WELCOME TO WEDGEFIELD - A Deed Restricted Community


1. Clarification on what credible coverage is for consumers turning 65 for the first time and still working and on employer group insurance. If the employer sponsored group insurance is equal to or greater than the benefits under original Medicare part a hospital and part b medical services, a consumer can avoid signing up for Part B without the late enrollment penalty which is 10% for each 12 months you were eligible for part b, had no credible coverage and the consumer did not enroll in Part B. This is a life time penalty.

2. If a consumer is still working full time over 65 and opts out of Part B, when that person retires and leaves the group insurance, you have 8 months to apply for Part B. After 8 months you have to use the general election period (GEP) to enroll in Part B. January 1 to march 31 are the GEP enrollment dates and the coverage for Medicare will be effective July 1.

3. This is a special election period (SEP) to enroll in a: MA, MA-PD or PDP plan. One has the month of July which is the effective date for original Medicare plus three months after July. The start date for a Medicare advantage plan or RX PDP or MED SUP is always the first of the month following enrollment.

4. When a person first obtains original Medicare part a and part B there is a penalty for not signing up for a RX PDP plan unless you are in a Medicare advantage plan with RX or are on group employer insurance that has credible RX coverage, or VA, or Tricare or some other similar RX credible coverage.

5. The penalty for not having RX PDP is 1% per month that applies when a consumer eventually signs up for a Medicare plan that has RX coverage. One year penalty is 12%, two years 24% and so on. The penalty is based on the national average for RX plans which is currently approximately $34/month. This penalty is added to the cost of your plan when you enroll for the rest of your life.

6. Open enrollment is around the corner:

  • a. October 1 to December 15 is open enrollment off marketplace. If the household AGI is over 400% (or under 100%) of the federal poverty level there is no advance premium tax credit or subsidy, so you enroll off marketplace and pay the full price for the policy.
  • b. October 15 to December is the annual election period (AEP) for consumers on Medicare who wish to make plan changes from one plan to another with the same insurance carrier or to enroll with a different carrier. If a person wants a Medicare supplement leaving a Medicare advantage plan this is the time to enroll in a stand-alone RX plan to go with the supplement.
  • c. November 1 to December 15 is the annual open enrollment on the marketplace. If you delay after December 15 you are out of open enrollment until next open enrollment starting November 1, 2018. It would be wise to check the rates and benefits as plans change in rates and benefits each year.
  • 7. Consumers who try to enroll themselves pay the same prices for the health insurance with Medicare or affordable care act (ACA) under age 65 plans regardless of whether an agent enrolls you or not. Agents are paid directly by the insurance companies so one does not pay more for the same plan with or without the assistance of an agent.

    8. The benefit of having a skilled agent assist in Medicare or ACA enrollment is to have the agent do a “needs analysis”. Some of the decisions include:

    1. Cost of plan
    2. Network of providers
    3. Cost of RX under the plan’s formulary, d. Need for coverage in your local service are or nationwide coverage.

    9. At this point in time there does not appear to be a “repeal and replace Obama Care” under way. 2018 enrollment looks to be similar to 2017 with changes in plan rates and benefits expected by the insurance carriers.

    Thomas Walyus is a local Wedgefield resident with over 20 years of health and life insurance experience. A complementary consultation on health or life insurance is available on request. 407-766-4780; twalyus @murrayins.net