Frequestly Asked Questions

If you’re wondering whether any Medicare Part D drug plan fully covers the donut hole, the short answer is no. Every Part D plan has a coverage gap (commonly called the donut hole) built into its structure. However, this isn’t as daunting as it may sound. Here’s what you need to know.

Key Points to Keep in Mind:

• All Part D plans include the donut hole, but they also provide discounts designed to help you manage costs while in it.

• Generic and brand name drugs come with significant discounts during the coverage gap, ensuring you don’t pay the full price.

• Using tools like Medicare’s drug plan finder or consulting a Medicare broker can help you find the most cost-effective and suitable plan for your needs.

Now, let's break it down for better clarity.

How Part D Plans Work

When Medicare Part D was introduced in 2006, a few plans initially offered coverage for both generic and brand-name drugs during the donut hole. However, by the next year, most carriers had scaled back on that coverage, and today, you won’t find a plan that provides full coverage for brand-name drugs in the gap.

But this isn’t a reason to worry. The Centers for Medicare and Medicaid Services (CMS) have implemented critical financial protections in every Part D plan. For example:

• Cost-sharing Protections: All plans follow federal guidelines that ensure you have financial safeguards in place during the coverage gap.

• Catastrophic Coverage: Once you’ve spent a certain amount on prescriptions, you enter the Catastrophic Coverage phase, where your medication costs drop significantly. This ensures you’re protected from crippling out-of-pocket expenses for high-cost medications.

These guarantees are built into every Part D plan, so you’ll always have a safety net to avoid bankrupting yourself over costly medications.

Generic Drug Coverage in the Donut Hole

While many Part D plans offer discounts on generic drugs in the gap, select plans go a step further and provide copays for certain generics. However, there’s a catch:

• Pharmacies frequently offer generic drugs at competitive prices (as low as $4) without the need for insurance.

• Paying extra for a higher-premium Part D plan because it provides added generic drug coverage may end up costing you more than the savings it provides.

The best way to determine which Part D plan suits your needs is to use Medicare’s drug plan finder tool. This helpful resource compares drug plans in your state and identifies the most cost-effective options based on your specific medications.

Brand Name Drug Coverage in the Donut Hole

Even if Part D plans don’t fully cover brand-name drugs during the gap, they still offer substantial discounts. These discounts often cover more than 50% of the medication’s cost, meaning you’ll never pay the full price for a covered formulary drug while in the coverage gap.

• While these discounts might not match the low copays you had before entering the gap, they still provide significant relief.

This level of cost-sharing helps ensure that even in the donut hole, your out-of-pocket costs remain manageable.

We Can Help You Navigate Your Drug Plan Options

At Boomer Benefits, we offer personalized assistance to our Medigap policyholders by conducting free Medicare drug plan analyses. Here’s how we can help:

• Plan Insights: We provide inside knowledge about plans, such as whether they require prior authorization, have quantity limits, or impose step therapy on your medications.

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  • Step Therapy is a cost-saving mechanism where carriers require you to try a less expensive drug before covering the cost of a pricier alternative.

• Medicare Savings Programs: Some individuals qualify for special savings programs that can help eliminate the coverage gap, and we’ll guide you through those options.

Take the stress out of choosing your plan. Our team offers proactive insights designed to save you both money and frustration at the pharmacy counter.

Contact Us Today for Personalized Assistance

Key Takeaways

1. No Part D plan fully covers the donut hole, but all plans include mechanisms to help you control costs.
2. Significant discounts are available for both generic and brand-name drugs in the donut hole, so you never have to pay 100% out-of-pocket.
3. For the best results, use Medicare’s drug plan finder tool or seek the expertise of a specialist to ensure your selected plan meets your individual needs.

Don’t go into your Part D decisions blindfolded. Contact FTJ Senior Insurance today to ensure you’re getting the best plan at the most competitive price.

If you're new to Medicare, you might not fully realize the wealth of health benefits available to you. The Welcome to Medicare Visit, for instance, is a valuable yet often underutilized benefit. According to the National Institutes of Health, only about 13% of new Medicare enrollees take advantage of this free health visit each year.

This guide will walk you through what the Welcome to Medicare Visit is, who’s eligible, what it includes, and how it differs from other wellness visits. If you're newly enrolled in Medicare, here’s how this invaluable benefit can help you prioritize your health.

Who Is Eligible for the Welcome to Medicare Visit?

The Welcome to Medicare Visit is designed for anyone enrolled in Medicare Part B. You’re eligible to schedule this visit within the first 12 months after your Part B coverage becomes effective. Whether you’ve chosen Original Medicare or Medicare Advantage, this benefit is open to you.

Cost: There’s no out-of-pocket cost for the Welcome to Medicare Visit, as long as your provider accepts Medicare assignment. The annual deductible and Part B coinsurance don’t apply for this visit.

Pro Tip: Medicare also covers several preventive services at 100%, regardless of the deductible. Don’t miss out on this opportunity to access early health screenings and services.

What Does the Welcome to Medicare Visit Include?

Your Welcome to Medicare Visit is more than a routine physical. It’s a comprehensive opportunity to review your health, address concerns, and plan for a healthier future. During the visit, your doctor will cover these key areas:

1. Medical History Review

Your doctor will discuss your medical history, including previous illnesses, surgeries, and medications. They’ll also note any family medical history that may increase your risk for certain conditions. Expect questions about your lifestyle, such as your diet, physical activity, and alcohol or tobacco use.

2. Mental Health and Depression Screening

Mental health is a critical part of overall well-being. Seniors often face an increased risk of depression or anxiety, particularly when dealing with chronic illnesses. Your doctor will assess your mood and perform a depression screening if needed. This service comes at no extra charge.

3. Safety Assessment

Your doctor will evaluate potential safety risks at home, such as fall hazards or lack of smoke detectors. They’ll provide safety tips to help prevent injuries and ensure your living environment promotes your well-being.

4. Basic Physical Exam

Key health metrics, such as height, weight, and body mass index (BMI), will be measured. Blood pressure, vision, and hearing tests will also be conducted. If additional tests or blood work are recommended, these may be covered by Medicare, though standard deductibles or coinsurance may apply.

5. End-of-Life Planning

If requested, your doctor can discuss advance directives, healthcare proxies, or other planning documents. They may also provide materials to review at home with your family.

6. Health Education

Your physician will offer tailored recommendations on improving your health. This might include advice about nutrition, exercise, and preventive services such as immunizations or screenings.

7. Referrals for Additional Tests

Your doctor might refer you for further tests or screenings, such as bone density scans or an abdominal aortic aneurysm ultrasound. Medicare often covers these screenings at 100% if you meet certain criteria. Be sure to confirm coverage with your doctor before scheduling additional tests.

How Is the Welcome to Medicare Visit Different from the Annual Wellness Visit?

The Welcome to Medicare Visit is a one-time benefit available only within your first 12 months of Part B enrollment. On the other hand, the Annual Wellness Visit (AWV) can be scheduled each year after your first year on Medicare.

Both visits include health assessments, but the AWV also emphasizes ongoing care. It may include cognitive screenings to detect early signs of conditions like Alzheimer’s or dementia. Like the Welcome visit, the AWV is free if your provider accepts Medicare assignment. However, additional tests recommended during the AWV may incur costs.

How to Schedule Your Welcome to Medicare Visit

Scheduling your Welcome to Medicare Visit is easy. Once your Part B coverage starts, contact your doctor’s office and request an appointment for this specific visit. Inform the scheduler so they allocate enough time to complete the necessary screenings.

What to Bring to Your Appointment:

• Medical Records: Include any relevant X-rays and lab results.

• Immunization Records.

• Current Medications: A list of all prescription and over-the-counter medications you use regularly.

• Family Medical History.

• Advance Directives or related documents, if available.

• Medicare Card or Medicare Advantage Card.

• A List of Questions you’d like to discuss with your doctor.

Plan for your appointment to last 30 minutes to an hour, depending on whether additional tests are needed. To ensure a smoother experience, consider bringing along a family member or friend for support and note-taking.

Don’t Forget Your Annual Wellness Visits

Preventive care is a vital part of staying healthy as we age, yet many adults miss out on this benefit. According to recent statistics, only about half of older adults are current with their vaccinations and screenings. With Medicare covering most preventive services at 100%, now is the time to take advantage of your yearly wellness checks.

Your doctor can help you stay on top of recommended screenings and ensure you access all the services you’re eligible for. Regular checkups can make a significant difference in your long-term health.

Personalized Medicare Guidance

Taking the first step toward better health starts with understanding your benefits. The Welcome to Medicare Visit is an excellent opportunity to establish a care plan and make the most of your coverage.

Not sure how to choose the best Medicare plan for your needs? Contact the team at FTJ Senior Insurance for personalized support. We're here to help you confidently choose the coverage that works for you, all at no cost.

Prioritize your health today. Schedule your Welcome to Medicare Visit and make Medicare work for you!

Here's What You Need to Know

Medicare is a vital resource for healthcare, especially for those 65 and older, but when it comes to dental care, things can get a little confusing. If you’ve been wondering whether Medicare covers dental services, you’re not alone. Here’s the full breakdown so you can better understand your options.

Does Medicare Cover Routine Dental Care?

Unfortunately, Medicare does not cover routine dental care. This means services like teeth cleanings, regular checkups, X-rays, and fillings are not included. For most of us, employer-sponsored health insurance plans typically include dental benefits during our working years. But once you transition to Medicare, routine dental coverage is no longer a standard benefit.

Why?

Medicare classifies dental care such as cleanings, extractions, dentures, and fillings as "not medically necessary." This means anything primarily focused on maintaining or improving oral health generally does not qualify for Medicare coverage.

When Does Medicare Cover Dental Services?

While routine dental care isn’t included, there are specific scenarios where Medicare may cover dental services, usually when it’s deemed medically necessary.

Here are a few examples of dental services Medicare might cover:

• Dental care related to other medical conditions: For instance, if you need surgery for a jaw injury or dental services as part of an oral cancer treatment plan, Medicare may help cover those costs.

• Pre-surgery dental exams: If your doctor orders a dental exam before a major surgery, such as a heart or kidney transplant, Medicare may cover the exam—but not any additional work you need to complete.

• Oral exams linked to radiation therapy: Patients undergoing head or neck radiation for cancer often require dental procedures or exams. Medicare should theoretically cover these medically necessary services, although beneficiaries often must file appeals to have their claims reviewed.

For standalone claims, the prescribing doctor must provide specific documentation to Medicare proving that the service is part of a medically necessary treatment plan.

What About Root Canals, Dentures, or Dental Implants?

Medicare does not cover root canals, crowns, or dentures, even though these procedures often require surgery. Similarly, dental implants to replace missing teeth are not covered. These exclusions highlight Medicare’s focus on medical, not dental, healthcare.

Options for Dental Coverage

While Medicare doesn’t generally cover dental care, there are solutions to make sure you don’t end up paying out-of-pocket for all of your oral health needs.

Dental Coverage Through Medicare Advantage Plans

Some Medicare Advantage plans (also known as Part C) offer limited dental benefits. These might include routine services such as cleanings, X-rays, and simple fillings.

However, it’s important to weigh the pros and cons:

• Coverage can vary year to year: Dental benefits under Medicare Advantage are not guaranteed and can change annually.

• Access to network dentists only: Often, you’ll need to stay within the plan’s dental provider network, which may not include your preferred dentist.

Pro Tip: Choose a Medicare Advantage plan based on its medical benefits first, and view dental as an added perk rather than the main decision factor.

Standalone Dental Insurance

For more dependable dental coverage, purchasing a standalone dental insurance policy is a smarter alternative. These policies are independent of Medicare and offer a wide array of dental care benefits, including preventative and major procedures.

Key benefits of standalone dental insurance include:

• Coverage for cleanings, X-rays, fluoride, fillings, and even crowns or root canals.

• Freedom to go to any dentist you prefer, without being confined to a network.

• Additional vision and hearing care benefits (depending on the plan).

• Immediate coverage for preventative services with no waiting period.

Standalone plans typically remain stable year after year, unlike Medicare Advantage plans, and can even cover family members in your household. For people on Medicare who want consistent and robust dental benefits, this is often the best choice.

Private Pay Options

If you prefer to pay for services out of pocket, check with your dentist to see if discounts are available for cash payments. Many dentists may reduce your bill by 5%–10% since paying cash saves them the time and costs of filing an insurance claim.

Final Thoughts

While Original Medicare doesn’t cover routine dental care, understanding your options can help you secure the coverage you need. Here’s a quick recap:

• Routine dental care is NOT covered by Medicare.

• Medically necessary dental services might be covered under Medicare Part A or B in limited circumstances.

• Consider Medicare Advantage plans if you’re looking for dental coverage as a bonus but focus on their medical benefits first.

• Opt for standalone dental insurance for reliable, comprehensive dental care coverage.

If you’re ready to explore dental insurance options to pair with your Medicare benefits, check out our trusted standalone dental plans. Get a quote today and find a plan that fits your needs and budget, so you can enjoy the peace of mind that comes with a healthy smile!

A frequent question among Medicare beneficiaries is whether Medigap Plan G is a Medicare Advantage plan. The simple answer is no. Medigap Plan G is not a Medicare Advantage plan. Instead, it’s a supplemental policy that helps cover costs that Original Medicare doesn’t handle, bringing peace of mind to those seeking more predictable healthcare expenses.

What is Medicare Advantage?

Before we get into the details of Plan G, it’s important to understand Medicare Advantage plans. Medicare Advantage plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans include all the benefits of Original Medicare (Parts A and B), often bundled with additional perks such as prescription drug coverage, dental, vision, and hearing care. Medicare Advantage plans also feature an annual maximum out-of-pocket limit for your healthcare costs. Keep in mind that most Medicare Advantage plans operate within specific networks of healthcare providers, meaning that you’ll need to stick to these networks to receive full coverage benefits.

What is Plan G?

Plan G, also referred to as a Medicare Supplement plan or Medigap, is a policy designed to fill the gaps left by Original Medicare. It is one of 10 standardized Medigap plans available and is offered by private insurance companies. Plan G works alongside your Original Medicare coverage, supplementing the costs Medicare doesn’t cover.

Additionally, there’s a high-deductible version of Plan G, which works similarly but requires you to meet a high deductible before coverage kicks in. Whether you choose the standard or high-deductible Plan G, both options provide financial relief for out-of-pocket costs such as coinsurance or deductibles.

What does Plan G cover?

Plan G covers a variety of healthcare expenses to lessen your financial burden. This includes:

• Medicare Part A coinsurance and hospital costs

• The first three pints of blood each year

• Skilled nursing facility coinsurance

• Medicare Part A deductible

• Medicare Part B coinsurance

• Medicare Part B excess charges

• Foreign travel emergency care

While Plan G itself does not have its own deductible, you are required to meet the Medicare Part B deductible before Plan G covers its portion of your expenses.

Key Differences Between Medicare Advantage Plans and Plan G

Understanding the distinctions between Medicare Advantage plans and Plan G can help you decide which option suits your healthcare needs.

• Coverage

Medicare Advantage plans combine all the benefits of Original Medicare with extras like prescription drug, dental, or vision coverage. On the other hand, Plan G supplements Original Medicare by covering certain out-of-pocket expenses.

• Networks

Medicare Advantage plans often require you to use a specific network of providers to access full coverage. However, Plan G allows you the freedom to see any healthcare provider that accepts Medicare, no referrals or networks required.

• Costs

Medicare Advantage plans generally feature lower monthly premiums but may result in higher out-of-pocket costs when receiving care. Plan G, while it can have higher premiums, ensures broader coverage without unexpected expenses. A common misconception is that Plan G has a maximum out-of-pocket limit; it does not. Instead, Plan G covers costs whenever Medicare approves a service and pays its portion.

For those considering the high-deductible Plan G, it’s important to note that although it requires you to meet the deductible first, it operates just like the standard Plan G afterward.

Which is the best option for you?

Your choice between Medicare Advantage and Plan G depends on your specific healthcare needs, preferences, and financial situation.

• If you value comprehensive coverage, the freedom to choose any Medicare-accepting provider, and want to avoid additional cost-sharing, Plan G might be the better fit. Plan G helps protect against Part B excess charges and doesn’t require you to work within a network. However, it does not cover extras like dental, hearing, or gym memberships, nor does it include prescription drug coverage.

• If you’re open to using a network of healthcare providers and prefer additional benefits such as dental, vision, and hearing coverage, a Medicare Advantage plan might be more suitable for you. Many Medicare Advantage plans also offer perks like gym memberships or prescription drug coverage, which Plan G does not.

Final Word

Plan G is not a Medicare Advantage plan. It’s a Medicare Supplement plan specifically designed to work alongside Original Medicare. Whether you choose Medicare Advantage or Plan G will depend on your healthcare needs, lifestyle, and budget. It’s crucial to research and compare your options carefully to make an informed decision.

Still unsure which option is best for you? Contact a FTJ Senior Insurance agent to help guide you through the process and find a plan that works for you.

We often hear this question from our clients: "Will Medicare cover my procedure?" Whether it’s surgery, a lab test, an injection, or a prescription, we wish the answer were as simple as yes or no.

Unfortunately, it’s not always that straightforward. While Medicare provides clear guidelines on covered services, several other factors can determine whether a specific procedure or service will be covered.

Key factors include:

• Establishing medical necessity

• Ensuring your doctor’s participation in Medicare

• Accurate medical coding of your bill

Below, we’ll guide you through each of these points to help you understand how coverage works.

Understanding Medical Necessity

Medicare uses the term "medically necessary" to describe health services or supplies required to diagnose or treat an illness, injury, or condition while meeting accepted standards of medicine.

For example:

• If you ask, “Will Medicare cover my facelift?” the answer is likely no, as cosmetic procedures are typically not considered medically necessary.

• However, certain treatments that aren’t initially deemed necessary could be covered if your doctor provides documentation proving their necessity. For example, Botox injections might be covered if prescribed to treat migraines.

Once you’ve determined your procedure is medically necessary, you’re one step closer to getting coverage.

Check Your Doctor’s Medicare Participation

For Medicare to cover your procedure, your doctor needs to:

• Accept Medicare as a payment source.

• Accept Medicare assignment: This ensures the doctor agrees to Medicare-approved rates for services, so you won’t be charged excess charges (an additional 15% that some doctors may bill above Medicare’s standard fees).

If your doctor doesn’t accept Medicare assignment, you may face these excess charges. However, if you have a Medigap plan (like Plan G), these charges will likely be covered.

Pro tip: Some states do not allow excess charges at all, so always check to see if this applies in your area.

Medigap as a Backup Plan

If you love your current doctor but they charge excess fees, a Medigap plan can save you from paying those costs out of pocket. Many Medigap plans are designed to fill gaps where Medicare leaves off.

The Importance of Accurate Medical Coding

Every service or procedure performed by your doctor is assigned a medical code. These codes are essential for ensuring accurate billing between the doctor’s office, the insurance company, and Medicare. If the code isn’t accurate, Medicare may deny coverage for the service.

A Common Example

Consider the “Welcome to Medicare” visit, which is 100% covered under Medicare Part B if properly coded. If the medical billing team enters incorrect codes, Medicare might refuse to pay, leaving you with the bill.

Our Client Service Team frequently assists policyholders in resolving coding errors like this. If you find yourself in a billing dispute, you don’t have to face it alone—we’re here to help at no additional cost.

Steps to Secure Medicare Coverage

To ensure your procedure is covered, follow these steps:

1. Check coverage: Use the Medicare What’s Covered app to verify whether your procedure is typically covered.
2. Confirm with your doctor: Make sure your doctor both accepts Medicare and Medicare assignment.
3. Double-check billing codes: Ask your doctor’s office to verify that the correct codes are submitted to Medicare.

When in Doubt, We’re Here to Help

Navigating Medicare can be confusing, especially when multiple factors come into play. If you’re a policyholder through FTJ Senior Insurance and you’ve received a bill you’re unsure about, contact us at 888-720-0874.

We’ll work with you to review your concerns, provide clarity, and help resolve billing issues so you can focus on your health—not the paperwork.

Medicare doesn't have to be complicated. With the right knowledge and support, you’ll be empowered to get the coverage you deserve.