October 15th is the start of Medicare’s Annual Open Enrollment Period that runs through December 7th. During this time, Medicare subscribers can make changes from their current plan.

Changes can include joining or changing:

• Medicare Advantage (MA) plan;
• Medicare Supplemental (Medigap) plan;
• Prescription Drug Plan (PDP) or
• returning to original Medicare coverage.

Background

Original Medicare is the government run health plan for seniors and disabled people that utilizes private doctors, hospitals and other service providers.

By comparison, Medicare Advantage plans, Prescription Drug plans and Medicare Supplemental plans are all run by private insurance companies. These including a variety of for-profits (eg. UnitedHealthcare, Humana, Aetna), national non-profit organizations such as Blue Cross and many regional non-profit insurers.

In addition, some individuals maybe eligible to receive their health insurance, as a retiree or spouse, through their former employer including federal workers. Service veteran may be eligible for health care and/or medications from the federal department of Veteran Affairs. And, many people may be eligible for federal, state or county financial assistance with the cost of their Medicare insurance, medical services and medications.

The Importance of Having a Good Medicare Plan

Selecting the best plan for you or your family member is a very important responsibility since the consequences can be significant both to your pocketbook and your ability to receive needed health care from your preferred providers.

However, the vast majority of people seldom make any changes in their insurance unless a crisis occurs. Your decision to stay or change your insurance plan in the Fall, generally results in a year long commitment, with few exceptions.

The Importance of Objective, Comparative Plan Information

Consumer Reports provides over 7 million subscribers with independent, comparative information and ratings of thousands of products and services. This information has proven to be highly valued by prospective buyers for over 70 years.

However, health insurance is a billion dollar,  very profitable private industry with millions of dollars spent on marketing and sales and few people understand the Medicare coverage that they need and the limitations that they are buying.

Understanding the complexities of different health insurance options and eligibility for financial assistance is a very challenging task. People should look for assistance early from knowledgeable family, friends, non-profit agencies and trusted insurance agents who have a proven track record of working in the best interest of their clients.

Keep in mind, the print and TV advertisements, written literature and presentations that you receive from insurance companies and agents are aimed at selling you their policies for a commission that keeps paying them every year. Insurance agents are expected to know the products that they are selling but generally do not first assess your medical needs, priorities, budget, comfort with risk and then share with you, all of your options including products and services that they don’t receive a commission.

An insurance broker, who represents multiple companies, may provide you with broader options, but is still making their living by selling the plans that they represent, not providing you with objective, comparative information to help you make an informed decision.

How to Avoid Problems and Select the Best Plan for You.

1. Invest time to become aware of the services your buying, what is excluded and your full costs as you would for any major purchase or commitment.
2. Define what what medical services and prescription drugs you currently need and use.
3. Identify any upcoming major tests, surgeries or intensive treatment you are likely to need in 2023.
4. Prioritize your preferences – what is most important to you?
5. List your preferred service providers ( eg.doctors, hospitals, pharmacies)and find out what insurance plans they accept.
6. List out your generic and brand-name medications and their costs.
7. Define your domestic and international travel plans for next year.
8. Define what you can afford to pay for your insurance and health care and prescriptions.
9. Identify what Medicare plan options you have, their advantages, disadvantages and cost:

• Original Medicare (no prescription drugs included)
• Part D Prescription Drug plans needed with original Medicare and Medigap plans
• Medicare Advantage HMO, PPO plans with and without prescription drug coverage
• Supplemental (Medigap) plans
• Employer plan (if available to you)
• VA and Federal worker plans (if available to you)

10. What to look for in Medicare Advantage plans

• Do your preferred providers have contracts with the plan(s) that you’re considering?
• What is the extent and cost of out-of-network coverage? Will you likely need it?
• What is the cost difference between in and out-of-network services?
• Are all of your medications and preferred pharmacy covered and at what cost?
• What are the plan’s premiums, deductibles, exclusions, co-pays and co-insurance rates?
• What is annual Maximum Out-of- Pocket limit of your health care expenses?

11. Find out if you qualify for any assistance programs based on your income & assets:

• Low Income Subsidy (LIS/Extra Help))-federal assistance with prescription drug costs
• Medicare Savings Plan (MSP)- federal/state/county assistance with Medicare Part B premium
• Medicaid -federal/state/county assistance with Medicare, prescription drugs & nursing home costs
• Hospital Financial Assistance – assistance with bills from participating hospitals
• Patient Assistance Programs (PAP)- assistance from participation pharmaceutical companies
• State Health Insurance Assistance Programs (SHIP) – assistance with the cost of prescription drugs from participating states

12. Resources to Help You with Medicare and Prescription Drug Plans

• Medicare.gov (800-633-4227), is an excellent resource with general information and specific help in evaluating the differences among Medicare Advantage and Prescription Drug Plans (which are used with original Medicare and Medigap plans). If you are not comfortable using a computer, ask for help from a family member, friend or social agency.
• State Health Insurance Assistance Program (SHIP) (877-839-2675)  Medicare contracts with states, counties and non-profit organizations throughout the country to provide individuals with personalized education, support and assistance. These free services include comparative plan information, information regarding eligibility for financial assistance as well as help with selecting a Medicare plan, enrolling, and resolving problems.
• Medicare Rights Center (800-333-4114)  is a national, nonprofit organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs, and public policy initiatives. MCR helps people understand their rights and benefits, navigate the Medicare system, and secure the quality health care they deserve. 

For more articles on the political/economic dimensions of Medicare plans/policies and their impact on patients’ access to affordable, effective treatment go to http://healthplanadvisor.org.

And, feel free to share your comments and questions.

Thank you.

Jim Sorrentino

Updated 10/11/22