When you turn 65 and enroll in Medicare you will likely be presented with many options. Your inbox and mailbox may suddenly become flooded. If you choose to work with a broker, you will have someone to guide you as you pick the best option for your needs. In addition to gathering helpful paperwork and information, there are many questions you can ask to own your medicare conversation.
Medigap vs. Medicare Advantage
The first question to ask your broker is whether you should choose a Medigap plan aka medicare supplement or if you should go with medicare advantage. It is a common Medigap vs. Medicare Advantage battle!
Medigap
Original Medicare is excellent coverage, but there are definitely gaps. There are copays and deductibles and there is no out of pocket maximum. As a result, if you have extensive medical needs, you may end up with rather large medical bills. This is why many people turn to a Medicare supplement plan. With one of these types of plans, you will pay an additional monthly premium, but you will drastically reduce or entirely eliminate your deductibles and copays. Think of it as more of an all inclusive approach to health insurance.
Medicare Advantage
Medicare Advantage will replace the original medicare entirely. You will still have access to at least the same benefits as Original Medicare and likely additional benefits as well. Additionally, you will usually have lower deductibles and copays with oop maximums. Unfortunately, you will give up access to the extremely broad original medicare network. This can be very limiting.
Your broker will be able to discuss with you your financial and medical concerns to guide you toward the most appropriate option. They will also take into consideration your geographical location. In some areas of the country, medicare advantage plans can work wonderfully. In others, not so much.
Medicare Savings Programs
You may also want to ask your broker if you are eligible for any of the Medicare Savings Programs. Many people are surprised to find that there is a monthly premium for Medicare. Most people only pay for Medicare Part B, but if you are living on a fixed income, it could still be tight.
There are 4 Medicare Savings Programs.
Qualified Medicare Beneficiary Program (QMB)
To be eligible for the Qualified Medicare Beneficiary Program, you must meet resource and monthly income limits. Your resources are namely your liquid assets:
- Money in a checking or savings account
- Stocks
- Bonds
***You do not have to count up to $1500 set aside for any funeral expenses.
| Individual | $1,153 | $8,400 |
| Married couple | $1,546 | $12,600 |
However, limits are slightly higher in Alaska and Hawaii. If you have income from working, you may qualify for benefits even if your income is higher than the limits listed. Also, limits tend to increase each year, so please apply even if you don’t meet these exact financial criteria.
If you are eligible for the Qualified Medicare Beneficiary Program, you will receive assistance paying for Part A and/or Part B premiums. Medicare providers aren’t allowed to bill you for services and items Medicare covers. This includes deductibles, coinsurance, and copayments, except outpatient prescription drugs. Also, you will be automatically enrolled in “Extra Help”, which is the program that helps pay for Medicare Part D.
Specified Low-Income Medicare Beneficiary Program (SLMB)
Like the QMB Program, the Specified Low-Income Medicare Beneficiary Program has monthly income limits and resource limits.
| Individual | $1,379 | $8,400 |
| Married couple | $1,851 | $12,600 |
Because the income requirements are a little less stringent, the SLMP Program onlyhelps pay for Medicare Part B premiums. However, you will still be automatically enrolled in the Extra Help program for Medicare Part D.
Qualified Individual Program (QI)
The Qualified Individual Program is a little bit different. The income limits are a little bit less stringent, but it is harder to enroll. Applications are granted on a first-come, first-served basis. Additionally, you must re-apply every year. That being said, priority is given to those who are re-enrolling. Also, you cannot get QI benefits in conjunction with Medicaid benefits.
| Individual | $1,549 | $8,400 |
| Married couple | $2,080 | $12,600 |
The QI program will help pay for your Medicare Part B premiums. Also, you will still be automatically enrolled in the Extra Help program for Medicare Part D.
Qualified Disabled and Working Individuals Program (QDWI)
Finally, there is the Qualified Disabled and Working Individuals Program. The QDWI program will only help to pay for the Medicare Part A premium. Many people already have a $0 Part A premium. You may want to look into the QDWI program if:
- You’re a working disabled person under 65
- You lost your premium-free Part A when you went back to work
- You aren’t getting medical assistance from your state
However, if you are still working, once you’ve met the 40 working quarters required your monthly premiums will disappear. At that point, you will no longer need the QDWI program. However, in the meantime, it may help to ease your financial burden. Additionally, you’ll still need to meet specific financial criteria.
| Individual | $4,615 | $4,000 |
| Married couple | $6,189 | $6,000 |
With the QDWI program, you will not be automatically enrolled in Extra Help. However, you can still apply with form SSA-1020B.
Special Needs Plans
You will also want to discuss any special needs plans that you may be eligible for, namely DSNPs and CSNPs.
DSNPS are dual eligibility special needs plans. This is if you are eligible for Medicare and Medicaid. They are a special type of Medicare Advantage plan that offers the full benefits of Medicare, plus Medicaid and many additional benefits as well. These plans offer major cost savings and many added benefits, so if you are eligible, you will want to discuss this option with your broker.
CSNPs are another type of medicare advantage plan. These are chronic illness special needs plans. They are medicare advantage plans designed for those with specific chronic illnesses.
There is a very long list of chronic conditions which may make you eligible. These are further divided into subcategories. There may be additional criteria based on your condition.
Network and Coverage
You’ll also want to review your plan’s network and costs with your broker. If you have doctors and hospitals that you wish you use, confirm with your broker that they are in the network. This only applies to Medicare Advantage Plans. Medicare Advantage works more like traditional health insurance so you will need to stay in network in order to be covered. If you choose a Medicare Supplement Plan, you will be able to see and visit any hospital that accepts Medicare. And almost all do.
If you are looking at Medicare Advantage or Medicare Part D for prescription drugs, you will also want to get an idea of what the costs might be according to your plans’ terms.
Reviews and Increases
Finally, when choosing a plan, make sure to ask your broker about their familiarity with the carrier. Some carriers may have a better reputation for customer service. Some may be more difficult to work with. Your broker may also offer to help with any customer service issues down the line with a plan you purchase through them.
Also, ask about rate increases. Yes, plans do tend to increase on a yearly basis, but some carriers have a more stable history than others. This is something you’ll want to consider.
Jesse Smedley is the Principal Broker for iHealthBrokers and the founder, president, and CEO of Smedley Insurance Group, Inc. and iHealthBrokers.com. Since the inception of SIG in 2007, Jesse has been dedicated to helping people save money on their health insurance by providing them with resources to educate themselves on all their health insurance options, both under age 65 and Medicare beneficiaries. He is featured in many publications as well as writes regularly for expert columns regarding health insurance and Medicare.
