Medicare Advantage Issues you Should Know before Selecting a 2023 Plan.

Use It or Lose It Benefits

As we enter the end of the year, it’s important to check if your health insurance plan has benefits that you need, but have not used and will be erased on New Year’s eve.

This applies to Medicare Advantage (MA) plans as well as some employer and marketplace plans.

Some plan benefits that you may have, but could use or lose, before year-end include:

  • Prescription drugs and vaccines
  • Preventative dental care
  • Contact lens/eyewear allowances
  • Healthy living rewards
  • Over-the-counter medication/supplies
  • Telehealth consults
  • Rides to/from medical appointments

Prescription Medications

The cost of prescription medications can be your highest medical expense each year and its one of the most complicated and least disclosed aspect of your health insurance. There can be considerable differences among private Medicare Advantage plans in their cost, choice & access to the medications that your doctor prescribes. 

To help understand these differences, go to Medicare Plan Finder and enter your medications for Medicare Advantage plans in your area and the program will show the comparative: medical and drug premiums, deductibles, co-pays and co-insurance and optional benefits for all plans. Then, you can select a more detailed comparison of up to 3 plans that you are most interested in buying for 2023, before December 7th.

A couple things of other things that you can do before year-end are to check if your current plan offers discounts for using: 1.a preferred pharmacy 2. a discount for 90-day supplies of your maintenance meds (usually generics) from your plan’s preferred pharmacy. Some plans provide up to a 33% discount for a 3-month supply over the cost of buying medications monthly. In some cases, the cost of your medications from your pharmacy can be cheaper by not running it through your insurance plan, especially if your meds are subject to a high deductible and/or co-payment. So, check with your pharmacy.

If you take Tier 3-5 maintenance medications and have already met your yearly deductible, consider having your prescription refilled with a preferred pharmacy before year-end. If you wait until after the 1st of the year, you’re likely to have to pay another deductible early in the year.

Finally, if you are diabetic and use insulin, you should definitely check to see (using the Medicare Plan Finder) what your current or another MA plans for 2023 charges for the insulin that your doctor prescribes. Some plans may include the insulin that you use for $35 or less a month.

Vaccines 

Many FDA approved adult vaccines are covered in full with no co-pay or deductibles through your plan’s network of providers (PCP, pharmacy). These include flu, pneumonia, Hepatitis B, Covid-19 virus. However, not all plans include other important FDA approved vaccines that prevent illnesses such as shingles, tetanus, diphtheria and pertussis. Many insurers require an out-of-pocket deductible payment and a high-cost Tier 3 co-payment.

This means you can have insurance coverage for vaccines, but you may have to pay up to the full cost for specific vaccines.

Preventative Dental Care

In recent years, a number of MA plans have added preventative and some restorative dental care to their plans. While plans often emphasize two “free” cleanings, x-rays and exams a year. Some plans have also expanded their dental coverage to include other services such as filling, root canals, crowns etc. However, a common limitation to these dental benefits is that there is a maximum fee that the plan will pay participating providers for each service/procedure and often full payment coverage is limited to a low-negotiated fee agreed to by a small group of local dentists. If your dentist does not participate in the plan and accept their fee schedule, you will need to pay for the service out-of-pocket and then submit a claim to your insurance company and request reimbursement up to what they allow, not what you paid. Finally insurance companies commonly don’t provide you with their allowable fee schedule and they usually won’t pay for more than the plan’s negotiated rate with their in-network dentists. So, in most cases you won’t know if your dental work is covered until it is completed, paid and you submit a claim for reimbursements.

If you haven’t used up your dental allowance for the year, check with your dental office and either book an appointment before year-end and/or ask to go on an appointment cancellation list. This is another use it or lose it benefit.

Eyewear/Contact Lens Allowance

Most insurance plans have an eyewear/contact lens allowance. The amount of the allowance varies by insurer from $75 to $300/yr. and is usually tied to the premium that you pay. This benefit is another use it, claim it, or lose it. There is no rollover of the benefit to the next calendar year and you usually need a recent eye exam in order your eyewear or contact lens.

If you have a simple lens prescription, there are many options for ordering what you want/need online at reasonable prices for both contacts & eyewear. Examples can include regular & prescription sunglasses, reading glasses and stocking up on contact lenses.

Healthy Living Rewards

More plans are including incentives for healthy living because they attract healthier customers that use fewer medical services and cost the insurance company less to serve. Some plans offer rewards up to $200/yr. in debit cards for taking brief online classes, getting a flu shot, completing surveys, having an annual physical, mammogram, colorectal & PSA screenings, vision test, use of a gym etc.

As with many benefits, you need to earn the rewards, report them, claim them or lose them. There is no roll-over of unclaimed rewards to the following year.

Over-the-Counter Medications/Supplies

Some MA plans also include an allowance of up to $100 a year for over-the-counter medications and supplies. However, there are a number of procedures to complete along with restrictions and limitations that vary for each plan. For example, some plans advertise a $100/yr. benefit, but the fine print states that it is limited to $25 a quarter with no carry-over of the unused benefit from one quarter to another.

So, check with your insurer for the benefit details, limitations and procedures for claiming your rewards.

Emergency, Urgent Care and Ambulance Services

Health care systems continue to evolved and there are new services that are available, less costly and more accessible than your doctors office or a hospital emergency room. The first level of service is a call to your primary care provider (PCP) during office hours for a phone consult. The second option is to use a “Telemed Service” affiliated with your PCP for questions and concerns that you may have. Telemed services are often covered by your insurance plans with either a low or no fee. The next level of services is an Urgent Care Center. These centers. are designed to divert people from overwhelmed emergency departments. They can diagnose and treat a limited number of medical conditions. Hospital Emergency Departments and Ambulance Service providers are costly and designed to provide a rapid response to people facing life-and-death crises such as heart attacks, strokes, serious accidents & injuries etc. Ambulance service providers are responsible for assessing, stabilizing and transporting patients experiencing a medical crisis to an emergency department. Insurance companies won’t reimburse ambulance companies for providing transportation to individuals with less acute problems. However, recently some insurance plans have added coverage for a limited number medical rides to and from medical appointments. Check your policy or call your plan’s customer service representative listed on the back of your insurance card for more benefit information.

Major Differences among HMO, PPO and Medigap Plans

Unlike original Medicare where you can receive services from any health care provider that has a service and payment contract directly with Medicare, private Medicare Advantage (MA) insurance plans have the primary contract with Medicare and are paid on per capita basis (approx. $12,000/yr./person.) with higher Medicare rates based on the patients’ diagnoses & medical conditions.

HMO plans have well-established provider networks with service contracts and geographical boundaries. Services and use of specialists need to be coordinated and approved by your primary care provider. The patient cost for receiving out-of-network services can be substantially higher than in-network services with the exception of emergency services.

PPO plans also have service and payment contracts with providers that can include broader geographical areas and have less restrictions on prior approval to receive services from speciality providers. However it’s important to note that PPO service providers,who participate in Medicare, are not required to accept all medical insurance plans. This is a common problem for subscribers in small regional MA PPO plans who want to receive services in another state in the absence of a formal contract between the insurance plan and the service provider.

However, a recent development addressing this issue is that national Medicare Advantage insurers such as United Health Care, Humana and Blue Cross affiliates have developed reciprocal agreements among their plans that allow for the acceptance of patients from other affiliated plans at the in-network rates, thereby increasing access to services with lower out-of-pocket expenses. This expanded MA PPO plan coverage can provide a more comprehensive and less costly alternative (for some people) to the option of buying a free-standing Medigap plan and a Prescription Drug Plan along with the cost of your original Medicare.

Medigap plans are private insurance plans used to supplement the coverage of original Medicare including the subscriber responsibilities for deductibles, co-payments and co-insurance. Plans differ based on the comprehensiveness of their coverage, 12 different plan designs and cost of monthly premiums among the different states and regions. If you sign-up for a Medigap plan, you also need to sign-up for a freestanding Prescription Drug Plan (PDP), unless you have credible medication coverage from an retiree employer plan or the VA.

Individuals with high medical expenses, such as renal dialysis and chemotherapy, are good candidates to consider a Medigap plan. MA plans generally require a 20% co-insurance payments for dialysis & chemotherapy until you have paid up to $7,900 -$11,700 in a calendar year, not counting the cost of self-administered medications.

Opportunities to Change Your Medicare Plans

The period of October 15 to December 7th is the annual open enrollment period. If you already signed up for a MA plan, you can still change your plan until December 7th. If you missed this deadline, you can switch from one MA plan to a different MA plan or switch from a MA plan to original Medicare and add a PDP between January 1 and March 31st.

You can make changes yourself by using Medicare.gov, calling the respective plans or calling the State Health Insurance Assistance Program SHIP (877-839-2675)

If you have any comments, or suggestions, please share them with us.

Thanks

Jim Sorrentino

How to Avoid Costly Mistakes in Choosing a Medicare Plan

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Medicare’s annual open enrollment runs from October 15th to December 7th. During this time, Medicare subscribers can join or change plans including:

  • Medicare Advantage plans:
  • Return to the original Medicare coverage
  • Medicare Supplemental (Medigap) plans;
  • Part D Prescription Drug plan

It is very important to make an informed choice of the best insurance plan for your medical needs, preferences, and budget. A bad choice can cost you thousands of dollars and prevent you from receiving services that you need from your preferred providers.

Medicare Insurance Options for Seniors

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Original Medicare is the government-run health insurance for seniors and disabled people that use private doctors, hospitals and other healthcare providers.

By comparison, Medicare Advantage (MA) plans that often include a prescription drug plan, stand-alone Prescription Drug plans (PDP) that are used with original Medicare and Medigap (Supplemental) plans are all sold by private insurance companies that are subsidized and regulated by Medicare.

These plans are offered by a variety of large for-profits (eg. United Healthcare, Humana, Aetna), national non-profit organizations such as Blue Cross and many regional non-profit insurers.

In addition, some seniors are eligible to receive their health insurance through their current or former employer.  And most Veterans are eligible to receive their health care and medications through the Veterans Administration.

Common Problems to Avoid

Your plan doesn’t include your preferred service providers.

If you don’t verify that your health care providers have a network contract with the insurer that you are considering, you could be facing huge bills. You could be responsible for paying the full cost of expensive services from health care providers or declined service.

Out-of-Network does not mean out of your area. Your preferred health care provider could be next door, but may not have a contract with your insurance company.

Be especially cautious of PPO plans, often sold by national insurers, that lead you to believe that you can go to any doctor anywhere. This is not accurate. Many times national insurers have not developed local provider networks or formal contracts. They often pay commissions to insurance agents to sell policies but do not have local staff to resolve provider and subscriber issues and concerns. These are often handled by central call centers.

The fine print in PPO plan documents includes this disclaimer: “Out-of-Network/non-contracted providers are under no obligation to treat plan members, except in emergencies”

This means that while you may have insurance, you may not be able to find a provider that accepts your plan, for a variety of reasons.

You Didn’t Anticipate High Deductibles and Out-of-Network Costs

Some plans, such as the Aetna Elite PPO are advertised as a $0 premium plan, however you need to pay the first $1,000 for many medical services plus an additional $350 deductible for Tier 3,4 & 5 drugs  including vaccines that do not have a generic equivalent. In HMO plans, you could be responsible for the full cost of “out-of-network” services.

Consumers need to be aware that each insurer decides what drugs to include and exclude, and what they will charge subscribers. Generally, you will be responsible for the full cost of medications that are not included in the plan’s formulary.  Drug prices can also vary by the pharmacy that you choose and if you choose a 90 day mail-order supply versus a more costly monthly supply.

In considering plans, you should not focus solely on the advertised premium cost, but rather your medical, drug, out-of-network needs and your projected out-of-pocket expenses including premiums, deductibles, co-pays, out-of-network charges and drug costs.unknown-1

Medicare.gov provides a  “plan finder” that helps you analyze medical & drug expenses among various plan options that are available where you live.

 

 

You Didn’t Consider Medigap Plans for High Medical Expenses and Maximum Choices

Many Medicare Advantage HMO plans have little or no out-of-network coverage and you may have to pay for the full costs of services that you receive. If you have serious medical conditions that require costly tests, hospitalization, nursing home rehabilitation, outpatient


surgery and intensive outpatient treatment such as cancer, heart disease, renal disease and/or you would like the freedom to select specialty providers outside of your plan’s network, you’ll need good coverage at an affordable price. “Original Medicare” has no limit on your annnual expenses. And, Medicare Advantage plans have a high annual maximum out-of-pocket limit of $6,700 but there is an alternative–Medigap plans.

As a general guide, if your projected annual out-of-pocket medical expenses (premiums, deductibles & co-pays – excluding your prescription drug expenses) exceeds $3,000/yr. and/or you want Medicare coverage across the country, you should explore a Medigap plan.

Medigap plans provide supplemental coverage to original Medicare and pays for deductibles and copays. All healthcare providers who participate in Medicare across the country are included and there are no out-of-network exclusions or surcharges.

Medigap plans are regulated by each state and you can receive information on the availability of plans and their premiums by contacting your state insurance department medicare.gov/contacts.

You Didn’t Think You Needed or Understood Differences in Prescription Drug Plansmed prices

Most Medicare Advantage plans include prescription drug (Part D) coverage. However, if you have “Original Medicare” with/or without a Medigap plan, you will also need to purchase a prescription drug plan (Part D) unless you have an approved employer drug plan or receive your medications from the VA.

If you don’t have a an approved drug plan and you want to purchase one at a later date, you are likely to be subject to a late enrollment penalty.

Part D plans are sold by private insurance companies and vary from state to state. For example, in New York State 27 plans are available from 10 different insurers. The premium and deductible cost of plans in New York varies widely from a Humana Walmart plan that costs $13 a month with a $435 deductible to a SilverScript plan that costs $91 a month with no deductible.

It is also important to check plans that you are considering to confirm that the medications that you need are included and what your co-pays and total annual expenses will be before enrolling in a plan.

Medicare.gov has a planfinder that compares the different cost of the various Part D plans based on the medications that you use and where you live.

You Didn’t Expect a Medicare Enrollment Penalties

penalty

Medicare rules require that if you want to receive Medicare benefits, you need to enroll and pay your Medicare Part B (outpatient) and Part D (prescriptions) premiums when you are first eligible. There are a few penalty exceptions, for example, if you receive creditable medical and drug insurance from you or your spouse’s employer, if you receive your medications from the VA.

Medicare penalties can be significant. The Part B (outpatient care) late enrollment penalty is 10% for each year, from the date of your initial Part B eligibility. The Part D (prescription drugs) penalty is 1% for each month from when you were initially eligible, or June 2006, the start of the program. There are a few circumstances when penalties can be reduced or eliminated.

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.

Investing time in planning and seeking objective advice in selecting a plan, can save you a lot of time, money and headaches. The following is a list of free resources that are available to help you.

Resources

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Social Security Administration, socialsecurity.gov, 800-772-1213

The Social Security Administration is the agency that you need to contact to apply for your Social Security benefits and enroll in Medicare Part B and D., In addition, you can be screened for eligibility (income and resources) and apply for “Extra Help” with your Part D premium and cost of your medications

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Medicare: Medicare.gov – 800-633-4227

An excellent resource with Medicare information and specific help in comparing Medicare Advantage and Prescription Drug Plans in your area.

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State Health Insurance Assistance Program  SHIP 877-839-2675

Medicare contracts with states, counties and nonprofit organizations to provide individuals with personalized education, support, and assistance with Medicare.

These free services include comparative plan information, eligibility for financial assistance as well as help with selecting a Medicare plan, enrolling, and resolving problems.

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Partnership for Prescription Assistance

 This is an online information resource tool. You can learn about assistance programs that are available for specific medications, along with the eligibility criteria and program applications.

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Medicare Rights Center, medicarerights.org , Helpline: 800-333-4114

The Medicare Rights Center is a national, nonprofit consumer service 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.

 

This article was updated in October 2019 from an earlier post.

Eight Costly Medicare Mistakes You Can Avoid

medicarecard

Ten thousand Baby Boomers turn 65 every day and are faced with making a decision of what Medicare option to select from many choices.

In addition, Medicare’s annual open enrollment runs from October 15th to December 7th. During this time, existing Medicare subscribers can join or change:

  • Medicare Advantage plans:
  • Return to the original Medicare coverage
  • Medicare Supplemental (Medigap) plans;
  • Part D Prescription Drug plan

It is very important to make an informed choice of the best insurance plan for your medical needs, preferences and budget. A bad choice could cost you thousands of dollars and prevent you from receive services that you need from your preferred providers.

Medicare Insurance Options for Seniors

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

By comparison, Medicare Advantage (MA) plans, Prescription Drug plans (PDP) and Medicare Supplemental plans (Medigap) are all run by private insurance companies but are subsidized and regulated by Medicare.

These plans include a variety of large for-profits (eg. UnitedHealthcare, Humana, Aetna), national non-profit organizations such as Blue Cross and many regional non-profit insurers.

In addition, some individuals are eligible to receive their health insurance, as a retiree or spouse, through their current or former employer and others receive their health care and medications through the Veterans Administration.

Eight Costly Medicare Mistakes to Avoid

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  1. Your plan doesn’t include your preferred doctors, hospitals, pharmacy and other service providers.

If you don’t confirm with your preferred providers that they have a network contract with the insurer you are considering, you could be facing a huge bill. For example, in some Aetna and United Health Care plans, you could be responsible for paying up to 40% of the cost of expensive services from out-of-network providers.

  1. Your plan’s coverage is too limited and costly for your needs.

Some plans that are sold, such as the Aetna Elite PPO ($0 premium plan), require that you pay the first $1,000 for many medical services and then pay up to 20% for future medical services. In addition, they require a $200 deductible for Tier 3-5 drugs.

While this plan is advertised as a zero premium, if you use a moderate amount of services and drugs, you could be paying up to the equivalent in $1,200/yr. in deductibles before your plan pays anything.

You should not focus solely on the advertised premium cost but rather your anticipated medical, drug and out-of-network needs and your projected total out-of-pocket expenses including premiums, deductibles, co-pays, out-of-network charges and drug costs.

Some regional plans such as Excellus Blue Cross and MVP limit your out-of-network coverage to $3,000 or less and you have to pay 30% of the cost of these services. If you have a serious medical condition that may need intensive treatment, and/or you travel for extended periods and would like the freedom to select specialty medical providers out of your plan’s network for your diagnosis and treatment, you’ll need adequate coverage at an affordable cost.

  1. Medical services that you need are very costly and uncertain.

Most insurers have shifted significant risks and financial responsibility from their company to their subscribers. It is common that plans now expect that subscribers will pay 20% of the cost of many expensive medical services such as Diagnostic Radiology (eg. MRI, CAT, PET scans); Outpatient Surgery; Radiation Therapy; Chemotherapy and other infusions; Dialysis; Medical Equipment and Prosthetics. These treatments could cost you thousands of dollars in annual out-of-pocket expenses.

If this is a concern, you should consider a Medigap plan that will eliminate the uncertainties of high out-of-pocket expenses and give you the broadest nationwide provider options for one monthly premium. With a Medigap plan, you will also need a separate prescription drug plan, but you can generally find both plans for a total cost of under $250 a month in upstate New York. The availability of Medigap plans and their premiums vary significantly by insurer, state and county. Here’s a link to locate plans in your community: Medigap .

  1. Prescription drugs that you need are not covered in your plan, or are too costly.

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Each plan creates their own formulary of drugs that they will cover, restrict, exclude and charge their subscribers. Insurers have been successful in moving subscribers away from brand name drugs to use their “preferred” generics and brand-name drugs by restricting access and offering lower co-pays for their “preferred” medications.

Each insurer separates their covered medications into 5-6 groups or tiers and each tier has the same subscriber dollar or percentage monthly charge.

However, there are significant differences among plans including which drugs they cover, if they charge deductibles and the cost they charge the subscriber. Your drug expenses will also vary, based on if you use a network “preferred”, standard or mail order pharmacy and if your pharmacy is subject to out-of-network charges. This is especially true of high-cost brand name and specialty drugs.

Another trend is that more plans are adding drug deductibles of up to $400 a year. This means that your insurer is not paying anything for your medications until you have paid the first $400.

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Medicare.gov has a very good Plan Finder feature that lets you enter your meds, preferred pharmacies and compare the plan’s total annual cost; what meds the plans cover, restricts and excludes; if there are deductibles, co-pays and restrictions; if there are generic equivalents; the cost of mail-order drugs and other network pharmacy options.

 

  1. You are not receiving federal or state financial assistance that you need and are eligible to receive.

There are a number of federal and state financial assistance programs that help low to moderate-income seniors and disabled persons. These can help lower the cost of your Medicare Part B (outpatient) health care and Part D (medications) premiums and co-pays; energy bills; VA benefits; food; property tax exemptions; housing, in-home services and much more.
benefitscheckupCheck Up is an excellent, free service offered through the National Council on Aging that screens people for hundreds of programs and services in each community across the country. For more information go to benefitscheckup.org/

  1. Medicare enrollment penalties

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Medicare rules require that if you want to receive Medicare benefits, you need to enroll and pay your Medicare Part B (outpatient) and Part D (prescriptions) premiums when you are first eligible. There are a few penalty exceptions, for example if you receive creditable medical and drug insurance from you or your spouse’s employer, if you receive your medications from the VA.

Medicare penalties can be significant. The Part B (outpatient care) penalty is 10% for each year, from the date of your initial Part B eligibility. The Part D (prescription drugs) penalty is 1% for each month since you were initially eligible, or June 2006, the start of the program.medicarepenalties

  1. Your choice of plans is not based on your likely needs and costs for the coming year.

You can easily be under-insured for your needs or paying too much in premiums, deductibles and co-pays for the services that you are likely to use in the coming year.

Make sure you’re not staying in your current plan because: it’s easier than changing; a persuasive salesperson, repetitive TV ads or friends have influenced you; you’re attracted to a low premium and not the true full cost of the plan.

You need to have objective and factual information that compares the benefits, costs and value of your various Medicare options to your needs and budget.

If you need help, contact State Health Insurance Assistance Program (SHIP)         877-839-2675 for free assistance in your community

  1. You’re not aware of your plan’s procedures for appealing the denial or restriction of services/medications and other quality of services issues.

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All private Medicare Advantage and Medigap plans are required to have procedures for reviewing and responding to complaints and appeals of decisions that deny or restrict medical services and prescription drugs.

To avoid problems, you should first review the plan’s Summary of Benefits, Drug Formulary, Provider directory and Appeals and Grievance procedures. These procedures include both internal and external reviews and responses to your concerns.

To start the process, you should contact your plan’s customer care center at the number on your insurance card.

You can also engage your medical provider and name a representative to assist you with your concerns. Medicare monitors the nature and frequency of complaints and disenrollment of subscribers from plans. These are factors in Medicare’s rating of plan. For more information, go to Medicare Quality Star Ratings.

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.

Investing time in planning and seeking objective advice in selecting a plan, can save you a lot of time, money and headaches.

Resources

SSA.jpeg

Social Security Administration, socialsecurity.gov, 800-772-1213

The Social Security Administration is the agency that you need to contact to apply for your Social Security benefits and enroll in Medicare Part B and D. In addition you can be screened for eligibility (income and resources) and apply for “Extra Help” with your Part D premium and cost of your medications

Unknown.jpeg

Medicare, Medicare.gov – 800-633-4227

An excellent resource with Medicare information and specific help in comparing Medicare Advantage and Prescription Drug Plans in your area.

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State Health Insurance Assistance Program  SHIP 877-839-2675

Medicare contracts with states, counties and nonprofit organizations throughout the country to provide individuals with personalized education, support and assistance with Medicare.

These free services include comparative plan information, eligibility for financial assistance as well as help with selecting a Medicare plan, enrolling, and resolving problems.

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Partnership for Prescription Assistance Partnership

 This is an online information resource tool. You can learn about assistance programs that are available for specific medications, along with the eligibility criteria and program applications.

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Medicare Rights Center, medicarerights.org , Helpline: 800-333-4114

The Medicare Rights Center is a national, nonprofit consumer service 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.