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01 General
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As we have discussed before, your insurance won’t cover everything involved in your healthcare. I like to compare it to caring for your car. You may have a warranty that will cover major repairs. The daily costs such as gas, oil changes, tires, etc. are your responsibility. Health insurance will cover emergencies and major occurrences. The daily costs of some prescriptions or over-the-counter medicines, knee compression sleeves, allergy medications, etc. are most likely your responsibility.
To help you with the daily costs, the InsuranceExperts.team has put together this Healthcare Savings Guide to give you resources and information to make your healthcare journey easier.
Your best resource is always your InsuranceExperts.team member. They are a phone call away!
360 Benefit Solutions offers several plans that are very affordable, provide robust benefits and provide PPO provider networks as well as Affordable Care Act plans.
Typically, you would be paying 104% of what you paid during your employment. This is the 50% your employer paid, the 50% you paid and a 2-4% administrative fee.
Great question!
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Supplement insurance plans help to pay for healthcare costs that are not covered by a person’s regular health insurance plan. These costs include copayments, coinsurance and deductibles. There are supplemental health insurance plans for accidents and specific conditions, such as cancer, critical illness, heart attacks and strokes or kidney failure.
- Doctors may not take all types of health insurance, and some don’t accept any insurance at all.
- Doctors may stop taking insurance if they believe the health insurance company isn’t offering enough compensation.
- If a doctor stops taking your health insurance, you have a few avenues, including asking if the doctor will take a reduced fee or provide flexible payment terms.
In some cases, cash prices are less than the negotiated insurance rates. However, if you pay cash, it will not go toward your deductible. If you are close to meeting your deductible, it may be wiser to have these services go through your insurance.
An EOB (Explanation of Benefits) is the statement you receive from the insurance company after your claim has been processed. It will state what the insurance pays and what your financial responsibly will be for the medical event.
A PPO is a Preferred Provider Organization and includes a large number of doctors and hospitals that accept the insurance plan. You don’t need a referral to see a specialist within a PPO. A HMO (Health Maintenance Organization) is a much smaller network and requires a referral from a primary physician to a specialist.
The max out of pocket limit is the maximum dollar amount you would pay before achieving 100% of your maximum benefit.
A co-pay is a set dollar amount you pay for a medical service, i.e., $50 co-pay for a doctor visit. The deductible doesn’t apply to the co-pay. Any services outside of the doctor visit would go toward your deductible.
The deductible is the dollar amount you must spend before you receive any health insurance benefit for medically necessary treatment.
Coinsurance is the amount you would pay after you meet your deductible, i.e., 80/20 coinsurance means that after your deductible insurance pays 80% of your medical bills and you pay 20% for any medically necessary service.
No. Private plans do not have open enrollment periods; you or your family can secure coverage at any time of the year.
Open Enrollment refers to the time in which one can enroll in an Affordable Care Act Plan (ACA) or for certain Medicare plans know as Annual Election Period (AEP). Typical open enrollment for ACA plans is November 1st – December 15th. AEP is October 15th – December 7th. There are Special enrollment periods for the ACA and Medicare if individuals meet specific qualifications.
02 Medicare
When you have other insurance, there are rules for whether Medicare or your other coverage pays first.
| If you have retiree health coverage (insurance from your or your spouse’s former employment)… | Medicare pays first. |
| If you are 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has 20 or more employees… | Your group health plan pays first. |
| If you are 65 or older, have group health plan coverage based on your or your spouse’s current employment, and the employer has fewer than 20 employees… | Medicare pays first. |
| If you have group health plan coverage based on your or a family member’s employment or former employment and you’re eligible for Medicare because of End-Stage Renal Disease (ESRD)… | Your group health plan pays first for the first 30 months after you become eligible for Medicare. Medicare pays first after the 30 month period. |
| If you have TRICARE… | Medicare pays first, unless you’re on active duty, or get items or services from a military hospital or clinic, or other federal health care provider. |
| If you have Medicaid… | Medicare pays first. |
| If you’re under 65 and have a disability, have group health plan coverage based on your or a family member’s current employment, and the employer has 100 or more employees… | Your group health plan pays first. |
| If you’re under 65 and have a disability, have group health plan coverage based on your or a family member’s current employment, and the employer has fewer than 100 employees… | Medicare pays first. |
Medicare covers blood work and other lab tests when a doctor is trying to diagnose or treat a specific illness. They have not been authorized to pay for routine blood work.
Check with your doctor’s office. Was the blood work request coded properly? Was the invoice from the provider coded properly? “Routine” can be defined different ways.
NOTE: Some Medicare Advantage plans cover routine blood work. Check with your provider or insurance agent.
Medicare covers 80% of the ambulance cost if certain criteria are met. The enrollee covers 20%. However, supplemental Medigap policies also cover ambulances. Ask your agent what your particular coverage pays.
Medicare criteria:
- Ambulance ride is medically necessary.
- Ride is the only safe way to transport the patient.
- The destination is a Medicare approved facility such as a hospital, skilled nursing facility or the enrollee’s home.
- The destination is the closest facility that could treat the patient.
- The ambulance company meets Medicare criteria.
The Inflation Reduction Act passed in August 2022 said
- vaccines recommended by Centers for Disease Control and Prevention were free starting in 2023
- if the enrollee has either a stand-alone Part D prescription drug plan
OR a Medicare Advantage Plan.
But in 2022, 9% of Medicare enrollees were not covered with a Part D plan.
IMPORTANT NOTE: It is best to enroll in Part D when you sign up for Medicare even if you don’t need prescription coverage at that time. If you don’t enroll in Part D WHEN YOU SIGN UP, you’ll be subject to a late enrollment penalty when you sign up later.
Contact your InsuranceExperts.team agent to confirm your Part D plan.
Even though you do not take any medications, you should enroll in a Medicare Part D plan when you initially sign up for Medicare. After your initial Medicare set up, you can only add Part D during an open enrollment period or if you have a special enrollment period due to loss of employer coverage. Adding Part D after your initial set up OR outside of a special enrollment period may result in a penalty when you do sign up for Part D. Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium” ($34.70 in 2024) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The penalty is rounded to the nearest $0.10 and added to your monthly Medicare premium. In addition, should your health change and you require medications, you would have to cover the medication costs yourself.
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Medigap |
Medicare Advantage
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You can enroll during the 6 month window that begins the month you enroll in Medicare Part B. Late enrollment could result in extra charges. |
You can enroll during the 7 month window that includes the month you turn 65 plus the 3 months before and after. After that initial period, you can enroll during the annual Open Enrollment which is 10/15 – 12/07. You can switch from original Medicare from 01/01 – 03/31. |
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Monthly premiums fall between $50 – 250 typically. It depends on your plan, local health care costs and other factors. In addition, you will pay your Part B premium. |
Plans have no premium or low premiums. You pay the Part B premium which is $164.90 presently. |
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Plans cover most co-pays, co-insurance fees, etc. |
You cover co-pays and co-insurance fees. The exact fees will be in your plan. There is an Annual Out-of-Pocket cost. |
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You can see any doctor or hospital that accepts Medicare patients. |
There are HMO and PPO plans with specific networks of doctors, specialists and hospitals. Your costs are higher if you go out-of-network. |
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You must purchase Part D separately to cover prescription costs. |
Most plans include prescription costs. |
03 Affordable Care Marketplace
It is calculated on your current year’s approximated Adjusted Gross Income.
There are two main reasons people choose the ACA: 1) These plans cover pre-existing conditions. 2) You can receive a substantial premium subsidy.
Yes, anyone can enroll in an Affordable Care Act plan. You can enroll during Open Enrollment which is November 1st through January 15th. You can also qualify for a Special Enrollment Period outside of Open Enrollment when you have a qualifying life event (For example, marriage, new baby, loss of insurance, etc.) All Affordable Care Act plans are HMO provider networks.
