Navigating the Medicare maze

Missteps to avoid as open enrollment period looms

Friday, September 20, 2019, Vol. 43, No. 38
By Hollie Deese

As 10,000 new beneficiaries each day age into a Medicare population that already supports 60 million, it is important to understand which plan to select when open enrollment begins Oct. 1.

And it is just as important for people who have been enrolled to re-evaluate their situation to make sure they are in the best plan.

“Sometimes they didn’t know how to get this information, or they moved to Tennessee and they didn’t know that things change if they move, or they retired and they just did what one of their friends recommended when they retired,” says Dee Stoffer, a licensed insurance consultant for American Republic Insurance Services.

“They didn’t know that every single person we meet needs an individual assessment.”

Individuals might even need two different plans in the same household because their prescriptions are different. Their health is different. Their care is different.

“It’s customized, and a lot of times we’ll run into people who picked the same thing as their spouse, but it may not be the best,” Stoffer adds.

Minor Medicare changes

Andrew Scholnick, a senior legislative representative for AARP in Washington, D.C., and works on the Medicare portfolio, says there aren’t too many significant changes for next year. For example, there are no work requirements beyond basic eligibility (65 years of age), which is working for 40 quarters over the course of one’s life.

Premiums are expected to only go up a few dollars, with last estimates putting Part B premiums at $144.30, an increase of roughly 6% from last year. Private insurance normally increases more than 10% annually, he says.

“It’s not like Medicaid, where they’re restricting eligibility,” Scholnick says.

What Medicare is trying to do more, though, is make little changes to help beneficiaries make better health care choices and more options in care, Scholnick adds.

“One of the things that they’ve done last year, and they’re going to continue to do for this year, is allowing Medicare Advantage plans to offer additional benefits for targeted individuals, particularly those with chronic care issues or chronic diseases,” he continues.

The Four Parts of Medicare

• Part A provides inpatient/hospital coverage.
• Part B provides outpatient/medical coverage.
• Part C offers an alternate way to receive your Medicare benefits
• Part D provides prescription drug coverage.

Also, last year Medicare allowed plans to offer medical transportation and greater use of telemedicine. This year, if a plan chooses to, Medicare will be able to offer more nonmedical services, such as transportation for grocery shopping or, for example, an air filter for enrollees with an asthma.

“Plans are allowed to do that. It is not that they necessarily will do that,” Scholnick says. “We would certainly urge all Medicare beneficiaries to review their choices during open enrollment, Oct. 15 to Dec. 7.”

If you’re approaching 65 you have what’s called an initial enrollment period - the three months preceding your 65th birthday, the month of your 65th birthday and then the three months following your 65th birthday. That is a seven-month window to enroll in Medicare without facing a penalty.

During open enrollment, if an individual has traditional Medicare, the person can choose to go onto a Medicare Advantage plan for the next year or a person on a Medicare Advantage plan can choose to go to traditional Medicare. It is also an opportunity to re-evaluate drug coverage and change prescription drug plans.

“This is really the time of year when beneficiaries and consumers and their family members should be looking at what drugs they are taking, were there any changes in the prescription drugs, were there any new disease diagnoses, or were there any changes in their health care providers, and start to evaluate, to see if it is the right coverage for you,” Scholnick explains.

“And sometimes it will be; other times they’ll want to look at a new prescription drug plan.”

People who wait too long can enroll during the next general enrollment period, which is January to March of each year, but might be faced with a delay in their coverage and an additional penalty and pay an additional premium.

There is a different process for people 65 and older who are still working, or the spouse is still working and getting coverage through their employer. When that individual leaves the employer or no longer receives coverage, they activate what’s called a special enrollment period with a three-month window from when you end coverage to then enroll without penalty.

One significant change in 2020 is that one of the Medicare supplemental plans, commonly called Medigap, will no longer offer Plan F or Plan C to newly eligible members. Medigap is extra health insurance an individual can buy from a private company to pay health care costs not covered by Medicare, such as copayments, deductibles and health care coverage while traveling outside the U.S.

Cody Crumes, a certified senior adviser with American Republic Insurance, says the Centers for Medicare and Medicaid Services has decided that any new Medicare beneficiary in 2020 will not be able to have a plan that has a zero deductible.

People currently on those plans will not be losing coverage. But they should review their plan because their premiums will be significantly higher.

“They can see and experience a huge cost savings by moving to one of the plans that’s going to continue after Jan. 1, 2020,” Crumes points out.

Different Medicare Advantage Plans

Health Maintenance Organization Plans (HMO): Usually requires a referral to get care within the network

Preferred Provider Organization Plans (PPO): Enrollees pay less to use in-network doctors, hospitals and other health care providers and more for those out of network.

Private Fee-for Service Plans (PFFS): This plan determines how much it will pay doctors, other health care providers and hospitals, and how much enrollees must pay for.

Special Needs Plans (SNPs): A Medicare Advantage (MA) coordinated care plan (CCP) specifically designed to provide targeted care with enrollment limited to special-needs individuals.

HMO Point of Service Plans (HMOPOS): An HMO Plan that may allow enrollees to get some services out-of-network services for a higher cost.

Medical Savings Account Plans (MSA): A plan that combines a high-deductible health plan with a bank account. Medicare deposits money into the account, usually less than the deductible.

Any change, no matter how minor, can going to cause confusion. Stoffer works with Crumes to host education sessions up to three times a week leading up to enrollment, and then daily sessions once enrollment opens.

“We are putting our heads together on some ideas for making people aware of what’s coming down the pipeline here these next few months,” Crumes says. “The thing that is most commonly heard whether we’re out in the public or whether we’re doing an educational meeting, is that this stuff is so confusing for the average person who’s not working in the insurance business.”

Website rollout worrisome

While two weeks before open enrollment might seem like a bad time to launch an overhaul of, that is exactly what is happening. Medicare is rolling out a new website Oct. 1 that is supposed to include more information to help people make decisions about which plan is right for them.

“We are cautiously optimistic about its rollout because they haven’t really done too much beta testing on it yet,” Scholnick says. “We would urge people that want to search the website and compare different plans and compare different options to start the process as early as possible and not wait until December. We don’t know how the website’s going to respond, or if there are any bugs or kinks that will need to be worked out.”

Crumes has worked through the new website versus the old and says one drawback is the inability to compare plans based on lowest out-of-pocket costs. Historically, this feature has been very helpful when looking up medicines.

“Whether you have a part C Medicare Advantage plan or whether you have a Part D standalone prescription drug plan, we always used to put information in people’s medicines and at their pharmacy to figure out what’s going to be the lowest out of pocket,” he says.

“Now for next year, what you’re going to have is you’re going to have two different options that you’re going to have to filter. You’re going to do lowest premium, which may not be the best way to do it, or you’re going to have lowest for your medicine and it doesn’t factor in the premium.”

The new plan finder is going to look different, too. Someone who’s been doing it for themselves for years will see a subtle change that could be enough to cause confusion when reenrolling.

“The average person is not going to be able to navigate through and figure out what the best plan is for them,” Crumes points out.

For example, Davidson County has 23 Medicare Advantage plans because each insurance company has a different formulary for their drug plan, a different physician provider network and different add-on benefits, such as dental, vision and hearing.

“Right now, the most important thing is to take time to review your options,” Scholnick says. “You might be able to save money by changing your prescription drug plan or looking at your different coverage options. Unfortunately, it takes time and energy and it’s confusing.

“So start the process early and not wait until the end of the year.”