Faq

If you have Medicare and other health insurance (like from a group health plan, retiree coverage, or Medicaid), each type of coverage is called a “payer.”The “primary payer” pays up to the limits of its coverage, then sends the rest of the balance to the “secondary payer.” If the “secondary payer” doesn’t cover the remaining balance, you may be responsible for the rest of the costs. If your group health plan or retiree coverage is the secondary payer, you may need to sign up for Medicare Part B before they’ll pay. This order of payment is called “coordination of benefits.” You will need to speak with the Employer benefits coordinator to determine if their coverage will be the primary or secondary.

Resources and locations to find information
o A representative at Clear Insurances Agency – (214) 642-2358
o Medicare.gov or 1-800-Medicare
o Social Security to start Medicare or cancel Medicare

Medicare health plans provide Part A (Hospital Insurance)and Part B (Medical Insurance)benefits to people with Medicare. It's an optional plan and offered to everyone with Medicare by private insurance companies approved by Medicare. The client must have Part A and B to participate in these plans. The plans cannot be used with Medicare Supplement / Medigap policies. Most plans will include Part D - Prescription Drug Coverage.

Medigap Benefits	Medigap Plans
	A	B	C	D	F*	G*	K	L	M	N
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Part B coinsurance or copayment	Yes	Yes	Yes	Yes	Yes	Yes	50%	75%	Yes	Yes***
Blood (first 3 pints)	Yes	Yes	Yes	Yes	Yes	Yes	50%	75%	Yes	Yes
Part A hospice care coinsurance or copayment	Yes	Yes	Yes	Yes	Yes	Yes	50%	75%	Yes	Yes
Skilled nursing facility care coinsurance	No	No	Yes	Yes	Yes	Yes	50%	75%	Yes	Yes
Part A deductible	No	Yes	Yes	Yes	Yes	Yes	50%	75%	50%	Yes
Part B deductible	No	No	Yes	No	Yes	No	No	No	No	No
Part B excess charge	No	No	No	No	Yes	Yes	No	No	No	No
Foreign travel exchange (up to plan limits)	No	No	80%	80%	80%	80%	No	No	80%	80%
Out-of-pocket limit**	N/A	N/A	N/A	N/A	N/A	N/A	$6,620 in 2022	$3,310 in 2022	N/A	N/A

* Plans F and G also offer a high-deductible plan in some states. With this option, you must pay for Medicare-covered costs (coinsurance, copayments, and deductibles) up to the deductible amount of $2,875 in 2025 before the policy pays anything. (Plans C and F aren't available to people who were newly eligible for Medicare on or after January 1, 2020.)

** For Plans K and L, after you meet your out-of-pocket yearly limit and your yearly Part B deductible, the Medigap plan pays 100% of covered services for the rest of the calendar year.

*** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in inpatient admission.

 

Medicare drug plans may have rules for if and how they cover drugs. These rules can be called:
o Prior authorization
o Step therapy
o Quantity limits
o Medication safety checks, drug management programs for safer use of opioid pain medications, and Medication Therapy Management (MTM) programs for complex health needs

Medicare does not label any plan as the “Best” in a market. Medicare will use a 5 Star rating to assign for a plan during the calendar year. The Star rating is not a substitute for not verifying the plan coverage. The factors our representatives use to find a plan for each client are provider networks, plan formularies, additional benefits, and affordability.

Assistance may be available in different ways. Many plans will apply a deductible to Part D and will place prescriptions in different Tiers. The maximum deductible for 2025 is $590. Depending on which Tier the prescription is assigned with the plan and if there is a deductible will determine the cost of the prescription. "Extra Help" is a Medicare program to help people with limited income and resources pay Medicare drug coverage (Part D)premiums, deductibles, coinsurance, and other costs.Some people qualify for Extra Help automatically, and other people must apply.

Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. Medicaid offers benefits not normally covered by Medicare, like nursing home care and personal care services. The rules around who’s eligible for Medicaid are different in each state.

Get help from your state paying your Medicare Part A (Hospital Insurance)and Part B (Medical Insurance)premiums through a Medicare Savings Program. If you qualify, Medicare Savings Programs might also pay your Part A and Part B deductibles, coinsurance, and copayments.You’ll apply for Medicare Savings Programs through your state. When you apply, your state determines which program you qualify for. Even if you don’t think you qualify, you should still apply. We have the applications and guidelines to apply for the Medicare Savings Programs.

o A representative at Clear Insurances Agency – (214) 642-2358
o Medicare.gov or 1-800-Medicare