By Sarah Gantz, The Philadelphia Inquirer Posted
Oct 9, 2019 at 10:12 PM
Medicare’s
fall open enrollment, which runs from Oct. 15 through Dec. 7, is an opportunity
to review your benefits and make changes in time for 2020.
But
signing up or reviewing your coverage can seem daunting.
Here’s
what you should know:
Q:
What’s the difference between traditional Medicare and Medicare Advantage?
Traditional
Medicare is managed by the federal government and offers coverage for hospital
services (Part A) and outpatient services, such as primary care doctors,
specialists and routine care (Part B). Medicare Advantage plans are run by
private insurance companies approved by the federal government. These
managed-care plans must cover all the same benefits as traditional Medicare
(though you’ll be limited to their provider networks), but may offer extras,
such as dental, vision, or hearing services.
Q: I
like my plan and in 2019, it covered the medications I needed — do I need to do
anything during the fall enrollment period?
Open
enrollment is a time when any current or new Medicare beneficiary can sign up
for a plan or switch plans. You can switch from traditional Medicare to
Medicare Advantage or vice versa, change your prescription drug plan, or pick a
different Medicare Advantage plan. (A supplement plan that begins after age 65
might be more expensive, however, because of underwriting practices.) People with
Original Medicare may buy a standalone Part D prescription plan, while Medicare
Advantage plans typically include prescription drug coverage.
We
heard a lot about prescription drug costs in the news this year, with President
Donald Trump’s call to require drug companies to include prices in their
television ads and several proposals in Congress to address rising prices. But
little has actually changed about how drugs are covered under Medicare.
But
each plan’s drug formulary, the list of covered medications, varies by plan and
will change every year, so it is important to make sure the plan you have is
still the best fit. Formularies rank medications into tiers, with lower-tier
drugs the preferred and least-expensive options. Higher-tier versions of the same
medication will cost more. Health plans frequently switch their preferred
choices and may even drop medications from the formulary. Even if your drugs
are still on the formulary, the plan may have changed how they’re covered. They
might limit the amount you can order or require prior authorization before
filling the prescription — which is not guaranteed to be granted.
Q: How
do I know which plan is right for me?
Which
plan you choose depends on your needs and your financial position.
Traditional
Medicare is accepted by most doctors, which could be important if you need care
while traveling out of state. Similar to many employer-based insurance plans,
Medicare Advantage plans have provider networks. If you go to an out-of-network
doctor or hospital, the visit may not be covered or may cost more. Medicare
Advantage may also include prescription drug coverage, whereas traditional
Medicare does not. People who do not have other prescription coverage will need
to buy a separate drug plan (Part D).
Use
Medicare’s online Plan Finder tool or talk to a volunteer counselor to decide
which plan best meets your needs.
Q: If
cost is my biggest concern, should I choose Medicare Advantage or traditional
Medicare?
There’s
no clear-cut answer. Your total out-of-pocket expense will depend on how the
plan you choose covers the services you use most. Both types of plans have a
premium for Part B (doctor’s services), $135.50 a month for most people in
2019, and a deductible. Traditional Medicare beneficiaries pay 20% of the Medicare-approved
rate for most doctor services after meeting their deductible. Supplemental
plans can help cover some of these extra expenses for traditional Medicare
members, though people who turn 65 after Jan. 1 will no longer be able to buy
supplemental plans with so-called “first-dollar coverage” that covers the Part
B deductible, which is $185 in 2019. Medicare Advantage may charge additional
premiums for its prescription drug coverage and extra services. Copays,
coinsurance, and deductibles will vary for Medicare Advantage plans.
Q:
What’s the difference between a premium, a deductible, a copay, and
coinsurance?
The
annual premium is the number that most often catches people’s attention, as
this is the price of the policy, paid monthly. A deductible is the amount
members must spend out of pocket before the plan begins paying a larger share
of your medical expenses. You will still be responsible for part of the bill
even after meeting your deductible — this is called coinsurance. Original
Medicare has a $185 deductible for Part B and 20% coinsurance after the
deductible is met. So you will be billed for the first $185 in medical
services, and after that, you will be responsible for 20% of the Medicare rate.
For Medicare Advantage, cost-sharing varies from one plan to the next. A copay
is a fee your plan may require you to pay when going to a doctor or picking up
a prescription. It is important to consider all of these potential sources of
out-of-pocket expenses — not just the premium — when deciding which plan is
right for you.
Q: How
do I choose supplemental coverage?
Supplemental
coverage is for people with traditional Medicare; it cannot be used to cover
out-of-pocket expenses associated with Medicare Advantage plans. Supplemental
coverage is known as Medigap plans because they cover “gaps” in traditional
Medicare plans, such as health expenses while traveling abroad, excess
medication charges, or copays. They are sold by private insurance companies and
are categorized by a letter system; plans with the same letter offer the same
coverage. Choose the one that fills the gaps you are most concerned about. And
be aware that prices can vary widely between companies, even for the same
coverage, according to the Centers for Medicare and Medicaid.
Q: Does
Medicare restrict which doctors I can see? Can I change doctors?
Most
doctors accept traditional Medicare, but always ask before making an
appointment. Medicare Advantage has in-network doctors, so call your doctor’s
office to see which plans they accept and double-check with your plan. You can
switch doctors at any time, but to avoid unexpected bills, make sure your new doctor
is covered by your plan.
Q: How
do I figure out which prescription plan will be the lowest cost to me?
Look
beyond the premium. Check that your medications are included in the plan’s
formulary — the list of medications covered, which will vary by plan, can
change annually, so it is wise to check every year. Formularies rank drugs into
tiers, with lower-tier medications the preferred and least-expensive options.
Higher-tier versions of the same medication will cost more and may be available
only after you’ve tried a lower-tier option. Also look at cost-sharing — how
much you will pay vs. how much the plan will pay — and whether you will be
required to fill prescriptions at certain preferred pharmacies. Medicare’s Plan
Finder allows you to search based on the medications you want covered.
Q:
Where can I go for help?
First,
don’t be surprised if you need advice. The options can get complicated and
scams abound during enrollment season. Pennsylvania and New Jersey both provide
free counseling. These programs do not offer legal advice, endorse plans or
sell insurance, which makes them an impartial resource. Pennsylvania’s APPRISE
program has a phone helpline and locations across the state, where people can
go for one-on-one assistance. Learn more online at aging.pa.gov or call
1-800-783-7067. New Jersey’s State Health Insurance Assistance Program
similarly staffs offices with volunteer counselors in addition to its helpline.
Find locations online at state.nj.us/humanservices or call 1-800-792-8820.
Nonprofit
organizations such as CARIE also provide assistance. Independent brokers —
those who are not bound to sell just one insurer’s products — can also be a
good source for help.
Q: How
do I find a reputable independent broker? How do I know their fees aren’t adding
to my premium cost?
Independent
brokers must be licensed by the state and could lose their licenses if they
don’t follow strict rules about selling private Medicare plans (Medigap, drug,
and Advantage plans). Brokers typically get an initial payment in the first
year of the policy they sell and half that fee in the following years the
individual remains in the plan. These fees are paid by the insurer, not the
consumer, and must be reported to federal regulators and are available online.
Q: Are
there any programs to help people pay for Medicare?
Yes,
people who meet income and asset qualifications may be eligible for one of
several financial assistance programs. The Qualified Medicare Beneficiary
program offers the highest level of assistance, helping pay for Part A and B
premiums, deductibles, coinsurance, and copays for individuals with a monthly
income of no more than $1,061 and assets of no more than $7,730 in 2019. Income
and assets requirements may vary by state and are higher for couples. The
Specified Low-Income Medicare Beneficiary program is available to people who
earn too much to be eligible for the QMB program and helps pay Part B premiums.
The Qualifying Individual program, which helps cover Part B premiums, has an
even higher income threshold and is available on a first-come, first-served
basis.
People
younger than 65 with a disability who are currently working may be eligible for
the Qualified Disabled and Working Individuals program, which helps cover Part
A premiums. Medicare beneficiaries in New Jersey may also be eligible for a state-run
assistance program that helps pay for prescription drugs for seniors and people
with disabilities.
The
National Council on Aging has developed a website, called BenefitsCheckup, to
help people find benefit programs and determine their eligibility.
Q: I’ve
seen advertisements for zero-dollar-premium Medicare Advantage plans. Are they
really free?
Everyone
pays a monthly premium for Part B, regardless of whether you have Original
Medicare or Medicare Advantage. The premium in 2019 is $135.50 a month for most
people. Medicare Advantage plans often include extra services, such as
prescription drugs, vision, or dental — for an extra charge. When a plan
advertises a “zero dollar premium,” it is referring to these additional
plan-specific benefits — you will still pay the Part B premium. It’s important
to keep in mind that premiums are only one source of out-of-pocket costs. Plans
with low premiums may have high deductibles, copays, and coinsurance. You
should also consider how much your medications will cost under the plan and
whether the doctors you see will be in-network, as these factors will also
affect how much you spend on health care in a year. Medicare’s online plan
finder, www.medicare.gov/find-a-plan, can help you
compare options.
Q: How
do I sign up for Silver Sneakers?
Silver
Sneakers is a fitness program offered by some Medicare Advantage plans that
gives members access to free gym memberships, fitness classes, and health
education resources. It is not part of Original Medicare. Plans that don’t
offer Silver Sneakers may have a similar fitness program — ask your plan
administrator. While the program can be a valuable benefit, also consider
whether the plan will meet your health care needs, how it covers the
medications you take, and whether you can continue seeing the same doctors.
And, as with any fitness membership, make sure that the facility fits your
physical needs, schedule, and location so you will use it enough to make it
worthwhile.
Q: What
happens if I don’t sign up during my ‘new to Medicare’ period? What if I plan
on working past 65 and want to keep my employer-sponsored health plan?
People
become age-eligible for Medicare at 65 and have a seven-month period to sign up
— their birth month plus three months before and after. Sign up early if you
want coverage to start when you turn 65. Missing this enrollment period could
lead to penalties that remain with you for the duration of your Medicare
coverage. The penalty for signing up late to Plan B is 10% of the premium for
every 12 months you were not enrolled. Part D prescription coverage has a
penalty of 1% of the premium for every month missed. If you miss your “new to
Medicare” enrollment period, you will most likely have to wait until the annual
open enrollment, which could leave you temporarily uninsured.
People
who have health insurance through an employer with more than 20 people on its
health plan and are actively working can keep their plan and delay signing up
for Part B until they retire without penalty. If you have coverage through a
company with fewer than 20 people, you’ll have to move to Medicare when you
become eligible. If you’re in any doubt, talk to your human resources
department. If you keep your employer-sponsored health plan beyond age 65, when
you do decide to retire, your employer will need to fill out a form verifying
you have had continuous coverage.
Q: How
do I decide if I should stick with my employer-sponsored health plan or
transition to Medicare?
If you
have the option of one or the other, you’ll need to crunch the numbers, as it’s
an individual decision. Consider the premium, deductible, and other
cost-sharing expenses of each plan, how prescriptions will be covered by each,
and how the doctor networks compare. If you are covered under a spouse’s plan,
look at how the employer handles dependent coverage. Often companies pay for a
large share of the employee’s health insurance, but require employees to pay
the full cost or at least a larger share of the cost of insuring spouses and
children. In this case, it may be more cost-effective for an over-65 spouse to
move to Medicare.
Q: I
have Medicare, but my wife has an employer-sponsored health plan with a health
savings account. Can we use the HSA to pay for my out-of-pocket medical
expenses?
Yes —
with limits. An employee’s HSA can be used to pay eligible medical bills for a
spouse who is covered by Medicare. Eligible medical expenses include copays for
prescriptions and services applied to your plan’s deductible, as well as Part A
and Part B premiums. An HSA cannot be used to pay for supplemental policy
premiums. Once you sign up for Medicare, however, you will no longer be allowed
to contribute pre-tax funds to an HSA.
Q: I
have an individual health plan through the Affordable Care Act marketplace.
What do I need to know about transitioning to Medicare?
People
with ACA marketplace health plans almost always transition to Medicare when
they turn 65. You may be able to keep your individual health plan, but you
won’t be eligible for a tax subsidy after age 65 and could face penalties if
you don’t sign up right away, so most people find it is better to switch to
Medicare than hold on to their ACA plan. The cost and coverage could be very
different from what you’re used to in an individual plan. The premium for
Medicare Part B is $135.50 in 2019, which may be a lot less than what many
people in their 60s pay for individual coverage. But people who have been
receiving an income-based tax subsidy to offset the cost of a marketplace
health plan may find that their Medicare costs are greater, though Medicare
also offers income-based financial assistance. Consider meeting with an
enrollment adviser to talk about plan options or visit the National Council on
Aging’s BenefitCheckup website to find out if you’re eligible for financial
assistance.
Q: How
do Medicare entitlements, such as those for individuals with a disability or
end-stage renal disease, coordinate benefits for individuals who also have
private health insurance?
People
who are under 65 may qualify for Medicare on top of their private health
insurance because of a disability or select medical condition. The private
health plan is considered primary insurance and billed first. Providers can
bill Medicare second to cover any remaining costs. Give both insurance cards
when you go to an appointment.
Experts
consulted for this report include:
—
Darlene Sampson, former director of the Pennsylvania Department of Aging’s
APPRISE Program, which offers free health insurance counseling to seniors.
— Diane
Menio, executive director of the Center for Advocacy for the Rights and
Interests of the Elderly (CARIE), a senior advocacy organization in
Philadelphia.
—
Frederic Riccardi, president of the Medicare Rights Center, a consumer
education and advocacy nonprofit in New York City.
— James
Long, broker-manager at Young’s Insurance Services Inc.
— Mary
McGeary, director of the New Jersey Department of Human Services’ SHIP, which
offers free health insurance counseling to seniors.
— Lina
Walker, vice president of health security at AARP Public Policy Institute.
— David
A. Lipschutz, associate director and senior policy attorney for the Center for
Medicare Advocacy, which provides education and legal assistance to seniors.
Distributed
by Tribune Content Agency
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