Navigating a complex system to protect your health
According to the U.S. Census Bureau, there are more than 40 million Americans 65 years and older. This age group is the fastest growing demographic in the nation, with the first baby boomers aging into Medicare in early 2010. While reaching this milestone is certainly reason to celebrate, it also means having to make new decisions and navigate through the increasingly complex world of health insurance.
“Seniors need to decide between the many options offered by government-run Medicare and other private health insurance programs,” says Louis Hogrefe, MD, a family medicine physician with Scripps Coastal Medical Center. “This is especially important in the fall during the annual open enrollment period for these programs.”
Enrolling into any type of Medicare program can happen as soon as you turn 65. Changing your coverage options, however, is only available during open enrollment, which begins in October each year. If you are a senior over the age of 65, you may want to review your current coverage and make the necessary changes based on your health, your lifestyle and your individual needs.
Evaluating your health coverage needs
Before making changes to your health care coverage, it’s important to evaluate your current coverage.
Dr. Hogrefe suggests considering these questions before making changes:
- Have there been any recent changes in the medications you take?
- Do you have a medical condition recently been diagnosed?
- Have you relocated in recent months?
- Does your doctor and hospital accept the coverage you are considering?
Knowing the answers to these questions will help guide you through the open enrollment process.
Medicare benefits are divided into four parts:
Medicare Part A
This helps cover your inpatient hospital care and can help pay for additional long-term care, such as home health care, hospice and skilled nursing care.
Medicare Part B
This covers your care by a physician, including outpatient care, physician appointments, preventive care and some medical equipment.
Medicare Part C
Also referred to as Medicare Advantage, this optional coverage is handled by a third-party insurance vendor that’s been approved by Medicare. It can often be used to fill in the payment gaps not covered by traditional Medicare.
Medicare Part D
This helps cover the cost of prescription drugs. This portion of Medicare is covered by a third-party insurance company. Co-pays on medications will vary based on the insurance carrier and whether the prescription medication is part of their list of allowable medications—also called the “formulary.”
“Seniors who are already enrolled in Medicare should track changes in their plans, specifically whether the cost of the plan has changed, or whether prescription drugs have been added or subtracted from the formulary of the current health plan,” suggests Dr. Hogrefe.
One alternative to traditional Medicare is to enroll into a Medicare Part C plan, often called a “Medicare Advantage” plan. There are many to choose from, and they are offered by private companies approved by Medicare. These plans must cover all of the services that original Medicare covers, and may also offer extra coverage such as dental, vision and hearing. These plans also include prescription drug coverage (Medicare Part D) and can be delivered by Medicare Health Maintenance Organization (HMOs), Preferred Provider Organizations (PPOs), private “fee-for-service” plans; and Medicare special needs plans.
To join a Medicare Advantage Plan, you must already be enrolled in both Medicare Part A and B. The Medicare Advantage plan may also require an additional monthly payment. In addition, Medicare Advantage Plans now have an annual cap on how much you pay for Part A and Part B services during the year.
During the open enrollment period, you may switch from Medicare Advantage back to original Medicare, or switch from a Medicare Advantage program that doesn’t offer prescription drug coverage to one that does. You may also join a prescription drug plan or switch prescription drug plans. Remember, you may only make changes to your plan during open enrollment.
Another option for those who do not choose a Medicare Advantage plan is a Medigap plan, also known as a supplemental plan. This is another way to access services and features not covered in original Medicare. You cannot, however, opt for both a Medicare Advantage plan and Medigap coverage. When you buy a Medigap policy, you must already be enrolled in Medicare parts A and B.
You may also want to check with your doctor for additional insight on which programs will work best for you based on your current health care needs. To get the facts about the latest changes with Medicare, call 1-800-Medicare or go to medicare.gov.
Find a physician
Call 1-800-SCRIPPS (1-800-727-4777) for a referral for a primary care physician who takes Medicare and Medicare Advantage plans or Medicare supplement plans.
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