It’s that time of year again: From October 15 through December 7, the 44 million Americans enrolled in Medicare will perform their annual dance of checking plan features, looking up covered drugs, calculating premiums—and maybe even changing partners.
This seven-week Medicare open enrollment window is your once-a-year chance to re-do your coverage, which could mean switching from one Medicare Advantage plan to another, picking a new prescription drug plan, or moving from Original Medicare to Medicare Advantage (or vice versa).
Even if you are happy with what you have, open enrollment matters: You may be facing changes to your plans, not to mention changes to your health.
“The difficult thing about Medicare is, when you really scratch the surface, the only way to really be successful is to do some homework,” says Philip Moeller, author of Get What’s Yours for Medicare: Maximize Your Coverage, Minimize Your Costs. “What’s good for you may not be good for your neighbor or even your spouse.”
This is your opportunity to make sure you have the best fit for the coming year and beyond—at the best price you can find. Here’s how to do that.
Know what’s on the table
Before you can make any changes to your game plan, you need to be familiar with all of the players.
Original Medicare consists of Part A to cover hospitalizations and Part B for physician and outpatient services. You pay a deductible, co-pays, and a monthly premium, which will be $135.50 a month in 2019 for most people.
With Original Medicare, you typically need to buy a Medicare Part D plan from a private insurer to cover prescription drugs. In 2019, average monthly Part D premiums are expected to decline a bit, from $33.59 to $32.50, according to the Centers for Medicare and Medicaid Services (CMS).
Plus, you may want a separate Medicare Supplement policy—also known as Medigap—to cover what Original Medicare omits. Depending on your plan choice, your age, and where you live, you could pay between $100 and $250 a month.
Medicare Advantage plans, which are sold by private insurers as an alternative to Original Medicare, wrap all or most of that coverage into one policy. The plans cover everything Parts A and B do, plus offer additional benefits, such as dental and vision insurance.
The average Medicare Advantage premium, which is on top of your Original Medicare premium, is expected to decrease slightly to $28 a month, according to CMS.
How your coverage could change
If you’re signed up for Original Medicare, don’t be lulled into thinking you have nothing to do. You still need to review your prescription drug coverage, and perhaps give Medicare Advantage a fresh look.
Part D plans are constantly shifting. So check to see if your plan’s list of covered drugs (what’s called a formulary) will continue to include the medicines you need. Look at Part D plans here.
Also, find out if your insurer is adding any new restrictions, such as prior authorization, quantity limits, or step therapy, which requires you to try generic and other lower-cost drugs before the most expensive medication can be prescribed.
With a Medicare Advantage plan, prescription drug coverage is typically included, so the same review applies. Plus, don’t assume your other plan benefits will stay the same.
Where to dig up plan updates
Now’s the time to unearth the junk mail you probably threw in the corner weeks ago. Anyone with a Medicare Advantage or Part D policy should have been mailed an Annual Notice of Change, a roughly 10-page document that outlines all the ways your plan will be different in 2019.
Insurers must also make available a document called the Evidence of Coverage (EOC). As of this year carriers don’t have to mail you this 140-plus-page booklet. Instead, they must make the EOC available on their websites by October 15.
In addition, you should have been mailed a Notification of Electronic Materials, which tells you what you can find online, such as lists of covered drugs and provider directories, and how you can obtain paper copies.
Anything missing? Call your insurers and ask them to resend the material.
What to look for in a new plan
As you compare prices and coverage for all the Medicare options in your area, pay attention to these features:
Networks. The main difference between Medicare Advantage and Original Medicare comes down to the providers you can see.
Under Original Medicare, you may visit any doctor that accepts Medicare, and many do. To keep costs down and be able to offer extra benefits, Medicare Advantage plans usually limit you to a smaller network of providers.
For any Advantage plan you are considering, including your current one, check the list of providers to make sure your doctors and other health care professionals will be in-network in 2019. That includes hospitals, home health agencies, and skilled nursing facilities.
Out-of-pocket costs. In addition to checking premiums, you’ll also want to look up the co-pays or co-insurance for primary care doctors and specialists. And see what the out-of-network costs will be should one of your providers leave the network.
Covered drugs. Just as you have reviewed which drugs are covered for your current Part D or Advantage plan, you want to review the formularies and restrictions for every policy you are considering.
Additional benefits. You may be gravitating toward Medicare Advantage because of the dental and vision coverage. Be sure to read the fine print about these extras so you understand any limitations.
In addition, Medicare Advantage plans are undergoing a substantial expansion. Private insurers may now cover non-medical items such as bathroom grab bars, transportation to medical appointments, and other types of assistance.
These rule changes are very new, so you won’t see the additions in most plans this year, according to Moeller. But wider changes are expected in 2020.
Why you should pause before you switch
As you explore your options, keep one caveat in mind. During open enrollment, it’s easy to move from one Medicare Advantage plan to another, change your stand-alone Part D prescription plan, or switch from Original Medicare to Medicare Advantage.
What’s trickier, however, is moving from Medicare Advantage to Original Medicare. That’s because in all but four states, if you don’t sign up for a Medicare Supplement policy within six months of when your Medicare Part B plan kicks in, insurers can later deny you coverage based on a preexisting condition, such as asthma, heart disease, diabetes, or a pending surgery.
“Lots of very smart people don’t understand this basic fact of Medicare,” says Judith Stein, executive director of the Center for Medicare Advocacy.
So switching to an Advantage plan could potentially eliminate the option of returning to Original Medicare with a supplemental policy later.
Where to find free help
Considerable’s Plan Finder tool can help your compare costs and coverage for private policies in your area. For personal, one-on-one help, you can call Considerable at 917-408-3690 or email [email protected]
The Considerable Medicare Supplement vs Medicare Advantage Quiz can help you navigate your choices, and Considerable’s Guide to Medicare can answer all of your most common questions.
Why you need one more check
It’s decision time. If you’ve found a plan you like, you’re ready to make the switch. Before you do, however, take one more step.
If you’ve done the bulk of your research online, call the plans you are considering and see if there have been updates to the premiums and plan features that haven’t been posted online.
And keep in mind, if you choose a Medicare Advantage plan, new rules this year allow you to switch to a different one or go back to Original Medicare through March of next year.
Congratulations, you’ve made it through another Medicare open enrollment dance. With a little effort and a lot of good information, you can find a partner that matches your needs step for step.