En español | Your health care needs are a key factor in any Medicare decision, from your daily pill regimen to your preexisting conditions to your desire to keep a favorite doctor.
Many Medicare beneficiaries have trusted doctors who have taken care of them for years, and they’d like to keep going to them. If that sounds like you, the first thing you might want to do before making any coverage decision is to ask your doctors if they accept Medicare or participate in Medicare Advantage plans in your area.
According to the Kaiser Family Foundation, 93 percent of primary care physicians accept Original Medicare, so the odds are good that your current physician does. Under Original Medicare, you don’t need a referral to see a specialist, as long as the specialist accepts Medicare.
On the other hand, Medicare Advantage plans have specific networks of medical providers. Some plans let you go to a doctor outside the network, but generally you’ll pay more out of pocket to see those providers. Many Medicare Advantage plans require a referral from a primary doctor to see a specialist. The government’s Medicare Plan Finder can help you find Medicare Advantage plans in your area, and it also lists the doctors within each plan.
Your preexisting conditions
One of the great things about Medicare is that it covers existing medical conditions, regardless of whether you chose Original Medicare or Medicare Advantage.
But if you are thinking of switching from Original Medicare to Medicare Advantage, there are a few things to keep in mind. First, your preexisting conditions will always be covered if you switch from Original Medicare to a Medicare Advantage plan. Second, the federal government has created a program allowing Medicare beneficiaries to try out a Medicare Advantage plan on a short trial basis: between Jan. 1 and March 31. If you discover you don’t like the plan during that three-month window, you can return to Original Medicare and enroll in a standalone Part D prescription drug plan, so you won’t lose drug coverage.
If you opt to return to Original Medicare, though, you may have difficulty getting a Medigap policy. That’s because the optimum time to purchase a Medigap policy is within six months of enrolling in Part B; otherwise, the insurance company can refuse to sell you a policy or charge you a higher premium because of your medical problems.
“Generally, people may not be able to switch Medigap plans, depending on where they live, or will have to pay more, depending on their age, medical requirements and/or other factors,” says Fred Riccardi, vice president of client services at the Medicare Rights Center. “For instance, companies can refuse to sell you a Medigap policy or impose certain medical requirements.”
There are some circumstances when beneficiaries who want to switch from Medicare Advantage to Original Medicare can purchase a Medigap plan without worrying about their preexisting conditions:
- If you leave Original Medicare and buy a Medicare Advantage plan for the first time and revert back in less than a year.
- If you select a Medicare Advantage plan when you first enroll in Medicare but decide within the first year that you want to switch to Original Medicare.
Beneficiaries who already have Medigap and want to buy a Medigap policy from a different insurer may want to dig deep into the ramifications of that choice. A new insurer can charge a higher premium for preexisting conditions and may even refuse to sell you a policy.
Among the major tasks Medicare beneficiaries have during the open enrollment season is making sure their prescription drugs are covered. For most of its history, Medicare did not have a prescription drug benefit. Congress added coverage for medicines that took effect in 2006.
As with most Medicare benefits, choosing a Part D prescription drug plan can be complicated, as the program has many twists and turns. Here are some questions and answers that can help you navigate the process:
What does Part D cover?
Part D pays for outpatient prescription drugs — in other words, medicine you take yourself. (If you receive chemotherapy, dialysis or other medicines that are injected or given intravenously at a doctor’s office or outpatient facility, Medicare Part B kicks in.) However, Part D does cover some self-injected medicines, such as insulin for diabetes.
What doesn’t Part D cover?
Part D does not pay for over-the-counter medications, such as cough syrup or antacids. It also doesn’t cover some prescription drugs, such as drugs used to help grow hair, medicines to help you gain or lose weight, or prescription vitamins.
Does Part D cover brand-name and generic drugs?
Yes. But most plans charge higher cost-sharing for brand-name drugs. In addition, each individual Part D plan has its own list of the drugs it covers and charges cost-sharing that varies by drug and sometimes even by where you fill your prescription.
What does Part D cost?
That’s complicated. How much you pay for prescriptions under Part D depends on the individual plan and how many medicines you take. Here’s a breakdown of the costs.
First, there will be a monthly premium. The Centers for Medicare and Medicaid Services (CMS) estimate that the average monthly Part D premium for 2019 will be $32.50, but the premiums can vary widely by plan. (If you are enrolled in a Medicare Advantage plan that includes Part D coverage, part of the premium goes toward prescription drugs.)
If your Part D plan charges an annual deductible, that means you have to pay full price for your medicines until you’ve met that threshold. The federal government sets the standard deductible every year; for 2019, a plan can’t impose an annual deductible higher than $415. But just like with premiums, deductible amounts vary by plan; some don’t impose any deductible.
Finally, many Medicare beneficiaries with high drug bills are subject to a coverage gap, commonly referred to as the “donut hole.” Up until now, these beneficiaries have had to pay a higher percentage of their drug costs while in the donut hole. The donut hole originally was scheduled to close in 2020 as part of the Affordable Care Act but Congress passed a law this year that closes that gap for brand-name drugs in 2019. Next year, once you incur $3,820 in drug costs, you’ll pay 25 percent of your brand-name and 37 percent of your generic prescription drug costs. Once your out-of-pocket costs reach $5,100, Part D’s catastrophic coverage kicks in and for the rest of the year you’ll pay no more than 5 percent of your drug costs.
What if I can’t afford a Part D plan?
Medicare has an Extra Help program that may pay some or all of your prescription costs, depending on your income and other financial resources. You might also be eligible for an assistance program in your state. Your State Health Insurance Program or Medicaid office can provide more details on those programs. In addition, some drug manufacturers offer discounts on their medications and have information about them on their websites.
How do I decide which Part D plan is best for me?
You’ll want to use the government’s Medicare Plan Finder. This online tool allows you to compare Part D plans available in your zip code that cover your prescriptions — and review each plan’s costs, including premiums and cost-sharing. The tool also shows which pharmacies in your area participate in the various plans.
You also can peruse the Star Ratings for Part D prescription drug (and Medicare Advantage) plans. This is the system CMS uses to measure the quality of the plans, from gauging customer service and member complaints to pricing and array of services offered.
How do I get Part D coverage?
You can sign up on the Medicare Plan Finder for a stand-alone Part D plan sold by insurance companies. These plans are used only in conjunction with Original Medicare. (Or you can enroll in a Medicare Advantage plan — an all-inclusive plan that may cover prescription drugs in addition to hospital care and doctor visits.)
Do I have to reenroll if I like my current Part D plan?
No. If you are satisfied with your plan, you don’t have to do anything and will remain enrolled for 2019. Of course, if your plan is no longer available (in that case, you will receive a letter from the insurer), you will need to choose another plan.
However, Medicare officials and experts strongly suggest that you check out your options during each open enrollment period, even if you are satisfied with your current plan. Plans routinely change premiums, deductibles, cost-sharing and the prescription drugs that they cover. You might find that a different plan is better suited to your current health care needs.