Article originally featured on MRT
Part A, Part B, Part D, and what’s this about Plan F, G and N? Navigating Medicare is like alphabet soup with a side of number crunch.
Over a two-month period at the end of every year, people over 65 and those with long-term disabilities are left are trying to figure out what kind of health coverage they need in the coming year.
Here’s your Houston How To primer on Medicare and Medicare Advantage plans for the 2020 open enrollment period. (Don’t worry, there’s a glossary for health insurance terms in the collapsed fact box.)
Glossary of terms
Medicare: The federal insurance program for people age 65 and older, and people with a chronic disability. See the part of your paycheck where taxes to fund the Medicare program are withdrawn? The funds go toward supporting this program, which insures more than 4 million people in the state.
Premiums: The amount you pay for health insurance every month.
Deductibles: The amount of money that an insured person must pay before insurance companies begin to pay out claims.
Out-of-pocket costs: Deductibles come first. After you fill that, your insurer will start paying a percent of your medical bills. You’ll have to pay the other portion — a reduced cost from what you would’ve paid if you were still trying to fill your deductible. Some plans will have separate meters for your deductible and out-of-pocket costs. Once you’ve hit the cap on the latter, insurers will cover the full costs.
Open enrollment: The period of time running from Oct. 15 to Dec. 7 when people who qualify for Medicare can look at their existing plans and swap to new plans if necessary. Changes made during open enrollment go into effect the first of the month after the changes are made. Medicare Advantage open enrollment, which is a separate period of time to make additional changes to a Medicare Advantage plan, runs from Jan. 1 to March 31.
Medicare Part A: The insurance plan that covers hospital care, home health aides, nursing facilities, hospice and lab tests. Usually purchased in conjunction with Part B, known as Original Medicare.
Medicare Part B: The insurance plan paying for doctor’s visits, ambulance services, some prescription drugs, durable medical equipment such as canes and oxygen tanks and mental health services. Usually purchased in conjunction with Part A, known as Original Medicare.
Medicare Advantage: Also known as Medicare Part C, it’s a type of Medicare plan offered by private health insurance companies that combines Parts A, B and D. These comprehensive plans don’t skimp out on coverage, and in some cases, may offer more than Original Medicare by including dental and vision benefits.
Medicare Part D: The insurance plan that covers drug prescriptions. These may have their own deductibles and out-of-pocket costs, but some plans up for enrollment may offer low-cost or no annual deductible. Each plan will offer a list of medications covered, sorted into tiers by cost.
Medicare Supplement: Also known as Medigap, these insurance plans fill in the holes that aren’t covered by Part A and B — namely, deductibles and co-pays, and sometimes other medical supplies. They don’t include prescription drug coverage, meaning that consumers have to buy a separate drug plan. Similar to Medicare Advantage plans, they’re sold by private insurers. These may have names ranging from Plan A to Plan N, which range in coverage and premium prices.
The Pros and Cons of Original Medicare vs. Medicare Advantage
If you already have an Original Medicare plan, you’re enrolled in both parts A and B, which cover doctor’s visits and hospital care, among other things. You have the option to sign up for Medicare Part D, the supplemental insurance that pays for prescription drugs.
The Medicare open enrollment period — which runs from Oct. 15 to Dec. 7 — might be the time that you decide to switch to a Medicare Advantage plan, an all-encompassing version of the Original Medicare plan, rather than juggling and signing up for parts A, B and D individually. Or you might just switch to new drug prescription plans.
Some people prefer to stick to Original Medicare because the insurance is accepted at any doctor’s office, according to the federal Medicare guide. In most cases, patients won’t need referrals to see specialists on an Original Medicare plan. But there is no cap to out-of-pocket costs if a patient runs up a high bill.
On, Medicare Advantage plans, patients usually must stick to a list of doctors in the insurer’s approved network. However, there are usually lower out-of-pocket costs compared to Original Medicare.
Before signing up for a Medicare Advantage plan, ask your primary care doctor — and any specialists you see — about which Medicare Advantage plans they accept. Be cautious about how you word the question, said Danielle Kunkle Roberts, president of Fort Worth-based Boomer Benefits.
“The question you need to ask about Medicare Advantage is ‘are you in the network for any Medicare Advantage plans?’” Roberts said. “If you just ask your doctor, ‘do you accept Medicare Advantage?’, you don’t know which plans. You want to ask which network, and you want to ask a lot of questions.”
How to Enroll
Some people are automatically enrolled in the Medicare system, while others need to sign up manually. If you aren’t drawing Social Security benefits yet, but will turn 65 or older within the next three months, you’ll have to sign up online at the Social Security Administration site. You’ll need an account with SSA, which offers a helpful checklist to set up an account and prepare for Medicare and Social Security benefit applications.
Savings programs and subsidies are available for low-income households that need help paying for premiums, co-pays and deductibles.
To look at Medicare plans, go to the Medicare website at medicare.gov/medicarecoverageoptions. You may also look at a comparison chart at MedicareHelp.org, which lists 55 Medicare Advantage plans available in Harris County, 35 Medicare Part D plans in Texas and 45 Medicare Supplement (also known as Medigap) plans in southeast Texas. (The regions are confusing, I know.)
You can turn to an insurance agent/broker, or contact the Texas Health Information, Counseling and Advocacy Program at 800-252-9240 for help signing up. With a maze of Medicare Advantage, Medigap and Medicare Part D options, it might be beneficial to see a qualified professional, said Michael Ledgerwood, a Medicare benefits consultant at Benefit Concepts Inc. in northwest Houston.
“We can collect the doctors a person uses and compare those in the various networks of the plans,” he said. “If person is considering a Medicare Advantage plan, we can find one that fits and includes most or all of the physicians a person’s using.”
Who needs Part D
Part D is the part that stumps most people on Original Medicare, Roberts said.
For relatively healthy Medicare beneficiaries, it might feel like an extraneous cost to have prescription drug coverage when you don’t take much other than a multi-vitamin every day. But when a day comes where you need the extra medication benefits, you might be slapped with a serious fee.
According to the federal Medicare website, patients may face a late enrollment penalty if “there's a period of 63 or more days in a row when you don't have Medicare drug coverage” or a plan from an credible provider such as an employer or union that covers drug benefits. That penalty is 1 percent of the national base beneficiary premium (for 2020, that’s $32.74) for each full month a patient goes without coverage, and tacked onto the monthly premium payment.
“The longer you wait, the more you owe,” Roberts said. “We advise that people go ahead and sign up for the least expensive drug plan in their county. There’s some in the $10 to $15 range every year that will prevent you from getting the penalty because you have the coverage.”
It’s also key, Roberts said, to have coverage in case you do get sick and can’t enroll in a Medicare drug plan until the next open enrollment period.
When to get Medicare Supplement
If you have Original Medicare, you may want to consider a Medicare Supplement plan to help cover additional costs. Medicare Supplement plans fill in what isn’t covered under Original Medicare, such as deductibles (the amount you have to pay before insurers pay out claims) and out-of-pocket costs (the percent you still owe once insurers start helping with some of the bills).
Medicare Supplement plans are standardized, and the main difference is who’s offering it and how much patients pay in monthly premiums.
The top three plans sold are plans F, G and N, Ledgerwood said, which don’t stand for anything but vary in deductible costs and caps. A plan G from Humana will do the same things as a plan G from Aetna — what’s different is how much the insurers pay for benefits.
Anyone who’s turned 65 after Jan. 1, 2020, cannot buy a Plan F because of changes to federal law around what deductibles can be fully covered and reimbursement rates for doctors. If you’ve turned 65 before 2020 and qualified for Medicare, you’re grandfathered in and able to enroll if still covered by a company or union health insurance plan. If you’re enrolled in Plan F, you won’t be kicked off.
Some Medigap policies such as Plan G and N offer similar coverage, but at different price points.
You can shop and change Medicare Supplement plans at any time, Ledgerwood said, and while insurers will ask you for your medical history, they won't force you to re-enroll every year.