En español | There's no getting around it. Medicare is a complicated program and every decision you make will have consequences – for your health and your wallet. To help you get the most out of your benefits — whether you are signing up for the first time or taking stock of your choices during open enrollment — AARP interviewed experts for their advice on how to get the most out of Medicare.
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Mind the calendar
The first and most important step is enrolling on time. Miss that deadline and it'll cost you — potentially for the rest of your life. Your Initial Enrollment Period (IEP) is the time you MUST sign up to avoid hassles. It spans seven months —from three months before you turn 65 until three months after. Here's what you need to know about enrollment timing for Medicare's parts.
Part A. This covers hospitals. Most people don't have a premium, so missing the deadline just means you won't have hospital coverage until you enroll.
Part B. This covers doctor visits and other outpatient services, like blood tests, X-rays, etc. If you don't have health insurance and don't sign up during your IEP, you'll pay almost $6,500 more in premiums over the next 20 years based on this year's $135.50 monthly premium. That's because Medicare will increase your premium by a 10 percent penalty for every 12 months you don't enroll when you should have.
The government penalizes you for not meeting the sign-up deadline because it doesn't want people waiting until they get sick to seek coverage. Insurance programs, like Medicare, only work if healthy and sick people are all in it together.
Part D: This covers prescription drug costs. Miss your IEP time and your monthly premium may be 1 percent higher for each month you aren't enrolled. The average monthly Part D premium for 2019 is $31.83. So, if you don't have good drug coverage and wait 24 months to sign up, you'll pay almost $8 a month more for your prescription drug plan for as long as you have drug coverage.
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Choose doctors carefully
You have a doctor who has taken care of you for many years and you want to keep seeing her. You've just retired to a new community and need a physician. You're satisfied with your current provider but would be open to change.
Whether you are new to Medicare or are evaluating your coverage during open enrollment, picking the best doctors for your needs and budget is how you make Medicare work best. Here are three things to consider:
1. Do they accept Medicare? There are several ways a provider can be part of the program:
- Participating. These providers agree to accept what's on Medicare's fee schedule as their full payment from the program. You or your supplemental insurance will still be responsible for 20 percent.
- Non Participating. These providers still take Medicare's approved payment, but they are allowed to charge you 15 percent more than that. This is known as a limiting charge.
- Opt out. Buyer beware. These providers can charge patients whatever they want.
- Medicare Advantage plans have networks of doctors. If you see a provider outside the network, you'll pay more.
2. Interview your prospective doctors
“People get a lot of their information about doctors by word of mouth,” says Deborah Dunn, a gerontological nurse practitioner from Livonia, Michigan. But she advises people to meet a new doctor and listen for what she calls “geriatric sensitivities.” For example:
- Are they asking what's going on in your life, like have you suffered the loss of a child or grandchild? That grief could bring on physical ailments, like trouble breathing.
- Have they asked you what kind of support system you have at home? Do you live alone? Do you feel safe at home?
3. Looking for a geriatric practice?
The Health in Aging Foundation has a website (healthinaging.org) that lets you search for geriatric specialists by state and zip code.
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Avoid surprise bills
Nothing stings like getting medical bills for services you thought were covered by Medicare or your supplemental insurance. Here's how to avoid that ... and what to do if it still happens.
Avoiding surprise bills:
- Check in advance if Medicare covers the treatment or procedure you're having. For instance, if you're getting an MRI or having your gall bladder removed, no sweat, Medicare most likely covers it. But if it's a tummy tuck you want, you're on your own — Medicare doesn't cover any elective cosmetic surgery. You can you go Medicare.gov and see a list of what's covered and what's not.
- Ask up front about your provider's Medicare status so you know if they accept what Medicare pays or don't participate in Medicare and can charge whatever they want.
Dealing with surprise bills
Don't pay it right away. “Most of the time what's happened is the provider hasn't sent the bill to the insurance company or they billed it but used the wrong billing code,” says Dunn. “I always tell people: If you get a bill for a lot of money, don't pay it. Ask questions."
- Check with your provider to see if they've billed insurance correctly.
- Call your Medigap insurer to see why they haven't paid the charges.
- If Medicare or your supplemental insurance has rejected a claim, file an appeal.
- If all else fails, negotiate with the provider for a lower amount.
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Know your rights
If Medicare denies a claim, you can appeal. And there are people who can help you. Casey Schwartz, a senior counsel at the Medicare Rights Center, says if you're on Medicare and want to appeal a claims decision, you can call the center's hotline at 800-333-4114. “We have materials that can walk people through how to put together an appeal and people who can talk through the process on the phone. In some cases we can represent people.” You can also ask your local State Health Insurance Assistance Program (SHIP) for help.
Here's what you need to know about the Medicare appeals process:
- You can designate someone to represent you in an appeal — and it doesn't have to be a lawyer. It can be a relative, a friend, an advocate, anyone you want.
- You can appeal anytime you're denied a service, piece of equipment or a prescription drug whether you are on Original Medicare or have a Medicare Advantage plan.
- You can also appeal a discharge from a hospital or nursing home. You'll be able to stay in the hospital at no extra charge — other than the copays and coinsurance — while your case is being reviewed.
- Get your doctor or other health care provider on your side. Ask them to put in writing a justification for why you need, or needed, the service or medication or equipment.
- If you or your doctor are worried your health could be seriously harmed by waiting for an appeals decision, you can ask for a quick answer within 72 hours.
Take advantage of benefits
Wellness visits, nutritionist meetings, telehealth ... There are lots of services Medicare pays for that the average person doesn't know about. Don't leave free care on the table.
Here are some tips to mastering the Medicare smorgasbord of care:
- Annual wellness visit – Every year you're entitled to see a doctor to review your medical history, what's changed in the past year and some basic screenings, like weight and blood pressure. This isn't a full physical, but it's a good, quick check-in.
- Eyeglasses – While Original Medicare doesn't cover routine eye check-ups and eyeglasses, it will pay for the first pair of glasses you may need after cataract surgery. Some Medicare Advantage plans also have vision coverage.
- Telehealth – Have trouble getting to and from your doctor's office? Medicare now pays for virtual check-ups with your doctor or other provider by phone or video chat.
- Nutrition counseling – If you have diabetes or kidney disease or have had a kidney transplant in the past 36 months, Medicare will pay for you to get a nutrition assessment and participate in individual or group counseling.
- Smoking – Medicare also pays for eight counseling sessions to help you quit.
To find the full array of services Medicare covers, go to medicare.gov.
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Keep good records
Most of us know to carry a list of our prescriptions with us to show to a new doctor or in case we wind up in the emergency room. But to take your use of Medicare to the next level, experts suggest you keep a running diary of your medical history – from any chronic conditions you have to what medical procedures or tests you've had.
Here are some tips for keeping your medical history up to date:
- Create a one-page summary of your basic health care information and take it with you to each doctor appointment. Give it to your provider at the beginning of each visit. It helps refresh your health care provider on your health status.
- Here's what your health record should include:
- Any conditions you have, including when they were diagnosed.
- Any hospital stays, including dates and any procedures done.
- If you've had physical or occupational therapy and what it was for.
- Your prescription drug list, including dosages of each medicine.
- Any medical equipment you're using, including oxygen, CPAP or insulin delivery devices.
- List of all your providers, including specialists, eye doctors and dentists. Include their phone numbers.
- Pharmacy information – where you regularly get your prescriptions filled.
- Your insurance information, including supplemental insurance.
- Your emergency contact and whether you have a Durable Power of Attorney or health care directive.
- Be sure to keep your list up to date by getting a summary of your visit after each medical appointment and by adding any new diagnoses and updating medications.
Be open to change
You may be perfectly happy with your current Medicare benefits. You like your Medicare Advantage (MA) plan. Or you're in Original Medicare because you like the freedom of seeing whatever doctor you want. You haven't had any problems with your Part D prescription drug plan. Doesn't matter. During every open enrollment you should do your homework to see if you can get a better deal.
"Taking the time to figure out which plans are likely to cost more or less can literally save thousands of dollars,” says Tricia Neuman, a senior vice president at the Kaiser Family Foundation and director of its Medicare policy. “It's not much fun to do this work, so people's inclination is to just keep the same plans from year to year."
Here are some tips on how best to make this decision:
- If you're in a Medicare Advantage plan, shop around. Compare the networks of doctors and hospitals in the plans in your area. Check out the list of prescription drugs that are covered.
- Consider using an insurance broker or agent, but be smart about it. Neuman says many people rely on insurance brokers and agents to help them make Medicare choices, but they get commissions, she says, so don't be shy about asking what their financial stake is.
- If you're in Original Medicare, revisit your decision on whether to buy a supplemental, or Medigap, policy.
- Think about whether you want to switch from Original Medicare to an MA plan or leave Medicare Advantage and go to Original. If you're uncertain, you may want to consult your local SHIP counselor. Go to shiptacenter.org to find a neutral counselor who can help.
- If you have a Part D prescription drug plan, shop around. Most people have dozens of plans to choose from in their area. It's common for the drugs available on these plans and the preferred pharmacies that give you the best deal to change from year to year.
- If you have a retiree health plan that complements your Medicare, check with your former employer to make sure it hasn't changed over the past year. Neuman says a growing number of employers are shifting their retirees into MA plans, and often retirees don't realize it.