific medication will cost; the tier under which a particular drug is categorized determines how much a policyholder will need to pay out-of-pocket to get that drug at the pharmacy.
Because drug tiers are not standardized, not all insurance providers will organize their formularies into the same number of tiers. A particular drug may be classified as Tier 1 in one insurance plan, but classified as Tier 2 under a different insurance plan–the same drugs aren’t always categorized in the same tiers. Upon enrolling in a plan, insurers typically provide policyholders with a pamphlet or documentation listing the medications that are included in their plan’s formulary, along with an explanation of the copays and/or coinsurance associated with each drug tier.
Medicare coverage for nursing homes is essentially nonexistent; Medicare usually does not cover nursing home costs. Nursing homes are considered to be custodial care, not medical necessities. Medicare only covers hospital and medical bills – things that it considers medically necessary.
The exception for Medicare is the Part A skilled nursing benefit, which provides 24/7 in-patient care after a hospitalization for up to 100 days. Skilled nursing facilities help patients after an injury – they’re not nursing homes in the sense that nursing homes are often a designated place for the care of aging seniors.
Nursing home coverage is best provided by long-term care insurance, purchased well in advance of the recipient needing nursing home coverage. Otherwise, he/she might not meet underwriting and will be paying a substantial premium for meager coverage. If a senior needs to move to a nursing home and cannot afford care, Medicaid is also an option to look into.
Taking the Next Steps
Learn more about Medicare coverage at HealthCare.com. Some Medicare Advantage plans may also include a long-term care component.
If you’re still working at 65, and you’re eligible for Medicare, you may not have to sign up right away; however, we highly recommended signing up for Medicare as soon as you’re eligible. If you don’t closely follow the rules that allow you to postpone enrollment in Medicare, you may face significant financial penalties when you do enroll.
Selectively Enrolling in Medicare
Remember, Medicare is split into two sections – Part A and Part B. Together, this is the federal insurance program also referred to as “Original Medicare”. While you don’t have to enroll in Medicare while still working, you might want to enroll in at least Medicare Part A while postponing Part B.
Occasionally, 65-year-olds enroll in Part A (which includes premium-free hospital coverage) and delay enrolling in Part B (which includes outpatient care and has considerable monthly premiums). There are also other aspects of the Medicare program, such as prescription drug coverage and private supplementary coverage, but they require both Part A and Part B first.
If you’re receiving Social Security benefits, then you’ll have to sign up for Medicare Part A even if you delay enrolling in Medicare Part B.
You Can Safely Delay Medicare Part B Enrollment If:
The employer offers “creditable coverage”, or coverage with benefits that are at least equivalent to Medicare.
You’ll want to confirm, in writing, that the coverage you’re using is creditable coverage. Contact your employer, insurance company, or Social Security if possible.
If you meet the above conditions, then you can delay enrolling in Medicare for up to 8 months after you (or your spouse, if you’re receiving coverage through them) have stopped working at the job that provides your current insurance.
You’ll have to enroll in person at your Social Security office once you do want to receive Medicare, since this scenario usually can’t be handled over the phone or online.
You Should Sign Up Right Away If:
You get health insurance from an employer with fewer than 20 employees;
You’re enrolled in individual health insurance, like an Obamacare plan;
You rely on a Christian health ministry, short-term insurance, or no insurance at all;
You’re using COBRA, retiree insurance, or health insurance from a previous job; or
You have VA health coverage.
Nearly all Americans over the age of 65 are enrolled in premium-free Medicare Part A, including all Social Security beneficiaries.
Instead of delaying enrollment, you could opt out of Medicare forever if you really wanted to. You’d need to speak with Social Security to opt out entirely, but this is rarely done.
It’s safe to postpone your coverage if you’re comfortable doing so. You’ll want to consider the financial implications of doing so first, since most Medicare beneficiaries are satisfied with their coverage and healthcare costs.
You Can Still Get Supplemental Coverage When You Do Join
You can generally join Medicare Supplement or Medicare Advantage without penalty within a few months of getting both Medicare Part A and Part B for the first time. Medicare Supplement and Medicare Advantage are two very important programs which help pay your out-of-pocket Medicare costs.
Taking the Next Steps
You can see if your current health insurance will allow you to postpone Medicare enrollment. If Medicare turns out to be a better option for your needs, browse our selection of Medicare Supplement plans to find coverage that will last a lifetime.
Medicare Supplement Plan F enrollment ends for good on January 1, 2020. Both regular Plan F and the high-deductible version of Plan F (HDPF) will be affected. With Medigap Plan F going away, Medicare beneficiaries will have fewer options available to them.
Next Best Alternative: Medigap Plan G
After 2020, new Medicare Supplement enrollees will still be able to join Medicare Supplement Plan G. Plan G is almost identical to Plan F. Plan G does not cover your annual Medicare Part B deductible of $185 – otherwise, it’s exactly the same as Plan F, the most popular and comprehensive Medigap plan.
HDPF is a great choice for those who want Plan F’s “full coverage” level of benefits but are confident in their ability to save money on their care. A high-deductible version of Plan G will be available for purchase by 2020. There are no other high-deductible versions of Medigap plans available at this time.
You Can Enroll in Medigap Plan F Now
If you join Medigap Plan F or HDPF by December 31, 2019, you can still keep your Plan F coverage forever. You’ll even be able to switch between different Plan F carriers if you choose.
Since Plan F is the most popular Medigap plan, insurance companies will continue to maintain it for existing customers well into the future. After all, there are still policyholders of other plans, like Plan J, that were discontinued many years ago.
Policymakers have not seriously discussed introducing any new Medicare Supplement plans to replace Plan F or Plan G.
Taking the Next Steps
We’ll connect you to local Medicare Supplement plans – including Plan F and Plan G – so that you can enroll in your favorite plan on time.
Yes, AARP Medicare plans do exist, and you can buy various forms of Medicare coverage from AARP; however, AARP itself is not a health insurance company. It is a nonprofit, nonpartisan organization that helps and advocates on behalf of people age 50 or older. It also partners with companies to offer its members products such as insurance.
AARP is one of the most recognizable Medicare plans in the marketplace. You’ll notice on any of the marketing materials for AARP Medicare plans that it’ll usually include words like “insured through UnitedHealthcare” or “from UnitedHealthcare”. That’s because UnitedHealthcare Insurance Company is the actual provider of Medicare coverage that is marketed through AARP.
AARP receives a royalty from UnitedHealthcare in exchange for the use of its name and brand. UnitedHealth is one of the largest health insurance companies operating in the U.S.
Medicare Part B is the component of Medicare that covers your preventative care and doctor visits. Medicare also places outpatient surgery, laboratory work, and medical equipment under the Part B umbrella.
If you’re not dealing with an immediate medical emergency or buying prescription drugs, then your health issues will probably be taken care of by Part B. The most common components of part B include:
Physician Visits: Doctor’s appointments are generally covered by Part B. There’s no limit to the number of medically necessary visits you can schedule. Part B also covers x-rays, urine samples, and blood work.
Outpatient Surgery: Same-day surgeries are covered by Part B. Longer hospital stays are covered by Part A.
Screenings: Part B covers the entire cost of screening visits for dozens of common medical conditions. You’re also entitled to receive a full wellness checkup once per year, free of charge.
Flu Shots and Vaccines: Flu shots, pneumococcal shots and hepatitis B shots are covered by Part B with no copayment.
Some Prescriptions: While you can’t rely on Part B to cover most prescription drugs outside of the hospital, certain lifesaving drugs for chronic conditions – like diabetes, hemophilia, and organ transplants – are covered by Part B.
Counseling Services: Counseling and therapy sessions are covered by Part B.
Medical Equipment: Durable medical equipment will be covered by Part B if it comes with a doctor’s prescription. Part B can pay for canes, commode chairs, glucose monitors, hospital bed, walkers, or other homecare devices.
Ambulance Services: Part B will cover your ambulance costs when you’ve had a sudden medical emergency or cannot be transported safely by other means. However, Part B does not cover medical transportation for routine care.
Part B generally doesn’t cover long-term care, hearing aids, glasses, or dental work.
Medicare Part B (along with Part A) makes up “Original Medicare”, which is provided by the federal government. Most doctors take Part B, and nearly all eligible American seniors are enrolled in Original Medicare.
Cost of Medicare Part B
The standard Medicare Part B premium in 2017 is $134 per month for new beneficiaries. Medicare sends a bill every 3 months. If your income as reported two years ago was over $85,000 ($170,000 if filing jointly), then you’ll pay a little more this year.
Part B enrollees pay a deductible of $183 per year. If you only have Original Medicare, you’ll be responsible for paying 20 percent of your medical costs once your deductible is reached. However, Medigap plans can cover these charges for you.
To enroll in Medicare Advantage, you’ll have to choose a plan and sign up through a broker or insurer. Medicare Part C is offered by multiple private insurance companies. You can’t join a Medicare Advantage plan until you enroll in Original Medicare. If you decide to enroll in Medicare Part C, it will replace your Original Medicare coverage.
Once you enroll in Medicare Advantage, you’ll only interact with your insurer and their provider network. However, you’ll continue paying for Original Medicare, which the federal government will use to reimburse your Medicare Advantage insurer. Fortunately, your plan will help you consolidate these bills.
How Medicare Part C Works
Medicare Advantage plans work to cover all Original Medicare services and may offer additional benefits. Unlike Medicare Supplement plans, which are standardized no matter who sells them, private insurers can choose what their Part C plans offer. Insurers may define their own premiums, deductibles, copayments, and physician referral systems. Your Medicare Advantage plan will negotiate payments to doctors that may be higher than what they receive from Original Medicare. However, fewer doctors will be enrolled in your Medicare Advantage plan compared to Original Medicare.
Billing and Costs
Once you sign up for Part C, your billing and care may be consolidated. You can typically access all your medical services with just one card, choose a primary care physician, and pay for different treatments with a single bill.
The average Part C plan cost $31.40 per month in 2017. For a small additional premium, many Medicare Advantage plans cover prescription drug costs (replacing Medicare Part D coverage). Most Part C carriers have a zero-premium plan available, with higher copayments or fewer additional benefits.
Taking the Next Steps
You only need to enroll in Part C one time. We recommend visiting our Medicare Advantage comparison tool, or asking us to connect you with a local broker who can offer a free, no-obligation quote.
Unfortunately, uninsured medical expenses (that is: medical costs that aren’t covered by your insurance plan) will NOT help you reach your deductible. Your deductible is the amount of money that you spend on covered medical expenses before your health plan shares the cost of your care.
For example, if you visited a doctor who wasn’t part of your insurance plan’s network after your deductible was reached, your insurer wouldn’t pay the doctor. Accordingly, medical costs that aren’t covered won’t count towards your deductible either.
This is why it’s important to seek care that’s covered by your insurance whenever possible. Uncovered medical costs also won’t affect your plan’s out-of-pocket maximum.
Medical devices that aren’t covered by your plan are treated the same way. Even if your treatment was necessary and appropriate, only covered costs will count towards your deductible.
You can ask a doctor to give you a prescription or referral that your insurance will cover. Some plans won’t cover specific drugs because they prefer to cover a very similar drug instead.
In limited circumstances, such as the need to see a specific doctor for a rare disease, your health insurer can pre-approve out-of-network care. Your plan may share the costs or pay for it as if it was in-network care.
Some health insurance plans offer limited recognition of out-of-network claims, or have a separate out-of-network deductible. If you visit a doctor and pay out-of-pocket, then it may be worth submitting a bill to your insurance company. Although your plan won’t be required to count the bill against your deductible, they may have adopted a more generous policy.
Health savings accounts and flexible spending accounts have more lenient rules about medical costs. If you have an HSA or FSA, you can still use them to pay for qualified medical expenses whether or not they’re covered by your insurance policy.
Taking the Next Steps
If you find that your healthcare coverage is too limiting for your needs, then consider finding another health insurance policy. Search through our database of plans to find a policy that works best for you.
When you age into Medicare by turning 65 years old, you cannot be denied supplemental insurance for Medicare. You also can’t be charged extra on account of your medical history. After a few months, supplemental plans will be free to charge you higher prices or deny you outright, depending on which type of supplemental coverage you want to join. So, whether it’s a Medicare Supplement plan or Medicare Advantage coverage, you should not be denied for coverage.
Medicare Supplement (Medigap):
Your Medicare Supplement Open Enrollment Period lasts for six months, starting from the 1st day of the month when you’re both 65 and join Medicare Part B. During your Open Enrollment Period, insurers cannot deny you coverage or increase the price of your plan due to medical conditions.
Once your Open Enrollment Period has ended, you’ll only have the guaranteed right to purchase a Medigap plan at the lowest possible rate if you qualify for a Special Enrollment Period. Fortunately, there are many ways to qualify for special enrollment.
Thirty-one states also require Medigap issuers to offer plans to Medicare beneficiaries under the age of 65, although not all plans may be available or affordable. In New York and Connecticut, insurers cannot deny or charge extra for Medigap at any time.
Medicare Advantage (Part C):
When you first become eligible for Medicare, you’re granted a 7-month Initial Enrollment Period (IEP) to sign up for Medicare Advantage. Medicare Advantage plans are privately-run options that replace your Original Medicare coverage (Parts A & B). Your IEP begins 3 months before the month that you turn 65, and lasts for 3 months after the month you turn 65.
In general, you can’t be denied coverage or charged more due to a health condition if you apply for Medicare Advantage during AEP. However, Medicare Advantage plans are not required to accept beneficiaries who qualified for Medicare due to a diagnosis of end-stage renal disease.
An HMO, also known as a Health Maintenance Organization, is one of the most common types of insurance plans.
In HMOs, there’s less separation between medical professionals and your insurance company. If you enroll in an HMO, you’ll be limited to a network of doctors and facilities that are closely linked to the HMO. The medical professionals you see may be direct employees of the HMO.
Focus on Primary Care
In an HMO, you’ll generally have to choose a doctor known as a primary care provider (PCP) that is part of the provider network of the HMO. When you have a medical issue, you’ll visit your PCP. Your PCP will work closely with your insurer. If you need to see a specialist, you’ll often need to get a doctor’s referral from PCP. The specialist you see will be restricted to a doctor within your HMO’s network. You may not need referrals for preventive care. HMO plans must also cover emergency care even outside of the network.
Cheaper Than Other Major Medical Plans
HMOs have more control over its doctors and facilities than other types of plans. HMOs limit the number of providers in their network so as to keep costs down. As such, they’re generally cheaper than comparable plans.
You can browse HealthCare.com with confidence, knowing that you understand the differences between insurance plans available in your area. Use our intelligent plan selection tool to choose an HMO if you prefer, or request an HMO on the phone from one of our affiliated brokers.
Some medical care has to be ordered by your primary care doctor. While you can visit a clinic or emergency room without prior authorization, other circumstances will require you to get a doctor’s note before receiving care. This note is called a referral.
How to Get a Doctor’s Referral
To get a doctor referral you’ll generally want to visit your primary care provider – whether they’re a family practitioner, internist, or pediatrician. If you have an injury to a body part, you could also visit a doctor who treats that body part. The doctor will screen your condition and give you a paper referral that you can take to the doctor of your choice that’s covered by insurance.
For instance, you can’t ask for an X-ray on your own. Your insurance policy might also ask you to get a referral before you visit a highly specialized doctor, like a cardiologist.
It’s very common for doctors to approve referrals, and your doctor should be happy to do so.
If Your Insurance Plan Doesn’t Require Referrals
If your plan lets you see a specialist without a doctor referral, that specialist may still need to write a referral for diagnostic tests or additional specialists. For example, a podiatrist (foot doctor) can write you a referral for multiple physical therapist visits. Sometimes getting a referral when you don’t need one will make it more likely that your plan approves your continuing care in the future.
When scheduling a visit with a medical professional for the first time, it’s a good idea to ask if they need a doctor referral from your insurer. You’ll want to make sure that the medical professional you’d like to see can accept you as a patient.
Thanks to the Affordable Care Act, you’re able to get health insurance even if you deal with pre-existing conditions. This applies whether or not you get health insurance by yourself or through your employer. Whether or not you sought treatment for the health issue before your coverage began, it will still be covered.
What’s a Pre-Existing Condition?
A pre-existing condition is a health issue that was present before a person enrolled in a health insurance plan. Pre-existing conditions are not uncommon. Anywhere from 27 percent of Americans (according to the AARP) to 50 percent of Americans (according to the Department of Health and Human Services) under the age of 65 have a medical issue that insurance companies would have categorized as a pre-existing condition. CNN believes that the most common pre-existing conditions were acne, anxiety, diabetes, asthma, sleep apnea, depression, COPD, obesity, atherosclerosis, and cancer.
Exceptions to Health Insurance Pre-Existing Conditions
Not all plans are regulated by the Affordable Care Act, which prevents discrimination based on pre-existing conditions. Limited medical, short-term medical, travel insurance, and supplemental coverage plans may have waiting periods for pre-existing conditions. There are a handful of exceptions to pre-existing condition protections for individuals:
Health insurance plans that serve as alternatives to the Affordable Care Act, such as short-term medical policies or Christian health plans, continue to set their own rules for pre-existing condition coverage. You probably won’t encounter this issue unless you specifically seek out these types of insurance.
If you enroll in a Medicare Supplement policy (also known as Medigap), then your supplementary coverage for conditions that were previously diagnosed or treated may be postponed for up to 6 months if you were uninsured before enrolling. However, your Original Medicare will still cover pre-existing conditions.
If you choose to enroll in Medicare Advantage, it will replace your Original Medicare coverage. Medicare Advantage enrollees need to continue paying any Part A and Part B premiums to stay enrolled in the program. However, Part C offers all of the services that are included in Medicare Part A and B.
Medicare Advantage operates more like traditional health insurance than Original Medicare. Multiple private insurers offer different Part C plans.
Out-of-Pocket Maximums Under Medicare Advantage: There’s a limit to the amount that any Medicare Advantage plan can ask you to pay in a single year. As of 2017, a plan can ask you to pay no more than $6,700 or less before you reach your annual out-of-pocket maximum. Your monthly premiums and prescription drug costs don’t count towards your out-of-pocket maximum. You’ll still pay those costs if your out-of-pocket maximum is reached.
Medicare Advantage plans can also choose to provide additional benefits that are not offered by Parts A & B. You can bundle important benefits such as hearing aids, travel insurance and prescription drug coverage into your Part C plan. Unlike Original Medicare and Medigap, the benefits offered by your plan may change every year.
SSDI: If you’ve just begun to receive SSDI payments, you can’t enroll in Medicare right away. Your enrollment begins automatically on the 25th month that you receive SSDI benefits. You’ll get your Medicare information and the official card in the mail soon after your 23rd month of receiving SSDI.
The 24-month requirement is cumulative, meaning that you don’t need to have received all 24 months during the same 24-month period to qualify.
If you have ALS (amyotrophic lateral sclerosis), your Medicare benefits will begin as soon as you receive your first SSDI payment. It typically takes 5 months for your first SSDI payment to arrive.
ESRD: If you’ve received a diagnosis of end-stage renal disease, you can enroll in Medicare by contacting your local Social Security office. To qualify, you must already receive SSDI or have worked in the U.S. for about 10 years to have paid a sufficient amount of taxes.
If you have ESRD but don’t meet those requirements, you can also get Medicare if you are the spouse or dependent child of a person who would have qualified.
The start of your Medicare coverage will depend on the type of treatment you receive.
If you take part in a home dialysis training program, your coverage will kick in during the first month of dialysis.
If you receive treatment at a dialysis facility, coverage will begin after your fourth month of dialysis.
If you’re admitted to the hospital for a kidney transplant or transplant-related health services, your coverage begins during the first month that you’re admitted.
If your transplant is delayed for more than two months after you’re admitted to the hospital, then your coverage will start two months before your transplant.
It is against the law for anyone to knowingly sell you a Medicare Supplement (Medigap) policy if you plan to stay on Medicare Advantage, and vice versa. You don’t need Medicare Advantage if you already have Medicare Supplement. Each type of plan covers many of the same things, so you’d be wasting your money. This means that you can’t have both Medigap and Medicare Advantage at the same time.
Medigap VS Medicare Advantage
Medicare Supplement plans are meant to fill your coverage gaps not paid for by Original Medicare (the government-run program also known as Medicare Part A and Part B). There are a number of blind spots in Original Medicare, any of which could burden seniors who lack supplementary coverage with significant out-of-pocket costs. Having a Medicare Supplement policy on top of Medicare Part A and Part B generally makes a lot of financial sense.
If you rely on Medicare Advantage coverage, you won’t need a Medicare Supplement plan. The two types of coverage aren’t even compatible, since each Medicare Advantage plan will have different cost-sharing rules than Original Medicare. Medicare Advantage plans operate similarly to what you’d find in traditional health insurance – they typically operate as an HMO, PPO or POS plan. Since Medicare Advantage’s provider network is more tightly managed than Original Medicare, Medicare Advantage plans can offer you insurance with fewer coverage gaps.
The rule against buying Medicare Supplement and Medicare Advantage at once protects Medicare beneficiaries from unknowingly buying something they don’t need.
While most private health insurance companies do not cover the cost of hearing aids, there are a few policies which do. Check with your insurance provider to find out if your plan includes coverage for hearing aids or hearing loss exams. Because consumer demand for these devices is on the rise, insurance coverage for hearing aids is slowly becoming more common and a number of states have proposed legislation to help people cover their cost. Also, some insurance plans offer discounts on hearing aids purchased through certain suppliers.
Although the Affordable Care Act requires insurers to cover the cost of audiological exams, the law does not require providers to cover the cost of hearing aid devices.
Coverage Varies By State
About 20 states in the U.S. require insurers to cover the cost of hearing aids for children under the age of 18, but only three – New Hampshire, Rhode Island and Arkansas – require health insurance plans to offer similar coverage for adults. The American Speech-Language-Hearing Association (ASHA) details coverage policies for each state.
In general, Original Medicare (Parts A and B) and most Medicare Supplement (or Medigap) plans do not cover the cost of hearing aids, routine hearing exams, or device fittings.
Medicaid coverage varies by state. Some state Medicaid programs offer hearing-related benefits, including coverage for hearing aids; other states don’t. The Hearing Loss Association of America website lists state-specific information regarding Medicaid coverage for hearing aids.
VA healthcare benefits include coverage for hearing aids if a veteran’s hearing loss is connected to their military service, or related to a medical condition for which they’re receiving treatment at a VA hospital. Veterans can also get hearing aids through the VA if their hearing loss is severe enough so as to interfere with their daily activities and functioning.
Flexible Savings Accounts (FSA) + Health Savings Accounts (HSA)
Most FSAs and HSAs allow policyholders to be reimbursed for the cost of hearing aids and batteries. Unlike FSAs, money in your HSA accumulates from year to year, allowing you to save toward their cost.
Health Reimbursement Accounts (HRA)
HRAs are funded through the workplace, so it is the prerogative of your employer to determine if hearing aids and batteries are reimbursable expenses. Check with your company’s benefits administrator or HR department to find out if hearing aids are considered a qualifying expense.
In order to get a breast pump covered by insurance, you shouldn’t have to do anything. Barring exemptions for a small number of insurance plans which are “grandfathered-in,” health insurance providers are required under the Affordable Care Act (ACA), or Obamacare, to cover the cost of a breast pump and lactation counseling without imposing cost-sharing measures such as deductibles, copayments, or coinsurance. This means that you have the right to a free breast pump through insurance. The ACA also requires workplaces to provide private space (which can’t be a bathroom) and sufficient break time throughout the day to accommodate employees who are nursing and need to pump milk.
Other coverage details vary from plan to plan; because the ACA doesn’t specify what kind of breast pump has to be covered, some health insurance plans will only reimburse women for the cost of a manual pump – rather than an electric pump (which is more efficient and less labor-intensive than a manual pump). And many healthcare plans don’t cover the cost of other breastfeeding supplies, such as nursing bras, bottles, and milk storage bags.
You can evaluate your health coverage and see if it’s the best option for your needs. If you’re unhappy with the breastfeeding benefits provided by your plan, then we can help you find a different one. Search our database of individual health insurance plans to find the right plan for you.
Like their name implies, consumers covered by HDHP insurance pay a smaller premium amount each month, but they must also pay thousands of dollars out-of-pocket before insurance begins to cover the cost of their medical expenses. While high-deductible health plans cost less than traditional insurance coverage on a monthly basis, HDHP insurance coverage can also be problematic if you get sick and need healthcare.
While high-deductible health plans can be considered as a type of “catastrophic coverage”, this type of plan comprises its own health insurance category. Additionally, the Internal Revenue Service (IRS) determines HDHP deductible thresholds and qualifying criteria (these guidelines change from year to year). For calendar year 2017, HDHPs plans must have a deductible of at least $1,300 for individuals and at least $2,600 for families. Of course, the deductibles may be larger – and often are.
HDHP Out-Of-Pocket Maximums
The IRS does provide some financial protection in the form of out-of-pocket maximums to people who are enrolled in HDHPs. In 2017, HDHP out-of-pocket maximums were set at $6,550 for individuals and $13,100 for families covered under the same plan. Slight adjustments to these limits are slated for 2018.
HDHP Coverage Details
HDHPs – like all plans under the ACA – are required to cover the cost of in-network preventive care, such as annual checkups, immunizations, and well-woman exams – whether or not the policyholder has met her plan’s annual deductible.
Some HDHPs may be compatible with a health savings account (HSA). HSAs allow those enrolled in high-deductible plans to use pre-tax dollars to pay for their medical and healthcare expenses. Money in an HSA belongs to the consumer and any funds left over at the end of the year carry over into the next year. Additionally, money in an HSA – and the interest earned on it – isn’t taxed.
HSA-Compatibility and HDHP Plans
An HDHP does not guarantee that your employer offers an HSA, only that they can.
Not all HDHPs are HSA-compatible. Being subject to a deductible over $1,300 does not make your plan HSA-compatible by default; HDHPs must be established as HSA-compatible by your insurance carrier.
Money in an HSA continues to belong to you, even if you change jobs or retire.
HDHPs & Prescription Drug Coverage
HDHPs cover the cost of prescription drugs that are considered “preventative.” Drugs that aren’t considered preventative must be paid for in full if you have yet to fulfill your out-of-pocket deductible. In other words, drugs must be included under your HDHP provider’s list of approved medications to be covered in full and do not count toward your deductible; if you take a drug that is not on your insurer’s list, you’ll need to pay for your prescription medication out-of-pocket until you meet your plan deductible.
Note: whether or not a medication qualifies as “preventative” is determined by your insurance carrier, so a particular drug may be considered preventative under one plan and not by another. If you’re unsure whether a particular medication is considered preventative under your plan, call your insurance provider to ask.
The Bottom Line
The most important thing to remember with a HDHP is that every decision you make about your medical care counts. HDHPs require consumers to take ownership and initiative over their own care, so it’s crucial for consumers to know what is and isn’t covered under their plan. Many routine health services intended to keep you well (e.g. colonoscopies, mammograms, and vaccinations) are covered at 100 percent by HDHPs. Policyholders should have a comprehensive understanding of their HDHP coverage, so they know what’s free.
Short-term health insurance is different from other types of coverage. These plans are designed to keep you protected from medical or financial catastrophe in case of an emergency. Short-term insurance isn’t a reliable way to maintain your health for long periods of time.
While traditional health insurance plans must help you pay for the 10 ACA essential health benefits, short-term plans don’t cover these benefits very well. In fact, short-term health insurance plans are under no obligation to offer any specific benefits.
Short-term health insurance can safely get you through a variety of temporary situations. However, short-term plans aren’t designed to compete with major medical health insurance (popularly known as Obamacare) when it comes to taking care of your ongoing medical issues.
For instance, short-term plans will almost certainly cover hospitalization bills, yet almost certainly exclude maternity coverage. Most short term plans will offer you at least one doctor’s checkup at a low cost over the course of your plan, but they won’t cover treatment for management of a pre-existing condition.
Ongoing Health Problems Are Not Covered: Since short-term health policies are designed to take care of immediate health needs, they are unsuitable for long-term maintenance of health issues. Short-term plans rarely cover medical devices, dental care, or vision care. Prescription costs are typically the planholder’s responsibility outside of a hospital setting as well.
You Will Get Emergency Care: Peace of mind from unexpected medical costs is a major benefit of short-term coverage. If you’re seriously ill or injured, short-term health insurance will cover the costs of your hospital visit. Short-term policies also cover follow-up care for acute medical issues until your coverage ends.
You Can See a Primary Care Doctor: Nearly all doctors accept short-term insurance. You will receive a welcome letter, insurance card, and other familiar benefits when you enroll. Although you have to pay for care on your own before hitting your deductible, the costs for a visit once you do reach your deductible are generally low. Some plans also include a checkup, free of charge.
You Can See a Specialist: Specialized doctors (such as a dermatologist, orthopedist, or neurologist) are frequently covered by short-term plans. Medical imaging (like x-rays) and mental health care are also common short-term benefits. Short-term plans often bundle in additional benefits such as life insurance or prescription drug discounts.
If you’re considering a short-term health insurance plan, you probably understand that your coverage will be limited compared to what you’d get with a major medical plan. Different short-term plans will cover Obamacare’s 10 essential health benefits in different, limited ways. Don’t expect your coverage to take care of your long-term needs.
If you compare plans before you buy, you’ll have a better idea of what’s covered. Short-term plans may look similar to other forms of health insurance, but they won’t operate in the same way when it comes time to pay. Since these plans don’t give you comprehensive health coverage, you’ll still pay a fee at tax time.
There are many unique situations where buying a short-term health plan makes sense. If you’re not able to buy a traditional plan until open enrollment, short-term insurance is a great option. Students, travelers, and new employees waiting for their coverage to begin have traditionally been safeguarded by short term health insurance as well.
Your doctor referral rules will depend on your specific plan. Doctor referrals will be based on the type of network your plan uses.
You’ll have a better understanding of the referral process – including whether you need a doctor’s referral – after you’ve gotten your first referral. Doctor’s referrals are often provided by your primary care physician.
If you’re staying in-network, you can generally take your doctor’s referral to any medical professional that’s willing to treat you. If you’re hospitalized, referrals to different departments in the hospital will be managed by the hospital.
You’ll generally need a doctor’s referral for specialized tests. For instance, you can’t order an x-ray on your own.
However, whether or not you’ll need a referral to see a certain doctor primarily depends on the type of network that your plan uses.
HMO or POS Network: You’ll probably need a doctor’s referral if you have one of these plans. These plans are based around the need to check in with a primary care physician (PCP) before you access specialized services.
PPO or EPO Network: You probably won’t need a referral for most specialists in a PPO or EPO, as long as you visit an in-network doctor.
Medicare Advantage (“Part C”): Since Medicare Advantage operates more like traditional insurance than Original Medicare, you can’t see just any Medicare doctor. Some Part C plans are structured as HMOs, where you’ll need to check in with your primary care physician to get a specialist referral. Other plans are PPOs, where you won’t need a referral for in-network care.
Self-pay: You’re free to pay a medical professional on your own if you’d like to see them without a referral. You may need to sign a waiver stating that you accept full responsibility for the cost of your visit. Although the main use of referrals is for your doctor to bill your insurance, you may need a doctor to write you a referral for services that you can’t order on your own.
What If I Don’t Have a Referral When I Go to the Doctor?
Many specialists won’t even see you without a doctor’s referral unless you’re willing to pay up front.
You can plan ahead by scheduling appointments with your primary care doctor and the specialist you’d like to be referred to before you receive a referral.
How Long Does My Referral Last For?
You’ll want to ask your doctor how many visits their referral will last for. Note that your doctor may write a referral for longer than your insurance company will accept. You may receive a follow-up letter from your insurance company confirming the details of your referral.
You can get multiple referrals to the same doctor once the original referral expires.
Getting Help with Referrals
Since each plan is different, you can call your insurance provider to learn about your plan’s referral procedure. You can also look at your plan’s manual online, or request a paper copy. Medical offices may be able to help you navigate your insurer’s procedures, but they might not have specific information about your plan.
There is no cap on Medicare Supplement benefits to the insured senior: no annual caps, no lifetime caps, and no caps on dollar amounts.
Without Medicare Supplement coverage, your 20 percent coinsurance on Medicare Part B care would also continue forever. In the absence of Medigap, there’s no cap on what your out-of-pocket expenses could be as a Medicare beneficiary.
Fortunately, Medicare Supplement plans fill in these coverage gaps (that’s why they are called “Medigap”). Your Medigap insurer will cover your entire 20 percent coinsurance.
Each of the 10 Medigap plan types take care of your Part B coinsurance as one of the core Medicare Supplement benefits. Beyond that, they treat different benefits differently. HealthCare.com can help you compare plans on our website, or by connecting you to a licensed broker.
If you’re wondering whether your health insurance covers contact lenses: it probably doesn’t. Whether you purchased insurance yourself or through an employer, the chances are very slim that your plan will cover contacts. However, your plan may offer a prescription lens discount at select retailers.
Plenty of carriers offer surprisingly affordable vision-only insurance policies that are separate from your main health insurance. These will work like traditional health insurance, but will only cover vision care. You’ll want to compare them to see which one offers the best contact lens coverage.
Medicare, Medicare Supplement, and Medicare Advantage
If you’re covered by Medicare, Original Medicare (Parts A and B) does not cover the cost of contact lenses. If you have have a Medigap plan, there are no Medicare Supplement plans that add vision coverage either.
One exception to this: you may receive contact lenses as a Medicare benefit following cataract surgery or other medically necessary vision procedure.
Some Medicare Advantage plans (Medicare Part C) come with vision insurance. You can see if any Medicare Advantage plans in your area cover contact lenses and exams by using our Medicare Advantage plan comparison tool.
No Medicaid programs cover contact lenses unless they’re medically necessary. However, all but 10 states offer eyeglasses under Medicaid.
Your Medicaid program may have partnered with a vision provider that offers a discount on contact lenses and related eye exams.
Contact lenses are only provided to veterans through Veterans Affairs when medically necessary. However, VA-eligible veterans may still qualify for discounts elsewhere.
Flexible Savings Accounts (FSA) + Health Savings Accounts (HSA)
Virtually all medically appropriate vision care qualifies as an eligible FSA or HSA expense. Unlike FSAs, money in your HSA accumulates from year to year, allowing you to save toward the cost.
Keep in mind, though, that this isn’t a comprehensive list of insurance companies that offer Medicare Supplement plans in NY. The NY State Department of Financial Services regulates the insurance industry in the state of New York, and keeps the full list of the Medigap insurance companies in New York.
In addition, not all insurers or plans operate across the state. Your individual plan options will vary according to ZIP code, whether that’s in Rochester (where you are), Western NY, Eastern NY, Buffalo, New York City, or Long Island.
As of August 2017, each of the Medicare Supplement companies in New York offers Medigap Plan F (the most popular plan type), Plan A (the most basic) and Plan B.
If you’re considering Medicare Supplement coverage, you’ll join 436,192 other Medigap enrollees in New York state (as of May 2017). Those Medigap enrollees represented 21 percent of the total Medicare people on Original Medicare; in other words, roughly one in five Medicare enrollees choose to supplement their Original Medicare with a Medicare Supplement plan. Further, of those, approximately 241,000 (or 55 percent of all Medigap enrollees), were enrolled in Medicare Supplement Plan F.
Most Popular Medicare Supplement Companies NY (2016)
The cost of Medicare Part B comes in the form of a monthly premium (along with deductibles and coinsurance). Unlike Medicare Part A, which is free to Medicare-eligible seniors, Medicare Part B recipients must pay this premium.
Medicare Part B premiums are based on your income levels. These charges may change each year, although they are not expected to increase until 2020.
For 2018, the monthly Medicare Part B premiums are somewhere between $134 and $428.60 per individual. If you receive Social Security benefits, this premium can be deducted out of your Social Security payments so that you don’t have to make regular payments.
Medicare Part B Late Enrollment Penalty: You need to enroll for Medicare Part B when you first become eligible. For people who stop working at 65, that means enrolling in Part B at the same time you enroll in Part A. If you don’t, then you will need to pay the Medicare Part B late payment penalty. This late enrollment penalty amounts to an increase of 10 percent for each year that you were late enrolling in Medicare Part B. You can read a more detailed explanation of the Medicare Part B late enrollment penalty here.
What Medicare Part B Covers: Medicare Part B covers the medical expenses associated with doctors, outpatient facilities and approved Medicare equipment. It doesn’t cover hospitalization, which is under Medicare Part A. Part B also doesn’t cover prescription drugs – that’s covered under Medicare Part D.
If you are enrolled in Medicare Part A, there is a deductible that insured seniors will need to pay for each inpatient hospital stay. Every time you visit the hospital for a new treatment, you will need to pay this Medicare Part A deductible out-of-pocket before Medicare covers you. This deductible is separate from your Medicare Part B deductible, and is counted entirely differently.
Cost of the Medicare Part A Deductible: You can think of the Medicare Part A deductible as the cost of admission that you pay out-of-pocket for each hospital stay. The exception to this: if you’re hospitalized, released, and then re-admitted subsequently within a tight timeframe, the second hospitalization will be counted with the first. For 2018, the amount of the Medicare Part A deductible is $1,340, and it’s adjusted upwards each year.
Offsetting Costs with Medicare Supplement: These deductibles can be quite costly to Medicare seniors, for both unexpected and recurring hospitalization, as each deductible is over $1,300. One way to safeguard against these large out-of-pocket payments is to purchase a Medicare Supplement plan. With the exception of Medicare Supplement Plan A (which offers the most minimal, core benefits of the 10 Medicare supplement plans), most of the Medicare Supplement plans will pay the Medicare Part A deductible on behalf of the insured.
Medicare Spouse Coverage Doesn’t Exist: Your Medicare coverage will not extend to your spouse, or any other family member. Whether you opt for Original Medicare (Parts A & B) or Medicare Advantage (private Part C coverage), your coverage won’t apply to anyone but you.
Medicare isn’t just an insurance program – it’s a benefit that you earned by contributing taxes over many years. Medicare only serves individuals who qualify. It’s not possible to extend your coverage to other people.
Your spouse should apply for Medicare if they’re eligible to do so. If they’re not yet eligible to apply, they’ll need to seek out health insurance on their own. It’s inadvisable to remain on private or employer-based insurance for the purpose of keeping your spouse covered until your spouse does become eligible for Medicare, since you’d be subject to a large penalty for not enrolling in Medicare in time.
Gaining Medicare Eligibility from a Working Spouse: If you’ve only lived in the U.S. for a few years, or have worked for less than 10 years, then you may not be eligible for Medicare on your own. In some cases, you may gain Medicare eligibility, including premium-free Medicare Part A, based on your spouse’s work history – even if you wouldn’t have otherwise qualified for Medicare.
If you’re married, divorced, or widowed from someone who did work for over 10 years to become eligible for Medicare, then you’ll probably be eligible to enroll in Medicare using your partner’s work history. You’ll want to apply at your local Social Security office to sort out the details.
Unfortunately, there is a Medicare Part B late enrollment penalty.
Medicare rules require you to enroll in Medicare Part B during your Initial Enrollment Period to avoid paying a late enrollment penalty that will be added to your Medicare Part B premiums. (As a reminder, unlike Medicare Part A, Medicare Part B isn’t free. You must pay for it out of your own pocket, or have it deducted from your monthly social security check.)
The Late Enrollment Penalty: The Medicare Part B late-payment penalty amounts to an increase of 10 percent for each 12-month period that you were late enrolling in Medicare Part B. For example, if you were eligible when you turned 65, but didn’t enroll until you turned 67, you will be charged 20 percent more in Medicare Part B premiums as everyone else, for as long as you have Medicare Part B. This penalty doesn’t go away, which is why you need to do everything you can to avoid it.
While government in general does have a lot of rules and regulations for little to no reason, I get the purpose of this penalty. The Medicare Part B late enrollment penalty is in place to help guide Medicare seniors to enroll in Part B at the right time.
Why Medicare Charges This Penalty: From an actuarial standpoint (the people who work for insurance companies and crunch the numbers), the older you are, the more you’ll need medical services. From Medicare’s perspective, they want you to enroll in Medicare as soon as you become eligible. It helps prevent Medicare seniors from waiting until they need a lot of medical services before they enroll. The technical insurance term is that they are trying to prevent “adverse selection”.
That said, there are many options for health insurance that’s not Obamacare. These Obamacare alternatives generally have very large doctor networks.
Christian health ministries, or faith-based healthcare, are religious charities that share the cost of healthcare among their members. Premiums can be as low as $100 per month. These plans have very specific rules about what they do and don’t cover. Around 1 million people are enrolled in faith-based plans. You won’t have to pay a tax penalty if you rely on this coverage.
Short-term health insurance lasts for up to 364 days at a time, with premiums as low as $50 per month. It won’t cover everything and will require you to pay thousands of dollars out-of-pocket before it shares the cost of your care. Short term plans are designed to affordably protect you in an emergency. They don’t cover pre-existing conditions or long-term health issues. Short term plans are popular with travelers, students, and those waiting for comprehensive coverage to begin. Around 160,000 plans are sold each year. You no longer have to pay a federal tax penalty if you rely on short term insurance, but it’s not available in all states.
Fixed-indemnity, or critical illness plans, give you predetermined amounts of money if you’re diagnosed with a certain disease (like cancer) or get into a specific accident (like losing a limb). You will not have to pay a federal tax penalty if you use fixed indemnity to replace Obamacare coverage.
Paying for care on your own is always an option, although it’s not a very affordable one.
You can also buy separate coverage for specific needs, like dental or vision insurance, from a number of insurers. Obamacare plans aren’t required to include dental and vision care.
If you have minimal income, you can apply for Medicaid, which is low-cost government insurance. There are different requirements to receive Medicaid in each state, and it must be renewed at least once per year.
Obamacare means your major medical health insurance must have certain coverage rules and consumer protections. On one hand, Obamacare plans won’t reject you for a pre-existing condition. Plus, you won’t be subject to a penalty under the individual mandate imposed by the Affordable Care Act. On the other hand, Obamacare insurance will charge you for 10 essential health benefits, even those that you don’t want.
Taking the Next Steps
Whether you’re considering on-Marketplace health insurance or something off-Marketplace, it’s good to take some time and research your options. Search our database of health insurance plans to find the right plan for each of you.
Adding to the confusion, pundits and the public alike use the term “Obamacare” to explain a myriad of loosely related healthcare issues that may or may not have anything to do with the law. Sometimes Obamacare is used to describe modern health insurance. Sometimes people use it to refer to individual plans, government-run insurance marketplaces, or specific health insurance reforms – like the ban on insurance companies rejecting people with pre-existing health conditions – that are found in the Affordable Care Act. Even changes to the Food and Drug Administration that were a part of the ACA can be called Obamacare. In reality, many aspects of healthcare in the US are mentioned in the Affordable Care Act.
The ACA is known as Obamacare because the law was associated with the President at the time it was signed. While the ACA was passed in 2010, most of the law didn’t come into effect until 2014.
Taking the Next Steps
Whether you’re looking for on-Marketplace or off-Marketplace health insurance, it helps to know that regardless of your choice, both kinds of plans are required to fulfill essential health benefits per the Affordable Care Act. Search our database of individual health insurance plans to find the right plan for you.
A health insurance deductible is the dollar amount you have to pay out-of-pocket for covered healthcare and medical services before your health insurance coverage “kicks in” and starts to cover the cost of your care. One exception to this occurs under the Affordable Care Act, as the law requires marketplace plans to cover the full cost of preventative care, whether or not a policyholder has fulfilled his or her annual deductible.
Health Insurance Deductible Amounts Can Vary by Metal Level: Annual health insurance deductible amounts vary from one health insurance plan to another. Plans with higher metal levels (such as “gold” or “platinum” plans) tend to have lower annual deductibles and higher monthly premiums. Plans categorized under lower metal levels (like “bronze” plans) tend to have lower monthly premiums and larger annual deductibles. In other words, plans with lower premiums have higher deductibles and vice versa.
Most insurance plans have two deductible amounts: an individual deductible, which applies to individuals who are the sole policyholders covered by their plan and a family deductible, which applies when more than one person is covered under the same plan.
We get this question a lot. If you know exactly what you want, you could sign up for health insurance in 10 minutes.
The signup process for health insurance is quite simple. Depending on whether you apply for health insurance, short-term health plans or Medicare Supplement, you’ll be asked slightly different questions. That said, it will take about the same amount of time to enroll in any of these options.
Online: Depending on the website, it can take fewer than 10 minutes to sign up for health insurance through an online application form. You’ll want to have your bank details and personal information on hand.
Once you enter your age and location information, it could take anywhere from a minute to an hour to choose a plan that you’d like to apply to. While you can filter plans based on their monthly cost, deductible or insurer, you also have the option of reading in-depth details about each plan. The amount of time that it takes to select an insurance policy will depend on how important of a decision that health insurance is for you.
Over the Phone: If you apply by calling a broker, HealthCare.com can connect you with a live broker in less than 20 seconds. We find that callers typically spend between 20 and 40 minutes on the phone when signing up for health insurance or a supplementary Medicare policy. Our partners will walk you through your options.
There’s generally a short health insurance waiting period between when you enroll in coverage and when your plan actually begins to cover you. Your waiting period will depend on the type of insurance you enroll in, and when you purchase it.
If you’re not comfortable going without insurance for 90 days, it’s possible to fill the gap in your coverage with a short-term insurance plan.
Obamacare Insurance Purchased During Open Enrollment or Special Enrollment: If you’re buying health insurance on your own, your health insurance waiting period generally starts on the:
First day of the following month, if you’ve enrolled within 15 days of the start of the current month. For example, if you buy health insurance on November 14, your coverage can start December 1; or the
First day of the month after next month, if you’ve enrolled once 16 days or more have passed during the current month. For example, if you signed up for health insurance on November 27, your coverage will start on January 1.
Immediately, if you adopt or give birth to a child.
Certain states may shorten delays in coverage if you apply during the Open Enrollment Period.
Employer-Based Health Insurance: If your company offers health insurance, they can postpone your coverage for up to 90 days after you begin work. However, coverage can start as soon as your first day on the job, depending on the plan your employer selects.
You can receive employer-based insurance even if you apply outside of the annual health insurance open enrollment period – starting a new job is a “qualifying life event” that allows you to purchase major medical health insurance. Similarly, if you have coverage elsewhere that ends after you’ve started work, you can sign up for employer-based insurance subject to the same health insurance waiting period.
Medicare: As long as you plan ahead, it’s easy for Medicare and supplementary Medicare coverage to begin on the first day of the month that you turn 65 years old. There are a number of Medicare rules that determine whether you’re automatically enrolled and when your coverage will begin.
Medicaid: If your application for Medicaid is approved, then coverage will begin on either the day that you applied or the first day of the month that you applied. The specific rules will depend on your state, and will be detailed in your application.
COBRA: Since you’re continuing your health insurance when you elect to use COBRA, there’s no health insurance waiting period to enroll.
Individual health insurance plans may offer dental care, but your plan isn’t required to include it. Dental coverage is frequently added to employer-based group plans, although they don’t have to provide dental care either.
Since dentistry isn’t considered an essential health benefit, there’s a great deal of variation between what each plan offers. You’ll have to check with your plan to see how it covers dentist checkups, tooth decay, and gum disease. Dentures and orthodontic work may or may not be treated the same as other basic dental needs.
There are plenty of surprisingly affordable dental-only insurance policies that are separate from your main health insurance. These will work like traditional health insurance, but will only cover dental care. You can compare standalone dental policies with HealthCare.com’s search engine.
Your health insurance must cover dental care to enrollees under 19 years old. Although you don’t have to purchase child dental coverage, it must at least be available as a benefit.
If you do include dental care with your health plan, then your premium and deductible will apply to dental care.
Medicare, Medicare Supplement, and Medicare Advantage
Does Medicare cover dental work? In general, Original Medicare (Parts A and B) does not cover the cost of dentures, routine dental exams, or tooth fillings. There are no Medicare Supplement plans that add dental coverage either.
Some Medicare Advantage plans (Medicare Part C) come with dental insurance.
Medicaid coverage varies by state. Some state Medicaid programs offer full oral health benefits, including coverage for root canals and crowns. As of 2016, seventeen states offer nothing more than emergency coverage, or no coverage at all. The Kaiser Family Foundation lists state-specific information regarding Medicaid coverage for dental care.
Recently discharged veterans may be eligible for routine dental care if they apply within 180 days of their discharge. If you have a service-related dental issue or a 100 percent disability rating, you can get dental care. If your dental health interferes with a surgery or certain vocational programs, you may also be able to receive dental care through the VA.
Flexible Savings Accounts (FSA) + Health Savings Accounts (HSA)
Virtually all medically appropriate dental care qualifies as an eligible FSA or HSA expense. Unlike FSAs, money in your HSA accumulates from year to year, allowing you to save toward the cost.
Taking the Next Steps
Using HealthCare.com’s search engine, you can browse a collection of affordable standalone dental policies for all ages.