Medicare - The Basics

Medicare – Some Important Considerations and Timelines

If you are about to turn 65, congratulations! In many cases, you will have more affordable plan choices with lower costs.

I encourage Medicare eligibles to consider Medicare Advantage plans, if they are not snowbirds or who are frequently out of the primary residential area.

The key to a successful plan match is how well your proposed plan will cover your prescriptions and which of your providers will be in network.

Prior to the introduction of Medicare Advantage plans (Medicare Plan C- circa 2003), the traditional pairing was Original Medicare, a Medicare Supplement plan and a stand alone drug plan (circa 2006).

The cost of the traditional pairing (MedSupp plus drug plan) can be hundreds of dollars more per month than a Medicare Advantage plan. Now that Medicare Advantage has been around for 20 years, the options and additional “perks” of the MA plans far exceed original Medicare.

For example, annual physicals, vision and dental are not part of Original Medicare. Medicare Advantage has a focus on preventive medicine and the product designs reflect this approach.

It is more standard than not to have a Medicare Advantage plan with a vision and dental allowance, free gym or fitness benefit, and some are beginning to offer hearing aids. Some carriers have introduced OTC benefits and Member Rewards (cash for certain health visits).

Although the “extras” are on the modest side, for seniors who may have lower incomes, there are potentially even more benefits.

The full Medicaid/Medicare beneficiary (dual eligible) and the QMB level (Qualified Medicare Beneficiary) through the Medicare Savings program can offer lower copays and cost shares.

To determine eligibility for these programs, in CT, the Department of Social Services has online applications.

Medicare Advantage – Limitations

Medicare Advantage does have some limitations. Since the focus is on preventive care and managing health delivery methods (urgent care vs emergency room, telemedicine vs in person visit), there may be some prior authorizations that are required. The “in network” providers have contracted rates, which is the cornerstone to the carrier managing healthcare costs.

The goal is to have the insured use good “health care consumer” judgement and not use the most expensive health care service when it is not warranted.

Prescriptions – Managing the Cost of Rx

Medicare prescriptions DO NOT count as part of the annual out of pocket maximum. For those on expensive medications, there may be options to manage the cost. A couple of examples are using www.goodrx.com or a similar online prescription discount program or contact the manufacturer for patient assistance programs. Using mailorder for routine maintenance medications can also save on the overall costs of health maintenance.

What is an HMO, PPO and does it matter?

For the average person, the network is not as critical as someone with complex healthcare needs who sees many specialists throughout the year.

An HMO (Health Maintenance Organization) may have a robust network with primary care and specialists and it may suffice. For someone who may need to see a specialist out of state, so a national or regional PPO (Preferred Provider Organization) might be more appropriate.

In any event, with a Medicare Advantage plan, you will be looking at some prior authorizations and more of a “hands on” approach to ensuring that the insureds are seeing their primary care provider annually as well as doing any age or gender recommended screenings (colonoscopy, mammogram, PSA test, etc.).

Think of your Medicare Advantage plan as your partner in your care. Understanding how the plan works and how you can best utilize the benefits can help with managing medical costs.

When can I enroll in a Medicare plan?

For the average person, who is not on an employer’s group plan, the important timeline to follow is the Part A and Part B enrollments. Having Part A and B are required for Medicare Supplement and Medicare Advantage enrollments.

If you are not collecting Social Security, your enrollment in Part A is not automatic. Part A is the hospital portion of the Medicare benefit. You can sign up for Part A and Part B, which is the doctor visit portion of the benefit, 3 months prior to your 65th birthday.

For people who have been on Social Security disability, the eligibility for Medicare is automatic after 24 months and one would have to “opt out” of the Medicare program.

The easiest way to enroll in Medicare is to go to www.ssa.gov and create an online account, if you don’t already have one. Make sure that your name is correct as well as your date of birth. Your Medicare application can hit a SNAFU if the records at Social Security are not accurate.

For anyone who is not US born, the process may be more complicated and an in person appointment at Social Security may help with the navigation. Start the application process early; it can take several months for more complex cases.

Social Security can verify Medicare eligibility based on work history and other factors and it is worth a phone call. You can do an internet search for a local Social Security office near you and call them to see if they can help over the phone.

Once you are on a Medicare plan, it is a good idea to see what’s new each year. Your plan will send an “ANOC” (annual notice of changes) to highlight what benefits are changing in the upcoming year. It’s possible the plan offerings can change, and you may have a new health condition or medication or maybe you just found out your provider is leaving the network. These and other factors can lead to shopping for a new plan.

Why “Do it Yourself” may not be the best option for choosing a Medicare Plan

Although www.medicare.gov and Medicare publications are useful, deciding on a plan without an experienced guide can lead to headaches down the road.

An insurance agent must have industry knowledge, comply with Medicare rules in addition to annual training with all the contracted carriers prior to being allowed to represent them. It’s beneficial to use an agent, which is at no cost to you, to help navigate plans and direct you to the most suitable options available.

Rather than listening to your friends, neighbors or family members, listen to your agent. An ideal plan for someone else may not be best for you. Also, your friend/neighbor/family does not know about all the plan options out there!

Read more at www.medicare.gov. You can download or order a Medicare and You Handbook, which is generated annually on the Medicare.gov website.

Alison L. Clarke, ALC Health Plans, All rights reserved c) 2023