Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial solutions.
With hosts licensed insurance agents Jennifer Lee, you are guided
through the ins and outs of Medicare, whether you are
(00:22):
nearing retirement, navigating your options, or just curious about what's available.
Everything you need to know is covered. Tune in for
knowledgeable insights, tips and answers to your Medicare questions so
you can take charge of your health and your future.
And Now Medicare three sixty.
Speaker 2 (00:45):
Welcome back to Medicare three sixty radio show where we
turn confusion into confidence for your healthcare and retirement decisions.
I'm your host, Jennifer Alfonzo Lee, certified long Term care Specialist,
investment Advisor, representative and under Premiere three sixty insurance and
financial solutions. Today's shows cover some of the most important
(01:07):
updates shaping twenty twenty six and how they affect just
about every senior in America. We'll be diving into the
twenty one hundred annual cap on prescription drug costs, the
insulin savings program that limits insulin to just thirty five
dollars a month, and how to file a Medicare appeal
(01:27):
if you ever were denied a coverage. These aren't just headlines,
they are life changing updates that can protect your health,
your wallet, and your piece of line. So definitely, twenty
twenty six marks eight miles so near for Medicare. For decades,
many seniors struggled with high drug costs and unpredictable out
(01:49):
of pocket bills. The doughnut whole phase confused everyone. So
in twenty twenty five, the first time ever, Medicare is
setting a heart ceiling. You'll never pay more than that
two thousand dollars per year out of pocket for any
covered prescription drugs under Part DY and in twenty twenty
(02:12):
six that will increase to twenty one hundred. But that's okay,
But the key thing is that it has to be covered,
So please make sure to review your drug plan to
just make sure all your drugs are covered.
Speaker 3 (02:28):
But that is a.
Speaker 2 (02:29):
Huge relief for anyone who takes expensive medications for diabetes,
heart disease, cancer, or autoimmune conditions. So let's just put
this in perspective. If you were paying five hundred dollars
five hundred dollars a month for meds. That's six thousand
dollars a year under like the cap for this year.
Speaker 3 (02:51):
Next year it.
Speaker 2 (02:53):
Would be twenty one hundred for twenty twenty six, and
your plan will cover the rest. So that's really great.
That just means more predictability, fewer tough choices, and more
room in your budget. Also, there is a kind of
a program where the insurance company could help you allocate
(03:16):
that into monthly installment payments as well if that's going
to help, so keep that in mind.
Speaker 3 (03:25):
So how it.
Speaker 2 (03:26):
Works is that the twenty one hundred limit applies to
your total at of pocket costs to cover your party drugs.
Speaker 3 (03:34):
Your deductible, your copays, and.
Speaker 2 (03:36):
Your co insurance all count toward that number. Once you
reach two thousand, you pay zero dollars for covered prescriptions
the rest of the year, But if you qualifiers, it
doesn't include your monthly plan premium. So that's one of
the biggest things to look at when choosing a drug
plan because oftentimes there are plans with larger premium amounts
(04:01):
compared to lower ones the drugs are covered or you're
paying very minimal on the drugs, but keep in mind
you are paying a larger premium. It also only applies
to drugs on your plan's formulary, so checking your formula
every year is crucial. And that's the thing, right, there
(04:22):
might be some prescription drugs that aren't covered for next
year that were covered this year or vice versa. Right,
maybe it wasn't covered this year so you had to
pick a different drug plan before next year it's covered,
so keep that in mind as well. It doesn't apply
to medications given in a doctor's office or hospital. Those
(04:43):
are built under Part B. So example, if you're getting
an injection like prolia at the doctor's office, they ordered it,
they injecting it, that should be Underpart B. So this
is part of the Inflation Reduction Act rollout that was
(05:05):
rolled out in twenty twenty five and which also introduced,
like the big item that was the Insulin Savings Program,
so that helped others as well. So diabetes affects over
sixteen million Americans on Medicare, and insulin has been one
of the most unaffordable drugs. Now, thanks to the Medicare
(05:29):
Insullin Savings Program, insulin costs are capped at thirty five
dollars per month prescription I mean for most beneficiaries. So
this cap applies to both Part D standalone drug plans
and Medicare advantage plans that include the drug coverage. This
(05:49):
means whether you get insulin, pens, fials, or pumps, your
maximum cost is thirty five dollars per month, even if
you haven't met your deductible. But remember keep in mind
you just you need to make sure that that insulin
is covered in the plan, right, because sometimes your insulin
(06:10):
may be covered in one prescription drug plan and not
the other, so that is very crucially important. So if
you are unsure whether your insulin is included, check your
plan's evidence of coverage document or call your plan directly.
The savings is immediate, tangible and could save many seniors
(06:31):
hundreds even thousands per year.
Speaker 3 (06:36):
See.
Speaker 2 (06:36):
Even with these improvements, plans still differ, and that's why
annual reviews are non negotiable as yourself, are all my
medications still covered and in the same tier because there
are tierle levels like Pier one, Tier two, three, four, five, six,
and so depending on the tier on your drug, you
(06:59):
could be paying very little or a lot and some
plans do have deductibles of six point fifteen or lower
depending on the plan itself, So you got to also
take that in consideration. Have my copays or deductibles change,
So that's what I'm mentioning. Some plans they are going
(07:22):
off a percentage of the cost of your drugs. Some
plans are going off a copay, so that might be
something that could be a very big cost depending on
how the drug the insurance company covers your drug. Did
(07:43):
my plan raise my premium or shrink my network? So
the biggest thing on that. There are plans that it
costs one hundred or two hundred dollars premium versus plans
that are at zero cost. Right, so really understanding how
your drug plan works, it.
Speaker 3 (08:00):
Makes all the difference.
Speaker 2 (08:03):
Does my advantage plans still include dental vision or hearing?
So definitely, there are plans that have decreased. Really most
of them, I feel like they've either stayed the same
or decreased. There are a few, I would say that
are trying to get their dental plan better. Even in
(08:23):
some cases where implants and may have been included may
now be excluded for next year. So make sure that
you are reading your annual notice of change your ANA
and that will show you for twenty twenty five what
changes are going to be in twenty twenty six. So
(08:44):
it's very clear and outline there. But of course your
licensed independent agent should also do that as well.
Speaker 3 (08:53):
Okay, so does it.
Speaker 2 (08:55):
Annual enrollment time October fifteenth to December seventh. It's your
time to compare your plans, and this year changes to
make it even more important because it's a lot of
instability right now. So definitely insurance companies have to pivot
and also change their plans, their drugs, their premiums, you
(09:17):
name it.
Speaker 3 (09:18):
There's just a lot of changes.
Speaker 2 (09:21):
So if you've been putting it off because it feels complicated,
my team at Premiere three to sixty can simplify it
for you in one personalized consultation. So let's shift gears.
Because sometimes even with the best coverage, Medicare or your
plan might deny service or a drug you need. So
(09:44):
maybe your doctor ordered in medication that wasn't on the formulay.
Maybe your plan said something wasn't necessary medically necessary. So
the good news is you do have the right to
appeal need denial and there's a clear process for doing it.
(10:05):
So let's walk through it step by step. First, you
know requests an explanation of benefits. Every month, your plan
sends you in explanation of benefits, listing what was covered
or what wasn't. If you see something denied, don't ignore
it right. Step two is file an a missile appeal
(10:26):
within sixty days, you call your plan or submit a
written appeal, stay clearly why disagree, and include documentation from
your doctor supporting medical necessity. So, really, for the prescription drugs,
what you could do is, if we know that it's
not even covered, still have your doctor run it through
(10:50):
and then it goes to the pharmacy and then it's
not approved. We could call in the insurance company to
file that appeal. Then the insurance company will contact your
doctor's office to see if what they say basically like
are they approving it with the justification of you taking
(11:13):
that prescription drug? Are there other prescription drugs you could
take alternate, or like are you allergic to the other ones?
Speaker 3 (11:22):
And so forth.
Speaker 2 (11:24):
So your doctor should send that back to the insurance
company and hopefully get it approved. The biggest thing I
would say is like sometimes a client gets a letter
of denial. You think it's a denial, but really no,
it's a pre The drug is covered but needs a
pre authorization from the doctor. So that's when the doctor's
(11:46):
office really needs to complete the information.
Speaker 4 (11:49):
Right.
Speaker 2 (11:50):
Some doctor's offices are really fast, some are very slow,
so sometimes things follow the crap and sometimes you need
an advocate for your own health. Of course, here at
Premier three to sixty, we will advocate for you and
we will help you guide you through that process.
Speaker 3 (12:06):
I know your time is valuable. You don't do this
for a living, and we do, so we know what
to do to help you.
Speaker 2 (12:14):
So step three. If it's denied again, escalate to an
independent review entity. You can tried another time to get
it appealed. So this level is handled by initial third party,
not your insurance company. So step four continue up with
the chain. If needed, you can go all the way
to the Medicare appeals counsel or even federal court if
(12:37):
that's serious.
Speaker 3 (12:38):
Right.
Speaker 2 (12:39):
So many seniors do win their appeals, especially when they
included detailed doctor letters or proof that the medication has worked.
You can help get help from your doctor or license
Medicare independent financial agent like our team who could guide
you through the process. So remember, appealing isn't planning, its
(13:00):
exercising your rights. So the biggest thing on this I
would say is just know your rights, know your advocacy,
have someone advocate for you like us, because that's what
we do. Oftentimes clients may complain about the insurance company,
but sometimes it's insurance companies not getting that approval or
(13:25):
that letter from the doctor. They have no clue what's
going on. Right, Sometimes things fall off the cracks your
case manager. If you're like at the hospital or skilled nursing,
they really either could help or break you know your
service at that point, but know that you do have
(13:47):
rights and you should make sure you're getting that right,
so advocate for yourself. We definitely love to advocate for
our clients too, especially if you do not know your
rights or you don't know what's covering your plan. We're
able to help you on that, and sometimes it's just
understanding what your plan covers to make sure that you're
(14:11):
getting the level of the care you need. So while
we are talking about finances, let's quickly touch on IRMA.
That's the income related monthly adjustment amount. If your income
is higher, you might pay more for parts B and D.
(14:32):
But what most retires don't know is if your income
recently dropped due to retirement, divorce, or the sale of
your property, you could appeal irma too.
Speaker 3 (14:42):
That's right.
Speaker 2 (14:43):
You just file form SSA dot DAH or for with
Social Security explaining your life change. Many seniors do reduce
that premium that way.
Speaker 3 (14:54):
So it's another.
Speaker 2 (14:54):
Example why staying proactive can save you real money. And
sometimes also right that falls through the cracks.
Speaker 3 (15:03):
So you definitely have to.
Speaker 2 (15:04):
Follow up with Social Security and sometimes it's a quick call.
I had one more client was they said no. The
client we then said no, she did sell her home
and she became a widow, and she's like, oh, okay, we.
Speaker 3 (15:17):
Didn't know about that part.
Speaker 2 (15:19):
So that's something. Definitely you could file that appeal, need
that form, let us know, we could provide that for you.
So with all these changes, scammers are taking advantage. It
is very concerning that with rules and regulations in place,
(15:40):
we still have scammers or just not even scameras telemarketing.
I know, I get it, they want your business, but
there's a right way to do it. Clients are getting
about ten fifteen twenty calls a day, even text messages.
They are not supposed to do that. If you did
not ask a request for information from a license agent,
(16:05):
then you are not supposed to get calls. You know,
clients are just now in the days where they're just
muting their calls not picking up the phone, which is
very unfortunate and very frustrating.
Speaker 3 (16:19):
I get that.
Speaker 2 (16:21):
So these scammers or calls i'll call claiming to update
your plan or come from your Medicare number, don't.
Speaker 3 (16:28):
Fall for it.
Speaker 2 (16:29):
Medicare never calls you out of the blue. I actually
had one instance for a client. They had called her.
They said, oh, you are on this plan, and she
knew exactly what plan she was on and it was
not that plan, but she kind of went along with it.
Then they wanted to ask her for her Medicare number,
So that right, Sometimes you may not know what you're
(16:52):
planning on and you just believe and trust that individual.
But yeah, do not give them your Medicare number. If
you get a suspicious call, hang up and contact one
hundred Medicare or your trusted advisor, just to make sure.
Because there's some really savvy letters and telemarketers that do
(17:13):
go out there and try to scam like hospice is
a big scam right now, where they get your information,
they build up Medicare five six thousand, who knows eight
to ten thousand, and well, you know you are not
(17:33):
liable for that. I mean, that's fraud, waste, and abuse.
So definitely guard your Medicare number like it's your credit card,
because once it's stolen, it's hard to undo the damage
as well.
Speaker 4 (17:50):
Okay, so with all these reforms, the two thousand cap
this year for Medicare, twenty one hundred next year, and
son savings drug negotiations, they're part of a larger movement
to make Medicare.
Speaker 2 (18:08):
Simple, fair, and more affordable. But of course, sometimes because
of these changes, these insurance companies are also saying that
they are not making any money, they're not being profitable.
Star ratings have definitely gone down for some insurance companies,
and they're actually fighting that too with the government because
(18:33):
just a little tangent off star ratings is the lower
the star ratings, the less money these insurance companies get
from Medicare and the government. The higher the star ratings,
the more money they get from the government, which entails
provides better.
Speaker 3 (18:51):
Services to their enrollers or the beneficiaries. Right, So that's
the thing.
Speaker 2 (18:59):
We are entering an era where preventive care, digital access,
and medication affordability are front and center. But with these
new programs come with new complexities why, which is why
education is your best defense. And at Premiere three sixty,
we do believe knowledge isn't just power, it is protection.
(19:22):
Understanding your rights, understanding your plans, how they work, maximizing
your benefits. Times are tough right now. Food costs, just
everything with inflation has dramatically increased, and then some of
our benefits are decreasing, which are unfortunate. But just knowing
(19:46):
and planning ahead, especially if you are relying on the
grocery cards utility cards, what can we do to help
better assist you, help help you better find better benefits
for you, and just even free services in your area
locally that may help your situation as well. So let's
(20:13):
just recap. The twenty one hundred cap is a game
changer for out of pocket prescription costs. You are able
to make these payments. I just can't remember on top
of my head what they're called. But you can divide
your payments into twelve if it may be easier for
(20:33):
you to.
Speaker 3 (20:34):
Pay for that.
Speaker 2 (20:37):
Then we have insulin say these programs that have been
actually been going on for quite a couple of years now.
It does make life more affordable for millions living with diabetes.
And if you're ever denied coverage, you do have the
right to appeal and fight your benefits. And the biggest
thing I always advocate is just advocating for yourself because
(21:02):
you may be the lucky ones that get the right
service providers, great doctors, great hospitals, great case managers. But
you also may be unlucky and get ones that truly
don't care. It's just a job to them, and you gotta,
you gotta fight for his rights. And I've seen it recently.
(21:24):
I had a client that was the hospital for very long.
He didn't know how long you could stay for the
hospital because typically right they the hospital wants to kick
you out right away because it definitely costs them a
lot of money versus what the payout is going to be.
(21:45):
And then so they were scared that he would be
kicked out, and then then they wanted to put him
in a cute skilled nursing facility and it was denied.
Speaker 3 (21:59):
And I thought that was strange, right because this.
Speaker 2 (22:02):
Person was in dire need, and so we helped call
through way with insurance company. Come to find out they
never received a authorization or referral, So how can you
even deny a claim. I think they were just going
off what the case manager was saying, which yes, you
know you should trust, but I mean, it doesn't make sense.
(22:25):
So we did our due diligence and then they could
go to that case manager and tell them, you know,
there was no authorization or approval even sent in. So
unfortunately for my client, things took a turn for the
worst and he did pass. It's very unfortunate. He's been
(22:46):
my client for quite a long time. And it's also
just sad. You know, my clients become part of my family,
as you know, reviewing their clients every single year or
just any time.
Speaker 3 (22:59):
Of the year.
Speaker 2 (23:00):
They have questions, so it is tough seeing that. That's
why advocacy for health making sure you are doing your
preventive exams and just making sure you're taking the steps
to be healthy, because I know I do have clients
that don't even go to the doctor. They don't care
(23:22):
to go to the doctor, so that's tough too. And
then sometimes it's just too late. When you do so
establishing that care, I would say it's very important get
to know your doctor.
Speaker 3 (23:33):
If you don't like your doctor, you could.
Speaker 2 (23:35):
Always find another doctor, right You don't have to stay
so definitely, these changes prove one thing Medicare is evolving.
Staying informed is how you'll take full advantage of all
your benefits.
Speaker 3 (23:51):
And all the rules and blows coming in to effect.
Speaker 2 (23:56):
So, if you'd like your personalized Medicare three sixty console,
or need help reving your plan or filing an appeal,
my team and I would love to help.
Speaker 3 (24:05):
Could visit Premier three.
Speaker 2 (24:06):
Sixty solutions dot com or call our office to schedule
your free consultation today. And so, I'm Jennifer Alfonso Lee.
This has been Medicare three sixty Radio Show, your trusted
guide to navigating Medicare with clarity and confidence. Until next time,
(24:26):
stay healthy, stay informed, and take care of each other.
Speaker 1 (24:31):
Thank you for joining the program Medicare at three sixty.
Hope you found today's episode insightful and empowering. Remember, understanding
your Medicare options is key to making the right choices
for your health and financial well being. If you have
questions or topics you would like covered in future episodes
of Medicare three sixty. Don't hesitate to reach out and
(24:54):
speak with our licensed insurance agent until next time. Stay
informed and take charge of your healthcare journey. This has
been Medicare three point sixty, your trusted source for all
things Medicare. Take care
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial solutions.
With hosts licensed insurance agents Jennifer Lee, you are guided
through the ins and outs of Medicare, whether you are
(00:22):
nearing retirement, navigating your options, or just curious about what's available.
Everything you need to know is covered. Tune in for
knowledgeable insights, tips and answers to your Medicare questions so
you can take charge of your health and your future.
And Now Medicare three sixty.
Speaker 2 (00:45):
Welcome back to Medicare three sixty radio show where we
turn confusion into confidence for your healthcare and retirement decisions.
I'm your host, Jennifer Alfonzo Lee, certified long Term care Specialist,
investment Advisor, representative and under Premiere three sixty insurance and
financial solutions. Today's shows cover some of the most important
(01:07):
updates shaping twenty twenty six and how they affect just
about every senior in America. We'll be diving into the
twenty one hundred annual cap on prescription drug costs, the
insulin savings program that limits insulin to just thirty five
dollars a month, and how to file a Medicare appeal
(01:27):
if you ever were denied a coverage. These aren't just headlines,
they are life changing updates that can protect your health,
your wallet, and your piece of line. So definitely, twenty
twenty six marks eight miles so near for Medicare. For decades,
many seniors struggled with high drug costs and unpredictable out
(01:49):
of pocket bills. The doughnut whole phase confused everyone. So
in twenty twenty five, the first time ever, Medicare is
setting a heart ceiling. You'll never pay more than that
two thousand dollars per year out of pocket for any
covered prescription drugs under Part DY and in twenty twenty
(02:12):
six that will increase to twenty one hundred. But that's okay,
But the key thing is that it has to be covered,
So please make sure to review your drug plan to
just make sure all your drugs are covered.
Speaker 3 (02:28):
But that is a.
Speaker 2 (02:29):
Huge relief for anyone who takes expensive medications for diabetes,
heart disease, cancer, or autoimmune conditions. So let's just put
this in perspective. If you were paying five hundred dollars
five hundred dollars a month for meds. That's six thousand
dollars a year under like the cap for this year.
Speaker 3 (02:51):
Next year it.
Speaker 2 (02:53):
Would be twenty one hundred for twenty twenty six, and
your plan will cover the rest. So that's really great.
That just means more predictability, fewer tough choices, and more
room in your budget. Also, there is a kind of
a program where the insurance company could help you allocate
(03:16):
that into monthly installment payments as well if that's going
to help, so keep that in mind.
Speaker 3 (03:25):
So how it.
Speaker 2 (03:26):
Works is that the twenty one hundred limit applies to
your total at of pocket costs to cover your party drugs.
Speaker 3 (03:34):
Your deductible, your copays, and.
Speaker 2 (03:36):
Your co insurance all count toward that number. Once you
reach two thousand, you pay zero dollars for covered prescriptions
the rest of the year, But if you qualifiers, it
doesn't include your monthly plan premium. So that's one of
the biggest things to look at when choosing a drug
plan because oftentimes there are plans with larger premium amounts
(04:01):
compared to lower ones the drugs are covered or you're
paying very minimal on the drugs, but keep in mind
you are paying a larger premium. It also only applies
to drugs on your plan's formulary, so checking your formula
every year is crucial. And that's the thing, right, there
(04:22):
might be some prescription drugs that aren't covered for next
year that were covered this year or vice versa. Right,
maybe it wasn't covered this year so you had to
pick a different drug plan before next year it's covered,
so keep that in mind as well. It doesn't apply
to medications given in a doctor's office or hospital. Those
(04:43):
are built under Part B. So example, if you're getting
an injection like prolia at the doctor's office, they ordered it,
they injecting it, that should be Underpart B. So this
is part of the Inflation Reduction Act rollout that was
(05:05):
rolled out in twenty twenty five and which also introduced,
like the big item that was the Insulin Savings Program,
so that helped others as well. So diabetes affects over
sixteen million Americans on Medicare, and insulin has been one
of the most unaffordable drugs. Now, thanks to the Medicare
(05:29):
Insullin Savings Program, insulin costs are capped at thirty five
dollars per month prescription I mean for most beneficiaries. So
this cap applies to both Part D standalone drug plans
and Medicare advantage plans that include the drug coverage. This
(05:49):
means whether you get insulin, pens, fials, or pumps, your
maximum cost is thirty five dollars per month, even if
you haven't met your deductible. But remember keep in mind
you just you need to make sure that that insulin
is covered in the plan, right, because sometimes your insulin
(06:10):
may be covered in one prescription drug plan and not
the other, so that is very crucially important. So if
you are unsure whether your insulin is included, check your
plan's evidence of coverage document or call your plan directly.
The savings is immediate, tangible and could save many seniors
(06:31):
hundreds even thousands per year.
Speaker 3 (06:36):
See.
Speaker 2 (06:36):
Even with these improvements, plans still differ, and that's why
annual reviews are non negotiable as yourself, are all my
medications still covered and in the same tier because there
are tierle levels like Pier one, Tier two, three, four, five, six,
and so depending on the tier on your drug, you
(06:59):
could be paying very little or a lot and some
plans do have deductibles of six point fifteen or lower
depending on the plan itself, So you got to also
take that in consideration. Have my copays or deductibles change,
So that's what I'm mentioning. Some plans they are going
(07:22):
off a percentage of the cost of your drugs. Some
plans are going off a copay, so that might be
something that could be a very big cost depending on
how the drug the insurance company covers your drug. Did
(07:43):
my plan raise my premium or shrink my network? So
the biggest thing on that. There are plans that it
costs one hundred or two hundred dollars premium versus plans
that are at zero cost. Right, so really understanding how
your drug plan works, it.
Speaker 3 (08:00):
Makes all the difference.
Speaker 2 (08:03):
Does my advantage plans still include dental vision or hearing?
So definitely, there are plans that have decreased. Really most
of them, I feel like they've either stayed the same
or decreased. There are a few, I would say that
are trying to get their dental plan better. Even in
(08:23):
some cases where implants and may have been included may
now be excluded for next year. So make sure that
you are reading your annual notice of change your ANA
and that will show you for twenty twenty five what
changes are going to be in twenty twenty six. So
(08:44):
it's very clear and outline there. But of course your
licensed independent agent should also do that as well.
Speaker 3 (08:53):
Okay, so does it.
Speaker 2 (08:55):
Annual enrollment time October fifteenth to December seventh. It's your
time to compare your plans, and this year changes to
make it even more important because it's a lot of
instability right now. So definitely insurance companies have to pivot
and also change their plans, their drugs, their premiums, you
(09:17):
name it.
Speaker 3 (09:18):
There's just a lot of changes.
Speaker 2 (09:21):
So if you've been putting it off because it feels complicated,
my team at Premiere three to sixty can simplify it
for you in one personalized consultation. So let's shift gears.
Because sometimes even with the best coverage, Medicare or your
plan might deny service or a drug you need. So
(09:44):
maybe your doctor ordered in medication that wasn't on the formulay.
Maybe your plan said something wasn't necessary medically necessary. So
the good news is you do have the right to
appeal need denial and there's a clear process for doing it.
(10:05):
So let's walk through it step by step. First, you
know requests an explanation of benefits. Every month, your plan
sends you in explanation of benefits, listing what was covered
or what wasn't. If you see something denied, don't ignore
it right. Step two is file an a missile appeal
(10:26):
within sixty days, you call your plan or submit a
written appeal, stay clearly why disagree, and include documentation from
your doctor supporting medical necessity. So, really, for the prescription drugs,
what you could do is, if we know that it's
not even covered, still have your doctor run it through
(10:50):
and then it goes to the pharmacy and then it's
not approved. We could call in the insurance company to
file that appeal. Then the insurance company will contact your
doctor's office to see if what they say basically like
are they approving it with the justification of you taking
(11:13):
that prescription drug? Are there other prescription drugs you could
take alternate, or like are you allergic to the other ones?
Speaker 3 (11:22):
And so forth.
Speaker 2 (11:24):
So your doctor should send that back to the insurance
company and hopefully get it approved. The biggest thing I
would say is like sometimes a client gets a letter
of denial. You think it's a denial, but really no,
it's a pre The drug is covered but needs a
pre authorization from the doctor. So that's when the doctor's
(11:46):
office really needs to complete the information.
Speaker 4 (11:49):
Right.
Speaker 2 (11:50):
Some doctor's offices are really fast, some are very slow,
so sometimes things follow the crap and sometimes you need
an advocate for your own health. Of course, here at
Premier three to sixty, we will advocate for you and
we will help you guide you through that process.
Speaker 3 (12:06):
I know your time is valuable. You don't do this
for a living, and we do, so we know what
to do to help you.
Speaker 2 (12:14):
So step three. If it's denied again, escalate to an
independent review entity. You can tried another time to get
it appealed. So this level is handled by initial third party,
not your insurance company. So step four continue up with
the chain. If needed, you can go all the way
to the Medicare appeals counsel or even federal court if
(12:37):
that's serious.
Speaker 3 (12:38):
Right.
Speaker 2 (12:39):
So many seniors do win their appeals, especially when they
included detailed doctor letters or proof that the medication has worked.
You can help get help from your doctor or license
Medicare independent financial agent like our team who could guide
you through the process. So remember, appealing isn't planning, its
(13:00):
exercising your rights. So the biggest thing on this I
would say is just know your rights, know your advocacy,
have someone advocate for you like us, because that's what
we do. Oftentimes clients may complain about the insurance company,
but sometimes it's insurance companies not getting that approval or
(13:25):
that letter from the doctor. They have no clue what's
going on. Right, Sometimes things fall off the cracks your
case manager. If you're like at the hospital or skilled nursing,
they really either could help or break you know your
service at that point, but know that you do have
(13:47):
rights and you should make sure you're getting that right,
so advocate for yourself. We definitely love to advocate for
our clients too, especially if you do not know your
rights or you don't know what's covering your plan. We're
able to help you on that, and sometimes it's just
understanding what your plan covers to make sure that you're
(14:11):
getting the level of the care you need. So while
we are talking about finances, let's quickly touch on IRMA.
That's the income related monthly adjustment amount. If your income
is higher, you might pay more for parts B and D.
(14:32):
But what most retires don't know is if your income
recently dropped due to retirement, divorce, or the sale of
your property, you could appeal irma too.
Speaker 3 (14:42):
That's right.
Speaker 2 (14:43):
You just file form SSA dot DAH or for with
Social Security explaining your life change. Many seniors do reduce
that premium that way.
Speaker 3 (14:54):
So it's another.
Speaker 2 (14:54):
Example why staying proactive can save you real money. And
sometimes also right that falls through the cracks.
Speaker 3 (15:03):
So you definitely have to.
Speaker 2 (15:04):
Follow up with Social Security and sometimes it's a quick call.
I had one more client was they said no. The
client we then said no, she did sell her home
and she became a widow, and she's like, oh, okay, we.
Speaker 3 (15:17):
Didn't know about that part.
Speaker 2 (15:19):
So that's something. Definitely you could file that appeal, need
that form, let us know, we could provide that for you.
So with all these changes, scammers are taking advantage. It
is very concerning that with rules and regulations in place,
(15:40):
we still have scammers or just not even scameras telemarketing.
I know, I get it, they want your business, but
there's a right way to do it. Clients are getting
about ten fifteen twenty calls a day, even text messages.
They are not supposed to do that. If you did
not ask a request for information from a license agent,
(16:05):
then you are not supposed to get calls. You know,
clients are just now in the days where they're just
muting their calls not picking up the phone, which is
very unfortunate and very frustrating.
Speaker 3 (16:19):
I get that.
Speaker 2 (16:21):
So these scammers or calls i'll call claiming to update
your plan or come from your Medicare number, don't.
Speaker 3 (16:28):
Fall for it.
Speaker 2 (16:29):
Medicare never calls you out of the blue. I actually
had one instance for a client. They had called her.
They said, oh, you are on this plan, and she
knew exactly what plan she was on and it was
not that plan, but she kind of went along with it.
Then they wanted to ask her for her Medicare number,
So that right, Sometimes you may not know what you're
(16:52):
planning on and you just believe and trust that individual.
But yeah, do not give them your Medicare number. If
you get a suspicious call, hang up and contact one
hundred Medicare or your trusted advisor, just to make sure.
Because there's some really savvy letters and telemarketers that do
(17:13):
go out there and try to scam like hospice is
a big scam right now, where they get your information,
they build up Medicare five six thousand, who knows eight
to ten thousand, and well, you know you are not
(17:33):
liable for that. I mean, that's fraud, waste, and abuse.
So definitely guard your Medicare number like it's your credit card,
because once it's stolen, it's hard to undo the damage
as well.
Speaker 4 (17:50):
Okay, so with all these reforms, the two thousand cap
this year for Medicare, twenty one hundred next year, and
son savings drug negotiations, they're part of a larger movement
to make Medicare.
Speaker 2 (18:08):
Simple, fair, and more affordable. But of course, sometimes because
of these changes, these insurance companies are also saying that
they are not making any money, they're not being profitable.
Star ratings have definitely gone down for some insurance companies,
and they're actually fighting that too with the government because
(18:33):
just a little tangent off star ratings is the lower
the star ratings, the less money these insurance companies get
from Medicare and the government. The higher the star ratings,
the more money they get from the government, which entails
provides better.
Speaker 3 (18:51):
Services to their enrollers or the beneficiaries. Right, So that's
the thing.
Speaker 2 (18:59):
We are entering an era where preventive care, digital access,
and medication affordability are front and center. But with these
new programs come with new complexities why, which is why
education is your best defense. And at Premiere three sixty,
we do believe knowledge isn't just power, it is protection.
(19:22):
Understanding your rights, understanding your plans, how they work, maximizing
your benefits. Times are tough right now. Food costs, just
everything with inflation has dramatically increased, and then some of
our benefits are decreasing, which are unfortunate. But just knowing
(19:46):
and planning ahead, especially if you are relying on the
grocery cards utility cards, what can we do to help
better assist you, help help you better find better benefits
for you, and just even free services in your area
locally that may help your situation as well. So let's
(20:13):
just recap. The twenty one hundred cap is a game
changer for out of pocket prescription costs. You are able
to make these payments. I just can't remember on top
of my head what they're called. But you can divide
your payments into twelve if it may be easier for
(20:33):
you to.
Speaker 3 (20:34):
Pay for that.
Speaker 2 (20:37):
Then we have insulin say these programs that have been
actually been going on for quite a couple of years now.
It does make life more affordable for millions living with diabetes.
And if you're ever denied coverage, you do have the
right to appeal and fight your benefits. And the biggest
thing I always advocate is just advocating for yourself because
(21:02):
you may be the lucky ones that get the right
service providers, great doctors, great hospitals, great case managers. But
you also may be unlucky and get ones that truly
don't care. It's just a job to them, and you gotta,
you gotta fight for his rights. And I've seen it recently.
(21:24):
I had a client that was the hospital for very long.
He didn't know how long you could stay for the
hospital because typically right they the hospital wants to kick
you out right away because it definitely costs them a
lot of money versus what the payout is going to be.
(21:45):
And then so they were scared that he would be
kicked out, and then then they wanted to put him
in a cute skilled nursing facility and it was denied.
Speaker 3 (21:59):
And I thought that was strange, right because this.
Speaker 2 (22:02):
Person was in dire need, and so we helped call
through way with insurance company. Come to find out they
never received a authorization or referral, So how can you
even deny a claim. I think they were just going
off what the case manager was saying, which yes, you
know you should trust, but I mean, it doesn't make sense.
(22:25):
So we did our due diligence and then they could
go to that case manager and tell them, you know,
there was no authorization or approval even sent in. So
unfortunately for my client, things took a turn for the
worst and he did pass. It's very unfortunate. He's been
(22:46):
my client for quite a long time. And it's also
just sad. You know, my clients become part of my family,
as you know, reviewing their clients every single year or
just any time.
Speaker 3 (22:59):
Of the year.
Speaker 2 (23:00):
They have questions, so it is tough seeing that. That's
why advocacy for health making sure you are doing your
preventive exams and just making sure you're taking the steps
to be healthy, because I know I do have clients
that don't even go to the doctor. They don't care
(23:22):
to go to the doctor, so that's tough too. And
then sometimes it's just too late. When you do so
establishing that care, I would say it's very important get
to know your doctor.
Speaker 3 (23:33):
If you don't like your doctor, you could.
Speaker 2 (23:35):
Always find another doctor, right You don't have to stay
so definitely, these changes prove one thing Medicare is evolving.
Staying informed is how you'll take full advantage of all
your benefits.
Speaker 3 (23:51):
And all the rules and blows coming in to effect.
Speaker 2 (23:56):
So, if you'd like your personalized Medicare three sixty console,
or need help reving your plan or filing an appeal,
my team and I would love to help.
Speaker 3 (24:05):
Could visit Premier three.
Speaker 2 (24:06):
Sixty solutions dot com or call our office to schedule
your free consultation today. And so, I'm Jennifer Alfonso Lee.
This has been Medicare three sixty Radio Show, your trusted
guide to navigating Medicare with clarity and confidence. Until next time,
(24:26):
stay healthy, stay informed, and take care of each other.
Speaker 1 (24:31):
Thank you for joining the program Medicare at three sixty.
Hope you found today's episode insightful and empowering. Remember, understanding
your Medicare options is key to making the right choices
for your health and financial well being. If you have
questions or topics you would like covered in future episodes
of Medicare three sixty. Don't hesitate to reach out and
(24:54):
speak with our licensed insurance agent until next time. Stay
informed and take charge of your healthcare journey. This has
been Medicare three point sixty, your trusted source for all
things Medicare. Take care
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