Prepare for Medicare Open Enrollment

From October 15th to December 7th, Medicare beneficiaries will have the opportunity to switch or enroll in Medicare Private Health Plans (Medicare Advantage Plan) and Prescription Drug Plans (PDP), as well as switch back to traditional Medicare A & B.  The Open Enrollment Period (OEP) is a risk free time to evaluate your current plan. New choices can be made regarding plans that would be effective as of January 1, 2013.

Specifically, here are the available options you have during the OEP:

(1) Dis-enroll from a Medicare Advantage Plan (MAP) by enrolling in a Part D-PDP. This automatically allows you to go back to the original Medicare Part A & B, and then purchase a Medicare Supplement.

(2) Change from your present PDP to another PDP.

(3) Enroll in a MAP with Prescription Drug coverage.

(4) Change from your present MAP to another MAP.

Let's explore these scenarios in more detail.

(1)  Dis-enrolling from a MAP and purchasing a Medicare Supplement. What goes into the process of effectively selecting a supplement? The first thing you should understand is that Medicare Supplements, sold by private insurance companies, are standardized.  This means that all the supplement plans labeled A to N have the same benefit structure regardless of the company selling the plan. For example, if you chose Plan F from the "X" insurance company, the benefits for Plan F are exactly the same for any other insurance company selling Plan F.  Once you decide on the appropriate benefits, you are selecting a plan based on  the service and price, which varies from one company to another.  You may also want to consider those plans that cover the additional 15% charged above the Medicare approved amount by those providers who do not accept Medicare assignment.

(2) Selecting the right PDP for you can be tricky. 

For example, Florida has 16 different insurance companies offering 34 different PDPs!  All Plans are not equal. In selecting a Plan, you should do an analysis of Plans in your geographic area by going to https://www.medicare.gov/find-a-plan/questions/home.aspx. 

Do not choose a PDP based on premium only.  The total annual cost is the best indicator for decision making. Other variables to consider are the deductibles and co-payment amounts. The latter can differ among plans, as well as among pharmacies, depending on whether the pharmacy is part of a preferred network.  Not all drug plans cover the same drugs equally, so some of your drugs may be covered under one plan; but not another. In select instances, you may also need mail order options for some of your drugs.  Not all Plans make this option available.  Also, certain drugs need pre-approval.  Finally, learn how to file an appeal if the PDP doesn't pay for your drug. ALWAYS APPEAL DENIED CLAIMS AND DRUGS.

(3)  If you decide to enroll in a MAP, you should be aware of the trade-offs involved.  

In most cases, these plans limit the availability of providers to a specific network.  As long as you stay in the provider network, you may only be subject to the Plan's co-pays and deductibles.  However, if you go out of the network, in a worst case scenario, you may not have reimbursable coverage. At the very least, your co-pays and deductibles will be greater than if you stayed in the network.  

MAPs operate in sharp contrast to the original Medicare Part A & B which allows freedom of choice. 

If you have original Medicare Part A & B and a Medicare Supplement that covers the 20% not covered by Medicare, and your provider accepts Medicare Assignment, you should never have any out-of-pocket costs with the exceptions of those few services not covered by Medicare.  

If you see a provider who does not accept Medicare Assignment, then you are subject to an additional 15%  charge above the Medicare approved amount.  This cost is a real out-of-pocket expense to you.  

If you see a provider who has opted out of the Medicare program entirely you would have no coverage and all charges would be out-of-pocket.  

The bottom line:  If you have original Medicare and want no out-of-pocket costs, you must obtain a Medicare Supplement that covers the 20% Medicare does not allow, and only visit providers who accept Medicare Assignment.  If you see providers who do not accept Medicare Assignment, be certain that your Medicare Supplement covers the additional 15% charged above the Medicare approved amount. Call your medical supplement to verify.

(4) Changing from one MAP to another should only relate to network availability and co-pays.  Perhaps your doctors and hospitals are in one MAP provider network and not the other.  These factors, along with premium costs, are the key considerations when selecting one MAP over another.

Remember, once you make your decision to enroll in a new plan effective January 1, 2013, you are locked into this Plan for the coming year, until the following Oct. 15 of every year, when you once again can re-evaluate and make any necessary changes through December 7th. As always, the more knowledge you have the easier it becomes to navigate the selection that is best for you..

Stay informed. Stay positive. Stay healthy.
-  The Patient's Advocate
   medicalclaimsfilingexpert@gmail.com