Consumers know fall is coming when stores start offering Halloween candy and flu shots, and the airwaves and mailboxes are flooded with ads for Medicare options.
This is the annual open enrollment period for the 65 million Americans covered by Medicare, the federal health program for the elderly and some people with disabilities.
From October 15 to December 7, people enrolled in traditional plans, or Medicare Advantage plans offered by private insurers, can change their coverage. (First-time enrollees typically enroll within a few months of their 65th birthday, whether it’s during open enrollment season or not.)
There are several new features for 2024, including lower out-of-pocket cost limits for some patients taking expensive drugs.
Regardless, beneficiaries should check their current coverage because health and drug plans may have made changes, including pharmacies, experts say. or medical provider in their network and the cost of the prescription.
The advice is to check, check and double check, said Bonnie Burns, a consultant with California Health Advocate, a nonprofit Medicare advocacy program.
But as anyone in the program or who helps friends or relatives make insurance decisions knows, it’s complicated.
Here are some things to keep in mind.
Medicare vs. Medicare Advantage
People on traditional Medicare can see any participating doctor or hospital (and most do), while people on Medicare Advantage must choose from a list of specific providers a network unique grid for that program. Some advantage plans offer a wider network than others. Always check to see if your preferred doctor, hospital and pharmacy are covered.
Because traditional Medicare doesn’t cover prescriptions, plan members should also consider enrolling in Part D, the optional drug benefit, which includes a separate premium.
Conversely, most Medicare Advantage plans include drug coverage, but be sure before signing up because some plans do not. These private plans are heavily advertised, often advertising that they offer additional features not found in traditional Medicare, such as dental or vision coverage. Read the fine print to see what limits, if any, apply to those benefits.
People 65 and older on traditional Medicare for the first time can purchase a supplemental or Medigap policy, which covers many of the out-of-pocket costs, such as deductibles and copays, that can be well worth it. tell. Generally, beneficiaries have six months after they enroll in Medicare Part B to purchase a Medigap policy.
So switching from Medicare Advantage back to traditional Medicare during open enrollment could cause problems for those who want to buy a supplemental Medigap policy. That’s because, with some exceptions, private insurers offering Medigap plans can deny applicants with health conditions or increase premiums or limit coverage Coverage for pre-existing medical conditions.
Some states give beneficiaries more assurance that they can switch Medigap plans without answering health questions, although the rules may vary.
Making all of this more confusing, every year there is a second round of open enrollment, but only for people in Medicare Advantage plans. They can change plans or switch back to traditional Medicare from January 1 to March 31.
Drug coverage is improved
Beneficiaries enrolled in a Part D drug plan or receiving drug coverage through their Medicare Advantage plan know that there are many copays and deductibles. But by 2024, for people who need a lot of high-cost drugs, some of these costs will disappear.
President Joe Biden’s Disinflation Reduction Act sets new annual limits on out-of-pocket drug costs for Medicare beneficiaries.
That policy would help people who have to take very expensive drugs to treat diseases like cancer, rheumatoid arthritis and Hepatitis.
According to KFF, this cap will greatly help beneficiaries who are in Medicare’s catastrophic insurance tier (estimated at 1.5 million Americans in 2019).
Here’s how it works: This limit is triggered after a patient and their drug plan spend a total of about $8,000 on drugs. KFF estimates that, for many patients, that means out-of-pocket costs of about $3,300.
Some people may reach their limit in just one month due to the high cost of many drugs that treat serious conditions. Once the cap is reached, beneficiaries do not have to pay anything out of pocket for their drugs that year, potentially saving them thousands of dollars each year.
It’s important to note that this new limit will not apply to drugs that are infused into patients, generally in doctor’s offices, such as many chemotherapy treatments for cancer. These drugs are covered by Medicare Part B, which covers doctor visits and other outpatient services.
According to the Medicare Rights Center, Medicare next year is also expanding eligibility for some low-income beneficiaries to qualify for low- or zero-premium drug coverage with no premiums. Lower deductibles and copays.
Insurers offering Part D and Advantage plans may have also made other changes to drug coverage, Burns said.
Beneficiaries should check the plan’s formulary, the list of covered drugs, and the amount they pay for the drugs. Be sure to note whether the prescription requires a copay, which is a fixed amount, or coinsurance, which is a percentage of the drug cost. In general, copays mean lower out-of-pocket costs than coinsurance, Burns says.
Help is available
In many parts of the country, consumers can choose from more than 40 Medicare Advantage plans. That can be overwhelming.
Medicare’s online plan finder provides detailed information about available Advantage and Part D drug plans by ZIP code. It allows users to drill down into details about benefits and costs as well as the network of medical providers under the plan.
Insurers have a duty to update their provider directories. But experts say enrollees should check directly with the doctors and hospitals they want to confirm that they participate in any Advantage plans. Neuman said people concerned about drug costs should check to see if their pharmacy is a preferred pharmacy and if it is in-network under their Advantage or Part D plan.
There can be significant differences in out-of-pocket spending from one pharmacy to another, even within the same plan, she said.
To get the most complete picture of estimated drug costs, Medicare beneficiaries should look up their prescription, dosage and pharmacy, said Emily Whicheloe, director of education at the Medicare Rights Center.
For people who have specific drug needs, you should also contact the plan and say, Hey, will you still cover this drug next year? If not, change your plans, she says.
You can get additional help with free enrollment through the State Health Insurance Assistance Program, which operates in all states.
Beneficiaries can also ask questions through a toll-free hotline operated by Medicare: 1-800-633-4227 or 1-800-MEDICARE.
Insurance brokers can also help, but be careful. Working with a broker can be great for that personalized touch, Whicheloe says, but know that they may not represent all plans in their state.
Whatever you do, avoid telemarketers, says Burns. In addition to TV and mail ads, phone calls touting private plans also bombard many Medicare beneficiaries.
Just hang up, Burns said.
KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of the core operating programs at America’s independent source of research, polling and health policy journalism. KFFan. Learn more aboutKFF.
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Julie Appleby – KFF Health News
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