Each year, Frank Nelson issues the same advice to seniors living in California’s San Luis Obispo and Santa Barbara counties: When you start seeing Halloween decorations pop up in stores, it’s time to reevaluate your Part D Medicare coverage.
As the program manager at the Central Coast Health Insurance Counseling and Advocacy Program office in Santa Maria, California, Nelson works to educate Medicare beneficiaries about the Medicare open enrollment period. (For coverage starting in 2014, open enrollment is Oct.1, 2013–Mar. 31, 2014. For coverage starting in 2015, open enrollment is Nov. 15, 2014–Feb. 15, 2015.) Open enrollment is time the federal government sets aside for anyone to sign-up for Medicare benefits, and for those who are already enrolled to make changes to their Part D plans which then take effect on January 1. (Note: If you’re just turning 65, you can enroll three months before your birth month, during your birth month or three months after your birth month.)
He adds that many health insurance headaches can be avoided if you stay on top of your coverage. "It can be a complicated maze,” Nelson says. “There are a lot of ways you can get tangled up in the nuances.”
Nelson oversees a volunteer staff of 16 counselors who provide assistance and outreach to Medicare beneficiaries who have questions about coverage or are overwhelmed by details and possible Medicare issues. Every state has a State Health Insurance Assistance Program, funded by the federal government. In California, the program is known as HICAP and is organized as a state-wide network of nonprofit organizations, authorized by state legislators and run by the California Department of Aging, to provide the public with free information and advocacy.
Whether you’re new to Medicare or a seasoned beneficiary, it is important to understand how Medicare works and how it can help you, particularly during the annual open enrollment period. Follow these simple tips to get started.
√ Check changes to Medicare Part D
The most common questions Nelson hears stem from prescription drug coverage. Medicare Part D (a prescription drug plan offered by Medicare-approved insurance companies) can change from year to year. Medications that were covered in 2013 may not be covered in 2014.
“Many people who have Part D choose an insurance provider and then they never recheck their coverage when it rolls into next year,” Nelson says. “They figure they have a good one so they do nothing, which can result in uncovered expenses in the new year that cannot be changed until the next open enrollment period.”
Part D plans should be specific to your medication needs. During open enrollment, call your Part D provider to make sure your prescriptions are still covered. If they’re not, Nelson suggests visiting Medicare.gov and search for your specific medications or meet with a HICAP representative to help.
√ Request local pharmacy pricing
Your drug coverage isn’t the only thing in a constant state of flux. Pharmacies are just as unpredictable. When you choose a plan, you can go to the pharmacy of your choice, but the prices and availability of medications are often different, depending on where you go, since your insurance company may have a different contract with each pharmacy. Three different chains might charge three different prices for the same medication. The best way to stay on top of your drug coverage is to search on Medicare.gov each year during open enrollment and search for your specific prescriptions, plan specifications or pharmacy options, Nelson says. You can also contact a prescription assistance program for help.
√ Purchase a supplemental policy
If you’re enrolling in Medicare, consider purchasing a Medigap policy through a private health insurance company. Medicare typically covers about 50 percent of health care expenses. Medigap supplemental plans pick up health care costs that aren’t already covered by Medicare (from hospice care to routine vision care). The government standardized Medigap offerings in 1992, so the benefits are the same for each type of plan no matter which insurer you choose—but premiums vary greatly from company to company.
“Medigap plans are standardized, so you’re shopping for price and level of service,” Nelson says.
You can sign up for a Medigap policy at any time, but you will be subject to a health screening if you’ve passed the period of initial enrollment in Medicare.
√ Sign up for a Medicare Advantage plan
You may be healthy at 65—but don’t assume you’ll stay in good health forever. Given the potential for future health issues, it’s smart to consider comprehensive health coverage, says Rick Appleby, connect manager at the Institute on Aging in San Francisco.
Offered by private insurance companies and regulated by Medicare, Medicare Advantage plans cast a wide safety net for seniors. They offer greater benefits, such as preventive services; inpatient and outpatient hospital care; and vision, dental, hearing and prescription drug coverage. Though some of these services might seem like “extras,” they could end up enhancing your quality of life.
“Imagine the worst-case scenario and think about how Medicare will respond,” Appleby says. “Will you ever be interested in home care or a day program? Figure out what you might need or want one day, and then find out whether Medicare alone covers that.”
Whether you choose Medigap or Medicare Advantage is a matter of personal preference, and one’s individual circumstances and geographic location, says Janet Van Deusen, manager of the Alameda County HICAP in Alameda, California. She provides legal assistance for seniors and explains that Medigap policies tend to have higher premiums but greater flexibility while Medicare Advantage plans have lower premiums but often require you to stay in network.
√ Ask for assistance
If you still have questions and need some guidance, you can turn to your local senior center or adult services agency for help. Senior centers in California may redirect you to your local HICAP, so it may be faster to call your local SHIP program office directly and set up a counseling session with a Medicare expert. There are tools in every county that provide support and advocacy. Visit Medicare.gov online for a quick list of resources on Medicare.
Says Appleby, “If you’re Web-savvy, sometimes an Internet search can be very helpful to fill in the blanks.”