Nov 282011

As you are considering your Medicare enrollment be sure and consider the $0 premium Medicare Part C plans that are available.  Now, this may not be for everyone depending on your health needs, but several companies offer this type of plan to those in a specific income bracket (don’t worry the majority of medicare subscribers fall into this bracket.)

The way this works is the Medicare part C plan replaces Medicare A, B, & if you choose D.  So the monthly premium that you pay for Medicare, is what pays for this insurance plan.  So while you would continue to pay your monthly Medicare premium you would not have to pay any additional premium.  I know this was a huge savings factor for my grandparents.

The easiest way to find these plans is by using the Medicare Plan research tool at

Additionally two options I can think of available in the NW United States are AARP Secure Horizons and/or Healthnet Violet Option 2 PPO.

Remember you need to weigh the benefits of no premium against the cost of co-pays, deductibles, etc to make sure it’s going to work for you.


Nov 252011

The Medicare enrollment deadline is quickly approaching and there have been many television commercials and newspaper articles discussing the various Medicare prescription plans.  However, all of them focus on the premiums and low tier one co-payments, but they all fail to explain some important factors.


Different plans have different pharmacy networks.  Generally you will need to use a network pharmacy to receive benefits; so you will want to make sure that there is a network pharmacy near your home.


This is where the tricky part comes in.  Different insurance companies assign each drug to a tier.  What tier it is in dictates how much of a co-pay you will have to pay when you pick up your prescription.  As for what medications are assigned to what tiers–well it varies plan to plan.

Therefore, to really know if a prescription plan is right for you, you need to know what tiers your prescriptions fall under.

This can be accomplished two ways.  1. Use the benefit comparison tool at 2. Contact each insurance plan you are considering.  You could either call them to request the pharmacy information or go to their website and view their pharmacy information.

You will need to know what tier your medication is in and what the co-pay for that tier is.

Co-pays within Tiers

Often the different tiers have a gradual price increase as you go up in tiers, however, some insurance plans have sharp jumps in price tier to tier.  For example a three tier (tier one is abbreviated T1 and so on) plan may read as: T1 = $15, t2=$35, and T3=$70.  Those are steep price jumps.  However, other plans could read like this: T1=$10, T2=$20, T3=$35, T4=$45, T5=50%

So understanding how many tiers a plan offers, where your medication fits into those tiers, and what the co-payment is for each tier offered is the best way to find out how much money you are going to spend on prescription drugs in addition to any monthly premiums that you pay.




Nov 232011

Medicare is divided into multiple letters that represent different Medicare plans.  The main plans that you hear about are Medicare part A, B, C, &D.

Medicare part A covers hospital expenses.

Medicare part B covers doctor office visits

Medicare part C, is actually a managed care replacement plan for Medicare Parts A, B, & D and are offered through private companies.  If you have a Medicare Part C plan, you would give your doctor your health insurance card and not your red, white, and blue, Medicare card.

Medicare Part D is prescription coverage.

If you have Medicare Part A and/or B then you may also purchase Medigap, supplemental insurance to help cover costs that Medicare does not cover.  Medigap insurance may also help pay deductibles, co-pays, and or co-insurance.

This post is meant as a very high level overview; details will be available in further posts or in tutorials/eBooks, etc available for purchase.

Nov 022011

The EOB, which stands for Explanation of Benefit is the statement that your insurance company sends you to show what was and was not covered by your insurance. Explanation of Benefits can be broken down into several parts.

1. Provider, Patient, and  Date of Service: I know this seems obvious, but make sure that the information is what you expect it to be.  If you think it’s not call your provider first to verify and request that they contact the insurance company.

2. Services: this area is a short description of what you had done.  This may include CPT and/or ICD-9 diagnostic coding.  The main reason you would need this information is if you felt your claim did not pay correctly and you wanted to file an appeal.  Also make sure you are being billed for the service you actually received.

3. Billed Amount: This is the actual billed charges from your provider.

4. The breakdown of what was or was not paid:  This is expressed differently depending on your insurance company; however, the information used is still the same.  After the billed amount will be information regarding what amount your insurance company allowed.  This number will have to do with whether you saw a network provider and therefore received a discount or it may be based on usual and customary rates, depending on your plan.

Once the price that the insurance company is willing to pay (the allowed amount) is determined, next comes deductibles, co-payments, and co-insurance.  The co-insurance may be expressed as “you pay this %” and “insurance pays this %” sections.  This is your responsibility to pay and the actual amounts and terms will depend on your health insurance plan.  These will be subtracted from the allowed amount.

5. Next will the amount that the insurance actually pays.  This may or may not leave a zero balance.  Often you will be responsible for co-payments, deductibles, and/or co-insurance.  However, if you saw a provider or had a procedure that is not covered by your insurance then you may be responsible for the entire bill.

6. Remark Codes: If you have to pay any amount the remark code at the bottom of the EOB should explain why you are having to pay it. For example, remark code D1: patient pays co-payments and deductibles, or something to that effect.  The one thing you have to understand is that these remark codes can be wrong–especially when a claim is denied payment.  In the cases where you think it is wrong you will need to contact your insurance company or if they have online access to your information, go online and compare the EOB information with your benefit plan information.  Remember, you always have the right to appeal.




Oct 112011

Medicare open enrollment used to start in November; however, with recent law changes Medicare open enrollment now begins October 15th and runs to December 7th.  It is always best to enroll or renew as early as possible to prevent any delay in coverage.

A quick review of Medicare:

Medicare part A covers hospital costs and some home health.

Medicare part B covers doctor office visits and some home health.

Medicare part C is also known as a Medicare Advantage Plan or a Medicare Replacement plan. This plan replaces your original Medicare plan, which is just another way of saying: If you have plan C then you do not qualify for plan A&B.    However, Part C covers hospital, doctor offices, home health, and for an additional premium some plans offer vision and dental.  They also offer prescription coverage.

Medicare part D is only prescription coverage.

Medigap is also known as Medicare supplemental insurance.  There are multiple types of policies, so be sure you get the right one for you.  A Medigap policy can only purchased if you have Medicare A and/or B.  You cannot buy a Medigap policy if you have Medicare part C.