The Facts / Glossary

What is Medicare?

Medicare is government-funded healthcare for people over the age of 65 who paid Federal Insurance Contributions Act (FICA) for 40 quarters, the equivalent of 10 years. You have the option to enroll for Medicare Part A and Part B within three months of your 65th birthday: three months before you turn 65 and three months after you turn 65.

  • If you missed the 7 month initial Medicare enrollment period when you turned 65, Medicare only allows new enrollments once per year during General Enrollment Period, and it can take up to 12 months to get your Medicare. General Enrollment is between January 1st and March 31st each year, and your plan will become effective July 1st. In addition, you will be penalized with higher premiums for the rest of your life. The only exception to the enrollment period is if you qualify for a Special Enrollment Period – if you've had certain life events, including losing health coverage (through your employer), moving, getting married, having a baby, or adopting a child. If you qualify for a special enrollment period, you usually have up to 60 days following the event to enroll in Medicare. However, please note that COBRA and retiree health plans are not considered coverage based on current employment and you will not be eligible for the special enrollment period when that coverage ends.

Basic Medicare comes in two parts:

Part A is premium-free coverage for hospitalization, short term nursing care and hospice care. If you have not contributed to FICA for at least 40 quarters, you can still buy Part A for a premium. Part A Coverage

Part B covers medically necessary services including doctor’s visits, surgeries, laboratory tests, a one-time welcome to Medicare visit and annual “wellness visits,” which are actually annual Medicare information sessions with your physician and not preventive physical exams. You can go to any doctor in all 50 states without a referral. However Part B does not cover routine preventive physical examinations. The cost for part B is $134.00 for a single filing up to $85,000 or a joint filing up to $170,000. Above these amounts, costs are indexed based on your income. Part B Coverage

Part C allows you to opt out from Part A and B and choose health coverage through a private insurance company, which is called an “Advantage Plan” (opting for Part C is actually the greatest disadvantage to you - FIND OUT WHY). Advantage plans are usually premium free. You will simply continue paying the part B premium of $134.00 for Medicare. They also include a prescription plan and perhaps dental services, eye care, hearing aids - even a membership to a spa! Advantage Plans come with these enticing benefits because Medicare pays the insurance companies to get you off their liability.

Be Careful!

The tradeoff is that you can only go to your primary care doctor. You’ll also need referrals from your doctor to go to an “in network” specialist, so you are giving up the freedom to choose your doctors that you would have had with original Medicare Parts A & B. Furthermore, you cannot make any changes to your elected plan – you won’t be able to go back to your original Medicare or switch to a different advantage plan until the open enrollment period, which occurs only once per year from October 15th through December 7th. Changes in your plan will take effect on Jan 1st so if you need to make changes before that, you are handcuffed for a full year. .

What You SHOULD NOT Buy: Medicare Advantage Plans

You may be tempted to get a Medicare Advantage Plan – Part C – to substitute Medicare. Medicare Advantage promises $0 premium for managed care, but be sure you know what you’re getting before you buy.

What is managed care?

Managed care means that you agree to visit only certain doctors and hospitals that are “in-network” and the treatment is managed by a large insurance company. The insurance company employs a team of doctors who have the final word on what treatments and care the company will cover. When your doctor determines a care plan, the insurance company (even without seeing you, the patient) has the ability to override the doctor and deny coverage, deeming the care unnecessary. Unfortunately, there is a clear conflict of interest when that decision is made by the very body that has to pay for the care.

You have the right to appeal this decision by sending a letter asking your insurance company to have a second team of doctor’s review the decision internally. However, these doctors are also employed by the insurance company and are no less biased than the first set of doctors who reviewed the request. They have up to 90 days to respond to the appeal, during which time you may have to put your medical care on hold. .

  1. Managed care plans are always sold with incentives (spa memberships, dental insurance, free hearing aids, free copayments, etc.) .However, when you buy into an Advantage managed care plan, you lose flexibility to choose your care providers and some of the best Medicare benefits. Remember: 90% of health benefits are used during the last 10 to 20 years of your life – you will want to leave all options open to be exercised as you wish when the time comes.
  2. Managed care organizations have a right to deny coverage, tests, or treatment they deem unnecessary and they exercise this option too often. This may not affect you at this time, but insurance coverage is for the unexpected. Make sure you are prepared. Watch the pitfalls of Medicare discussed on Good Morning America

Part D is a Medicare program administrated by a third party, usually an insurance company, that offers coverage for prescription drugs. The cost is based on what plan you choose and how much medication you take. In addition, if you do not take any prescriptions you can choose not to enroll. However, if and when you need it, you will only be able to enroll once a year during the yearly open enrollment period between Oct 15th and Dec 7th, effective Jan 1st. Moreover, you will be penalized with a penalty of 1% of the national premium rate per month for each month you delay enrollment for the rest of your life. Part D is not a one size fit all; it needs to be customized for each one based on the medications you take.

More on the part D late enrollment penalty

Should I enroll in Medicare Part D?

Contact Eli for more information about Medicare Part D.

Beware! Parts A and B cover limited hospital and medical care, leaving many big gaps. In order to have complete coverage and still have freedom of choice, you need to choose Parts A, B & D along with a supplement.

Part A Coverage


Admission First 60 Days 61-90 Days Over 90 Days (not covered; 60 day once-in-a-lifetime reserve you can use)
$1316 deductible per benefit period* Fully covered $329 deductible per day x 30 days = $9,870 $658 deductible per day x 60 days = $39,480

The Risk A benefit period begins upon admission to a facility and ends 60 days after the last service you received there. If you are readmitted after 60 days, you begin a new benefit period and all costs apply. (Rather than a calendar year deductible like part B or private insurance plans)

Your hospitalization coverage under Part A is exhausted after a hospital stay of 150 days. The hospital will put a lien on your assets to cover your extended stay, which is in addition to the over $50,000 of copayments you accumulated during the first 150 days of your stay.
Medicare supplement plans will cover all of the gaps and covering hospitalization beyond the 150 days up to 365 days

Hospitalization coverage is the biggest gap with Medicare and the most urgent reason that you need to supplement Medicare to fill this dangerous gap.


10-20 Days 21-100 Days Over 100 Days
Fully covered $164.50 deductible per day x 80 days = $13,160 No coverage

The supplement will pick up the $13,160 gap up to 100 days. After 100 days, you are no longer covered – even if you (a) have a supplemental policy (b) are at home receiving home care. You will need to buy a long-term care policy to ensure you’re covered. Don’t assume Medicare covers you for long term care! This is the biggest mistake people make and when they finally realize their mistake, it’s usually too late to buy a long-term care policy.

Should I buy a long-term care polict> Contact Eli for more info

Please note that the Medicare supplement policy is only supplementing Medicare, meaning that it fills the gap only when Medicare covers part of the costs. If Medicare does not cover a particular expense, the supplement won’t cover it either. One exception to this is international emergencies, which are covered up to $50,000 by most Medicare supplement plans.

Part B Coverage

After a $183 deductible, Medicare will cover 80% of approved charges for physician’s services, inpatient and outpatient care, medical and surgical services and supplies, physical and speech therapy, diagnostic tests, and durable medical equipment. A supplement will help cover the remaining 20% of costs.

Supplemental Insurance

There are many serious gaps in Medicare so make sure you’re covered → You’ll need supplemental insurance – also known as Medigap policies – to ensure maximum coverage. Supplemental insurance will pick up the remaining 20% of costs after Medicare Part B has paid 80% of the approved charges if the doctor accepts assignment,* and up to the current charges if the doctor does not accept assignment.

*Assignment means that your doctor, provider, or supplier agrees to accept the Medicare-approved amount as full payment for covered services. Legally, if a doctor does not accept assignment, he can only charge a patient up to 150% of the Medicare approved charges.

Choose your plan wisely. It is important to choose the original Medicare and the right supplemental insurance from the start:

  • 90% of health benefits are used during the last 10 to 20 years of your life.
  • With so many different supplemental policy options, even intelligent people make the wrong decisions.

What You SHOULD Buy: Supplemental insurance that’s right for you

If you’re paying more than $71/month* for a Medicare supplement, you’re wasting your money.
*price subject to change based on policy owner’s zip code

Eli has done the research for you. Contact Eli to select the right supplemental plan for you.

What Eli recommends:

Plan F covers all the gaps, deductibles and copayments.

The Benefits:
Plan F also covers the difference between what your doctor bills and what Medicare pays, and covers you even when you’re traveling outside the US (up to $50,000). Plan F also covers Medicare Part A’s gap, covering hospitalization beyond 150 days up to 365 days. Plan F’s monthly premium is $279. Check to see the cost in your area.

High Deductible Plan F gives you the same great benefits with a lower monthly premium and lower annual cost.

See for yourself:

Monthly Premium Annual Premium Cost Deductible Annual TOTAL Cost
Plan F $279 $3,348 $0 $3,348 *regardless if used
High Deductible Plan F $71 $852 $2,200 $3,052 *only if maxed out of pocket

LESS IS MORE! You get the same comprehensive coverage and pay less!

  • By choosing the High Deductible (HD) Plan F, you pay just $852 premium and a maximum of $2,200 for your deductible – that’s less than the cost of the regular Plan F.
  • After a $183 deductible, Medicare will cover 80% of approved charges (See above Part B Coverage. This will be your primary coverage.) and your Plan F supplement will help cover the remaining 20% of costs -- this will be your secondary coverage. Therefore, it is likely you will never maximize your Plan F deductible, and even if you do maximize it once every few years, you still come out ahead.

Consider this scenario: You visit the doctor ten times in a year and the doctor charges $200 for each visit.

Medicare Pays Patient Responsibility
Visit 1 $13.60 (80%) after deductible $183 Medicare deductible and $3.40 for the 20% left.
Your toal responsibilty to pay will be $186.40
Visits 2-9 $160 $40 towards High Deductible Plan F deductible

For visit number 1, you’ve paid $183 to satisfy the Medicare deductible and an additional $3.40 for the 20% copayment, all of this is accountable towards the HD Plan F deductible, totaling $186.40.

For the other 9 visits, you paid 20% copayments = $40 each, also counting towards HD Plan F deductible for a total of $360. totaling $546.40, in addition you’ve also paid an $852 annual premium. At the end of the year, your total comes to $1,398.40.
Compare $1,398.40 to the $3,348 cost of the regular Plan F without the high deductible and you’ll see that you’re way ahead of the game!

Therefore, by choosing the HD Plan F, you save $1,949.60 for the identical coverage. Instead of paying up front for the coverage, choose the HD Plan F and pay only if you use it.

Most people will not maximize their deductible under the HD Plan F. The savings quickly add up! Five years in the above scenario = $9,748 in savings. Ten years is $19,496 in your pocket.

  • If you have extensive medical expenses beyond what Medicare covers, this supplement is there as a safety net – and still at a lower cost to you.
  • If you are not happy with the HD plan, you can upgrade to the no deductible plan at any time (no open enrollment waiting time) even if you have a preexisting condition.

Eli is here to make this complicated process as simple as possible so you can make the best – and most financially sound – decision.

Remember, your health is your wealth!
Get Your Free Consultation

For more information, contact Eli today.