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Tag: Medigap

  • Turning 65? When to enroll in Medicare

    Turning 65? When to enroll in Medicare

    Turning 65 is fraught for all kinds of reasons, one of which is that you will need to consider whether you should enroll in Medicare. Here’s what I just explained to a friend.

    Should you enroll in Medicare at 65? If you’re not actively working or you do not have health insurance coverage through your job or your spouse’s current job, you will need to enroll in Medicare when you turn 65. And, if you have insurance through your job or through your spouse’s job but the employer has fewer than 20 employees, you also should enroll in Medicare at 65. If you do not, you will pay a penalty for each year you delay enrolling.

    You can enroll before your 65th birthday. You can and should enroll in the three months before your 65th birthday to ensure you are covered on the first day of your birthday month. Contact your Social Security office to enroll. You do not have to sign up for Social Security at that time. In fact, if you can afford to delay taking Social Security, you should, in order to earn larger benefits down the road.

    What choices do you need to make? You need to choose between traditional Medicare, which you should get automatically (but you should confirm) and a Medicare Advantage plan. Traditional Medicare gives you coverage for care from almost all doctors and hospitals across the US, without administrative barriers to care like prior authorization. You pay for supplemental coverage, sometimes called Medigap, to fill coverage gaps–about $2,500 a year for a comprehensive policy–but then you have few out-of-pocket costs; almost all your care is covered in full.

    Medicare Advantage restricts your access to care to its network of providers and has administrative barriers to care such as prior authorization requirements, which can cause undue delays. Medicare Advantage plans also have been found to engage in widespread and persistent inappropriate denials of care and coverage. But, Medicare Advantage plans have an out-of-pocket cap so they save you money if you do not need a lot of care.  If you do, you could spend as much as $9,350 out of pocket in 2025 for in-network care alone. You cannot buy supplemental coverage to cover these costs. If you opt for Medicare Advantage, you will need to choose your Medicare Advantage plan carefully. Do not trust an insurance agent or broker to help you because they generally work on commission. You can compare options online here. You can call your State Health Insurance Assistance Program for free guidance.

    N.B. If you opt for Medicare Advantage when you first enroll in Medicare, you could be locked in. You can always enroll in traditional Medicare, but you might not be able to buy supplemental coverage. It will depend upon where you live. Your federally guaranteed right to Medicare supplemental coverage, sometimes called Medigap, ends one year after you first enrolled in a Medicare Advantage plan, with some limited exceptions. Only four states–NY, CT, ME and MA–require Medicare supplemental insurers to sell you coverage after your initial enrollment period.

    How about prescription drug coverage? With traditional Medicare, you will need to enroll in a Medicare Part D prescription drug plan. You can compare your options online. With Medicare Advantage, prescription drug coverage is almost always included. If you go with a Medicare Advantage plan, to save money, you should choose a Medicare Advantage plan that covers the drugs that you use at the lowest cost. That said, the drugs these plans cover and your out-of-pocket costs can change at any time. Moreover, it can sometimes be cheaper to get your drugs through Costco or another pharmacy. 

    Here’s more from Just Care:

  • Even with Medicare, older adults struggle to afford their care

    Even with Medicare, older adults struggle to afford their care

    Maggie Shaw writes in AJMC  about new findings reported in the Annals of Internal Medicine that many older adults struggle to pay the $1,600 Medicare Part A deductible. These findings corroborate a slew of earlier findings that cost is a barrier to care for people with Medicare, be they in traditional Medicare or Medicare Advantage.

    Most people in traditional Medicare have supplemental coverage to pick up those costs, either through Medigap, insurance they buy to fill coverage gaps, Medicaid, if their income is low, or retiree coverage from their jobs. How many people in Medicare Advantage can afford their care?

    Cost is a barrier to care for far too many people with Medicare, whether they are in traditional Medicare or Medicare Advantage. Traditional Medicare needs an out-of-pocket limit so that people who cannot get supplemental coverage still have financial protection. Usually, they sign up for Medicare Advantage, thinking they have protection because it does have an out-of-pocket cap.

    But, in Medicare Advantage, people are too often denied the care they need or forced to go through too many hoops to get their Medicare Advantage plan to cover their care. Moreover, when it is covered, they can have high out-of-pocket costs and they can’t get supplemental coverage to fill cost gaps. We have only a limited understanding of how often that leads Medicare Advantage enrollees to forego needed care.

    The AJMC study found that between a third and a half of all people with Medicare lack financial stability. Black and Hispanic adults with Medicare are particularly at risk financially; many do not have supplemental coverage. An NBER study a few years back found that even a $10 copay increase for prescription drugs under Medicare Part D led many to stop filling their prescriptions.

    The people most at risk in Medicare have incomes too high to qualify for Medicaid, up to 400 percent of the federal poverty level. Some of them qualify for Medicare Savings Programs that help with their costs. But, this help is not automatic and too often they do not apply for these programs. It’s a hassle.

    Instead, people with Medicare are left without needed care. The authors recommend that policymakers either make it easier for people with low incomes to qualify for help with their out-of-pocket costs or add an out-of-pocket maximum to Medicare.

    Here’s more from Just Care:
  • How to switch to Traditional Medicare from Medicare Advantage?

    How to switch to Traditional Medicare from Medicare Advantage?

    For years, I’ve been advising people to enroll in Traditional Medicare for easy access to medically reasonable and necessary care. And, I continue to believe that anyone who can afford the upfront costs of Traditional Medicare with supplemental coverage should enroll in Traditional Medicare. Medicare Advantage plans save you money, so long as you’re healthy; but your health care coverage should cover the care you need when you’re sick and you can’t count on a Medicare Advantage plan to do that. So, one Just Care reader asks, how easy is it to switch from a Medicare Advantage plan to Traditional Medicare?

    First things first: Twice a year, during the annual Medicare Open Enrollment period between October 15 and December 7 and during the Medicare Advantage Open Enrollment period between January 1 and March 31, you have the right to disenroll from Medicare Advantage and switch to Traditional Medicare. The issue becomes getting supplemental coverage to fill gaps in traditional Medicare if you don’t have Medicaid or retiree coverage that fills those gaps.

    Here are the benefits of enrolling in Traditional Medicare, along with the challenges of doing so, and your rights.

    The benefits of enrolling in Traditional Medicare:

    • You will have easy access to the medical and hospital care you deserve, without the need for prior authorization or a referral from your doctor to a specialist; you won’t need to go through hoops to get care, nor will you face care delays or denials of care your treating physician says you need.
    • You and your doctor decide the care you need, not an insurance company that profits from denying you care.
    • You will be covered for care from virtually any doctor or hospital in the US; you will not be limited to coverage from a narrow group of physicians in your community.
    • With supplemental coverage, either through Medicaid, your former employer or union or a Medigap plan that you buy in the individual market, you are likely to have almost all your care covered without having to pay out of pocket for that care.

    The challenges of switching to Traditional Medicare:

    • With certain exceptions, if you want to sign up for Traditional Medicare after you’ve been in a Medicare Advantage plan for more than a year, you have no guaranteed right to buy supplemental coverage in all but four states, New York, Massachusetts, Connecticut and Maine. And, because Traditional Medicare has no out-of-pocket limit, you could have higher out-of-pocket costs in Traditional Medicare than you would in a Medicare Advantage plan, which tends to limit your out-of-pocket expenses for medical services to an average of $5,000 for in-network care but could cap those costs as high as $8,700 in 2024.
    • Even if your Medicare Advantage plan is not covering the care you need from the providers you need to see, you can only switch to Traditional Medicare during the Medicare Open Enrollment Period between October 15 and December 7, effective January 1 of the following year and during the Medicare Advantage Open Enrollment Period between January 1 and March 30, effective the month after you disenroll from your Medicare Advantage plan.
    • If you are able to switch to Traditional Medicare and you don’t have Medicaid or a union or employer retiree plan to provide supplemental coverage, supplemental coverage could cost a lot, easily $200 a month or more. Medigap Plans K and L tend to be lower cost and cap your out-of-pocket expenses.

    Your rights to buy a Medigap without medical underwriting or a waiting period:

    • When you first enroll in Medicare, you have a guaranteed right to buy Medigap coverage to fill gaps in Traditional Medicare during a six month open enrollment period beginning the month you turn 65.
    • If you enrolled in a Medicare Advantage plan when you were first eligible for Medicare and disenroll within 12 months, you have a guaranteed right to buy Medigap coverage.
    • If you move out of your Medicare Advantage plan’s service area, you have a right to switch to Traditional Medicare and a guaranteed right to buy Medigap coverage.
    • If you had supplemental coverage from your employer or union and that coverage ends, you have a guaranteed right to buy Medigap coverage.
    • If your Medicare Advantage plan ends its coverage or commits fraud, you have a guaranteed right to buy Medigap coverage.

    Insurers still might sell you Medigap coverage even if none of the above federal rights apply to your situation:

    You still might be able to buy a Medigap policy in your state if you want to switch from a Medicare Advantage plan to Traditional Medicare and none of the above guaranteed federal rights to buy Medigap apply. Contact your State Health Insurance assistance Program or SHIP for free help. Or call your state department of insurance to see if you can buy a policy. Some Medigap plans have out-of-pocket limits like Medicare Advantage and cost much less than more comprehensive Medigap plans.

    Here’s more from Just Care:

  • Congress must stop the Medigap madness

    Congress must stop the Medigap madness

    On one hand, “Medigap,” health insurance coverage that supplements traditional Medicare, is an incredible product. It usually picks up all but a little of people’s out-of-pocket Medicare costs. On the other hand, people must choose among a sea options they are hard-pressed to understand. And, they must pay a lot of money for Medigap, in order not to worry about their out-of-pocket health care costs. Congress needs to stop the Medigap madness.

    Jake Johnson reports in Common Dreams about  Sen. Elizabeth Warren‘s recent report on how insurance companies encourage insurance agents through money and prizes to upsell people Medigap plans. Even though Medigap is regulated by the federal government, both state and federal governments allow the insurers offering Medigap to run away with the store, scamming “millions of seniors …, offering agents lavish vacations to steer unknowing beneficiaries into more expensive plans,” according to Senator Warren.

    The insurance companies offering Medigap profited handsomely off the $16 billion in premiums they collected last year alone. Older adults are “getting fleeced.” Warren wants federal and state regulators to step in.

    People in traditional Medicare, who don’t have Medicaid or retiree coverage to fill gaps in coverage, need an affordable Medigap plan. They tend to assume that traditional Medicare with Medigap is less affordable than Medicare Advantage, corporate health insurance coverage. But, should you need costly health care services, traditional Medicare plus Medigap can be far more affordable than Medicare Advantage. Medicare Advantage plans typically come with $5,000 in out-of-pocket costs for in-network care alone. Sometimes these costs are higher; Medicare Advantage plans can set our-of-pocket costs for in-network care as high as $8,300 this year.

    Unfortunately, people can’t trust their insurance agents to help them understand the benefits of traditional Medicare over Medicare Advantage. These agents often steer them to Medicare Advantage plans, where they make the biggest commissions. And, when people opt for traditional Medicare, they can’t trust their insurance agents to steer them to the Medigap plan that best meets their needs.

    What you can do: Contact your  State Health Insurance Assistance Program (SHIP) for free unbiased assistance choosing a Medigap plan.

    Warren wants the Centers for Medicare and Medicaid Services, which oversees Medicare, to step in. But, it’s hard to see how additional regulations would help much to protect people from predatory sales agents. The only truly non-predatory solution would be for the government to sell people a government-issued Medigap policy or, better still, cap or eliminate out-of-pocket costs in Medicare.

    If Congress were to add an out-of-pocket cap to traditional Medicare, it would reduce people’s need for Medigap coverage altogether. That’s what’s needed. And, it would save Medicare money.

    The Congressional Budget Office recently found that a high out-of-pocket cap–$8,500–would reduce Medicare spending. It would also give people the choice of traditional Medicare without having to buy Medigap supplemental coverage.

    Here’s more from Just Care:

  • 2023 Medicare and You Handbook continues to mislead on Medicare Advantage

    2023 Medicare and You Handbook continues to mislead on Medicare Advantage

    The 2023 Medicare and You Handbook is now available for your reading pleasure. Unfortunately, it continues to mislead and confuse in significant ways about Medicare Advantage. Though the Centers for Medicare and Medicaid Services (CMS) would like you to believe otherwise, Medicare health plans administered by corporate health insurers–euphemistically called Medicare Advantage–cover fewer costly services, often from lower quality providers, than traditional Medicare.

    Here’s what’s seriously misleading and what’s true in the Medicare Handbook:

    • The Handbook says: Medicare Advantage plans “may have lower out-of-pocket costs” than traditional Medicare. Here’s what’s true: You could spend as much as $7,550 out of pocket if you need costly care. However, so long as you are healthy or forgo needed care, you will likely spend less on your health care. The problem is that you need health insurance to protect you in the event you need costly care. It’s of far less importance if you’re healthy.
    • The Handbook says: Medicare Advantage plans “must cover all medically necessary services that Original Medicare covers.” Here’s what’s true: You have the same Part A and B benefits in theory as people in traditional Medicare. In practice, Medicare Advantage plans have their own rules as to what services are medically necessary. They tend to be far more restrictive than Original Medicare, second-guessing treating physicians, whom they have hand-picked for their networks, as to what care is medically necessary. So, Medicare Advantage plans are likely to cover fewer services for shorter periods of time and, sometimes, from lower quality providers. And, the government is unable or unwilling to oversee them and hold them accountable when they do not do so. Only in theory are Medicare Advantage plans required to cover all medically necessary services that Original Medicare covers.
    • The Handbook says: Medicare Advantage plans “may offer some extra benefits that Original Medicare doesn’t cover—like vision, hearing, and dental services.”  Here’s what’s true: You may have extra “benefits” like vision, hearing and dental, but these benefits tend to be extremely limited in scope and tend to require you to pay large out-of-pocket costs.
    • The Handbook says: With Medicare Advantage plans, “you can’t buy and don’t need Medigap,” supplemental coverage that picks up costs that Medicare does not cover. Here’s what’s true: You can’t buy Medigap, but you likely would be better off with it if you need costly care. Without supplemental coverage, most people in Medicare Advantage, unlike people in traditional Medicare with supplemental coverage, are constantly having to choose between their health care and other basic needs. Or, they could be pushing themselves into medical debt.

    Here’s what the Medicare Handbook does not say:

    The government pays corporate health insurers a flat upfront payment to cover care for enrollees through Medicare Advantage, with little if any regard to the cost or quality of services each plan offers. These insurers have a compelling financial incentive to spend as little as possible on enrollees’ care and pocket as much of the money they receive as possible. While there is technically a limit on the amount they can pocket, they have ways to game that limit.

    Here’s more from Just Care:

  • Your right to buy a Medigap policy when you enroll in traditional Medicare

    Your right to buy a Medigap policy when you enroll in traditional Medicare

    Between October 15 and December 7, it’s the Medicare Annual Open Enrollment Period, during which time you have the right to enroll in traditional Medicare and disenroll from your Medicare Advantage plan. But, depending upon the circumstances surrounding your enrollment in traditional Medicare and the state you live in, you might not have the right to buy a “Medigap” policy, insurance that fills gaps in traditional Medicare. And, since traditional Medicare does not have an out-of-pocket limit, without supplemental coverage, you put yourself at grave financial risk.

    To be clear, unlike Medicare Advantage, which has an annual out-of-pocket maximum, traditional Medicare has no maximum. But, unlike Medicare Advantage which requires you to pay copays that can total thousands of dollars a year in order to get care, with traditional Medicare you can protect yourself financially through supplemental insurance that fills gaps. You can get supplemental insurance from a former employer or Medicaid, or from a an insurance policy you buy in the individual market, which is sometimes called a Medigap policy.

    However, if you don’t buy a Medigap policy when you first enroll in Medicare, you could end up locked into a Medicare Advantage plan.

    What are your rights to buy a Medigap policy?

    • When you first enroll in Medicare at 65 or later, you have the right to buy a Medigap policy of your choosing, regardless of your age or health, for six months during your initial enrollment period. You should buy the policy when you enroll in traditional Medicare to minimize your out-of-pocket costs.
    • If you enroll in a Medicare Advantage plan when you are first eligible for Medicare at 65 or later, you have the right to buy a Medigap policy if you switch to traditional Medicare within 12 months, up to 63 days after you leave your Medicare Advantage plan.
    • If you are enrolled in traditional Medicare with a Medigap policy and drop that policy to enroll in a Medicare Advantage plan, you have the right to get that Medigap policy back if you disenroll from your Medicare Advantage plan within 12 months of joining, but you must apply for coverage no later than 63 days after you leave your Medicare Advantage plan.
    • If you live in Massachusetts, Minnesota or Wisconsin, you always have the right to buy a Medigap policy but the insurer can charge you more based on your health status if you are not buying the policy during your initial enrollment period.
    • In Massachusetts, Maine, Connecticut and Vermont, you always have the right to buy a Medigap policy and the insurer cannot charge you more based on your health status.
    • If your Medicare Advantage plan leaves or you leave the area and you switch to traditional Medicare, you have a guaranteed right to buy a Medigap policy so long as you do so within 63 days of your Medicare Advantage plan coverage ending.
    • If you have retiree coverage from a former employer that fills gaps in traditional Medicare and that coverage end, you have a guaranteed right to buy a Medigap policy.
    • If your Medicare Advantage plan is found not to comply with its legal obligations or somehow misled you, you have a guaranteed right to buy a Medigap policy.
    • If you are under 65 and have Medicare because you are receiving Social Security Disability Income, you have no guaranteed right to buy a Medigap policy under federal law.

    There are a variety of standardized Medigap plans, some of which fill more gaps in coverage than others. To learn more about your Medigap options and how to choose a Medigap plan, click here.

    Here’s more from Just Care:

  • Medicare open enrollment: Can you buy supplemental insurance?

    Medicare open enrollment: Can you buy supplemental insurance?

    Harris Meyer writes for Kaiser Health News about the confusion surrounding the purchase of Medicare supplemental insurance for people who opt for traditional Medicare during the Medicare annual open enrollment period, which began October 15 and goes through December 7. Can you buy supplemental insurance? Whatever you do, don’t trust an insurance agent to advise you; rather go to your local State Health Insurance Assistance Program or SHIP, for free unbiased advice.

    If you have traditional Medicare, having supplemental insurance is necessary if you want to protect yourself from unlimited out-of-pocket costs. But, many people do not understand that or, if they do, might not be able to buy supplemental insurance. Supplemental insurance, which fills gaps in traditional Medicare, comes in three forms–retiree coverage from your former employer, Medicaid or an insurer in the individual market.

    Medicare supplemental insurance or “Medigap,” which you buy in the individual market, picks up a lot of the coinsurance costs and deductibles that people with traditional Medicare would otherwise have to pay. With it, you can sleep at night without worrying about out-of-pocket costs if you need hospital or medical care. You have the right to buy Medigap insurance during the six months after you first enroll in Medicare Part B.

    There are a series of standardized Medigap plans labeled A through N. They all cover the basic coinsurance costs for medical services. But, some also cover coinsurance for nursing home care and others pick up some of the hospital deductible as well. Some Medigap plans have lower premiums because they require you to pay a high deductible before coverage kicks in. Premiums differ depending upon the type of plan and insurance company offering it you choose.

    If you are in a Medicare Advantage plan and want to move to traditional Medicare, it is sometimes not possible to buy Medigap insurance. A lot depends on the state you live in. Some states guarantee you the right to buy Medigap coverage, no matter your age or health status–New York, Massachusetts, Connecticut and Maine. And, eight states, including those four, do not allow Medigap insurers to charge you more based on your health status or age.

    In most states, the Medigap premium charged and whether you can even buy Medigap coverage at all, depends on your health status. Medigap insurers are not likely to sell you insurance if they don’t have to and the insurance company believes you will incur large health care costs.

    There are a few other situations in which you can buy Medigap insurance, some under federal law and some under state laws. For example, you always have the right to buy a Medigap plan if you sign up for Medicare Advantage when you first enroll in Medicare and then decide you want to switch to traditional Medicare within 12 months. Many states also guarantee you the right to buy a Medigap plan if you lose your retiree supplemental coverage.

    Medigap premiums can easily be $1,500 or more a year and, if you are able to buy a policy after your initial enrollment period, the insurer can charge you more in most states, depending upon your health status. But, if you see a doctor or go to the hospital during the course of the year, you might spend less for the Medigap policy than you would for deductibles and copays in Medicare Advantage.

    Medicare Advantage plans, unlike Medigap plans in most states, cost the same for everyone, no matter their health status or age. That said, Medicare Advantage plans can charge you up to $7,550 a year out of pocket for in-network care alone, excluding prescription drugs.

    If you qualify for Medicare because of a disability, you have no right to buy Medigap coverage under federal law. Most states do require insurers to sell you a Medigap policy. But, 19 states do not. And, if you have end state renal disease–kidney failure–only 14 states give you the right to buy a Medigap plan.

    Contact your state health insurance assistance program or SHIP for guidance on buying a Medigap policy in your state. You can call 1-800-677-1116 for the phone number of your local SHIP.

    Here’s more from Just Care:

  • More people are choosing lower-cost Medigap plans

    More people are choosing lower-cost Medigap plans

    One of the great things about traditional Medicare is that if you can afford a comprehensive Medicare supplemental insurance policy, “Medigap,” you do not have to worry about out-of-pocket costs for services that Medicare covers. The catch is that the cost of that supplemental insurance policy can be high. Allison Bell reports for ThinkProgress that, increasingly, people are opting for lower-cost Medigap policies.

    Signing up for traditional Medicare and buying a lower-cost Medigap policy is actually a smart alternative to Medicare Advantage, through which people get their Medicare benefits through private insurers. With Medicare Advantage, depending upon the plan you choose, your out-of-pocket costs for in-network care alone can be as high as $7,550; the average is about $5,500. And, in Medicare Advantage, you can’t buy a policy to protect you from those costs, much less for your out-of-pockets costs for out-of-network care.

    Many people choose traditional Medicare over Medicare Advantage because they do not want to restrict their access to doctors and hospitals. But, because Medicare does not have an out-of-pocket limit, to protect themselves from financial risk, they usually buy a Medigap policy if they don’t have retiree coverage or Medicaid to fill gaps.

    A new poll shows that about one in three people who enroll in traditional Medicare choose Plan N. Plan N fills most gaps but does not cover physicians’ excess charges if you see doctors who do not take assignment. The good news is that about 90 percent of doctors take assignment–accept Medicare’s approved rate as payment in full, so having coverage for physicians’ excess charges is often not necessary. And, plan N costs less than other Medigap options.

    Still, about two in three people who enroll in traditional Medicare choose Plan G, which covers all out-of-pocket costs with the exception of the Part B deductible. The advantage of Plan G is that when you need health care, you don’t need to worry about the cost.

    Here’s more from Just Care:

  • Your projected Medicare benefits and costs in 2021

    Your projected Medicare benefits and costs in 2021

    We’re in the midst of the annual Medicare Open Enrollment Period, but we still don’t know what Medicare costs will be in 2021. We do know, however, that Congress has limited the amount Medicare Part B premiums can increase. As a result, Medicare costs should not go up a lot in 2021.

    The standard Part B premium likely will increase. The standard premium was projected to increase to $153.30 from $144.60 a month. But, Congressional legislation likely will limit the increase to less than $2.50 a month.

    However, if your annual income is $88,000 or more, your Part B premium is likely to increase even more. The Part B deductible will also likely increase several dollars from $198.

    The Part A premium, deductible and coinsurance will also be higher. The deductible to be paid at the start of a Part A hospital benefit period is projected to be $1,452 in 2021, up from $1,408. Supplemental coverage you get through the private insurance market or through a former employer or Medicaid, generally pays some or all of this cost.

    If you’re in a Medicare Advantage plan, a private insurance plan that offers Medicare benefits, you are still responsible for paying the Medicare Part B premium. On top of that, if you need a lot of costly care, your out-of-pocket costs could be as high as $7,550 in 2021, for in-network care alone. In addition, you will have a deductible and copays for your drugs.

    The standard Part D prescription drug plan will have a deductible of $445 in 2021. You will need to spend $6,550 before you receive catastrophic coverage. You will be responsible for 25 percent of the cost of your drugs until then. Once you reach the catastrophic coverage level, you will be liable for no more than 5 percent of the cost of your drugs.

    If you have diabetes and need insulin, some plans will offer insulin with a maximum $35 out-of-pocket monthly cost. However, the premiums for these plans are likely to be higher.

    If you are new to Medicare, you will have the choice of a range of Medigap plans, supplemental coverage that fills gaps in Medicare. But, the two most popular plans, C and F, will no longer be available. Instead, you will have a choice of D and G. Unfortunately, you may be locked into a Medicare Advantage plan if you are currently enrolled in one. Your ability to buy supplemental coverage if you want to switch to traditional Medicare may be restricted, depending upon the state you live in and your health status.

    Here’s more from Just Care:

  • Enrolling in Medicare? Here’s a checklist

    Enrolling in Medicare? Here’s a checklist

    Most people get Medicare just before they turn 65 (though people with disabilities get Medicare after they receive SSDI for 24 months and people with ALS get Medicare the first month they receive SSDI). As a general rule, you are way better off with Medicare, public health insurance, than with private health insurance. But, figuring out when to enroll in Medicare and what to do can be daunting. And, each fall, you need to revisit your options because they can change significantly from one year to the next. Here’s a checklist:

    • Do you have health care coverage from a current job, either yours or your spouse’s?
      • If you do not, you likely want to sign up for Medicare in the three months before your 65th birthday month, so that your Medicare coverage begins on the first day of your birthday month.  (Your current health insurance in most cases will no longer be your primary coverage after your birthday month.)
      • If you have health care coverage from either your or your spouse’s current job, click here for advice on whether you should sign up for Medicare. Depending upon the job, you may need to enroll in Medicare in order to avoid penalties. Note: COBRA does not count as insurance from your job.
    • Have you already signed up for Social Security?
      • If not, you can sign up for Medicare online through the Social Security Administration. You do not need to sign up for Social Security to enroll in Medicare. Keep in mind that when you sign up for Social Security affects the amount of your monthly check. Click here for advice on when to claim Social Security benefits.
      • If you’ve already signed up for Social Security, you will get Medicare automatically. You should receive a notice in the mail about your automatic enrollment in Medicare Part A (hospital insurance) and Part B (medical insurance), both of which you need whether you enroll in traditional Medicare or a commercial Medicare Advantage plan. The Medicare Part A premium is fully paid for if you or your spouse worked for at least 40 quarters and paid taxes; if not, there’s an additional premium. The Medicare Part B premium, which you must pay no matter which Medicare plan you choose, will be deducted from your Social Security check automatically.
        • You will be automatically enrolled in traditional Medicare, government-administered insurance.
        • You can choose to join a Medicare Advantage plan (Part C), instead of traditional Medicare, by signing up with a Medicare Advantage plan; you will be automatically switched out of traditional Medicare.
    • Key differences between traditional Medicare and Medicare Advantage commercial health plans
      • A Medicare Advantage plan, commercial insurance that contracts with Medicare to offer benefits, is often a lot more expensive and a lot more complicated than it at first may seem. Deductibles, coinsurance and copays can be extremely high, and you cannot buy supplemental coverage to cover these costs as you can with traditional Medicare. At the same time, unlike traditional Medicare, Medicare Advantage plans limit your choice of doctors and hospitals to their network. Your annual out-of-pocket costs for in-network care can be as high as $6,700 and, if you need to go out of network, your costs can be far higher. Here are four key differences between traditional Medicare and a Medicare Advantage plan.
      • If you choose traditional Medicare, as 70 percent of people do, Medicare will cover your care from almost all doctors and virtually every hospital in the US. You will want supplemental insurance to fill gaps in traditional Medicare and prescription drug coverage. With that, all or nearly all of your costs for medical and hospital care should then be covered, so you can budget for your care. And, it will be simpler to access care when you need it.
    • What do you need to consider each Fall, during the Medicare open enrollment season?  Each Fall, you will be able to switch Medicare plans. Because Medicare Advantage plans and Part D drug plans can change significantly from one year to the next, you will likely be better off if you do some homework. Here are two questions you should answer during the Open Enrollment Period.
      • If you’re in traditional Medicare, you can assume your coverage will remain the same in terms of access to doctors and hospitals. So, no homework there. But, you will need to check into your Medicare Part D drug plan options, which can change dramatically from one year to the next. (Here’s a Medicare tool to help you choose.)
      • If you’re in a Medicare Advantage plan, you cannot assume your coverage will remain the same each year. The network doctors and hospitals can change at any time, and the premiums, copays and deductibles can change each year. You will need to do some research around costs and to ensure you are in a Medicare Advantage plan that allows you to see the doctors and hospitals you want to use. You can switch to traditional Medicare. But, if you do not have Medicaid or retiree coverage to fill gaps, you will need a Medigap policy.

    For more about Medicare benefits, Medicaid, Social Security and long-term services and supports, click here. 

    To understand when Medicare is the primary payer and when it is secondary, click here. 

    If you have Veterans’ or other military benefits, learn how they work with Medicare.