Medicare: The ABCDs to Know & Tips for Open Enrollment

Every year, Medicare has an open enrollment period: October 15 – December 7.

During this time, Medicare beneficiaries can do the following:

• Switch from Original Medicare to Medicare Advantage, or vice versa;
• Switch from one Medicare Advantage plan to another;
• Change Medicare Part D (prescription drug) plan; or
• Enroll in a Medicare Part D (a late enrollment penalty may apply).

Medicare health and drug plans can make changes each year—things like cost, coverage, and what providers and pharmacies are in their networks.  It is important for Medicare beneficiaries to review their current plans, options, and needs for the next year. Many beneficiaries fail to take any action during open enrollment; Medicare is not a “set it and forget it” insurance plan.

Before you can start deciding if and what to change about your Medicare benefits, you have to understand the basics of Medicare.

In this article, I’ll review the basics of Medicare Parts A, B, C (also known as Medicare Advantage) and D. Then, I’ll share some tips on navigating the Medicare Open Enrollment period and how to get help, if you’re considering making a switch or if you need help affording the Medicare premiums.

What to Know About Medicare A, B, C, and D

It’s easy to get confused by all the letters associated with Medicare. Here’s what to know:

Medicare Part A 

This type of Medicare covers stays in the hospital and skilled nursing facilities, home health services, and hospice care – as long as certain conditions are met. There are no monthly premiums if you or your spouse paid sufficient Medicare payroll taxes while working. Otherwise, you can buy Part A services by paying monthly premiums.

Medicare Part B 

This provides coverage for primary care, for outpatient specialty care, and for other forms of doctors’ services, both in and out of the hospital. It also covers lab work and screenings, some forms of durable medical equipment and supplies, such as wheelchairs and oxygen (if certain conditions are met), and most drugs or vaccines that are administered in a doctor’s office.

Unless your income is limited enough to qualify for state assistance, you pay a monthly premium for Part B. Medicare typically pays 80% of the Medicare-approved cost of each service and you pay 20%. If you have supplemental insurance, it may cover the out-of-pocket expenses.

Medicare Part C (also known as Medicare Advantage)

This provides an alternative way to receive Medicare services through private managed-care plans (HMOs and PPOs).  These Medicare Advantage plans must cover all the same services as the traditional Medicare program (Parts A and B), but may charge lower copays. The plans may also offer Part D drug coverage and some extras, at their discretion, such as routine dental, vision and hearing care.

You may pay a monthly premium in addition to the Part B premium, although some plans charge no premiums of their own. Medicare Advantage plans may restrict your choice of doctors and other providers, or charge higher copays for going out of network.

Note: A special type of plan to know about is PACE (Program of All-Inclusive Care for the Elderly), which provides comprehensive services to older adults who are eligible for nursing home care. Learn more here: Program of All-Inclusive Care for the Elderly (PACE).

Medicare Part D

This helps pay for prescription drugs that you use at home. (Think: “D” is for “drug coverage.”)

You can get this coverage in one of two ways: by joining a private “stand-alone” Part D drug plan for an additional monthly premium (if you are enrolled in traditional Medicare), or by enrolling in a Medicare Advantage plan that includes Part D coverage in its benefits package.

Different options allowed by Medicare

Older adults can end up with a variety of different Medicare arrangements. These include: 

• Original Medicare (generally people will have Parts A and B)
• Original Medicare with a Medicare Supplement (or Medigap) Plan
• Original Medicare with a drug plan (e.g. Parts A, B, D)
• Original Medicare with a drug plan and a Medicare Supplement (or Medigap) Plan
• Medicare Advantage Plan (with or without a drug plan)  

A Medigap plan helps older adults pay their share of out-of-pocket costs; learn more here: What’s Medicare Supplement Insurance (Medigap)?

Beneficiaries may also have private insurance from an employee or retirement plan.

How to Navigate Medicare Open Enrollment

If you’re an older adult, throughout October you are likely inundated with mail from various health insurance companies. As mentioned before, Medicare’s Open Enrollment is October 15-December 7.

Since Medicare’s Open Enrollment is the time that beneficiaries can sign up for (or change) Medicare Advantage Plans, this means October is when the insurance companies are in serious competition for your business.

Unfortunately, this often ends up being a confusing time for older adults and families. Medicare offers an overwhelming list of options. There’s a lot of flexibility, but this also leads to a lot of uncertainty about what — if anything — to do about one’s Medicare coverage.

In my work as a social worker and geriatric care manager, I’ve found that about 80% of older adults (or their family members) are unable to tell us what type of insurance they have.

Generally, about one-third of all Medicare beneficiaries have Medicare Part C, which means they are in a Medicare Advantage Plan. (But of those that have Medicare Advantage Plans, only about 40% are aware that they do not have Original Medicare. )

The competition among Medicare Advantage Plans can be fierce, so there are rules about what the insurance companies can and cannot do, to try to get your family’s business.

What Medicare Advantage Plans can and can’t do

In order to market to potential customers, Medicare Advantage Plans are allowed to conduct certain activities, such as using direct mail, radio, television, and print advertisements. Plans can also send emails, but they must provide an opt-out option in the email for people who do not wish to receive them.

Medicare Advantage Plans are not allowed to:

• Call you if you do not give them permission to do so
• Visit you in your home, nursing home, or another place of residence without your invitation
• Ask for your financial or personal information (like your Social Security number, Medicare number, or bank information) if they call you
• Provide gifts or prizes worth more than $15 to encourage you to enroll. Gifts or prizes that are worth more than $15 must be made available to the general public, not just to people with Medicare
• Disregard federal and state consumer protection laws for telemarketing, the National Do-Not-Call registry, or do-not-call-again requests
• Market their plans at education events or in healthcare settings (except in common areas)
• Sell you life insurance or other non-health products at the same appointment (known as cross-selling), unless you request information about such products
• Compare their plan to another plan by name in advertising materials
• Use the term “Medicare-endorsed” or suggest that their plan is a preferred Medicare plan
  • Plans can use Medicare in their names as long as it follows the plan name (for example, the Acme Medicare plan) and the usage does not suggest that Medicare endorses that particular plan above other Medicare plans
• Imply that they are calling on behalf of Medicare

If you feel a plan or agent has violated Medicare’s marketing rules, you should save all documented proof, when available, such as an agent’s business card, the plan’s marketing materials, and your phone call records. Report the activity to 1-800-MEDICARE or your local Senior Medicare Patrol (SMP). To contact your SMP, call 877-808-2468 or visit www.smpresource.org.

What to do during Medicare Open Enrollment

I recommend older adults take the following steps during Open Enrollment:

1. Review your current Medicare coverage. 

This is a great time to check and make sure you’re clear on the type of Medicare you have. Be sure to find out if you currently have a separate Part D plan, and be sure identify any types of supplemental insurance.

Note: If you’re involved in the care of an aging parent, this is great information to know!

2. Ask yourself how satisfied you’ve felt over the past year.

If everything feels like it’s been going well, then you may not need to change much during Open Enrollment. However, if you’ve been paying a lot of out-of-pocket costs, or if you’ve run into issues accessing a form of medical care that you wanted, then it might make sense to consider making changes to your Medicare coverage.

3. Use the Medicare website to compare available plans for the following year.

During Open Enrollment, Medicare.gov usually will have a section allowing you to search and compare plans in your state.

How to Get Help Choosing, Changing, or Paying for a Medicare Plan

To provide support to Medicare beneficiaries, each state has a State Health Insurance Assistance Program (SHIP). SHIPs offer local, personalized counseling and assistance to people with Medicare and their families. Your local SHIP can be found at: https://www.shiptacenter.org/

If you (or your parents) have limited income and resources, you can get help paying some or all of the Medicare premiums, deductibles, and coinsurance through Medicare Savings Programs. Learn more here: Medicare Savings Programs (MSPs).

Other Useful Resources

For more on Medicare Open-Enrollment, here’s a podcast episode in which Dr. K and I discuss Medicare and I explain how to know if you should switch plans:

(For a short tutorial on how to search the transcript, see here.)

And here are the online resources that I routinely recommend to my clients:

• Medicare.gov
  • Medicare’s Plan Finder 
  • MyMedicare
• MedicareInteractive.org
  • Six things to know about Fall Open Enrollment
• MedicareRights.org
  • Differences between Original Medicare and Medicare Advantage
• State Health Insurance Insurance Assistance Program (SHIP)

I hope this information has been helpful to you. Although it can take some effort to review one’s Medicare insurance and make changes if needed, it can make a big difference to the services you’ll get later during the year. Good luck with Medicare Open Enrollment!

[Michelle Allen is an experienced social worker and geriatric care manager based in Atlanta, and is one of our featured experts providing guidance in my Helping Older Parents programs. Since our members have raved about the Medicare guidance she’s been sharing with them, we decided to have her share this info with our regular Better Health While Aging readers as well. — L. Kernisan]