Decisions to Make regarding Medicare Open Enrollment

Seniors enrolling in Medicare for the first time or those wanting to make a switch in coverage can do so October 15 through December 7 every year. Why? Because this is the time when prescription and health care plans adjust costs, coverage options, and determine which pharmacies and providers are included in their networks for the coming year.

Therefore, the open enrollment period is the time when seniors or individuals with current Medicare plans can also change their current prescription or health care options and coverage, depending on need.

Comparing coverage plans

Medicare offers a variety of health and prescription coverage plans. Coverage and options differ between states, and sometimes even counties. For example, Medicare plan options can depend on whether you have a Medicare health plan such as a PPO, an HMO, or private fee-for-service plan, and whether you get help from Medicaid, supplemental security income, Medicare savings programs (MSP), or even support through Social Security.

Major components of Medicare include:Medicare and you

 Medicare Part A (Hospital insurance)
 Medicare Part B (Medical insurance)
 Medicare Part C (Medicare Advantage plans)
 Medicare Part D (Prescription drug coverage)

An individual receiving medical care may fall into coverage options offered through any of these parts or a combination of some of them. Billing and coverage questions, forms, and help determining which is which and what is covered when it comes to claims can be overwhelming for many seniors.

What about Medicare advantage plans?

Medicare Advantage plans cover the same and sometimes even more than ‘original’ Medicare, but have different premiums, deductibles, and co-pays based on plan. Medicare advantage plans include:

• HMO/HMOPOS – Health Maintenance Organization/Health Maintenance Organization Point of Service
• PPO – Preferred Provider Organization
• RPPO – Regional Preferred Provider Organization
• PFFS – Private Fee-For-Service
• MSA – Medicare Medical Savings Account
• EGWP – Employer Group Waiver Plan
• SNP – Special-Needs Plans

So what are my options?

Options for Medicare enrollment include:

• Making a change from one prescription plan to another (also includes joining or dropping a prescription plan)
• Switching from an original Medicare to a Medicare Advantage plan or vice versa
• Switching from one Medicare Advantage plan to another

Understanding the differences between options, health care plans, and making choices can be difficult, especially in today’s often convoluted healthcare environment. Individuals opting for Medicare for the first time should know that Medicare is not part of the health insurance marketplace rolled out under the Affordable Care Act, so you will not be dealing with any marketplace during the open enrollment period.

Individuals already enrolled in Medicare and who are satisfied with their services and coverage don’t need to do anything during the open enrollment period. However, changes in prescription policies are common. Review your prescription and other forms of coverage for next year to ensure you’ll be covered.

Consumers should note that if you are covered only under Medicare Part B (medical insurance) and don’t have Medicare Part A (Hospital insurance), you are not considered covered by the healthcare law’s requirements for health insurance.

What if I want to transition from the Marketplace to Medicare?

If you become eligible for Medicare after you have enrolled in the Marketplace, you can cancel your Marketplace coverage and enroll in Medicare during the open enrollment period. You may also take advantage of the initial enrollment period, which means that you can sign up for Medicare during a seven-month period of time that begins three months prior to the month you turn 65 years of age, during the month you  turn 65, and the following three months after you turn 65.

Yes, it can be confusing. Support and resources through the Alliance of Claim Assistance Professionals (ACAP) is available to first-time enrollees or others confused by what to do when assessing options during the open enrollment period to get the best coverage that meets your needs.