Medicare can be confusing and lead to unexpected costs. This is especially true if you’re not informed on the front end when you first become eligible for Medicare; or, if you delay enrollment, when you enroll that first time. The three most common surprise-cost culprits sprung on those new to Medicare include:
1.) Medicare Income-Related Monthly Adjustment Amount (IRMAA)
2.) Part B late enrollment penalty (LEP)
- For each 12-month period you delay enrollment in Medicare Part B, you may have to pay a 10% Part B premium penalty, UNLESS you have other credible coverage that is compliant with Medicare rules (such as insurance based on your or your spouse’s job-based insurance).
3.) Part D late enrollment penalty (LEP)
- For each month you delay enrollment in Medicare Part D (Prescription Drug Plan), you may to pay a Part D late enrollment penalty unless you have creditable coverage that is as good or better than the basic Part D benefit or get “extra help” (Low Income Subsidy).
The good news, if you want to call it that, is if you get dinged for income adjustments or penalties – Yes, you can appeal.
In cases of IRMAA adjustments you can request a new initial determination right out of the chute if you have experienced a life-changing event that caused an income decrease, or if you think the income information Social Security used in making the initial determination is incorrect. If you don’t agree, you can also file for reconsideration or file an appeal.
You can also appeal your Part B and/or your Part D Late Enrollment Penalties (LEP) though the processes for doing so are different for Part B and Part D.
For Part B LEP, just follow the instructions on the notice that you received informing you of the penalty. You will need to prove that you were enrolled either in Part B or in coverage through current employment during the period of time for which you are being penalized.
For Part D LEP, you can appeal the penalty if you think you were continuously covered or if you think the amount of the penalty was calculated incorrectly. This appeal must be filed with Medicare’s contractor (MAXIMUS Federal Services) for handling appeals.
For more information on adjustments, penalties and how to file an appeal refer to this month’s Medicare Minute Newsletter courtesy of The Medicare Rights Center.
And go to:
Medicare Part B Premium Appeals | HHS.gov
Medicare IRMAA Life Changing Event Form
Late Enrollment Penalty (LEP) Appeals
If you have questions, we are happy to help:
Phone: 866-845-8600; Ext 130
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- Tom Barrett
- February 13, 2020
- confusion, cost, costs, coverage, employees, federal, health plans, healthcare, insurance, medical, medicare, penalties
- 0 Comments
There are four basic parts of Medicare: A, B, C, and D. Each part helps pay for certain medical services. Here are 5 things to know about Part A:
#1 Part A is one of two parts of what is considered “Original Medicare”. (Part B is the other).
#2 Most people don’t have to pay a premium for Part A. They’ve already paid into the system in the form of the Medicare tax deductions in their paycheck if they (or their spouse) worked at least 40 calendar quarters (10 years) in the U.S.
#3 Medicare Part A helps cover the costs of inpatient care in the hospital, short-term skilled nursing facilities, home health care, and hospice care.
#4 Benefit periods apply. These benefit periods measure the use of inpatient hospital and skilled nursing facility services. Medicare will stop paying for your inpatient-related hospital or skilled nursing facility costs (such as room and board) if you run out of days during your benefit period.
#5 Most people either add a Medicare Supplement (Medigap) Plan or they opt to enroll in a Medicare Advantage Plan. Both of these options in different ways can serve to limit liability, extend benefit periods, and cover some out of pocket costs (like deductible and coinsurance) associated with Medicare Part A.
You can read more about Medicare Part A covered services in this Medicare Minute Newsletter courtesy of the Medicare Rights Center.
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- Tom Barrett
- January 28, 2020
- cost, costs, coverage, federal, healthcare, hospital costs, hospital coverage, insurance, medical, medicare, Medicare Part A
- 0 Comments
‘Tis the season for open enrollment in the world of health insurance! Open enrollment for Medicare 2020 has already begun (October 15th – December 7th, 2019). Additionally, individual open enrollment is underway (November 1st – December 15, 2019). Lastly and most important to this article is the fact that many employers are in the midst of their group health plan open enrollment. Many group plans renew January 1st so it’s a busy time of year for employers, brokers, and insurance carriers.
This article is designed to assist employers in knowing what to focus on during this busy season.
The most important thing we need to focus on is the premiums that you pay to the insurance carriers. We know this is a huge expense and we work with you to keep this competitive to what’s available in the marketplace.
Most of the January 1st group health insurance renewals are out. Perhaps your increase is palatable enough to forgo shopping and just renew as is. However, that is more the outlier than the norm. Typically, it’s best to assist us with the necessary data needed in order to shop your policy with the competing carriers in the marketplace. By now, your account managers at BBG have been working hard to gather the necessary data for shopping. These items include:
- Current Census
- Average Total Number of Employees (ATNE). This is based on how many total employees you employed each month and dividing by 12. Estimates are used for the remaining months of the year.
- Names of your employees who are eligible but waive off the plan
- The reason they are waiving
- If you are a 51+ group we’ll need what is called an Employer Risk Assessment Form (ERAF)
The above will allow us to obtain street rates in the small group market place and potentially underwritten rates in the 51+ marketplace. Street rates are off the shelf rates that are based on your group’s census alone. They are still subject to underwriting but give us a good benchmark to know if we should pursue underwritten rates
Medical Health Questionnaires (MHQs)
The dreaded MHQs need not be so dreaded anymore! Most insurance carriers prefer to receive electronic MHQs via programs like FormFire. Some carriers now require FormFire MHQs. BBG has dedicated team members who can assist your employees in completing this process. We’ve worked hard this year to streamline the process to allow us to help a larger number of you in a shorter amount of time.
So when are MHQs needed? This answer is different depending upon what market segment you are in…
1-50 Small Groups
If you have 50 and under total employees, FormFire MHQs will be needed to obtain underwritten rates from any competing carriers. However, BBG is all about efficiency so we first obtain street rates to determine if this is even worthy of your time. If we determine that it is then we highly suggest proceeding with FormFire.
The only exception here is when we obtain community rates. Community rates are different from underwritten rates and are typically more expensive than their underwritten counterparts. We’ve been finding that mostly micro groups and other groups with certain characteristics that may adversely impact underwriting are served best by community rates.
51-99 Mid-Size Groups
If you have between 51-99 total employees some carriers require MHQs to release any underwritten rates. However, there are a few carriers who will release underwritten rates if your renewal is <25% and you’ve completed an ERAF.
100+ Large Groups
Typically MHQs are not needed in the 100+ market segment; although, there are exceptions where MHQs can be helpful. Your account manager will assist to know when this applies to you.
When Not to Shop the Market
There are only two instances when it makes sense to not shop the market. 1.) If you are in the 51-99 market and your incumbent carrier asks for your “no shop” number. A no shop number is an increase you are willing to accept in agreement for not shopping.
In our experience, if a carrier is asking for your “no shop” number, they are willing to play ball and negotiate. If you are not sure what a reasonable no shop number is, talk to your account manager and they can assist you with this. However, you can always be aggressive and ask for a flat increase. What’s the worst they can say? No? If the carrier cannot meet it, we can always shop your policy.
2.) Or if you are in the 1-50 market your incumbent carrier may be able to provide some rate relief in an agreement to not shop your policy. The amount of rate relief available in the small group market is much smaller but if you received a favorable renewal a few points of rate relief may be enough for you to decide to stay put. Your account manager and BBG will let you know if this is a feasible option for your specific group.
At BBG, we are fully aware that the most important work we do is to assist the employers we work for in keeping healthcare costs and the coverage your employees receive competitive to what’s in the marketplace. The most important benchmark number we look at is your average cost per employee per year. This number is found by taking your total costs and dividing by your total employees enrolled in the health plan. We realize your enrollment can fluctuate and by looking at this number we are looking at a comparable number year over year.
Open enrollment is always a busy time of the year but the exercise of shopping, completing FormFire, and allowing BBG to negotiate with the carriers on your behalf is the important work. This work allows you to maintain strong benefits year after year.
An ‘Annual poll of employers by Kaiser Family Foundation finds premiums rose 5% for family plans; ‘It’s the cost of buying an economy car.’
Let us show you how we help our employees operate at substantially below this scary number through SharedFunding.
Click here for The Wall Street Journal article for more insights into the survey results.