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Category: Frequently Asked Questions

I am covered by traditional Medicare and was recently notified by my doctor that she is participating in an “ACO” created by the ACA. What is an ACO and how does this affect me?

The ACA created a new Medicare payment model, called the Accountable Care Organization, or ACO, as part of an ongoing effort to try to lower costs and improve the quality of care in Medicare.  ACOs are groups of doctors, hospitals, and other health care providers that form partnerships to collaborate and share accountability for the quality and cost of care delivered to their patients.  There are several types of ACOs, and Medicare’s payments to them vary based on their success in meeting quality and spending goals.  If any of your doctors or clinical practitioners are participating in a Medicare ACO, you still have access to all your Medicare benefits and may continue to see any Medicare provider that you choose.  All providers are required to notify you of their participation in a Medicare ACO.

I recently turned 65 and I am eligible for Medicare Part A without having to pay a premium. But I have not yet signed up for Medicare Part A or Part B. Can I purchase a Marketplace plan?

Yes, if you are not covered by Medicare, an insurer can sell you a Marketplace plan. But because you are eligible for premium-free Medicare Part A, you are not eligible to receive the premium tax credit to help reduce the cost of a Marketplace policy, even if you would qualify based on your income.

Also keep in mind that if you sign up for a Marketplace plan, rather than enroll in Medicare Part B when you are first eligible to do so, and then later you decide to sign up for Medicare, you may be required to pay a penalty for delaying enrollment in Medicare Part B.  Your monthly Part B premium may go up 10% for each year that you could have had Part B, but didn’t.  You may also owe a late enrollment penalty for Part D drug coverage, which is equal to 1% of the national average premium amount for every month you didn’t have coverage as good as the standard Part D benefit.

I am about to turn 65 and sign up for Medicare but am not sure what my options are for coverage. Where can I go for more information?

To learn more about your coverage options under Medicare, including the Medicare Advantage plans, Part D prescription drug plans, and Medigap supplemental policies available in your area, and how to enroll, you can go to the Medicare Plan Finder on www.Medicare.gov or call 1-800-MEDICARE.  You can also contact the State Health Insurance Assistance Program in your state or the Social Security Administration.  Medicare provides links and phone numbers for these and other organizations at the following website: http://www.medicare.gov/contacts/.  Information about Medicare Advantage plans, Part D drug plans, and Medigap policies is not available through the federal or state Marketplaces.

I am age 60 and have been receiving Social Security disability insurance (SSDI) payments for two years. I recently received my Medicare card, and I would like to get coverage to supplement my Medicare Part A and Part B coverage. I live in a state that does not require insurance companies to sell Medigap supplemental policies to people under age 65. Can I purchase a Marketplace plan to supplement Medicare?

No, companies that sell Marketplace plans are prohibited from selling these plans to you if they know you are covered by Medicare.  If you do not live in a state that requires insurance companies to sell Medigap policies to people under age 65, some insurance companies still may voluntarily sell Medigap policies to people under 65, although they will probably cost you more than Medigap policies sold to people age 65 and older.  If you want prescription drug coverage to supplement your Medicare Part A and Part B benefits, you can purchase a Part D prescription drug plan.  You can also look into receiving your Medicare-covered benefits through a Medicare Advantage private plan, such as an HMO or PPO.  Medicare Advantage plans are not allowed to turn down people with Medicare based on your health status or having a pre-existing condition, but access to providers is generally more limited than in traditional Medicare.
Keep in mind that when you turn 65 and are enrolled in Part B, you will get a six-month opportunity to enroll in any Medigap policy you want.

Did the ACA change how much my doctor is paid by Medicare?

The ACA temporarily increased Medicare payments by 10% for certain services provided by primary care practitioners (including doctors, nurse practitioners, and physician assistants) as well as general surgeons practicing in underserved areas.  These increases were in place from 2011 through the end of 2015.

Until April 2015, Medicare was required to pay doctors based on a certain formula.  The ACA did not make any changes to that formula, but Congress repealed it in the Medicare Access and CHIP Reauthorization Act (MACRA).   Among other things, this law created a new method for determining how Medicare pays physicians. Specifically, Medicare payments to physicians will be based on either their participation in an alternative payment model that assumes financial risk, or their performance on quality and spending measures. Medicare is currently working on implementing this new system, which will begin to affect physician payments in 2019.

I am enrolled in a Medicare Advantage plan. Did the ACA make changes to this program?

Yes, the law did make some changes to the Medicare Advantage program.  This program is an alternative to traditional Medicare, where people on Medicare can choose a private plan, such as an HMO or PPO, to receive Medicare-covered benefits.  The law reduced federal payments to these plans to bring them closer to the average costs of traditional Medicare.  The law also provided additional payments to plans that earn high quality ratings.

In addition, the law limited how much cost sharing plans can charge enrollees for certain services, and limited how much plans can spend on administrative expenses and profits (referred to as “medical loss ratio” requirements.)

To learn more about how your coverage options under Medicare, including all of the Medicare Advantage plans, Part D drug plans, and Medigap supplemental policies available in your area, you can go to the Medicare Plan Finder on www.Medicare.gov or call 1-800-MEDICARE.

I am enrolled in a Medicare Part D drug plan. Did the ACA make changes to my Medicare drug coverage?

Yes, the law included changes that could save you money if you have very high prescription drug costs.  If you are enrolled in a Medicare Part D plan and you have very high drug costs, the law is helping to reduce the costs you pay when you reach a gap in coverage that is sometimes referred to as the “doughnut hole.”  This gap in coverage is being phased out between now and 2019 for brand-name drugs.  If your total drug costs are more than $3,820 in 2019, after that point you will pay 25% of the cost of your brand-name drugs and 37% of the cost of your generic drugs.  In 2020, you will pay 25% for both brand-name and generic drugs.

The law also included a new requirement that people on Medicare with higher incomes pay a higher premium for Part D coverage.  These higher premiums are paid by single beneficiaries enrolled in Part D plans with incomes greater than $85,000 and married couples with incomes greater than $170,000.

I am in my early 60s and have signed up for a Marketplace plan so that I have health insurance coverage until I qualify for Medicare at age 65. What happens when I go on Medicare?

When you turn 65, you should sign up for Medicare and notify your Marketplace plan that you now qualify for Medicare coverage.  Your Marketplace coverage will not be cancelled automatically by your plan when you turn 65 and sign up for Medicare, but if you receive premium tax credits to help you pay for your Marketplace plan premium, your eligibility for these tax credits will end when your Medicare Part A coverage starts (people with Medicare are not eligible for these tax credits, and the premium tax credit can only be used for the purchase of Marketplace coverage, not Medicare).

If you choose to enroll in Medicare Part A and keep your Marketplace coverage, you will have to pay the full price for your Marketplace plan, and Medicare will be the primary payer.  If you were receiving financial assistance for your Marketplace coverage prior to signing up for Medicare, you will receive a letter in the mail from the Marketplace informing you that you are no longer eligible to receive this financial assistance since you are enrolled in Medicare Part A. You should contact your Marketplace plan to make sure that your financial assistance is stopped when your Medicare coverage begins. If you do not stop receiving the premium tax credit and other financial assistance for your Marketplace plan when your Medicare coverage begins, you may have to repay some or all of the amount of financial assistance you received for the months you had both types of coverage.

If you decide to drop your Marketplace coverage when you become eligible for Medicare, make sure your Medicare coverage has started before you cancel your Marketplace plan so that you avoid any gaps in coverage.  You can start signing up for Medicare three months before your 65th birthday.

I am turning 65 years old next month, but I am not entitled to Medicare without having to pay a premium for Part A because I have not worked long enough to qualify. Can I sign up for a Marketplace plan?

Yes, in general, people age 65 or older who are not entitled to premium-free Medicare can purchase health insurance coverage in the Marketplace (except undocumented immigrants).  If you sign up for a Marketplace plan, you will be eligible for premium tax credits to make the coverage in the Marketplace more affordable if your income is between 100% and 400% of the federal poverty level ($12,140 to $48,560 for an individual in 2019).

Keep in mind that if you are able to continue working, you may be able to earn enough work history to qualify for premium-free Medicare in the future.  So another option for you to consider would be to sign up for Part A and Part B coverage when you turn 65 (you will have to pay a premium for both Part A and for Part B), and when you become eligible for premium-free Part A through your work history, you will then only have to pay a premium for Part B.

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