A Beginner’s Guide to Navigating Medicare

navigating MedicareThis last year, hubby and I have been navigating retirement. My husband turns 65 this year and just received his Medicare card in the mail. That means now it’s time to start navigating Medicare. I’m not too far behind – I’ll qualify for Medicare in a year and a half.

Although relieved that this time has arrived, we want to understand the ins and outs of Medicare to ensure we receive the medical coverage we need. I downloaded Medicare’s official handbook, which I confess was overwhelming and gave me a headache.  This was more complicated than I thought.

So, if this describes you and you need help navigating Medicare, join me as I share my research to help you walk through the process.

Enrollment

This is important: The Initial Enrollment Period (IEP) begins three months before your 65th birthday month, includes your birthday month, and continues for three months after. Timely enrollment is crucial to avoid potential penalties.

If you or your spouse is actively working and covered by an employer’s health insurance plan when you turn 65, you may qualify for a Special Enrollment Period (SEP). This allows you to enroll in Medicare without penalties once the employment or the group health plan coverage ends. You may also qualify for SEPs if certain life events or circumstances affect your health coverage. It’s important to note that the rules for SEPs can be complex, and eligibility criteria may vary. If you believe you qualify for a SEP, consider contacting the Social Security Administration or your local State Health Insurance Assistance Program (SHIP) for personalized assistance and guidance based on your specific situation.

If you applied for Social Security benefits (or the Railroad Retirement Board) at least four months before turning 65, you’ll automatically get Part A (Hospital Insurance) and Part B (Medical Insurance) when you turn 65. Like my hubby, you’ll receive your Medicare card in the mail three months before your birthday. But you still need to make important decisions about how you get your coverage, including adding drug coverage.

If you miss both your IEP and any available SEPs, the General Enrollment Period runs from January 1 to March 31 each year, but you may need to pay a penalty for late enrollment.

Coverage takes effect the month after you enroll.

The Basics of Navigating Medicare

What exactly is Medicare? As you probably already know, it’s a federal health insurance program primarily designed for individuals aged 65 and older. It also covers younger individuals with certain disabilities or specific medical conditions.

The program consists of different parts, each addressing specific healthcare needs. Let’s discuss the four parts:

  • Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
  • Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, and some home health care.
  • Part C (Medicare Advantage): A private insurance plan that combines Parts A and B, often with additional benefits like prescription drugs, dental and vision coverage, and fitness programs.
  • Part D (Prescription Drug Coverage): Offers prescription drug coverage through private insurance plans.

Choosing Your Coverage

It’s important to understand as we start down the Medicare maze, that you have two main ways to get Medicare coverage:

  • Original Medicare (Parts A & B). In addition to Original Medicare, you may also choose to buy supplemental coverage (Medigap) from a private health insurance company to help pay for out-of-pocket expenses and add Medicare drug coverage (Part D).
  • Medicare Advantage (Part C): This is a Medicare approved plan from a private company that bundles Part A, Part B, and usually drug coverage (Part D). Some plans offer extra benefits like vision, hearing, and dental services as well.

Let’s consider the pros and cons of Original Medicare (Parts A and B) versus Medicare Advantage (Part C) to determine which suits your healthcare needs and preferences.

Original Medicare (Parts A and B):

Original Medicare is the traditional fee-for-service program offered by the federal government. It is widely used and provides coverage for hospital stays (Part A) and medical services (Part B).

My misconception was that Original Medicare was free. If you or your spouse made payroll contributions to Medicare for at least 10 years, you may not pay a premium for Part A. However, there are other costs. You’ll pay a deductible before Part A begins to pay a share of your costs, which is $1,632 for 2024 – not annually – but per benefit period. A benefit period begins the day you are admitted to a hospital or skilled nursing facility for an inpatient stay, and it ends once you have been out of the facility for 60 consecutive days. If you were to be readmitted after 60 days at home, a new benefit period would start, and you would be responsible for meeting the entire deductible again.

There is no copay for hospital stays up to 60 days, but copays are required for longer stays. For example, you’ll pay $408 per day for days 61-90.

You can see how all these costs could add up fast. By the way, there is no cap on what you pay.

Part B is optional and charges a monthly premium. Most people keep Part B, especially if they’re retired and don’t have any other medical insurance. Part B covers doctor visits, outpatient care, lab tests and X-rays, preventive services, ambulance and emergency room services, and more. For most people, the standard premium for 2024 is $174.40, but can change each year. It is usually deducted from your monthly Social Security benefit. If you have limited income and resources, you may be able to get help from your state to pay your Part B premium if you meet certain conditions.

There are costs involved with Part B as well. Medicare pays 80% of the cost for most medical bills, but you’ll pay the remaining 20%, with no yearly limit on what you pay out-of-pocket. In addition, you’ll pay an annual deductible of $240.00 (in 2024) before Part B starts paying a share of your costs.

This is why many people purchase a Medicare Supplement Insurance (Medigap) policy (see below for more details) to help pay the share of costs and fill gaps in coverage.

Original Medicare does not include prescription drugs. If you want drug coverage, you can join a separate Drug plan (Part D) for which you’ll pay a separate premium (see below for more details).

Pros:

  1. Wide Acceptance: Original Medicare is widely accepted by healthcare providers across the country.
  2. Freedom to Choose Providers: You have the flexibility to choose any healthcare provider who accepts Medicare. You don’t need a referral to see a specialist and you don’t have to worry about your doctor leaving a plan’s network.
  3. Predictable Costs: Costs are generally more predictable, with set premiums, deductibles, and copayments.

Cons:

  1. Limited Coverage: Original Medicare does not cover certain services like dental, vision, and hearing.
  2. No Out-of-Pocket Maximum: There is no cap on out-of-pocket expenses, potentially leading to higher costs.
  3. Requires Additional Coverage: You may need to purchase supplemental coverage (Medigap) to fill gaps in coverage at an extra cost, which we’ll discuss next, as well as Part D for prescription drug coverage.

Supplemental Coverage (Medigap):

Medigap policies, also known as Medicare Supplement Insurance, are private health insurance plans designed to fill the gaps in coverage left by Original Medicare (Parts A and B). Policies are standardized, and the basic benefits in each are the same. Most policies don’t include prescription drug coverage. These policies are popular since they offer additional financial protection by covering out-of-pocket costs like copayments and deductibles.

Now, let’s take a closer look at the benefits and disadvantages of Medigap policies:

Pros:

  1. Comprehensive Coverage: Medigap plans cover certain out-of-pocket costs that Original Medicare doesn’t, such as copayments, coinsurance, and deductibles.
  2. Predictable Costs: With a Medigap policy, you can have more predictable healthcare costs since it helps cover the expenses that Original Medicare doesn’t.
  3. Freedom to Choose Providers: Similar to Original Medicare, Medigap policies generally allow you to see any healthcare provider who accepts Medicare patients.
  4. Travel Coverage: Some Medigap plans offer coverage for emergency medical care while traveling outside the United States.
  5. Guaranteed Renewal: As long as you pay your premiums, Medigap policies are guaranteed renewable, meaning the insurance company cannot cancel your policy.

Cons:

  1. Premiums: While Medigap policies provide comprehensive coverage, they come with additional premiums on top of your Original Medicare premiums.
  2. Not Standalone Coverage: Medigap policies only work alongside Original Medicare. They cannot be used with Medicare Advantage plans.
  3. Standardized Plans: Medigap plans are standardized, meaning the coverage is the same for each letter category (e.g., Plan F, Plan G) regardless of the insurance company. However, premiums may vary.
  4. Enrollment Period: The best time to enroll in a Medigap policy is during your Medigap Open Enrollment Period, which starts when you’re 65 or older and enrolled in Medicare Part B. If you apply for a Medigap policy outside of your initial enrollment period, the insurance company may use medical underwriting, which could affect your ability to get coverage or the cost of the premiums.
  5. Prescription Drug Coverage: Medigap policies don’t cover prescription drugs. If you need drug coverage, you’ll need to enroll in a separate Medicare Part D prescription drug plan.

Medicare Advantage (Part C):

Part C refers to a Medicare-approved plan from a private insurance company that offers an alternative to Original Medicare (Part A & Part B) for your hospital and medical insurance. Plans must cover all medically necessary services that Original Medicare covers and you’ll have the same rights and protections you would have under Original Medicare. Most plans include prescription drug coverage. You cannot buy Medigap or add a separate Medicare drug plan in most cases if enrolled in Medicare Advantage.

Although you may have to pay the plan’s premium in addition to your Part B premium, some plans have a $0 premium and may even help pay all or part of your Part B Premium. Medicare Advantage plans have been growing in popularity. These plans often include additional benefits beyond what Original Medicare covers, such as vision, dental, fitness programs, and prescription drug coverage. Many people appreciate the convenience of having all their coverage bundled into one plan.

Out-of-pocket costs vary  and may have lower or higher out-of-pocket costs for certain services.  However, all Medicare Advantage plans put a cap on your annual out-of-pocket costs, which is $8,850 in 2024.

Pros:

  1. All-in-One Coverage: Medicare Advantage plans often offer perks and may include coverage for vision, dental, and prescription drugs.
  2. Out-of-Pocket Maximum: Plans have a yearly limit on out-of-pocket costs, providing financial protection.
  3. Care Coordination: Many plans offer coordinated care and additional services, such as wellness programs.

Cons:

  1. Network Restrictions: You may be limited to a network of healthcare providers, potentially limiting your choices. Some plans offer non-emergency coverage out of network, but typically at a higher cost. In addition, referrals may be needed to see specialists.
  2. Change in Plans: Medicare Advantage Plans must follow rules that Medicare sets; however, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (for instance, whether you need a referral to see a specialist or whether you have to go to doctors that belong to the plan’s network for non-emergency care). Plans can change annually, affecting coverage and costs. However, the plan must notify you about any changes before the start of the next enrollment year.
  3. Additional Costs: Some plans have extra costs like copayments and coinsurance for services.

Original Medicare versus Medicare Advantage Considerations:

  • Healthcare Needs: Assess your specific healthcare needs and whether you need coverage for services not included in Original Medicare.
  • Budget: Consider your budget, including premiums, deductibles, and potential out-of-pocket costs.
  • Provider Preferences: If you have specific healthcare providers you prefer, check if they are in the network of Medicare Advantage plans.
  • Stability vs. Flexibility: Decide whether you prioritize the stability of Original Medicare or the added benefits and potential flexibility of Medicare Advantage.
  • One Year Trial Period: In most states, you have a one-year trial period for Medicare Advantage. This means if you change your mind after one year and switch back to Original Medicare you are guaranteed the right to purchase a Medigap plan, without medical underwriting. You also might be able to a buy a Medicare Part D prescription drug plan. After this first year, however, insurers do not have to grant you a Medigap policy if you decide to switch and can consider your medical history when determining whether to provide coverage. Your plan might cost substantially more than it would have if you had signed up earlier.

Be sure to read the fine print. Although advertisements might seem like you’ll get a free gym membership and home meal delivery after surgery, often there’s strings attached. For instance, many plans offer dental care, but it is probably a limited network and a percentage of coverage.

Joel Mekler, a health benefits professional, Medicare expert and writer of the “Medicare Moments” weekly column in New Castle Pennsylvania, advised in an interview for US News: “If an individual is very healthy and they don’t see a doctor that much, they might want to think about a Medicare Advantage plan. But if somebody sees a doctor quite frequently and if they have a chronic condition, they might want to pair original Medicare with a Medigap plan.” Of course, you’ll want to consider potential future health care needs when choosing the best plan for you, the article adds.

In the end, it’s essential to carefully review plan details, coverage options, and associated costs before making a decision based on your individual preferences and needs.

Prescription Drug Coverage (Part D) Plans:

Medicare Part D, also known as Prescription Drug Coverage, is a voluntary program that offers prescription drug coverage for Medicare beneficiaries. It’s designed to help individuals with the costs of prescription medications. Part D plans are popular among those who want specific coverage for prescription medications. Many Medicare beneficiaries choose to enroll in a standalone Part D plan or opt for a Medicare Advantage plan that includes prescription drug coverage. Be aware that both of these plans may include premiums, deductibles, copays, or coinsurance.

Here’s what you need to know:

How Medicare Part D Works:

  1. Voluntary Enrollment: Medicare Part D is optional and is offered through private insurance companies approved by Medicare. Beneficiaries can choose to enroll in a standalone Part D plan to complement their Original Medicare coverage or select a Medicare Advantage plan (Part C) that includes prescription drug coverage.
  2. Coverage Options: Part D plans provide a list of covered medications, known as a formulary. Each plan has its own formulary, and it may include both generic and brand-name drugs. Plans may also have different cost-sharing structures for medications.
  3. Monthly Premiums: Beneficiaries pay a monthly premium for their Part D coverage. Premiums can vary depending on the specific plan chosen, and individuals with higher incomes may pay an additional income-related monthly adjustment amount (IRMAA).
  4. Deductibles and Cost-Sharing: Part D plans often have an annual deductible that beneficiaries must pay before the plan starts covering the costs of medications. After meeting the deductible, beneficiaries typically pay a percentage of the drug costs (co-insurance) or a fixed amount (co-payment) for each prescription.
  5. Coverage Gap (Donut Hole): There is a coverage gap, often referred to as the “donut hole,” in which beneficiaries may be responsible for a higher percentage of their drug costs. However, the Affordable Care Act (ACA) has been gradually closing this gap, reducing the out-of-pocket costs for beneficiaries.
  6. Catastrophic Coverage: Once out-of-pocket spending reaches a certain limit, beneficiaries enter the catastrophic coverage phase. During this phase, costs are significantly reduced, and the plan covers a higher percentage of drug expenses.

Considerations:

  • Formulary Review: Before enrolling in a Part D plan, it’s essential to review the plan’s formulary to ensure that it covers the specific medications you need.
  • Plan Comparison: Since multiple Part D plans are available, beneficiaries should compare plans based on premiums, deductibles, copayments, and coverage for their specific medications.
  • Enrollment Periods: Initial enrollment in a Part D plan is typically done when individuals first become eligible for Medicare. However, there are specific enrollment periods, such as the Annual Enrollment Period (October 15 to December 7), during which beneficiaries can review and change their Part D coverage.

Evaluate your prescription drug needs and select a Part D plan that aligns with your medications and preferences. Ensure your chosen Part D plan covers the specific medications you require, considering potential changes to your prescription needs over time.

Resources and Assistance:

Medicare Resources:

Need more help with the Medicare maze? Utilize official Medicare resources, including the official website, helpline, and publications, to access accurate and up-to-date information.

State Health Insurance Assistance Programs (SHIPs):

Take advantage of SHIPs for personalized counseling and assistance in understanding your Medicare options.

Conclusion:

Joining Medicare marks a significant step toward securing your health and well-being in your senior years. By familiarizing yourself with the various parts, enrollment periods, and coverage options, you empower yourself to make informed decisions tailored to your unique healthcare needs.

You’ll have at least one chance each year to make changes to your Medicare plan during open enrollment periods.

Remember, the key to a smooth Medicare transition is early research, thoughtful consideration, and proactive enrollment. Hope this blog helped with navigating Medicare. Are you on Original Medicare or Medicare Advantage? Are you happy with your choice? Have any tips before hubby and I make our final decision? I’d love to hear in the comments below!

 

juliegorges

Julie A. Gorges is the author of two young adult novels, Just Call Me Goody Two Shoes and Time to Cast Away and co-author of Residential Steel Design and Construction published by McGraw Hill. In addition, hundreds of her articles and short stories have been published in national and regional magazines, and she received three journalism awards from the Washington Newspaper Publishers Association while working as a newspaper reporter. Julie currently lives in southern California with her husband, Scott, and has two grown children and three grandchildren.

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2 Responses

  1. Hi Julie, this all lost on me. Living in Australia, our Medicare system is totally different to yours. We have our own Medicare card as soon as we turn 18. That doesn’t mean we don’t need health insurance, but Medicare is a stop gap for those who opt out or can’t afford private health insurance, although some things are only claimable through Medicare. It seems no matter what system, health care in any country is difficult to navigate.

  2. Julie, this article will be so helpful to so many people, including myself.
    Thank you for taking the time to explain this so thoroughly.

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