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 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:
Part A – This helps pay for a stay 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.
Part B – This helps pay for doctors’ services, both in and out of the hospital, and outpatient care such as lab work and screenings. Also covered are some 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 percent of the Medicare-approved cost of each service and you pay 20 percent. If you have supplemental insurance, it may cover the out-of-pocket expenses.
Part C – This provides an alternative way to receive Medicare services through private managed-care plans (HMOs and PPOs). These 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.
Part D – This helps pay for prescription drugs that you use at home. 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.
Medicare allows beneficiaries to have Original Medicare, Original Medicare with a Medicare Supplement (or Medigap) Plan, Original Medicare with a drug plan, Original Medicare with a drug plan and a Medicare Supplement (or Medigap) Plan, or a Medicare Advantage Plan (with or without a drug plan). 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.
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 your parents have limited income and resources, they can get help paying some or all of the Medicare premiums, deductibles, and coinsurance through Medicare Savings Programs (MSPs). Learn more about Medicare Savings Programs (MSPs) here: https://www.medicare.gov/basics/costs/help/medicare-savings-programs
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
- MedicareInteractive.org
- MedicareRights.org
- 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]
I presently have a Medigap policy Plan J with a premium of $250 a month or $3,000 a year that is all inclusive and covers everything. I am considering switching to Plan F Hi Deductible which also includes everything has a premium of $50 a month or $600 a year. It is my understanding that I am responsible for paying the first $2,400 should the cost reach that amount at which time the plan will kick in and pay all above my deductible. Now this seems to me to be a no brainer. If my costs do not reach that deductible I will be able to pocket the remainder. It is as if I am betting against myself since my Plan J has me paying $3,000 a year ahead of time whether I use it or not. What am I missing? Why doesn’t everyone take this deal? I can bank the $2,400 difference and use it to pay any bills until I hit the deductible, which is the worst case scenario.
David
You’re right, David. And I’m glad you’re looking at this closely. Plan J was discontinued in 2010 because updates to Medicare made some of its offerings redundant. Prior to 2010, it was the most coverage anyone could get when enrolled in Medicare. Now you can probably get all the coverage you need and save money. Also, many Medigap specialists recommend that you consider Plan G if you are looking at Plan F. Good luck finding what’s right for you!
We did this- the “hi option” plan and we are now in the free-zone meaning we pay a monthly premium of about $125 and all else is “free” – no out of pocket, deductibles, copays etc. It also covers preventive care, which is a bonus for mammograms and DEXAs which Medicare Traditional only covers every other year. Anyway, if you stay healthy during the initial years, its a win. We prefer NOT to have a Medicare Advantage plan as having my own choices for medical care is important to me. Espeically where I live, which has minimal specialists and quality health care. Just my take on this!
Your readers need to understand that if they switch from original Medicare with medigap insurance to an Advantage plan and then want to go back to original Medicare with medigap supplemental they will have to undergo a physical and submit health records which means they may not qualify to renter medigap or if they do it will be at a vastly higher premium than before they switched. Best to stay on medigap as long as financially able before switching to an Advantage plan when your finances won’t cover the medigap premium.
Agreed, Jan Hinton! And there are only two exceptions to this:
1. You bought a Medicare Advantage plan when you first became eligible for Medicare, but then disenrolled within the first 12 months.
2. You moved outside the Medicare Advantage plan’s service area, or the plan stopped operating where you live.
My wife and I both turn 65 this spring (2021). We independantly have asked for hard copy information so we can study advantage and medigap. No one will send anything except for a cover sheet type ad. They all seem to only want to communicate on the phone. It makes me think it’s all a scam. They cant be held to anything over the phone and I cant remember details from a phone call anyway.
Im very frustrated.
It really is a tough decision. You can find more written information if you search plans through Medicare.gov. You may also want to check with your preferred providers to see what plans they accept. That may help narrow down your choices.
Yes, I’m turning 65 next month and I’ve received so many calls from all plans and companies. Some are nice, for some reason most of the females are rude. I hang up and they call back over and over.
No matter how many #s they call from and I block….here they are again. Females can’t take “No and Stop calling.
It’s been horrible.
It’s so annoying! And some can be dangerous scams. Read AARP’s article on Medicare Enrollment scams. And I’m hopeful that we can make progress with the BENES Act.
I am so confused about choosing a medicare supplement. I have done alot of research an am still confused. Not sure what plan I need or who to go with. Some tell me med cand are free but need an extended supplemental plan. Im lost trying to navigate thru all these plans. Not sure if I need more than can d right now. Health is good but what if something happens?
lynette, the choices can feel so overwhelming. A Medicare Supplement is the right plan for many, but for some a Medicare Advantage Plan makes the most sense. AARP just published a good article on this topic, and calling your state’s SHIP is a good idea, too.
Good luck as you make this decision!
Medicare may not be a type of coverage everyone expects to plan for, but it’s worth looking into as early as possible, preferably with a broker bt your side to help break down the details. Great write-up here!
Thanks for the feedback, Robert S. I agree–it’s definitely something that should be planned for.
Thank you both for a highly informative and thorough session on these critical topics for senior citizens. I was in the insurance business for 35 years …not health insurance,…and have helped my sister who is a paraplegic and on Medicare and Medicaid for the past 6 years. Even with my experience traversing all of the elements of these issues facing seniors is at least difficult, and sometimes nearly impossible. I cant imagine how someone who is elderly and has little to no experience with insurance of any kind can deal with all the issues they face as they grow older and their needs change. Additionally, i have found one of the biggest obstacles of getting correct information and answers to key questions and issues on a TIMELY basis can be very hard due to the caliber of personnel one deals with in both governmental agencies and private insurers. Finally, adding the overwhelming volume of Medicaid Advantage commercials on TV which seniors are inundated with before and during the open enrollment period by the Joe Namaths and Jimmy Johnsons of the world, makes ones RED FLAG go up in the effort to avoid making what may be a very costly mistake as we all decide whether to keep our current insurance plan/s , change to a new one etc. I recently experienced that on behalf of my sister and literally spent many hours over a two week period just sorting out the difference between the Med Supp and RX Cov policies she had in place compared to the Medicare and Medicaid Adv policy she now has which provides better benefits and actually costs her less than the premium she was paying before. I dont know what a “novice” would have done to sort out and understand what was being offered to them. KEEP UP THE GOOD WORK!
Your sister is lucky to have such a helpful and knowledgeable brother!
My practice is in Canada where most older adults don’t have private or supplementary medical insurance or have limited options offered through their employer or former employer. Although this simplifies things, there is a downside to having only one main insurer (the province where the person lives).
I’m so glad you found the article helpful and thanks so much for taking the time to leave a comment!