Medi­care Open En­roll­ment: What you need to know when it’s time to se­lect the plan for you

Record Observer - - Senior Satellite - By MIKE ZIMMER

Older or dis­abled Amer­i­cans with Medi­care cov­er­age have from Oct. 15 to Dec. 7 to de­cide on whether to switch from tra­di­tional Medi­care to a Medi­care Ad­van­tage Plan. This is also the time of the year when you should com­par­i­son shop your Medi­care Part D drug pre­scrip­tion plan.

If you are al­ready en­rolled in a Medi­care Ad­van­tage or drug plan, care­fully read the “An­nual No­tice of Change & Ev­i­dence of Cov­er­age” let­ter from your in­sur­ance com­pany. This let­ter is not an­other sales pitch that we all re­ceive most of the year in the mail. This let­ter is re­quired by CMS to no­tify you of the cost and ben­e­fit changes in your cur­rent plan for the up­com­ing year. If you ac­ci­den­tally threw yours away, call you in­sur­ance com­pany. When you re­ceive it, make sure you read the changes and ask ques­tions if you do not un­der­stand it. Which Road Do I Choose: Tra­di­tional Medi­care Or

Medi­care Ad­van­tage The open en­roll­ment pe­riod is your op­por­tu­nity to switch plans, in­clud­ing mov­ing be­tween the govern­ment-run tra­di­tional Medi­care pro­gram and a Medi­care Ad­van­tage Plan.

Medi­care Ad­van­tage plans, of­fered by pri­vate in­sur­ance com­pa­nies, re­ceive pay­ments from the fed­eral govern­ment to help cover the costs of ben­e­fi­cia­ries. They re­strict mem­bers to their net­work of doc­tors and hos­pi­tals and a list or for­mu­lary of cov­ered drugs. With some rare ex­cep­tions, you can­not leave the plan midyear, even if the plan drops drugs from the for­mu­lary or your hos­pi­tals, physi­cians, spe­cial­ists or med­i­cal equip­ment sup­pli­ers leave the plan.

But un­like tra­di­tional Medi­care, Medi­care Ad­van­tage plans often cover den­tal, hear­ing and vi­sion care. Some plans waive the three-day in­pa­tient hos­pi­tal stay be­fore go­ing into a skilled nurs­ing fa­cil­ity. But most im­por­tantly, they cap your outof-pocket ex­penses. Once you reach that limit, the in­surer pays for cov­ered ser­vices, and you pay noth­ing. But keep in mind, the de­tails of th­ese plans — such as the caps on mem­ber spend­ing, the pre­mium prices and ser­vice ar­eas — can change from year to year.

On the other hand, with tra­di­tional Medi­care, pa­tients can go to any provider who par­tic­i­pates in the pro­gram, and most providers do. Be­cause there is no limit on the share of med­i­cal ex­penses you pay, most folks pur­chase a Medi­care Sup­ple­ment (“Medi­gap”) Plan or have other in­sur­ance to lower those costs

Check Your Plan’s Net­work If you choose a Medi­care Ad­van­tage Plan, make sure you check with the Plan to ver­ify that your doc­tors, hos­pi­tal and other providers are in the Plan’s net­work. You may also con­tact your physi­cian’s di­rectly to see if they par­tic­i­pate with the Medi­care Ad­van­tage Plan. Con­firm Where Your Drugs Are

Avail­able When choos­ing a drug plan, also known as Medi­care Part D, the to­tal costs of the drug plan are most im­por­tant. Con­sider fac­tors be­yond the monthly premi­ums. You will pay dif­fer­ent amounts when the plan first be­gins each year, than when you are in the cov­er­age gap (called the dough­nut hole) and af­ter you reach the cat­a­strophic stage.

Find out whether the low­est price is avail­able at your fa­vorite phar­macy or if you must travel else­where to get that price. Most plans of­fer their low­est prices only at their pre­ferred, in-net­work phar­ma­cies.

Also, ask what other re­stric­tions ap­ply. For ex­am­ple, do you need prior au­tho­riza­tion or have to try an­other drug first be­fore you can get the one your doc­tor pre­scribed? Also, will the price var y de­pend­ing on the fre­quency or the quan­tity of your pre­scrip­tion?

You can also save thou­sands of dol­lars just by switch­ing phar­ma­cies. That’s be­cause drug plan prices can de­pend on whether a drug­store is a pre­ferred phar­macy within the plan’s net­work.

Do You Qual­ify For A Sub­sidy? Folks with a lower-in­come may qual­ify for the “ex­tra help” sub­sidy that pays for the premi­ums of cer­tain drug plans and other costs. They may also be el­i­gi­ble for as­sis­tance to re­duce their share of med­i­cal costs in tra­di­tional Medi­care.

Premi­ums and sub­sidy amounts can change each year, so if you al­ready have the sub­sidy con­firm that it is enough to cover the plan’s pre­mium next year. Oth­er­wise, you can be billed for the dif­fer­ence.

Watch The Calendar There’s a lot to con­sider and only seven weeks to do it. And re­mem­ber, the An­nual Open En­roll­ment Pe­riod is from Oct. 15 through Dec. 7.

Mike Zimmer is pres­i­dent of Bay State In­sur­ance Agency Ltd. in Centreville. He is avail­able to an­swer your ques­tions or speak to your groups re­gard­ing Medi­care, Medi­care Ad­van­tage, Medi­care Sup­ple­ments and Medi­care Part D (Pre­scrip­tion Plans). He may be reached at 410-758-1680.


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