Consumers know it’s fall when stores start offering Halloween candy and flu shots — and the airwaves and mailboxes fill with ads for Medicare options.
It’s annual open enrollment time again 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, participants in the traditional program or Medicare Advantage plans, which are offered by private insurers, can change their coverage. (First-time enrollees typically sign up within a few months of their 65th birthday, whether during open enrollment season or not.)
There are a few new features for 2024, including a lower out-of-pocket limit for some patients on expensive medications.
Whatever happens, experts say, it’s a good idea for beneficiaries to examine their current coverage, because health and drug plans may have made changes, including to the pharmacies or medical providers in their networks and how much prescriptions cost.
“The advice is to check, check and check again,” says Bonnie Burns, a consultant with California Health Advocates, a nonprofit Medicare advocacy program.
But as anyone in the program or who helps friends or family members with coverage decisions knows, it’s complicated.
Here are a few things to keep in mind.
Know the Basics: Medicare vs. Medicare Advantage
People in traditional Medicare can see any participating doctor or hospital (and most do participate), while those in Medicare Advantage must choose from an itemized list of providers – a network – that is unique to that plan. Some Advantage plans offer a broader network than others. Always check whether your preferred doctors, hospitals and pharmacies are covered.
Because traditional Medicare does not cover prescriptions, members should also consider signing up for Part D, the optional drug benefit, which includes a separate premium.
Conversely, most Medicare Advantage plans include drug coverage, but be sure to check before you enroll because some do not. These private plans are heavily advertised, often touting that they offer “extras” not available in traditional Medicare, such as dental or vision coverage. Read the fine print to see what restrictions, if any, are placed on such benefits.
Those age 65 and older who are new to traditional Medicare can purchase a supplemental or “Medigap” policy, which covers many out-of-pocket costs, such as deductibles and copays, which can be significant. Generally, beneficiaries have six months after enrolling in Medicare Part B to purchase a Medigap policy.
So switching from Medicare Advantage to traditional Medicare during open enrollment could pose problems for those who want to purchase a supplemental Medigap policy. That’s because private insurers offering Medigap plans, with some exceptions, can turn away applicants with health problems, or increase premiums or limit coverage of pre-existing conditions.
Some states offer beneficiaries more guarantees that they can switch Medigap plans without answering health questions, although the rules vary.
To make all this even more confusing, there is a second open enrollment period each year, but it is only for those with a Medicare Advantage plan. They can change their plans or return to traditional Medicare from January 1 to March 31.
Drug coverage has changed – for the better
Beneficiaries who have enrolled in a Part D drug plan or receive drug coverage through their Medicare Advantage plan know that there are many copays and deductibles. But by 2024, some of these expenses will disappear for those who need a lot of expensive medicines.
President Joe Biden’s Inflation Reduction Act places a new annual cap on Medicare beneficiaries’ out-of-pocket costs for medications.
“That policy is going to help people who are taking very expensive medications for conditions like cancer, rheumatoid arthritis and hepatitis,” said Tricia Neuman, senior vice president and head of KFF’s Medicare policy program.
The cap will greatly help beneficiaries who fall into Medicare’s “catastrophic” coverage — an estimated 1.5 million Americans in 2019, according to KFF.
Here’s how it works: The cap is triggered after patients and their drug plans together spend about $8,000 on medications. KFF estimates that this means about $3,300 in out-of-pocket expenses for many patients.
Some people could reach the limit within one month, given the high prices of many drugs for serious conditions. After the limit is reached, beneficiaries will not have to pay anything out of pocket for their medications that year, saving them thousands of dollars annually.
It is important to note that this new limit will not apply to medications administered to patients, usually in doctor’s offices, such as many cancer chemotherapeutics. These drugs are covered by Medicare Part B, which pays for doctor visits and other outpatient services.
According to the Medicare Rights Center, next year Medicare will also expand opportunities for some low-income beneficiaries to qualify for low- or zero-premium drug coverage with no deductibles and lower copayments.
Insurers offering Part D and Advantage plans may also have made other changes to drug coverage, Burns said.
Beneficiaries should consult their plan’s “formulary,” a list of covered medications, and how much they will have to pay for the medications. Be sure to note whether prescriptions require a co-pay, which is a fixed dollar amount, or coinsurance, which is a percentage of the drug cost. In general, copayments mean lower out-of-pocket costs than coinsurance, Burns said.
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 details on the Advantage and Part D drug plans available by zip code. Allows users to view details about each plan’s benefits, costs, and healthcare provider network.
Insurers are expected to keep their supplier directories up to date. But experts say enrollees should contact directly the doctors and hospitals they would most like to confirm that they are participating in a particular Advantage plan. 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, Neuman said.
“There can be a significant difference in out-of-pocket expenses between one pharmacy and another, even in the same plan,” she said.
To get the most complete picture of estimated drug costs, Medicare beneficiaries should look up their prescriptions, dosages and their pharmacies, says Emily Whicheloe, education director at the Medicare Rights Center.
“For people with specific drug needs, it’s also a good idea to contact the plan and say, ‘Hey, will you still cover this drug next year?’ If not, change to a plan,” she said.
Additional enrollment assistance can be obtained for free through the State Health Insurance Assistance Program, which operates in all states.
Beneficiaries can also ask questions through a toll-free Medicare hotline: 1-800-633-4227 or 1-800-MEDICARE.
Insurance brokers can also help, but with a caveat. “Working with a broker can be fun for that personal touch, but know that they may not represent all plans in their state,” says Whicheloe.
Whatever you do, avoid telemarketers, Burns said. In addition to TV and mail ads, many Medicare beneficiaries are inundated with phone calls promoting private plans.
“Hang up,” Burns said.
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