By GEORGE FJELD
Are you confused with all the mail and all the pitches you see and hear about Medicare? Which ones are necessary directives from Medicare and which ones are simply sales pitches?
What Medicare do you have and what do you need?
If you want to change your Medicare enrollment for the coming year you need to make that change by next Wednesday, Dec. 7 — did you know that?
These are the questions many older Vermonters are asking. It’s also why there is an avalanche of information, solicitations and calls.
Medicare is the national health insurance that covers most older Americans and less able individuals. It is not all free. Part A is free for most and Parts B and D are often paid for by a deduction from one’s Social Security income. Medicare allows wide choices in health care providers as most Vermont providers are covered. However it does not cover all the costs. There is a deductible as well as a copay for services and care. Part A deductible is $1,600 and there is no copay until certain limits are reached. Part B deductible is $226 and then there is a 20% copay.
We are in a period called open enrollment when you may choose among different options for Medicare health care coverage. Here are some things to know as you make your choices.
Basically, the different parts of Medicare you may choose from are:
Part A (Hospital Insurance) helps to cover services such as inpatient care in hospitals, skilled nursing facility care, hospice care, home health care, and blood.
Part B (Medical Insurance) helps to cover services from doctors and other health care providers, outpatient care, medical equipment, and preventative services.
Part D helps to cover prescription drugs. It is an optional benefit available to everyone with Medicare. Part D is provided by private insurance companies that contract with Medicare.
Together, Parts A and B are commonly referred to as “Original Medicare.”
After enrolling (or buying Medicare), one can purchase a “gap” insurance policy that covers the difference between what hospitals, doctors and other providers charge and what Medicare pays. It may provide additional benefits as well. This is commonly called MediGap. This is sold by commercial insurance companies and varies in cost (in addition to Medicare premium) and how broad the coverage is. These policies are regulated by the state.
The other option is to opt out of Medicare into a Medicare Advantage plan. This is commercial insurance that replaces Medicare. If you have this, you no longer have Medicare but, instead, a contract with a commercial insurance company. If you choose this option, you want to read the details of the contract, which spell out what benefits you will receive and who gets to choose your providers (either you or the insurance company). These policies usually provide prescription drug insurance. These policies are often sold with extra benefits not available with Original Medicare. These can include dental, vision and healthy choices like gym memberships. The insurance company gets to choose the level of benefit and who provides the benefit. The state of Vermont reviews and approves these policies to be sold in Vermont.
The Vermont Department of Financial Regulation offers the following tips:
• Read the fine print and don’t be fooled by how an ad looks or appears. Many websites and print ads look like they are from Medicare but are not. When looking for information about Medicare, go to the official website at medicare.gov. Websites with similar addresses like Medicare.com, Medicare.org, or Medicare.net are not official.
• Don’t believe agents who claim to work for Medicare, or ads that claim to offer plans that are “sponsored” or “endorsed” by Medicare. There are no Medicare sales representatives.
• Hang up on unsolicited phone calls trying to sell you a Medicare plan. Neither insurance companies nor insurance agents are permitted to make unsolicited Medicare-related calls.
• Although recent policy changes allow Medicare Advantage plans to offer benefits that aren’t health-related to enrollees with certain chronic conditions, insurance agents can’t guarantee that you will be eligible for those benefits before you enroll.
• Don’t give out your personal information over the phone to someone who tells you that you must provide information to keep your Medicare coverage.
If you see or hear a Medicare Supplement advertisement or solicitation that you think is deceptive, misleading or a scam, report it to the department by email at email@example.com or by phone toll-free at 1-800-964-1784. You can report a Medicare Advantage-related concern at 1-800-MEDICARE and ftc.gov/complaint.
Medicare has a website, medicare.gov, that has tools to help choose health and prescription drug plans. It is relatively easy to use and includes all the plans approved in the state of Vermont.
When choosing, it’s important to consider your present health condition and future needs. High-need individuals — think cancer, heart disease or dementia — generally fare better with Original Medicare and a substantial Medigap policy as well as Part D prescription drug coverage. Delaying enrollment in a prescription drug plan will result in permanently increased prices when you do enroll.
Medicare Advantage plans generally are less expensive and best for people with low-impact chronic disease or are healthy and can take advantage of the additional options provided. They are not portable and are location dependent (you must change plans if you move). For this reason, they are usually not ideal for snowbirds i.e.: those who travel south in the winter (although some do have nationwide coverage, usually for an additional premium).
Plans can be changed during open enrollment which ends Dec. 7 this year. You can opt out of a Medicare Advantage plan and back into Original Medicare anytime during the first year and then during open enrollment in subsequent years. There is no penalty for switching unless you didn’t have prescription drug coverage.
Dr. George Fjeld, MD, of Brandon retired last year. He practiced family medicine, in Brandon for 37 years.