INFO | Senior Insurance Specialty Group

Understanding HMO vs. PPO: Which Health Insurance Plan is Right for You?

Linde Mills — Thu, 05 Sep 2024 00:15:54 +0000

Choosing the right health insurance plan involves more than just comparing premiums and out-of-pocket costs. It’s also essential to understand how each plan covers preventive care, which can significantly impact your overall health and expenses. Let’s take a look at key differences between Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans, with a particular focus on preventive care coverage.

First – What is an HMO?

Health Maintenance Organization (HMO) plans are designed to coordinate and manage your care through a network of providers. Here’s how they typically work:

Primary Care Physician (PCP): You must choose a PCP who oversees your care and provides referrals to specialists.
Referrals Needed: Specialist care and certain tests may require referrals from your PCP.
Network Limitations: Coverage is generally limited to in-network providers, except in emergencies.
Lower Costs: HMO plans often feature lower premiums and out-of-pocket costs compared to PPOs.

Understanding Preventive Care in HMO Plans

Preventive care is essential for maintaining health and detecting potential issues early. Here’s what you need to know about how HMO plans cover preventive services:

Routine Screenings and Tests:

Bone Scans and Colonoscopies: HMO plans often cover these preventive services, but may have limits on the frequency of coverage. It’s important to check these details to avoid unexpected costs.
Mammograms and Pap Smears: These are generally covered, but the frequency of coverage might be subject to specific guidelines. For example, mammograms may be covered annually, while Pap smears might be covered every three years, depending on your age and health history.
Lab Tests: Limits on Coverage: HMO plans might have restrictions on certain lab tests or require referrals for specialized testing. For instance, routine blood work is usually covered, but advanced genetic tests or some imaging studies may have specific coverage rules or limitations.

Physicals vs. Wellness Visits:

Physicals: HMO plans usually cover annual physicals, which are comprehensive exams intended to assess overall health. However, you might need a referral from your PCP if the physical includes additional tests or procedures.
Wellness Visits: These visits focus on preventive care and maintaining health. They often include vaccinations, screenings, and counseling. HMO plans typically cover these visits as part of preventive care, but check with your plan for any specific coverage details or potential co-payments.

Preventive Care Coverage:

Routine and Preventive Services: Many preventive services are covered by Medicare without cost-sharing for in-network providers. This includes vaccinations, screenings, and counseling services. It’s important to verify that all recommended preventive services are covered and that you understand any potential co-payments.
Specialist Referrals: For most preventive care beyond routine check-ups, you may need a referral from your PCP to see a specialist or undergo certain tests. Many Medicare Advantage Plans in Tennessee do not require referrals to a specialist. Ensure that your PCP provides the necessary referrals if necessary to avoid additional costs and to stay within your plan’s coverage network.
Pap Smears: Medicare Part B covers Pap smears and pelvic exams for women to check for cervical and vaginal cancers. The exams also include a clinical breast exam to check for breast cancer. Medicare usually covers these screenings every 24 months, but more frequently if a woman is at high risk for cervical or vaginal cancer, or if she’s of childbearing age and had an abnormal Pap test in the past 36 months.

What is a PPO?

Preferred Provider Organization (PPO) plans offer more flexibility in choosing healthcare providers and accessing care:

No PCP Required: You can visit any doctor or specialist without a referral.
Network and Out-of-Network Coverage: PPO plans cover both in-network and out-of-network providers, though out-of-network care typically incurs higher costs. Keep in mind the provider has to be willing to bill the insurance company. The provider can refuse to bill the insurance company, so always check.
Higher Costs: PPO plans generally have higher premiums and out-of-pocket expenses.

Understanding Preventive Care in PPO Plans

PPO plans can vary in their coverage of preventive services. Here’s what to keep in mind:

Routine Screenings and Tests: Bone Scans and Colonoscopies: Some PPO plans have limits on how frequently these tests are covered. For example, bone density tests might be covered every two years, while colonoscopies may be covered every 10 years for average-risk individuals. Be aware of these limitations to avoid unexpected costs.
Mammograms and Pap Smears: These are often covered annually or biennially, depending on your age and risk factors. Check your plan’s specifics to understand the frequency and any potential out-of-pocket costs. Medicare Part B covers Pap smears and pelvic exams for women to check for cervical and vaginal cancers. The exams also include a clinical breast exam to check for breast cancer. Medicare usually covers these screenings every 24 months, but more frequently if a woman is at high risk for cervical or vaginal cancer, or if she’s of childbearing age and had an abnormal Pap test in the past 36 months.
Lab Tests: Limits on Coverage: PPO plans might have limits on certain lab tests or require pre-authorization for more expensive tests. For instance, genetic testing or advanced imaging may have specific coverage rules or limits.

Physicals vs. Wellness Visits:

Physicals: These are typically comprehensive exams that might include a review of your overall health and more extensive testing. Medicare does not cover physicals, however many Medicare Advantage both HMO and PPO do.
Wellness Visits: These are preventive visits focused on maintaining good health and preventing disease. They often include vaccinations and screenings.

Preventive Care Coverage:

Routine and Preventive Services: Medicare covers many preventive services without cost-sharing. This includes vaccinations, certain screenings, and counseling services. However, make sure your provider is in network with your PPO or HMO plan, and check if any specific services are excluded or require cost-sharing.

Understanding the differences between HMO and PPO plans is crucial for making an informed decision. HMO plans require in-network providers, with potentially lower costs but less flexibility, while PPO plans provide more freedom at a higher price point. Knowing how each plan covers preventive services, including limits on tests and screenings, can help you choose the plan that best fits your healthcare needs and budget. Always review the details of your plan carefully to ensure it aligns with your health goals and financial expectations.

Remember, we are here to help! Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

*We do not offer every plan available in your area. Currently, we represent 11 organizations that offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

10 Ways to Avoid Common Medicare Mistakes

MISG — Mon, 05 Aug 2024 23:27:13 +0000

Navigating Medicare can be complex, and making mistakes can lead to financial repercussions or missed opportunities for coverage. Whether you’re new to Medicare or reviewing your options, understanding common pitfalls can help you make informed decisions. Here are some key mistakes to avoid:

1.Missing Initial Enrollment Period (IEP) – Your Initial Enrollment Period begins three months before your 65th birthday month, includes your birthday month, and extends three months after. Failing to enroll during this window could result in delayed coverage and potential late penalties for Part B (medical insurance) and Part D (prescription drug coverage).

2.Not Understanding Coverage Gaps – Original Medicare (Parts A and B) doesn’t cover all healthcare costs. For comprehensive coverage, consider additional plans like Part C (Medicare Advantage) or Medigap (Medicare Supplement Insurance) plans. Without supplemental coverage, you may face significant out-of-pocket expenses.

3.Overlooking Part D (Prescription Drug Coverage) – Part D helps cover prescription drug costs. Not enrolling in a Part D plan when first eligible can lead to a penalty if you later need prescription coverage. Review plans annually during the Open Enrollment Period (October 15 to December 7) to ensure your medications are covered at the lowest cost.

4. Not Reviewing Medicare Advantage Plans Annually – Medicare Advantage plans can change their coverage, networks and costs each year. Failing to review your plan annually during the Open Enrollment Period could mean missing out on better coverage options or lower costs.

5.Assuming Medicare Covers Everything – Original Medicare covers many healthcare services, but not everything. For example, it doesn’t cover routine dental, vision, or hearing care. Understanding what’s covered and what isn’t can help you plan and budget for additional health expenses.

6.Choosing the Wrong Medigap Plan – Medigap plans help pay for costs that Original Medicare doesn’t cover, such as deductibles, copayments, and coinsurance. Each plan (labeled A through N) offers different coverage levels. Choosing the right plan depends on your healthcare needs and budget. Research and compare plans carefully.

7.Not Taking Advantage of Preventive Services – Medicare covers many preventive services at no cost to you, such as screenings for cancer, diabetes, and cardiovascular conditions. Regular screenings can catch health issues early when treatment is most effective.

8.Assuming Spousal Coverage Automatically Transfers – If you’re covered under your spouse’s employer health insurance and they turn 65 or retire, you may need to enroll in Medicare separately. Understanding coordination of benefits and enrollment timing can prevent coverage gaps.

9.Ignoring State and Federal Assistance Programs – Various programs offer financial assistance for Medicare premiums, copayments, and other healthcare costs based on income levels. Check eligibility for programs like Medicaid, Medicare Savings Programs, or Extra Help to reduce healthcare expenses.

10.Not Asking Questions or Seeking Help – Medicare rules and options can be complex. Don’t hesitate to ask questions, either through Medicare itself or a trusted insurance agent specializing in Medicare plans. Understanding your coverage options ensures you receive the care you need without unexpected costs.

Navigating Medicare requires attention to detail and proactive decision-making. By avoiding these common mistakes and staying informed about your options, you can maximize your benefits and ensure comprehensive healthcare coverage throughout your retirement years.

Remember, we are here to help! Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

Medicare Savings Programs: Are You Eligible?

MISG — Tue, 09 Jul 2024 00:16:51 +0000

Navigating the complexities of Medicare can be challenging, especially for individuals on fixed incomes or facing financial constraints. While Medicare provides essential healthcare coverage for millions of Americans aged 65 and older, many individuals struggle to afford the out-of-pocket costs associated with premiums, deductibles, and co-payments. Fortunately, Medicare Savings Programs (MSPs) offer financial assistance to eligible beneficiaries, providing a lifeline for those in need. In this blog post, we’ll explore what Medicare Savings Programs entail, who is eligible, and how these programs can make a meaningful difference in the lives of Medicare beneficiaries.

Understanding Medicare Savings Programs

Medicare Savings Programs are state-administered initiatives designed to help low-income Medicare beneficiaries afford their healthcare costs. These programs provide assistance with Medicare premiums, deductibles, coinsurance, and copayments, ensuring that eligible individuals have access to essential healthcare services without facing undue financial hardship.

Types of Medicare Savings Programs: There are several types of Medicare Savings Programs, each catering to different income levels and financial needs:

Qualified Medicare Beneficiary (QMB) Program: The QMB program helps individuals with incomes slightly above the federal poverty level (FPL) by covering Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments. Beneficiaries enrolled in QMB are not responsible for any Medicare cost-sharing expenses.
Specified Low-Income Medicare Beneficiary (SLMB) Program: SLMB provides assistance to individuals with incomes slightly above the federal poverty level but below 120% of the FPL. This program covers Medicare Part B premiums only, helping beneficiaries afford their monthly insurance costs.
Qualified Individual (QI) Program: QI is designed for individuals with incomes slightly above 120% of the federal poverty level but below 135% of the FPL. Like SLMB, QI covers Medicare Part B premiums, offering financial relief to eligible beneficiaries.
Qualified Disabled and Working Individuals (QDWI) Program: QDWI assists disabled individuals under 65 who are working, have lost their premium-free Part A coverage due to returning to work, and meet income and resource requirements.

Eligibility Criteria

Eligibility for Medicare Savings Programs is based on income and asset limits established by each state. While these criteria may vary slightly from state to state, individuals typically must have incomes below a certain threshold and limited resources to qualify for assistance. Additionally, eligibility for MSPs is separate from eligibility for other low-income assistance programs, such as Medicaid.

How to Apply

To apply for Medicare Savings Programs, you can contact your state’s Medicaid office or local Social Security Administration office. The application process may require providing documentation of income, resources, and Medicare enrollment. Upon approval, beneficiaries will receive notification of their eligibility and any assistance they qualify for under the program. If you live in Tennessee, we can help guide you!

Medicare Savings Programs offer a vital safety net for low-income Medicare beneficiaries, providing much-needed financial assistance to help cover healthcare costs. By easing the burden of premiums, deductibles, and other out-of-pocket expenses, MSPs ensure that eligible individuals can access the care they need to stay healthy and maintain their well-being. If you or someone you know is struggling to afford Medicare costs, explore the options available through Medicare Savings Programs and take advantage of this valuable support system. Your health and financial security are worth it.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

Understanding Medicare’s Preventive Services: What’s Covered?

MISG — Tue, 11 Jun 2024 11:46:31 +0000

Medicare isn’t just about providing healthcare coverage when you’re sick; it’s also about preventive care to help keep you healthy and catch potential issues early. Understanding what preventive services Medicare covers is crucial for beneficiaries to make the most of their coverage and prioritize their health and well-being. Today, we are going to explore Medicare’s preventive services, what’s covered, and how beneficiaries can take advantage of these essential healthcare offerings.

Preventative Service Options

Medicare offers a comprehensive array of preventive services aimed at maintaining health, preventing illnesses, and detecting medical conditions early when they’re most treatable. These services are divided into different categories, including:

Welcome to Medicare Visit: This initial preventive visit, available within the first 12 months of enrolling in Medicare Part B, includes a review of your medical and social history, vital measurements, and personalized health advice.
Annual Wellness Visit: After the first year of Medicare Part B coverage, beneficiaries are eligible for an annual wellness visit. During this visit, your healthcare provider will develop or update a personalized prevention plan based on your current health and risk factors.
Screening Services: Medicare covers a wide range of screening tests and services to detect various medical conditions early, such as cancer, cardiovascular disease, diabetes, and osteoporosis. These screenings may include mammograms, colonoscopies, bone density scans, and cardiovascular risk assessments.
Vaccinations: Medicare covers several vaccines recommended by the Centers for Disease Control and Prevention (CDC) to prevent illnesses such as influenza (flu), pneumococcal disease, and hepatitis B. Beneficiaries should check with their healthcare provider to ensure they’re up to date on recommended vaccinations.
Counseling Services: Medicare also covers counseling and education services to promote health and prevent disease. This may include counseling on topics such as smoking cessation, obesity, nutrition, and alcohol misuse.
Advance Care Planning: Medicare covers advance care planning discussions between beneficiaries and their healthcare providers to help them make informed decisions about their future medical care preferences.

Learn What is Provided

It’s important for Medicare beneficiaries to understand that while many preventive services are covered at no cost, some services may require payment of deductibles, coinsurance, or copayments. Additionally, coverage may vary depending on factors such as the beneficiary’s age, risk factors, and whether the service is provided by a participating Medicare provider.

Schedule Regular Appointments

To take advantage of Medicare’s preventive services, beneficiaries should schedule regular appointments with their healthcare providers and discuss which screenings and preventive measures are recommended based on their age, gender, and medical history. Staying proactive about preventive care can help beneficiaries stay healthy, detect medical conditions early, and ultimately improve their quality of life.

Medicare’s preventive services play a crucial role in promoting the health and well-being of beneficiaries across the nation. By understanding what preventive services are covered and how to access them, Medicare beneficiaries can take proactive steps to protect their health and enjoy a better quality of life in their golden years. Stay informed, stay proactive, and prioritize your health with Medicare’s preventive services.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

Medicare and Telehealth: How Virtual Visits Are Changing Healthcare

MISG — Mon, 06 May 2024 22:52:31 +0000

In recent years, telehealth has emerged as a transformative force in healthcare, offering patients greater access to medical services and providers without the need for in-person visits. This is particularly significant for Medicare beneficiaries, many of whom may face challenges accessing traditional healthcare due to mobility issues, transportation barriers, or residing in rural areas. Today we are exploring how Medicare is adapting to the rise of telehealth and the ways in which virtual visits are revolutionizing healthcare delivery for older adults.

The Rise of Telehealth in Medicare

Telehealth, encompassing services such as video consultations, remote monitoring, and electronic communication between patients and providers, has gained momentum within the Medicare program. Recognizing its potential to improve access to care and enhance patient outcomes, Medicare has expanded coverage for telehealth services over the years.

Medicare Coverage for Telehealth Services

Medicare coverage for telehealth services has evolved, especially in response to the COVID-19 pandemic. Temporary waivers and regulatory changes have enabled Medicare beneficiaries to receive a broader range of telehealth services from various providers, including doctors, nurse practitioners, and mental health professionals. These services encompass primary care, specialty consultations, mental health counseling, and chronic disease management, among others.

Benefits of Telehealth for Medicare Beneficiaries

Telehealth offers numerous benefits for Medicare beneficiaries, including:

Enhanced Access: Telehealth eliminates geographic barriers, enabling beneficiaries to connect with healthcare providers from the comfort of their homes.
Convenience: Virtual visits save time and effort associated with traveling to a healthcare facility, making it easier for older adults to access timely care.
Continuity of Care: Telehealth facilitates regular check-ins and follow-up appointments, promoting continuity of care and proactive management of chronic conditions.
Safety: Amidst public health concerns such as the COVID-19 pandemic, telehealth minimizes the risk of exposure to infectious diseases by reducing the need for in-person visits.

Challenges and Considerations

While telehealth offers significant advantages, certain challenges and considerations remain, including:

Digital Divide: Some Medicare beneficiaries may lack access to the technology or internet connectivity required for telehealth visits, exacerbating disparities in healthcare access.
Reimbursement and Regulation: Medicare reimbursement policies and regulatory frameworks for telehealth services continue to evolve, impacting provider participation and sustainability.
Patient-Provider Relationships: Establishing and maintaining rapport through virtual interactions may pose challenges for some patients and providers, emphasizing the importance of effective communication and technology literacy.

Looking Ahead

As telehealth becomes increasingly integrated into the healthcare landscape, it is positioned to play a central role in Medicare’s efforts to improve access, quality, and efficiency of care delivery. Continued innovation, policy refinement, and investment in infrastructure are essential to maximize the potential of telehealth in meeting the evolving needs of Medicare beneficiaries.
Telehealth represents a promising avenue for transforming healthcare delivery for Medicare beneficiaries, offering greater convenience, accessibility, and quality of care. By embracing telehealth and leveraging its benefits, Medicare is paving the way for a more patient-centered and technologically advanced healthcare system.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!
*We do not offer every plan available in your area. Currently, we represent 11 organizations that offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

10 Easy Ways to Make the Most of Your Medicare Coverage

MISG — Tue, 02 Apr 2024 14:57:22 +0000

Ah, Medicare – your ticket to quality healthcare as you enjoy your golden years. But are you getting the most out of this valuable benefit? Here are some tips to help you squeeze every last drop of coverage goodness out of your Medicare plan!

Get to Know Your Medicare ABCs
Understanding the different parts of Medicare can feel like decoding a secret message, but fear not! Part A covers hospital stays, Part B covers medical services, Part C (Medicare Advantage) bundles Parts A and B, and Part D covers prescription drugs. Knowing these basics will help you navigate your coverage like a pro.
Enroll at the Right Time
Enrolling in Medicare during your Initial Enrollment Period (IEP) is crucial to avoid late enrollment penalties. If you miss your IEP, you can enroll during the General Enrollment Period (GEP), but it’s best to get it done early to keep those penalties at bay.
Explore Extra Coverage Options
Consider adding a Medicare Supplement (Medigap) plan or enrolling in a Medicare Advantage plan to beef up your coverage and minimize out-of-pocket costs. It’s like adding sprinkles to your ice cream – extra goodness all around!
Give Your Coverage a Check-Up
Your healthcare needs change, so it’s essential to review your Medicare coverage annually during the Annual Enrollment Period (AEP). Make sure your plan still fits your needs and budget, and make changes if necessary.
Take Advantage of Preventive Services
Did you know that Medicare covers a slew of preventive services? From screenings to vaccines to annual wellness visits, these services can help you stay healthy and catch any potential health issues early. It’s like a healthcare spring cleaning for your body!
Know Your Prescription Drug Coverage
If you have Medicare Part D prescription drug coverage, stay on top of your plan’s formulary to ensure your medications are covered. Consider switching plans if your current one no longer fits the bill. Keep in mind if you change plans and do not have a prescription drug plan you could end up with a penalty unless your current prescription plan is considered creditable with Medicare.
Stick with In-Network Providers
If you’re on a Medicare Advantage plan, sticking with in-network providers can help you maximize your coverage and keep costs down. It’s like shopping at your favorite store – you get the best deals when you stay loyal!
Embrace Telehealth
Telehealth services are a convenient and cost-effective way to receive healthcare services. Give them a try when appropriate to save time and money – plus, you can stay in your PJs!
Don’t Take No for an Answer
If Medicare denies coverage for a service or treatment, you have the right to appeal. Don’t be afraid to stand up for yourself and fight for the coverage you deserve.
Stay Informed and Stay Healthy
Stay informed about changes to Medicare coverage and regulations. Follow reputable sources for Medicare news and updates to ensure you have the most up-to-date information. And most importantly, take care of yourself – because your health is the ultimate wealth!

By following these tips, you can make the most of your Medicare coverage and ensure you’re getting the healthcare you need, when you need it. Cheers to your health!

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

The Pros and Cons of Medicare Supplement Insurance (Medigap)

MISG — Wed, 13 Mar 2024 01:10:14 +0000

As Medicare experts, we often get asked about the benefits and drawbacks of Medicare Supplement Insurance, also known as Medigap. Understanding these can help you make an informed decision about whether this type of coverage is right for you. Today we are going to review the pros as well as the cons having Medigap.

Pros:

Coverage of Medicare Gaps: One of the biggest advantages of Medigap plans is that they help cover the “gaps” in Original Medicare, such as deductibles, copayments, and coinsurance. This can provide you with greater financial predictability and protection against high out-of-pocket costs.
Freedom to Choose Providers: With Medigap plans, you can typically see any healthcare provider who accepts Medicare. This can be advantageous if you want to continue seeing a specific doctor or specialist without worrying about network restrictions.
No Referrals Needed: Unlike some Medicare Advantage plans, Medigap policies do not require referrals to see specialists. You have the freedom to visit any specialist without needing approval from a primary care physician.
Coverage While Traveling: Many Medigap plans offer coverage for emergency medical care when you’re traveling outside the United States. This can provide peace of mind for seniors who enjoy traveling or spending time abroad.
Guaranteed Renewable: As long as you pay your premiums on time, your Medigap policy is guaranteed renewable. This means the insurance company cannot cancel your coverage as long as you continue to pay your premiums.

Cons:

Higher Premiums: Medigap plans typically have higher monthly premiums compared to Medicare Advantage plans. However, this trade-off can be worthwhile for those who want more comprehensive coverage and predictable out-of-pocket costs.
Requires Original Medicare: To enroll in a Medigap plan, you must already be enrolled in both Medicare Part A and Part B. This means you’ll need to pay the premiums for Part B in addition to your Medigap premiums.
No Prescription Drug Coverage: Medigap plans do not cover prescription drugs. If you want this coverage, you’ll need to enroll in a separate Medicare Part D plan.
Limited Enrollment Period: The best time to enroll in a Medigap plan is during your six-month Medigap Open Enrollment Period, which starts the month you’re 65 and enrolled in Medicare Part B. Outside of this period, you may be subject to medical underwriting, which could result in higher premiums or denial of coverage.
Plan Standardization: Medigap plans are standardized in most states, meaning the coverage for each plan type is the same regardless of the insurance company. While this simplifies comparison shopping, it also means you may not find as much variation in coverage options.

Medigap plans offer valuable benefits for Medicare beneficiaries who want greater financial protection and flexibility in their healthcare choices. However, it’s important to weigh the pros and cons carefully and consider your individual healthcare needs and budget before making a decision.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

Physicals are NOT Covered with Medicare, but a Wellness Visit IS!

MISG — Mon, 05 Feb 2024 23:52:30 +0000

Most of us have had experiences with a yearly physical exam. These routine exams are a procedure that allows your provider to assess your general health. Most private insurance plans cover these yearly physicals, however, Medicare Part B does not. Instead, Medicare Part B covers a one-time exam called an Initial Preventive Physical Examination (IPPE), and then afterward, an annual wellness visit.

First, What Does an IPPE Visit Include?

When you first enroll in Medicare, they allow you an IPPE that is covered one time, within the first 12 months of receiving Medicare Part B coverage. This initial physical exam will cover the following items to assess your overall health:

Record and evaluate your medical and family history, current health conditions and prescriptions.
Check your blood pressure, vision, weight, and height to get a baseline for your care.
Make sure you are up to date with preventive screenings and services, such as cancer screenings and shots.
Order further tests, depending on your general health and medical history.
You do not pay a copayment for your “Welcome to Medicare” visit. The Part B deductible does not apply to the cost of the visit either.

When the exam is complete, your provider will give you a prevention plan, or list, of screenings and preventive services that are recommended for you. *These services are not part of the “Welcome to Medicare” visit and may require you to pay a copayment when you get them. Your Part B deductible may also apply. *

>>New to Medicare? Make sure you sign up for your Medicare.gov account!

Physical Exams vs. Wellness Visit

What’s Included in a Physical Exam?

An annual physical exam is an assessment of your body’s overall health. The primary purpose is to look for health issues. The list below shows some of the things your doctor may do during a physical exam (This is not a comprehensive list).

Visually check your body overall for signs of existing health issues
Look into your eyes, ears, nose and throat for potential problems.
Listen to your heart and lungs to detect irregular sounds.
Check your body for abnormalities.
Test your motor function and reflexes.
Perform pelvic and rectal exams.
Measure your weight, height and blood pressure.

Again, as a rule, Medicare does not cover annual exams. This and any recommended testing or screenings are separate services, so there may be additional costs related to each depending on your Medicare plan.

What’s included in a Medicare Wellness Visit?

A Medicare Wellness Visit (wellness exam) is a review of your overall health and well-being by combining information from your visit with your medical records to assess your risk for common preventable health issues such as heart disease, type 2 diabetes and cancer. The purpose of a wellness visit is to develop a baseline for current well-being and prevent future issues. Medicare covers a wellness visit on time every 12 months (11 full months must have passed since your last visit), once you have had Medicare Part B for 12 months, you are eligible for it. Based on what’s learned, your provider will create a prevention plan including screenings you should have.

Some of the things your provider may do during a wellness exam (this is not a comprehensive list).

A health risk assessment (questions you answer about your health)
A review of your medical and family history
A review of your current prescriptions and providers
Measure and document your height, weight, and blood pressure
Look for signs of memory loss, dementia or frailty
Assess your health risk factors and treatment options
Provide specific health advice
Develop a screening schedule for the preventive services recommended for you

Although Medicare Part B covers your annual wellness exam and many preventive screenings with no copay or deductible, if your provider performs additional services and tests during your appointment that aren’t covered, you will be responsible for these costs. Be sure to state clearly to your provider and their office that this is a Medicare Wellness visit and NOT an annual physical to avoid unexpected bills.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

The Importance of a Medicare.gov Account

MISG — Sun, 07 Jan 2024 23:44:58 +0000

Your online Medicare account (previously called MyMedicare account), is a helpful online portal that lets you manage your Medicare plans at any time, from anywhere you have an internet connection. A great benefit to accessing this account is saving time as opposed to calling a Medicare agent with your questions.

The Information You Can Access

When you access the Medicare.gov website, there is a lot of information for Medicare beneficiaries, along with information for those beginning their Medicare journey.

Without an account, you can use the Medicare.gov website to:

Learn basic information about Medicare
Learn how health plans and drug coverage work
Learn what Medicare covers
Find health and drug plans in your area
Compare health and drug plans
Find care providers
Compare hospitals, nursing homes, and other providers near you
Learn how to sign up for coverage
Locate forms, publications, and information about things Medicare mails you
File claims, complaints, and appeals
Use Medicare’s live chat feature (available 24/7 except some holidays)
If you’re not ready to create an account yet, you can sign up for news and updates at the bottom of the Medicare.gov website’s homepage. They will email you things like reminders about open enrollment and ways to save costs.

Additional benefits to creating your own account:

View your Medicare Summary Notice within 24 hours of your visit
Manage details and claims
Add your prescriptions to help you better compare health and drug plans in your area.
View your Original Medicare claims as soon as they’re processed.
Print a copy of your official Medicare card.
Review a list of preventive services you’re eligible to get in Original Medicare.
Learn about your Medicare premiums, and pay them online if you get a bill from Medicare.
Receive letters
Retain a record of your drugs, pharmacy preferences, and see information about your current coverage. This information is especially useful when comparing alternative coverage plans.
Add your prescriptions to help you better compare health and drug plans in your area.
Review a list of preventive services you’re eligible to get in Original Medicare.
Learn about your Medicare premiums, and pay them online if you get a bill from Medicare.

Signing Up for Your Medicare.gov Account

REMEMBER: The government uses .gov web addresses, make sure that the site you are applying on is the official Medicare.gov website.

You will need your Medicare number to create your account, along with your Part A or Part B start date, both of which can be found on your Medicare card. If you don’t have your Medicare card yet, you can log into your secure Social Security account to get your Medicare Number, or call 1-800-MEDICARE (1-800-633-4227) for help. TTY users can call 1-877-486-2048.

Things to note:

If you join a Medicare health or drug plan, your plan may offer an online account to track your claims.
Give Medicare permission to talk to someone you trust such as a spouse, family member or care giver. Medicare cannot share any information about your Medicare account, like claims or billing, unless you give them written permission first. Fill out and mail an authorization form or log into your Medicare account to permit them.

It is not a requirement to create a Medicare.gov account to use Medicare services, but it definitely has its advantages. We encourage you to take a moment and review your options and what you may get out of it. If you have additional questions, we are always happy to help!

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!

*We do not offer every plan available in your area. Currently, we represent 11 organizations which offer 126 products in your area. You can contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance Program for help with plan choices.

How an Explanation of Benefits HELP You

MISG — Fri, 01 Dec 2023 02:51:22 +0000

You have received an Explanation of Benefits (EOB), but what IS it, exactly?

An EOB is NOT a Bill

Let’s go ahead and clear this one up. An EOB is not a bill! An EOB is there specifically to help you understand the charges for any visits or prescription claims.

If It’s NOT a Bill, Why Do You Want It?

While an EOB is not a bill, It is an important document from your insurance provider that explains how your insurance processed the claim for the services you received. It also details how much your health plan covers on these services and what you should owe when you get a bill from your provider. Anyone enrolled in Medicare Advantage and Medicare Prescription Drug Plan (Part D) will receive an EOB the month after a claim.

What Information Your EOB will Include

Your EOB will include information about several things:

You as a patient
Your health plan
Who your provider was
Date care was provided
Description of service provided
A claim number (could be called a reference number)
Cost of care (provider charges)
Amount provider will be paid (allowed charges)
How much your health plan will pay your provider
What you owe after the insurer has paid
May show some (not all) of your copayment or coinsurance payments you have made
The person who will get reimbursed if there are overpayments

How to Use This Information

This detailed EOB can assist in helping you determine if the bills from your provider are correct.

One example may be the ambulance service. Often they do not obtain your insurance information. This could result in an expensive bill to you directly that could be paid, or partially paid, by your insurance. Seeing that your ambulance bill is NOT on your EOB is a red flag that you will need to contact them and give them your insurance information.

Other issues could include billing from diagnostics, hospital care, dental, and vision with the advantage plans. You always should be looking at your EOBs to verify that these bills are accurate and have gone through your insurance.

A Few More Things

If you have not received an EOB or have misplaced it, you should contact your insurance company as soon as possible. A representative will verify your mailing address or confirm if you have a paperless option chosen. If you have a paperless option, you may be able to view your EOB at any time.

Give Karen or Matt a call with any questions at 865-203-2040 or email us at contact@seniorinsurancespecialty.com!