It goes without saying that your prescription drug coverage is one of the most important parts of your Medicare coverage as a whole. Your Part D plan can make a big difference in your annual drug costs, but if you're not sure what your options are, it can be a little confusing.
By the time you're finished with this article, you'll understand what you need to know about Medicare Part D, how it works, what it costs, and how to find the best Part D plan for you.
What is Part D and what does it cover?
Simply put, Part D is your prescription drug plan. You are required to have either a Part D plan, or some other form of acceptable coverage, also known as “creditable coverage,” or the government will tack on a penalty whenever you do finally join a Part D plan. We’ll go into that a little bit later on.
If you’re enrolling in a Medicare Supplement, and don’t have any other kind of prescription drug plan, you’ll need to also enroll in a Part D plan if you haven’t already.
On the other hand, if you’re enrolled in a Medicare Advantage plan, and you already have prescription drug coverage through that plan, you cannot enroll in a Part D plan.
Part D covers your prescription drugs, specifically most of your outpatient drugs. If you’re administered a prescription while admitted to a hospital or a skilled nursing facility, those will be covered by your Part A instead. Other drugs, specifically dialysis drugs administered by your provider or at a dialysis facility are covered by Part B. Chemotherapy drugs for cancer treatment are also covered under Part B as well.
Each plan will have a very long list of drugs that it covers, but we’ll talk about that later.
Now, don’t worry, you don’t need to write all that down or memorize it. Just know that if you’re picking up your prescriptions from a pharmacy, or order them online, it’s almost certainly covered by Part D.
What does it NOT cover?
So what does Part D not cover?
When we’re talking about Part D, it’s important to remember that these plans are NOT standardized. What’s that mean for you?
In other words, Medicare has a few ground rules about what they’re allowed to charge you, and a few other things, but outside of that, they can cover anything they want.
So when we’re talking about what Part D doesn’t cover, it’s usually more of a conversation about what most insurance companies don’t like to cover on these plans. Think of the following list as a general guide more than a list of rules set in stone.
The following items are generally not covered by your Part D plan, though your plan MAY be different. You should always check with the company if you have any specific questions.
As I said, these aren’t really hard and fast rules, so it’s possible that your plan may cover some of these. For example, the vast majority of Part D plans don’t cover viagra, but many plans may cover the generic equivalent, Sildenafil.
Always check with the company if you have any questions. There are literally thousands of different Part D plans across the country, so it’s impossible to know for sure without checking with the individual company that offers the plan you’re interested in.
How does Part D work?
There are two big things that make every Part D plan work, and you need to understand both of them.
The first is what’s called a Drug Formulary, and the other is called your Part D phases. Let’s talk about both of them.
A Formulary is another word for a list of drugs that your Part D Plan covers. Most plans have pretty similar lists, but if you’re taking a highly specialized drug, you’ll want to be sure that it’s covered by using the plan finder tool on Medicare’s website.
Each plan’s formulary is organized into different tiers, usually five, with the lowest tier drugs being the cheapest, and the higher tiers being the most specialized and expensive.
I cannot stress this enough, each plan is different, and each plan can change from year to year, including the plan you’re on currently. Make sure you do your research each and every year during AEP so that you’re going with the right plan.
If you’re unsure or just have questions, give us a call and we’ll be happy to help you out.
Part D Phases
There are four phases or levels to your Part D plan, and they all revolve around how much you spend on prescriptions during the calendar year.
Keep that phrase in mind, calendar year, because that’s how long it lasts, and once you’ve made a decision, you usually cannot start a new plan until January 1st of the following year. So make sure you make the right decision.
In this portion of the plan, you pay the full retail cost of the drugs, but depending on the plan you choose, there may be a special reduced cost, especially if you’re using a generic or a “Tier 1” drug. Whatever the cost, they’ll be laid out in black and white when you choose your plan.
You’ll pay 100% of the cost of the medication you use until your total out of pocket expenses reach your deductible amount. That could be different depending on your plan, but the maximum allowable deductible as set by Medicare as of 2020 is $435.
A lot of people never get out of this phase, especially they only use generic drugs, which you can usually get for a couple dollars, or possibly even free for some drugs.
Initial Coverage Phase
Next up is the initial coverage phase. At this point you’ll pay a specific copay for each drug as listed on your plan. The great thing about Medicare’s plan finder tool is that you can find out exactly how much each drug you’re taking now will cost at this stage with each plan that you’re considering.
For people taking higher tier drugs, especially specialized drugs for chronic illnesses, or newer brand name drugs, this can be a big money saver. You stay in this phase until your total drug costs come to $4,020.
Notice, I said total drug costs, because both your costs and the insurance company’s cost is factored in to get to that number. It’s based on the actual retail cost of the drug, and once you’ve surpassed that, you enter what’s called The Coverage Gap.
The Coverage Gap (The Donut Hole)
The Coverage gap is sometimes called “The Donut Hole” because it’s where you’ll end up paying the highest percentage of your drug costs after the co-payment phase, and before your catastrophic coverage kicks in.
In this phase you’ll pay 25% of the RETAIL cost of your prescriptions. This will not be the same copay cost that you were paying during the initial coverage phase, but whatever the retail cost that your plan has listed for the drugs you’re taking.
Once again, this is why the Medicare plan finder tool is so helpful. You’ll be able to see all of this ahead of time as you’re shopping around for your Part D plan during the Annual Enrollment Period.
Obviously you want to stay in the initial coverage phase for as long as possible, but it’s very helpful to know exactly what you’ll be dealing with, when and if you get into this phase of your Part D plan.
Now, the good news is that this doesn’t go on forever. Once your personal out-of-pocket costs reach $6,350, you enter the final phase of your Part D plan, what’s known as catastrophic coverage.
Catastrophic coverage comes into effect once you’ve surpassed the spending amounts for all other phases of your Part D plan. The first thing you should know is that there is NO maximum out of pocket amount for your catastrophic coverage phase.
I’ll repeat that again, there is NO maximum out of pocket for your catastrophic coverage phase. It’s important to keep this in mind when shopping for new plans during your annual enrollment period. Once you reach this phase, you’ll be paying either a specific co-pay or 5% of the retail cost of the drug, whichever is more, for the rest of the calendar year, until your plan restarts on January 1 of the following year.
Now, the vast majority of people will never reach catastrophic coverage, but for people with a serious illness, or who need to take a high amount of Tier 4 and 5 drugs, this will still save you a lot of money.
The Part D Penalty - What it is and how to avoid it
But what if you’re just turning 65 and you’re saying to yourself, I’m healthy, I never go to the doctor, and I don’t have any prescriptions. Why should I bother signing up?
Well there are two really good reasons, there’s the immediate penalty you’ll pay, and there’s also a tremendous risk you’re running as well.
Let’s talk about the actual dollars and cents first. Your Medicare Part D penalty is calculated by multiplying 1% of the national base beneficiary premium by the number of months you went without a Part D plan or other creditable prescription drug coverage.
As of 2020, the national base beneficiary premium was $32.74, so one percent of that would come to about 33 cents. So for example, if you went without creditable coverage for three months, once you enrolled in a Part D plan, your penalty would be an extra dollar per month. 3 percent of 32.74 actually comes out to 98 cents, but Medicare rounds that to the nearest 10 cents, and here’s the kicker, that penalty lasts the rest of your life!
Now, is an extra dollar a month gonna break the bank? I hope not, but that’s not really the biggest problem with putting off your Part D decision.
When you first become eligible to enroll in Medicare, you have a 7-month window to pick a Part D plan. That’s three months before you turn 65, the month you turn 65, and then the three months immediately after.
If you don’t sign up for a plan during this period, you won’t be able to do so again until the annual enrollment period, which means you won’t have any prescription drug coverage in affect until the following January.
Here’s the other part you may not know. Once you enroll in Medicare, that’s Part A & B, no one is allowed to sell you a prescription drug plan from anywhere else. If you don’t have a Part D plan, you’re out of luck until the start of next year.
We buy insurance to protect against the unknown, now what happens when you get seriously injured or sick and you’ve gotta pay full price for all your prescriptions?
Would you drive your car around for months at a time without insurance on it? I hope not. Why would you do the same thing with your body? Do yourself a favor and get a Part D plan, because you never need help paying for prescriptions, until you do.
How much does it cost?
Like we talked about earlier, there are literally thousands of different plans all around the country with their own unique costs and benefits. All that said, MOST of the time, you can expect to pay somewhere in the ballpark of $30 per month for your Part D plan premium.
To be more specific, let’s take that number we gave you a minute ago, the national base beneficiary premium of $32.74.
That doesn’t mean that’s the amount you’re going to pay. Medicare WILL charge you more per month if your income was over a certain amount.
Here are the numbers direct from the Medicare.gov website. As of 2020, if you made $87,000 or less as an individual, or $174,000 or less when filing jointly, you won’t have to worry about paying any extra. However, after that you’ll get an extra charge added to your premium each month.
Yes, I’m sorry to be the bearer of bad news here, but the government will charge you extra if you make more money. This is what’s known as the “Income-Related Monthly Adjustment Amount” or IRMAA for short. Medicare does the same thing with your Part B, but the premiums will be calculated differently.
Medicare bases this off your tax returns from two years ago, so if you’re watching this in 2020, your 2018 tax returns would be used, because this is the most recent tax return provided to Social Security by the IRS.
You can appeal the decision by Medicare, but if you’re denied, you’ll have to pay the monthly premiums until the following year. That’s the good news here, because if your tax returns next year show your income is under that amount, your premium will decline to the appropriate level.
To make it simple, you have the option to deduct your monthly premiums from your social security check. Just contact the insurance company you have your Part D plan with and they’ll walk you through exactly how it works.
How to find the best plan for you
Medicare has put together a very handy tool called the Medicare Plan Finder, where you can enter in your information, as well as any prescription drugs you’re taking, and find the plan in your area that best fits your needs.
If you already have an existing account with Medicare.gov, there’s a good chance that you may already have a lot of your existing prescriptions stored on the site, but just for the sake of demonstration, let’s assume that you’re starting from scratch.
So as you can see here, I’m going to click the option “Drug plan (Part D)” and enter my zip code.
Just for the sake of example, I’m going to check here that I’m not receiving any extra help, but if you are, make sure to put that in.
On the next page when it asks whether or not you want to see your drug costs, make sure you check “Yes”. That’s a major piece of the puzzle when you’re making this decision, so you want to be sure you have all your information available.
I also recommend checking the “Both” option when it asks about using a retail or mail order pharmacy. Your plan will almost always have a mail order option, and sometimes you can get a better price by ordering through the mail as opposed to picking it up in person.
Next you’re gonna want to add the list of drugs you’re taking. You can get extremely specific with the kinds of drugs, as well as the dosage and frequency, so be sure to include everything you’re using.
In this example we’re just gonna use a couple of generic drugs to keep this moving along. The important thing here is you understand how to use the website to find what works best for your situation.
Once you’re done adding drugs to your list, click ahead to the next page.
Here’s where you’ll pick the pharmacies that you use all the time. You can choose up to three different pharmacies to compare. Notice that I’ve only selected two on the map, since I’ve already got the mail order pharmacy selected.
This doesn’t mean that these are the only places you’ll be allowed to go to pick up your prescription, but you do want to make sure that whichever pharmacies you pick here are the ones that are easiest to get to.
Now we come to the long list of prescription drug plans available in your area. Notice you have a couple of different ways to filter and sort through your plans.
First, with the green “Filter” button on the top right, you can sort by the plan’s star rating. This rating is put together by the Centers for Medicare and Medicaid Services (CMS) and measures four categories of service:
The bottom line is that these ratings come from Medicare, not any private insurance organization.
You can also pick your preferred insurance company, if that’s something you care about.
Also, see that check box over there on the left? You can filter out any drug plan that doesn’t cover you across the US. This is helpful if you live near a state line, or maybe you just like to travel across the country, and you want to make sure you’re covered just in case.
So I’ll click on that box and hit “Apply Filters”, and now all the plans we have left are valid across the United States.
You can sort your plans three different ways:
In general, I recommend you sort by the lowest drug & premium cost since that’s going to give you the most accurate idea of what your cost for the year will be.
If you have a couple of different plans you’re not sure about, you have the option to compare up to three of them at a time. Just click the “Add to Compare” button and you’ll get a blue bar on the bottom of your screen like this with all three plans you’ve chosen.If you’re very healthy, if you’re one of those people who never goes to see the doctor, and you just don’t have more than one or two generic prescriptions that cost very much, then you still have the option to sort by the monthly premium.
Another common question is whether or not you should use this opportunity to plan for the worst case scenario. For example, should you do research on how much your drug costs would be if you were diagnosed with cancer?
Unless you’re a doctor, I’d advise against it. There are too many unknowns, and too many different kinds of cancer therapies depending on your situation. If you’re that worried about a potential cancer diagnosis down the road, your best bet would be a cancer insurance policy. Learn more about your options here.
As you scroll down through the comparison screen, you’ll get an estimate of all your total cost with each plan, including through the mail order pharmacy option.
Once you’re ready to enroll, just click the “Enroll” button and get started.
Need more help?
Here at Senior Benefit Help, we offer a free annual policy review service that can help you figure out what plan is best for you.
If you’re not already a policyholder with us, give us a call at 800-701-3951 or click here to send us a message.
When people think of insurance, specifically life insurance, they often assume that their coverage is good for the full amount on day one. Unfortunately, that’s not always true.
By the time you’re done with this article, you’ll have a good understanding of what insurance companies look for when issuing a life insurance policy with no waiting period, and what health conditions are considered more serious than others when it comes to life insurance.
Guaranteed acceptance life insurance: No waiting period?
Millions of people have seen the commercials for guaranteed issue life insurance, where you won’t be asked any health questions and your rates can start as low as $9.95 per month. Those policies have a catch: you’ll usually have to wait up to two years before you’re covered for the full amount of the policy.
For example, if you bought a $10,000 life insurance policy from Colonial Penn, and three months later you died of a heart attack, your family wouldn’t actually get $10,000. Instead, they’d get whatever you’d paid into the policy during those three months, plus an additional 7% of interest.
That’s why they don’t need to ask any medical questions, because for the first two years, they’re not doing anything except paying you a moderate return on the money you’ve already paid in. The fact is, there is no such thing as a guaranteed acceptance life insurance policy with no waiting period. Any company that offered it would go out of business in a week, for obvious reasons.
If you live longer than 24 months, you’ll be fully covered for the amount of the policy, but if you could see that far into the future, you wouldn’t have to worry about life insurance.
If you’re in good health, or even average health, there’s a good chance you can qualify for coverage that is fully effective on day one.
Let’s talk about how you can do it.
How to get life insurance with no waiting period
Since an immediate coverage plan is the best kind of insurance, naturally every insurance company is going to ask some questions about your current health, your medical history, and some may go further than that.
The bottom line is that an insurance policy is an ironclad contract to pay (usually) a large sum of money to your beneficiary when you die. Before the insurance company signs that contract, they want to make sure they cover their bases, and won’t have to pay out thousands and thousands of dollars if you’ve only paid in a couple of months worth of premium.
This is especially true when it comes to seniors and anyone over the age of 50. Our health never gets better as we age, and so insurance companies often have a different set of standards for people in this age group. This is actually a good thing, since many health issues that would not be covered in a younger person are considered standard, or at least not a deal breaker.
Read on to learn more about how insurance companies look at your health, and whether or not you’re eligible for immediate coverage.
Where can I get life insurance with no waiting period?
Every major company who offers life insurance offers some form of insurance product that has no waiting period. After the first month’s premium has been paid, you are fully covered for the “face amount” of the policy, otherwise known as the death benefit.
This is the absolute best form of life insurance you can get, and believe it or not, it’s the cheapest as well. Speaking of the price...
How much does it cost?
The rate is dependent on a few factors, most importantly your age. Insurance gets a little bit more expensive every year we get older, but the good news is that with most life insurance policies, once you lock in your rate, it does not increase. You should always ask your agent to clarify this if you’re not sure.
The other things that the insurance company will want to know before giving you a quote will be your gender, height & weight, and whether you’re a smoker or not.
We’ve put together a sample table of rates below for a $10,000 whole life policy for a male and female non-smoker. Remember that your monthly premiums may differ based on the options available to you because of your medical history. If you’re a smoke, the rates will be a little bit higher depending on your age.
These pieces of information will allow most insurance companies to give you a basic quote, but that doesn’t mean that you’ll qualify.
Do I qualify for life insurance with no waiting period?
First of all, how healthy are you? Do you have a history of any major illnesses or conditions? Insurance companies make their money by understanding risk, so they need to make sure they’re not taking on too big of a risk by insuring a person with a lot of major health problems, so expect to answer a lot of questions. Don’t be surprised if the insurance company also requires you to undergo a physical examination, which includes getting your blood drawn for analysis.
The thing to remember is that every insurance company’s health screening questions are a little different. Each company looks at the risks associated with a health condition a little differently, and that’s one reason why one company’s rates can be so different than another’s for a very similar product.
Still, even though every company has a different idea of what a good risk is, there are some very common health history questions that every company asks when you first apply with them. We put together a list of health conditions below to help you better understand your options.
AIDS, AIDS Related Complex (ARC), or HIV
No insurance company will offer you immediate coverage if you’ve been diagnosed with AIDS, HIV, or ARC at any point in your life.
An HIV diagnosis carries with it a host of other potential complications, so even if you’ve been successfully treating and managing your diagnosis for years, life insurance companies are still unwilling to offer you full coverage right away.
If you currently have any form of internal cancer, you will be unable to receive immediate coverage on your life insurance policy. However, if you have a form of skin cancer, especially basal cell skin cancer, there are insurance companies who can offer you immediate coverage.
Insurance companies are much more flexible with a current skin cancer diagnosis because the process of treatment and removal is much simpler, and the rate of survival is extremely high as long as it is treated quickly.
But what about if you’re currently cancer-free? To get immediate coverage, most insurance companies need to get proof that you’ve been cancer-free for a minimum of 3 years, sometimes more than that.
If you’ve ever received cancer treatments, even if it was more than 10 years ago, expect to get questioned about it before you’re approved for coverage. Insurance companies have access to your medical records (only after you’ve given them permission) and they’ll be able to see which medications you’ve been prescribed. This doesn’t mean you’ll be denied, but they’ll want confirmation from either you or your doctor that you’ve been cancer-free for the appropriate amount of time.
If you’ve never had cancer but you’ve been concerned about it because of your family history, or because you’re a smoker, there are plans that can offer you a lump sum payment if you’re ever diagnosed with internal cancer. You can read more about cancer insurance here.
Heart & Circulatory Issues
Heart disease is the top cause of the death in the United States according to the CDC, so naturally the insurance company you’re applying for coverage with will want to know about the health of your heart.
There are all kinds of potential issues that can affect your circulatory system, so we’ve put together a list of the most common heart-related issues and what you can expect to hear from most insurance companies.
This is one of the big ones. Each year over 800,000 Americans have a heart attack, and at least 25% of those attacks happen to someone who’s had one before. Numbers like that are a big reason why a recent history of heart attack is such a big issue with your insurer.
If you’ve had a heart attack in the past three years, you will be unable to get first day coverage from your life insurance company, since the numbers show there’s a good chance you’re at risk for another one very soon.
Once you make it past that three year window, you’ll be eligible once again, assuming there are no other major issues on your medical report.
When you have a stroke, it means a blood vessel in your brain is either clogged or ruptured. This is a very serious condition that can seriously disable or kill you if not treated quickly.
If you’ve had a stroke in the past three years, expect to be declined for an immediate life insurance policy. Until you can show that you are at a low-risk for recurrence, insurance companies will be unwilling to take on the risk of insuring you for a large sum the day you make your first payment.
This also includes a Transient Ischemic Attack (TIA), more commonly known as a mini-stroke. A mini-stroke can give you stroke-like symptoms, including weakness on one side of the body, vision problems, and slurred speech. This is caused by a temporary blockage in a blood vessel in your brain, and puts you at risk of an actual stroke later on.
Anytime you have surgery, it’s a big deal, but especially when doctors have to go in and operate on your circulatory system. This would include putting in a stent, pacemaker, or a defibrillator to help with your circulation.
These surgeries can either be preventive or corrective in nature, meaning they can be used to prevent a bigger issue, or to stabilize your health after a major episode like a heart attack.
Depending on which company you go with, you’ll need 2-3 years distance between today’s date and your last circulatory surgery before you’ll be able to get first-day coverage.
Congestive Heart Failure
Congestive heart failure (CHF) is what happens when your heart isn’t operating as well as it should, specifically when it comes to pumping blood through your system. This leads to a buildup of fluid in the area surrounding your heart, which can include your lungs.
Your CHF diagnosis can never be “cured” but the symptoms can be managed and if you make certain lifestyle changes early enough, much of the damage can be avoided. CHF is usually the result of other circulatory problems being left untreated for too long, since the stress of having to work harder for too long will weaken your heart and leave it vulnerable to complications.
A diagnosis of CHF will disqualify you for immediate coverage with most insurance companies, however a few companies have immediate coverage plans that are available for a higher rate.
Contact us to discuss your options and find out what plan is best for you.
High Blood Pressure
Despite what you may think, high blood pressure is not an automatic disqualifier by itself for most companies. Often referred to as hypertension by the medical profession, this condition is very common in people over 50, so as long as there are no other major complications, this is usually not a big deal.
Other Heart & Circulatory Issues
If you’ve had other major health issues that involve your heart or circulatory system, such as an aneurism or angina, you’ll need at least 2-3 years between your last episode and today’s date. depending on the company you want to go with.
You already know how serious a heart condition can be for your long term health. Insurance companies know it too, and that’s why they take steps to make sure your heart is in good working order before they agree to life insurance coverage with no waiting period.
Diabetes has the nickname “The Silent Killer” because of the way it can cause lots of other complications if not managed properly. This is especially true when it is paired with circulation issues.
The good news is a diagnosis of diabetes by itself is not usually enough to disqualify you for immediate coverage with most companies. The disease can be managed with proper treatment, as well as keeping your diet under control.
The bad news is that if your Diabetes has progressed to the point where you’ve experienced complications like diabetic neuropathy, retinopathy, or others, most insurance companies will not offer you first day coverage.
In addition, the ones that do offer immediate coverage in this case tend to be very picky about anything else having to do with your medical history. For example, if you have a history of diabetic complications AND one of the heart issues that were discussed above, you will not be able to get coverage without some kind of waiting period.
Mental Health & Nervous Disorders
The next thing the insurance company is going to look for are any signs of mental health issues in your past. This can include a large amount of antidepressants showing up on your prescription history, and depending on the severity of your issues, records of any stays you’ve had at mental health treatment facilities.
No company will offer you immediate coverage if they feel you are a danger to yourself or others. One common question about life insurance is whether or not suicide is covered. Even though no company will pay out a death claim for suicide right away (you’ll usually have to be covered for at least a year before you’d be eligible), they want to make sure you don’t have a history of self-harm.
Alzheimer's or Dementia
Aside from general mental health issues, insurance companies also want to avoid fully insuring those diagnosed with Alzheimer’s or Dementia. Most people think of these as purely mental issues, but they often go hand in hand with physical complications as well.
Sufferers often experience a lack of control over their bodily functions, which can include the respiratory system and lead to a loss of breathing. Many people also easily lose their balance which can lead to further injury thanks to the body’s already weakened state.
Lou Gehrig's Disease (ALS)
Amyotrophic Lateral Sclerosis (ALS), also known as Lou Gehrig’s Disease, is a slow degeneration of the movement ability of your body. This is caused by the death of neurons in your brain that control motor function and your ability to control your arms and legs, among other body parts.
A long time sufferer will continue to see weakness and experience a slow decline in their ability to move muscles and will eventually need round the clock assistance for even the most basic tasks.
A Parkinson’s Disease diagnosis is characterized by an increase in tremors, and similar to ALS, you will also experience a slow loss of control over motor function, including speech. There is no cure for Parkinson’s, though the effects can be controlled substantially through treatment, and sometimes even through surgery.
Most companies do not offer a day one coverage to someone suffering from Parkinson’s but there are a few who do. Give us a call today 800-701-3951 to learn more about what your options are.
Your liver stops working when it can no longer filter out harmful substances from your body. Oftentimes this is the result of an unhealthy lifestyle, especially a long habit of alcohol abuse, other times it can be a reaction to a medication that you’ve been taking. This can lead to major health problems, including hepatitis.
If you are currently experiencing liver failure, no insurance company will offer you full coverage with no waiting period. If you have been diagnosed in the past, but it has been more than three years and you are treatment free, there are several companies who can insure you with no waiting period.
Treatment and even reversal of liver failure is possible, but many times a transplant is the only option.
Speaking of organ transplants, if you’ve ever had one, it’s unlikely you’ll be able to qualify for immediate coverage with any company.
Not only that, but if any doctor has recommended a transplant for you, you won’t qualify either. You won’t be able to get insured prior to the operation, at least not with an immediate plan.
Organ transplants are very tricky procedures with an extremely high failure rate. Even if the surgery is deemed successful, most people require years of anti-rejection medications, which carry their own set of side effects that can have fatal consequences. The risk of death after a successful operation is higher than you may think, and insurance companies know this, so unfortunately you’re out of luck when it comes to getting immediate coverage.
Systemic Lupus is an autoimmune disease, and the most common form of Lupus. The inflammation can often be severe enough to cause lots of other serious complications, including stroke or heart attack.
No insurance company offers first day coverage on a Systemic Lupus diagnosis. Because of the amount of future complications that could spring up, there are just too many variables for insurance companies to deal with, so they do not offer life insurance with no waiting period.
If you’re diagnosed with another form of Lupus, it’s possible that you may be able to get immediate coverage, depending on what medications you take and what else is in your medical history. Some less common versions of Lupus can be milder and less severe.
The use of oxygen is an automatic non-starter for insurance with no waiting period. Whether you’re currently on oxygen, or you’ve been advised to start using it by a licensed medical professional, you’re probably not in the greatest of health, and so the insurance company would want to apply a waiting period before fully covering you.
Insurance companies do not count the use of inhalers or sleep apnea masks as using an oxygen tank to maintain normal breathing, so if you’re asthmatic, it’s not necessarily a disqualifier.
The good news for some people is that this is usually not an “ever” question for insurance companies, meaning that as long as you haven’t used since a specific period of time in the past (usually 2 years), you will probably be able to qualify for coverage.
Chronic Obstructive Pulmonary Disease is an incurable condition that is characterized by an inflammation of the lungs and other air pathways, and can make it very difficult to breathe. Many people find that they need an inhaler or even regular oxygen use in order to live their daily lives.
Over 3 million people in the United States have some form of COPD. This used to be diagnosed separately as either chronic bronchitis or emphysema, but both of these have since been brought under the umbrella definition of COPD by medical professionals.
Unlike asthma, which is characterized by periodic episodes of tightness in the chest and is often triggered by some outside factor, COPD is a constant condition that can involve lots of coughing and phlegm that builds up in the airways.
Most people who develop COPD are smokers, but some get it from prolonged exposure to harmful chemicals or air pollution, like asbestos and dust. The symptoms may be managed, but there is no way to reverse the condition.
COPD can be an obstacle to getting immediate coverage with most companies, but there are a few specific carriers who offer coverage with no waiting period. Contact us today to find out which company suits your situation best.
Mobility Issues & Activities of Daily Living
Are you currently confined to a bed or a wheelchair? Do you need regular assistance with any of the following: Eating, bathing, dressing, toileting, transferring, or continence?
If you answered yes to any of those questions, it will be very difficult for you to get immediate coverage with no waiting period. Someone who is not able to move around or take care of themselves is understandably seen as a major health risk. After all, if you’re unable to move around, there are probably other issues at play as well.
The one exception to this is if you’ve had a major injury that temporarily leaves you unable to move around. For example, if you had a car accident and broke your leg, and can no longer get in and out of bed without help, this would not be treated the same way as if you were incapacitated because of a disease. In the case of the broken leg, most insurance companies would cover you.
The other thing to remember is that when you’re applying for life insurance, and they ask you if you receive home health care, It is NOT necessarily the same definition as Medicare’s definition of home health care. For example, someone coming over to cook, clean, and do your laundry is not the same as someone who has to come over and help you out of bed, dress you and bathe you.
There are a few companies who will insure someone who needs help with these activities of daily living, as long as there is nothing else seriously wrong with them. This is rare, because as we discussed, if someone needs help with these things, it’s almost certain that there are other major health issues they’re dealing with.
No insurance company will offer immediate coverage for someone confined to a bed or wheelchair for a disease.
Future Medical Tests & Procedures
One question you will have to answer if you’re looking for first-day coverage will be about any “unknowns” in your near future.
Specifically, they will ask whether you have any tests pending that you do not have the results for (like a biopsy), or any major procedures that you’ve been advised to undergo but haven’t gone through with yet.
Insurance companies hate the unknown. If you’re waiting on test results they’ll want to wait until you get those results back before they insure you. Likewise, if you’ve been advised that you need some kind of surgery or procedure, they’ll want to hold off until you’re sure you’re in the clear.
No insurance company will cover you if you have tests or major procedures pending.
Other qualifying factors
The other thing that may surprise you is that the insurance company will do a very basic background check on you. First of all they’ll want to make sure you’re actually who you say you are. It might seem crazy, but many fraudsters try to use old social security numbers to take a life insurance policy out on a person who died many years ago, or who the medical system just has no records for. If the policy is approved, they’ll try to say that this person (who doesn’t actually exist) has died, and try to pick up a check.
A more likely scenario they’re protecting against would be someone taking a life insurance policy out on you without your knowledge. Now all of a sudden, without you even realizing it, you’ve got someone who stands to pick up a big check if you were to suddenly die.
The insurance will want to know if you have a criminal history, especially if you have any convictions related to fraud, check forgery, or any other kind of financial crimes. Since insurance companies deal in large sums of money on a regular basis, they are always being targeted by shady characters for money laundering schemes.
Many insurance companies (though not all of them), will do a “soft pull” of your credit history to see if you have a large amount of debts that are in default.
Also, most companies will ask about illegal drug use. It’s true that unless you go through an in-person medical exam, it’s tough for insurance companies to know for sure if you’re telling the truth. However if you have a history of drug or alcohol abuse counseling, or you’ve been prescribed certain medications that are designed to deal with overdoses like Narcan, this will most likely be on your report, and you can be denied.
Burial insurance with no waiting period
If you are between the ages of 50-85, you may qualify for a special kind of life insurance policy, known as burial insurance, also called final expense insurance. These are usually smaller policies than normal life insurance products, and you do not need to get a physical examination in order to qualify for coverage.
Generally the amount of the policy can be anywhere from $5,000 all the way up to $35,000. Some companies offer more, but this is not very common.
Let’s talk about your coverage options
Give us a call at 1-800-701-3951 and we can discuss your coverage options.
Cancer kills 600,000 people a year in the United States, second only to heart disease. We all know someone who’s been affected. But did you know your health plan probably doesn’t cover all the costs associated with cancer treatment? And yes, I’m talking about Medicare too.
By the time you’re done with this article, you’ll know why cancer insurance is an absolute must have, the two main types of cancer insurance policies available on the market and how they work, how much coverage you need, and of course the answer to the big question, how much does it cost?
Is cancer insurance worth it?
So I hear this all the time when I’m talking to clients. Is cancer insurance really worth it? My answer is almost always a emphatic YES!
First of all, the biggest reason why you need cancer insurance? Statistically you’re extremely likely to get it at some point in your life.
According to the American Cancer Society, about 40% of men and 39% of women are at risk of developing some form of cancer in their lifetime.
Right now you’re saying, “I already have health insurance, why do I need cancer insurance?” That’s a great question, so let me give you a few reasons why a cancer plan is a great investment on your part.
Medicare Advantage Plans and Cancer Insurance
If you’re one of the millions of people currently enrolled in a Medicare Advantage plan, you need to hear this. Let’s look at the maximum out of pocket for your plan. As of 2020, the maximum amount you can be made to pay out of pocket is $6,700 for an in-network provider, and up to $10,000 for an out-of-network provider. Now, your plan may have a lower amount, but this is *maximum* you’re allowed to be charged.
Do you know the fastest way to reach your maximum out of pocket with a Medicare Advantage plan? Radiation and Chemotherapy. Now let’s say you’ve got $10,000 in savings set aside for a rainy day. You’ve been responsible and you’ve tried to prepare for this exact situation. That’s great, but you need to keep two things in mind:
First, that out of pocket maximum is a “calendar year maximum”. That means if you start treatment in August, and you reach your out of pocket maximum in December, once January begins a couple of weeks later, you’re back at square one again. Now you’ve gotta pay *another* $6,700 out of pocket.
The second thing to remember is that your out of pocket maximum does not cover prescription drug costs! Now you’re adding several thousands more depending on what prescriptions you’re using.
The American Cancer Society put out a study called “The Costs of Cancer” and it’s full of great information. One of the biggest things they found was that the highest costs associated with cancer get dropped on you in the first three months.
Take a look at what it says here on page 16 of the report:
Cancer costs are front-loaded. In each cancer scenario, the patients with employer-sponsored insurance and individual market insurance experienced the highest out-of-pocket costs in the first 2-3 months after being screened and diagnosed with cancer. In each case, the cancer patients paid large amounts in applicable deductibles, co-pays and co-insurance in these months until they reached their co-insurance or out-of-pocket maximum.”
Notice the last sentence in that paragraph:
“It is important to note that these protective out-of-pocket maximums only last for one plan year, and in January the patients would once again be subject to cost-sharing.”
Cancer never hits at a good time, but if you’re diagnosed later on in the year, you’re at risk of paying a lot more than if you had caught it early in the year.
Medicare Supplements and Cancer Insurance
Now what about people with a Medicare Supplement?
It’s true, your out of pocket costs are a lot lower for a lot of things. Maybe you’re on a Plan F and the only thing you have to worry about paying is that monthly premium.
By the way, if you’re on a Plan F, that premium is going to skyrocket in the next few years, so if you’re able to, I highly suggest switching over to a Plan G or Plan N if you’re still in good shape healthwise, but that’s another topic for another time.
So you may not have a ton of costs for the treatments, and specialists, and the hospital visits, but don’t forget, that Plan F does not cover your prescription drugs.
If you’re like most people with a Medicare Supplement, your Part D plan wasn’t selected with a future cancer diagnosis in mind, so once you spend past that initial coverage period, you hit what’s called “the coverage gap” and now you’re responsible for 25% of all drug costs until you hit $6,350 in total out of pocket drug costs and reach what’s called the “catastrophic” phase.
Now you’re only responsible for 5% of the cost of your prescriptions, but 5% of a big bill is still a lot of money, and you’ve already paid over $6,300 in drug costs alone!
We’ve already talked about the direct costs of a cancer diagnosis, let’s go over the indirect costs.
The indirect costs of cancer
The indirect costs of cancer include things like transportation to treatments, lodging, family care which covers things like babysitting and other help with daily activities, and the biggest cost of them all, the cost of any lost income as a result of being unable to work.
By the way, when we talk about lost income, we’re not just talking about your income, we’re also talking about the income of whoever has to help look after you. Whether it’s your spouse or a friend or family member, helping someone going through a cancer treatment can be a full-time job.
Do you really want the people you care about to have to worry about paying the bills and keeping the lights on while you’re dealing with cancer treatment?
A good cancer plan can give you peace of mind and enough money so that you don’t have to worry about where your next meal is coming from.
Imagine dealing with something like this without the extra safety net of a cancer plan. There are always stories like these out there.
Take a look at one woman’s story of dealing with the financial costs of a cancer diagnosis.
Thank God she got through it, but did you hear that last statistic? Up to 16% of people WITH INSURANCE quit the treatment plan because it’s taking too big of a toll on their finances. That’s 1 out of 6 people!
What is cancer insurance?
So what is cancer insurance? Cancer insurance is exactly what it sounds like. Your policy covers you in the case of a cancer diagnosis, and once either you or your doctor submits the paperwork to the insurance company, you’ll qualify for benefits.
Now, it’s important to remember that a lot of policies only cover internal cancer. So for example, most forms of skin cancer would not qualify for a benefit, because removing skin cancer is much simpler to remove and doesn’t require the long and complicated procedures that treating internal cancer does.
What are the types of cancer policies?
Cancer policies are usually divided up into two different kinds - scheduled benefits policies and lump sum benefit policies.
Scheduled benefits cancer policy
Scheduled benefits policies are designed to cover cancer treatments and other expenses when needed. These expenses can include transportation to and from a healthcare provider, lodging, surgery, medications, and even a certain amount paid to you as soon as you’re diagnosed. The policy has a “scheduled” amount that is allotted for a certain kind of expense, and once that amount is used, the policy cannot be used to pay that particular expense anymore.
For example, a scheduled benefits policy may have $5,000 set aside for a certain kind of procedure. Once that portion of the benefit has been exhausted, the rest of that money has to come from somewhere else, usually out of your own pocket.
Not only that, but a lot of the costs that this policy covers will have to be paid in full by you first, and then you’ll be reimbursed by the insurance company later.
Allstate Scheduled Benefits Cancer Policy
Let’s take a look at an example of a scheduled benefit cancer policy, this one is from Allstate.
Now, I’m not picking on Allstate, they do a lot of good things, but I just wanted to show you an example of a scheduled benefit policy and the kinds of limits that are placed on you. A lot of companies have scheduled benefit policies designed like this, which is why I don’t like to offer them to people.
The one thing I want you to notice here is that they keep using the phrase “cash benefit” over and over throughout this whole thing. What they’re doing is making it seem as though you’re gonna get all this money paid directly to you, but that’s not really the case.
See the first paragraph here, “Our coverage pays you a cash benefit to help with the costs associated with treatments, to pay for daily living expenses – and more importantly – to empower you to seek the care you need.”
Wow, that’s awesome! I get cash paid directly to me if I ever get cancer to help with the bills?
What about the next paragraph down below: “With the cash benefits you can receive from this coverage, you may not need to use the funds from your retirement plans or 401(k) for cancer or specified disease treatments and expenses.”
It just keeps getting better and better! But wait, what’s that sentence right before it? “Benefits are paid directly to you unless otherwise assigned.”
What’s that mean? It means that you’re not going to actually get any cash paid to you except in very specific situations, and usually only after you’ve used your own money first.
Let’s go to the next page here, and WOW! So much more on these cash benefits and what you can do with them! Protect your finances, use them for travel, pay the mortgage, use them for living expenses!
But how much do I actually get? Let’s take a look at the numbers over here on the right. So you notice they have three different levels of plans, and let’s take a look at how much the plan is actually going to pay you.
Continuous hospital confinement, up to $300 per day for up to 70 days. Up to $300 a day for at-home nursing. Between $5,000 and $10,000 for radiation and chemotherapy.
Here’s outpatient lodging, which is $50 per day. I don’t know anywhere worth staying that only costs $50 per day. What about transportation? It says “coach fare” which means whatever the minimum price is, that’s what you’ll be paying. But look down in the fine print, you have to go at least 70 miles, and you’re only covered up to 700 miles.
And by the way, you do know that the insurance company isn’t going to pay for that sort of thing ahead of time, right? You’re still paying for this, now you’re just waiting on reimbursement once you’ve sent them the bill.
And what if you live in a city or close to one with a health provider you need to see regularly? If you need to take a cab or an uber to the doctor who’s 20-30 minutes away, you’re paying for that out of your own pocket!
So we keep going down further, and we see a few more benefits here covering some different things. I still haven’t seen anything about those cash benefits they were so excited about at the beginning of this. OK, here we go, all the way down at the bottom, under the “Optional/Additional Benefits” we see you can get between $2,000 to $5,000 paid directly to you when you opt in for this extra benefit. I don’t know about you, but for most people that’s maybe 1-2 months of living expenses, and then what?
So what’s the point of all this? Once again, I’m not picking on Allstate. This kind of plan is typical throughout the insurance business. It’s usually a little cheaper than most lump-sum cancer plans, and it’s also a big money maker for insurance companies. Why?
Because the simple fact is that most people will never use the majority of the benefits of their scheduled benefit cancer policy. Unfortunately, either they won’t qualify because of the restrictions on things like transportation and lodging, or they’ll max out their benefits on one or two items, and because they don’t understand the policy, and the agent who sold it to them is long gone, they have no one to turn to. Sadly, the other reason is because they don’t live long enough to use all the benefits they paid for.
Lump sum cancer policy
For all of these reasons and more, we HIGHLY recommend a lump sum cancer policy instead.
Typically these are very simple and straightforward policies that pay you a cash benefit directly if you’re diagnosed with cancer. Once you’ve been diagnosed by your doctor, either you or the doctor will submit a few forms to the insurance company, and usually within about 5-10 business days at the most you’ll have a check in your hand for the benefit amount.
This is a check you can spend on literally anything, and because it’s an insurance check, it’s tax free. Do you want to pay off the mortgage? Go ahead. Do you need the extra money to pay for medications and treatment that’s not fully covered by your insurance? You can do that.
We’ve even had clients who have got the terrible news that they’re terminal, and that they only have about 6-12 months left to live. You know what they did? They used the money and took their family on that trip around the world they always wanted.
Why in the world would you want to spend your time filling out reimbursement forms from the insurance company when you could just get one big check and use it how you wanted?
How much cancer insurance do I need?
So this all sounds great, but right now you’re saying to yourself, how big of a cancer policy do I actually need? Most companies allow you to purchase up to $75,000 in coverage, but most of my clients never go that high.
If you already have basic health insurance or some kind of private plan that takes care of most of these things, $10,000-$20,000 in coverage will give you enough to handle the initial shock and expenses that come with this sort of diagnosis.
But if you don’t have health insurance, or maybe you just have a family history of cancer, or you’re a smoker and have been for years, or it’s just something you’ve been worried about for awhile and you want to get it off your mind, a higher amount would probably make sense for you.
Cancer insurance is not a substitute for regular health insurance, but if your plan isn’t set up for a lot of cancer treatments, or maybe you’ve just got a big deductible that you’ll have to meet before it kicks in, this kind of policy will help you bridge that gap and give you peace of mind.
The best part is, there aren’t a lot of health questions to answer. As long as you’re not currently hospitalized or in a nursing home, have never been diagnosed with HIV or AIDs, and haven’t had cancer in the past 5-10 years, you can qualify. The specific health questions are a little bit different with each company, but if you can answer no to those three questions, you’re usually able to qualify for coverage.
One last thing, most companies also offer what’s called critical illness coverage. We’ll talk about those plans in another video, but the idea is generally the same. Most plans offer a lump sum payment for either a heart attack, cancer, or stroke diagnosis, and just like the cancer plan, you’re free to do what you want with that money.
How much does cancer insurance cost?
So you’re thinking it sounds like a good idea, but how much does a policy like this cost?
Like everything else in insurance, it starts with your age and health. Each time you have a birthday party, that policy is gonna get a little bit more expensive each year.
Each company’s rates are a little different, but they’re similar enough that we put together a list of prices below. These are just some ballpark figures for a $10,000 policy at different ages.
30 years old - $6.00/month
40 years old - $9.00/month
50 years old - $16.00/month
65 years old - $30.00/month
70 years old - $35.00/month
Call us at 1-800-701-3951 today and get a more accurate quote for your area. Or click here and send us a message.
The short answer is no (most of the time). Original Medicare does not cover most dental procedures unless they are considered Medically necessary, or they take place while you’re admitted to the hospital.
As one expert puts it, “These omissions have been in place since Medicare was created in 1965, so it’s not as if some new problem has emerged. What has become clearer, however, is that huge and growing numbers of seniors face substantial dental, hearing and vision expenses.”
For example, when you’ve been admitted to the hospital, and you need a dental exam before a procedure can be done, that would be covered. In another case, if you had a major injury, like a car accident where your jaw or teeth needed work, that would also be covered.
Things like cleanings, fillings, and tooth extraction are not covered as they are usually elective procedures. Original medicare does not cover routine and preventive dental work, so it’s up to you to cover the cost of that yourself, either out of your own pocket, or with a separate insurance plan that covers routine work.
Medicare Advantage Dental Coverage
Your Medicare Advantage plan however, may offer options for routine treatment of dental issues, as well as annual or semi-annual cleaning. All of this depends on the specifics of the plan you’re enrolled in, as no two plans are the same.
If you currently have a Medicare Advantage Plan and you’re considering switching plans during your annual enrollment period, make sure that your plan has the level of dental care that is important to you.
However, if you’re currently on a Medicare Supplement plan, and considering switching to a Medicare Advantage plan in order to get better dental benefits. The out of pocket costs and security you’d be giving up from your supplement far outweigh whatever dental benefits you’d be receiving with an Advantage plan.
There’s a better option available that can save you money, and lets you keep the security of your Medicare Supplement.
Other Options for Dental Coverage
That doesn’t mean you’re out of luck if you don’t have dental coverage through Medicare. There are other options, and they probably won’t cost you as much as you think.
Try a Separate Dental Insurance Policy
Most insurance companies offer separate dental policies that take care of the routine costs and procedures that come up. Not all plans may be available in your area, but there are plenty of options available.
Typically these plans allow for regular cleanings, and have a scheduled amount available for certain procedures like tooth extractions, root canals, and more.
The best part is, these plans are much more affordable than you might think.
Contact us today to learn more about your options for Dental Care
Does Medicare cover dental implants?
Original Medicare does not cover dental implants. Even though this is a surgical procedure, it falls under the routine dental care category and isn’t covered by your Original Medicare benefits or your Medicare Supplement Plan.
If you’re on a Medicare Advantage plan, you should check your policy information or ask your insurance company for your specific benefits.
However, a stand alone dental insurance policy will cover most if not all of the cost of a dental surgery, as well as other regular dental care.
Does Medicare cover dentures?
Unfortunately original Medicare does not cover dentures in any situation. This falls under the routine and elective procedures that Medicare does not cover with Part A or B.
A Medicare advantage plan may offer denture options, but be sure to check with your plan’s insurance company to see what your copayment will be.
Typically dentures can run as high as $3200 without any insurance, so unless you’ve got a separate dental policy, you could run into a really pricey situation.
Does Medicare cover braces?
Original Medicare does not cover braces. These are classified as elective, and in general, Original Medicare doesn’t pay for anything that could be considered a cosmetic procedure.
This is a pretty ironclad rule. Unless something is deemed “medically necessary” Medicare won’t cover it.
The cost of braces out of pocket can vary wildly from state to state, and it’s also highly dependent on who your orthodontist is. The range is anywhere from $3,000 all the way to $10,000. It’s not uncommon for providers to offer a cash discount. Ask your dentist if they do the same.
A Medicare Advantage plan, while it may offer you some extra dental benefits along with your medical policy, will end up costing you thousands of dollars in out of pocket costs before you reach your out of pocket maximum.
Does Medicare cover Invisalign?
Just like Original Medicare doesn’t cover regular braces, it definitely does not cover Invisalign. This would fall under the category of a cosmetic and elective procedure, so Medicare would not deem the procedure medically necessary.
Typically the out of pocket cost for Invisalign braces can range anywhere from about $2,000 all the way up to over $9,000.
Some standalone dental policies will cover some of the cost with a copay or a coinsurance payment.
Does Medicare cover tooth extraction?
Other than extreme emergencies, where deemed medically necessary, Medicare does not cover tooth extraction. Regardless of the pain that may come up, an extraction is almost always classified as an elective procedure.
Without coverage, you’re probably looking at around $200 on average for a tooth extraction, possibly more depending on how complicated the process is, and if the tooth is damaged.
Does Medicare cover root canals?
No, Medicare does not cover root canal surgery. A lot of people have a false impression of the root canal procedure, thinking that it’s a highly sensitive and difficult surgery. If you’re like most people, you’ve probably heard a joke or two about the pain and discomfort involved.
Still, it’s classified by health insurers and Medicare as a routine procedure. Millions of root canal surgeries are done each and every year, and they’re usually considered an elective procedure except in extreme cases. As was stated above, if you’re admitted to the hospital, and it’s determined that a root canal is necessary, then it will be covered. Otherwise you’ll be forced to cover the cost out of your own pocket, or with a separate dental policy.
If you’re enrolled in a Medicare Advantage plan, it’s very possible you have routine dental coverage, including for a root canal procedure. Consult your policy documents or the agent who sold you the policy.
Still have questions? We’re here to help.
Click here to drop us a message, or just give us a call at 800-701-3951