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What happens to your maximum out-of-pocket (MOOP) if you change plans throughout the year in the Open Enrollment Period (OEP) or from a life qualifying event that gives you a Special Enrollment Period (SEP)?

Your out-of-pocket expenses from your Part A & B of coverage towards your new plan’s MOOP limit will follow you if you change plans.

As noted by the Centers for Medicare and Medicaid Services (CMS) in the Medicare plan manuals:

"During a contract year, when an enrollee switches to another [Medicare Advantage] plan of the same type (for example, from one HMO to another HMO) offered by the plan, his/her accumulated annual contribution toward the annual MOOP limit in the previous plan to date is to be counted towards his/her MOOP limit in the new MA plan. As applicable, this transfer of MOOP applies to both in-network and out-of-network MOOP."

However, CMS does provide some flexibility so companies can allow your MOOP to transfer between Medicare Advantage plans even when the plans are not similar (for example, you were in an Aetna HMO and join an Aetna PPO). The Medicare Advantage plan manual continues on to note:

"Additionally, MA [Medicare Advantage] plans may extend the transferability of the enrollee’s contribution toward his/her annual MOOP so that it applies to an enrollee’s transfer during the contract year to any MA plan type offered by the MAO [Medicare Advantage Organization]. For example, if an enrollee makes a mid-year change to move from an HMO to a PPO offered by the same MAO, his/her current contribution toward the MOOP limit may follow the enrollee and be counted towards the MOOP limit in the PPO. This allows those enrollees who are eligible to make mid-year plan changes to freely select among the diverse MA plan options offered by an MAO."

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Everyone knows the over or under 20 employees rule when Medicare is primary, right? Well, did you know that number of employees eligible for the group health plan jumps to 100, if you are eligible for Medicare because of disability and under the age of 65?

When Medicare pays first, you must enroll in Original Medicare A & B even if you are covered by a group health plan. Delaying Part B in these circumstances can result in out-of-pocket expenses and penalties. After enrolling into Original Medicare, this person has the option to pick a Medicare Health Plan or stay on the group health plan as secondary coverage. Click the button below to download a cheat sheet of other situations that you could come across where Original Medicare enrollment is important as it pays first.

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Does Medicare cover long-term care? No.

A beneficiary could end up in a skilled nursing home after a fall, surgery, or other incidents that require temporary rehabilitation that IS covered by Medicare. However, once you are discharged and no longer covered by Medicare you move to self-pay.

If you are transferred to a skilled nursing home due to the reasons listed above and it’s determined that your level of care requires custodial care (24 hours) you can apply for Medicaid or Medicaid spend down to qualify for assistance. For example, if your income is above the Medicaid annual limit, but your level of care costs can spend down your assets/income to below Medicaid level, you could be approved. The level of care would be assessed by the facility and Medicaid.

Medicaid programs vary from state to state. Most often, eligibility is based on your income and personal resources. Many states have higher Medicaid income limits for nursing home residents. You may be eligible for Medicaid coverage in a nursing home even if you haven’t qualified for other Medicaid services in the past. Learn more: https://www.medicare.gov/what-medicare-covers/what-part-a-covers/how-can-i-pay-for-nursing-home-care

Many people are advised to cancel their Medicare Health plans when they have Medicaid and move into a long-term care facility. This is because Nursing Home Medicaid will cover all of your health care costs – skilled care (physicians and nurses), non-skilled care, medications, supplies and durable goods, etc. – once you are in the program and living in a nursing home.

Long-term care costs are expensive and require a financial analysis that you can self-pay for two or more years to be accepted to a facility. Most people who enter nursing homes start by paying for their care out-of-pocket. Individuals do have the ability to purchase a long-term care insurance policy when they are healthy, or add long-term care riders to their life insurance or annuity policies to help in these circumstances.

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We get a lot of questions about what and when is home care covered?

Home care is covered by Medicare when a doctor orders a plan of care for necessary services for someone who is homebound because of chronic illness or injury. Someone is considered ‘homebound’ when he or she has trouble leaving home without the help of either a person or medical equipment because of illness or injury.

A patient whose doctor recommends not leaving home because of a medical condition is also considered homebound.

Home care is generally covered under Medicare Part B. But it can be covered through Part A in some cases after you have been in a hospital as an inpatient for at least three days, or a Medicare-covered skilled nursing facility. In that case, Medicare Part A can cover your first 100 days of home care. Part B covers any days beyond 100. But either way, you don’t have any cost-sharing for covered benefits.

The home health agency sends the bills to Medicare, and the agency must tell you if Medicare won’t cover any items or services its workers provide and the related costs you will incur.

People can qualify for additional options with Home & Community-Based Services (HCBS) Waivers Medicaid or ABD Medicaid. States can offer a variety of unlimited services under an HCBS Waiver program. Programs can provide a combination of standard medical services and non-medical services. Standard services include but are not limited to: case management (i.e. supports and service coordination), homemaker, home health aide, personal care, adult day health services, habilitation (both day and residential), and respite care. States can also propose “other” types of services that may assist in diverting and/or transitioning individuals from institutional settings into their homes and community.

You can apply for these services using the Department of Human Services website for your state, click the button below to visit the PA Independent Enrollment Broker (PA IEB) page.

Learn more: https://paieb.com/en

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Fact finding prior to a Medicare appointment can save you a lot of time. No one likes sitting down for an appointment only to find out the client isn’t even enrolled into Original Medicare Part A or B yet. Or, you are puzzled by the enrollment period you are going to use to get them on a policy as soon as possible, especially when they continue to work past age 65.

There can be times that the hardest part of being a Medicare sales agent is piecing together the situation at hand to see if you have opportunity for a potential new client. Either they give you mixed signals, or not enough information to help carve a clear path to the end goal. I found an amazing step-by-step question guide that CMS created to help walk you and your client through each “if that, then this” situation. It takes the guess work or self-doubt out of the equation.

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