December 7 is a critical deadline many do not want to miss. Open enrollment for Medicare Part C and Part D is currently underway and will come to an end on that date. The deadline comes quickly, and if it passes, a door closes for people who’ve been receiving Medicare and want to change their coverage.
Although figuring out what type of Medicare plans are best for you is far from easy as A-B-C, there are resources readily available to help. One such resource is Donna C. Bryant Hammer of Madison.
Bryant presented a workshop on Medicare/Medicaid on Saturday, Nov. 3 at the Family Caregiver Resource Fair. She was one of several presenters at the no-cost event, which took place at St. Peter’s Parish located at 5001 North Sherman in Madison. The Area Agency on Aging and American Family Insurance served as the major sponsors for the third annual event, a gathering held during National Caregiver’s Month.
Bryant, who is now retired, was the lead counselor for the Medigap Helpline and helped coordinate the Wisconsin State Health Insurance Information Program (SHIP). Throughout her career, she conducted countless trainings on Medicare, Medicaid, health insurance, long-term care, and state and federal regulations. Bryant worked for the Wisconsin Insurance Commission, auditing insurance agencies and was instrumental in developing consumer protection regulations.
Bryant began her presentation by discussing having worked with Medicare for 30 years. “I know Medicare, and it knows me,” she asserts, adding, “It’s not getting any simpler.” Key issues include timing of when to initially go on Medicare as well as what type of plan(s) to sign up for. Also, be aware that for Medicare purposes, there is a difference between still being actively employed (and getting insurance through your employer) and being fully retired and on retiree insurance coverage through your former/previous employer.
It’s important to be familiar with frequently used terms and acronyms within the health care industry. CMS refers to the Centers for Medicare and Medicaid Services, “the federal agency that actually pays for the bills for Medicare and Medicaid.” She referred to handouts, including “Your Medicare Coverage Choices,”—in a nutshell, the thought processes for deciding whether you want Original Medicare or a Medicare Advantage Plan.
Medicare is for people 65 and older or people that are disabled with certain conditions. When a person goes on kidney dialysis for end stage renal disease, you can go on Medicare within 90 days of starting dialysis regardless of your age. If you develop ALS (Lou Gehrig’s Disease), it’s right away from the point you are eligible for Social Security Disability benefits.
Original Medicare includes Part A (hospital insurance or a skilled care facility) and/or Part B (medical insurance.) You usually pay a monthly premium for Part B; the amount of the premium depends on what you earn.
Medicare Part C is available through Medicare Advantage Plans (like an HMO or PPO). Medicare Part C automatically includes both Part A and Part B, and sometimes Part D coverage (prescription drug coverage) is included under Medicare C Plans as well. Generally, in choosing Medicare Advantage Plans (Medicare C) as opposed to having Part A and Part B, “you don’t lose anything,” according to Bryant. “You might get something extra” (depending on the particular plan you choose.)
With Medicare Advantage plans, you may or may not need approval to see a specialist, depending on the specific individual plan you select. And to clarify, “You can only have a Medicare supplement policy with Medicare A and B (not with Part C).”
Avoid penalties, protect your rights
If you are retired (and not disabled), you have a seven-month window for signing up for Medicare. You must sign up for Medicare the first three months before you turn 65, the month you turn 65, or some time during the three months after your 65th birthday month. Otherwise, there are penalties for failing to do so.
Many folks work past age 65 and receive medical insurance through their employer while they are employed. Generally speaking, “if you’re actively employed (key) and get insurance through your work, do not take Medicare Part A when it first becomes available to you at age 65.” Further, she says, “as long as you’re actively employed and covered under employer insurance, you do not need Medicare Part A or Medicare Part B.” But, if you’re going to choose Part C platform to receive your Medicare….If your first step into Medicare waters is a Medicare Advantage Plan, then you have a 12-month period to try it out. If it doesn’t fit (your needs), then you’re able to switch plans.
However, if your first step is Part A Medicare just because you’re still working, you have sabotaged that trial period. “It is important to protect your right to go back to original Medicare and a supplemental plan….(Again) If you’re actively employed, do not take Medicare Part A when it becomes available at age 65.”
“Take Part B if you’re retired and not covered under actively-at-work group insurance,” she advises.
It’s complicated, she stresses, so give her a call if you have questions. Her new office number is (608) 442-5858, her client cell phone is (608) 338-9800, or you can reach her at email@example.com or at 608-535-9155. “So there’s no such thing as, you can’t get a hold of me!” she laughs.
When it comes to Medicare Part D, it can be a tricky to understand, too. Medicare Part D is considered prescription drug coverage, but, in fact, Medicare actually pays for drugs in three different ways (Part A, Part B, and Part D), depending on how the medication is administered (pill form, IV, injection, nebulizer, pump, etc.) and where it is given (hospital, doctor’s office, our home, long-term care facility.) .
Signing up for and having Medicare Part D (prescription drug) coverage is optional. “It’s optional,” Bryant cautions, “but there is a consequence of not taking it.” The penalty is 1% added per month, if you did not take Part D when you should have, nor did you maintain what’s considered “creditable prescription drug coverage.”
In Wisconsin, Senior Care Rx (prescription) Plan is an option to consider. If you don’t want to pay $15 a month or $30 a month for a Medicare Part D plan, you can do Wisconsin Senior Care without a Part D penalty. Currently in Wisconsin, Bryant details, “everyone over age 65 is eligible to join Senior Care. “ There is no asset test, though income eligibility does come into play. Everyone on Senior Care pays an annual enrollment fee of $30.
On an annual basis, employers are supposed to inform those insured under their plans whether or not the plan is creditable, but they are not required to do so by law. Bryant encourages folks to call, ask, and write down the name of the person that provides the answer. To protect yourself if they cannot or will not tell you over the phone if their employer plan is creditable, Bryant says, get Senior Care. She also cautions that employer group plans can decide to end coverage at any time.
If you’re a vet and receiving your medical care through the Veterans’ Administration (VA), it is usually considered to be creditable prescription coverage. But check with your county VA service officer to make sure that the medication and drugs you’re getting from them are considered creditable coverage, Bryant says. There are nuances about VA care, so it’s paramount to make sure and be fully informed.
Who is considered the primary payer? “Medicare is always primary,” Bryant indicates. The only time Medicare is not primary is if you still have employer group coverage and are not fully retired yet. Title 19 (Medicaid) is always the payer of last resort.
Promising plan comes to Dane Co.
Bryant discusses a promising Medicare plan, now being offered locally for the first time, that involves no premiums and no co-pays. “There’s not been a plan of this caliber available in this area before,” she enthuses, and she wants everyone to be aware of it. Named Advocare, it’s a Medicare Advantage Coverage Plan by Security Health Plan (a Medicare-approved HMO plan) that’s been available in other counties in Wisconsin for a couple of years. “It’s been rated excellent for every year of its existence,” Bryant explains. (She notes that it had been given a 5-star rating, until recently when it was downgraded to 4 ½ because of some glitches with a computer system conversion.)
With original Medicare, you have to spend three nights in the hospital or it will not trigger your (physical therapy/ stay, etc.) rehab benefits. Conversely, Advocare, waives this three-day stay requirement.
Additionally, while there is no Medicare outside of the U.S. (Part A and Part B Medicare coverage), Advocare provides worldwide coverage for emergency out-of-network and urgently needed care while enrollees travel.
Not really in the hospital?!
She offered up the following scenario. You go to the emergency room with chest pains, fearing you might be having a heart attack. They give you medicine, put you in a regular hospital room, and keep you there for two days. Essentially, you’re in a room with an IV stuck in your arm. “It looks like you’re in the hospital. It feels like you’re in the hospital.” But, she cautions, it’s possible officially you have not been admitted into the hospital. You may be in “for observation”—in which case, Medicare’s not going to pay for that hospital stay.
This situation is chronic nationwide, Bryant laments, adding, it’s “really prolific in the state of Wisconsin.” She advises folks to find out if they are considered an inpatient when they’re in the hospital. And what if you (or your loved one) aren’t? “You can ask the hospital to change it from observation (status/classification) to inpatient.” She reiterates, “Always ask, ‘Am I officially admitted (into the hospital)-- or is this just observation?’”
More details on Part D
Medicare D plans typically have formularies, determining which medications will be paid for under the plan. “If you’re eligible for Extra Help, you want to make sure you apply for it…Extra Help is very beneficial,” Bryant explains, and some people automatically get it, such as those on Title 19 (Medicaid). There is extra help to pay Part D costs, if you have limited income and resources. “There are programs out there to help people. You just may not know where it is, or how to access it.”
If you appear to lose a benefit, or if it is reduced in any way, shape, or form, it’s a good idea to call and ask how and why the benefit changed. Sometimes mistakes are made, however, if a change indeed does occurs, “maybe you can apply for some benefits on your own.”
In terms of joining a Part D Plan, you can join during the 7-month initial enrollment period, as well as during open enrollment October 15 through December 7. Coverage starts January 1.
“If you do not take Medicare when you are initially eligible, and then you decide, ‘Maybe I should take it’….There’s a general enrollment period January, February, and March…Then Medicare Part B doesn’t start until July.”
It’s very important that you strategically time when you’re going to leave work and when you’re going to sign up for Medicare, so you don’t miss the window of opportunity. “I’ve seen people go a year without Medicare,” Bryant says.
Look beyond the book
Be aware that Part D plans have the right by federal law to apply restrictions to your medications. More specifically, to limit the number of medications you’re taking and to mandate prior authorization. Then, there is the issue of Step Therapy, which, says Bryant, causes people the most problems and is the most dangerous of the limitations. Say you have multiple sclerosis (MS) and you’re receiving an injection that costs $2400 a month. They think you should go back to the $100 per month medication. “I have seen people set back years…Step Therapy gives the plan the ability to not pay for whatever you’re already taking. “
The most efficient and effective way to start the selection process for your Part D Plan, Bryant recommends, especially if you take a couple of medications every day and/or you have a long-standing health condition, is to get on the computer through Medicare Plan Finder web tool (https://www.medicare.gov/find-a-plan/questions/home.aspx or call 1-800-633-4227. “They will issue you the three plans that best meet your needs.”
But before making a final selection, call and find out about restrictions. “No one should try to choose this plan based on what is or is not listed in the abbreviated form only!”
After Bryant’s presentation, one of the attendees asked about dental care, which Medicare does not pay for. She ardently recommends the MATC downtown dental clinic. “They do a good job and for 30 bucks, they make sure you can come back two or three times.”