It's that time of year again for the Annual Medicare Open Enrollment Periods. Online marketing, direct mail, print, and TV ads are everywhere. Individuals and businesses with employees that are Medicare eligible, or who will become eligible in the coming year, may not know how to handle the Medicare health insurance enrollment options and requirements. They can be confusing and lead to costly enrollment mistakes.
First, when an individual is new to Medicare, they have their own, personal Initial Enrollment Period for Part A (Hospital), Part B (outpatient) and/or Part D (drug coverage). A personal Initial Enrollment Period can occur at any time during the year. It starts 3 months before a person gets Medicare and lasts for 3 months after they get Medicare.
It is very important to enroll in Medicare as soon as eligible, or to document qualified creditable coverage. Individuals that decline to enroll in Medicare when first eligible, and do not document qualified creditable coverage, will face penalties when they finally do enroll in Medicare. The penalties are in the form of higher premiums. The penalty for Part B is particularly harsh, a 10% higher monthly premium that lasts for the rest of their life. Also, some may pay a higher premium because of their income at the time of eligibility, another reason why some advance estate planning is helpful.
Most people become eligible for Medicare when they age-in by turning age 65. They can also qualify for Medicare at any age, 24 months following a determination that they are fully disabled. There are other less common ways in individual can become eligible for Medicare, such as being blind, having end-stage renal disease, or because they receive Railroad Retirement benefits. If a newly eligible individual would like to make an immediate enrollment into a Medicare HMO style Managed Care plan, they can do so during their Initial Enrollment Period.
Second, the annual Medicare Open Enrollment Period is from October 15 - December 7. It is only for individuals who want to join, drop, or switch a Medicare Advantage Plan or to join, switch, or drop drug coverage. Any changes made during this period will take effect on January 1.
Third, the annual Medicare Advantage Open Enrollment Period is from January 1 - March 31, or as stated above, within the first three months an individual first gets Medicare. This time period allows individuals to switch from one Medicare Advantage Plan to another, with or without a drug plan, to join a Medicare drug plan, or, very importantly, to drop their Medicare Advantage completely and go back to Original Medicare. Changes made during this period will take effect the first day of the month following the change.
Original Medicare (also called fee-for-service) means an individual receives their Medicare benefits directly from the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS). It has significant out-of-pocket costs, including a large Part A deductible, a 20% Part B coinsurance, and zero outpatient drug coverage. So Original Medicare beneficiaries should also purchase a Medicare Supplemental Plan (such as Plan G or Plan N) to cover the out-of-pocket costs of Medicare Parts A and B, and purchase a Part D Medicare drug plan.
Medicare Managed Care enrollment is when a Medicare beneficiary chooses to switch from Original Medicare Parts A, B and D into a commercial Medicare HMO company plan called Medicare Advantage. The Medicare Advantage HMO will control many aspects of a person's access to covered health services, such as deciding which providers they can see with coverage, and deciding when a treatment is covered or denied. In exchange for this control, individuals can get added perks that are not covered by Original Medicare such as Silver Sneakers gym memberships, limited dental, vision, and hearing services, a health spending account, and/or other rebates and financial incentives.
To join any Medicare Advantage plan, you need to be a U.S. citizen, be enrolled in Part A and Part B, live in the plan's service area, and know your Medicare ID number and Parts A/B start dates as printed on your Medicare ID card.
Finally, Medicare Special Enrollment Periods are available throughout the year if an individual has had a material change in their life circumstances such that a change in their coverage is needed. Qualifying events can include but are not limited to: a change in plan benefits, loss of eligibility for other coverage, retirement, marriage, divorce, death of a spouse, relocating to an address outside the service area or to an area that offers new plan options, diagnosis of a serious illness, moving in or out of a nursing home, or a material change in finances such as becoming dual eligible for Medicaid, or eligible for Medicare Extra Help. Changes made during a Special Enrollment Period will generally take effect right away, and in some cases can even be made 30-90 days retroactive.
In many cases, Medicare eligible individuals have more than one coverage, and require consistent management of which coverage is the primary payer of which services, called Coordination of Benefits or COB. When COB is not managed well, individuals receive medical bills in the mail for services that should be covered.
When any insurance denies coverage, enrolled individuals have procedural appeal rights within the coverage plan. In some cases, they have a right to an external appeal by an outside review.
Appeal levels are limited and should not be used up casually. An enrollee should not use up an appeal level by making a telephone call to lodge a complaint, or by sending a letter of grievance. Instead, the issue should be timely and professionally appealed. It should include meaningful written arguments supported by relevant regulations, medical records, coverage contract terms, and other evidence on which a favorable decision can be made.
Those with questions, big insurance denials of coverage, high out-of-pocket medical costs, or those wanting to plan in advance, are encouraged to seek out knowledgable professionals to help understand their options, and assert their coverage rights and benefits.
You can make changes to your Medicare, Medicare Advantage and Medicare drug coverage during enrollment periods and when certain qualifying events happen in your life.