NEWS

65 or older? Here’s what you need to know about Medicare

Linda Leicht
For the News-Leader

If you are 65 or older, you have been receiving plenty of mail inviting you to learn more about Medicare Advantage plans or supplements (Medigap policies), and information from Medicare about plans and policies available to you.

Open enrollment for Medicare ends Dec. 7, so there is only a little time left to pick your policy.

If you still haven’t decided what to do, here is a basic primer in Medicare options and some advice from a few experts:

What is Medicare?

Medicare is a government health insurance program available to anyone at least age 65 and to some people on disability. It was established in 1965 through the Social Security Administration.

Medicare Part A covers hospitalization and is available at no premium for those who qualify for Medicare.

Medicare Part B covers outpatient care, such as routine doctor visits. There is a premium — currently a minimum of $104.90 — for Part B. Medicare replacement insurance plans, called Medicare Advantage plans, can be purchased at the same premium or higher, depending on the plan and the location. Also available are Medigap policies, which supplement the basic Medicare Part B coverage at an additional premium.

Medicare Part D covers prescription medications, which are not covered under Part B or Medigap policies. Medicare Advantage plans have prescription drug coverage.

When do I need to get Medicare?

Before you turn 65, you will get a notification from Medicare that you will soon be eligible for coverage. At that time, if you are covered under a group insurance policy through your work or your spouse’s employer, you can opt to stay in that plan if it qualifies, although you likely should sign up for Part A.

You can sign up any time during a seven-month window — between three months prior to your 65th birthday month, during that month or the three months following your birthday month. If you plan to leave your employment or will no longer have a group policy, you have eight months to enroll in Part B before facing a penalty.

What’s the difference between an Advantage plan and a Medigap policy?

A Medicare Advantage plan is an insurance policy that replaces basic Part B coverage. Each community will have a number of plans from which to choose, with premiums and coverage options negotiated by area health care systems. In Springfield, those systems include CoxHealth and Mercy.

Advantage plans vary in many ways. Some are limited to a specific health care system. The premiums, co-pays and out-of-pocket limits will all be different, and each plan will include a formulary of prescription medication it covers. Plans will also offer services beyond the required coverage, such as Silver Sneakers fitness memberships and dental or vision coverage.

Medigap policies will supplement your standard Part B. To purchase a Medigap plan, you must first sign up for Part B with Medicare — not for an Advantage plan — and then you must select the supplement that works best for you. In addition, you will be required to purchase a separate prescription drug plan, Part D. A Medigap plan will cover the expenses that Medicare does not cover, such as the 20 percent co-pay.

How do I pay for my Medicare coverage?

If you are collecting Social Security, the basic premium plus the cost of your replacement or supplement will be deducted from your monthly payment. If you are not collecting Social Security yet, you will be billed quarterly by Medicare.

Finding a plan

Deciding whether to get an Advantage plan or a Medigap policy, and then choosing the right one for you can be confusing, especially for a first-timer. But there are experts, from private insurance brokers to certified senior advisers, who can help you navigate Medicare. Be sure you know if your adviser represents a specific insurance company and take that into consideration.

Janet Michel is a certified senior adviser and a national Social Security adviser who owns her own business, Health and Life Planning, in Springfield. She is trained by Social Security and each insurance company to provide information and help people decide the best coverage for them.

She says one of the first decisions most 65-year-olds will have to make is whether to stay on their employer-provided group coverage or move to Medicare Part B. One of the first things to determine is if the group coverage qualifies, something your employer will be able to tell you through a “statement letter.”

“If it’s a good plan, you can stay on it,” she explained. “But look at what you are paying for that group plan. A Medicare Advantage plan may be better.” The most likely difference will be in drug coverage.

If you do not sign up for Part B as soon as you are eligible, you could be subject to a penalty that will be reflected in your future premiums when you do sign up. However, if you forestall Medicare because you have a qualified group policy, you will not be subject to a penalty, she said.

Once you decide that Medicare is for you, the next decision is the type of coverage you want.

“You have the option between a supplement (Medigap policy), which covers what Medicare doesn’t cover, or getting an Advantage plan, which works more like a group plan and replaces Medicare,” Michel said.

There are pluses and minuses for both choices.

A Medigap policy can be costly, on top of the Part B premium, but if you have a chronic condition and are likely to have high medical and hospitalization costs, it could save you in the long run. And, if you sign up for a Medigap policy at 65 you are guaranteed coverage, with no medical questions asked. However, if you wait, you will not only have to give medical information, you will pay even higher premiums and could be turned down completely.

Michel advises that if you choose to purchase a Medigap policy, you should look at the companies’ histories, especially each company’s record of raising rates, because you will not be able to switch companies except under specific circumstances.

An Advantage plan will be much cheaper than a Medigap policy but will include co-pays, deductibles and out-of-pocket limits. All plans cost at least the basic Medicare premium (currently $104.90), but could have an additional premium. How much it will cost you depends on the contract negotiated in your community, and those costs could change each year. Drug coverage is often a deciding factor, so Michel advises that you compile a complete list of prescription medications you take and compare the costs in each plan. Also, most plans will have a single health care system in its network, so make sure the plan you get will allow you to go to the doctor and hospital of your choice.

You can change your Advantage plan each year or if your circumstances change, such as a move out of the community or state.

A personal choice

Debbie Morrissey is a community support specialist at the Southwest Missouri Office on Aging. One of her jobs is to help seniors navigate Medicare, whether it is during open enrollment in November and December or when they are approaching 65.

SWMOA offers personal assistance with plan comparisons and enrollment during this time, but Morrissey warns, “We book up pretty fast.”

Morrissey can help seniors evaluate the plans offered in their area, help them decide whether a Medigap or Advantage plan works best for them, if they should stay on an employer-provided plan or, if they qualify, whether VA benefits are the answer for them.

You need to take several things into consideration — including health, genetics and finances — before deciding the type of coverage and the best policy for you, she said.

“It’s a very personal choice,” Morrissey pointed out.

But it is a choice that seniors should make so that their benefits will be coordinated, she said. Make sure Medicare knows how you are getting your coverage and let your health care providers know, too.

“If you want your billing to go to all the right people, let them know,” she said. “So you don’t get stressed.”

Cost is a major stressor, so Morrissey helps seniors find a policy that fits their health needs and their pocketbook. Those who can’t afford the basic premium can apply for assistance through the state. Programs such as Medicare Savings and Missouri Rx can help with premiums, co-pays and deductibles for those who qualify.

Morrissey can help with that, but she also pointed out that there are other ways to “tweak” things to fit a budget. “Some of what we do is help you figure out how to live on your income,” she said.

Still time for help

Judee Steward is a senior advocate at Cox Senior Health. She deals with a wide range of resources for seniors, including transportation, housing and, of course, Medicare policy comparisons. Even though the deadline is looming, she is still taking appointments.

She is also able to help seniors find and apply for financial assistance if they cannot afford needed health coverage. Although she works at CoxHealth, she is an agent for Missouri CLAIM (Community Leaders Assisting the Insured of Missouri), a state health insurance assistance program. In that capacity, she has knowledge of all the plans and policies available and can help seniors make good choices.

“I never tell them what to do or what to choose,” Steward said. “I have to be very unbiased.”

While younger retirees are often computer savvy enough to go to medicare.gov and sign up themselves, many of the older seniors need someone to help with that, Steward said.

“They’re just so grateful to have somebody do that manual work,” she said. “The more choices there are, the harder it is to decide.”

Need help with Medicare?

There are a few places to turn for help in deciding your Medicare coverage.

• Medicare, medicare.gov or call 800-MEDICARE

• Missouri CLAIM office, MissouriCLAIM.org or call 800-390-3330

• Southwest Missouri Office on Aging, swmoa.com, or call Debbie Morrissey at 417-862-0762 or 800-497-0822

• Cox Senior Health’s CoxHealth Senior Advantage program, coxhealth.com, or call Judee Steward 417-269-3616

* Health and Life Planning, healthlifeplanning.com, or call Janet Michel at 417-501-5220