Original Medicare Open Enrollment Basics
Original Medicare consists of Part A (hospital coverage) and Part B (physician and outpatient services). You’ll also want to consider a stand-alone Part D drug plan that helps pay for prescription drugs. There are monthly premiums for Part B and Part D; Most people don’t pay a premium for Part A.
Doctors and medicines. Since Part A and Part B are standard for all Medicare beneficiaries, there’s nothing you can change with this coverage. You can go to any doctor or facility that accepts Medicare. However, Part D plans vary, so now is an opportune time to review your drug coverage and switch plans, or add a Part D plan if you don’t already have one. You can even switch from Original Medicare to a private Medicare Advantage plan during open enrollment if you want to. (Below).
It’s also an opportune time to confirm that your preferred doctors and medical facilities will continue to accept Medicare in the new year. Chances are they will: Experts estimate that more than 90 percent of doctors participate in the program and the vast majority of hospitals do, too, but it never hurts to ask.
Supplementary insurance. Original Medicare doesn’t pay for everything. Under Part B, for example, you are responsible for 20 percent of the cost of a doctor’s visit or lab test. Medicare supplement insurance, also known as Medigap insurance, helps pay for non-covered expenses, including some copays and coinsurance. Supplemental insurance is optional and is not subject to the open enrollment period. You can buy a Medigap policy at any time during the year. And you can change your Medigap coverage at any time during the year.
However, there is something very important to know about changing your Medigap policy: Insurers that carry this coverage cannot reject a policy within six months of your Medicare eligibility, even if you have a chronic medical condition, have overweight, smoker or have any other disease. That’s called a guaranteed issue rule. But once the initial registration period is over, these companies may refuse to sell you a policy or charge you a much higher premium. And that goes for your ability to change policies once you have one. There are four states, Connecticut, Maine, Massachusetts, and New York, with laws that require insurers to sell you a Medigap policy all the time or at least once a year.
Neuman points out that if you don’t have pre-existing conditions, you can probably switch Medigap policies without paying more. It’s worth a look if you’re not happy with your current add-on plan.
Also, if you left your job or retired, you may have signed up for COBRA (temporary coverage for people who lose their coverage due to job loss) or a retiree health plan through your employer or union . If your COBRA coverage ends or your retiree coverage goes away, you’ll have 63 days to buy a Medigap policy under the government’s guaranteed issue rule.
Medicare Advantage Open Enrollment Basics
Medicare Advantage, also known as Part C, is a private insurance alternative to original Medicare that bundles Parts A, B, and (usually) D. Think of it as a one-stop-shop option, unlike original Medicare, which requires you to you look for separate drug coverage and supplemental insurance.
Read your letter. Every September, Medicare Advantage plans must send their members a letter called the Annual Notice of Change. This letter will list any changes to the plan starting in January, such as benefits, costs, or the geographic area the plan covers.
You’ll want to use this information when deciding whether to stay with your current MA plan, switch to a different MA plan, or switch to Original Medicare.
Special open enrollment period for MA plans. If you already have an MA plan, you’ll have more time to decide what to do. The special open enrollment period runs from January 1 to March 31. During this time, you can switch from one MA plan to another or to Original Medicare. If you switch to Original Medicare, you will also be able to get a separate Part D prescription drug plan. This special period only applies to people who already have an MA plan.
Go to the doctor or hospital. Pay close attention during open enrollment if you have a Medicare Advantage plan. Most MA plans are organized around networks of doctors and other medical providers, including hospitals. If you use providers within the network, you will pay less than if you use providers outside of your plan’s network.
During open enrollment, you should check your MA plan’s provider directories to make sure your doctors are still in the plan. If not, you may want to consider switching plans, depending on how important it is for you to continue seeing specific providers.
If you’ve had a significant change in your health, such as a serious illness like cancer, you’ll want to confirm if the doctors and medical facilities you need to help you through this illness are available in-network under your current plan. Otherwise, you risk facing large out-of-network bills.
Open Enrollment and Medicare Prescription Drugs
Medicare beneficiaries get their prescription drugs in one of two ways: through a stand-alone Part D prescription drug plan or as part of their Medicare Advantage plan.
A common check for both options during open enrollment should be whether the drugs you take are still covered by your current plan, and at what cost. Beneficiaries should also see which pharmacies their current plan prefers and if they remain the most convenient for you. You should also consider whether you can save money by receiving your medications by mail and whether your plan offers it.
“People can take time to choose a drug plan when they first join Medicare and stick with it for years to come,” says Neuman. “But following a plan can come at a cost because drug plans change from year to year, and people’s drug needs change over time. We’ve seen people save hundreds, if not thousands, of dollars by comparing plans.”
The amount Medicare beneficiaries will have to pay out-of-pocket for prescriptions will change thanks to the Reduce Inflation Act of 2022. Currently, people who reach a certain level of out-of-pocket costs for prescription drugs: the limit is $7,050 for 2022 — Enter what’s known as “catastrophic” coverage and owe 5 percent of the costs above that level. Beginning in 2024, people with catastrophic prescription drug costs will have no additional out-of-pocket costs once they reach the threshold level. Then, beginning in 2025, out-of-pocket costs for prescription drugs will be capped at $2,000 a year.
People who get their drugs as part of their Medicare Advantage plan can’t choose a stand-alone drug plan, Neuman cautions. “They get whatever drug coverage the plan provides.” That means that as people consider whether to stay with their current MA plan or switch plans, she says, they should also consider the specific prescription drug coverage built into their MA plan.
Switch between Medicare options
Here’s what to consider if you’re thinking about switching from one Medicare option to another during open enrollment:
- Switch from original Medicare to a Medicare Advantage plan. Make sure your providers are covered in-network in the MA plan you select. Also keep in mind that you will likely be subject to more management of your care: some plans will require referrals to specialists, and MA plans often require plan prior authorization for some diagnostic tests and other services.
- Switch from Medicare Advantage to Original Medicare. The rules allow you to do this, but there’s a big caveat: If you want to go back to original Medicare, you may not be able to get a supplemental (Medigap) plan — or at least one that’s affordable — that helps you pay some out-of-pocket costs. under Original Medicare.
- Switch between MA plans. This is the time of year to take a hard look at your current Medicare Advantage plan and shop around to see if there’s a plan where you live that best fits your needs and your pocket.
Financial assistance if you can’t afford Medicare
If you’re having trouble paying your Medicare premiums, copays, and other out-of-pocket costs, the federal government has four Medicare Savings Programs that help people with limited incomes. There is also a program called Extra Help that helps beneficiaries with their out-of-pocket costs for prescription drugs. Even if you haven’t qualified for these programs before, open enrollment is a good time to check if your financial circumstances now allow you to qualify.
The Inflation Reduction Law may also soon come into play. Beginning in 2024, Medicare beneficiaries with annual income up to 150 percent of the federal poverty limit ($20,385 for an individual in 2022) who also meet the program’s resource limit may qualify for the full benefits of the Extra program. Help. The income threshold for full benefits is currently 135 percent of the federal poverty guidelines ($18,347 for one person in 2022).
How to get help choosing a Medicare plan
Beneficiaries can compare plans and change their enrollment by going to www.medicare.gov. During the open enrollment period, there is also live chat support on the website.
In addition, Medicare has a 24/7 hotline where representatives can answer your questions about open enrollment. That toll-free number is 800-633-4227. Also, each state has a State Health Insurance Assistance Program (SHIP) with counselors who can help answer your questions.
Dena Bunis covers Medicare, health care, health policy, and Congress. She also writes the Medicare Made Easy column for the AARP Newsletter. Bunis, an award-winning journalist, spent decades working for metropolitan dailies, including as Washington bureau chief for the Orange County Registry and as a health and workplace policy writer for Newsday.