Medicare Open Enrollment begins on October 15th and continues through December 7th. Effective dates of new plans or changes to existing policies will be January 1st. Pa residents can apply for Part D prescription drug coverage, and also change from a Medicare Advantage contract to original Medicare benefits, or enroll in an Advantage plan, and terminate an existing Supplement contract. Of course, you can also leave all existing plans in place and make no changes.
The single payer concept for Seniors pays about 80% or expenses, leaving the balance to be paid by the applicant. There are four portions to Medicare. Part A consists of hospitalization and related expenses, including your room and surgery charges. Part B is standard medical insurance benefits. Part D is prescription drug benefits, and is provided in several ways. Part C is Medicare Advantage plan coverage, which replaces original Medicare benefits and can provide drug prescription benefits, depending on the contract.
Cover Your Out-Of-Pocket Expenses
Private insurers offer Medigap plans to help pay for may of the out-of-pocket expenses that may not be covered under original government-provided coverage. Prescription drug benefits are provided separately (Part D), although many Advantage contracts include the coverage. NOTE: If your prescriptions changed during 2016 (or new ones were added), reviewing existing drug plans is highly recommended. Also, prescriptions are classified as Tier1, Tier 2, Tier 3, Tier 4, and Specialty (Generic, preferred generic, non-preferred brand, and preferred brand). The choice of which type your physician chooses can greatly impact your cost.
Your two “payers” (original Medicare and the private carrier providing the supplement) follow “coordination of benefits” rules to determine which expenses are paid by whom. The “primary” payor is the first to pay expenses up to the limits of the policy. The “secondary” payor pays the balance, although some bills still may be uncovered. A comparison of Medigap plans in Pennsylvania also provides details about which expenses are paid.
Expenses that are medically necessary are generally paid, along with portions of copays, deductibles, and coinsurance. Many preventative expenses are also paid, including (but not limited to) mammograms, lung cancer screenings, nutrition therapy, testing for Glaucoma, and prostrate cancer screenings.
Standard Enrollment Period
When you reach age 65 or become eligible for Medicare Parts A and B, your initial Open Enrollment period begins. Otherwise, as previously mentioned, from October 15th through December 7th is the regular period. During this time, you can change your original Medicare coverage to a Medicare Advantage plan. You can also change from an Advantage plan back to original Medicare.
You may also change Advantage plans if your current policy does not include prescription drug benefits, and the new plan does include them. Also, you can change from a plan that offers prescription drug benefits to a plan that omits it. You can also apply for original Part D prescription drug coverage, change to another Part D plan, or simply terminate an existing plan without picking up a new one.
Second Enrollment Period
Generally, if the standard deadline of December 7th is missed, you will have to wait until the following year to request a change from an existing plan. But there is a second Open Enrollment period that begins on January 1st and continues to February 14th. It benefits current Medicare Advantage policyholders since they are allowed to terminate their existing plan, and change to an original Medicare contract. You are not required to remain with the same company.
Also, if you change to original Medicare benefits, a deadline of February 14th is provided to enroll in a Medicare prescription drug plan. Typically, the effective date of benefits is the first day of the month following the date your application is processed.
Prescription Drug Plans
If you are already enrolled in Part D (prescription drug) coverage, you can continue that plan, unless it is no longer offered. You may also compare other offered options in your area to determine if a more cost-effective policy is available. Many Advantage contracts include these benefits already. Shown below are 12 of the popular prescription drug plans from approved carriers. For this example, we used Allegheny County (Pittsburgh area). Additional information is provided by the Pa DOI.
Humana Walmart Rx Plan
Aetna Medicare RX Saver
Humana Preferred Rx Plan
Symphonix Value Rx
EnvisionRx Plus Silver
EnvisionRx Plus Clear Choice
Express Scripts Medicare Value
First Health Part D Value Plus
Magellan Rx Medicare Basic
AARP MedicareRx Saver Plus
Watch Your Mail
In October, you generally will start receiving materials and information regarding next year’s options, and changes that may have occurred since the last enrollment. As previously mentioned, you are not obligated to change plans. And if you are not notified that your existing plan was terminated or no longer available, the policy will continue if you do not take any action.
However, you should quickly review any paperwork you receive, either from your existing company, or from the Center for Medicare and Medicaid Services (CMS). For instance, The ANOC (Annual Notice Of Change) and EOC (Evidence Of Coverage) correspondence should always be promptly viewed.
Many tools are also available that help you find providers in your area. Often, specialists are more difficult to locate, but with the assistance from our website (and government websites), you can view available different doctors, hospitals, suppliers of medical equipment and other needed supplies, dialysis treatment facilities, home health services, and nursing homes.
APPRISE is a free state-supported program that aids Seniors with counseling and free information. Both paid employees and volunteers are provided to answer questions about various programs, including Medicare, Medicaid, Medigap coverage, and Long-Term Care plans. Presentations are also offered to various groups and organizations. However, since the volunteers are generally not licensed with the Pa Department of Insurance, it remains prudent to continue to utilize reputable and experienced websites like ours, and the independent brokers we represent.
NOTE: We do not endorse specific plans or carriers for Senior products. Also, we are not affiliated with CMS or the Medicare program.