Medicare Open Enrollment (10/15-12/7): It’s Not as Scary as You Think.
During open enrollment, people can join or switch Medicare drug plans or can switch from a Medicare Advantage (MA) plan to Original Medicare. By law, people on dialysis can only join or switch to an MA “Special Needs Plan” (SNP) that accepts people with ESRD. SNPs are not available everywhere, but a proposed law would allow those with ESRD to join any MA plan.
Patients who have Medicare are advised to review their health and drug plan each year. The Medicare & You booklet that is provided annually in print or electronically to each person with Medicare suggests those with Medicare review and compare their plan with other available plans.
What Should Patients Compare?
- Coverage: Does the plan cover the services and drugs the patient needs? ‘
- Original Medicare covers any kind of dialysis as well as living and deceased donor transplant services.
- MA plans have to cover the same services Original Medicare covers, and MA plans may cover some services that Original Medicare does not cover.
- Cost: What are the premiums, deductibles, coinsurances, copays? Is there an out-of-pocket cap on costs? Are premiums and out-of-pocket costs as affordable as they could be? What rules must the patient follow to get the best price for drugs and services?
- There are annual changes in the Original Medicare Part A hospital deductible and daily copays for longer stays and in the Part B annual deductible. There is a 20% coinsurance for Part B approved costs. Original Medicare has no cap on out-of-pocket costs but a Medigap plan, if available, can help pay those costs.
- Insurance companies that sell MA plans set their own deductibles, copays, and coinsurance—which may be different from Original Medicare. CMS did set a cap on MA plan out-of-pocket costs of $6,700; some MA plans have a lower cap.
- Convenience: Does the plan cover the dialysis clinic, doctor, hospital, and pharmacy that the patient wants to go to, and are these open on the days and hours the patient needs? Can the patient access medical records using an electronic health record system if desired?
- Choice: Does the plan have a wide or narrow choice of dialysis clinics, doctors, hospitals? Is a referral required to see a new doctor? Are doctors accepting new patients with that insurance?
- Original Medicare does not require referrals—although some doctors that accept Original Medicare may—and Original Medicare covers HD and PD and living and deceased donor transplants anywhere in the U.S. and its territories where those services are offered.
- Insurance companies that sell MA plans contract with a network of dialysis and transplant providers. MA costs “in-network” are generally lower than “out-of-network” costs.
- Quality of care: How satisfied is the patient with his or her care?
- The Medicare website provides ratings on health and drug plans.
- Travel: Does the plan cover services the patient needs when traveling within or outside the U.S.? This fact sheet explains Medicare coverage outside the U.S.
- Original Medicare covers dialysis and transplant services anywhere in the U.S. and its territories, but covers services outside the U.S. only in very limited situations. If the patient has a Medigap plan C, D, E, F, G, H, I, J, M, and N, these pay 80% of the billed charges for certain medically necessary emergency care outside the U.S. after the patient has met a $250 deductible for the year.
- MA plans have to cover dialysis within the U.S. for the in-network cost. Some MA plans may cover services outside the U.S. The patient should talk with the MA plan to find out what is and is not covered and how to file claims.
- Other coverage: Does the patient have coverage from an employer or union or some other source like Veterans, Indian Health Service, etc.?
- An employer or union plan is required to pay first for the first 30 months the patient is eligible for Medicare, whether the patient enrolled in Medicare or not. If a patient chooses to enroll in Medicare while working, s/he can keep both plans. However, if the patient is not working and is receiving COBRA, enrolling in Medicare allows the employer to drop COBRA coverage. Be aware that if a patient drops employer or union coverage s/he may not get it back.
- Medigap coverage may be available to those with Original Medicare—but not to those with an MA plan. Federal law protects those who turn 65 for 6 months after they enroll in Part B to get a Medigap plan. Some states do not have regulations that limit insurance companies from denying Medigap coverage to people under 65 on dialysis. Although the Affordable Care Act (ACA) prevented this kind of discrimination in other types of insurance, the ACA does not protect people from age or health discrimination in Medigap plans. There is a database that provides a list of Medigap plans and their benefits by state based on the patient’s health status (excellent, good, poor) and age 65 or younger. You can search that database here.
Dialysis staff should inform their patients that Medicare health and drug plan coverage can change from year-to-year. Encourage your patients to take the time to compare their coverage to other options to be sure they have the best coverage they can afford. Besides the Medicare Plan Finder, there are federal and state agencies with trained staff to help patients who don’t feel confident to do this important research. Making this effort could help patients save money by choosing a better plan or identifying programs to help them stay as healthy as possible. Below is a guide that may help your patients to do this comparison.
A Step-by-Step Guide for Patients Who Want to Compare Plans
- Go to the Medicare Plan Finder.
- You can do a general search, but a personalized search can help you compare your current plan (if you have one) to other options if you enter your:
- Zip code on file with Medicare
- Medicare number
- Last name
- Date Medicare Part A took effect
- Date of birth
- Enter your Medicare and other coverage and whether you get extra help.
- Enter each drug name, dose, and how often you take drugs you take now or may need to take in the next year (ask your doctor or the transplant program). If you entered a drug list before, you can use that list as it is or change it.
- Choose one or more pharmacies (the lowest cost will be from your plan’s “preferred” pharmacies.
- Update your results, if desired, to:
- Limit your monthly plan premium
- Limit your annual deductible
- Choose 3 different options for your drugs
- Choose options for nationwide coverage or to see any doctor (the latter is for health plans only)
- Choose Special Needs Plans for people with Medicare/Medicaid, with chronic health condition, or in a long-term care facility
- Change health status (excellent, good, or poor)
- Search for plans sold by a certain company
- Choose if you want to search for just prescription drugs plans for those with Original Medicare, health (MA) plans with drug coverage, or health (MA) plans without drug coverage
- When you see the options, you can compare up to three. With a personalized search, you’ll see your current drug and health plan. Use the dropdown menu to sort by:
- Overall Star rating (patient satisfaction)
- Lowest monthly premium
- Plan name
- Lowest annual plan deductible
- Drug restrictions (choose one with the fewest limits)
- Off formulary drugs
- Lowest annual estimated retail drug cost
- Lowest annual estimated mail order drug cost
- Be sure to click on Lower Your Drug Costs to see if you can get help to pay for your drug(s) from a patient assistance program or state pharmacy assistance program
If you change your plan during open enrollment, your new plan will start on January 1. You can look for answers about the Medicare Plan Finder in the Frequently Asked Questions (FAQs).
No Internet access at home? A friend or family member may be able to help. Public libraries have computers with Internet access. Or, you can call 1-800-MEDICARE to get help comparing up to three plans.
Get help with Medicare options, other insurance, learn where to file a complaint, and more by clicking on Forms, Help, & Resources on the Medicare site. Choose your state in the dropdown menu and check the box or boxes for topics of interest.