October 15-December 7 Is Medicare’s Annual Enrollment Period for Parts C & D
October 15-December 7 Is Medicare’s Annual Enrollment Period for Parts C & D
Did you know that each year people with Medicare have a choice as to whether to keep the type of Medicare they have or switch to another type of Medicare? When patients are looking at their Medicare options, they need to understand the differences between types of Medicare and look at what works best for them in their unique situation. Some questions to consider:
Original Medicare, also called fee-for-service Medicare, has two “parts.”
Part A covers hospitals, hospice, and some other services after a deductible per “benefit period.” There is a new Part A deductible each time the patient is hospitalized if the patient is out of the hospital 60 days or longer between admissions.
Part B covers doctors and most outpatient care at 80% after an annual deductible as a primary payer.
The Part A and B deductibles change each year. Patients with Original Medicare can have other coverage – Medicaid, Medigap (Medicare supplement), or an employer plan – to pay Medicare deductibles, coinsurance, and copays.
Medicare Advantage (MA) plans are also called “Part C” or “Medicare replacement” plans and come in a variety of types:
Health Maintenance Organization (HMO) plans may or may not have drug coverage. Some MA HMOs require patients to get a referral from their primary care doctor before the plan will cover care from specialists. These plans require patients to use providers in the plan’s “network” or pay for care in full except MA HMOs must cover emergency care, out-of-area urgent care and out-of-area dialysis.
Preferred Provider Organization (PPO) plans usually have drug coverage. Patients don’t have to have a primary doctor or need a referral to see doctors out of the plan’s network. However, patients pay more for out-of-network care and for extra benefits the plan offers.
Private Fee-for-Service (PFFS) plans may offer drug coverage, but if not, patients can buy a stand-alone Part D drug plan. Some PFFS plans have a network and patients can see anyone in the network or can see providers out-of-network that accept their plan, but they may have to pay more to see them.
Special Needs Plans (SNPs) cover people with different needs. There are SNPs for people on Medicaid, for people who are institutionalized, or for people with chronic conditions. There are even SNPs for chronic conditions that accept people on Medicare who are on dialysis.
Prescription Drug Coverage (Part D) may be purchased separately from an insurance company or may be included in an MA plan. Different plans have different formularies (covered drugs) and out-of-pocket costs for covered drugs. People with low income and limited assets may get “extra help” to pay premiums and out-of-pocket costs. The standard plan has a deductible, copays or coinsurance and a period when there is no coverage but pharmacy makes must discount brand name and generic drugs.
There are special circumstances that allow anyone with an MA or Part D plan to switch plans at other times besides the annual enrollment period.
The type of Medicare a patient chooses may depend on the patient’s unique situation and what s/he anticipates the cost will be for premiums, deductibles, copays, or coinsurance.
| Patient’s Unique Situation | Considerations with Medicare |
|---|---|
| Was the patient already in an MA plan when diagnosed with ESRD? | S/he can stay in that plan or choose another plan sold by the same company. If not, the patient can only choose an SNP that accepts patients on dialysis |
| Does the patient qualify for Medicaid too (“dual eligible”)? | If the patent has full Medicaid, s/he should not have bills for covered services. Some states require those who are “dual eligible” to be in Medicaid SNPs which can limit choice of providers, which may limit dialysis type. |
| Does the patient have an employer group health plan and was s/he home trained in the first 3 months OR has it been 33 months since starting in-center dialysis? | Medicare would be primary if they have been eligible for it for 30 months or more. The EGHP could pay all or part of the Medicare out-of-pocket costs. |
| Does the patient have an employer group health plan and has s/he been on dialysis less than 30 months? | Medicare is secondary if s/he has been eligible for Medicare <30 months. Patients can delay enrolling in Medicare Part A and B until the end of the Medicare secondary payer period unless they are eligible for Medicare due to disability too. If they get a transplant, it’s best to enroll in Part A for the month of transplant to protect the Part B immunos benefit now or anytime later. Also, enrolling in Medicare Part A and B as a secondary payer keeps providers that accept Medicare from billing patients the difference between the charge and what the employer plan pays if that plan has paid at least 100% of Medicare’s allowed charge. |
| Does the patient have a retiree plan through a former employer? | Some retiree plans for those 65 and older are Medicare Advantage plans. |
| Can the patient get a Medigap plan at his/her age with ESRD in the state? | If a Medigap plan is available, it may be easier to plan and budget premiums for Original Medicare Part B, Part D and Medigap which pay all or most of Medicare Part A and B out-of-pocket costs than to pay MA plan out-of-pocket costs. |
| Does the patient have higher earnings? If so, the Medicare Part B (and Part D) premium will be higher? | These higher premiums apply in Original Medicare and Medicare Advantage plans, including those no or low premium MA plans. |
| Does the patient take many drugs and/or costly drugs? | Different Part D plans have different premiums and cover drugs with different copays or coinsurance. They may also require prior authorization for some drugs, may have quantity limits on some drugs, or may require the patient to take and fail on a cheaper drug before paying for a costly drug (step therapy). Making a list of drugs and comparing allows the patient to see which plan has the best coverage for the price. |
If a patient wants to switch from an MA plan to Original Medicare, the annual disenrollment period is January 1-February 14. If the patient disenrolls from his/her MA plan, s/he has until February 14 to join a Part D plan for drug coverage. Before disenrolling from an MA plan, the patient needs to find out if s/he is eligible for Medicaid or a Medigap plan. Otherwise, s/he could have high out-of-pocket costs for Original Medicare and Part D.
Finally, there are resources to help patients choose the best Medicare and drug plan. The Medicare Plan Finder allows patients to enter a list of their drugs and choose whether they want to see just drug plans or health plans (MA plans). They can contact their state health insurance assistance program or call 1-800-MEDICARE to compare Medicare and drug plans, coverage, cost, and convenience (preferred pharmacy). Taking the time to do some homework and seeking the help they need will allow each patient to choose the plan that will work best for his/her unique situation.
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