7 pointers for navigating Medicare open enrollment

With Medicare open enrollment for 2013 kicking off Oct. 15, now is the time for new enrollees and existing subscribers to assess their medical needs to determine the right health insurance coverage.

During the open enrollment period, which runs through Dec. 7, all coverage decisions for 2013 must be made. Current participants don't have to take action unless they want to make changes to their existing benefits, but it's wise to review your coverage, keeping in mind any health changes.

Here are seven things to remember when evaluating Medicare needs.

1.Know your A, B, C and D.

To the uninitiated, Medicare may seem like an alphabet soup of jargon. The breakdown of the main parts of the program ––which is available to all U.S. citizens or permanent residents, starting at age 65 ––is as follows:

medicare-open-enrollmentPart A This covers basic hospitalization, care in a nursing home or rehabilitation center, hospice care and some at-home services.

Part B This is the portion of Medicare that covers doctor’s visits, outpatient services, medical supplies andpreventive services; many seniors choose to supplement this portion with a so-called Medigap plan from a private insurer to pay expenses not fully covered by the federal Medicare plan.

Part C – Also known as Medicare Advantage, this is an HMO-like system that combines A’s and B’s services and sometimes prescription drugs.

Part D – This is a fee-based prescription program of which there are many options available frominsurance companies and other private firms approved by Medicare.

2.Look beyond the monthly premium.

When evaluating the cost of a plan, the monthly premium is just one factor to consider, says Nicole Duritz, vice president for health and family at AARP, an advocacy group for people 50 and over.

You also need to check whether on deductibles or co-pays, and review your medical needs from the previous 12 months as well as what you anticipate needs for the next year.

“You could be on a big health kick, and don't have to take blood pressure medication because you got yourself healthy, or as an alternative, if a chronic condition has cropped up, you want to consider how your spending might go up,” Duritz says.

3.Mind the Medigap.

While Medicare offers guaranteed coverage, it isn't necessarily complete coverage, says Eric Maddux, a spokesman for PlanPrescriber.com.

To close the gap in what's covered, supplemental plans are available from private companies. The higher the monthly premium for these so-called Medigap plans, the less you'll have to pay out of pocket for doctor's appointments and services.

Under so-called “original” Medicare, “there’s no maximum out-of-pocket cost and no limit to the amount Medicare can charge them in a worse-case scenario,” Maddux says.

4.Now or later for Medigap?

It's decision time on whether to buy a Medigap policy during your first six months of Medicare enrollment, because that's a “guaranteed issue” window when you can’t be rejected, "no matter your health status," Duritz says.

Once you’re outside those six months, there’s no guarantee of being accepted by a Medigap plan, Duritz says.

5.Pluses, minuses of Medicare Advantage.

Medicare Advantage allows people to combine their Medicare A and B coverage under one privately-managed plan.

These plans include HMO-style offerings under which care is coordinated through a network of doctors and hospitals, according to Cindy Polich, president of United HealthCare’s Medicare division. In-network pharmacies may offer cheaper prices for drugs, whether through an in-store or a mail-order option, Polich says.

One advantage of such “coordinated care” is that subscribers may be able to more easily come home following a hospital stay, and head off “unnecessary” return visits, Polich says.

Other benefits include wellness features, such as gym membership as well as vision, dental and hearing care, that may not require additional premium costs, Polich says.

However, those with kidney disease, diabetes, heart ailments or other chronic conditions should compare how much is required out-of-pocket with such plans, says Lita Epstein, author of “The Complete Idiot’s Guide to Social Security and Medicare.”

“Many Medicare Advantage plans cherry-pick their customers by not fully covering the costs of chronic illnesses with the hopes that people with these chronic illnesses will not pick their plan,” Epstein says.

6. A prescription for drug plans.

Those who don't take medications regularly now need to think about what their future needs could be and also the long-term cost of potential penalties.

Under Medicare regulations, those who don’t have drug coverage for 63 consecutive days are subject to a penalty of 1 percent of the national average monthly cost for a prescription plan ($31.08 this year) The penalty is added to your premiums for a lifetime, even if you eventually sign up for a plan, Maddux says.

If you’re enrolled in the prescription plan, you should review whether you can save money by switching to a network that may offer a better price for a drug you take if you move all of your prescriptions to that network, Maddux says.

Using generics for name-brand medicines also will save money, so stay informed about commonly prescribed drugs, such as Lipitor, becoming available in generic form, Maddux says.

7. Welcome to Medicare.

During the first 12 months of enrollment, a new Medicare member can make an appointment with his or her doctor for an initial health assessment, review the patient’s history and determine whether additional diagnostic tests or screenings are needed, Duritz says.

Under the federal health care reform law, all patients, regardless of age, also are entitled to a once-a-year wellness visit.

For Medicare subscribers specifically, the new law now ensures out-of-pocket costs aren’t charged for certain diagnostic and preventative services, including colonoscopies, mammograms, diabetes screenings and immunizations.

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