Each fall, Medicare patients get a chance to switch their insurance plans. But only about 10 percent actually do. And that means millions of people are potentially missing out on thousands of dollars of savings and leaving themselves open to nasty surprises about their benefits or health care choices.
“People’s medical needs change as they grow older, and their plans [and what they cover] may change from year to year,” says Tricia Neuman, senior vice president of the nonprofit Kaiser Family Foundation and director of its program on Medicare policy. “Reviewing the options each year makes a lot of sense.”
Here are some common situations that might cause you to consider a change during the annual open enrollment window, from Oct. 15 to Dec. 7. Answers are based on interviews with several Medicare experts and guidance from Medicare itself.
And a reminder: Switching from a Medicare Advantage (MA) plan to original Medicare (OM) carries a big risk if you intend to buy a Medigap policy that covers expenses Medicare doesn’t. In most states, Medigap insurers can turn you down due to preexisting conditions, or charge you more based on your health or age, if you’ve had Medicare Part B for more than six months. Factor that into your decision-making.
1. My prescription costs have jumped.
That happens usually due to one of two scenarios: You’ve been prescribed a new drug your Plan D policy doesn’t cover, or your current medicines have fallen off your Plan D’s formulary (list of covered medicines), Neuman says. Each September, Part D prescription plans will send out a list of changes to drug coverage, giving you time to make sure your medicines are still covered. If not, you can shop around for another plan or ask your doctor to apply for an exception in covering your favored medicine.
2. I’ve decided to spend my winters (or summers) in a different state.
Advantage plans typically charge more to go to doctors outside of their networks; in some cases they won’t cover any charges if it’s not an emergency. So a Midwesterner might have to pay more to see out-of-network doctors while in Florida. You need to read the details of your plan, or talk with a representative, to know where you stand. If you’ll be living a dual-residence existence for years to come, you might consider a switch to original Medicare, with the usual caveats.
3. I need surgery and prefer a specific doctor.
Original Medicare allows patients to choose any doctor or hospital that accepts Medicare. But if you’re in a Medicare Advantage plan and its surgeons don’t meet your needs, you may need a different MA plan or to switch to OM. The people who really need to focus on whether doctors are in network are those who’ve suffered major problems like cancer and heart attack, says Joseph Antos, health care expert at the American Enterprise Institute. “A specialist may be key to their treatment,” he says.
4. I’m super healthy and rarely need a doctor.
If you’re in original Medicare, all should be well: As a “pay-for-service” arrangement, not seeing the doctor isn’t costing you anything extra beyond your mandatory parts B and D monthly insurance premiums. If you’re in an MA plan in which you’re paying a monthly premium on top of your standard Part B premium, that may be for a plan that offers lots of extras, such as gym memberships. Consider switching to a lower-cost MA plan that doesn’t offer services you don’t plan to use in the coming year.
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5. I’ve been diagnosed with a chronic condition.
A serious medical change should trigger a full review of your Medicare coverage. Make sure your Plan D policy pays for new prescriptions. Consider the care you’ll need. If you want a gym membership or disease-specific programs, find an MA plan that offers them. But if you will need lots of specialists, there’s an argument for OM. Making critical changes early can “really affect your pocketbook and save you money,” says Gretchen Jacobson, a vice president with the Commonwealth Fund.
6. My income has dropped sharply.
If you are in original Medicare, your Part B monthly premium is locked in, but your Part D drug plan isn't. And there's a chance you can find a lower-cost policy that covers the medicines you are on. If you’re in an Advantage plan, consider a switch to a plan in which there is no extra payment on top of the mandatory Part B premium. And you might qualify for help. Ask your state Medicaid office about Medicare Savings Programs. Find the state offices here or call 800-MEDICARE (800-633-4227).
7. My former employer is changing its retiree health benefits.
Some companies provide retirees with Medigap supplemental insurance, which covers many health costs not covered by OM. If you have changes to your retiree benefit coverage, or for some reason that coverage no longer is offered, contact Medicare’s Benefits Coordination & Recovery Center (855-798-2627). Someone can tell you whether you fall in the window in which Medigap insurers cannot deny you coverage based on preexisting conditions.
8. My regular doctor is no longer in network for my plan.
If you deeply want to stay with a doctor, ask directly whether he or she is moving to a different MA plan, accepting OM patients or dropping out of Medicare completely. If you decide to make a change, make sure a short-term decision won’t affect your long-term coverage (for example, switching to original Medicare to temporarily stay with one doctor but sacrificing Medigap coverage for the long term). It might be safer to ask your doctor to recommend a colleague in your current plan.I’m in need of serious dental care.Original Medicare doesn’t cover routine dental care costs, but many Medicare Advantage plans do. If you don’t have your own dental insurance and can’t afford dentistry costs out of pocket, consider finding an MA plan that will cover a portion of the costs of your needed work. Antos warns that figuring out what portion of your dental bills an MA plan will cover is complicated, so it helps to know what services you will use in the coming year.
Tamara Lytle is a Washington-area writer and editor whose work focuses on politics, government and health care policy.