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Marketplace or ACA

There are different types of Marketplace health insurance plans available to meet different needs.  Some plans restrict your provider choices or encourage you to get care from the plan’s network of doctors and hospitals.

Depending on the number of plans offered in your area, you may find any or all of these types of metal levels—Bronze, Silver, Gold, and Platinum.  As the colors suggest, the benefits are more enhanced as you move from Bronze to Platinum.

There are pros and cons for each option. It is important to choose the right option based on your needs. This is what you need to know as your get started:

  • Open Enrollment is from November 1 to December 15 with a January 1 start date. When enrolling December 16- January 15, it will start Feb 1. There are special instances that allow you to enroll at other times throughout the year, such as losing group health coverage or a change in Medicaid status
  • In some instances, you can get tax credits to help pay for your health insurance

ACA insurance is required to provide Essential Health Benefits for all plans, you will see additional benefits when we compare them side by side in the Marketplace. It includes the following general categories:

  • Ambulatory patient services (or outpatient care)
  • Emergency services
  • Hospitalization
  • Maternity and newborn care (before and after your baby is born)
  • Mental health and substance use disorder services (including counseling and psychotherapy)
  • Prescription Drugs
  • Rehabilitative services and devices (to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services including oral and vision care

Contact us for more explanation and help in selecting the right policy for you and your family.

Medicare Supplement (Medigap) Insurance

This is insurance sold by private insurance companies, that can help pay some of the health care costs that Original Medicare does not cover, such as co-payments, coinsurance, and deductibles.  This insurance “supplements” Original Medicare.  Original Medicare pays first and then the supplement pays its portion.  A Medigap plan is different from a Medicare Advantage plan. Medicare Advantage is a way to get Medicare benefits, but Medigap supplements your Original Medicare benefits.

What you should know about Medigap plans:

  • You must have Medicare Part A and Part B.
  • If you have a Medicare Advantage Plan and wish to go back to Original Medicare with a supplement, first make sure you can leave the Advantage plan, then you can enroll in the Medigap plan before the policy begins.
  • You pay a monthly premium to the private insurance company for your supplement, but you must also pay the Part B premium to Medicare.
  • A Medigap policy can only cover one person. If you and your spouse want a Medigap plan, then you need to get 2 separate policies.
  • You can get a supplement from any carrier licensed in your state to sell one.
  • Any standard Medicare Supplement policy is guaranteed renewable, even if you have health issues. This means the insurance company can not cancel your Medigap policy if you pay the premium.
  • Prescription Drugs are not covered in a Medigap policy, if you want drug coverage you will have to join a Medicare Prescription Drug Plan (Part D) offered by private insurance companies.
  • It is illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan unless you are switching back to Original Medicare.

Comparing Medicare Supplements

Medicare Supplement policies are the same across the US and must follow federal and state laws designed to protect you. Insurance companies can only sell a “standardized” policy categorized in most states by letters.  (See the chart) All policies offer the same basic benefits but some offer additional benefits, so you can choose which one meets your needs.  As you can see from the chart, there are many options to choose.  As licensed agents, we can help you understand these plans and choose the right plan for you.

Short Term Medical Insurance

These type plans are a great alternative for consumers looking for major medical coverage that did not qualify for subsidies on ACA or bridging a gap from group insurance to an open enrollment period without a qualifying event or waiting for a new job insurance to become effective. These plans are not regulated by ACA, therefore can be written anytime throughout the year.

Benefits of Short Term Medical:

  • You can start the coverage quickly, maybe even the next day.
  • You can drop this coverage without any penalties.
  • You can choose from a range of premiums, deductible and benefit maximum amounts.
  • You can apply for another term of coverage if needed.
  • You can choose your own doctor and hospital without restriction but may be less expensive by using their network providers.
  • These are great for healthy people, but were not designed to cover all of the Essential Benefits on ACA
  • Some plans are renewable for up to 3 years.

These plans typically will not cover your routine office visits, maternity, mental health, or preventive care. They do not cover pre-existing conditions and DO require underwriting.  This means someone with a lot of health issues may not be able to get this type of coverage. Be sure to check the list of exclusions on any plan.

Give us a call to find out if short term insurance is an option for you.

Medicare –Over 65 or Disabled

To Watch a Short Video Presentation About Medicare Click Here

Medicare Basics

Medicare is a health insurance program for:

  • People age 65 or older
  • People under 65 with certain disabilities
  • People of all ages with End-Stage Renal Disease (kidney failure or transplant) or Lou Gehrig’s Disease

Medicare is made up of 3 parts:

Part A Hospital Insurance– Most people do not pay a premium for this as they have paid it through their payroll taxes while working. Medicare Part A covers inpatient care in hospitals, skilled nursing facilities (not long-term care), hospice care, and home health care.

Part B Medical Insurance –Most people pay a monthly premium for Part B which can change every year. Medicare Part B helps cover doctors and outpatient care, physical and occupational therapy, and some home health care. You can get a penalty if you do not take Part B when you are eligible, and you pay every month for the duration of your coverage.

Part D Prescription Drug Coverage-Most people will pay a monthly premium for this coverage which can change every year.  Part D helps lower prescription drug costs. Private insurance companies provide coverage. If you decide not to enroll in a drug plan when first eligible, you will pay a monthly penalty for the duration of the coverage.

Who is Eligible for Medicare?

Usually, you are eligible for Medicare if you or your spouse worked for at least 10 years at a job that paid into Medicare and you are 65 years old.

If you are not 65, you might also qualify for coverage if you have a disability or End- Stage Renal disease (kidney failure or transplant) or Lou Gehrig’s disease.

Guidelines:

You can get Part A at age 65 without paying a premium if:

  • You already get retirement benefits from Social Security or Railroad Retirement
  • You are eligible to get Social Security or Railroad benefits but have not filed for that yet
  • You or your spouse had Medicare-covered government employment

You can get Part A if you are under 65 without having a premium if:

  • You have received Social Security or Railroad Retirement
  • You are on disability for 24 months, have kidney dialysis or transplant, or have Lou Gehrig’s disease

Even though you don’t have to pay a premium for Part A under those conditions, you must pay for Part B (which can change every year). It will be deducted from your Social Security or Railroad Retirement check.  If you are not drawing those, Medicare will collect the premium for 3 months at a time.

Medicare Supplement (Medigap) Insurance

This is insurance sold by private insurance companies, that can help pay some of the health care costs that Original Medicare does not cover, such as co-payments, coinsurance, and deductibles.  This insurance “supplements” Original Medicare.  Original Medicare pays first and then the supplement pays its portion.  A Medigap plan is not the same as a Medicare Advantage plan. Medicare Advantage is a way to get Medicare benefits, but Medigap supplements your Original Medicare benefits.

What you should know about Medigap plans:

  1. You must have Medicare Part A and Part B.
  2. If you a Medicare Advantage Plan and wish to go back to Original Medicare with a supplement, first make sure you can leave the Advantage plan, then you can enroll in the Medigap plan before the policy begins.
  3. You pay a monthly premium to the private insurance company for your supplement, but you must also pay the Part B premium to Medicare.
  4. A medigap policy can only cover one person. If you and spouse want a Medigap plan, then you need to get 2 separate policies.
  5. You can get a supplement from any carrier licensed in your state to sell one.
  6. Any standard Medicare Supplement policy is guaranteed renewable, even if you have health issues. This means the insurance company can not cancel your Medigap policy as long as you pay the premium.
  7. Prescription Drugs are not covered in a Medigap policy, if you want drug coverage you will have to join a Medicare Prescription Drug Plan (Part D) offered by private insurance companies.
  8. It is illegal for anyone to sell you a Medigap policy if you have a Medicare Advantage Plan, unless you are switching back to Original Medicare.

Comparing Medicare Supplements

Medicare Supplement policies are the same across the US and must follow federal and state laws designed to protect you.  Insurance companies can only sell a “standardized” policy categorized in most states by letters.  (See the chart)  All policies offer the same basic benefits but some offer additional benefits, so you can choose which one meets your needs.  As you can see from the chart, there are many options to choose.  As licensed agents, we can help you understand these plans and choose the right plan for you.

Part D Prescription Drug Plans

These policies help cover prescription drug costs. You can sign up for Part D Prescription Drug Coverage 3 months before your 65th birthday.  If you do not enroll by 3 months after your 65th birthday, you will get a late enrollment penalty that you must pay every month for the duration of your drug coverage.  If you work passed your birthday and have credible coverage, you will not incur the late penalty, but you must enroll within 63 days of losing the credible coverage to avoid a penalty at that time.  The late enrollment penalty is calculated by taking 1% times the national average premium times the number of months you did not have coverage.

If you are already in a Part D stand-alone drug plan or a Medicare Advantage plan that includes drug coverage, you are able to switch plans during the annual enrollment period from Oct 15-Dec 7th each year.

How Does It Work?

Each year the drug coverage rules change, but they are based on the true out pocket cost or actual retail cost of the medicines. There are 4 stages:

  1. Deductible Stage– presently, during the deductible stage, if your plan has a deductible, you will pay the first $545 (2024) then move to the Initial Coverage Phase
  2. Initial Coverage Phase-presently, you pay copays until the retail cost gets up to $5030
  3. Coverage Gap (Donut Hole) Phase– then in the coverage gap phase, you will pay 25% of all medicines until your retail cost gets up to $8000
  4. Catastrophic Coverage Phase– finally in this stage you will pay $0 for all medications until Dec 31st.

How to choose a plan

It is vital to review your Part D coverage every year, especially if you are taking any new medicines.

You can start by looking on Medicare.gov   Enter your medicines and pharmacies to see all of the plan options.  You can see the monthly costs for each medicine and the differences in pharmacy.

Each plan has a preferred, standard, or out-of-network pharmacy.  Most plans have a mail-order option as well. They can vary drastically from plan to plan.

Contact us to check your medications for you, to make sure you are on the best-suited plan, and to explain any details you do not understand.  Then let us do the enrollment for you.

Individuals with low annual incomes may qualify for Extra Help from Medicare.  Extra help helps pay your Part D premiums and out-of-pocket drug costs.

Enroll using this link. https://www.ssa.gov/medicare/part-d-extra-help

Medicare Advantage Plans

Medicare Advantage Plans (Part C) are health plans from private insurance companies.  These plans generally cover all Medicare-covered healthcare and can include prescription drug coverage.  There are 4 types:

  • Medicare Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Private Fee-for-Service Plans
  • Medicare Special Needs Plans

These plans generally offer extra benefits and lower co-payments than on Original Medicare.  These are managed care plans that may require you to see doctors that belong to the plan or go to certain hospitals for services.

Generally, Medicare Advantage plans include benefits such as dental, vision, hearing, OTC (health care products) and gym membership, many plans offer more than this also.

There are special Medicare Advantage plans available specifically to honor the people that have served in our Military. These plans offer many additional benefits.

To join a Medicare Advantage Plan, you must have Medicare Part A and Part B.  You will need to continue to pay your monthly Part B premium to Medicare.  The standard Part B premium amount for 2024 is $174.70 (depending on your income).

When you can enroll

Medicare limits when you can join, switch or drop a Medicare Advantage Plan. You can join anytime beginning 3 months before the month of your 65th birthday and 3 months after the month you turned 65.

If you are on disability and have Social Security, you can join 3 months before to 3 months after month 25 of your disability.

You can switch or drop your Medicare Advantage plan during Annual Enrollment Period each year between Oct 15-December 7th.

Please contact us to go over all of your needs in detail and help you find a plan that fits you.

Life Insurance

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Short Term Care Insurance

Short-term care refers to a wide range of medical and non-medical assistance to get people back on their feet following an accident, illness, or surgery. It typically lasts several weeks or a few months, or sometimes longer depending on the severity of the condition being treated. Short-term care options include skilled nursing rehab, home health, home care, and respite. The biggest difference between long term and short-term care is the length of time needed to recover and the goal of care.

Benefits:

  • Issue ages 18-89
  • Daily benefits up to $450 and benefit periods up to 360 days
  • Elimination periods of 0 or 20 days
  • No prior hospital stay required
  • Guaranteed renewable if you pay the premium
  • Benefits are paid directly to you to use as you need
  • Restoration of benefits
  • Optional additional riders available
  • More affordable than long term care insurance

Long Term/Short Term Care

To Watch a Short Video About Long Term Care Click Here

What is Long Term Care Insurance?

Long Term Care is services that help meet the medical and non-medical needs of people with chronic illness or disabilities who cannot care for themselves for long periods of time.  These services include dressing, bathing, transferring (to or from bed to chair), incontinence, eating and using the bathroom.  These services can be provided at home, in the community, in assisted living facilities or in nursing homes.

Long term care insurance was developed to provide the needed financial protection against the cost of long- term care that regular health insurance and Medicare do not cover.  Long term services can last years and can be very expensive.  These insurance policies can be purchased based on the need for care.  Some plans pay a daily benefit for a duration of time like 2 or 3 years and some pay until a maximum dollar amount has been paid.  You can build the policy with an inflation rider to use the premiums as a tax deduction and to keep up with the rising cost of health care.

Who should get this coverage and why do I need it?

  • It is never too early to consider long term care insurance, the younger you are the less expensive it will be. Anyone age 45 or older, NOW is the time to start planning.
  • The coverage is guaranteed renewable for life as long as you make the payments
  • You have to health qualify for these products, so if you wait until something has happened and you need the services, it will be too late.
  • 70% of all people age 65 and up will use long term care at some point in their lives. That is 7 out of 10 people.  That is a very high number to consider.
  • This coverage will protect your retirement assets that you worked your whole life to achieve.
  • This will reduce the emotional and financial stress on you and your family with care giving responsibilities.
  • You can make the decision to stay in your home for care, or chose the assisted living or nursing home facility of your choice.

Myths surrounding Long Term Care

  1. I am probably already covered for long-term care.
    ANSWER: Most people think their insurance covers long-term care expenses, but that is not true.  Long-term care is NOT covered by other insurance.  Long-term care insurance policies cover day-to-day personal care assistance when you are not able to perform everyday tasks like bathing and dressing.
  2. Medicare or Medicaid will cover my long-term care.
    ANSWER: Medicare does not cover long-term care. Medicare pays for skilled care in a nursing home, only for short periods of time (up to 100 days), while recuperating following a hospital stay. Medicare does not cover personal or custodial care costs. Medicaid does pay for long-term care, but only after you spend down all of your assets and income.
  3. Long-term care is only for the elderly.
    ANSWER: Long-term care is not just for the elderly, younger people may need it due to unexpected illnesses, diseases, injuries, or accidents.
  4. I won’t need long-term care insurance because my family will be able to care for me.
    ANSWER: Families do and will help provide care for you, but when It’s time for professional help or staying in a nursing home, they generally cannot afford to pay those costs for you.
  5. I can’t afford long-term care insurance.
    ANSWER: Long-term care insurance can be more affordable than you thought and can be tailored to meet your needs and budget. The costs can be managed by making a retirement plan that is right for you. The younger you are when you purchase this insurance, the lower the premiums.

How much Long-Term Care Insurance do I need?

The cost of these policies varies by state and by region.  Where you retire helps determine the amount of coverage you will need. The type and duration of care, the provider you use, and where you live are huge factors.

In 2021, the national average costs for long-term care in the US were:

  • $7756 a month for semi-private rooms in a nursing home
  • $8821 a month for private rooms in a nursing home
  • $4300 a month for an assisted living facility
  • $74 a day for services in an adult daycare center

In 2020, Missouri had the cheapest semi-private room at $5080 and private room at $5749 per month, but   Alaska had the most expensive with semi-private rooms for $37,143 and private rooms for $36,378 per month.  So, you can see geography makes a difference.

It is projected for the national average costs for long-term care in the US to be:

2030 cost of a semi-private room will be $10,318 and a private room will be $11,787

2041 cost of a semi-private room will be $14,283 and a private room will be $16,316

Example: In Missouri, for a private room it is $5931 a month in 2023 x 12 months = $71,172 per year,
(factor in 3% medical inflation rate)
$95,649 per year in 10 years or
$136,379 per year in 20 years

The average length of time for men is 2.2 years x $136,379 = $300,034

The average length of time for women is 3.7 years x $136,379 = $504,602

Alzheimer’s patients average is 8 years x $136,379 = $1,091,032

These numbers may be confusing to you, please reach out to us and we can explain exactly how we came up with those figures.  If you want to do a calculation for another state, we can do that also.  Imagine how much more the Alaska numbers would go up with the pricing being so much higher there.

Different types of care

Long-term care takes place in a nursing home that provides custodial care but may include skilled care, intermediate care, and custodial care.  The patient can be transferred within the facility as their needs change.  Nursing homes provide a great range of 24-hour care.

Home Health care is used for recovering from an injury or illness and 24-hour care is not needed.  This is most often custodial care provided by visiting nurses, therapists, or home health aides. Services may include things like respiratory therapy, cleaning and bandaging of wounds, monitoring health and assistance with bathing and dressing.

Adult day care centers provide care in a group setting for aged or disabled people who live at home, and/or may need help with the basic activities of daily living due to physical or mental impairment. These centers usually provide elderly people with social interaction, therapeutic activities, preventive health services, and nutritional meals.

Hospice care is compassionate care for those terminally ill patients nearing the end of life. This care tries to make the patient as comfortable as possible until the end, it can take place in a facility or at home.

Respite care provides some time off for the caregiver (usually a relative) who regularly provides care for an elderly or disabled person.  This can be offered in a community center, nursing home, or at home through a service.

Traditional Long Term Care vs Hybrid Long Term Care

With traditional long-term care insurance, you pay the premiums, and if and when you need it due to age or illness, the policy pays out a daily benefit.  Some people feel they are “throwing away “money if they die and never use the insurance.

  • These plans have huge flexibility for monthly benefits, benefit periods, inflation protection, and waiting period.
  • Traditional long-term policies can have the option of being tax-qualified.
  • They are guaranteed renewable as long as you pay the premium.
  • Premiums are paid monthly, quarterly, semi-annual, or annually.

Hybrid long-term care plans allow you to draw funds from the policy for your long-term care, and the insurance company pays for the care when the funds run out.  With these plans, if you die without using the coverage, your beneficiary receives the money as a death benefit (like life insurance).

  • If you pay your premiums, you will have a contractually guaranteed death benefit, guaranteed cash value, and guaranteed amount of long-term care coverage.
  • These plans allow you to choose your options at the beginning but have very little flexibility afterward.
  • Some of these plans can be purchased as a one-time lump sum and others can be paid over a short period of time, which can make them very costly.
  • Hybrid policies are not tax deductible because they are not tax-qualified.
  • Many hybrid plans do not require a medical exam to get a policy as they use simplified underwriting.

Short Term Care Insurance

Short-term care by definition refers to a wide range of medical and non-medical assistance to get people back on their feet following an accident, illness, or surgery. It typically lasts several weeks or a few months, or sometimes longer depending on the severity of the condition being treated. Short-term care options include skilled nursing rehab, home health, home care, and respite. The biggest difference between long-term and short-term care is the length of time needed to recover and the goal of care.

Benefits:

  • Issue ages 18-89
  • Daily benefits up to $450 and benefit periods up to 360 days
  • Elimination periods of 0 or 20 days
  • No prior hospital stay required
  • Guaranteed renewable as long as you pay the premium
  • Benefits are paid directly to you to use as you need
  • Restoration of benefits
  • Optional additional riders are available
  • More affordable than long-term care insurance

Call us today to look at the many choices of coverage you have and the cost to you for each.