Clients often ask us for help with Medicare planning. The rules can be confusing, and making assumptions can be costly. Cardan Capital Partners Co-Founding Partner Marti Awad recently teamed with Carol Janz Booth of Group Insurance Analysts Inc., to share some tips to help you make proactive choices when it comes to your Medicare coverage.
The annual window known as Medicare Open Enrollment is Oct. 15-Dec. 7 every year and should be on your radar. During this time, you can join, change or drop a Medicare Advantage Plan (Part C) or Prescription Drug Plan (Part D).
For those already enrolled, it is easy to go into auto-pilot mode and just renew your current plans because you made your decisions when you first signed up for Medicare. However, your circumstances and/or coverage may have changed, and so to maximize your Medicare healthcare dollars and care, it is imperative to assess if you should change a plan. Knowing when and how to do this will be less daunting with the following checklist of questions to ask and timeline to follow.
Care: Doctor and hospital choice
Do your providers accept the coverage? Do you want to keep your doctors?
Some doctors take Original Medicare but don’t participate in Medicare Advantage plans. Ask your doctors which coverages they participate in before making any changes.
Do you need to get referrals?
Certain Medicare Advantage plans, such as a Health Maintenance Organization (HMO) plan, may require a referral from your primary doctor before you can see a specialist. Take time to understand how referrals work if you wish to keep your specialists.
Do you have to choose your providers from a network?
HMO-type plans coordinate care and often require you to seek care from providers in your network. They also may require you to pick a primary care doctor. Other plan types, such as a Preferred Provider Organization (PPO) or a Point of Service (POS) plan, may allow more freedom to go out of network — but you may pay more for the covered services.
Do the doctors you desire accept new patients and Medicare assignment?
Simply stated, ask the providers if they accept new patients and accept Medicare assignment.
Most doctors, hospitals and providers accept Medicare assignment. That means they agree to accept the Medicare-approved amount as payment in full for services and/or equipment provided. If they do not accept Medicare assignment, you may be asked to pay for the entire bill at the time of service. You also may be charged up to 15% more than the Medicare-approved amount for nonparticipating providers. While the non-participating provider generally is required to submit a claim to Medicare on your behalf, in some cases, you may be required to submit your own reimbursement claim to Medicare using Form CMS-1490S.
The Physician Compare tool on Medicare.gov will help you search for providers that accept Medicare assignment in your area. State Health Insurance Assistance (SHIP) is another source to assist your search, and your licensed Medicare broker also could help with this task.
Do your plan/plans cover the services you need or the services that are important to you?
Each Medicare Advantage plan has a Summary of Benefits and Coverage that lists inpatient, outpatient, home health care coverage, preventive services, ambulance services, durable medical equipment, lab tests, imaging, prescription coverage (if Part D is included) and more. Plans have differing cost-sharing, so if specific services or items are important to your care, ask the plan provider for more information.
What about your other coverages, such as employer coverage, COBRA or retiree coverage?
If you are age 65 and have employer coverage, you can delay signing up for Medicare without penalty, provided you sign up within eight months after that employment or coverage ends. Neither COBRA nor retiree health insurance coverage offered through a former employer counts as “creditable coverage” according to Medicare rules. You have eight months to sign up after employment ends, or you risk penalties.
Does the Medicare Advantage plan have a good quality rating?
Medicare Advantage plans are rated on a scale of 1 to 5 with a 5-star rating being the highest. These ratings score performance and quality and are updated every fall. Visit Medicare.gov for more information about the criteria.
What does Original Medicare cover?
Original Medicare covers services and supplies in hospitals, doctors’ offices and other settings under Part A (Hospital Insurance) and/or Part B (Medical Insurance). For more information about Original Medicare, visit the U.S. government’s official Medicare website.
What happens if I already have coverage in Medicare Advantage Plan or the Part D drug plan?
- 1. You should receive an Annual Notice of Change and /or Evidence of Coverage from your plan in the fall, usually before or around Oct. 1. These notifications update any changes in the plan’s costs, benefits and/or rules for the upcoming year.
2. After reviewing your coverage for the next year, this is the time (Oct. 15 – Dec. 7 ) to make changes to another plan.
3. This is also the period to look at other options in your area that may better meet your needs with your health coverage or drug coverage. For example, drug formularies (lists) change year to year, so you may find one of your drugs is no longer on the formulary for the coming year. Another example would be an upcoming surgery that you know will satisfy your out-of-pocket maximum. You may change your plan to meet your anticipated costs for that upcoming year.
4. Your Medicare advisor may assist you with analyzing these annual notices of change, but it is imperative that you review your plans annually to avoid consequences, such as higher costs or no coverage for the upcoming year.
5. You may research plans using the Plan Finder tool on www.medicare.gov.
How much are your premiums, deductibles and other costs?
These costs are listed in the plan descriptions and Annual Notices of Coverage — and they change annually. Make sure to look at what may have increased or decreased in cost.
How much do you pay for services, hospital stays or doctor visits?
Same as above. Review each plan summary to see which co-payments (flat-dollar amounts ) and co-insurances (percentages ) may apply.
What is the yearly limit on what you pay out-of-pocket?
Medicare Advantage plans are required to set an out-of-pocket maximum. This is the total dollar amount you might pay for covered services during the plan calendar year. There is no out-of-pocket limit set on Original Medicare, which can place individuals in a dire financial situation if they only have Original Medicare — or, in other words, no cap on healthcare expenses.
What will my prescription drugs cost?
The drug plan negotiates each year with the pharmacies and manufacturers to establish co-pays and coinsurance rates and guidelines set by Medicare. The amount you pay for your drugs depends on the different coverage stages you go through based on the type of medications (generic, brand, specialty), and the number of medications you take on a daily basis. The coverage cycle starts over each year on Jan. 1. The drug costs are explained in the Summary of Benefits or Evidence of Coverage provided by your plan.
Does the plan I want fit my budget? If not, what are the alternatives?
There are tools on Medicare.gov to compare plans in your area. A Medicare broker is also a local agent to help search for a plan that fits your budgetary needs. Financial assistance is available for low-income households by calling Medicare and SHIP. (phone numbers are listed below under resources ).
Will the plan cover you in another state or outside the United States?
Original Medicare covers services from any approved provider, regardless of location. Medicare Advantage plans may charge more for out-of-network care or may not cover you at all outside your state of residence — so be thorough in your selection if you split your time between states or travel extensively.
Emergency care is covered globally. It is prudent to purchase an international policy for foreign travel.
What is a Medicare broker? How does a Medicare broker get paid?
Medicare insurance brokers assist clients with Fall Open Enrollment by analyzing their needs and current plans — Part D and Part C. These brokers make recommendations at no charge. They also provide year-round client service and back-end policy support — such as addressing billing errors or helping with appeals if a claim is denied — once coverage begins. Medicare insurance brokers are independent agents giving unbiased opinions and are appointed with different insurance companies.
Independent Medicare brokers are paid by the insurance companies, not by the clients. The monthly premium you pay for your policy includes a commission built in for your Medicare insurance broker. The price you pay for your insurance is exactly the same whether you buy it direct or through a Medicare insurance broker.
Am I familiar with the resources available to me?
There are a few to consider:
- Official U.S. government Medicare: Visit Medicare.gov, or call 1-800-MEDICARE (800-633-4227)
- Medicare & You (.pdf): This handbook can be accessed from Medicare.gov and is published annually by the Centers for Medicare and Medicaid Services.
- Social Security Administration: 800-772-1213 and www.ssa.gov
- State Health Insurance Assistance Program: The program’s website, shiptacenter.org, features state-specific information. Colorado residents can find more information from the Colorado Department of Regulatory Agencies’ website or call 1-866-696-7213.
What is the Medicare Plan Finder Tool?
Located on Medicare.gov, the Medicare Plan Finder lists the plans available in your area. It also details the premiums and personalized information about the out-of-pockets costs you will pay for your drugs.
In summary, your satisfaction with your Medicare plans depends on your yearly call-to-action to review your plans and on asking the right questions. Seek help from your Medicare insurance broker and available resources — and also pay attention to the dates and deadlines so you don’t miss out for the coming year.
Timeline and important dates
- September and October: Review and compare your plans
- Oct. 15: Medicare Open Enrollment begins
- Dec. 7: Enrollment ends
- Jan. 1: Coverage begins
- New Change: Jan. 1-March 31 Medicare Advantage Open Enrollment Period
Note: Be sure to understand the difference between Fall Open Enrollment with Medicare and open enrollment for federal marketplaces called “Exchanges.” The enrollment period of exchanges overlaps with Fall Medicare Open Enrollment but is not meant for people who are Medicare-eligible.
The content contained in this article is meant for educational purposes and is not an endorsement of Group Insurance Analysts Inc. Information presented is not meant to be a complete discussion of Medicare, and no plan-specific benefits are included. All expressions of opinion are as of its publishing date and are subject to change.