Open Enrollment is still under way. An expert spells out the options
By Brian Krantz, Founder & CEO, Plan Medicare
There’s still time. This year’s Medicare Open Enrollment remains in force until December 7th. So if you’re currently on Medicare or are Medicare-eligible, here’s your chance before time runs out to enroll or make changes to your coverage, which means adding, dropping, or changing your Medicare plan. Even if you are happy with your current health and drug plan, Fall Open Enrollment is when you can review what you have, compare it with other options, and make sure that your current coverage is likely to meet your needs for the coming year.
Here’s what’s worth considering:
Are you happy with your current coverage? Once you enroll in a Medicare plan, you are unable to change it until Open Enrollment. So if you found yourself dissatisfied with your plan in any way, now is the time to explore alternative options.
How will your current insurance change next year, and will it still provide you with the most suitable coverage for your needs? Every year insurance companies reserve the right to change their plans. This could involve which doctors are in your network, the drugs that are covered in your drug plan, and the rates and costs of your policy. It is very important that you read all correspondence that comes from your current insurance carrier, so you understand all the changes that are going to be implemented for the following year. A trained expert can be of assistance here.
Are your costs going to increase? Monthly payments, copays, deductibles, and drug costs should all be considered.
Will your needs change? Do you anticipate having new health issues to deal with next year? While this is obviously hard to predict, if you expect you’ll have any procedures or know of any potential issues that could arise in the following year, it’s important to review all of the options available to you, so you can make the best decision.
Are your drugs still covered? Drug plans often change their formularies to include (or remove) medications. It’s very important to review your current list of medications with an expert to make sure that the drug plan you are currently enrolled in will continue providing you with the best coverage at the most affordable price.
Open Enrollment is the time you can change from Original Medicare to a Medicare Advantage Plan or enroll in a Medicare Supplement Plan. There are a few exceptions, but the majority of policyholders are only eligible to change plans during this short period. Understanding the key benefits and differences of both options is crucial in making the right decision.
Original Medicare Plans
Original Medicare, also known as fee-for-service Medicare, consists of two parts: Medicare Part A and Medicare Part B, both of which are offered by the government and overseen by the Centers for Medicare and Medicaid. Part A covers care from hospitals, skilled nursing facilities (but not custodial or long-term care), hospice care, and some home health care-related services. Medicare Part B covers doctors’ services, outpatient care, medical supplies, and preventive services.
Medicare Supplement Plans
Also known as a Medigap policies, Medicare supplement plans help pay for some out-of-pocket costs that Original Medicare does not cover. These include copayments, coinsurance, and deductibles. Such costs can be significant. Supplement plans are offered by private insurance companies and available to those who are eligible for Medicare. They augment Original Medicare. Medicare Advantage Plans, by contrast, operate on their own.
Here are the key features of Medicare supplement plans: Choice of doctors. You can select your preferred doctors and hospitals (so long as they accept Medicare patients). Access to specialists. You can see specialists without needing a referral. Guaranteed renewals. Medicare supplement plans are automatically renewed, so long as you continue to pay your premium on time, and you haven’t misstated any material facts when you first enrolled. Freedom. Your coverage travels with you anywhere in the U.S.A. Convenience. With a supplement plan, there are virtually no claim forms to file.
Medicare supplement plans do not include: Drug coverage. When you enroll in a Medicare supplement plan, you must also enroll in an accompanying Prescription Drug plan (the Part D Plan). There are no exceptions; even if you do not take any medications, you are required to participate in a Part D plan (or else you will be subject to penalties). Additional coverage. Supplement plans do not cover eventualities such as long-term care, dental coverage, cosmetic surgery, vision care, eyeglasses, hearing aids, or acupuncture.
Part D Plans
Medicare Part D is a drug program that helps pay for the costs of prescription drugs. It is offered by private insurance companies and approved by Medicare for eligible recipients. You are eligible for prescription drug coverage under Part D if you are signed up for benefits under Medicare Part A and/or Part B.
You can purchase drug coverage as a standalone Medicare Prescription Drug plan (also known as PDP). Most who do so typically combine it with a Medicare supplement plan, which does not include the drug coverage. The two are purchased separately. The costs for Part D coverage vary among private companies’ plans and the kinds of drugs that are offered—up to a certain limit.
Medicare Advantage Plans
There are Medicare-approved alternatives to Original Medicare, Supplement, and Part D Plans. They’re known as Medicare Advantage Plans. Private companies offer these plans, which may also provide vision, dental coverage, hearing benefits, health and wellness programs (such as gym membership), and some prescription drug coverage.
Advantage plans combine Parts A, B, and D into one plan with one Medicare ID Card.
Medicare pays a fixed amount for your Advantage care to the private insurance company providing your plan. The total resulting cost you pay for deductibles, premiums, and copays is often lower than the total cost for those same expenses under Original Medicare. But you are responsible for paying your regular monthly Part B premium, in addition to the Medicare Advantage (Part C) plan premium. (These amounts often are deducted from your Social Security payments.)
For those who are not burdened with chronic medical conditions, and who have an eye to saving on funds, Advantage plans can be a plus. That’s the upside.
The downside? Advantage plans offer a narrower range of providers than are available in Original Medical, they may require referrals from your primary care physician, and many also require prior authorization. While there are deductibles for hospitalization and outpatient care, and 80 percent of costs are thereafter covered, out-of-pocket expenses can be extensive.
For those facing a serious illness or those who use numerous services, or those, perhaps, who have had Covid-19 and are experiencing ongoing side effects, Original Medicare. combined with a supplement plan, is likely to be more beneficial. That’s because the annual premiums in supplement plans are typically less than the out-of-pocket limits of Advantage plans—should those limits be met.
There are several varieties of Advantage plans, most of which feature drug coverage. They include:
HMOs (Health Maintenance Organizations). Here, you’re required to choose a primary care provider and obtain referrals for seeing specialists. These plans typically have lower monthly premiums than PPOs, with which they’re frequently compared. They’re also likely to involve lower out-of-pocket expenses.
PPOs (Preferred Provider Organizations), by contrast, allow you to switch among primary care providers and do not require referrals to see specialists, whether they’re in or out of network. The downside? They may involve higher monthly premiums and higher out-of-pocket medical costs.
PFFSs (Private Fee-for-Service plans) allow you to see any provider that accepts its terms. Each PFFS sets an annual limit on out-of-pocket costs. These plans may not offer medication coverage, in which case you may enroll in a standalone Part D plan.
SNPs (Special Needs Plans) combine Parts A and B of Original Medicare with Part D prescription drug coverage. But only certain individuals qualify: those with chronic or disabling conditions, such as diabetes or end-stage renal disease; those who are eligible for both Medicare and Medicaid; and those living in institutions such as nursing homes or who require nursing care at home.
MSAs (Medicare Medical Savings Account plans) are run like non-Medicare health savings account plans. They involve a savings account from which you pay your medical costs—but only once you meet a high annual deductible. For an extra fee, they may include dental, vision, hearing, and long-term care not covered by Medicare. Anyone who is Medicare-eligible may enroll in an MSA.
There are numerous factors to consider during the Open Enrollment period. No matter which Medicare plan you are enrolled in, it’s wise—even at this late date—to take the time to review your current coverage and consider all of your options for next year to make certain you have the best health insurance coverage.
Plan Medicare was founded in 2009, with the goal of helping individuals navigate the confusing Medicare landscape. With plan options in dozens of states around the country, this is one of the leading insurance agencies for seniors turning 65 and older.
Operating out of offices in Manhattan and on Long Island, Plan Medicare specializes in advising individuals who are turning sixty-five, or are coming off their employer health plans, on their options for Medicare; this includes comparing and evaluating Medicare Supplement Plans, Medicare Advantage Plans, and Prescription Part D Plans.
Brian Krantz, Plan Medicare’s founder, is a leading Medicare insurance agent who is consistently ranked in the top three Medicare agents across the nation by the largest insurance carriers. With over a decade of experience, he and his staff of seven have helped thousands of New Yorkers find the best Medicare insurance policies that fit their needs and budget. These services are offered entirely free of charge to Plan Medicare clients. Brian prides himself on always doing right by his clients, and has grown his business in large part by word of mouth.
He lives with his wife and two children on the Upper East Side of Manhattan.
To contact Plan Medicare, log onto www.planmedicare.com, or call 516-900-7877 to request a free Medicare consultation.