Medicare Advantage plans?
Open enrollment periods?
There are changes coming for persons eligible to receive Medicare benefits. Some are good and some are not.
Medicare Part A covers hospital visits. Medicare Part B is for medically necessary services, like doctors' office visits and home health care. Medicare Part C is Medicare Advantage plans (MAPs). Part D is prescription drug coverage.
Medicare supplements, called Medigap plans, "provide, for a price, things that Medicare typically does not cover," explained Lorraine Ryan, media relations officer for the Centers for Medicare and Medicaid Services (CMS). That could be dental or vision coverage, or a reduction in out-of-pocket costs like co-pays and deductibles.
"The best time to buy a Medigap policy is within the first six months you are eligible for Medicare," Ryan said. "In those first six months, they have to sell you what you want to buy."
After that, the provider does not have to sell any given policy to a recipient. Pre-existing conditions often play a role in what is available.
Medicare Advantage plans (MAPs) replace Medicare A and B. They are offered by various private insurance companies. They generally carry a monthly premium that is lower than Medicare Part B's. Medicare Part A is generally provided at no premium. People who opt for a MAP show a card from their insurance provider, rather than a Medicare card, when they go for treatment. However, unlike original Medicare, the MAP coverage is not accepted everywhere.
Medicare recipients may go to Warren General Hospital for treatment, but the hospital does not accept all MAPs.
According to Director of Community Relations and Development Karen Coombs, the hospital accepts original Medicare and Medigap plans, and some Medicare Advantage plans: Unison Health (United Healthcare); Today's Options; Humana; and Aetna Medicare PPO for enrolled state retirees.
That leaves out Highmark Blue Cross Freedom Blue. That's not new, according to Coombs, because the hospital has "not had this plan in the past."
And, while Humana's HMO and PPO plans will be accepted, the company will not offer its private fee for service (PFFS) plan in this area for the coming year.
In fact, CMS is requiring that private fee for service (PFFS) plans must have networks. "Most carriers have chosen to discontinue their PFFS plans rather than establish a network for them," Insurance Agent Donna Dates of Winans Insurance said.
The loss of PFFS options leaves local people with fewer choices.
"In our area, we have a great challenge in having many options when it comes to MAPs," Dates said. "Our area is made even more complicated because our local hospital has chosen to" not accept certain MAPs.
"Medicare recipients should have their plans checked every year," Warren and Forest counties APPRISE Coordinator Elaine Krill said. "These plans change dramatically, sometimes, from year to year."
"They can call us and have it done free or they can call any insurance person that they trust to do that comparison," Krill said.
Sometimes, enrollees don't have any choice but to switch.
Warren County residents enrolled in plans that are not going to be offered next year - like the PFFS plans - will need to pick a new plan.
They could go with another MAP or go back to original Medicare.
Dates suggested that those who have letters announcing the termination of their MAPs keep them as proof to provide to their new carriers.
Medicare has an open enrollment period through Dec. 31.
"Medicare allows them a period of time that they can get back to original Medicare and pick up a supplement without a health check," Dates said.
People with pre-existing conditions can gain an advantage there.
There is no penalty for people who stay on a group health care plan instead of going to Medicare as soon as they are eligible. If the person loses that group coverage, they have eight months to switch without a health check.
Shopping for the right plan isn't only a good idea for those who have to switch.
"Insurance companies may charge different premiums for the exact same coverage," Ryan said. "That's why it's important for people to shop." She suggests www.medicare.gov as a good starting point.
Donut hole closing
For Medicare Part D recipients, the biggest change is a shrinking of the donut hole in prescription drug coverage.
In years past, Part D coverage was in full effect until the recipient and provider had paid a total of $2,840 in medication costs.
After that, the recipient was put in "the donut hole" and, according to Krill, "paid 100 percent until you hit about $4,600."
At the $4,600 threshold, Medicare's catastrophic coverage kicked in and covered about 95 percent, Krill said.
The span from $2,840 to $4,600 is called the donut hole.
According to Krill, there will be about a significant reduction in that hole next year.
In 2011, brand name medications will be provided at a 50 percent discount in the donut hole. The change for generic medications is only 7 percent, but, according to Dates, that's better than nothing.
"It's better than 100 percent," she said.
The step down is one of several in the process of eliminating the donut hole. "They're gradually closing it," Dates said. "I understand it's closing in 2014."