"You’re in pretty good shape for the shape you are in."
- Dr. Seuss
Fall can be one of the most beautiful seasons, and one of the busiest. In addition to heading back to school and trick-or-treating, fall also brings the start of Open Enrollment in Medicare Plan D and Medicare Advantage Plans, and is a great time for those 65 and over to begin thinking about their health care coverage options for next year.
Some Key Points: Medicare is a program sponsored by the Federal Government that helps senior citizens and certain other individuals who qualify, to pay for health care. It’s divided into four parts: A, B, C, and D. Parts A and B are considered the “original” Medicare program, while parts C and D are supplemental. Part A covers some (or all) of hospital and skilled nursing needs, hospice care, blood transfusions, and inpatient psychiatric care. Part B covers doctors, outpatient mental health services, therapy, part-time skilled nursing home care, and other medical services.
Medicare Part C: Part C (originally referred to as “Medicare + Choice, and now called Medicare Advantage) is a health insurance option available to people who are already eligible for Part A and who are enrolled in Part B. It allows private health insurance companies to provide all the Part A and Part B Medicare benefits. The insurance companies can offer benefits that aren’t covered under the original Medicare (although they may charge a premium for extra coverage). Most Medicare Advantage Plans offer prescription drug coverage.
Be aware that choosing a Medicare Advantage plan also means tying yourself to a specific network of doctors and specialists. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, and Private Fee-for-Service Plans.
Medicare Part D: Medicare Part D is a supplement to original Medicare that offers prescription drug coverage through private insurance companies. Each Medicare Prescription Drug Plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost.
A drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.
A Medicare drug plan can make some changes to its formulary during the year within guidelines set by Medicare. If the change involves a drug you’re currently taking, your plan must do one of these:
- Provide written notice to you at least 60 days prior to the date the change becomes effective.
- At the time you request a refill, provide written notice of the change and a 60-day supply of the drug under the same plan rules as before the change.
Part D does not offer coverage for over-the-counter drugs, prescription vitamins and minerals, fertility drugs, anorexia or weight gain/loss drugs, hair growth or cosmetic drugs, drugs that treat symptoms for the common cold, drugs covered under Part A or B, and certain anti-anxiety and anti-seizure drugs.
Most Part D plans charge a monthly premium, with an average of $33.13 (average according to the Centers for Medicare and Medicaid Services). Many plans also require a person to meet an annual deductible of $360 for 2016.
Medicare Supplemental Insurance (Medigap): This is a policy, sold by private companies, can help pay some of the health care costs that Original Medicare doesn't cover, like copayments, coinsurance, and deductibles.
Some Medigap policies also offer coverage for services that Original Medicare doesn't cover, like medical care when you travel outside the U.S. If you have Original Medicare and you buy a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health care costs. Then, your Medigap policy pays its share.
A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.
Medigap policies can't work with Medicare Advantage Plans. Your Medigap policy can't be used to pay your Medicare Advantage Plan copayments, deductibles, and premiums. If you have a Medicare Advantage Plan, it's illegal for anyone to sell you a Medigap policy unless you're switching back to Original Medicare.
If you join a Medicare Advantage Plan for the first time, and you aren’t happy with the plan, you’ll have special rights to buy a Medigap policy if you return to Original Medicare within 12 months of joining.
The best time to buy a Medigap policy is during your 6-month Medigap open enrollment period, because you can buy any Medigap policy sold in your state, even if you have health problems. This period automatically starts the month you're 65 and enrolled in Medicare Part B. After this enrollment period, you may not be able to buy a Medigap policy. If you're able to buy one, it may cost more.
If you apply for Medigap coverage after your open enrollment period, there's no guarantee that an insurance company will sell you a Medigap policy if you don’t meet the medical underwriting requirements, unless you're eligible except under special situations.
How to Enroll: If you are already enrolled in Medicare and want to sign up for Part D or for a Medicare Advantage plan, you should do so between October 15 and December 7th each year (this is referred to as the annual enrollment period). This is also the time to enroll in a different plan, or make changes to your existing plan.
If you are new to Medicare, you have seven months total to decide to sign up for Part D or Medicare Advantage (three months before, three months after, and the month you become eligible for Medicare- this is referred to as the initial enrollment period). Most people qualify for free enrollment in Part A and the standard premium for Part B, and by signing up during the initial enrollment period, you can avoid late enrollment penalties and higher premiums.
If you miss both the initial enrollment period and the annual enrollment period, you can usually still sign up during the General Election Period, from January 1st to March 31st. If you sign up during this period, your benefits will begin July 1st, and you may have to pay a premium penalty for late enrollment. For Advantage Plans, if you are currently enrolled by January 1st, you may dis-enroll and return to original Medicare- as long as you do so before February 14th.
There are occasional exceptions to these enrollment periods, and you may qualify to sign up during the Special Enrollment Period--visit www.medicare.gov or talk to a financial professional if you think you may qualify for late enrollment.
We would be happy to assist you with enrollment or answer any questions you may have so please don’t hesitate to contact us.