By asking the right questions about Medicare, you can avoid unexpected costs and penalties. These considerations will also guide you as you choose the Medicare plan that best suits your health needs and lifestyle.
Common Annual Enrollment Period Questions
This list of frequently asked questions covers a range of Medicare topics. To get started, here are six questions that address what you need to know about Medicare to make sure you can find the best health insurance plan for your needs and budget.
[READ: Medicare Mistakes to Avoid.]
1. When Is Medicare Open Enrollment?
The annual fall open enrollment period for Medicare, also known as the annual election period, runs from October 15 to December 7 each year. During this period, you can switch from original Medicare to a Medicare Advantage plan or join, change or discontinue your Medicare Part D drug plan.
This enrollment period is for those who have previously enrolled in Medicare. If you are just turning 65 — and thus becoming eligible for Medicare — you can sign up for Medicare during a seven-month time period known as “initial enrollment.” This period starts three months before you turn 65 and continues through the month you actually turn 65 and three months after your birthday.
The Medigap open enrollment period, also known as the guaranteed issue period, coincides with initial enrollment. Some states have additional periods where people can get any Medigap plan they want or switch Medigap plans without being charged more if they have health problems — but in most states, there is a limited period to enroll in a Medigap plan.
If you’re signed up for a Medicare Advantage plan and wish to switch to a different Medicare Advantage plan or change to original Medicare, you can do so each year between January 1 and March 31. Also, it’s important to note that in most states, you may not be able to get a Medigap plan if you initially sign up for a Medicare Advantage plan and then decide to switch to original Medicare later.
[8 Reasons to Switch Medicare Part D Plans]
2. Do You Have Any Expensive Procedures or Tests Coming Up?
If you have health issues or you know that you’ll need expensive tests and procedures in the next year, you should think about deductibles when choosing your Medicare plan for the year. The more health risks and conditions you have, and the older you get, the more likely it is that unexpected and potentially costly health problems will arise over the next year. Choosing a plan with higher premiums but lower deductibles and out-of-pocket costs for hospitalization may be the most sensible choice.
On the other hand, if you’re not anticipating any changes in your health needs, sticking with a lower-premium plan — such as a Medicare Advantage plan with a $0 premium — may be a better bet.
“A good candidate (for Medicare Advantage) is someone who can understand the rules and embrace them,” notes Barbara Hopkins, a Portland, Maine-based, self-employed Medicare educator with nearly 30 years of experience in health payer operations. “Second of all, if they have not had huge health problems up until the point of being 65, they’re going to be a pretty good candidate because it costs less to join a Medicare Advantage plan, and chances are they are going to be using less expensive services.”
[READ: Get These 9 Screenings to Keep Your Medicare Costs Down]
3. Do All of My Doctors Accept Medicare?
When you’re choosing a plan, look closely at the plan’s network restriction. Seeing an out-of-network doctor versus one available within your plan’s network can affect any out-of-pocket costs you may have to pay.
Medicare
With original Medicare (Part A and Part B), there are basically three types of providers, says Joel Mekler, a health benefits professional, Medicare expert and writer of the “Medicare Moments” weekly column in the New Castle (Pennsylvania) News.
— Participating. These providers “accept assignment,” meaning they agree to charge only the amount that Medicare allows for services.
— Nonparticipating. In-network providers who do not accept assignment can charge the patient the difference between what they charged and what the insurance company paid. This charge can be “up to 15% above the amount that Medicare will pay,” Mekler says.
— Opt-out. These providers will not accept Medicare at all. If you want to see a physician that has opted out of Medicare, you will need to pay out of pocket for all of your medical care.
Medicare Advantage
With most Medicare Advantage plans, you’ll be limited to only seeing doctors in the plan’s network, whereas with original Medicare, you can see any doctor, though you may have to pay a higher price to see out-of-network providers.
Hopkins says if you’re considering a Medicare Advantage plan, it’s essential to consider “the rules of the Medicare Advantage plan that they’re choosing. They need to make sure their provider is in the network. They need to make sure that the hospitals they want to use are in the network as well. If they are not, they need to know if it’s possible to see doctors beyond the specific network or not.”
However, there is some flexibility with Medicare Advantage plans. All Medicare Advantage plans are either preferred provider organizations (PPO) or health maintenance organizations (HMO). In general, Medicare Advantage plans that are a PPO will allow you to see a wider network of providers than you can with a HMO.
“Although a Medicare PPO is a little more expensive, it allows for a larger network,” Mekler says. “In other words, with a PPO, somebody could go in or out of the plan’s network. Unlike with an HMO, you won’t need a referral from your primary care doctor to see a specialist if you have a PPO.
[Read: What to Do When Your Doctor Leaves Your Health Plan.]
4. How Much Do I Want the Extra Perks?
Medicare Advantage offers perks that original Medicare doesn’t, such as coverage for dentures, eyeglasses and fitness benefits, like SilverSneakers. However, you may need to pay extra for some of these perks or accept additional premiums.
Shub Debgupta, founder and CEO at Predict Health, a health care analytics company in Arlington, Virginia, says that some innovative perks to reduce social isolation or improve living conditions that can affect health are becoming more commonplace among Medicare Advantage plans. Specifically, he points out that it’s becoming more common for beneficiaries who are eligible for both Medicare and Medicaid to receive assistance with air conditioning or air filters for their homes.
He also believes that technology support will become a more popular perk offered by Medicare Advantage plans in the near future. With more of our daily life becoming dependent on technology, this could be a very helpful service for seniors.
Financial planning is yet another Medicare Advantage perk that is quickly gaining steam, Debgupta adds.
5. How Do I File an Appeal?
Although many seniors find the perks offered by Medicare Advantage advertisements very appealing, eligible individuals should know that an April 2022 report from the inspector general’s office found that some Medicare Advantage insurance providers denied care or payment for care that would have been covered under original Medicare. In fact, 13% of the instances of denied prior authorization by Medicare Advantage providers met the eligibility requirements of original Medicare.
Debgupta says that it’s vital for people who have a claim denied to understand their rights of appeal.
“When people do appeal or refile, the second refiling acceptance rate is in the nineties. Some of those (denials) are primarily paperwork glitches. The majority of appeals get accepted,” he points out.
6. Does the Plan Cover Prescription Drugs?
Medicare drug coverage, Part D, helps pay for prescription drugs, though this coverage is optional. It’s important to note that if you don’t sign up for drug coverage when you first enroll in Medicare and you don’t have other coverage at the time, you’ll need to pay a late penalty for the entire time that you are on Medicare.
You can add a Medicare drug plan if you have Medicare Part A and Part B. Alternatively, you can sign up for a Medicare Advantage plan that provides drug coverage.
All plans are required to cover a wide range of commonly prescribed medications. Each plan has a different formulary, which lists what medications are covered. The formulary must include no fewer than two drugs in each of the most commonly prescribed drug classes.
By looking at your medical history, taking stock of your health savings account and reviewing the doctors that you see most often, as well as the medications that you take, you’ll be equipped to make a wise decision when you sign up for or adjust your existing Medicare coverage. When it comes to health care, knowledge truly is power.
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6 Questions to Ask During Medicare Open Enrollment originally appeared on usnews.com
Update 10/21/24: This story was published at an earlier date and has been updated with new information.
