Understanding Open Enrollment: What Every Senior Should Know

Written by NYPress on . Posted in News Our Town, Our Town.


By Joanna R. Leefer

This time of year could try any senior’s soul. Between Oct. 15 and Dec. 7, adults 65 and up who are eligible for Medicare can switch from one health plan to another without penalty.
During this open enrollment period, seniors are deluged by TV ads, letter campaigns and e-mail messages encouraging them to switch medical plans.

The reason? During this time, if you are not completely satisfied with your current plan—or if your health needs have changed—you can look for a plan that better meets your needs. This also is also the time when you can switch from one prescription drug plan to another without complications.
Below are a few explanations that may clarify some of these terms:

Medicare. This is a federal program that pays for certain health care expenses for people aged 65 or older, and for some younger people who meet special criteria. Medicare Part A covers hospitalization and nursing home care. Medicare Part B covers doctor visits, outpatient medical procedures, and some medical tests. The special enrollment period allows you to change your type B coverage, although your decision could impact your hospital or nursing homes coverage as well.

Medicare Part B. This is also referred to as Original Medicare. This program requires you to pay a monthly premium of $104.90, and an annual deductible of $147. After these costs are met, Medicare B will cover 80 percent of most medical exams and procedures; you or yet another health plan must pay the rest. Part B coverage includes most preventative-care services, annual physicals, depression screening, HIV screening, mammograms, prostate cancer screening, flu shots and diabetes tests.

Medicare Part B also covers most medical equipment, home health care, outpatient physical, occupational and speech therapy, outpatient mental care services and emergency transportation.
It is important to note that Medicare Part B does NOT cover most dental care, eye exams, hearing aids, alternative medicine and cosmetic surgery. It also does not cover prescription drugs. Many of these services can be added to your care by applying for a Medicare Supplemental Insurance plan, often called a Medigap plan.

Medigap plans. These are private health insurance plans designed to supplement Medicare. They cover such costs as copayments, coinsurance and annual deductibles. The names of some Medigap plans are: AARP Medical Supplement, Humana Medical Supplement and Emblem Health Medical Supplement. Their costs and coverage vary, depending on what they offer, but enrolling in one of these plans will provide you with the 20 percent payment not covered by Medicare—and may also provide additional coverage of such services as vision, hearing and dental care. Every Medigap policy must be clearly identified as “Medicare Supplement Insurance.”

Medicare Part C (Medicare Advantage) plans. These plans are administered by private companies that are approved and regulated by the federal government’s Centers for Medicare and Medicaid Services (CMS). The emphasis here is on “private.” They are plans that the government contracts; they offer policies that cover doctor visits, hospitalization and, sometimes, prescription medication. Medicare Advantage plans must offer benefits on par with traditional Medicare, but many providers include more as a way to attract customers. Some of these services may include vision, hearing and dental care. The most common types of Medicare Advantage include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Private Fee-For-Service (PFFS) plans.

Medicare Advantage plans require you to pay the same monthly premium you would pay for Medicare Part B. Many include additional services under this fee, while other plans offer “tiers” of service at varying cost levels. Some even include gym or health club memberships. In exchange for these extra benefits, these plans may require that you adhere to a limited “network” of providers. If you decide to purchase a Medicare Advantage Plan, find out what additional services are actually included before signing up. A plan that includes vision care, for example, may only reimburse an annual eye exam, but not glasses. Remember that you will rarely get more from a similarly priced program without giving up other benefits.

Medicare Part D. This is the prescription drug program. Private pharmaceutical companies approved and regulated by the federal government provide Medicare Part D plans. These programs require payment of monthly premiums ranging from $15 to $165, plus small co-payments for each drug. People who enroll in traditional Medicare must also select a Medicare Part D prescription program. Many Medicare Advantage plans include a drug plan or plans. If not, you must select one as well.

Before you switch plans, it’s important to evaluate your needs.

8 Questions to ask before changing health plans

How much will I have to pay for premiums, deductibles, doctor visits or hospital stays?

Are all the services I need covered under this plan? If not, is there a way to obtain coverage without paying large additional amounts?

Are my doctors in this plan? If not, can I continue to see an “out of network doctor” even if it costs a bit more?

What services will I give up if I switch plans?

Will I have to choose my hospital and health care providers from a limited network?

Are the hospitals/nursing facilities in my network convenient to me? Do they have good ratings?

Will I need physician referrals to visit specialists?

Are my prescription drugs on the plan’s formulary? What is my prescription medication copayment?

Does the plan I selected have a good quality rating?

Joanna Leefer is an eldercare advisor with 10 years experience working with aging issues. She was the primary caregiver for her parents for over seven years and worked for FRIA Inc. (Friends and Relatives of Institutionalized Aged) an advocacy organization for the elderly. For more information on her services, log onto www.joannaleefer.com. Her book Eldercare Basics will be available in spring 2013.

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