The annual Medicare open enrollment period opens October 15th and closes December 7th. This year there have been a lot of changes so this newsletter is longer than usual. You will need extra time to prepare.
Due to Covid 19 this is the year you may want to look long and hard at your plan and its coverage. A few weeks ago, one of our clients went to Mt. Sinai at midnight because he had Covid symptoms and was having trouble breathing.
Fortunately, he was there for only three weeks. As we worked with the hospital on his discharge and post-hospital rehab, we became aware that he had a very modest Medicare Advantage plan. He is a veteran and has used medical services from the VA and until this point, his medical care was satisfactory. But the Medicare Advantage plan he had offered almost no options for rehab. We got to work with the hospital case management team, the customers service seton of the Medicare plan and used the governor’s list of facilities that would take post-Covid patients. We searched as far as Palm Beach County and found only one facility that would consider taking him – after he had a negative Covid test. The hospital said they do to test patients being discharged as there were to many false results both positive and negative. We were in a quandary. We kept speaking with the client and he seemed to be improving everyday so I asked the doctor if he could go home and home care, physical therapy and occupational therapy were built around him. They approved the plan and he was home on Labor Day with all of the medical equipment and supplies he needed. After laying in bed for four and a half weeks, he is now making progress. He is walking around his condo several times a day and we will get a Covid test in a week that we think will be negative. He was able to have this outcome because he had a professional team to supporting an advocating for him.
After this experience, on October 15th, we will be reviewing other plans that will better suit him and his medical needs in the future. For this purpose, we use a Medicare specialist and work hand-in-hand with her. We have already sent her the information she needs including his medications, OTC items, and birth date. Even though the actual plan will not go into effect until 1/1/21, we will be prepared for it.
In General:
Due to changes in plans, benefits and premiums, Medicare professionals believe that everyone should evaluate and consider switching plans every year.
As we did for this case, everyone on Medicare needs to do their homework. Soon, those who have Medicare Advantage plans should have received two documents: the Annual Notice of Change (ANOC) and the Evidence of Coverage (EOC) as they are required to be mailed by September 30th. The EOC provides specific details about when the plan will cover costs, which will be needed if an appeal is filed. The ANOC lists the changes for the plan from 2020 to 2021. These documents are very important as they tell the subscriber information such as whether current prescriptions are in a different tier (at a different price), new restrictions including prior authorization, if pharmacies changed. You may also need to contact your plan for specific information.
- Medigap C and F will pay the Part B deductible, but those plans are no longer available for newly-eligible Medicare enrollees. Plan G is still available for newly-eligible enrollees; it is the same plan as Plan F except enrollees cover the Part B deductible themselves.
- Medicare is a very complex subject. Below is an overview of the Medicare plans and its components, and questions that should be asked. Once the questions are answered, plans can be evaluated that best one’s needs. It is very important to spend time comparing plans.
Medicare Plans and Components:
Part A covers hospital care, skilled nursing, hospice and some home health care. 99% of Medicare recipients DO NOT pay a premium for Medicare Part A as they have met the 40 quarters (10 years) of qualifying employment.
Part B covers doctor visits, preventive care, outpatient care and hospitals and some home health care. The good news is that for most Medicare recipients there will be only an increase of $8.70 for Medicare Part B premiums. But in 2021 the ‘high-income’ threshold increased this year to $87,000 for a single individual and $174,000 for a couple and it will be indexed annually. For 2021, the Part B premiums for high include beneficiaries is projected to range from $245/month to $368/month, depending on the income. The deductible in 2020 was $198, it has not yet been established for 2021.
Part C is also known as a Medicare Advantage plan. It substitutes for parts A and B and, in most cases, Part D, the drug plan. There is a small difference in 2021 premiums. Premiums vary by location and coverage.
Part D covers prescription drugs. Key changes include:
- Initial Deductible will start at about $13/month; with an average of $30.50/month and the ‘high-income’ enrollees will have a higher premium that will be indexed in the future.
- “Out of Pocket” costs after deductible:
- Not to exceed 25% of the cost of brand-name and generic costs
- Donut hole still exists but is dependent upon how insurers design their coverage
- Once the catastrophic coverage threshold of $6,550 is reached, additional out-of-pocket costs are capped at the greater of 5% of the cost of the drug or a copay of $3.70 for generics and $9.20 for brand-name drugs.
- Must cover a wide range of insulins for no more than $35/month
The first big decision Medicare beneficiaries must make is whether to go with traditional Medicare (parts A, B and D) using supplemental insurance or a Medicare Advantage plan (Part C). Medicare Advantage plans have lower premiums, but they usually require members to get their care only from network doctors and hospitals. Both options have deductibles, copays and co-insurance, where the individual/spouse pays a percentage of the bill.
Like our client, as you grow older, you may want to have more coverage and use a supplement plan. Each person’s needs are different so take the time to evaluate the best pan for you or your loved-ones.
According to the U. S. government, the most pressing questions that need to be addressed are:
- Coverage: How well does the plan cover the services you need?
- Your other coverage: If you have other types of health or prescription drug coverage, make sure you understand how that coverage works with Medicare.
- Costs: How much are your premiums, deductibles, and other costs? How much do you pay for services like hospital stays or doctor visits? Is there a yearly limit on what you could pay out-of-pocket for medical services? Make sure you understand any coverage rules that may affect your costs.
- Doctor and hospital choice: Do your doctors accept the coverage? Are the doctors you want to see accepting new patients? Do you have to choose your hospital and health care providers from a network? Do you need to get referrals?
- Prescription drugs: Do you need to join a Medicare Prescription Drug Plan? Do you already have creditable prescription drug coverage? Will you pay a penalty if you join a drug plan later? What’s the plan’s overall star rating? What will your prescription drugs cost under each plan? Are your drugs covered under the plan’s formulary? Are there any coverage rules that apply to your prescriptions?
- Quality of care: Are you satisfied with your medical care? The quality of care and services offered by plans and other health care providers can vary. How have Medicare and other people with Medicare rated your health and drug plan’s care and services?
- Convenience: Where are the doctor’s offices? What are their hours? Which pharmacies can you use? Can you get your prescriptions by mail? Do the doctors use electronic health records (EHRs) or E-prescribe? Can you get an electronic copy of your information by email or to store in a personal health record? Which pharmacies can you use? Is the pharmacy you use in the plan’s network? If it’s in the network and your plan offers preferred cost sharing, does your pharmacy offer preferred cost sharing? You may pay less for some drugs at pharmacies that offer preferred cost sharing. Can you get your prescriptions by mail?
- Travel: When we resume travel, will the plan cover you if you travel to another state or outside the U.S.?
