Medicare's fall open enrollment, which runs Oct. 15 through Dec. 7, is an opportunity to review your benefits and make changes in time for 2019. But signing up or reviewing your coverage can seem daunting. We asked Inquirer readers what they'd like to know about Medicare, and brought an excellent list of questions to this panel of experts:
Darlene Sampson, director of Pennsylvania Department of Aging's APPRISE Program, which offers free health insurance counseling to seniors.
Mariel Lorenz, a line supervisor for the Center for Advocacy for the Rights & Interests of the Elderly (CARIE) in Philadelphia.
Diane Menio, executive director for CARIE, who also will be at the Inquirer's 55+Thrive event Saturday, Oct. 13, for a panel discussion on Medicare.
Frederic Riccardi, vice president of client services for the Medicare Rights Center, a consumer education and advocacy nonprofit in New York.
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 (within their provider networks), but may offer extras, such as dental, vision, or hearing services.
How do I know which 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. Say you spend winters in Florida. 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.
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), currently $134 a month, and a deductible. Traditional Medicare beneficiaries pay 20 percent 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. Medicare Advantage may charge additional premiums for its prescription drug coverage and extra services. Co-pays, co-insurance, and deductibles will vary for Medicare Advantage plans.
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 deductibles and co-pays. 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.
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.
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.
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 versus 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.
What happens if I don't sign up during my "new to Medicare" period?
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 percent of the premium for every 12 months you were unenrolled. Part D prescription coverage has a penalty of 1 percent 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.
Do I need to do anything during open enrollment if I already have Medicare?
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.) If you have traditional Medicare and are happy with your medical coverage, there's no need to change. But if you have Medicare Advantage or a stand-alone drug plan, it's important to review any updates coming in 2019. These plans commonly switch which medications are covered and may adjust rules about which drugs and services require prior authorization. Don't assume that because your plan currently covers the medication you need that that will be the case next year.
Where can I go for help?
First, don't be surprised if you need advice. The options can get complicated. 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 can also be a good source for help.
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.
Join Inquirer journalists and celebrity keynote speaker Genie Francis for a day of education, inspiration and resources for the 55+ community on Saturday, October 13, 11am, Downtown Philadelphia Marriott. Register: www.philly.com/55thrive
Do you have more general questions about Medicare? Email them to firstname.lastname@example.org.