You can spend the night in a hospital — and still not be considered an inpatient. That distinction can affect what Medicare pays and what you may owe.

Imagine this:

You go to the emergency room because you’re sick or injured.

The hospital decides you need to stay.

You’re moved to a hospital room. You sleep in a hospital bed. Nurses check on you. You receive medications, meals, tests and treatment.

Naturally, you assume:

“I’ve been admitted to the hospital.”

But under Medicare, that may not actually be the case.

You could be receiving outpatient observation services instead.

And here’s something every Medicare beneficiary — and especially their family members — should know:

Being in the hospital and being admitted as an inpatient are not necessarily the same thing.

That distinction can affect how Medicare covers your care and, in some circumstances, whether Medicare will cover skilled nursing facility care after you leave the hospital.

What Is Observation Status?

Observation services are hospital outpatient services used while a doctor determines whether you need to be admitted as an inpatient or can be discharged.

The confusing part is that observation care may not feel like outpatient care.

You may be in a hospital bed overnight — or longer — while receiving treatment.

According to Medicare, your inpatient or outpatient status affects how much you pay for hospital services and may also affect whether Medicare will cover care you receive in a skilled nursing facility afterward.

Medicare explains the distinction between inpatient and outpatient hospital status.

What you can do: Don’t determine your status based on how long you’ve been in the hospital or where your bed is located.

Ask:

“Am I officially admitted as an inpatient, or am I receiving outpatient observation services?”

When Are You Actually Considered an Inpatient?

Under Original Medicare, you’re considered an inpatient beginning when you’re formally admitted to the hospital with a doctor’s order.

That means simply going through the emergency department doesn’t automatically make you an inpatient.

Spending the night doesn’t necessarily make you one either.

Your status depends on whether the hospital has formally admitted you.

What you can do: If you or a family member is staying in the hospital, ask the hospital staff to confirm the patient’s official status.

If you’re unsure, ask again.

Why Does Inpatient vs. Observation Status Matter?

There are several reasons.

One is how Medicare pays for the hospital care itself.

Inpatient hospital care is generally covered under Medicare Part A, subject to Medicare’s applicable coverage and cost-sharing rules.

Outpatient hospital services, including observation services, generally fall under Medicare Part B.

You can review Medicare’s information about inpatient hospital care and outpatient hospital services.

But there’s another reason this distinction can become especially important.

It may affect what happens after you leave the hospital.

Leaving the Hospital for Rehab? This Is Where Status Can Really Matter

Suppose your doctor determines that you aren’t ready to go home.

Instead, you need additional rehabilitation or skilled nursing care.

You may assume Medicare will cover a stay in a skilled nursing facility because you just spent several days in the hospital.

But with Original Medicare, there’s an important requirement to understand.

For Medicare to cover a qualifying skilled nursing facility stay under the traditional rule, you generally need a 3-day qualifying inpatient hospital stay.

And Medicare specifically states that time spent in the emergency room or under outpatient observation doesn’t count toward that 3-day inpatient requirement.

Medicare explains the requirements for Skilled Nursing Facility coverage.

Here’s an example:

Imagine you arrive at the hospital on Monday.

You remain under observation Monday and Tuesday.

On Wednesday, the hospital formally admits you as an inpatient.

You’re discharged to a skilled nursing facility on Friday.

You may feel as though you spent five days in the hospital.

But the days spent under observation generally don’t count toward Original Medicare’s qualifying inpatient hospital stay requirement.

That could become very important when determining whether the subsequent skilled nursing facility stay qualifies for Medicare coverage.

What you can do: If skilled nursing or rehabilitation is being discussed, don’t wait until discharge day.

Ask:

“Do I have a qualifying inpatient hospital stay for Medicare-covered skilled nursing facility care?”

There Is an Important Medicare Advantage Difference

If you have a Medicare Advantage plan, don’t automatically assume the Original Medicare three-day rule works exactly the same way for your plan.

Medicare Advantage plans must cover the benefits Medicare requires, but plans can have different rules and processes. Medicare notes that some Medicare Advantage plans may not require the three-day minimum inpatient hospital stay before covering skilled nursing facility care.

Network and prior authorization requirements may also apply.

What you can do: If you have Medicare Advantage and skilled nursing or rehabilitation is being recommended, contact your plan and ask:

“What are my plan’s requirements for skilled nursing facility coverage, and does this facility participate in my plan’s network?”

Don’t rely solely on assumptions based on Original Medicare.

There’s Another Important Protection: MOON

If you have Original Medicare and you’re receiving observation services as an outpatient for more than 24 hours, the hospital generally must give you a notice called the Medicare Outpatient Observation Notice, commonly called the MOON.

The MOON explains that you’re an outpatient receiving observation services rather than an inpatient and how that status may affect what you pay.

Medicare explains this notice and other hospital protections in its information about inpatient and outpatient hospital status.

Don’t treat the MOON as just another piece of hospital paperwork.

Read it.

Ask questions.

Make sure you understand what your status means.

What you can do: If you’ve been in the hospital under observation and haven’t received or don’t understand the notice, ask hospital staff about your status and the MOON.

What About Your Medications While You’re Under Observation?

Here’s another potential surprise.

Because observation is outpatient care, the way Medicare covers medications you normally take at home can be different from what you might expect during an inpatient hospital stay.

Medicare Part B generally doesn’t cover most drugs that are considered self-administered drugs in an outpatient hospital setting.

That can potentially leave you responsible for charges for certain medications provided while you’re receiving outpatient care.

Medicare provides more information about outpatient hospital services and what you may pay.

What you can do: If you’re under observation, ask whether medications you’re receiving are covered by Medicare and whether you should expect any additional medication charges.

5 Questions to Ask While You’re in the Hospital

This is one of those articles worth sharing with your spouse, adult children or whoever might advocate for you during a hospital stay.

You don’t need to memorize all of Medicare’s hospital rules.

Remember these five questions:

1. Am I officially admitted as an inpatient, or am I under outpatient observation?
2. When did my inpatient admission officially begin?
3. Have I received a Medicare Outpatient Observation Notice (MOON), if applicable?
4. If I’m being discharged to skilled nursing or rehabilitation, have I met Medicare’s coverage requirements?
5. If I have Medicare Advantage, what does my specific plan require and is the facility in-network?

Sometimes knowing the right question to ask is more useful than trying to understand every Medicare rule yourself.

What If You Think Your Hospital Status Is Wrong?

Ask questions while you’re still in the hospital.

Talk with your doctor, hospital case manager, discharge planner or patient advocate about your status and why you’re being treated as an outpatient rather than admitted as an inpatient.

Medicare also provides beneficiaries with important rights and protections.

You can learn more through Medicare’s information about your Medicare rights and protections.

If you’re being discharged and believe Medicare-covered hospital care is ending too soon, there may also be specific appeal rights and deadlines that apply to your situation.

What you can do: Don’t wait until weeks after discharge to start asking questions. Hospital status and discharge decisions are worth understanding while you’re still there.

The Bigger Medicare Lesson

This is a perfect example of why knowing how to use Medicare matters.

A Medicare beneficiary can spend several nights in a hospital and reasonably believe:

“Of course I’m an inpatient. I’m in the hospital.”

But Medicare doesn’t determine inpatient status simply by counting the nights you’ve slept in a hospital bed.

And if rehabilitation or skilled nursing care is needed afterward, misunderstanding that distinction could become much more significant.

You don’t need to become an expert in Medicare hospital billing.

You need to know enough to ask:

“What is my official status, and what does that mean for my coverage?”

Why We’re Talking About This

There are things people don’t always learn when they enroll in Medicare.

We’re going to talk about them.

Not to make Medicare more complicated — but to help you understand the questions to ask, recognize potential problems and make more informed decisions about your healthcare.

Because sometimes avoiding an unexpected healthcare bill starts with knowing what to ask before the bill ever exists.

Want to Learn More?

The information in this article was based on guidance from Medicare.gov, the official U.S. government website for Medicare.

Official Medicare resources:

• Inpatient vs. Outpatient Hospital Status
• Medicare Inpatient Hospital Coverage
• Medicare Outpatient Hospital Services
• Skilled Nursing Facility Coverage
• Medicare Rights & Protections

Questions About Your Medicare Coverage?

Medicare can be confusing, and sometimes the answer depends on your individual situation.

If you have questions about your current Medicare coverage, are approaching Medicare eligibility, or simply want help understanding your options, I’m happy to help.

I’ve been helping individuals navigate health insurance and Medicare for more than 33 years, and I believe understanding your coverage is just as important as choosing it.

Have a Medicare question? Let’s talk.

James Bokshan, CLU, ChFC, RHU, REBC
(248) 840-2074
jbok99@gmail.com

No pressure. No obligation. Just straightforward help understanding your Medicare options.

This article is intended for educational purposes and isn’t a guarantee of coverage. Medicare rules, individual circumstances and Medicare Advantage plan requirements can vary. Always verify your individual coverage and costs with Medicare, your insurance carrier and your healthcare providers.

The post In the Hospital on Medicare? Ask Whether You’re an Inpatient or Under Observation appeared first on Health Insurance Experts, LLC.

A medical bill arrives in the mail. Before you write the check, there’s another document Medicare beneficiaries should know how to read.

You open the mailbox and there it is.

A bill from a doctor, hospital, laboratory or other healthcare provider.

Maybe you recognize the service.

Maybe you don’t.

Maybe the amount is much higher than you expected.

The natural reaction is to assume:

“Medicare must have processed it, so this must be what I owe.”

Not necessarily.

Here’s something I wish more Medicare beneficiaries knew:

If you have Original Medicare, one of the first things you should do before paying an unexpected medical bill is compare it with your Medicare Summary Notice.

Your Medicare Summary Notice — commonly called an MSN — can help you understand what was billed to Medicare, what Medicare approved, what Medicare paid, and what Medicare says you may owe.

And despite the word “Notice” appearing on it:

Your Medicare Summary Notice is not a bill.

Let’s look at what it is — and how you can use it.

What Is a Medicare Summary Notice?

If you have Original Medicare, Medicare sends you a Medicare Summary Notice every three months when you receive Medicare-covered services during that period.

The MSN summarizes claims submitted to Medicare for your care.

It shows information including:

• The services or supplies providers billed to Medicare
• Whether Medicare approved the claim
• What Medicare paid
• The maximum amount you may be billed
• Information about denied claims
• Information about your appeal rights

You can see Medicare’s explanation of the Medicare Summary Notice.

You can also access Medicare claims information through your Medicare.gov account.

What you can do: Don’t automatically throw your Medicare Summary Notice into the “insurance paperwork” pile. It contains information worth reviewing.

First Things First: An MSN Is NOT a Bill

This deserves to be repeated.

Do not send money because you received a Medicare Summary Notice.

The MSN is Medicare’s explanation of how claims submitted during that period were processed.

Your healthcare provider may separately send you a bill for your portion.

That’s where the MSN becomes useful.

You can compare the provider’s bill with what Medicare says happened with the claim.

What you can do: Put the provider’s bill next to your Medicare Summary Notice and compare them before paying an amount you don’t understand.

What Should You Look For?

You don’t have to understand every code or abbreviation on the document.

Start with a few basic questions.

1. Do You Recognize the Provider?

Look at the names of the doctors, hospitals, laboratories, suppliers and other providers who submitted claims.

Ask yourself:

“Did I actually receive care from this provider?”

Sometimes the name appearing on a Medicare claim isn’t identical to the name you recognize from the doctor’s office. A practice may bill under a larger organization or health system.

So an unfamiliar name doesn’t automatically mean something is wrong.

But it is worth investigating.

What you can do: If you don’t recognize a provider or service, don’t ignore it. Call the provider or Medicare and ask questions.

2. Do You Recognize the Service?

Look at the description and date of service.

Does it correspond with an appointment, test, procedure or medical service you remember receiving?

Pay particular attention to services you don’t recognize.

Medicare encourages beneficiaries to review their Medicare claims for accuracy.

This isn’t only about billing mistakes.

Reviewing your claims can also help identify potential Medicare fraud or misuse of your Medicare number.

Medicare provides guidance about how to spot and report Medicare fraud and abuse.

What you can do: If you see a service you’re certain you didn’t receive, investigate it promptly.

3. Was the Claim Approved?

Your MSN tells you whether Medicare approved the service.

If Medicare didn’t pay something, don’t stop at:

“Medicare denied it.”

Find out why.

There may be an explanation on the MSN.

A denial doesn’t necessarily mean the situation is hopeless or that you automatically owe whatever amount appears on a provider bill.

There are circumstances in which Medicare’s decision can be appealed.

Medicare explains the Original Medicare appeals process.

What you can do: Read the explanation associated with a denied claim before deciding what to do next.

4. Look at “Maximum You May Be Billed”

This is one of the most useful pieces of information on the MSN.

Medicare’s MSN includes a column showing the maximum amount you may be billed for a claim.

Compare that amount with the bill you received from the provider.

If the provider’s bill is higher than what you expected based on the MSN, don’t simply assume you need to pay it.

Call the provider’s billing department and ask them to explain the difference.

There may be another insurer involved, a Medigap claim still being processed, or another reason the balances don’t match yet.

What you can do: Compare the amount the provider is requesting with the information Medicare provides before paying an unexpected balance.

5. If You Have a Medicare Supplement, Give It Time to Process

If you have Original Medicare plus a Medicare Supplement — also called Medigap — there can be more than one step involved in processing your claim.

Medicare processes its portion first.

Information may then be sent to your Medigap insurer so it can determine what it owes under your policy.

That means a provider’s initial statement isn’t always the end of the story.

If your Medigap policy should cover some or all of the remaining Medicare-approved cost, make sure that claim has been processed before assuming the provider’s current balance is your final responsibility.

Medicare explains how Medigap works with Original Medicare.

What you can do: If you receive a bill shortly after Medicare processes a claim, verify whether your Medicare Supplement has processed its portion before paying an unexpected balance.

What If You Have Medicare Advantage?

Here’s an important distinction.

The Medicare Summary Notice we’re discussing is for people with Original Medicare.

If you’re enrolled in a Medicare Advantage plan, your plan will generally provide its own Explanation of Benefits, often called an EOB.

The concept is similar:

Don’t automatically treat an EOB as a bill.

Use it to understand how your plan processed the claim, what the provider charged, what the plan paid and what the plan says you may owe.

If something doesn’t make sense, contact your Medicare Advantage plan and the provider.

What you can do: Know which document applies to you:

Original Medicare → Medicare Summary Notice

Medicare Advantage → Your plan’s Explanation of Benefits

What If Medicare Denied Something?

This is another reason not to immediately pay a large bill.

If Original Medicare denies a service you believe should have been covered, you have the right to appeal Medicare’s decision.

Your MSN contains information about how and when to appeal.

Appeals have deadlines, so don’t put a questionable denial aside for six months and assume you can deal with it later.

Medicare provides step-by-step information about filing an Original Medicare appeal.

If you have Medicare Advantage, the appeal process goes through your Medicare Advantage plan and follows different procedures. Medicare provides separate guidance for Medicare Advantage appeals.

What you can do: If you believe something was incorrectly denied, read your notice and pay attention to the appeal deadline.

Watch for Something Else: Medicare Fraud

Reviewing your MSN isn’t only about protecting your wallet.

It’s also one way to protect your Medicare benefits.

Look for:

• Services you never received
• Medical equipment you never ordered
• Providers you’ve never seen
• Duplicate services
• Dates that don’t make sense

Again, an unfamiliar item isn’t automatically fraud.

Ask first.

But if you discover that Medicare was billed for something you definitely didn’t receive, don’t ignore it.

Medicare provides instructions for reporting suspected Medicare fraud.

What you can do: Treat your Medicare number like other important personal information, and review claims regularly for services you don’t recognize.

Before You Pay an Unexpected Medical Bill, Ask These 6 Questions

Keep this list somewhere handy:

1. Does this bill match a service I actually received?
2. Has Medicare processed the claim yet?
3. What does my Medicare Summary Notice say I may owe?
4. If I have Medigap, has my Medicare Supplement processed its portion?
5. If Medicare denied the service, why was it denied — and do I have appeal rights?
6. Does anything on the claim look unfamiliar or incorrect?

If something doesn’t add up, make a phone call before writing a check.

An Easy Habit That Can Help

You don’t need to become an expert in medical billing.

Create a simple system.

When you receive an unexpected medical bill:

Bill → Medicare/EOB → Supplement → Pay

In other words:

1. Review the provider’s bill.

2. Compare it with Medicare’s MSN or your Medicare Advantage EOB.

3. If you have secondary coverage, make sure that coverage has processed the claim.

4. Then determine what you actually owe.

That extra few minutes can be worthwhile when something doesn’t look right.

The Bigger Medicare Lesson

Most people spend a lot of time learning about Medicare before they enroll.

What happens afterward matters just as much.

Understanding your Medicare Summary Notice is one of those small skills that can help you become a better healthcare consumer.

You don’t have to understand every billing code.

You don’t have to know every Medicare regulation.

You simply need to know enough to stop when something doesn’t look right and ask:

“Is this really what I owe?”

Why We’re Talking About This

There are things people don’t always learn when they enroll in Medicare.

We’re going to talk about them.

Not to make Medicare more complicated — but to help you understand the questions to ask, recognize potential problems and make more informed decisions about your healthcare.

Because sometimes avoiding an unexpected healthcare bill starts with knowing what to ask before you pay it.

Want to Learn More?

The information in this article is based on guidance from Medicare.gov, the official U.S. government website for Medicare.

Official Medicare resources:

• Understanding Your Medicare Summary Notice
• Original Medicare Appeals
• Medicare Advantage Appeals
• How Medigap Works With Original Medicare
• Reporting Medicare Fraud & Abuse

Questions About Your Medicare Coverage?

Medicare can be confusing, and sometimes the answer depends on your individual situation.

If you have questions about your current Medicare coverage, are approaching Medicare eligibility, or simply want help understanding your options, I’m happy to help.

I’ve been helping individuals navigate health insurance and Medicare for more than 33 years, and I believe understanding your coverage is just as important as choosing it.

Have a Medicare question? Let’s talk.

James Bokshan, CLU, ChFC, RHU, REBC
(248) 840-2074
jbok99@gmail.com

No pressure. No obligation. Just straightforward help understanding your Medicare options.

This article is intended for educational purposes and isn’t a guarantee of coverage or payment. Medicare rules, individual circumstances and private-plan requirements can vary. Always verify your individual coverage and costs with Medicare, your insurance carrier and your healthcare providers.

The post Before You Pay That Medical Bill: Check Your Medicare Summary Notice appeared first on Health Insurance Experts, LLC.

The post Your Medicare Wellness Visit Isn’t a Physical — And That Can Affect Your Bill appeared first on Health Insurance Experts, LLC.

A few questions before you receive care could help prevent an unexpected bill later.

One of the things I tell my clients is that having good Medicare coverage and knowing how to use that coverage are two different things.

You can do everything right when choosing your Medicare coverage and still run into an unexpected bill because of how a service was provided, where you received it, or how it was billed.

That’s why Medicare education shouldn’t stop after you enroll.

Here’s something many people on Medicare aren’t told: There are questions you can ask before receiving care that may help you avoid problems afterward.

Here are seven I think every Medicare beneficiary — and their family members — should know.

1. Don’t Just Ask, “Do You Take Medicare?”

If you have Original Medicare, there’s a better question:

“Do you accept Medicare assignment?”

A provider who accepts assignment agrees to accept the Medicare-approved amount as payment in full for covered services. You may still be responsible for your deductible and coinsurance, but the provider agrees to Medicare’s payment rules.

Most providers accept assignment, but Medicare recommends checking.

You can learn more about Medicare assignment and what it means when a provider accepts Medicare directly from Medicare.gov.

If you have Medicare Advantage, you’ll want to ask a different question:

“Are you currently in-network with my specific Medicare Advantage plan?”

Don’t assume that because a doctor’s office “takes Medicare,” it accepts your particular Medicare Advantage plan.

What you can do: Verify this before seeing a new doctor, specialist or other provider.

2. Ask Whether the Office Is Hospital-Owned

Your doctor’s office may look like any other medical office but be owned by or affiliated with a hospital or health system.

That distinction can matter.

Depending on the facility and how the services are billed, receiving care in a hospital-based setting can affect what you pay.

Before a visit or procedure, ask:

“Is this considered a hospital-based facility, and should I expect a separate facility charge?”

This is especially worth asking when you’re being sent somewhere new for testing, imaging, a procedure or specialist care.

What you can do: Ask about both the professional charge and any facility charge before receiving non-emergency care.

3. Know What Your Medicare Wellness Visit Actually Covers

Here’s one that surprises a lot of people:

Medicare’s Annual Wellness Visit is not the same thing as a traditional annual physical.

The Medicare Wellness Visit focuses largely on prevention and creating or updating a personalized prevention plan.

Medicare says you generally pay nothing for the covered Wellness Visit if your provider accepts assignment.

However, if your provider performs additional tests or services during that same appointment that aren’t covered under the preventive benefit, you may have coinsurance or a deductible — or, for a non-covered service such as a routine physical, potentially be responsible for the full cost.

So if you go in for your Wellness Visit and also need another medical issue evaluated, don’t assume everything discussed that day will automatically fall under the no-cost preventive benefit.

Medicare explains what’s included in the Yearly Wellness Visit and what you may have to pay.

What you can do: Before the visit, ask what is included in your Medicare Wellness Visit and whether addressing additional concerns could result in another charge.

4. Before a Test or Procedure, Verify the Coverage Requirements

Your doctor recommending a service doesn’t necessarily answer every insurance question about that service.

This is particularly important if you’re enrolled in Medicare Advantage because plans may have network requirements, prior authorization requirements or other coverage rules.

Before a scheduled MRI, procedure, surgery, therapy program or other expensive service, ask:

“Has my Medicare coverage been verified, and are there any authorization or network requirements I need to meet?”

Then verify with your Medicare Advantage plan when appropriate.

What you can do: Don’t wait until the day of an expensive procedure to find out whether all of the coverage requirements were met.

5. If You’re Asked to Sign an ABN, Read It

If you have Original Medicare, you may occasionally receive something called an Advance Beneficiary Notice of Non-coverage, or ABN.

Pay attention to it.

An ABN generally means your provider believes Medicare may not pay for a particular item or service.

The notice should identify what Medicare may not cover, why the provider believes Medicare may not pay, and an estimate of the cost.

Signing an ABN isn’t simply routine paperwork.

It’s giving you important information about potential financial responsibility and choices you have about receiving the service.

Medicare explains Advance Beneficiary Notices and your rights when Medicare may not cover a service.

What you can do: Before signing, ask:

“Why do you believe Medicare may not cover this, and approximately how much could I owe?”

If you choose the option that requires the provider to submit the claim to Medicare and Medicare denies it, you retain the ability to appeal that decision.

6. If You’re in the Hospital, Ask One Very Important Question

“Am I an inpatient, or am I under outpatient observation?”

It may sound like a technical distinction.

It isn’t.

You can be lying in a hospital bed, receiving medications, meals, tests and nursing care — and even spend the night — without technically being admitted as an inpatient.

Medicare considers observation services outpatient services.

Your status can affect how your hospital care is billed and, with Original Medicare, may also affect whether Medicare covers a subsequent stay in a skilled nursing facility.

For traditional Medicare-covered skilled nursing facility care, Medicare generally requires a qualifying inpatient hospital stay of at least three consecutive days. Time spent in observation before you’re formally admitted doesn’t count toward that requirement.

Medicare provides a helpful explanation of the difference between inpatient hospital admission and outpatient observation status.

You can also read Medicare’s requirements for Skilled Nursing Facility care.

What you can do: If you or someone you care for is hospitalized, ask about inpatient versus outpatient status. If the stay continues, don’t be afraid to ask again.

7. Ask What You Should Expect to Pay — Before You Receive the Service

This might be the simplest question on the list:

“What should I expect my responsibility to be?”

An estimate isn’t a guarantee, and there are situations where an exact cost can’t be known beforehand.

But for scheduled, non-emergency care, asking ahead of time may uncover something worth investigating.

Maybe the facility isn’t in your Medicare Advantage network.

Maybe there’s a facility charge you weren’t expecting.

Maybe the service isn’t covered the way you thought.

Maybe the provider doesn’t accept Medicare assignment.

Those are much easier conversations to have before the service than after a large bill arrives.

What you can do: Ask the provider’s billing department for an estimate and verify your benefits with your Medicare plan when appropriate.

The Bigger Medicare Lesson

Choosing your Medicare coverage is important.

Knowing how to use it is just as important.

You don’t need to understand every Medicare billing code or memorize hundreds of pages of Medicare rules. But knowing a handful of questions to ask can make you a much more informed healthcare consumer.

Before your next appointment, remember:

1. Original Medicare: Do you accept Medicare assignment?
   Medicare Advantage: Are you in-network with my specific plan?
2. Is this a hospital-based facility, and is there a separate facility charge?
3. What is included in my Medicare Wellness Visit?
4. Are there authorization or network requirements for this service?
5. Why am I being asked to sign an ABN, and what could I owe?
6. If I’m in the hospital, am I inpatient or under observation?
7. What should I expect to pay?

Why We’re Talking About This

There are things people don’t always learn when they enroll in Medicare.

We’re going to talk about them.

Not to make Medicare more complicated — but to help you understand the questions to ask, recognize potential problems, and make more informed decisions about your healthcare.

Because sometimes avoiding an unexpected healthcare bill starts with knowing what to ask before the bill ever exists.

Want to Learn More?

The information in this article was verified using Medicare.gov, the official U.S. government website for Medicare.

Additional Medicare resources referenced in this article:

• What it means when a provider accepts Medicare assignment
• Medicare Yearly Wellness Visits
• Inpatient versus outpatient hospital status
• Medicare Skilled Nursing Facility coverage
• Advance Beneficiary Notices and Medicare beneficiary protections

James Bokshan, CLU, ChFC, RHU, REBC

Helping individuals understand their health insurance and Medicare options for more than 33 years.

This article is intended for educational purposes and is not a guarantee of coverage. Medicare rules and individual plan requirements can vary. Always verify your coverage and costs with Medicare, your insurance carrier and your healthcare providers.

The post 7 Questions to Ask Before Your Next Medical Appointment When You Have Medicare appeared first on Health Insurance Experts, LLC.

A Short-Term Medical Plan May Be the Right Solution

Health insurance premiums continue to rise, leaving many facing a difficult decision.

Some individuals and families have found that Marketplace (ACA) plans now come with monthly premiums that strain their budgets while still requiring high deductibles and significant out-of-pocket costs before many benefits begin.

As a result, many people have made the difficult decision to go without health insurance altogether.  This can be a life altering financial decision in a health emergency.

For healthy individuals, there may be another option.

What Is a Short-Term Medical Plan?

Short-term medical insurance is designed to provide temporary protection against unexpected illnesses and injuries. Think: Catastrophic Insurance. These plans can run anywhere from 1 to 6 months at a time.   The state law limits one company to 185 days of coverage per 365 days as a maximum, however, some carriers only allow shorter durations with their own internal rules.  If you need coverage for more than 185 days, you must switch to another carrier for insurance.

These plans are intended for people who want coverage for major medical events, while understanding that certain services, like preventative care, are not covered.

If you qualified, a short-term plan can provide valuable financial protection at a fraction of the monthly cost of traditional health insurance.

What Does a Short-Term Medical Plan Cover?

Most short-term medical plans help pay for expenses related to:

• Hospitalizations
• Emergency room visits
• Surgery
• Physician visits for new illnesses
• Diagnostic testing
• Major accidents
• Serious illnesses

If an unexpected medical event occurs, these plans can help protect you from the financial impact of large medical bills.

What Isn’t Covered?

Short-term medical plans are not comprehensive health insurance and generally do not cover:

• Pre-existing medical conditions
• Routine preventive care
• Annual physicals
• Immunizations
• Maternity care
• Mental health services
• Chiropractic care
• Most prescription drug benefits
• Routine wellness services

Short Term policies are not “qualifying insurance” and therefore do not follow the rules set forth in the Affordable Care Act. Because of these limitations, short-term plans are generally best suited for individuals who are relatively healthy and primarily want protection against unexpected medical emergencies.

Is a Short-Term Medical Plan Right for You?

Every situation is different.

A short-term medical plan may be worth considering if you:

• Missed the Marketplace Open Enrollment Period.
• Are between jobs or waiting for employer coverage to begin.
• Recently lost other health insurance coverage due to non payment.
• Are healthy and primarily want protection against major medical expenses.
• Are looking for a lower monthly premium than many Marketplace plans.

Rather than remaining uninsured, many Michigan residents choose a short-term plan to help protect themselves financially until they become eligible for other health insurance options.

We’re Here to Help

At Health Insurance Experts, we’ll explain your options and help you determine whether a short-term medical plan makes sense for your situation.  Give us a call and we can provide quotes for you and/or your family ranging from just the basic emergency coverage to those options with a few more advantages.

Curious is you would qualify?  If you have to answer yes to any of the below, we would NOT be able to submit an application for short term coverage.

Are you 65 and 11 months or older?

Over 300 lbs (if male) or over 250 lbs (if female)?
Now pregnant, an expectant parent, in the process of adopting a child or undergoing infertility treatment?

For any of the following conditions within the last 5 years, have you or any person to be insured received any abnormal
test results or medical or surgical treatment, or consulted a health care professional, or taken medication for:
Any heart disorder?
Any emphysema or chronic obstructive pulmonary disease (COPD)?
Any Crohn’s disease, ulcerative colitis or hepatitis B, C, D or other?
Any AIDS or tested positive for HIV?
Any stroke?
Any diabetes, except gestational diabetes?
Any cancer or tumor (except basal cell skin cancer) which has been removed?
Any alcoholism, chemical dependency, drug or alcohol abuse?

A notable drawback: If any of the above conditions do occur while you are on coverage, you will not be able to apply for new coverage with another carrier once your plan expires. This is important for those who are looking to utilize a couple of different companies for coverage beyond 6 months in a year.

Coverage availability and plan benefits vary by state, carrier, eligibility, and underwriting. Short-term medical plans are not ACA Marketplace plans and do not provide all of the essential health benefits required under the Affordable Care Act.

The post Looking for Affordable Health Insurance? appeared first on Health Insurance Experts, LLC.

6 Ways to Lower Prescription Drug Costs in 2026

If your medications cost more than they did a few years ago, you are not alone. Rising prescription drug costs continue to affect millions of Americans, including people with Medicare, employer-sponsored insurance, Marketplace coverage, and comprehensive health plans.

The most successful strategy is often combining multiple approaches.

Consumers can potentially lower prescription costs by:

• Comparing pharmacy prices
• Using GoodRx discounts
• Reviewing TrumpRx and government program pricing
• Exploring manufacturer copay assistance
• Evaluating Canadian pharmacy options
• Reviewing Medicare prescription drug coverage annually

No single solution works for everyone. The best approach depends on your medications, insurance coverage, and overall healthcare needs.

1. Compare Pharmacy Prices Before Filling Your Prescription

Prescription prices can differ significantly between pharmacies, even for the same medication.

Comparing pharmacy prices is one of the easiest ways to save money on prescriptions. Many insurance companies have a preferred pharmacy that offers the best price when utilizing your coverage.  Checking multiple pharmacies may uncover lower pricing options that can reduce your out-of-pocket expenses.

2. Use GoodRx and Other Prescription Discount Programs

One of the most popular tools for prescription drug savings is GoodRx.

GoodRx allows consumers to:

• Search medications quickly
• Compare pharmacy prices
• Access discount coupons
• Use the service free, but obtain additional discounts through membership programs

Many consumers are surprised to learn that the GoodRx price may sometimes be lower than their insurance copay. This is why many healthcare professionals recommend comparing GoodRx vs insurance pricing before filling a prescription.

3. Check Cash Prices Through TrumpRx

TrumpRx provides consumers with another way to compare prescription drug prices and identify potential savings opportunities. The platform offers transparency into discounted pricing for both brand-name and generic medications. Consumers can compare cash prices against their insurance copays and determine which option provides the best value.

As prescription drug costs continue to rise, comparing insurance pricing against cash-pay programs has become an increasingly important strategy for reducing healthcare expenses.

4. Look for Manufacturer Copay Assistance Programs

Some drug manufacturers offer copay savings cards designed to reduce out-of-pocket costs for eligible patients. These programs are more common for newer brand-name medications that do not yet have generic alternatives.

Patients searching for ways to lower prescription costs should always check whether manufacturer assistance is available before paying full price.

5. Review Your Medicare Part D Coverage Every Year

One of the most effective ways to lower prescription drug costs for Medicare beneficiaries is to review Medicare prescription drug coverage annually.

Many people automatically renew their existing plan each year without realizing that formularies, premiums, deductibles, and pharmacy networks frequently change.

Finding the best Medicare Part D plan depends on your specific medications, preferred pharmacies, and healthcare needs. A plan that worked well last year may no longer provide the best value this year.

6. Consider Canadian Pharmacy Pricing

For many brand name medications, Canadian pharmacies may offer substantial savings compared to U.S. retail prices.

Consumers searching for prescription drug savings often compare Canadian pricing for maintenance medications that are taken long term.

We can help identify pricing differences and determine whether international pharmacy options may provide meaningful savings, which can be as high as 80-90% less than the U.S.

The Bottom Line

Healthcare and prescription costs change every year. Regularly reviewing your medications and available savings opportunities can help ensure you’re never paying more than necessary.

Need assistance reviewing your Medicare prescription drug coverage? A licensed health insurance professional can help analyze your medications, compare available plans, and identify opportunities to lower prescription costs both now and in the future.  Please give us a call, we would love to see if we can help!

The post Save Money on Prescriptions appeared first on Health Insurance Experts, LLC.

What Should You Do If Your Health Insurance Agent Disappears?

One of the most common complaints I hear from consumers is surprisingly simple:

“My agent won’t call me back.”

Maybe you’ve left multiple voicemails. Maybe you’ve sent emails and received no response. Perhaps you’ve been trying for two weeks or more to get an answer to a simple question.

It’s frustrating, especially when you’re dealing with something as important as your health insurance.

The good news is that if your agent disappears, your insurance coverage is still safe. Your policy belongs to you and is backed by the insurance company—not the agent. Your premiums, benefits, and coverage remain in force even if your agent stops returning calls.

Start by Contacting the Agency

If your agent works for an agency, call the main office and ask to speak with a manager.

Explain the situation and let them know you’ve been unable to get a response despite multiple attempts. Most reputable agencies want satisfied clients and will either address the issue or assign another representative to help.

Document Your Communication Attempts

Whenever I suspect someone is avoiding communication, I start documenting everything.

Keep a record of:

• Dates and times of phone calls
• Voicemail messages left
• Emails sent
• Text messages
• Responses received (if any)

Good documentation can be extremely valuable if questions arise later about what was communicated and when.

YOU CAN CHANGE AGENTS

If you’ve lost confidence in your current representative, you can request a new Agent of Record without affecting your coverage, premiums, or benefits. Your policy stays exactly the same.  Many people don’t realize that they are free to change agents.

If you’re considering a change, don’t feel like you’re stuck. A good agent should be willing to review your current coverage, answer your questions, and help you understand your options before asking for your business. The goal is to find someone you trust to be there when you need them.

A new agent can often take over servicing your account and help with:

• Coverage questions
• Claims assistance
• Enrollment issues
• Renewal reviews
• Medicare questions
• Marketplace plan changes

Why This Happens

Unfortunately, not every insurance professional focuses equally on service.

Some organizations place a heavy emphasis on new sales and less emphasis on ongoing client support. Others build their business around long-term relationships and helping clients long after the initial enrollment.

The difference becomes obvious when you need help.

A good agent doesn’t disappear after the application is submitted. They remain available to answer questions, help solve problems, and advocate for their clients when issues arise.

Marketplace and Medicare Members Have Options

If you have an Affordable Care Act Marketplace plan, you can update your information through HealthCare.gov and assign a new agent if needed.

If you have Medicare coverage, you can authorize a new broker to become your representative and help manage your plan going forward.

In both cases, changing agents does not affect your coverage.  The new agent you choose can also have you sign an AOR Form and submit it to the carrier on your behalf.

The Bottom Line

Health insurance can be confusing enough without having to chase down the person who is supposed to be helping you. Over the years, I’ve spoken with many people who reached out only after becoming frustrated with poor communication. In most cases, their biggest concern wasn’t finding a new plan—it was finding someone who would actually answer the phone, explain things clearly, and be available when questions came up. That’s a reasonable expectation, and it’s one every insurance professional should strive to meet.

The best insurance relationships don’t end after enrollment—they begin there.

If you’re currently dealing with an unresponsive agent and simply need answers, don’t hesitate to reach out to a trusted local professional for guidance. Even if you ultimately keep your current coverage, a knowledgeable and responsive advisor can help you understand your options and point you in the right direction.

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