Texas Medicare Made Clear

Medicare Frequently Asked Questions

Medicare Made Clear

 

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Texas Medicare FAQ's

General Medicare FAQ

Medicare is a federal government program that helps older folks and some disabled people pay their medical bills and prescription drug costs. The program is divided into four parts: Part A, Part B, Part C, and Part D.

  • Part A is called hospital insurance and covers most hospital stay costs, as well as some follow-up costs.
  • Part B, medical insurance, pays some doctor and outpatient medical care costs.
  • Part C is also called Medicare Advantage. It is run by private insurers and Medicare Managed Care plans (such as an HMO that provides Medicare-covered services as well as other coverage).
  • Part D covers some prescription drug costs.

Medicare Part A is funded primarily by payroll taxes, which end up in the Hospital Insurance Trust Fund. Medicare Part B revenue comes from both general revenues and premiums paid by Medicare beneficiaries. Medicare Advantage (Part C) is also funded by general revenues and by beneficiary premiums, while the Medicare Part D prescription drug plan is funded by general revenues, premiums and state payments.

Source: https://www.medicareresources.org/faqs/how-is-medicare-funded/

You will have to pay a late-enrollment penalty of 10% of the Medicare Part B premium for every year you should have had coverage. The penalty applies as long as you receive Medicare benefits. If you miss the initial enrollment period or the eight-month window after you or your spouse stops working, you can only sign up from January through March in any year for coverage to begin July 1.

Medicare covers a large variety of medical services. This includes doctor visits, preventive care, lab tests, emergency services, and even medical equipment. It also includes things like surgeries, and the treatment for cancer and do not forget hospital stays.

Medicare only covers care that is medically necessary.

Although enrolling in Medicare Part B is optional, you should NOT skip Part B unless you have other coverage. Otherwise you will be stuck owing 20% of the cost of a surgery or expensive CT scan.

Anyone age 65 or over is eligible for Medicare. Most people age 65 and over are covered under Medicare Part A at no cost, based on their work records or on their spouse’s.

People over 65 who are not eligible for free Medicare Part A coverage can enroll in it and pay a monthly fee for the same coverage. The premium base rate will depend on the number of work credits you have earned. If you pay for Part A hospital insurance, you must also enroll in Part B medical insurance, for which you will pay an additional monthly premium.

No. You have to be enrolled in Medicare in order to be eligible to enroll in a Medicare Part D plan, Medigap plan, or Medicare Advantage plan. A Medicare Part D prescription drug plan only requires that you be enrolled in Medicare Part A. However, in order to enroll within a Medigap plan or a Medicare Advantage plan, you must first be enrolled in both Medicare Part A and Medicare Part B.

Medicare covers most clinical services and supplies that are medically necessary to treat a beneficiary’s condition or injury. Your benefits and costs will depend on which parts of Medicare you’re enrolled in, whether you get your coverage through Original Medicare or a Medicare Advantage plan, supplemental coverage, and whether you have prescription drug coverage.

Medicare generally does not cover health-care services if you are moving to another country, even if you are still enrolled in Medicare. If you are a Medicare beneficiary moving outside the U.S., plan ahead and make sure you have health-care coverage (other than just Medicare) in that country. However, you might still want to retain your Medicare coverage in case you ever move back to the U.S.

According to Medicare.gov, a pre-existing condition is any health condition or disability that you have prior to the coverage start date for a new insurance plan. If you have Original Medicare or Medicare Advantage, you are generally going to be covered for all Medicare benefits even if you have a pre-existing conditions or a disability. However, if you’re enrolled in a Medicare Supplement (Medigap) plan or have end-stage renal disease (ESRD), there are some exceptions.

All the rules about how much Medicare Part A will pay depends on how many days of inpatient care you have during what is called a “benefit period,” or spell of illness. The benefit period will begin the day you enter the hospital or skilled nursing facility as an inpatient and will continue until you have been out for 60 consecutive days. If you are in and out of the hospital or nursing facility several times but have not stayed out completely for 60 consecutive days, all of your inpatient bills for that time will be figured as part of the same initial benefit period.

Medicare Part A pays only certain amounts of a hospital bill for any one benefit period—and the rules are slightly different depending on whether the care facility is a hospital, psychiatric hospital, or skilled nursing facility, or whether care is received at home or through a hospice.

All people covered by Medicare Part A must pay an initial amount before Medicare will pay anything. This is called the hospital insurance deductible. The deductible is increased yearly every January 1.

Part B medical insurance is intended to cover basic medical services provided by doctors, clinics, and laboratories. However, the lists of services specifically covered and not covered are long, and do not always make a lot of sense.

Making the effort to learn what is and is not covered can be important, because you may get the most benefits by fitting your medical treatments into the covered categories whenever possible.

Part B insurance will pay for:

  • doctor services (including surgery) provided at a hospital, a doctor’s office, or your home
  • mammograms, pelvic exams, bone density tests, and PAP smears for women
  • an annual flu shot
  • a one-time physical exam (called a “wellness exam”) done within six months of when you enroll in Medicare Part B
  • medical services provided by nurses, surgical assistants, or laboratory or X-ray technicians
  • outpatient hospital treatment, such as emergency room or clinic charges, X-rays, injections, and lab work
  • an ambulance, if required for a trip to or from a hospital or skilled nursing facility
  • drugs or other medicine administered to you at a hospital or doctor’s office (for prescription drug benefits, consider enrolling in Medicare Part D, discussed below)
  • medical equipment and supplies, such as splints, casts, prosthetic devices, body braces, heart pacemakers, corrective lenses after a cataract operation, glucose monitoring equipment, and therapeutic shoes for diabetics, and equipment such as ventilators, wheelchairs, and hospital beds
  • some kinds of oral surgery
  • some of the cost of outpatient physical and speech therapy
  • a limited number of services by podiatrists and optometrists
  • some care and counseling by psychologists, social workers, and daycare personnel
  • some preventative screening exams, such as for cancer, glaucoma, and osteoporosis; as well as diabetes and heart disease, but only if your doctor says you’re at risk for them
  • manual manipulation of out-of-place vertebrae by a chiropractor
  • Alzheimer’s-related treatments
  • scientifically proven obesity therapies and treatments, and
  • part-time skilled nursing care, physical therapy, and speech therapy provided in your home.

When all of your medical bills are added up, you will see that Medicare pays, on average, only about half the total. There are three major reasons why it pays so little.

First, Medicare does not cover a number of major medical expenses, such as glasses, hearing aids, dental work, dentures, and a number of other costly medical services.

Second, Medicare pays only a portion of what it decides is the proper amount—called the approved charges—for medical services. When Medicare decides that a particular service is covered, it determines the approved charges for it. Part B medical insurance then usually pays only 80% of those approved charges; you are responsible for the balance of 20%.

Third, the approved amount may seem reasonable to Medicare, but it is often considerably less than what doctors usually charge. If your doctor or other medical provider does not accept assignment of the Medicare charges, you are personally responsible for the difference, up to a certain maximum.

Note that there are several types of treatments and medical providers now for which Medicare Part B pays 100% of the approved charges versus the usual 80%. These categories of care include home health care, clinical laboratory services, and flu and pneumonia vaccines.

For Original Medicare, Part A and Part B a simple way to determine your exact Medicare effective date is to refer to the lower right corner of your Medicare card or to refer to your letter from either the Social Security Administration or the Railroad Retirement Board.

If you have any questions about when your Medicare coverage starts, you can contact Social Security at 1-800-772-1213, Monday through Friday, from 7AM to 7PM. For TTY services, call 1-800-325-0778.

If you worked for a railroad, you can call the Railroad Retirement Board at 1-877-772-5772, Monday through Friday, from 9AM to 3:30PM. For TTY services, call 1-800-325-0778.

If you enroll into a Medicare Advantage or Medicare Prescription Drug Plan, the date your coverage starts can vary, depending on when you enroll and which election period you qualify for. For questions about your effective date on these types of Medicare plan options, you must contact the Medicare health or drug plan directly.

If you get Social Security benefits, you can change your Medicare address online at the Social Security website. If you change your address online, you will be asked a series of questions to verify your identity. Your answers must match the information Social Security has in its records. You can only change your address online if you have established a permanent password, which can be created by visiting My Social Security.

If you do not want to answer the questions online or you do not have a permanent password, you cannot submit a change of address online. Instead, you can call the Social Security Administration at 1-800-772-1213 (TTY 1-800-325-0778), Monday through Friday, from 7AM to 7PM and speak to one of their representatives or visit your local Social Security office.

Not every doctor may accept Medicare assignment (a payment agreement). Doctors who have been approved to accept Medicare assignment can fall into any of the following categories:

  • Participating doctors accept Medicare assignment, meaning that they accept the Medicare-approved amount as payment for their services. These doctors charge the Medicare program 80% and the beneficiary 20% of the cost of the benefit.
  • Non-participating doctors can choose to either accept or not accept Medicare assignment. If the doctor does not accept Medicare assignment, you might have to pay a 15% additional charge above the cost of the service, known as a Medicare excess charge. You would then be responsible for up to 35% of the reduced Medicare-approved amount instead of 20%.
  • Doctors who have opted out of Medicare may charge you whatever they see fit for services and supplies, and you are responsible for the full cost of these benefits.

To find a participating doctor in your area, you may use the Medicare.gov Physician Compare tool. This tool will help you find an approved Medicare doctor based on medical specialty, geographical area, or doctor’s name. In addition to finding Medicare-approved physicians, this tool provides information about each doctor, along with maps and directions to help you find the doctor’s office.

That will depend on your situation. If you have worked at least 10 years (40 quarters) under Medicare-covered employment and paid Medicare taxes during that time, you qualify for premium-free Medicare Part A and will be automatically enrolled at age 65 even if you’re still working. If your spouse has enough employment quarters, you can also qualify for premium-free Medicare Part A based on his or her work history.

Another Medicare eligibility requirement is that you need to be an American citizen or permanent legal resident of at least five continuous years.

If you don’t have enough work history to get Medicare Part A without paying a premium, you can decide to delay enrollment if you already have health coverage through an employer or union (or through your own work or your spouse’s employer). Medicare Part B always comes with a monthly premium, so you may similarly choose to delay your Part B enrollment if you or your spouse are still working and have employer-based group coverage.

Remember that if you don’t sign up for Medicare when you’re first eligible and don’t have other coverage based on current employment, you could have to pay a late-enrollment penalty later when you do enroll. The late-enrollment penalty applies to Medicare Part B (and Part A, if you have to pay a premium for it).

One thing to consider is that even if you have health coverage through your employer or union, Medicare may help pay for some of the costs not covered by your group health plan. For example, enrolling in Medicare may be useful if you work for a small company (less than 20 employees) because Medicare could be the primary payer before your group health insurance. You may want to consult with your employer or union benefits administrator for specifics on how your health coverage and costs may compare with Medicare.

If you do decide to wait until your group coverage ends to enroll in Medicare Part A and/or Part B, you’ll have an 8-month Special Enrollment Period to sign up for Medicare that starts once you stop working or your group coverage ends (whichever happens first). You can also enroll in Medicare at any time that you are still working and have employer-based coverage.

If you choose COBRA after you stop working, do not wait until your COBRA coverage ends to sign up for Medicare. If you delay enrolling in Medicare Part A and/or Part B after your Special Enrollment Period ends, you’ll have to wait until the next General Enrollment Period (January 1 to March 31 every year) to enroll, and you may have to pay a late-enrollment penalty.

Medicare Part A, also known as hospital insurance, is part of Original Medicare, which is federal Medicare health insurance for qualified Americans aged 65 and older or to those of any age who enter their 25th month of receiving disability benefits through Social Security or the Railroad Retirement Board. You may also qualify at any age if you have certain health conditions, such as end-stage renal disease or amyotrophic lateral sclerosis (or Lou Gehrig’s disease). To be eligible for Medicare, you must be a U.S. citizen or a legal permanent resident of at least five continuous years.

Medicare Part A generally covers medically necessary services and supplies needed to treat a certain disease or condition and care when you’re a hospital inpatient in a Medicare-enrolled hospital. The following list describes some of the main services and supplies Part A specifically covers (this is not necessarily a complete list).

  • Hospital care: If you’re admitted as an inpatient, Medicare covers semi-private rooms, prescription drugs given as part of your inpatient treatment, meals, general nursing, and more.
  • Long-term care hospitals: Medicare covers long-term care hospital services if you were transferred from an acute-care hospital or admitted to the long-term care hospital within 60 days of being discharged from an inpatient hospital stay.
  • Skilled nursing facility care: If your doctor determines that you need care in a Medicare-certified skilled nursing facility, Medicare Part A covers certain services and supplies, generally for a limited time.

Medicare may cover services and supplies including, but not limited to: semi-private rooms, meals, skilled nursing care, medications, medical supplies and equipment, and ambulance transportation. There are several qualifying factors that determine whether Medicare will cover your stay in such a facility.

  • Nursing home care: Medicare might cover care in a skilled nursing facility (described above) as long as you need skilled nursing care and not just custodial care (help with eating, dressing, bathing, etc.).
  • Hospice: Medicare covers doctor services, nursing care, medical equipment, medical supplies, and more. To qualify, your doctor must certify that you’re terminally ill and expected live six months or less; you must agree to accept palliative care (aimed at easing your pain instead of delivering a cure); and you must sign an agreement stating that you’re accepting hospice care instead of other Medicare-covered treatments for your health condition.
  • Home health services: Medicare may cover certain home health services, generally for a limited time while you recover from a hospital stay. Medicare may cover intermittent at-home skilled nursing care, physical therapy, occupational services, and more for beneficiaries whose doctors certify that they need this care at home. The home health agency caring for the beneficiary must be Medicare-certified.

Medicare is a federal health insurance program that provides benefits to American citizens and permanent legal residents (of at least five continuous years) aged 65 and older, or who have a qualifying disability or illness. Most people are automatically enrolled into Original Medicare, Part A and Part B, when they become eligible; however, some people need to manually enroll in Medicare. Medicare Part A is hospital insurance; Medicare Part B is medical insurance.

You may want to take a look at these Medicare plan options.

  • Medicare Advantage (Medicare Part C) gives you a way to get your Original Medicare coverage through a private, Medicare-approved insurance company instead of directly through the government. Medicare Advantage plans provide all your Medicare Part A and Part B benefits other than hospice care, which Part A still covers. But many Medicare Advantage plans include extra benefits, such as routine dental and vision services. And most Medicare Advantage plans include prescription drug coverage, letting you get all your Medicare benefits through a single plan. You still need to continue paying your Medicare Part B monthly premium, besides any premium the Medicare Advantage plan might charge.
  • If you stay with Original Medicare, be aware that prescription drugs aren’t covered in most situations. Medicare Part D offers prescription drug coverage through private, Medicare-approved insurance companies. You may want to consider adding a stand-alone Medicare Prescription Drug Plan.
  • If you decide to stay with Original Medicare, another option you may have is to sign up for a Medicare Supplement (Medigap) insurance plan to help pay for Original Medicare’s out-of-pocket costs. Different Medigap plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.

Availability and costs of Medicare plan options may vary from one insurance company to another, and from one geographic area to another.

Medicare pays just for limited ambulance services. If you go to a hospital or skilled nursing facility (SNF), ambulance services are covered only if any other transportation could be a danger to your life or health. If the care you need is not available locally, Medicare helps pay for necessary ambulance transportation to the closest facility outside your local area that can provide the care you need.

If you choose to go to another facility farther away, Medicare payment is determined based on how much it would cost to go to the closest facility. All ambulance suppliers must accept assignment. Medicare does not pay for ambulance transportation to a doctor’s office. Air ambulance is paid only in emergency situations, such as when you can’t be easily reached by land, or if heavy traffic could prevent you from getting crucial care quickly. If you could have been transported by land ambulance without serious danger to your life or health, Medicare pays only the land ambulance rate and you are responsible for the difference.

If you have end-stage renal disease (ESRD), in some cases Medicare may cover ambulance services to and from a dialysis facility. If you have questions about Medicare coverage of ambulance transportation, contact Medicare at 1-800-MEDICARE (1-800-633-4227; TTY users 1-877-486-2048), 24 hours a day, 7 days a week.

Original Medicare is made up of Part A (hospital insurance) and Part B (medical insurance), and includes certain coverage for mental health care when the care comes from a Medicare-assigned health-care provider. Learn more about this Medicare coverage below.

Medicare Part A covers hospital inpatient mental health care, including room, meals, nursing, and other related services and supplies. This care can be received in a general hospital or a psychiatric hospital.

Medicare has a lifetime limit of 190 days of inpatient care in a psychiatric hospital.

Medicare uses benefit periods for hospital coverage. A benefit period begins the day you’re admitted as a hospital inpatient, and ends when 60 days in a row have passed since you have received inpatient care.

Your Medicare Part A costs for mental health care are listed below. Please note that the deductible and coinsurance amounts may vary year to year. You pay:

  • The Medicare Part A deductible – $1,364 in 2019  (the full deductible amount is applied for each benefit period)
  • No coinsurance ($0) for days 1-60
  • $341 coinsurance per day in 2019 for days 61-90
  • $682 coinsurance in 2019 per “lifetime reserve day” after the 90th day. Lifetime reserve days are days that you remain an inpatient beyond the 90-day hospital stay that Medicare covers. Medicare pays for your covered costs, charging you a daily coinsurance amount, for up to 60 of these days in your lifetime.
  • All costs after your lifetime reserve days are used up

In addition to Medicare Part A costs, you may have some costs associated with Medicare Part B even when you’re a hospital inpatient (for example, doctor services).

Medicare Part B covers mental health services usually given outside a hospital, including visits with health professionals such as doctors, clinical psychologists, and clinical social workers. Some of the other mental health services that Medicare Part B may cover include, but aren’t limited to:

  • Annual depression screenings
  • Psychiatric evaluation
  • Certain diagnostic tests your provider orders
  • Partial hospitalization (a structured program of outpatient psychiatric services as an alternative to inpatient mental health care)
  • Individual and group psychotherapy by licensed professionals permitted by the state where therapy takes place
  • Medication management
  • Family counseling as part of your treatment

Your Medicare Part B costs for mental health care are listed below. Please note that the deductible and coinsurance amounts may vary year to year. The annual depression screenings are free if you get them from a Medicare-assigned health-care provider. For other mental health services, you pay:

  • The Medicare Part B deductible – $185 in 2019
  • 20% of the Medicare-approved amount of health-care provider services
  • A possible additional copayment or coinsurance if you receive your services as a hospital outpatient. The amount you pay depends on the service provided, but is generally 20%of the Medicare-approved amount.

If you’re enrolled in a Medicare Advantage plan, you still get the same coverage listed above, and your plan might include additional benefits, such as prescription drug coverage. Offered by private Medicare-approved insurance companies, Medicare Advantage plans must provide at least the same coverage as Medicare Part A and Part B (except for hospice care, which Medicare still covers). You still continue paying your Medicare Part B premium along with any premium the Medicare Advantage plan may charge.

The only chiropractic service covered by Medicare is manual manipulation of the spine to correct subluxation. Subluxation of the spine is when one or more of the bones of your spine move out of position. This is covered by Medicare Part B (medical insurance) in instances where it is medically necessary and provided by a chiropractor or other qualified provider. You do not need an X-ray to prove you have a subluxation of the spine.

One way you may be able to get additional Medicare chiropractic coverage is through a Medicare Advantage (MA) plan. Some Medicare Advantage plans could provide additional chiropractic coverage benefits. Check with your Medicare Advantage plan directly to see what chiropractic services are covered. You still need to continue paying your monthly Part B premium along with any premium the plan might charge.

No. Original Medicare does not cover dentures. In general, Medicare does not cover any routine dental care, including cleanings or check-ups, and never pays for dentures. It may cover the cost of teeth extraction before an inpatient procedure, but will not cover the cost of dentures after the procedure. For example, if you broke your jaw, then Original Medicare would cover any teeth extraction related to the jaw injury.

Certain Medicare plan options offered by private Medicare-approved insurance companies — such as Medicare Advantage plans — might offer dental coverage.

Original Medicare, Part A and Part B, does not generally cover routine eye exams for eyeglasses or contact lenses. However, Medicare Part B will cover an annual eye exam every 12 months if you have diabetes or are at high risk for glaucoma. Part B coverage also includes diagnostic tests and treatment for certain eye diseases, such as lucentis, aflibercept, and ocular photodynamic therapy.

Because Medicare Advantage plans must offer at least the same coverage as Original Medicare, these plans (offered by private, Medicare-approved insurance companies) also cover the circumstances described above. However, some Medicare Advantage plans may offer additional coverage, which could include routine vision benefits. Certain Medicare Supplement (Medigap) plans may also cover vision-related costs or provide additional eye coverage for an extra cost.

Durable medical equipment (DME) is reusable medical equipment, such as walkers, wheelchairs, or crutches. If you have Medicare Part B, Medicare covers certain medically necessary durable medical equipment if your physician or treating practitioner prescribes it for you to use in your home.

To be covered, the prescribed medical equipment must be:

  • Durable.
  • Used for a medical purpose.
  • Not typically useful if you aren’t sick or hurt.
  • Used in your home.*

*If you are currently residing in a hospital or nursing home that is providing you with Medicare-covered care, these facilities don’t qualify as your “home.” However, a long-term care facility does qualify as your home. If you’re staying in a skilled nursing facility and the facility provides you with durable medical equipment, the nursing facility is responsible for the durable medical equipment.

Some examples of durable medical equipment that Medicare covers may include, but isn’t limited to: Hospital beds, infusion supplies, oxygen equipment, patient lifts, and blood sugar monitors. If you have questions about whether a particular item or supply is covered, call 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. Medicare customer service representatives are available 24 hours a day, seven days a week.

It depends. Residents of the U.S., including citizens and permanent residents, are eligible for premium-free Medicare Part A if they have worked at least 40 quarters (10 years) in jobs where they or their spouses paid Medicare payroll taxes and are at least 65 years old. Legal immigrants who are age 65 or older who do not have this work history can purchase Medicare Part A after residing legally in the U.S. for five years continuously. Legal immigrants (non-citizen permanent residents) under age 65 with disabilities may also qualify for Medicare, but typically first must meet the same eligibility requirements for SSDI (disability benefits) that apply to citizens, which are based on work history, paying Social Security taxes on income, and having enough years of Social Security taxes accumulated to equal between 20 and 40 work credits (5-10 years). New immigrants are not eligible for Medicare regardless of their age. Once immigrants meet the residency requirements, eligibility and enrollment works the same as it does for others.

You will typically be automatically enrolled in Original Medicare, Part A and B, after you’ve received Social Security disability benefits (or certain Railroad Retirement Board disability benefits) for two straight years. Your Medicare coverage will start 24 months from the month you qualified for disability benefits. In some cases, this could be earlier than the month when you received your first check. You must be either a U.S. citizen or legal permanent resident of at least five continuous years to be eligible for Medicare.

Note that certain conditions may qualify you for Medicare under age 65, but have different enrollment details than those described above.

  • If you have Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis, or ALS), you’re enrolled in Medicare automatically the first month you receive disability benefits from Social Security or the Railroad Retirement Board.
  • If you have end-stage renal disease (ESRD), you might qualify for Medicare, but you’re not automatically enrolled. If you’re on dialysis or you’ve had a kidney transplant, contact Social Security (information below).

You can get more information about Medicare and Social Security disability benefits from the Social Security Administration:

If you are happy with your coverage under traditional Medicare, you do not need to take any action during the Medicare Open Enrollment period. If you do nothing during the Medicare Open Enrollment period, your coverage under traditional Medicare will continue next year.

The timing of enrollment does not matter, as long as you enroll before the Medicare Open Enrollment period ends on December 7. Keep in mind that it can take some time to compare plans, and you may want to have a list of all the medications you take and the providers you see before you sit down to compare plans. If you wait until the end of the Medicare Open Enrollment period to enroll in a plan, you should still receive your new plan information before your new coverage takes effect on January 1.

You can, but generally only under special circumstances that qualify you for a Special Enrollment Period (SEP). These circumstances include (but are not limited to) moving to a new location that is outside of your current plan’s service area or where additional plan options are available, moving back into the U.S. after living abroad, moving into or out of a facility, or if Medicare terminates your current Medicare Advantage plan.

Some beneficiaries can change coverage on a quarterly basis. This includes enrollees who receive assistance from Medicaid and enrollees who receive Extra Help paying their Medicare drug plan premiums and cost sharing, who can switch Part D plans or Medicare Advantage plans once per calendar quarter in the first three quarters of the year, and during the Medicare Open Enrollment period that runs from October 15 through December 7 each year. Some beneficiaries can change coverage from month to month. This includes beneficiaries in certain institutions, such as nursing homes, who are allowed to switch Medicare Advantage or Part D plans once a month for as long as they are living there.

If you are currently enrolled in a Medicare Advantage plan and would like to switch to traditional Medicare, or switch to another Medicare Advantage plan, you may do so during the Medicare Open Enrollment period, which runs from October 15 through December 7 each year, or during the second Open Enrollment Period just for people in Medicare Advantage plans (the Medicare Advantage Open Enrollment period), which runs from January 1 through March 31. If you are in traditional Medicare, you can switch Part D plans or switch to a Medicare Advantage plan during the Medicare Open Enrollment period that runs from October 15 through December 7; you cannot use the Medicare Advantage Open Enrollment period (from January 1 to March 31) unless you are enrolled in a Medicare Advantage plan before January 1.

Hospice programs­­ provide care and support people who are terminally ill. Their focus is on comfort, or “palliative” care, not on curing an illness. The National Hospice and Palliative Care Organization reports that 1.43 million Medicare beneficiaries were enrolled in hospice care for at least one day in 2016.

Medicare covers almost all aspects of hospice care with little expense to patients or families, as long as a Medicare-approved hospice program is used (in 2016, there were more than 4,300 Medicare-certified hospice programs in the US). When a Medicare beneficiary enters hospice the hospice benefits are provided via Original Medicare, even if the beneficiary had previously been enrolled in Medicare Advantage.

But if a Medicare Advantage enrollee who is in hospice care needs treatment for something that isn’t part of the terminal illness or related conditions, they can choose to use Original Medicare or their Medicare Advantage coverage.

To qualify, a patient must be eligible for Medicare Part A, and a doctor must certify that the patient is terminally ill and has six months or less to live. Medicare-approved programs usually provide care in your home or other facility where you live, such as a nursing home or, in some cases, hospitals.

Medicare covers a full complement of medical and support services for a life-limiting illness, including drugs for pain relief and symptom management; medical, nursing and social services; certain durable medical equipment and other related services, including spiritual and grief counseling, which Medicare typically doesn’t cover. There’s no deductible for hospice care, and copays for covered medications related to the terminal condition won’t exceed $5 (note that if a hospice patient needs medications that aren’t related to the terminal condition, their Part D plan would still have to cover them with its normal cost-sharing requirements, and their medical provider has to notify the Part D plan that the medications are unrelated to the terminal condition. This can be complicated, but it’s important for beneficiaries and their families to understand).

Medicare will also cover respite care, which is a short-term stay at a qualified hospice facility. It gives the usual caregiver a chance to rest. Respite care may last up to five days at a time.

Typically, Medicare does not cover room and board in facilities like nursing homes, but in-patient hospice care is covered during respite care, or at other times if the hospice programs deems it necessary and arranges it. If a hospice patient receives respite care, the patient will be billed 5 percent of the Medicare-approved cost of the inpatient care, and Medicare will pay the other 95 percent. Medigap plans can help to cover the out-of-pocket costs associated with hospice care, including respite care.

Hospice care continues as long as the hospice medical director or doctor recertifies that you’re terminally ill.

Source: https://www.medicareresources.org/faqs/does-medicare-cover-hospice-care/

In general, once you’re enrolled in Medicare, you don’t need to take action to renew your coverage every year. This is true whether you are in Original Medicare, a Medicare Advantage plan, or a Medicare prescription drug plan. As long as you continue to pay any necessary premiums, your Medicare coverage should automatically renew every year with a few exceptions as described below.

There are some exceptions where you will need to take action to continue your coverage. Some situations where your Medicare Advantage or stand-alone Medicare Part D prescription drug plan coverage won not be automatically renewed include, but aren’t limited to:

  • Your plan reduces its service area, and you now live outside of its coverage area.
  • Your plan doesn’t renew its Medicare contract for the upcoming year.
  • Your plan leaves the Medicare program in the middle of the year.
  • Medicare terminates its contract with your plan.

If your Medicare plan doesn’t renew its contract with Medicare for the coming year, your Special Election Period will run from December 8 to the last day of February of the following year. If you have Medicare Advantage and don’t enroll in a new plan by the date that your current plan ends its contract with Medicare, you’ll be automatically returned to Original Medicare.

Keep in mind that your new coverage starts on the first day of the month after you submit your enrollment application, meaning if you apply on February 8, your new Medicare plan wouldn’t begin until March 1.

You’ll also get a three-month Special Election Period if your Medicare Advantage or Medicare Part D Prescription Drug Plan terminates its contract with Medicare. This period starts two months before the contract ends and runs an additional month after the contract ends. If Medicare terminates your plan’s contract, you will have a Special Election Period that begins 1 month before the termination effective date and ends 2 months after the effective date of the termination.

While you may not need to renew your Medicare coverage, it’s still a good idea to review your coverage annually. Benefits, provider and pharmacy networks, drug formularies, and cost sharing can all change from year to year and affect how much you pay out of pocket. Comparing plans annually is one way to make sure your coverage continues to meet your health needs and budget.

During the Medicare Open Enrollment period, from October 15 to December 7, you can make many changes to your Medicare coverage, depending on the coverage you already have. You can change from traditional Medicare to a Medicare Advantage plan (or vice versa). If you prefer Medicare Advantage, you can choose among the Medicare Advantage plans offered in your area during this period. If you are in traditional Medicare, and want prescription drug coverage, you can choose among Medicare prescription drug plans.

Medicaid is a joint federal and state program that helps pay medical bills for people with low income and limited resources. Eligibility for Medicaid depends on income level and family size.

Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. Medicaid may pay for homemaker, personal care, and other services that are not covered by Medicare. There are Medicaid programs that pay some or all of Medicare’s premiums and may also pay deductibles and coinsurance for certain people who qualify for Medicare and need financial assistance.

Absolutely not. Medicare is a federal health coverage program designed for the elderly and individuals with certain qualifying health conditions such as ESRD (End Stage Renal Disease). Medicaid is a state-run health coverage program that primarily targets low-income individuals that live within the state.

New To Medicare FAQ

If you signed up for Social Security before age 65 (eligibility for full benefits currently begins at age 66), you will automatically be enrolled in Medicare parts A and B and receive your card three months before your 65th birthday. Part A covers hospitalization and is generally premium-free; Part B covers outpatient care, such as doctors’ visits, x-rays and tests, and costs $134 a month for people who enroll in 2017 (or more for high earners).

Everyone else needs to take steps to enroll—or face a lifetime late-enrollment penalty (unless you’re still working and have employer coverage; see below). Go to www.socialsecurity.gov to sign up anytime from three months before until three months after you turn 65 (your “initial enrollment period”), even if you are waiting to file for Social Security benefits.

People who are turning age 65 have an initial enrollment period that lasts until three months after their 65th birthday. If you don’t sign up during that period, you’ll have to wait for a general enrollment period or a special enrollment period (if you delayed signing up because you had an employer group health plan). Coverage start dates depend on what type of period you signed up in.

Anyone age 65 or over is eligible for Medicare. Most people age 65 and over are covered under Medicare Part A for free, based on their work records or on their spouse’s work records.

People over 65 who are not eligible for free Medicare Part A coverage can enroll in it and pay a monthly fee for the same coverage. The premium base rate depends on the number of work credits you’ve earned. If you pay for Part A hospital insurance, you must also enroll in Part B medical insurance, for which you pay an additional monthly premium.

The rules of eligibility for Part B medical insurance are simpler than for Part A: If you are age 65 or over and are either a U.S. citizen or a permanent resident who has been here lawfully for five consecutive years, you are eligible to enroll in Medicare Part B medical insurance. This is true whether or not you are eligible for Part A hospital insurance.

That depends on the size of your company. If you or your spouse (if you’re covered by your spouse’s insurance) is still working for a firm with 20 or more employees, the employer’s insurance is your primary coverage, and Medicare is secondary and can fill any gaps in coverage. You aren’t required to sign up for Medicare at 65, and you won’t have a late-enrollment penalty as long as you sign up within eight months of leaving your job and losing work-based coverage (or losing coverage under your spouse’s insurance).

This depends on your situation. If you’ve worked at least 10 years (40 quarters) under Medicare-covered employment and paid Medicare taxes during that time, you qualify for premium-free Medicare Part A and will be automatically enrolled at age 65 even if you’re still working. If your spouse has enough employment quarters, you can also qualify for premium-free Medicare Part A based on his or her work history.

Another Medicare eligibility requirement is that you need to be an American citizen or permanent legal resident of at least five continuous years.

If you don’t have enough work history to get Medicare Part A without paying a premium, you can decide to delay enrollment if you already have health coverage through an employer or union (or through your own work or your spouse’s employer). Medicare Part B always comes with a monthly premium, so you may similarly choose to delay your Part B enrollment if you or your spouse are still working and have employer-based group coverage.

Remember, if you don’t sign up for Medicare when you’re first eligible and don’t have other coverage based on current employment, you could have to pay a late-enrollment penalty later when you do enroll. The late-enrollment penalty applies to Medicare Part B (and Part A, if you have to pay a premium for it).

One factor to consider is that even if you have health coverage through your employer or union, Medicare may help pay for some of the costs not covered by your group health plan. For example, enrolling in Medicare may be useful if you work for a small company (less than 20 employees) because Medicare could be the primary payer before your group health insurance. You may want to consult with your employer or union benefits administrator for specifics on how your health coverage and costs may compare with Medicare.

If you do decide to wait until your group coverage ends to enroll in Medicare Part A and/or Part B, you’ll have an 8-month Special Enrollment Period to sign up for Medicare that starts once you stop working or your group coverage ends (whichever happens first). You can also enroll in Medicare at any time that you are still working and have employer-based coverage.

If you choose COBRA after you stop working, do not wait until your COBRA coverage ends to sign up for Medicare. If you delay enrolling in Medicare Part A and/or Part B after your Special Enrollment Period ends, you’ll have to wait until the next General Enrollment Period (January 1 to March 31 every year) to enroll, and you may have to pay a late-enrollment penalty.

Yes, in certain situations, you can delay your Medicare Part B enrollment without paying higher premiums (also known as a late-enrollment penalty). If you didn’t enroll in Medicare Part B when you were first eligible because you or your spouse was working and had group coverage through an employer or union, you can choose to sign up for Medicare Part B during a Special Enrollment Period (SEP) without paying a late-enrollment penalty.

You can sign up for Medicare Part B at any time that you have coverage through current or active employment. Or you can sign up for Medicare during the eight-month Special Enrollment Period that starts when your employer or union group coverage ends or you stop working (whichever happens first). If you get COBRA or retiree benefits after you stop working, keep in mind that this doesn’t count as coverage based on current employment; make sure you don’t wait until your COBRA benefits end to enroll in Medicare Part B.

Remember that if you do not enroll in Medicare Part B during your Special Enrollment Period, you’ll have to wait until the next General Enrollment Period, which occurs from January 1 to March 31 each year. You may then have to pay a late-enrollment penalty for Medicare Part B because you could have had Part B and did not enroll. If you owe a late-enrollment penalty, you’ll pay a 10% higher premium for every 12-month period that you were eligible for Medicare Part B but didn’t sign up for it. You may have to pay this higher premium for as long as you’re enrolled in Medicare.

There are a few other situations when you may be able to delay Medicare Part B without paying a late-enrollment penalty. For example, if you were volunteering overseas or if you were living out of the country when you turned 65 and weren’t eligible for Social Security benefits, you may be eligible for a Special Enrollment Period when you return to the United States. The length of your SEP will depend on your situation. If you aren’t sure if you qualify for a Special Enrollment Period, call Medicare to confirm at 1-800-633-4227 (TTY users 1-877-486-2048), 24 hours a day, seven days a week.

It depends. If you’re receiving benefits from Social Security or the Railroad Retirement Board (RRB) at least four months before you turn 65, you do NOT need to sign up; you’ll automatically get Part A and Part B starting the first day of the month that you turn 65. You should receive your Medicare card in the mail three months before your 65th birthday. If you are NOT receiving benefits from Social Security or the RRB at least four months before you turn 65, you will need to sign up with Social Security to get Parts A and B. To sign up to receive Parts A and B, you can enroll online with Social Security, call Social Security at 1-800-772-1213, or visit your local Social Security office.

It depends on how you are receiving your current insurance. If you are receiving employer-sponsored health insurance through either your or your spouse’s job when you turn 65, you may be able to keep your insurance until you (or your spouse) retire(s). You will need to contact your employer’s benefits representative to find out whether or not they will continue your coverage when you turn 65. Since Medicare Part A is premium-free for most beneficiaries, you may want to enroll in Part A as soon as you are eligible (i.e., three months prior to the month of your 65th birthday), even if you will continue to receive employer-sponsored insurance at that time. If you are covered under an employer plan, you may want to delay signing up for Part B until you (or your spouse) retire(s). However, it is a good idea to check with Social Security or Medicare to confirm you will not fact a penalty for late enrollment. Similarly, unless you have drug coverage that is as good as what Medicare drug plans offer, you will need to sign up for a Medicare prescription drug plan when you enroll in Medicare or you may face a late enrollment penalty.

If you do not sign up for Part B at the appropriate time, you may face a late enrollment penalty that will increase your Part B premium by 10% of the standard monthly premium for each 12-month period that you delayed enrollment. Similarly, there is a late enrollment penalty if you do not sign up for Part D coverage when you were first eligible to do so and do not have drug coverage that is as good as what Part D offers (“creditable coverage”). The Part D penalty for late enrollment is equal to 1% of the national average premium multiplied by the number of months you did not have “creditable” drug coverage.

If you have coverage through a Marketplace plan, you should sign up for Medicare when you turn 65 and notify your Marketplace plan that you now qualify for Medicare coverage. Your Marketplace coverage will not be cancelled automatically by your plan when you turn 65 and sign up for Medicare, but if you receive premium tax credits to help you pay for your Marketplace plan premium, your eligibility for these tax credits will end when your Medicare Part A coverage begins (people with Medicare are not eligible for these tax credits, and the premium tax credit can only be used for the purchase of Marketplace coverage).

If you choose to enroll in Medicare Part A and keep your Marketplace coverage, you will have to pay the full price for your Marketplace plan, and Medicare will be the primary payer. If you were receiving financial assistance for your Marketplace coverage prior to signing up for Medicare, you will receive a letter in the mail from the Marketplace informing you that you are no longer eligible to receive this financial assistance since you are enrolled in Medicare Part A. You should contact your Marketplace plan to make sure that your financial assistance is stopped when your Medicare coverage begins. If you do not stop receiving the premium tax credit and other financial assistance for your Marketplace plan when your Medicare coverage begins, you may have to repay some or all of the amount of financial assistance you received for the months you had both types of coverage.

If you decide to drop your Marketplace coverage when you become eligible for Medicare, make sure your Medicare coverage has started before you cancel your Marketplace plan so that you avoid any gaps in coverage. You can start signing up for Medicare three months before your 65th birthday.

If you are eligible for Medicare, your initial enrollment period for Part A and Part B begins three months before the month of your 65th birthday and ends three months after it. For example, if your 65th birthday is in June, your enrollment period will extend from March 1st through September 30th. Once you have Part A and Part B, you are then also eligible to enroll in a Medicare Advantage (Part C) plan and/or a Part D (prescription drug) plan. If you are already receiving Social Security benefits when you turn 65, you will automatically be enrolled in Part A and Part B. If you are not already receiving Social Security benefits and you want to enroll in Medicare, you should contact Social Security.

Part B is voluntary, but you may face a penalty for late enrollment if you do not sign up it when you turn 65, unless you or your spouse are still working and have a group health plan from the employer. Similarly, Part D is voluntary, but you may face a penalty for late enrollment if you sign up for a Part D plan after your initial enrollment period ends and you go for more than 63 days without a source of drug coverage at least as good as what Medicare Part D offers.

Unless you or your spouse is still working and has current employer coverage, you should sign up for both Medicare Part A and Part B at 65. Retiree coverage can fill gaps in Medicare (which would otherwise require medigap and Part D policies or a Medicare Advantage plan), but it’s secondary to Medicare after age 65, and it may not kick in at all if you don’t sign up for Medicare. Federal retiree coverage is an exception; it remains your primary coverage if you don’t sign up for Medicare, but you will pay a penalty if you decide to sign up for Part B later.

Yes, as long as you haven’t enrolled in Medicare. If you are able to delay signing up for Medicare parts A and B (see above), you can continue contributing to an HSA. Before you decide, determine whether the HSA’s tax breaks, any employer contributions and other benefits are more valuable than the premium-free Part A coverage.

For Original Medicare, Part A and Part B a simple way to determine your exact Medicare effective date is to refer to the lower right corner of your Medicare card or to refer to your letter from either the Social Security Administration or the Railroad Retirement Board.

If you have any questions about when your Medicare coverage starts, you can contact Social Security at 1-800-772-1213, Monday through Friday, from 7AM to 7PM. For TTY services, call 1-800-325-0778.

If you worked for a railroad, you can call the Railroad Retirement Board at 1-877-772-5772, Monday through Friday, from 9AM to 3:30PM. For TTY services, call 1-800-325-0778.

If you enroll into a Medicare Advantage or Medicare Prescription Drug Plan, the date your coverage starts can vary, depending on when you enroll and which election period you qualify for. For questions about your effective date on these types of Medicare plan options, you can contact the Medicare health or drug plan directly.

The annual Medicare Open Enrollment period begins on October 15 and continues until December 7. For 2020 coverage, open enrollment will run from October 15, 2019, to December 7, 2019.

During the annual enrollment period (AEP)  you can make changes to various aspects of your coverage.

  • You can switch from Original Medicare to Medicare Advantage, or vice versa.
  • You can also switch from one Medicare Advantage plan to another, or from one Medicare Part D (prescription drug) plan to another.
  • And if you didn’t enroll in a Medicare Part D plan when you were first eligible, you can do so during the general open enrollment, although a late enrollment penalty may apply.

If you want to enroll in a Medicare Advantage plan, you must meet some basic criteria.

  • You must be enrolled in Medicare Part A and B.
  • You must live in the plan’s service area.
  • You cannot have End-Stage Renal Disease (some exceptions apply; ESRD patients will be able to enroll in Medicare Advantage plans as of 2021, under the terms of the 21st Century Cures Act).

Source: https://www.medicareresources.org/faqs/when-is-the-next-medicare-open-enrollment-period/

Medicare beneficiaries with incomes above $85,000 for individuals and $170,000 for married couples are required to pay higher premiums. The amount you pay depends on your modified adjusted gross income from your most recent federal tax return. To determine your 2019 income-related premium, Social Security will use information from your tax return filed in 2018 for tax year 2017. If your income has gone down since you filed your tax return, you should contact Social Security and provide documentation regarding this change. At your current income level, in 2018, you would pay about $4,100 in annual Medicare premiums combined for Part B ($3,252) and Part D (around $835, on average).

Here’s a quick rundown of your Medicare coverage options beyond Original Medicare:

  • You can have Original Medicare and enroll in a stand-alone Medicare Part D Prescription Drug Plan.
  • You can have Original Medicare and purchase a Medigap (Medicare Supplement) plan. There are 10 standardized Medigap policies in most states, and they cover varying amounts of your Medicare Part A and Part B costs (such as coinsurance and deductibles), depending on the Medigap policy.
  • Or you can enroll in a Medicare Advantage plan. With a Medicare Advantage plan, you get your Medicare Part A and Part B benefits through a private, Medicare-approved insurance company. Many Medicare Advantage plans include prescription drug coverage, so you can get all your Medicare health and drug benefits in a single plan.

You typically continue paying your monthly Medicare Part B premium with any of these options.

Medigap FAQ

What is Medigap? By definition, Medigap is private insurance that fill in the gaps between your Medicare benefits and what you must pay out of pocket. You purchase them from private insurance companies to help pay for things that Medicare does not pay for. This includes deductibles and copays that otherwise you would be responsible for.

Sometimes called a Medicare supplement, Medigap policies give you freedom to choose your own doctor. Once insured, you can never be dropped due to health reasons.

Medigap carriers offer 10 standardized insurance plans. They are each labeled with a letter of the alphabet. Each insurance plan has a different combination of benefits. (There is also one high deductible insurance plan.)

Some of the gaps that Medigap plans can cover for you are:

  • Hospital deductibles, copays and an extra 365 days in the hospital
  • The first 3 pints of blood as necessary in a transfusion
  • Outpatient deductibles, coinsurance and excess charges
  • Skilled Nursing coinsurance
  • Foreign travel emergency care

The best time to apply for a Medicare supplement is during your open enrollment window. This window runs for six months from the effective date of your Medicare Part B, or when you turn 65, whichever is later. During this window, the insurance company cannot deny you coverage for any health reason, nor can they can raise their rates just on you due to any health conditions.

Some people choose to delay their enrollment into Medicare because they have other creditable coverage such as employer group health insurance. For these individuals, their 6-month Medigap open enrollment window will begin later one whenever they enroll in Part B, which is usually when they retire.

The cost of a Medigap policy depends on which plan letter you choose, and then varies by zip code, age, gender and tobacco use. Some carriers also offer household discounts if your spouse also has the same policy. We can provide quotes to find the least expensive Medigap Plan F in your area.

We also like to see which company has the lowest rate and has a history of low annual rate increases as well.

It depends. If you are applying for a Medigap policy during your initial Medicare enrollment period, then regardless of your past or current health problems, you are guaranteed the right to purchase any Medigap policy at the same premium the offering company charges other people your age. Some policies may make you wait up to six months before covering a pre-existing condition, and some may offer “discounts” for non-smokers.

If you are applying for a Medigap policy after your initial enrollment period, then in most circumstances, insurance companies are allowed to apply medical underwriting to your application, which means they may reject your application on the basis of a health condition or may charge you higher premiums even if they agree to sell you a policy. There are certain circumstances in which companies may not underwrite applications for Medigap outside of the initial open enrollment period, and some states limit or prohibit underwriting. Check with your state’s insurance department about your Medigap rights and protections.

Yes. Medigap plans and Medicare supplements are the same thing. Just two different terms.

There are two primary ways that you can shore up your Original Medicare benefits. You can enroll in a Medigap plan which will pay after Medicare. This covers some or all of the gaps depending on the plan you choose. Your other option is a Part C Medicare Advantage plan. These plans are private insurance policies which pay instead of Medicare. When you enroll, you agree to use their network and pay copays for services as you go along.

Some Medigap plans help to pay for copays and coinsurance but leave the deductible for you to pay. For example, in 2019 Plan G has a deductible of $185.

Most Medigap plans cover your inpatient and outpatient copays under Medicare. However, on Medigap Plans like, N, the plan requires you to pay a copay of up to $20 for doctor visits and $50 for E.R. visits. These are copays that you will experience on that plan.

Medicare supplements are private health insurance policies, just like life insurance. When you first turn 65 or enroll in Part B, whichever comes later, you get a ONE-TIME window during which you can buy any supplement. During this window, the insurance company cannot turn you down for health reasons. After that six-month open enrollment window passes, you can still apply to change your Medicare supplement. However, you now have to answer the health questions on the application. You must be able to pass the carrier’s underwriting to be accepted.

It’s important for you to know certain health condition may result in you being unable to change. You will want to try to use your one-time open enrollment window wisely. Be sure to choose a carrier with a proven track record of low rate increases.

You can change Medicare supplement plans at any time of year – but in most states you will have to pass medical underwriting to do so.

This is a very common misconception because people get confused about the Annual Election Period that Medicare holds each fall. During this time, you can freely change your Medicare Part D drug plan and/or your Medicare Advantage plan.

This period DOES NOT, however, apply to Medicare supplements, also known as Medigap plans.

If you are past your one-time open enrollment window, you can apply to change plans at any time of year, but it may require underwriting. 

Medicare Advantage plans and Part D plans can only be changed at certain times of year, but Medicare supplements are different.

No. You and your spouse must each enroll in a Medigap plan in order to obtain Medigap coverage.

Medical underwriting involves a review of your medical history. Some health insurers use underwriting to determine whether they will provide coverage to a prospective beneficiary, what premium to charge, and whether to impose a waiting period before coverage starts.

If you’re enrolled in Medicare, and you decide to add a Medicare Supplement (also known as Medigap or MedSup) insurance plan to your Original Medicare coverage, the private insurance company might require underwriting before selling you a Medigap policy.

You can avoid underwriting, and enroll in any Medigap plan that’s available where you live, if you sign up for the Medigap plan during your six-month Medigap Open Enrollment Period. This period begins on the first day of the month that you’re both 65 years old and enrolled in Medicare Part B. For example, if you turn 65 on July 14, and are enrolled in Medicare Part B, you have until December 31 to enroll in a Medigap plan. If you apply for a Medigap plan during your Medigap Open Enrollment Period, your acceptance into the plan is guaranteed, and the plan can’t charge more if you have a health condition. As a prerequisite, you must be enrolled in Original Medicare, Part A and Part B.

If you apply for Medigap coverage after your open enrollment period has passed, you may have to go through medical underwriting. The insurer may review your medical history and refuse to sell you a policy, or sell you one at a higher cost, if you do not meet its underwriting requirements.

Sometimes you can join a Medigap plan after the Medigap Open Enrollment Period without undergoing a medical underwriting review. For example, if you’re enrolled in a Medicare Advantage plan and the plan leaves the Medicare program, you might have a “guaranteed-issue right” to a Medigap plan.

No. Modern Medigap — Medicare supplement — plans do not include prescription drug benefits. Instead, Medicare offers separate prescription drug coverage plans. Medicare enrollees can get prescription coverage either by switching to a Medicare Advantage plan (most of them include prescription coverage) or by purchasing Medicare Part D (prescription drug plan, or PPD) to go along with Original Medicare.

Source: https://www.medicareresources.org/faqs/do-medicare-supplement-plans-include-prescription-drug-coverage/
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You may want to find out if you qualify for Medicaid, if your income and assets are low enough. Medicaid helps many low-income people on Medicare with their Medicare premiums and cost-sharing requirements, and may also cover some benefits that are not covered by Medicare, such as dental services and long-term services and supports. To find out if you qualify, you can contact the State Medical Assistance Office or the State Health Insurance Assistance Program (SHIP) in your state. SHIPs offer local, personalized counseling and assistance to people with Medicare and their families. You can call 877-839-2675 to get the phone number for the SHIP in your state.

If you do not qualify for Medicaid and you want to stay in traditional Medicare, you could try to switch to a less expensive Medigap policy. However, if you are applying for a Medigap policy outside your initial open enrollment period, then in most circumstances, insurance companies are allowed to deny your application based on medical underwriting or can charge you higher premiums. You can find more information about the Medigap plans available in your state by contacting your state’s health insurance department or your SHIP.

Another option could be to enroll in a Medicare Advantage plan. Medicare Advantage plans provide all benefits covered under Medicare Part A and Part B, but often have lower cost-sharing requirements than traditional Medicare. They also have limits on out-of-pocket spending, but include physician networks, which means that you will pay more if you see a provider out-of-network. Medicare Advantage plans may charge a premium in addition to the Part B monthly premium. For free assistance with understanding your options for supplemental coverage, contact your local SHIP.

Medicare Advantage FAQ

Medicare Advantage plans are private health plans, such as HMOs or PPOs, that are offered by health insurers that have contracts with the Medicare program to offer benefits to people with Medicare. The plans provide all Medicare-covered benefits under Parts A and B, and usually provide Part D prescription drug benefits as well. Some Medicare Advantage plans may also provide benefits that are not covered under traditional Medicare, such as eyeglasses, some dental care, or gym memberships. The plans also have a limit on out-of-pocket spending for services covered under Parts A and B, and may have lower cost-sharing than traditional Medicare for Medicare-covered services. However, Medicare Advantage plans restrict the health care providers that their enrollees can see (provider networks) whereas beneficiaries in traditional Medicare may see any doctor that accepts Medicare, without needing prior authorization or a referral from their primary care doctor.

Medicare Part C plans, also known as Medicare Advantage plans, are private health insurance plans, mainly HMOs and PPOs, for people enrolled in Medicare. If you enroll in a Medicare Advantage plan, you still have Medicare, but you get all of your Medicare-covered benefits through a private plan. Most Medicare Advantage plans also cover prescription drugs and may cover other services, such as vision, dental, and hearing benefits. If you have Part A and Part B already, and are covered under the traditional Medicare program, then you do not need to sign up for a Medicare Advantage plan during Open Enrollment unless you want to get your Medicare benefits through a private plan.

There are two primary ways that you can shore up your Original Medicare benefits. You can enroll in a Medigap plan which will pay after Medicare. This covers some or all of the gaps depending on the plan you choose. Your other option is a Part C Medicare Advantage plan. These plans are private insurance policies which pay instead of Medicare. When you enroll, you agree to use their network and pay copays for services as you go along.

No, Medicare Advantage plans charge the same premiums to all enrollees; they are not permitted to vary premiums based on age, smoking history, gender, or pre-existing medical conditions.

Yes. You will have to pay your monthly Medicare Part B premium to Medicare alongside the monthly premium you pay to your Medicare Advantage plan or Medigap plan.

No, each plan may have a unique list of covered drugs. The list of covered drugs is known as a formulary. Medicare requires all Medicare Part D plans to cover at least two medications in each therapeutic category/class approved by Medicare. The drugs within the formulary are assigned to tiers. The tier determines the co-payment or out-of-pocket costs a person within the plan will pay for the drug. If you take a medication that is not covered on your Part D plan’s formulary, you will pay full retail price.

There are four main types of Medicare Advantage plans, but Health Maintenance Organization (HMO) plans and Preferred Provider Organization (PPO) plans are the most common types. Here is a comparison of the two varieties:

  • HMO plans require that beneficiaries see health-care providers, doctors, and hospitals within the plan’s network except in urgent and emergency situations. In some plans, known as HMO Point-of-Service (HMO-POS) plans, beneficiaries may be able to go out-of-network for certain services, but may have to pay a higher cost.
  • PPO plans do not require that beneficiaries use in-network providers and do not require a referral to see a specialist.
  • HMO plans may require that beneficiaries choose a primary care physician.
  • PPO plans do not require that beneficiaries choose a primary care physician.
  • Both HMO and PPO plans generally include prescription drug coverage through a Medicare Advantage Prescription Drug plan (MAPD).

About HMOs

You will need to choose a primary care doctor upon enrolling into most HMO plans, and most of the time this doctor will have to refer you to see a specialist. Some services, like yearly screening mammograms, do not require a referral.

Prescription drugs are covered under most HMO plans called Medicare Advantage Prescription Drug plans. Check with the plan you’re interested in first if you want it to include Medicare Part D prescription drug coverage.

If your physician leaves the plan’s network of providers, you will be notified of his or her departure. You can then select another doctor from within the plan’s network.

Another thing to remember is that if you use an HMO, you agree to receive coverage within that plan’s network except in urgent and emergency situations. You can still receive health care outside of the plan’s network, but be aware that the plan may not pay for these services.

About PPOs

Medicare Advantage PPO plans provide another managed-care option for beneficiaries who want greater provider flexibility. With a PPO plan, your out-of-pocket costs will generally be lower if you use doctors and hospitals in the plan’s preferred provider network. You may also choose to use out-of-network providers, but your copayment and coinsurance costs may be higher.

As mentioned, PPOs don’t require members to have primary care doctors, and referrals aren’t needed before seeing a specialist. If you prefer the convenience of getting specialist care directly, without needing a referral from a primary care physician, this may be one factor to consider when choosing between an HMO or PPO plan.

Like HMOs, you can get Medicare prescription drug coverage through your PPO plan by enrolling in a Medicare Advantage Prescription Drug plan. Keep in mind that not every PPO plan includes prescription drug benefits, and costs and benefits may vary by plan.

Medicare plans are rated on a scale of 1 to 5, with a 5-star rating being the highest score a plan can receive. More stars indicate better performance and quality:

  • 5-star rating: Excellent
  • 4-star rating: Above Average
  • 3-star rating: Average
  • 2-star rating: Below Average
  • 1-star rating: Poor

For Medicare plans providing health coverage, such as Medicare Advantage or Medicare Cost plans, each plan is given an overall summary rating based on how it performs across five main categories:

  • Staying healthy: Plans are rated on whether members had access to preventive services to keep them healthy. This includes physical examinations, vaccinations like flu shots, and preventive screenings.
  • Chronic conditions management: Plans are rated for care coordination and how frequently members received services for long-term health conditions.
  • Member experience: Plans are rated for overall satisfaction with the health plan.
  • Member complaints: Plans are rated on how frequently members submitted complaints or left the plan, whether members had issues getting needed services, and whether plan performance improved from one year to the next.
  • Customer service: Plans are rated for quality of call center services (including TTY and interpreter services) and processing appeals and new enrollments in a timely manner.

For Medicare Part D stand-alone Prescription Drug Plans and Medicare Advantage plans that include drug coverage, Medicare star ratings are also based on the following criteria:

  • Member experience
  • Member complaints
  • Customer service
  • Drug safety and drug pricing accuracy

The drug safety score is based on factors such as how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition. Plans are also rated for whether drug pricing information on Medicare Part D Prescription Drug Plan and Medicare Advantage Prescription Drug plan websites is up-to-date and accurate. In addition, the percentage of plan members who got prescriptions for certain drugs with a high risk of serious side effects when there may have been a safer drug choice is also reviewed and scored.

The overall rating gives a quick summary of a plan’s performance, but you can also look up how the plan scored for individual areas within the above main categories. For more information on the criteria Medicare considers when rating its plans, visit Medicare.gov.

Keep in mind that plan ratings can change from year to year and are updated every fall. If you are enrolled in a Medicare plan, be sure to check the Medicare star ratings every fall so you can make an informed decision about whether to stay on the plan or switch to a different plan.

You might have been searching for Medicare Advantage plans available in your zip code and found a plan with a $0 monthly premium. This plan may appear to be “free” in the way that you don’t have to pay an additional monthly amount to be covered by the plan. You generally still have to pay your Medicare Part B premium, however.

Keep in mind that Medicare Advantage plans are offered by private insurance companies which generally do business to make a profit. In order to offer $0 premium plans, they may charge in other ways, such as copayments/coinsurance. A copayment or coinsurance is an amount you pay whenever you receive a service (such as a doctor visit or an emergency room trip) or pick up a prescription drug. In fact, plans with lower premiums or $0 premiums may have higher copayments/coinsurance.

Another way a $0 premium Medicare Advantage plan may cost you is with a deductible. A deductible is an amount, for example $1,000, that you must pay out of pocket before your Medicare Advantage plan begins to pay your medical bills. Most Medicare Advantage plans have separate medical and prescription drug deductibles. You may have a $0 medical deductible, for example, but a $250 prescription drug deductible. Some Medicare Advantage plans have both $0 premiums and $0 deductibles.

The out-of-pocket maximum for Medicare Advantage plans is not a deductible; it is the highest yearly amount you will have to pay out of pocket for covered health-care services. This spending maximum is one important difference between Medicare Advantage plans and the traditional fee-for-service Medicare program; Original Medicare doesn’t have a yearly cap on your health-care costs.

This yearly cap does not include monthly premiums, but annual deductibles, coinsurance, and copayments may all count towards this maximum limit. The out-of-pocket maximum may be different for each individual Medicare Advantage plan and can change from year to year. Once you have reached the plan’s spending limit for that year, then your Medicare Advantage plan will cover 100% of covered health-care costs for the rest of the year.

An out-of-pocket maximum is a limit on the amount you pay for medical bills. This amount may vary year to year, and among plans. Knowing you have a maximum can be very reassuring. If you have a $50,000 surgery, for example, your out-of-pocket costs will generally be significantly less than that if you have a Medicare Advantage plan.

Usually amounts you spend on coinsurance or copayments for covered services count towards your out-of-pocket maximum. For example, if you visit a primary care doctor and pay $10 and visit the emergency room and pay $100, these amounts will generally count towards your out-of-pocket maximum.

Costs that typically do NOT count towards your out-of-pocket maximum include:

  • Premiums
  • Bills from out-of-network health-care providers
  • Services not covered by the plan

Original Medicare, Part A and Part B, does not cover any of the costs associated with gym memberships or fitness programs. However, there are other Medicare plan options that may cover the cost of a gym membership.

Medicare Advantage plans must offer at least the same amount of coverage as Original Medicare (besides hospice care, but that’s still covered under Medicare Part A), and may also offer additional benefits. These extra benefits could include gym membership. If you sign up for a Medicare Advantage plan, you’re still in the Medicare program and need to continue paying your Medicare Part B premium, as well as any premium the Medicare Advantage plan may charge.

On the other hand, Medicare Supplemental plans do not typically include fitness membership.

Because these Medicare plan options are offered through private, Medicare-approved insurance companies, their availability and benefits may differ by location. You may want to compare plans to see if one in your area offers coverage for health club membership costs.

The annual Medicare Open Enrollment period begins on October 15 and continues until December 7. For 2020 coverage, open enrollment will run from October 15, 2019, to December 7, 2019.

During the annual enrollment period (AEP)  you can make changes to various aspects of your coverage.

  • You can switch from Original Medicare to Medicare Advantage, or vice versa.
  • You can also switch from one Medicare Advantage plan to another, or from one Medicare Part D (prescription drug) plan to another.
  • And if you didn’t enroll in a Medicare Part D plan when you were first eligible, you can do so during the general open enrollment, although a late enrollment penalty may apply.

If you want to enroll in a Medicare Advantage plan, you must meet some basic criteria.

  • You must be enrolled in Medicare Part A and B.
  • You must live in the plan’s service area.
  • You cannot have End-Stage Renal Disease (some exceptions apply; ESRD patients will be able to enroll in Medicare Advantage plans as of 2021, under the terms of the 21st Century Cures Act).

Source: https://www.medicareresources.org/faqs/when-is-the-next-medicare-open-enrollment-period/

Between January 1 and March 31 each year, if you are enrolled in a Medicare Advantage plan, you can leave your plan and return to Original Medicare, and buy a Part D prescription drug plan to supplement your Original Medicare. As of in 2019, you also have the option to switch to a different Medicare Advantage plan during this time. From 2011 through 2018, there wasn’t an option to switch to a different Medicare Advantage plan outside of the fall open enrollment period unless you had a circumstance that allowed you a Special Enrollment Period. But the 21st Century Cures Act (Section 17005) expanded the timeframe of the window (from one and a half months to three months) starting in 2019, and allows people to switch from one Medicare Advantage plan to another.

Only one switch during this time frame is allowed each year — you can change your mind multiple times during the enrollment period in the fall, but can only switch to a different Medicare Advantage plan (or back to Original Medicare) once in the first quarter of the new year. But if you sign up for a Medicare Advantage plan in the fall and then decide you don’t like it once it takes effect in January, you have until the end of March to make a change.

You can only sign up for Part D coverage during the first three months of the year if you’re switching from a Medicare Advantage plan back to Original Medicare. You cannot, for example, be enrolled in Original Medicare with a Part D plan and then switch to a different Part D plan during the January — March enrollment period. Instead, you’d need to make that change during the fall election period (October 15 to December 7).

Source: https://www.medicareresources.org/faqs/when-is-the-next-medicare-open-enrollment-period/

You may switch Medicare Advantage and Part D plans every year during the annual Medicare Open Enrollment period (October 15 through December 7), and, if you are enrolled in a Medicare Advantage plan, you can also switch during the Medicare Advantage Open Enrollment period (January 1 through March 31). It is generally a good idea to compare your plan options every year, even if you are happy with your current coverage, since plans often make changes to their benefits, cost sharing, premiums, and/or provider networks from one year to the next. In addition, you may find another plan that meets your needs better than your current plan if your health needs have changed during the year.

Not necessarily. You will need to contact the company that is offering your plan to find out if/which benefits are available out-of-state. If your plan does not offer out-of-state coverage, there may be another plan offered by the same firm that does, or a similar plan offered by another firm in your area. If you decide that you would like to switch to a different plan, however, note that you will need to wait until the annual Medicare Open Enrollment period (October 15-December 7). You can also use the annual Medicare Advantage Open Enrollment period (January 1-March 31) to switch to a different Medicare Advantage plan or switch to traditional Medicare.

 Yes. You can change Medicare Advantage plans or switch to traditional Medicare between October 15 and December 7 each year. You can also use the annual Medicare Advantage Open Enrollment period (January 1-March 31) to switch to a different Medicare Advantage plan or switch to traditional Medicare.

There are a couple of ways to find out if your doctor is in a Medicare Advantage plan network. If you have a particular plan or insurer that you’re looking into, you can go to the plan’s website and look for their searchable directory or find a plan directory on the website, where you can search for your doctor. You may also contact your provider directly to see if they participate in any Medicare Advantage plans. You should then verify with the plan(s) that the doctor is, in fact, in their network.

If you’re already in a Medicare Advantage plan and you want to switch to traditional Medicare, you should contact your current plan to cancel your enrollment and call 1-800-MEDICARE (1-800-633-4227). Note there are specific enrollment periods each year to do this. The first period when you can switch from your Medicare Advantage plan to traditional Medicare is during the Medicare Open Enrollment period that runs October 15 to December 7. When you make the switch back to traditional Medicare during the Medicare Open Enrollment period, the change will take effect on January 1 of the following year. The second period you can switch from Medicare Advantage to traditional Medicare is during the Medicare Advantage Open Enrollment Period that runs from January 1 to March 31. If you switch to traditional Medicare and you want prescription drug coverage through Medicare, you will also need to sign up for a stand-alone prescription drug plan (PDP) for your drug coverage.

If your current Medicare Advantage plan is not being offered next year and you do not choose another plan, you will be enrolled by default in traditional Medicare. In this case, you will need to select a Part D prescription drug plan (PDP) if you want Medicare drug coverage, unless you have drug coverage from another source of coverage (for example, the VA or from your former employer or union).

If you would prefer to stay enrolled in a Medicare Advantage plan, you may shop around and enroll in a new plan during the Medicare Open Enrollment period, which runs from October 15 through December 7. Note that when a plan is discontinued, you will typically qualify for a Special Enrollment Period (SEP), which gives you more time to enroll in a new plan outside of the annual Medicare Open Enrollment period. If you receive notice that your plan is not being renewed in the following year, you will have from the first day of the Medicare Open Enrollment period (October 15) through the last day in February of the following year to select a new plan or switch to traditional Medicare. You can also use the annual Medicare Advantage Open Enrollment period (January 1-March 31) to switch to a different Medicare Advantage plan or switch to traditional Medicare.

If you enroll in a plan during the Medicare Open Enrollment period that runs from October 15 to December 7 each year, your coverage takes effect on January 1 of the following year.

No, you do not need to do anything during the Medicare Open Enrollment period if you like your current Medicare Advantage plan, as long as it continues to be offered the following year. However, it is still a good idea to compare your plan options each year, since plans often make changes to their benefits, cost-sharing, premiums, and/or provider networks from year-to-year. By comparing your current plan to others available in your area, you can confirm that your plan is still the best plan for you.

Medicare Part D FAQ

Medicare Part D is the Medicare prescription drug benefit which is offered by private stand-alone prescription drug plans, sometimes called PDPs, and Medicare Advantage plans that cover drugs. If you are covered under traditional Medicare and you want drug coverage, you can enroll in a stand-alone drug plan during the Medicare Open Enrollment period. If you did not sign up for a Part D plan when you got your Part A and Part B coverage and you do not have another source of drug coverage that is at least as good as Part D coverage, be aware that you may be charged a late enrollment penalty. Once you are enrolled in a Part D plan, you can switch drug plans during the Medicare Open Enrollment period.

Anyone entitled to Medicare Part A (whether actually enrolled or not) or who is currently enrolled in Medicare Part B may join Medicare Part D to get help paying prescription drug costs. Enrollment is voluntary except for people who also receive benefits from Medicaid (Medi-Cal in California). If you qualify for Medicaid, the government automatically enrolls you in a Medicare Part D plan through which you will receive your prescription drug coverage.

Even if you aren’t taking any medications right now, it might make sense to enroll in a drug plan so that you have coverage in case your needs change in the future. If you don’t have coverage and the Medicare Open Enrollment period has ended, you won’t be able to sign up for coverage until the next Medicare Open Enrollment period begins, and your coverage wouldn’t take effect until January 1 of the following year. This could put you at risk of paying a lot out of pocket for prescriptions if your needs change. Also be aware that there is a late enrollment penalty for Part D. If you don’t sign up for a Part D plan when you are first eligible to do so, and you decide later you want to sign up, you will be required to pay a late enrollment penalty equal to 1% of the national average premium amount for every month you didn’t have coverage as good as the standard Part D benefit.

To enroll into a Medicare Part D Prescription Drug Plan, you need to have either Medicare Part A or Part B, and you have to live in the service area of the plan you choose. If you’re eligible for Medicare because of age, your seven-month Initial Enrollment Period for Part D usually takes place at the same time as your Initial Enrollment Period for Part B, starting three months before your 65th birthday, including your birthday month, and ending three months later. If you qualify for Medicare through disability, you’ll get a subsequent Initial Enrollment Period for Part D when you turn 65 years of age.

The Medicare Part D late-enrollment penalty may apply if you enroll any time after your Initial Enrollment Period for Part D and go without creditable prescription drug coverage for more than 63 days in a row. If you don’t enroll in Medicare Part D when you’re first eligible, your next opportunity will be during the Annual Election Period that occurs from October 15 to December 7 of every year. During this time, you can enroll into a stand-alone Medicare Prescription Drug Plan if you have Original Medicare or get drug coverage through a Medicare Advantage Prescription Drug plan. You can also use this period to switch plans or disenroll from your plan.

You’re not required to enroll into a Medicare Part D Prescription Drug Plan. However, if you go without creditable prescription drug coverage for 63 or more days in a row after you’re first eligible , you may have to pay a late-enrollment penalty if you enroll into a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan later.

There are four types of costs associated with Medicare Part D prescription drug coverage: premiums, deductibles, copayments, and a coverage gap during which period you must pay the full cost of your medications. People with low incomes may apply for a subsidy from the Social Security Administration to reduce these costs.

Part D premiums range from $10-$100 per month (depending on the plans available in your area and on the particular plan you choose). The maximum deductible—the amount you must pay out-of-pocket before Medicare will contribute to your prescription costs—in 2019 is $415. After you meet the deductible, Medicare will pay roughly 75% of your prescription costs.

After you and your plan together pay a certain amount for covered generic prescription drugs ($3,820 in 2019), your plan stops paying and you must pay the full cost of the prescription. The plan begins to pay again—and pays 95% of all further costs—when total expenditures reach a “catastrophic” level ($5,100 in 2019).

However, you will receive a discount on the cost of your medications while you are in the coverage gap.

Low-income Medicare beneficiaries may qualify for a subsidy to help pay costs associated with Part D plans. This subsidy is called Extra Help. Also, under certain circumstances, the copayment for prescriptions may be waived or reduced.

You may qualify for a low-income Part D subsidy if:

  • you are eligible for Medicaid, or
  • your income is less than 150% of the federal poverty level and your assets, not including your own home, are less than $14,390 ($28,720 for a married couple).

In addition to low-income subsidies, circumstances exist in which a Part D plan enrollee may not have to pay the normal copayment for a covered drug. These include:

  • People who live in a long-term care nursing facility, and who are enrolled in both Medicare Part D and Medicaid, have no copayments.
  • Some plans waive or reduce copayments for certain drugs, particularly generic versions, to coax people to join that particular plan. But the plan can change this copayment waiver at any time.
  • Pharmacies may waive copayments for any enrollee with a low-income subsidy, for any drug. But the waiver is not automatic; you have to ask for it.

No, each plan may have a unique list of covered drugs. The list of covered drugs is known as a formulary. Medicare requires all Medicare Part D plans to cover at least two medications in each therapeutic category/class approved by Medicare. The drugs within the formulary are assigned to tiers. The tier determines the co-payment or out-of-pocket costs a person within the plan will pay for the drug. If you take a medication that is not covered on your Part D plan’s formulary, you will pay full retail price.

If you have health insurance in addition to Medicare, this might include creditable drug coverage. The plan must tell you each year whether or not the prescription drug coverage is creditable, meaning it covers at least as much, on average, as Medicare’s standard prescription drug coverage does. Some common examples of creditable coverage include (but are not limited to) health insurance from:

  • Employer group coverage or union plans
  • United States Department of Veterans Affairs (VA)
  • TRICARE
  • Indian Health Service (IHS)

You can continue to use this prescription drug coverage alongside your Medicare benefits without penalty, as long as it’s creditable.

If you’ve gone 63 consecutive days without creditable prescription drug coverage, either because you didn’t enroll when you were first eligible or because you lost your creditable coverage and didn’t get new coverage in time, then you may have to pay a late-enrollment penalty when you do enroll into Medicare Part D.

The Medicare Part D late-enrollment penalty is added to the premium of the Part D Prescription Drug Plan you enroll into. Your Medicare Prescription Drug Plan determines this penalty by first calculating the number of uncovered months you were eligible for Medicare Part D, but didn’t enroll into a Medicare Prescription Drug Plan or Medicare Advantage Prescription Drug plan. Your Medicare Prescription Drug Plan will then ask you if you had creditable prescription drug coverage during this time. If you didn’t have creditable drug coverage for 63 or more days in a row after you were first eligible, the Medicare Prescription Drug Plan must report the number of uncovered months to Medicare.

For example, let’s say you disenrolled from your Medicare Prescription Drug Plan effective February 28, 2019, and then decided to enroll into another Medicare Prescription Drug Plan during the Annual Election Period, with an effective date of January 1, 2020. This means you didn’t have creditable drug coverage from March 2019 through December 2019, which adds up to 10 uncovered months.

Currently, the late-enrollment penalty is calculated by multiplying 1% of the “national base beneficiary premium” ($33.19 in 2019) times the number of full, uncovered months that you were eligible but didn’t join a Medicare drug plan and went without other creditable prescription drug coverage. This number is then rounded to the nearest $.10 and added to your Medicare Prescription Drug Plan monthly premium cost. The “national base beneficiary premium” may increase each year, so the total of your late-enrollment penalty can also increase each year.

While you can’t entirely avoid the coverage gap by switching plans, some plans do offer some additional coverage in the gap beyond what all plans are required to offer. And the coverage gap is gradually being phased out in all Part D plans. In 2019, you will get coverage of at 75% of your brand-name drug costs in the gap and 63% of your generic drug costs, no matter what plan you choose. But Medicare drug plans differ in other ways that can have a big impact on your out-of-pocket costs, including monthly premiums, the list of drugs covered by each plan, how much the plan charges for preferred and non-preferred drugs, and how much the plan charges for high-cost specialty drugs. Not everyone will save money by switching plans, but it generally makes sense for everyone to compare their plan options each year to see if there is a less expensive option for the coverage you need.

Enrolling in a new drug plan during the Medicare Open Enrollment period will disenroll you from your previous plan, so you don’t need to contact the previous plan to drop that coverage. You should notify the pharmacy where you fill your prescriptions so they can update their records with your new plan information.

You can submit a new application for a plan other than the one to which you initially applied during the Medicare Open Enrollment period. Keep in mind that the last plan application you submit before the Medicare Open Enrollment period ends on December 7 is the coverage that will take effect on January 1 of the following year.

No. Drug coverage from the VA (Veterans Affairs) is considered creditable prescription drug coverage, which means the coverage is at least as good as what Medicare drug plans provide, so you do not need to enroll in a Medicare Part D plan. Other sources of creditable drug coverage include the Federal Employee Health Benefits (FEHB) program, TRICARE (military health benefits), and Indian Health Services (IHS). People with creditable coverage should receive a notice from the source of that coverage letting you know that your coverage is, in fact, creditable. You should keep this notice in case you need to show proof that you had creditable coverage if you decide later you want Medicare prescription drug coverage.