This is confusing for most people. I’m here to try to help you make sense of it and ensure you have the best coverage for your situation.

This is a brief summary. You can obtain more detailed information from the Medicare.gov website or by calling me.

Why this is confusing:

• Medicare has four components:
  • Part A: Major medical/hospitalization
  • Part B: Office visits and outpatient services
  • Part C: Medicare Advantage plans, in which benefits are provided on behalf of Medicare by a private insurer.
  • Part D: Drug plans, which may be included in Part C.
• Medicare supplements (aka “Medigap” plans): Identified by letters A-N, the features of each plan are standardized by the government. However, the pricing isn’t.
• Medicare Part D prescription plans: Drug costs aren’t covered under Original Medicare and require a separate plan.
• Medicare Advantage plans (aka Medicare Part C):
  • These plans offer comprehensive benefits.
  • These plans may cost less than Supplement plans; some have zero monthly premiums.
  • Most of these plans include Part D (drug) coverage.
  • The plans provide a maximum cap on out-of-pocket expenses each year, which Original Medicare does not.
  • Plans may be HMO or PPO. Other options are available in specific states, and program names may vary by state.
  • Plan availability varies by county in each state.

   

Special topics:

• Late enrollment penalties: In most cases, consumers are required to sign up and pay a premium for Medicare Part B (office visits and outpatient services) on turning age 65.
  • The requirement is waived if the consumer has creditable health insurance coverage through work.
  • Persons who are disabled or have end state renal disease can start on Medicare before turning 65.
• Enrollment periods:
  • Initial Enrollment period: This is a 7 month period starting 3 months before your 65th birthday. You need to contact Medicare and set up your account. You cannot enroll in any Medicare plan before your Medicare number is issued. Medicare Advantage plans require enrollment in Medicare Part B.
  • Annual Election Period: This is a window in which you can select your Medicare Advantage plan for the next year. It runs between October 15th and December 7th, with the selection in effect on January 1st.
    • There is a “buyers remorse” period in January and February in which you can drop the Advantage plan and return to Medicare in January and February at the start of the plan year.
  • Special Election Periods: There are a variety of these based on moving, loss of insurance coverage through work, marriage, gaining or losing Medicaid coverage, and incurring specific chronic or critical illness or disabilities.
• Formularies: This is essential to choosing the correct Medicare coverage.
  • A formulary is a list of drugs that a plan covers, and their assignment into one of 4-5 tiers based on brand v. generic and cost. Tier 1 provides the lowest costs to you; Tier 5 is the highest.
  • What you need to know:
    • Tiers are not standardized. They will vary between insurers and will as between plans offered by the same insurer.
    • Both whether a drug is covered and the placement of a drug in a tier will vary, and the costs impact to you can be substantial.
      • In my case, a drug I use for allergy-induced asthma cost $43/month under one plan and $400/month under another. No kidding.
  • Drug costs can also be impacted by what pharmacy you use. Most insurers have “preferred pharmacies” which offer lower costs.
  • Plan calculators provide estimates of total annual costs based on plan premiums and the drugs you currently take.
• Physician participation
  • You or I can determine whether a physician participates in a specific insurance plan by referring to online directories provided by each insurer.
• What Medicare doesn’t do:
  • Long term care: Medicare covers some in-home care as well as hospice care, but only 1 month of nursing home care. According to the CDC, the average American requires 3.6 months of nursing home care, and the cost of what’s not covered can be $30,000 or more.
  • Fidelity Investments has estimated that the average person over age 65 will incur more than $225,000 in medical expenses that Medicare doesn’t now cover.