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Medicare open enrollment has started. Here’s what you need to know.

I like my plan and in 2018 it covered the medications I needed – do I need to do anything during fall enrollment period?


Medicare's fall enrollment period, which runs through Dec. 7, is in full swing. The advertisements, with their big promises and baffling insurance jargon, can make your head spin, but it's important to take the time to review your coverage. We asked Inquirer readers to share their Medicare questions and brought the list to this panel of experts:

  1. Darlene Sampson, director of Pennsylvania Department of Aging's APPRISE Program, which offers free health insurance counseling to seniors.

  2. Mary McGeary, director of New Jersey Department of Human Services' SHIP, which offers free health insurance counseling to seniors.

  3. Lina Walker, vice president of health security, AARP Public Policy Institute.

  4. James Long, broker-manager, Young's Insurance Services Inc.

  5. Nan Rosner, independent broker, Rosner Insurance.

Our first installment addressed the difference between original Medicare and Medicare Advantage, what to consider when choosing a plan, doctor networks, prescription medications, and more. Read it at

I like my plan and in 2018 it covered the medications I needed – do I need to do anything during fall enrollment period?

People with original Medicare will likely buy a standalone Part D prescription plan, while Medicare Advantage plans (Medicare benefits administered by a private insurer) typically include prescription drug coverage. The 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. All of these possibilities need to be examined as you review potential plans.

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.

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 will be $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, co-pays, and co-insurance. 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,, can help you compare options. 

What's the difference between a premium, a deductible, a co-pay, and co-insurance?

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 co-insurance. Original Medicare has a $185 deductible for Part B and 20 percent co-insurance 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 percent of the Medicare rate. For Medicare Advantage, cost sharing varies from one plan to the next. A co-pay 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.

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, co-insurance, and co-pays for individuals with monthly income of no more than $1,032 and assets of no more than $7,560. 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 who qualify for the QMB, SLMB or QI programs are also eligible for an assistance program for medication expenses.

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.

To find out whether you're eligible for assistance, contact your state's Medicare counseling program: New Jersey SHIP at 1-800-792-8820 or Pennsylvania APPRISE at 1-800-783-7067.

I am turning 65 soon but plan to work until I'm 70 and want to keep my employer-sponsored health plan. Will I face a penalty if I don't sign up for Medicare right away?

This is an important issue because if you are required to sign up for Medicare in the initial seven-month enrollment period surrounding your 65th birthday but fail to do so, you will have to pay a monthly penalty for as long as Medicare covers you. People who have health insurance through a company 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.

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. Watch for more on this topic in the coming weeks.

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 co-pays 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.

I have an individual health plan through the Affordable Care Act marketplace. What do I need to know about transitioning to Medicare?

People with Obamacare 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 will be $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 an Obamacare 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.