Written by Carol Marak, founder of the Elder Orphan Facebook Group
This Medicare Fall Open Enrollment Guide is meant to clear up some confusion about the health insurance program, what you should do during the annual election period that runs from October 15 to December 7, and how to evaluate whether it’s time to change your Medicare Advantage plan or Part D drug plan.
Table of Contents
- Overview of terms
- The enrollment period
- Original Medicare versus Medicare Advantage
- How to decide if you want to make a change
To make this guide the most comprehensive, let’s start at the beginning with the common terms you need to know. Make sure you become familiar with each part of Medicare, Part A, Part B, Part C, and Part D. This glossary explains all the terms used in the Medicare program. (https://www.medicare.gov/glossary/)
Here’s a quick overview of the most frequently used terms of the Medicare program.
Original Medicare consists of two parts: Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). Medicare Part A covers inpatient care received in a hospital, a skilled nursing facility, and, in very limited circumstances, at home. Enrollees don’t pay a premium for Medicare Part A. However, Parts B and D come at a cost. The average monthly Part B premium is $135.50 which covers preventative care (doctor visits and medical services and supplies that are medically necessary to treat your health condition,) and Part D, which covers prescription drugs.
This is the payment Medicare requires out of pocket until the insurance company starts paying for the services. Medicare’s current Part A deductible is $1,364 per benefit period. Part B has an annual deductible of $185.
A copay is the amount you must pay each time you use a medical service. With Part B, once your deductible has been met for the year, you’ll typically be liable for 20% coinsurance, which means you’ll pay 20% of the Medicare-approved amount for most services.
The initial enrollment period refers to the time when you were eligible and signed up for Medicare. This period is seven months long, beginning three months before the month of your 65th birthday and ending three months after the month of your 65th birthday. If you fail to sign up for Medicare during your initial enrollment period, you’ll still have an opportunity to do so later, But beware the rule: If you fail to sign up during that time, you may see a 10% increase in the Part B premiums going forward for every 12-month period you were eligible for Medicare but didn’t enroll.
If you’re still working for a company with 20 employees, and that company provides health insurance, you are eligible to hold off signing up for Part B. You will be given a special enrollment period that lasts eight months, beginning the month after you leave your job or the month your health insurance terminates (whichever happens first.)
Medigap or Supplement insurance covers a number of services that Medicare does not, offering additional coverage on top of what Medicare provides. There’s an additional cost for Medigap insurance (on top of your regular Part B premium amount) and it includes expenses such as copayments, coinsurance, and deductibles under Medicare. Private companies sell Medigap policies and will step in to pay the share of your overall costs the policies call for after Medicare pays its approved amount for the services. To qualify for Medigap, you must have Medicare coverage under Parts A and B.
Original Medicare refers to Parts A (covers hospital visits) and B (covers diagnostics, doctor visits, and preventative care.) Medicare does not cover prescription drugs. You will need Part D to cover medications. Medicare also does not cover long-term care expenses, eyeglasses, or dental work.
Medicare Advantage Programs combines Medicare Parts A and B into one, and can but not always cover services like vision, dental care, and hearing aids. However, many Medicare Advantage plans offer additional benefits and most cover prescription drugs.
You will pay a premium for a Medicare Advantage plan. Our best tip, get acquainted with Medicare even before you initially qualify. Doing so will help you understand the Medicare rules and the terminology it uses.
This Medicare Fall Open Enrollment
Medicare open enrollment period start October 15 through December 7, 2019. This is your chance to change:
- From Original Medicare to a Medicare Advantage plan
- From Medicare Advantage to Original Medicare
- Find a more suitable Medicare Advantage plan
- Find a different Medicare prescription drug plan
Changes made during the Medicare Fall Open Enrollment will take effect on January 1, 2020.
The Fall Open Enrollment Period is the most significant time for you to review your coverage. Be on the lookout for the Annual Notice of Change Packet from the Medicare Advantage Plan. You will also receive an Annual Notice of Change for your Part D drug plan. Both are due in your mailbox by September 30.
Please note the Annual Notice of Change is only a summary of changes. You can find a copy of the Evidence of Coverage on your insurance carrier’s website, or call your insurance company’s Customer Care to ask them to mail you an Evidence of Coverage.
Once received, get organized and start doing research–especially if you plan to switch plans. Here are the steps to follow if you have a Medicare Advantage Plan:
1. ASK: Which changes apply to you
Check the changes to the benefits and costs.
- Review your coverage to make sure it will meet your needs in the next year.
- Do the changes affect any services you use?
- Look in each section for benefit information and cost changes. Check the changes in your prescription drug coverage.
- Will your drugs be covered?
- Are your drugs in a different tier, with different cost-sharing?
- Do any of your drugs have new restrictions, such as needing approval from the private insurance carrier before you fill your prescription?
- Can you keep using the same pharmacies? Are there changes to the cost of using the pharmacy?
- Review the 2020 Drug Guide and look for information about changes to the drug coverage.
- Your drug costs may have increased. Talk to your doctor about lower cost drug options that can save in annual out-of-pocket costs. To get additional information on drug prices visit https://go.medicare.gov/drugprices. These dashboards highlight which manufacturers have been increasing their prices and also show other year-to-year drug price information. Keep in mind that your plan benefits will determine exactly how much your own drug costs may change.
Check to see if your doctors and other providers will be in your network next year.
- Are your doctors, including specialists you see regularly, in our network?
- What about the hospitals or other providers you use?
- Look in the insurance carrier’s Provider Directory.
Think about your overall health care costs.
- How much will you spend out-of-pocket for the services and prescription drugs you use regularly?
- How much will you spend on your premium and deductibles?
- How do your total plan costs compare to other Medicare coverage options?
2. COMPARE: Learn about other plan choices
Check coverage and costs of plans in your area.
- Use the personalized search feature on the Medicare Plan Finder at https://www.medicare.gov website. Click “Find health & drug plans.”
- Review the list in the back of your Medicare & You handbook.
Once you narrow your choice to a preferred plan, confirm your costs and coverage on the plan’s website.
3. CHOOSE: Decide whether you want to change your plan
- If you want to keep the current plan, you may not need to do anything. You will stay in.
- To change to a different plan that may better meet your needs, you can switch plans between October 15 and December 7.
Keep good records and the Medicare enrollment period becomes so much easier to navigate. You’ll find that you won’t dread the annual election period because you’re so prepared.
If you are enrolled in a Medicare Advantage plan, and you want to switch from Medicare Advantage to Medigap, you can use the Annual Election Period to return to Original Medicare. You can choose a new Part D drug plan as well. However, for the Medigap plan, you will need to apply and in most cases will need to answer health questions. There is no guarantee that you will be accepted.
Before cancelling your Medicare Advantage Plan, make sure you are approved by the Medigap plan with a January 1st effective date. Then apply for a Part D drug plan which will automatically disenroll you from your Medicare Advantage plan.
If you are not able to qualify for a Medigap plan due to health conditions, you can consider switching to a different Medicare Advantage plan.
Citizens turning 65 years of age are eligible for Medicare during a 7 month initial enrollment period. That’s the time to sign up for Part A and/or Part B.
When eligible, you can sign up during the 7-month period that:
- Begins 3 months before the month you turn 65
- Includes the month you turn 65
- Ends 3 months after the month you turn 65
The coverage start date will depend on when you sign up. If you wait until the month you turn 65 (or the 3 months after you turn 65) to enroll, your coverage could be delayed. This could cause a gap in your coverage. So, sign up during the first 3 months before turning 65.
If you are receiving Social Security, the Social Security Administration will automatically sign you up at age 65 for parts A and B of Medicare. Medicare is operated by the federal Centers for Medicare & Medicaid Services, but Social Security handles enrollment.
If you don’t sign up for Medicare Part B when you’re first eligible, you’ll have to pay a late enrollment penalty. You’ll have to pay this penalty for as long as you have Part B and could have a gap in your health coverage.
Special circumstances (Special Enrollment Periods)
Once your Initial Enrollment Period ends, you may have the chance to sign up for Medicare during a Special Enrollment Period (SEP). If you’re covered under a group health plan based on current employment, you have a SEP to sign up for Part A and/or Part B anytime as long as:
- You or your spouse (or family member if you’re disabled) is working.
- You’re covered by a group health plan through the employer or union based on that work.
You also have an 8-month SEP to sign up for Part A and/or Part B that starts at one of these times (whichever happens first):
- The month after the employment ends
- The month after group health plan insurance based on current employment ends
- You may also qualify for a Special Enrollment Period for Part A and Part B if you’re a volunteer, serving in a foreign country.
Typically, you don’t pay a late enrollment penalty if you sign up during a SEP.
Note: COBRA and retiree health plans aren’t considered coverage based on current employment. You’re not eligible for a Special Enrollment Period when that coverage ends. This Special Enrollment Period also doesn’t apply to people who are eligible for Medicare based on living with End-Stage Renal Disease (ESRD).
Contact your local SHIP office–get expert advice, and save research time. The State Health Insurance Assistance Programs (SHIPs) give free, in depth, one-on-one insurance counseling and help. SHIPs are government programs funded by the federal U.S. Department of Health and Human Services. Find your state’s SHIP office
Contact your local Area Agency on Aging – Call the local Area Agency on Aging and ask if they have programs that help with Medicare Open Enrollment. Find your local Area Agency on Aging
Use Medicare’s online plan finder–Medicare has an online plan finder and comparison tool. This tool shows available plan options for 2020. Use Medicare’s online plan finder
Find a Medigap Policy plan finder
Call 1-800-MEDICARE (1-800-633-4227) and ask a representative to run a search for plan options and mail the results. Have your Medicare number from your red, white, and blue Medicare card available. The automated system will ask for your Medicare number at the beginning of the call. You can either say your Medicare number or enter it with the phone keypad—enter the numbers and press the * key for any letter(s).
Extra Help with Medicare prescription drug plan costs — Anyone who has Medicare can get Medicare prescription drug coverage. Some people with limited resources and income also may be able to get Extra Help with the costs — monthly premiums, annual deductibles, and prescription copayments — related to a Medicare prescription drug plan. https://www.ssa.gov/pubs/EN-05-10508.pdf
General Medicare Questions https://www.medicarerights.org/PartB-Enrollment-Toolkit/Part-1-QA-General.pdf
Ways to contact Medicare.gov https://www.mymedicare.gov/helppages/customerservice/