Medicare is a critical program that provides health insurance to millions of Americans aged 65 and older, as well as to younger individuals with certain disabilities. Medicare Part B is a key component of this program, offering coverage for essential medical services and preventive care. Let’s delve into the details of what Medicare Part B covers and why it’s important for beneficiaries to understand this coverage.

Understanding Medicare Part B

Medicare is divided into different parts, each covering specific healthcare services. Part B, often referred to as medical insurance, focuses on medically necessary services and preventive care to help maintain your health and treat medical conditions. Unlike Medicare Part A (hospital insurance), which covers inpatient hospital stays, Part B primarily addresses outpatient services.

Services Covered by Medicare Part B

Here’s a breakdown of what Medicare Part B typically covers:

1. Doctor’s Services: Part B covers visits to doctors and other healthcare providers for medically necessary services, including office visits, specialist consultations, and certain outpatient care.
   
   
2. Outpatient Care: This includes a wide range of services and supplies needed as part of treatment on an outpatient basis, such as lab tests, X-rays, durable medical equipment (like wheelchairs or walkers), and some prescription drugs administered in a doctor’s office.
   
   
3. Preventive Services: Medicare Part B emphasizes preventive care to help catch health issues early or prevent them altogether. This includes screenings for conditions like cardiovascular disease, diabetes, and cancer, as well as vaccinations like flu shots.
   
   
4. Ambulance Services: Part B covers medically necessary ambulance transportation to a hospital or other medical facility when other transportation could endanger health.
   
   
5. Mental Health Services: Coverage includes outpatient mental health services like counseling and therapy from licensed professionals.
   
   
6. Some Prescription Drugs: Part B covers specific prescription drugs, such as those used with durable medical equipment (like insulin for diabetes), certain vaccines (like flu shots), and certain medications administered in a clinical setting.
   
   
7. Other Services: Part B also covers a range of other services deemed medically necessary, like physical therapy, occupational therapy, and some home healthcare services.

Costs and Enrollment

Understanding the costs associated with Medicare Part B is crucial for beneficiaries. While most people do pay a standard premium for Part B coverage, the amount can vary depending on income. Additionally, Part B typically requires beneficiaries to pay an annual deductible and coinsurance or copayments for covered services.

Enrollment in Medicare Part B usually occurs automatically if you’re receiving Social Security benefits when you turn 65. However, if you’re not automatically enrolled, you’ll need to sign up during specific enrollment periods to avoid late enrollment penalties.

The Importance of Supplemental Coverage

Despite its comprehensive coverage, Medicare Part B does not cover all medical expenses. Many beneficiaries choose to complement their Part B coverage with additional insurance plans, such as Medicare Supplement (Medigap) policies or Medicare Advantage plans, to help cover deductibles, copayments, and services not covered by Medicare.

Medicare Part B plays a crucial role in providing essential medical coverage to older adults and individuals with disabilities. By understanding what Part B covers and how it fits into the broader Medicare program, beneficiaries can make informed decisions about their healthcare needs. If you have specific questions about Medicare Part B or need guidance on choosing additional coverage options, contact us at Hilgerman Insurance Solutions where we can guide you through every step of the way.

Hilgerman Insurance Solutions of Camarillo is an independent insurance agency that specializes in the senior market, while offering health insurance solutions for small businesses and individuals. We are contracted with most of the top insurance providers to offer you plans that best suit your needs, all with personal hands-on service and support. 

Our commitment is to provide expertise, friendly service along with a timely response. Please feel free to contact us today for a quote and/or no-cost consultation.   

Hilgerman Insurance Solutions
(805) 279-5482
deb@hilgermanins.com  
www.hilgermanins.com

1.  How your Initial Deductible affects what you pay for formulary drugs.
2.  Reminder:  What to do if your prescription is not covered by your 2024 Medicare drug plan.

1.  How your Initial Deductible affects what you pay for formulary drugs.

Question:  How does the Part D Initial Deductible work?  I use a drug with a $43 copay, but the pharmacy charged me $350.

If your Medicare Part D plan has a deductible (the standard 2024 Medicare Part D deductible is $545), you must pay the deductible before your Medicare plan coverage begins to pay a share of the retail drug cost – unless you are purchasing:
– a lower-cost medication excluded from your plan’s deductible,
– an insulin product covered by your Medicare plan,  or
– a Medicare covered ACIP recommended vaccine.

Finally, you will receive immediate coverage of all formulary drugs when your Medicare drug plan has a $0 deductible.

Example 1 – What do I pay when my first purchase of the year is a $390 Tier 4 drug and I have a $545 deductible?

You will pay $390.  If you have a Tier 4 formulary medication that costs $390 (retail) and your Medicare plan has a $545 deductible, you would pay the full retail cost of $390 and you would have a remaining deductible balance of $155 ($545 – $390) that you must pay before your plan’s cost-sharing coverage begins.

Example 2 – What will I pay when my first purchase of the year is a $37 Tier 2 drug excluded from my deductible?

You will pay your plan’s Tier 2 copay.  Many 2024 Medicare Part D plans exclude Tier 1 and Tier 2 drugs from the plan’s deductible – and these low-cost drugs receive immediate coverage.  So, if you have a $545 deductible with Tier 1 and Tier 2 drugs excluded, and you purchase a Tier 2 generic that has a retail price of $37 (with a copy of $6) – you pay only the $6 copay and your $545 deductible is not affected.

Example 3 – What do I pay for a $750 Tier 3 drug that is more expensive than my Part D plan’s $545 Initial Deductible?

Around $592.  When you purchase a drug with a retail price higher than the balance of your deductible, your cost would split across (or “straddle“) two or more phases of your Part D coverage.  You first pay the deductible balance and then you would pay all or a portion of your Tier 3 copay for the remainder of the retail price that falls into your Initial Coverage phase.

So, if your Medicare Part D plan has a $545 deductible and you purchase a $750 Tier 3 drug that has a $47 copay, you would first pay the $545 deductible and the remaining amount of the retail price or $205 ($750 – $545) would carry-over into your Initial Coverage phase where you have a $47 copay on the $205 balance.

In the end, your total cost for this first purchase of a $750 Tier 3 drug would be $592 ($545 + $47).

Example 4 – What do I pay for a $15,175 Tier 5 specialty drug when I have a $545 Initial Deductible?

Around $3,333.  Your coverage cost in this example would be calculated like the straddle claim in Example 3, above.  However, if you are using any brand-name medication with a retail cost over $12,051, having a 25% cost-sharing, you will move through (or straddle) all four phases of your drug coverage with a single purchase: you will satisfy your $545 deductible, enter and exit your Initial Coverage phase, then enter and exit the Donut Hole, and finish in the Catastrophic Coverage phase (where, starting in 2024, you will have $0 cost-sharing).

The total cost of your first $15,175 purchase would be around $3,333 calculated as: $545 deductible + $1,121 in initial coverage phase + $1,667 in the Coverage Gap + $0 in the Catastrophic Coverage phase.  Again, once reaching the 2024 Catastrophic Coverage phase, you will have no cost-sharing ($0) for formulary drugs through the end of the year.

Example 5 – What do I pay for Tier 3 Insulin when I have not met my Part D plan’s $545 Initial Deductible?

No more than a $35 copay.  Just as in 2023, all 2024 Medicare drug plans offer all insulin on the plan’s formulary at a copay of no more than $35 based on the Inflation Reduction Act.  If you are still in the deductible phase, you will pay a copay of no more than $35 even though you have not met your plan’s $545 initial deductible – and your insulin purchase will not affect your $545 deductible.

2.  Reminder:  What you can do when one of your prescriptions is not covered by your 2024 Medicare drug plan.

During the first 90 days of your plan coverage, you can ask your Medicare prescription drug plan for a one-time, transition fill (a temporary 30-day supply of your medication).  To initiate a transition fill request, call the Member Services telephone number found on your Member ID card. 

Question:  How much will I pay for a transition fill of a non-formulary drug?

Usually 25% to 50% of retail.  Your Medicare Part D plan will charge you the same cost-sharing as if your formulary exception request was granted and your non-formulary drug is being covered by your 2024 plan.  For example, if your Medicare Part D plan agrees to cover a non-formulary drug, you may be asked to pay the cost-sharing of a Tier 4 Non-Preferred drug.  You can use our plan search tools (PDP-Finder.com or MA-Finder.com) to see your plan’s cost-sharing for all tiers and phases of coverage.

Question:  Will I receive a transition fill of a non-formulary drug even though I was enrolled in a different Medicare Part D plan last year?

Yes.  A transition fill is available to all Medicare plan members who were previously using a medication, even new members.

Question:  How long will I have to get my transition fill?

90 days.  Your 30-day supply transition fill is usually only available for the first 90 days of your Medicare drug plan coverage.  If you live in a long-term care (LTC) facility, then you are granted a 91-day transition fill that may extend over a longer period.

Question:  Is it possible to get an extension for my transition fill?

Maybe.  Your Medicare Part D plan may provide you with a transition fill extension, however, such an extension is provided only on a case-by-case basis in exceptional situations such as when you have filed a formulary exception request that has not been fully processed by the end of your transition fill period.

Question:  I just started using a new medication in 2024 and it is not on my plan’s formulary, can I still get a transition fill?

This is not the intent of the transition fill policy.  Transition fills are for medications that you were using previously and that are no longer covered by your new Medicare Part D plan (or now have drug usage management restrictions).  Instead of a transition fill, you should initiate a formulary exception request for coverage of your non-formulary drug.  The Centers for Medicare and Medicaid Services (CMS) notes that the “purpose of the transition policy is to address situations when an enrollee’s ongoing drug therapy (whether the Part D sponsor is able to actually ascertain ongoing therapy or not) could be potentially interrupted by a drug being non-formulary”. 

Question:  Can I get a transition fill if I used a medication last year that is no longer covered by the Medicare Part D program?

No, unless the non-Part D drug is used for a medically-accepted indication.  Specific medications are excluded from the Medicare Part D program (such as weight-loss drugs) or sometimes medications are removed from the market due to FDA health and/or safety concerns.  Usually, you cannot get a transition fill for a drug excluded from the Medicare Part D program or a medication that was removed from the marketplace. 

As an example, the brand-name drug Ozempic is covered by many Medicare drug plans for the treatment of diabetes, but is not covered by Part D as a weight-loss drug.

Question:  If my medications are now subject to drug restrictions (such as prior authorization), is it possible to get a transition fill while requesting a formulary exception?

Yes.  According to CMS, the transition fill policy will apply to both non-formulary Part D drugs and “Part D drugs that are on a sponsor’s formulary but require prior authorization or step therapy or that have an approved [quantity limit] lower than the beneficiary’s current dose, under a plan’s utilization management requirements”. 
Please remember, transition fills for controlled drugs, such as opioids, may have additional Medicare restrictions.

Navigating the intricacies of Medicare plans is a crucial decision for seniors, and choosing the right coverage requires careful consideration. At Hilgerman Insurance Solutions, we understand the challenges that come with the abundance of policies and information available. Many individuals end up making hasty decisions, potentially leading to overpayment for plans that may not adequately address their needs. In this guide, we explore the common pitfalls to avoid when enrolling in Medicare, aiming to empower you with the knowledge needed to make informed and cost-effective choices for your healthcare coverage.

Choosing the Right Medicare Plan: Common Errors to Avoid

Selecting the appropriate Medicare plan is a significant aspect of a senior’s healthcare journey, yet it often becomes a daunting task due to the vast array of options. The following are the six most prevalent mistakes to steer clear of during the Medicare enrollment process:

Signing up too late or too early:

The timing of Medicare enrollment is critical, with penalties for late enrollment. Understanding when to enroll, especially if still working or covered under a spouse’s plan, can prevent long-term consequences.

Not knowing the difference between plans:

Differentiating between Medicare Advantage and Medicare supplement plans is vital. While original Medicare may require supplementation, Advantage plans (Part C) offer an all-in-one solution, including prescription drug coverage.

Guessing when choosing a plan:

Avoid the temptation to hastily select a plan out of frustration. Working with Deborah of Hilgerman Insurance Solutions will ensure you are given accurate information regarding the plans that work in YOUR best interest.  She does the research for you to enable you to make an informed decision.

Failing to apply for financial assistance:

Many seniors are eligible for financial aid but may not be aware of it. Exploring available assistance options for prescriptions, coinsurance costs, and health plan premiums is crucial, especially for those with modest retirement income.

Not evaluating coverage each year:

Medicare beneficiaries should annually review their coverage as insurance companies make policy changes. Assessing whether the current plan aligns with evolving health needs and considering potential cost savings is essential.

Not seeking help:

The Medicare enrollment process need not be faced alone. Hilgerman Insurance Solutions is here to assist as experienced brokers, examining all available options and guiding you through the selection process. We prioritize your unique needs, ensuring you find the most suitable plan, even if it means helping you sign up through the Medicare site.

As you embark on the journey of Medicare enrollment, Hilgerman Insurance Solutions is dedicated to ensuring you make well-informed decisions tailored to your specific healthcare needs. By avoiding these common errors, you can navigate the complexities of Medicare with confidence, knowing that you have a knowledgeable and supportive partner in Hilgerman Insurance Solutions. We are here to simplify the process, providing expert guidance and helping you secure the coverage that best aligns with your individual requirements.

Hilgerman Insurance Solutions of Camarillo is an independent insurance agency that specializes in the senior market, while offering health insurance solutions for small businesses and individuals. We are contracted with most of the top insurance providers to offer you plans that best suit your needs, all with personal hands-on service and support. 

Our commitment is to provide expertise, friendly service along with a timely response. Please feel free to contact us today for a quote and/or no-cost consultation.   

Hilgerman Insurance Solutions
(805) 279-5482
deb@hilgermanins.com  
www.hilgermanins.com