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Medicare and Dental Coverage

Medicare and Dental Coverage

 

Aside from a few exceptions, dental expenses are excluded from Original Medicare, Part A and Part B, coverage. This includes most routine dental services and items such as:

  • Oral exams
  • Routine cleanings
  • Fillings
  • Crowns
  • Bridges
  • Extractions
  • Dental implants
  • Dental appliances, including dentures, retainers, and dental plates

However, in certain rare situations, Medicare does cover certain dental procedures. The main exception concerns inpatient hospital services where hospitalization is necessary due to a dental procedure. For example, if you’re admitted to the hospital for a dental emergency, the costs of the hospitalization would be covered under Medicare Part A even if the dental service itself is not covered by Original Medicare.

There are a few other instances where Original Medicare may cover dental care, but these are best considered rare occurrences and not usual treatment. Examples include, but are not limited to:

  • You have a health condition where certain dental services require you to be hospitalized to receive the service.
  • A dental procedure is needed as an essential part of, or in preparation for, another covered medical procedure. For example, Medicare may cover extractions needed to prepare your jaw for radiation if you’re undergoing cancer treatment. Please note that Medicare doesn’t cover follow-up dental services you may need once the covered procedure has already been performed.
  • You need surgery to reconstruct a damaged jaw due to an accident.
  • You need a dental exam before undergoing complicated surgeries or treatments that are covered by Medicare, but are otherwise unrelated to dental care. For example, Medicare may cover oral exams that are part of a pre-op exam before a kidney transplant surgery or heart valve replacement procedure.

If a physician provides the dental exam in an outpatient setting, Medicare Part B  covers the cost as a medical expense, not as a dental expense. If it’s provided in a hospital while you’re an inpatient, Medicare Part A covers it as part of the hospital costs.

These costs are subject to your normal Medicare cost sharing, which may include coinsurance and/or copayments and the Medicare deductible. Of course, Medicare will cover only the costs that it approves.

How can Medicare beneficiaries get dental insurance?

Because Medicare Advantage plans are required to provide at least the same amount of coverage as Original Medicare (except for hospice care, which is still covered by Part A), these plans also cover the procedures mentioned above. Some Medicare Advantage plans may include more comprehensive dental coverage. If dental benefits are included, this may include routine dental services not covered under Original Medicare. Benefits vary from plan to plan, so check with the specific Medicare Advantage plan if you’re interested in learning more about dental coverage. Medicare Advantage plans are offered by private insurance companies that are approved by Medicare.

Are there dental insurance options outside of Medicare?

If you choose to remain covered by Original Medicare or can’t find a Medicare Advantage plan in your area that offers dental benefits, you may have dental coverage options outside of the Medicare program. For example, you can get private dental insurance either through a licensed insurance broker like eHealth or an employer. Compare the different types of dental plans in your area and weigh your needs against them. The costs of a dental plan can vary by plan and provider.

Some dental insurance plans have network restrictions, similar to the way that Medicare has you visit doctors and health-care providers who accept Medicare assignment. With a network-type dental plan, you must see professionals who reside in the dental plan’s network.

There are other options as well. If you have limited income and qualify for state assistance, some Medicaid programs include dental coverage. Medicaid programs are run at the state level, and dental coverage is an optional benefit under federal guidelines, meaning that states may choose whether or not to include this coverage. If you’re eligible for Medicaid, contact your state’s Medicaid department for more information on whether help with dental costs is available.

Another option, if it’s available in your area, is that you may be able to join a dental discount program, even if you have Original Medicare. Typically, you pay a once-a-year fee for savings on dental care. With a dental discount program, you’re not “insured,” so the company doesn’t pay dental benefits, as dental insurance does. Instead, you pay a discounted price for your dental care at participating dental-care providers.

Dental discount programs and network-style dental insurance plans are often found in areas where the population is large enough to create a network of dental-care providers who can offer lower rates for those members. That means they aren’t available everywhere. You may want to shop around for all your dental options. Be sure to compare dental plans and dental programs so you can get what works best with your typical dental needs.

Do you have questions about your dental coverage options as a Medicare beneficiary? If you’d like help finding a Medicare Advantage plan option that may include dental benefits beyond Original Medicare, feel free to contact an eHealth licensed insurance agent today to get personalized assistance.

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Medicare and Cataracts

Medicare and  Cataracts: Taking the Fear Out of Removing Cataracts

 

According to the World Health Organization, cataracts are the leading cause of blindness in the world. The most obvious symptom is clouded vision. The word “cataract” actually means “waterfall” because, with cataracts, it can seem like you’re looking through a sheet of water.

If you’re diagnosed with cataracts, this isn’t necessarily a cause for alarm. According to the National Eye Institute, this condition is a normal part of the aging process and is common among people over age 60. As such, Medicare covers the surgery required to correct cataracts, as well as glasses or lenses if they are necessary after the surgery.

According to the American Optometric Association, there are different types of cataracts: nuclear, cortical, and posterior subcapsular cataracts. These are found on different parts of the eye. If you have multiple cataracts, doctors typically remove them one surgery at a time. Cataracts in your other eye may be removed at a different time as well.

In cataract surgery, the natural lens of the eye that has the cataracts is removed and replaced by an artificial lens. The surgery can be performed on an outpatient basis, and only an ophthalmologist can perform this type of surgery.

Surgery isn’t necessarily the only way to deal with cataracts. Talk to your doctor about your options and what may be best for your situation.

Medicare coverage of surgery to correct cataracts

Talk to your doctor if you think you have cataracts.  Medicare doesn’t cover routine vision exams, but Medicare Part B does cover certain preventive and diagnostic eye exams. Ask your doctor if a diagnostic exam to check for cataracts would be covered by Medicare.

Some important things to know:

  • If you’re getting the procedure as an outpatient, Medicare Part B covers the fees for the surgeon, the facility, the anesthesia, and the surgery both to remove the damaged natural lens with the cataracts and to replace it with an artificial, intraocular lens. You’ll pay the normal Medicare Part B cost sharing, which may include your Medicare deductible, and/or 20% of the amount approved by Medicare after you have reached your deductible. Medicare pays for any follow-up care after your cataracts are removed, subject to the Medicare coinsurance and deductible.
  • If you’re getting the procedure as an inpatient, you’ll be covered under . Your costs may include the Part A deductible for each benefit period and/or daily coinsurance costs if your hospital stay exceeds 60 days. Check with your doctor if you’ll be admitted to the hospital as an inpatient or getting an outpatient surgery; this affects which part of Medicare you’re covered under and your costs.
  • There’s always a chance that your surgeon doesn’t accept Medicare assignment (a payment agreement with Medicare where your doctor agrees not to charge you above the Medicare-approved amount for a medical service). If this happens, then you may have to pay a much higher amount for the surgery. To protect yourself from this possibility, check with your doctor to make sure that the surgeon slated to perform this surgery does, in fact, accept Medicare assignment. If not, have your doctor to refer you to a surgeon who does accept it. You can also find doctors and hospitals through Medicare.gov’s Physician Compare tool; simply filter your search results to only show providers that accept assignment.
  • Medicare also pays for lenses and frames for one pair of glasses or contacts that your doctor prescribes after your cataracts are removed and an intraocular lens is inserted. You must get these glasses or contacts through a Medicare-approved supplier. Medicare covers the cost of lenses for both eyes (subject to deductible and coinsurance), even if the cataracts were only removed in one eye.
  • Please note that Medicare will only pay for standard frames. If you’re uncertain as to which frames are Medicare eligible, ask your doctor or health-care provider for a list of eligible frames to avoid extra costs.
  • Medicare doesn’t cover any additional costs for surgeries or procedures that are unrelated to cataracts.
  • Generally, Medicare doesn’t cover vision correction eyeglasses, contacts, or LASIK surgery for reasons unrelated to cataracts. Medicare also doesn’t cover eyeglass “extras” like bifocals, tinted lenses, scratch resistant coating, or any contact-lens accessories. You’ll be responsible for any extra costs if you choose to get upgraded frames.

The Medicare Advantage (Part C) program also covers cataract surgery, since Medicare Advantage plans are required to offer at least the same level of coverage as Original Medicare, Part A and Part B. These plans may also include other benefits, like dental and hearing-related services, and sometimes provide more coverage. Some Medicare Advantage plans include prescription drug coverage (Original Medicare prescription coverage is limited), so they can give you health and medication benefits in one policy.

Some Medicare Advantage plans offer more complete vision coverage, such as routine eye exams and glasses (regardless of whether you’ve had cataract surgery). If you’d like help finding Medicare Advantage plan options that may include broader vision coverage, contact eHealth to speak with a licensed insurance agent today. Or, to start browsing plan options right away, just enter your zip code into the plan finder tool on this page.

For more information about how Medicare covers surgery to correct cataracts, you can call Medicare at 1-800-MEDICARE (1-800-633-4227, TTY users call 1-877-486-2048) 24 hours a day, seven days a week.

Sources

American Optometric Association, “Causes of cataracts.”

National Eye Institute, “Facts About Cataract.”

World Health Organization, “Priority eye diseases.”

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Applying for Your Medicare Card

Applying for Your Medicare Card

 

For some people, Medicare enrollment occurs automatically, while others need to manually enroll. Medicare sends you a red, white, and blue card when you’re signed up.

You’re generally eligible for Medicare if you’re a United States citizen or permanent legal resident of at least five continuous years, and you generally qualify by age (65 or older). However, you may qualify for Medicare before turning 65 if you receive Social Security or certain Railroad Retirement Board disability benefits; see details below. You may also qualify for Medicare before age 65 if you have amyotrophic lateral sclerosis (ALS) or end-stage renal disease (ESRD). Read on for more information.

Sometimes you’re automatically enrolled in Medicare

Medicare enrollment may happen automatically if the following situations apply.

If you turn 65 years old

If you’re already receiving Social Security or Railroad Retirement Board benefits, you’ll be automatically enrolled in Original Medicare, Part A and Part B, when you reach age 65. Your Medicare card should arrive about three months before your 65th birthday, and your Medicare coverage starts the first day of the month you turn 65.

If you retire before 65

You can apply for Social Security retirement benefits when you’re 61 years and 9 months old or older; see the agency’s contact information below. However, in most cases, you don’t qualify for Medicare until the age of 65 (see exceptions below).,

If you’re eligible for Railroad Retirement Board (RRB) benefits, see the agency’s for information about retiring before age 65, or call them at the number listed below.

If you qualify for Medicare because of disability

If you get Social Security or Railroad Retirement Board disability benefits, you’ll be automatically enrolled in Medicare after 24 months of collecting disability. Your Medicare card should arrive in the 25th month.

If you have amyotrophic lateral sclerosis (ALS)

People with ALS, or Lou Gehrig’s disease, are automatically enrolled in Medicare Part A and Part B the same month their disability benefits start.

Unless the situations above apply to you, you’ll need to manually enroll in Medicare. If that’s you, here’s how to get your Medicare card.

If you’re new to Medicare

You’ll have to manually apply for Medicare if:

  • You live in Puerto Rico. You may get automatically enrolled in Part A as described above, but you’ll need to sign up for Part B.
  • You aren’t receiving retirement benefits yet.
  • You have end-stage renal disease (ESRD).

If you have end-stage renal disease (ESRD), you can apply for Medicare at any time. Otherwise, you’re first eligible to enroll during your seven-month Initial Enrollment Period, which typically starts three months before you turn 65, includes the month of your 65th birthday, and ends three months later. When your Medicare coverage begins and when you get your Medicare card depends on the month you sign up during this period.

If you don’t enroll in Medicare during your Initial Enrollment Period, in most cases you’ll have to wait until the General Enrollment Period, which takes place from January to March 31 every year. You may have to pay a late-enrollment penalty for Medicare Part B (and for Medicare Part A, if you don’t qualify for premium-free Part A).

Some people decide to delay Medicare Part B enrollment if they have other coverage, since Part B comes with a premium. If you’re working and have health coverage through an employer, you can sign up for Part B with a Special Enrollment Period when you stop working or that coverage ends. You won’t have to pay a late enrollment penalty if you sign up during a Special Enrollment Period.

If you worked for a railroad, you’d apply for Medicare through the Railroad Retirement Board. Otherwise, you’d sign up through Social Security.

Getting a Medicare card starts with a phone call:

  • Social Security: 1-800-772-1213, Monday through Friday, from 7AM to 7PM. If you’re a TTY user, you can call 1-800-325-0778.
  • Railroad Retirement Board: 1-877-772-5772, Monday through Friday, from 9AM to 3:30PM. If you’re a TTY user, you can call 1-312-751-4701.

You can also sign up online at in person.

If you’re married, you and your spouse should each have your own separate Medicare cards with separate Medicare claim numbers. Don’t mix them up, and never use each other’s cards.

If you need a new Medicare card sooner

Have a doctor’s appointment? If you can’t wait 30 days for your new card to arrive, you can visit your local Social Security office or call 1-800-772-1213 (TTY users 1-800-325-0778) Monday through Friday, from 7AM to 7PM.

The agency will mail you a letter that you can use as proof of Medicare eligibility until you receive your new Medicare card. You should receive this letter within 10 days of submitting the request.

If you receive Railroad Retirement Board benefits, you should call your local RRB office or 1-877-772-5772. TTY users can dial 1-312-751-4701. Representatives are available Monday through Friday, from 9AM to 3:30PM.

Keeping your Medicare card safe

Keep your Medicare card in a safe place, and don’t let anyone else use it. Always have your card handy when you call Medicare with questions.

You should take your Medicare card with you when you receive any health care services or supplies. Even if you haven’t reached your deductible, your doctor will need your card information to submit a claim. That claim will be applied to your deductible so you can use your benefits sooner. If you receive a new Medicare card, show it to your doctor’s office staff so they can make a copy of the updated information.

If you misplaced or lost your card, you can get a replacement Medicare card.

 

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Medicare Coverage in Tennessee

Medicare Coverage in Tennessee

 

The Medicare program provides health insurance coverage to eligible U.S. citizens and legal permanent residents (having lived in the U.S. at least five continuous years) who are age 65 or older.  In Tennessee, as in the rest of the country, you might qualify for Medicare under the age of 65 in certain situations.

There were 1,224,504* beneficiaries enrolled in the Medicare program in Tennessee in 2015, according to a Centers for Medicare & Medicaid Services report. Of this total, there were 426,921 residents enrolled in Medicare Advantage plans. Another CMS report stated that every Medicare beneficiary in 2016 has access to at least one of the 68 Medicare Advantage plans available statewide.

Types of Medicare coverage

There are various ways you can get Medicare coverage in Tennessee (as in all states). You can enroll in Original Medicare, Part A and Part B (many beneficiaries are automatically enrolled when they become eligible). You can also explore other options, such as Medicare Advantage plans, Medicare Advantage Prescription Drug plans (MAPDs), Medicare Prescription Drug Plans (PDPs), and Medicare Supplement (Medigap) plans. Each comes with different out-of-pocket costs and coverage details. Medicare beneficiaries in Tennessee may want to compare all available plans in their service area with their health and prescription drug needs in mind.

Original Medicare refers to Medicare Part A (hospital insurance) and Part B (medical insurance).  This coverage comes with out-of-pocket costs (such as copayments and deductibles), and includes only limited prescription drug coverage. Original Medicare doesn’t cover most prescription medications you’d take at home.

You can augment your Original Medicare coverage with a Medicare Supplement plan and/or a Medicare Prescription Drug Plan, or you can receive your Medicare benefits through a Medicare Advantage plan – many of them include prescription drug coverage.  No matter which way you decide to get Medicare coverage, in most cases you need to continue paying your Part B premium.

Medicare Insurance Plan Type Description
Medicare Advantage plan A health plan offered by private insurance companies that contract with Medicare. Medicare Advantage plans provide your Medicare Part A and Part B benefits; hospice care is covered directly under Part A, however, instead of through your Medicare Advantage plan. Many Medicare Advantage plans include extra benefits, such as routine vision services. There are several types of Medicare Advantage plans; not every type may be available in your part of Tennessee.
Medicare Advantage Prescription Drug plan A type of Medicare Advantage plan that provides Medicare prescription drug coverage (and may include extra benefits as well, such as routine dental services). This type of plan offers all your Medicare coverage in a single policy.
Stand-alone Medicare Part D Prescription Drug Plan Prescription drug coverage offered by private insurance companies that contract with Medicare. Meant to work alongside your Original Medicare coverage, a Prescription Drug Plan can help pay for your medications. Please note that each plan maintains its own formulary (list of covered prescription drugs); this is also true of Medicare Advantage Prescription Drug plans. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.
Medicare Supplement (Medigap) plan If you decide to stay with Original Medicare, another option you may have is to enroll in  a Medicare Supplement (Medigap) plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.

Please note that the plans described above may vary in terms of availability, certain coverage details, and out-of-pocket costs. To get details about plans in your part of Tennessee, just enter your zip code in the form on this page.

Tennessee SHIP and Commission on Aging & Disability

The state of Tennessee offers a variety of programs that aim to educate and empower its senior population, including the State Health Insurance Assistance Program (SHIP) and the Tennessee. Volunteer counselors in the SHIP program offer free and unbiased counseling on Medicare insurance plans to beneficiaries, caregivers, and family members. The Commission website offers links to various resources related to aging and disability. These agencies help answer questions Tennesseans may have regarding their Medicare coverage.

*Statistical data from the Centers for Medicare & Medicaid Services, “On its 50th anniversary, more than 55 million Americans covered by Medicare” as of July 28, 2015; and “2016 MA Part D Landscape State-by-State Fact Sheet” as of September 21, 2015.

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Medicare Hospice Care Coverage

Medicare Hospice Care Coverage

When you or a loved one becomes a hospice patient, the last thing you want to worry about is insurance coverage. The final stages of a fatal disease can be mentally, emotionally, physically, and financially devastating for patients and their families. Hospice care is available under Medicare Part A to help ease the burden in all four of the above areas.

Hospice coverage is critical when a person reaches the final stages of cancer, kidney disease, or similar life-threatening diseases. The patient may need around-the-clock care during this time, and a hospice team can provide necessary medical care, while also relieving some of the caregiving burden.

What is hospice care?

Hospice care provides medical services for people with terminal conditions, usually in the patient’s home. A Medicare-approved hospice team administers non-curative medical services and support for patients with a terminal illness. This hospice team may include doctors, nurses, and other health professionals who work with you to create a plan of care.

To be covered by Medicare, a hospice patient can only receive palliative treatment. This is treatment to control symptoms and manage pain, not to cure the illness. Hospice care is meant to keep the patient as comfortable as possible. The focus is on maximizing the quality of life for each day the patient has left.

As a Medicare beneficiary, you have the right to stop hospice care at any time if you want to begin curative treatments.

Hospice-care eligibility

Not everyone is eligible for hospice care. Patients must meet the following requirements to be covered by Medicare:

  • You must be eligible for Medicare Part A.
  • You must sign a statement agreeing to hospice care instead of standard Medicare-covered medical care to treat the terminal illness and related health conditions.
  • You must agree to receive palliative care for your condition instead of curative treatment.
  • A hospice physician, along with your regular doctor (if you have one) must determine that you are terminally ill with a life expectancy of six months or less.
  • The hospice care must be received through a Medicare-approved hospice program.

Length of hospice care

Although hospice care is intended for patients who have six months or less to live, you can get hospice care for longer than this if a hospice doctor continues to certify that you’re terminally ill and you still meet eligibility requirements. You need to be recertified by your doctor at the beginning of each benefit period.

Hospice-care benefit periods are for 90- or 60-day periods. If you’re just starting hospice care, you can receive hospice services for two 90-day benefit periods, followed by unlimited 60-day periods. Your benefit period starts on the first day you begin hospice care and ends after 90 or 60 days.

Benefit periods don’t have to be consecutive. Hospice care may be cancelled at any time, and the patient may return to the standard Medicare benefits. For example, if your illness goes into remission or your condition improves, you may not need to continue you hospice care. If you’re eligible again, you may return to hospice care at any time.

What Medicare hospice care covers

Medicare hospice care covers medically necessary services and supplies to care for your terminal condition. As mentioned, any care you receive must be through a Medicare-approved hospice program.

Coverage includes:

  • A one-time hospice consultation with a physician or medical director to discuss your treatment options. You’re covered even if you end up deciding not to get hospice care.
  • Physician services
  • Nursing care
  • Home health and hospice-aide services
  • Homemaker services
  • Medical equipment and supplies
  • Prescription medications for pain and symptom management
  • Physical and occupational therapy
  • Speech-language pathology services
  • Medical social worker services
  • Nutrition counseling
  • Grief counseling for the patient and family
  • Limited respite care for caregivers
  • Limited inpatient care to manage pain and symptoms related to the condition

A hospice doctor and nurse are on call 24 hours a day, seven days a week. Remember that you’re still covered for health care that isn’t related to your terminal illness.

What Medicare hospice care doesn’t cover

There are some limits to hospice coverage. Medicare will not pay for any treatment or medications meant to cure your illness. You’re also not covered for any care that wasn’t set up through your Medicare-approved hospice program. If you aren’t sure whether a service may be covered, check with your hospice team first.

Medicare doesn’t cover housing if you live in an institution, such as a hospice facility or nursing home.

Medicare does cover limited inpatient facility care if it’s for respite care and is arranged through your hospice team.

Costs for hospice care

Hospice patients pay the following costs:

  • Prescription drugs: Maximum of $5 copayment per outpatient prescription medication to manage pain and symptoms.
  • Respite care (inpatient): You’ll pay 5% of the Medicare-approved amount for a maximum five-day stay. Note that you can get respite services more than once as long as it is on an infrequent basis.
  • Room and board: Medicare doesn’t cover costs if you’re staying in a nursing home or hospice facility, unless it’s for short-term respite care.

Medicare covers all other hospice care costs. There’s no deductible for Medicare-covered hospice care.

Hospice care may be worth looking into if you or a family member has been diagnosed with a terminal illness. Understanding all of your treatment options, including hospice, will help you decide the best course of action for you and your family.

For more information, see: Centers for Medicare and Medicaid Services. “Medicare Hospice Benefits.”

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Medicare Coverage for Florida

Medicare Coverage Overview for Florida

The federal Medicare program provides health insurance coverage to eligible United States citizens and permanent legal residents who are age 65 or older, or under 65 with certain medical disabilities or illnesses, including those in Florida.

According to the Centers for Medicare & Medicaid Services (CMS), there were 3,968,885 total beneficiaries enrolled in the Medicare program in Florida in 2015. Of this total, there were 1,601,277 residents enrolled in a Medicare Advantage plan, through which they are guaranteed the same coverage as provided through Original Medicare, Part A and Part B (except hospice care, which is still covered under Part A). Also in 2015, 1,401,435 Florida residents received their Medicare prescription drug coverage through a stand-alone Medicare Part D Prescription Drug Plan (PDP), while 1,518,812 received coverage for both their medications and Original Medicare benefits through a Medicare Advantage Prescription Drug plan (MAPD).

The government-sponsored program known as Original Medicare refers to Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).

There are many Medicare plan options in Florida, listed in the table below. Each plan type comes with different out-of-pocket costs, coverage of health services, and additional benefits. Medicare beneficiaries in Florida may want to compare all available plans in their county with their health and prescription drug needs in mind.

Here are some Medicare plan options that may be available in your part of Florida.

Medicare Insurance Plan Type Description
Medicare Advantage plan Offered by private insurance companies that contract with Medicare, Medicare Advantage plans provide Medicare Part A and Part B benefits (except for hospice care, which Part A still covers). Medicare Advantage plans often include additional benefits, such as routine vision or hearing care. Many plans include prescription drug coverage; these are sometimes referred to as Medicare Advantage Prescription Drug plans.
Medicare Prescription Drug Plan Under Medicare Part D, private health insurance companies that contract with Medicare offer stand-alone Medicare Prescription Drug Plans. These plans are designed to work alongside your Original Medicare coverage. Each plan maintains its own formulary (list of covered medications). The formulary may change at any time. You will receive notice from your plan when necessary.

Another choice you may have if you’re enrolled in Original Medicare is a Medicare Supplement plan. Also known as Medigap, these plans are also offered by private insurance companies and can help you pay your out-of-pocket costs for services covered under Original Medicare.

Medicare dual-eligible beneficiaries in Florida

Florida residents who are enrolled in both the Medicare and Medicaid programs are also known as “dual-eligible,” and may be qualified to participate in programs that assist with out-of-pocket Medicare costs.

The Medicare “Extra Help,” or “Low Income Subsidy” (LIS) program, is one program you might qualify for if you’re a dual-eligible beneficiary. Qualifying individuals may receive help with prescription drug costs and even Medicare Prescription Drug Plan premiums if their income falls under a certain threshold. If you’re interested in finding out whether you qualify to receive assistance with your Medicare out-of-pocket costs, contact Florida’s State Health Insurance Assistance (SHIP) agency, called FloridaShine.

You can start comparing plans at your convenience; just enter your zip code in the box on this page.

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Changing Medicare Supplement (Medigap) Plans

Changing Medicare Supplement (Medigap) Plans

The best time for you to sign up for a Medicare Supplement plan, also called Medigap, is when you turn 65 and are covered under Medicare Part B. This six-month period, known as your Medigap Open Enrollment Period, typically starts on your 65th birthday if you’re already enrolled in Part B. During this period, you’re guaranteed acceptance into any Medicare Supplement plan available in your area without submitting to a complete medical review or being denied coverage because of pre-existing conditions. If you choose not to get Medicare Part B right away, then your Medigap Open Enrollment Period may also be delayed and will start automatically once you’re at least 65 and have Part B.

Your health status when enrolling in a Medigap plan can play an important role in which Medigap plan you choose, and your age at the time may determine how much you pay for it.

Like anything else, your needs are subject to change, so the plan you originally chose may not cover all of your needs for the rest of your life. There are numerous reasons for switching Medicare Supplement plans; some common ones are described below.

Your current Medigap plan provides more coverage than necessary

Are you paying for benefits that you don’t need and never use? Perhaps you’re in good health and don’t use all of your Medigap benefits. A cheaper plan may make more sense if this is the case.  Review the options in your area to find the best fit for your needs.

Out-of-pocket costs are too high

Let’s say you’re in poor health, and there’s another Medigap plan that will help you save more money. Switching Medicare Supplement plans may be difficult in this kind of situation if you’re outside your Medigap Open Enrollment Period. If you’re not turned down because of your health, you may have to wait up to six months to be covered for costs associated with a pre-existing condition, and you may be charged higher premiums for this coverage.

You may still be able to switch plans with guaranteed issue in certain situations. For example, if your Medigap company goes bankrupt or misled you, you may be able to change Medicare Supplement policies with guaranteed issue.

But some states have laws that make sure certain Medigap policies are always available. Check your state’s insurance website to see what’s available in your area. You might want to check different insurance companies to find out their rules for switching Medigap plans. There may be companies that sell guaranteed-issue plans. For personalized assistance, you can always contact eHealth to speak with a licensed insurance agent about your options.

Someone you know is paying less than you are for the same Medigap plan

Medicare Supplement plans are named with letters, such as Plan A, and standardized such that plans of the same letter name offer the same benefits. In most states, there are 10 Medigap plans — Plan A through Plan N (some plans, such as Plan E, are no longer sold). Massachusetts, Minnesota, and Wisconsin have their own versions of Medigap. In all other states, insurance companies must offer the same standardized benefits, but they can pick which of the 10 plan categories they want to offer and they can price the plans differently.

Any company that sells Medigap must offer at least Plan A. If the company sells more than one Medigap plan, it must next offer at least Plan C or Plan F.

Now that you know some of the basics, try to determine why your friend pays a different amount. He may have a policy through a different Medigap insurance company. How old is your friend? Did she switch policies, or has she had the same one since she was first enrolled?

Medigap insurers can set premiums in any of these ways:

  • Attained-age rated–The premium is based on your current age and increases with your age.
  • Entry-age-rated–The premium is set using your age when you first enroll.
  • No-age rated–The premium is the same for everyone who has the same policy.

As mentioned, it’s worth noting that, depending on your health status, your success in changing Medigap plans is not always guaranteed. Once your Medigap Open Enrollment Period passes and you try to join a plan, the insurance company generally has the right to do a complete review of your medical history. The company may then decide to raise the costs of your policy or deny you coverage outright.

You have a Medicare Advantage plan and switch to Original Medicare with Medigap

Medigap and Medicare Advantage (Medicare Part C) plans don’t work together. If you drop your Medicare Advantage plan, and return to Original Medicare, Part A and Part B, you can apply for a Medigap plan, but getting the plan you want depends on the situation.

Consumer protection rules called “guaranteed-issue rights” make sure that you can get a Medigap policy in spite of any health condition you have, and at a rate that isn’t set higher due to your condition, in certain situations.

  • If you had a Medicare Advantage plan for the first time, and for less than a year, this is considered your “trial right” period. You can switch back to Original Medicare and get the same Medicare Supplement plan you had before making the change (you have guaranteed-issue rights to the Medigap plan) if the same insurance company still sells your former plan.
    • If your former Medigap policy is no longer sold, you may be able to choose a different plan with guaranteed issue. You can enroll in a Medigap Plan A, B, C, F, K, or L offered by any private insurance company in your state.
  • If you had the Medicare Advantage plan for more than a year, then there is generally no guaranteed-issue right under federal law that will let you rejoin the same Medigap policy you had. You may, however, be able to find acceptance to a plan by shopping around.
  • Even if you had the Medicare Advantage plan for more than a year, if you lost coverage for certain reasons (for example, you moved out of the Medicare Advantage plan’s service area or the plan left Medicare or stops covering your service area) and you switch to Original Medicare, you have a guaranteed-issue right to Medigap plans A, B, C, F, K, or L offered by any private insurance company in your state.

The list above shows just a few of these situations. For more information, see this publication from the Centers for Medicare & Medicaid Services.

You have an older Medigap policy that’s no longer sold

You may wish to reconsider switching plans if this is your sole reason for changing plans. You don’t have to change plans just because the one you have is no longer offered.

For example, none of the 10 Medigap plans currently offered includes coverage for prescription drugs. If your Medigap plan does, then you may wish to hang on to it.

There are other reasons you may want to change plans, but you’re generally allowed to keep a discontinued Medigap policy, complete with its original benefits intact. Keep in mind that if you enrolled in your Medigap policy before 1992, your plan may not be guaranteed renewable and may cost more than the standardized plans currently available. If your Medigap insurance company decides not to renew your policy, you’ll have a guaranteed-issue right to enroll in a different Medigap plan.

Other points to keep in mind when switching Medigap plans

  • If you decide to change Medigap plans, you have a 30-day “free look” period where you can temporarily carry both plans to see which one you like better. However, during this period, you’ll pay premiums on both plans, and you must cancel the first policy after the first month. Or, if you decide you’d rather stay with your original Medigap plan, you can cancel the second policy after the 30-day trial period.
  • As mentioned above, you don’t need a Medigap plan when you have a Medicare Advantage policy. Medigap only covers out-of-pocket costs associated with Original Medicare, Part A and Part B.
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Types of Medicare Insurance Plans Available in Puerto Rico

Types of Medicare Coverage Available in Puerto Rico

 

If you live in Puerto Rico, you may be eligible for Medicare Part A and Part B coverage. Puerto Rico is a territory of the United States, and residents of Puerto Rico (as well as other territories, such as the Northern Mariana Islands, Guam, the Virgin Islands, and American Samoa) can qualify for Medicare if they meet eligibility requirements.

Here’s an overview of how Medicare works if you live in Puerto Rico, including eligibility, enrollment, and your coverage options.

Medicare coverage in Puerto Rico

Here’s a rundown on your Medicare options.

  • You can choose to stay with the federally administered Medicare program, which is Original MedicarePart A (hospital insurance) and Part B (medical insurance).
  • Original Medicare offers limited prescription drug coverage, so you can enroll in an optional stand-alone Medicare Part D Prescription Drug Plan that works alongside your Medicare Part A and Part B coverage.
  • You can also enroll in a Medicare Supplement (Medigap) plan to help pay for out-of-pocket costs in Original Medicare. Different Medigap plans pay for different amounts of those costs, including copayments, coinsurance, and deductibles.
  • Another option is a Medicare Advantage plan, available through the Medicare Part C program. These plans offer an alternative way to get your Original Medicare benefits; they include at least the same amount of coverage as Original Medicare (except for hospice, which is still covered through Original Medicare). One major benefit is that many Medicare Advantage plans provide additional coverage beyond Original Medicare, such as routine dental services, prescription drugs, or wellness programs. A Medicare Advantage Prescription Drug plan combines health benefits and prescription drug coverage into one policy.

Out-of-pocket costs, coverage details, and plan benefits vary among Medicare-approved private health insurance companies. Medicare beneficiaries in Puerto Rico should compare all available plan options in their location with their health and prescription drug needs in mind.

Medicare eligibility in Puerto Rico

You’re typically eligible for Medicare if you’re either a United States citizen or permanent legal resident of at least five continuous years. In Puerto Rico, as in the United States, residents are generally first eligible for Medicare when they turn 65 or through disability if they’re younger than 65 and have been receiving Social Security or Railroad Retirement Board disability benefits for at least two years. You may also qualify for Medicare at any age if you have end-stage renal disease or amyotrophic lateral sclerosis (also known as Lou Gehrig’s disease).

When you’re newly eligible and signing up for Medicare for the first time, you’re enrolling in Original Medicare, Part A and Part B, the government health-care program for those over 65 and certain disabled individuals.

If you’ve worked for at least 10 years while paying Medicare taxes, you typically get Part A without a premium, but most people pay a monthly premium for Part B.

Medicare enrollment in Puerto Rico

Medicare enrollment in Puerto Rico works differently than it does in the United States. Puerto Rico residents who are already receiving Social Security or Railroad Retirement Board benefits when they turn 65 are automatically enrolled in Part A, but they must always sign up manually to get Part B. You can apply for Part B separately through Social Security or the Railroad Retirement Board (if you worked for a railroad); the contact information is below.

The best time to sign up for Medicare is generally during your Initial Enrollment Period, the seven-month period when you’re first eligible for Medicare. If you qualify because of age, this period starts three months before the month that you’re Medicare eligible, includes the month you turn 65, and continues for another three months afterwards. If you qualify because of disability, your Initial Enrollment Period starts three months before the 25th month of disability benefits and lasts seven months. You can also sign up for Part A at this time if you’re not automatically enrolled; for example, you’ll need to manually enroll in both Part A and Part B if you’re not yet receiving retirement benefits when you turn 65.

You can also sign up for Part A and/or Part B during the General Enrollment Period, which runs annually from January 1 to March 31. If you sign up during the General Enrollment Period after you’re first eligible, you might have to pay a late-enrollment penalty for Part A and/or Part B. For example, if you delay Part B enrollment until the General Enrollment Period, you may be charged a permanent premium increase of 10% for each full 12-months that you were eligible for Part B, but did not enroll. If you’re not eligible for premium-free Part A because you haven’t worked enough quarters, you may owe a late-enrollment penalty for Part A as well.

In certain situations, you may be able to delay Medicare enrollment and sign up through a Special Enrollment Period. For example, some people wait to enroll in Part B if they have employer-sponsored health coverage, since Part B comes with a monthly premium. The employer coverage must be based on current employment (either through your own work or your spouse’s work). In this situation, you’ll have an eight-month Special Enrollment Period to sign up for Medicare when you stop working or the health coverage ends (whichever happens first).To sign up for Part A and/or Part B, you can do any of the following:

You can enroll in Medicare Part A and/or Medicare Part B in the following ways:

  • Online at SocialSecurity.gov.
  • By calling Social Security at 1-800-772-1213 (TTY users 1-800-0778), Monday through Friday, from 7AM to 7PM.
  • In person at your local Social Security office.

If you worked at a railroad, enroll in Medicare by contacting the Railroad Retirement Board (RRB) at 1-877-772-5772 (TTY users 1-312-751-4701). Railroad Retirement Board representatives are available Monday through Friday, from 9AM to 3:30PM.

Medicare plans in Puerto Rico

Once you’re enrolled in Original Medicare, Part A and Part B, you may have other options as well, including Medicare Advantage plans, Medicare Prescription Drug Plans, and Medicare Supplement plans. An eHealth licensed insurance agent can help you explore Medicare plans in your area; just give us a call today to get started.

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How Medicare Part D Covers Prescription Drugs

How Medicare Part D Covers Prescription Drugs

 

Medicare Part D is prescription drug coverage offered through Medicare-approved private insurance companies.

If you have Original Medicare, you can get drug coverage through a stand-alone Medicare Prescription Drug Plan that works alongside your Part A and Part B coverage. You can also get this coverage through a Medicare Advantage Prescription Drug plan. Medicare plans that cover prescription drugs may vary when it comes to costs and covered medications. Taking the time to learn how Medicare Part D works and to compare Medicare plan options can help you save money by finding coverage that covers your prescription drugs at the lowest cost.

How Medicare Part D works

As mentioned, beneficiaries enrolled in Original Medicare, Part A and Part B, have the option of getting prescription drug benefits through a Medicare Prescription Drug Plan. Original Medicare does offer limited prescription drug coverage: You’re covered for medications you get during covered inpatient hospital and skilled nursing facility stays or prescription drugs you get in an outpatient setting (for example, an outpatient clinic). However, these tend to be the types of medications that you can’t give yourself, such as infusion or chemotherapy drugs. For most other prescription drug coverage of medications that you’d take on your own (also known as “self-administered” medications), you’ll need to enroll in a Medicare Prescription Drug Plan.

Another option is to get your prescription drug coverage included in your Medicare Advantage plan. Also known as Medicare Part C, the Medicare Advantage program offers an alternative way to get your Original Medicare benefits. All Medicare Advantage plans must cover at least the same level of benefits as Medicare Part A and Part B (with the exception of hospice care, which is still covered under Part A of Original Medicare). Unlike Original Medicare, however, many Medicare Advantage plans also include prescription drug coverage, giving you the convenience of having all of your Medicare benefits covered through a single plan.

One important thing to keep in mind is that you generally shouldn’t enroll in a Medicare Prescription Drug Plan and a Medicare Advantage plan at the same time. Instead, you should get your prescription drug benefits through a Medicare Advantage Prescription Drug plan if there’s one available in your location. In fact, if you enroll in a Medicare Prescription Drug Plan and are already enrolled in a Medicare Advantage Prescription Drug plan, you’ll be automatically disenrolled from your Medicare Advantage plan and returned to Original Medicare. The exception to this is if you’re enrolled in a type of Medicare Advantage plan that doesn’t cover prescription drugs (such as a Medical Savings Account plan or certain Private Fee-for-Service plans); in this case, you’re allowed to enroll in a stand-alone Medicare Prescription Drug plan for your Part D coverage.

Every Medicare Prescription Drug Plan and Medicare Advantage Prescription Drug plan has a drug formulary, which is a list of the prescription drugs covered by the plan and the costs associated with each medication. Keep in mind that formularies may change at any time; your Medicare plan will notify you if necessary.

Here’s how it works. A Medicare plan that includes prescription drug coverage will typically place covered drugs in its formulary into tiers, with different costs for each tier. Medications on higher tiers usually have higher copayments and coinsurance than drugs placed on lower tiers. For instance, a Medicare Prescription Drug Plan might cover generic drugs with a $10 copayment, certain brand-name drugs with a $25 copayment, and other brand-name drugs with a $35 copayment. Medications not listed in the formulary are usually not covered by the plan, meaning you might be responsible for the full cost for these prescription drugs. Check with your plan if you have questions. In some cases, you can request an exception, as explained below.

When considering enrollment in a Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug plan, it’s extremely important to make sure all the medications you take are included in the drug formulary before you sign up.

Your Medicare plan should send an Evidence of Coverage notice every fall, specifying how much you’ll pay for prescription drugs at different levels of your plan’s formulary. The plan should also send an Annual Notice of Change document, which lists cost and coverage changes that will go into effect the following year. You should read both documents carefully when deciding whether to stay with your current plan, taking into consideration how your plan meets your current health and prescription drug needs.

Every Medicare plan that includes prescription drug coverage make its drug formulary available. For more information, you can contact your Medicare plan or visit the plan’s website to get a copy of its current drug formulary.

Medicare Part D formulary changes

As mentioned above, Medicare plans that cover prescription drugs can make changes to their formularies during the year in certain situations. However, these changes are limited to protect members who may have joined a plan specifically because of the prescription drugs listed in the formulary.

A Medicare plan that covers prescription drugs must notify its members in writing at least 60 days before any mid-year changes to its formulary become effective or provide you a written notice of the change and a 60-day supply of your medication at the time that you refill your prescription.

The notification must include:

  • The name of the affected prescription drug
  • The type of change (for example, whether the Medicare plan is removing the medication from its formulary or changing its tier status)
  • The reason for the change
  • Alternatives to the affected medication that are in the same drug class or cost-sharing tier
  • The new cost-sharing requirements for the affected medications
  • Information on how members can request a coverage determination or exception

A Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan is allowed to add new prescription drugs to its formulary, place medications on a lower tier (thereby reducing the copayment or coinsurance cost), or remove medication management requirements at any time of the year. Medication management requirements may include coverage rules like prior authorization, step therapy, and quantity limits:

  • Prior authorization requires that you and/or your prescribing doctor must first request approval from the Medicare plan before it will cover the medication. Your doctor must demonstrate that the prescription drug is medically necessary for the Medicare plan to cover it.
  • Quantity limits restrict the maximum dosage or amount of a medication that you’re allowed when filling a prescription.
  • Step therapy requires that you must try first take one or more similar, lower-cost alternative medications before the Medicare plan will cover the prescription drug that your doctor prescribed.

Medicare has strict rules limiting when a Medicare plan can remove a medication from its formulary or move it to a higher tier; these rules are meant to protect beneficiaries who may be affected by midyear changes to medications that they take. The plan can make “maintenance” changes to its formulary after March 1, such as replacing a brand-name medication with a generic drug, or removing a medication for safety reasons or because of its effectiveness.

Requesting a coverage determination or exception

You have the right to request the following from your Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan:

  • A coverage determination, which is a written notice from your plan stating whether it will cover a specific prescription drug, whether you’ve met eligibility rules for coverage, and your costs for the medication. It may also include any requirements (such as prior authorization) for getting coverage of the drug and any exceptions to those rules.
  • An exception to cover a drug that is not on the formulary
  • An exception to waive coverage rules, such as prior authorization, quantity limits, or step therapy
  • An exception to pay a lower copayment for a medication on a more costly tier

When a medication you need isn’t covered by the Medicare plan or is covered at a higher tier, you can first request a coverage determination from your plan. If your condition warrants adding the medication to the formulary or altering the cost, the plan will notify you in its coverage determination of this exception to its plan rules. The Medicare plan may require a process called step therapy, where you must first try a similar, less expensive medication that’s been proven effective for your condition before it will cover the more expensive drug.

However, if your doctor believes it’s medically necessary for you to take a prescription drug that isn’t covered by your plan, you can request an exception to have the plan’s original coverage decision waived.

Either you, your doctor or prescriber can submit the exception, stating why it’s medically necessary for you to take a different medication that isn’t covered or is covered at a higher tier. This request can be submitted in writing or by phone. Your Medicare plan is required to notify you of its decision within 72 hours. If you need a medication faster than that because waiting for a standard decision could be dangerous to your life or health, you can file an expedited request to receive a decision within 24 hours. If you still don’t agree with the plan’s decision, you can appeal. For more information on the Medicare appeals process, visit Medicare.gov.

Medicare Part D coverage of vaccines

Although Medicare Prescription Drug Plans and Medicare Advantage Prescription Drug plans may cover different medications, all Medicare plans with prescription drug coverage must cover all commercially available vaccines that are medically necessary to prevent illness. Certain shots (such as the hepatitis B and pneumococcal vaccines) are covered under Part B as part of its preventive coverage; if Part B covers a vaccine, it’s not required to be covered under Part D.

What Medicare Part D doesn’t cover

Medicare excludes certain medications from Part D formularies. Excluded medications may include, but are not limited to, those in the following drug classes:

  • Weight loss, weight gain, or anorexia drugs
  • Fertility drugs
  • Cosmetic or hair growth drugs
  • Non-prescription, over-the-counter drugs
  • Medications that treat cold or cough symptoms
  • Medications that treat sexual or erectile dysfunction
  • Prescription vitamins or nutritional supplements (except for prenatal vitamins and fluoride preparations)

Finding a Medicare plan that covers your prescription drugs

Would you like help finding Medicare Advantage Prescription Drug plans and stand-alone Medicare Prescription Drug Plans in your area? You can do so in a few ways. If you’re ready to browse plans now, use the plan finder tool on this page to start comparing plan options; you can even enter your current list of prescriptions to view plan options that cover your specific medications. Would you prefer to get on-the-phone assistance? Simply pick up the phone and dial the number on this page to discuss your Medicare prescription drug needs with a licensed insurance agent.
This website and its contents are for informational purposes only. Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.

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Medicare Coverage in New Jersey

Medicare Coverage in New Jersey

 

The Medicare program provides health insurance coverage to eligible U.S. citizens and permanent legal residents of at least five years who are age 65 or older, in New Jersey and nationwide. You may also qualify for Medicare if you’re under age 65 in certain situations.

According to a report from the Centers for Medicare & Medicaid Services*, there were 1,485,769 beneficiaries enrolled in Medicare in New Jersey in 2015. Of this total, there were 233,355        residents enrolled in Medicare Advantage plans. In 2015, 876,915 New Jersey residents received Medicare prescription drug coverage through stand-alone Part D Prescription Drug Plans (PDPs), while 183,598 beneficiaries in the state received coverage for both their medications and Original Medicare benefits through Medicare Advantage Prescription Drug plans.

Types of Medicare coverage

Original Medicare refers to Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). You’re automatically enrolled into the program at age 65 if you’re already receiving Social Security Administration (SSA) or Railroad Retirement Board (RRB) retirement benefits. Enrollment is also automatic if you’ve been receiving SSA or certain RRB disability benefits for at least 24 months in a row, or if you have amyotrophic lateral sclerosis (also called Lou Gehrig’s disease – your Medicare benefits start the same month that you qualify for SSA or RRB benefits in this case).

There are many Medicare plan options beyond Original Medicare in New Jersey, although availability of specific plans depends on exactly where you live. These include Medicare Advantage plans, Medicare Advantage Prescription Drug plans, stand-alone Medicare Part D Prescription Drug Plans, and Medigap plans. Medicare plan types and individual plans may have different out-of-pocket costs, coverage of health services, and (in some cases) additional benefits.

Medicare Insurance Plan Type Description
Medicare Advantage plan A health plan offered by private insurance companies that contract with Medicare. Medicare Advantage plans provide all your Medicare Part A hospital and Part B medical benefits besides hospice care, which remains covered under Medicare Part A. Types of Medicare Advantage plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, and others.
Medicare Advantage Prescription Drug plan A Medicare Advantage plan that includes prescription drug coverage. With a Medicare Advantage Prescription Drug plan, it’s possible to get all your Medicare benefits in one plan. Note that with any type of Medicare Advantage plan, you need to pay your Medicare Part B premium every month, in addition to any premium the Medicare Advantage plan may charge.
Stand-alone Medicare Part D Prescription Drug Plan Prescription drug coverage offered by private insurance companies that contract with Medicare. This kind of plan is designed to work alongside your Original Medicare, Part A and Part B, coverage. Like Medicare Advantage Prescription Drug plans, stand-alone Medicare Prescription Drug Plans may vary in terms of out-of-pocket costs and which prescription drugs they cover. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.
Medicare Supplement (Medigap) plan Medigap plans are also offered by private insurance companies and can help you pay your out-of-pocket costs for services covered under Original Medicare.

New Jersey State Health Insurance Assistance Program (SHIP)

Medicare beneficiaries, caregivers, and their families can consult New Jersey’s State Health Insurance Assistance Program (SHIP) for free help with questions regarding health insurance. This assistance program is offered at many locations across the state, and its goal is to educate beneficiaries on Medicare benefits and claims, long-term care, and supplemental policies. Counselors are trained volunteers who provide information on different health insurance options and how to deal with insurance claims. Volunteers are not affiliated with any specific insurance company or product, but provide unbiased information.

You can also get your questions answered by one of eHealth’s licensed insurance agents by calling the phone number below; or, to compare Medicare plans in your area right away, just enter your zip code in the form on this page.

*Statistical data from the Centers for Medicare & Medicaid Services, “On its 50th anniversary, more than 55 million Americans covered by Medicare” as of July 28, 2015.

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