People with Medicare, it’s time to mark your calendars! Open Enrollment Period runs from Oct. 15 to Dec. 7.
Open enrollment is but one of the terms you will encounter when trying to decipher the maze known as Medicare. Let’s not forget initial enrollment period; general enrollment period; original Medicare; Medicare Advantage; supplemental insurance; prescription drug coverage; and late enrollment penalties.
So, yes, if you think it’s a complicated issue, you’re right — and you’re not alone!
Even the experts agree that signing up can be a daunting experience.
“It is complicated and intimidating,” suggests Barry Klitsberg, president of Queens Interagency Council on Aging and a longtime employee of the U.S. Department of Health and Human Services. “People don’t know where to start.”
A good place might be to get an understanding of what Medicare is and what it provides.
Medicare is a federal health insurance program run by the Centers for Medicare & Medicaid Services. It provides healthcare insurance for Americans aged 65 and up who have worked and paid into the system through payroll tax and for certain younger people with disabilities.
Among the items Medicare does not cover are long-term (or custodial) care, most dental care, eye exams related to prescribing glasses, dentures, cosmetic surgery, acupuncture, hearing aids and routine foot care. Still, Medicare has much to offer.
Depending on the situation, some people may get Medicare automatically and others need to apply. Individuals collecting Social Security or Railroad Retirement benefits before they turn 65 will be automatically enrolled into Medicare when they turn 65. Individuals who are eligible for Medicare but who are not yet collecting Social Security of Railroad Retirement benefits will have to actively enroll into Medicare by contacting the Social Security Administration.
It is important to note that, while Social Security works with the CMS by enrolling people in Medicare, they are not the same.
An individual is entitled to apply for Social Security benefits beginning at age 62. Eligibility for Medicare comes approximately three years later during the initial enrollment period, with eligibility beginning three months prior to one’s 65th birthday, extending through one’s birth month and continuing for the next three months, giving new enrollees a seven-month window.
There are two choices for how to obtain Medicare coverage, original Medicare and Medicare Advantage.
Original Medicare includes Part A (hospital insurance), which covers hospital inpatient care, skilled nursing facility care, home health and hospice care; and Part B (medical insurance), which covers doctors’ services, outpatient care, durable medical equipment (like wheelchairs) and preventive services (like screenings, shots and yearly wellness visits). To this you may add Part D (prescription insurance) as well as supplemental insurance.
Medicare Advantage, also known as Part C, includes Part A, Part B and usually prescription drug coverage as well. Additional benefits may be included such as dental, eye care and hearing care.
According to the CMS, you usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working for a certain period of time. For Part B, most individuals pay a monthly premium; the amount can vary depending on income. The premium is generally deducted directly from a person’s Social Security.
The CMS indicates that if you have original Medicare, you may see any doctor who is enrolled in Medicare and accepting new patients. Referrals are not needed. You generally pay a portion of the cost for each covered service. You can join Part D and you may buy supplemental insurance to pay costs that original Medicare doesn’t cover.
If you don’t have prescription drug coverage, or the coverage you have isn’t at least as good as Medicare, you should consider enrolling in Part D. If you need prescription drug coverage, you have to sign up for it.
Medicare.gov, the official federal government website, indicates two ways to get prescription drug coverage: Medicare Part D or a Medicare Advantage Plan (see below) that offers drug coverage. Costs will vary, depending on the drugs you use, the plan you choose and other factors.
Note that there are different types of Part D plans, and each one may cover different prescriptions. Each drug plan has its own list of covered drugs (called a formulary). Many plans place drugs into different “tiers” on their formularies, with drugs in each tier having a different cost. It is important to find out which plans cover the drugs you need.
Something else to look out for is what is known as the coverage gap, or donut hole, a temporary limit on what a plan will cover. This gap begins after you have spent a certain amount for covered drugs. The amount may change each year.
Klitsberg indicated that the donut hole has been shrinking and, in 2019, the gap will be disappearing for brand-name drugs. He suggested that in 2020, it will do likewise for generic drugs.
According to the CMS, you have up to three months after your Medicare coverage starts to join a Part D plan. It warns that “if you don’t join a Medicare drug plan when you’re first eligible for Medicare, you may have to pay a monthly Part D late enrollment penalty if you join a plan later.” The penalty goes higher the longer you wait to enroll.
The CMS also warns that there are risks for not signing up for Part B: You may pay all of the costs for doctors’ services, outpatient care, medical supplies and preventive services; you will have to wait until the general enrollment period (Jan. 1 to March 31 each year) to sign up if you decide you want Part B later; and you may have to pay a late enrollment penalty for as long as you have Part B. The penalty amount increases the longer you go without Part B coverage.
Whether it’s best for you to sign up for Part B depends on your individual situation, such as your employment status, among other considerations.
Do you need a supplemental insurance (or Medigap) policy? Original Medicare pays for much, but not all, of the cost for healthcare services and supplies. Some people opt for additional coverage from a private company to fill in the gaps in Parts A and B. You need both Part A and Part B to buy a Medigap policy, which can cover costs like coinsurance, copayments and deductibles. According to Elder Law Review, a publication of Ronald Fatoullah & Associates, “Under Original Medicare, there is no limit on how much you pay out of pocket per year unless you have supplemental insurance.”
Medicare Advantage Plans (Part C) are offered by private companies approved by Medicare. You must have both Medicare Part A and Part B to join. The CMS suggests that “it may be more cost effective for you to join a Medicare Advantage Plan because your cost sharing is lower or included.”
Signing up for Part C places an individual in a health maintenance organization. Members must generally get a referral from their primary care physician in order to see a specialist or other doctors. You may pay lower costs for covered services as long as you see doctors or go to hospitals that belong to the plan’s network.
You can join a Medicare Advantage plan when you first become eligible for Medicare (the seven-month window). These plans include Part A, Part B and usually Part D coverage. Some offer extra benefits like vision, hearing or dental.
You usually have to pay a monthly premium, in addition to your Part B premium, and a copayment or coinsurance amount for covered services.
Premium deductibles and copayments can vary significantly from plan to plan, so it is important to compare costs and coverage each year.
Medicare Advantage insurers negotiate with healthcare providers to find the lowest cost providers each year. In recent years, these provider networks have become smaller, with fewer specialists, according to reports. In addition, providers can join or leave a network at any time.
The right coverage can make all the difference. It is important, therefore, to be aware of any changes in coverage.
“In October, you should start comparing your current coverage with other options to see if you can save some money and to ascertain whether your provider(s) are still covered under your plan’s network,” Fatoullah’s publication advises. You can change your health or prescription drug coverage between Oct. 15 and Dec. 7 each year, the open enrollment period, or annual election period or annual coordinated enrollment period.
Klitsberg suggests it is vital for anyone enrolled in a Medicare plan to “read your mail.” Every year, you will be receiving information on any changes in costs and coverage. And, he points out, during the open enrollment period “you have a lot of choices.”
There is a lot to consider when choosing Medicare coverage. For further information, visit Medicare.gov, where the government’s official guide to the program, “Medicare & You,” runs more than 100 pages, or call 311 and ask for “HIICAP,” the Health Insurance Information Counseling and Assistance Program.
Original Date: Oct 42018