Dear Marci,

I have a Qualified Health Plan (QHP) from my state’s health insurance Marketplace. I’m turning 65 soon, though. Should I enroll in Medicare if I have Marketplace coverage?

-Tina (Cortland, NY)

Dear Tina,

If you have a Qualified Health Plan (QHP), deciding what to do as you approach Medicare eligibility depends on your circumstances. In most cases, you should enroll in Medicare and disenroll from your QHP, but there are two exceptions:

You have End-Stage Renal Disease (ESRD).
If you have kidney disease that requires dialysis or transplant and are eligible for Medicare, you have the choice to enroll in or stay enrolled in a QHP with cost assistance (tax credits).
Be sure to consider how the QHP’s coverage and costs compare to Medicare before deciding to delay Medicare enrollment.
For counseling regarding your insurance options, contact your State Health Insurance Assistance Program (SHIP).
You do not qualify for premium-free Medicare Part A.
If you are eligible for Medicare but would have to pay a premium for Part A, you can keep your QHP with cost assistance as long as you do not enroll in any part of Medicare.
You should consider all consequences carefully before deciding to keep a QHP instead of Medicare. If you ever decide to enroll in Medicare, you may have to wait for the General Enrollment Period (GEP) to sign up. Using the GEP to enroll means you may experience gaps in coverage and incur a late enrollment penalty (LEP).
If you qualify for premium-free Part A, you should not continue using the Marketplace to get health and drug coverage. Enroll in Medicare when you are first eligible and disenroll from your QHP in a timely manner to avoid paying extra premiums.

Here are additional notes to remember when considering whether to enroll in Medicare if you have a QHP from the Marketplace:
You are ineligible for cost assistance (tax credits) to help pay for your QHP premium once you are eligible for premium-free Part A.
It is likely not cost-effective to have both Medicare and a QHP.
There is no guarantee that a QHP will pay for your care if you have or are eligible for Medicare Part B, meaning you may have little or no coverage.
You may experience gaps in coverage and late enrollment penalties when attempting to enroll in Medicare late.
I hope this helps you with your decision to enroll in Medicare or not.

-Marci

Dear Marci,

I am recently retired from the military and am turning 65 soon. I believe I must enroll in Medicare, even though I have TRICARE benefits. How does TRICARE for Life work with Medicare?

-Jaime (Salt Lake City, UT)

Dear Jaime,

TRICARE is a health insurance program provided by the federal government to active duty and retired military personnel and their family members. There are many different TRICARE programs. TRICARE for Life (TFL) is a program for Medicare-eligible military retirees and their dependents.

TFL acts as a supplement to Medicare. This means that TFL typically covers your Medicare cost-sharing (deductibles, coinsurances, and copayments). TFL may also pay when services are not covered by Medicare or when you have used up your Medicare benefits.

If you are eligible for premium-free Part A, you should sign up for Medicare and enroll in Medicare Part B to continue receiving TRICARE benefits when you are no longer an active duty service member or covered by an active duty service member. After enrolling in Medicare, you should automatically receive your TRICARE benefits through TRICARE for Life. If you delay Part B enrollment, you may face late enrollment penalties and gaps in coverage.

TFL also offers a pharmacy program that provides creditable drug coverage. You may choose to delay Part D enrollment without penalty and continue using TFL’s pharmacy program.

Remember, there are many different TRICARE programs. If you are an active duty service member (ADSM) or active duty family member (ADFM), you may receive your health benefits through a different TRICARE insurance program (such as TRICARE Standard or Prime). You typically can delay Part B enrollment if you are an ADSM or ADFM and enroll in Medicare when you are no longer active duty using the Part B Special Enrollment Period (SEP).

If you need assistance with TRICARE for Life or a different TRICARE program, visit TRICARE’s website for more information and contact information.

Thank you for your service, and congratulations on retirement.

-Marci

Dear Marci,

I have Veterans Affairs (VA) health coverage and am turning 65 in late March of this next year. Do I need to enroll in Medicare?

-Chris (Springfield, OH)

Dear Chris,

For our other readers, let’s start with a quick review of Veterans Affairs benefits, also called VA benefits. VA benefits are administered by the federal government for veterans—people who served on active duty in the U.S. Armed Forces for a required period of time and received an honorable discharge or release. VA benefits include pensions, educational stipends, and health care, among other benefits.

It is important to know that VA benefits do not work with Medicare, though you can be enrolled in both.


In order for your VA coverage to pay for your care, you must generally receive health care services at a VA facility.
In order for Medicare to pay for your care, you must receive care at a Medicare-certified facility that works with your Medicare coverage.
VA benefits will not pay for Medicare cost-sharing like deductibles, copayments, or coinsurances.

This means that if you choose not to enroll in Medicare and to keep only your VA coverage, you will not have health insurance for facilities outside the VA system. Enrolling in Medicare gives you more flexibility in what doctors and facilities you go to, while also having VA benefits to cover things not covered by Medicare, such as hearing aids and dental care.

Some people choose to enroll in Medicare Part A for added hospital insurance because it’s often premium-free, but they turn down Part B because of the monthly premiums. In this scenario, though, you would likely face a premium penalty and coverage gap if you decided to enroll in Part B in the future.

VA benefits do offer creditable drug coverage. This means that if you are enrolled in VA drug coverage, you can delay Medicare Part D enrollment without having a late enrollment penalty. Be sure to compare the costs and benefits of Part D and your VA drug coverage to decide which best suits your needs. Typically, VA drug coverage has no premiums and no or limited copayments for prescriptions—but you must use VA pharmacies and facilities. You may want Part D coverage if you:
Live far from a VA pharmacy or facility, or do not want to use a VA provider to get prescriptions.
Want the flexibility of filling prescriptions at retail pharmacies or find the VA formulary too restrictive.
Reside in a non-VA nursing home and want to get prescriptions from the long-term care pharmacy that works with your nursing home.
Qualify for full Extra Help, which has lower copays than VA coverage.

If you decide to enroll in Medicare Part B and Part D, you should do so during your Initial Enrollment Period (IEP). Your IEP is the three months before your 65th birthday month, the month of your 65th birthday, and the three months after. Because you are turning 65 in March, your Initial Enrollment Period is from December through June.

-Marci

Dear Marci,

I recently got a letter in the mail saying my Part D premium is increasing next year. I found a different plan that covers my medications for a lower premium, but I’m not sure what to do next. How do I change my Part D plan now?

-Theodore (Selmer, TN)

Dear Theodore,

First, it’s helpful to know that you can only change your Part D plan during certain times of the year. Here are the enrollment periods you can use to change your coverage:

Fall Open Enrollment Period: This period runs from October 15 through December 7, with changes becoming effective January 1. It is sometimes also called the Annual Open Enrollment Period.
Medicare Advantage Open Enrollment Period: Only those with Medicare Advantage Plans can use this enrollment period. If you get prescription drug coverage through a Medicare Advantage Plan, you can also make changes to your coverage from January 1 through March 31.
Special Enrollment Period (SEP): Under certain circumstances, you may be eligible to use a SEP to make changes to Part D coverage. Here are some examples of SEPs:
You move out of your Part D plan’s service area.
You have or lose Extra Help.
You lose creditable drug coverage through no fault of your own.
We are currently in the Fall Open Enrollment Period, so you can change your Part D plan!

There are a few ways to enroll in a new plan:
Call 1-800-MEDICARE (1-800-633-4227).
Enroll online through Medicare Plan Finder.
Contact the plan directly to enroll.
Enroll through an insurance broker, if you work with one.
It is usually best to enroll through Medicare, since it’s helpful for Medicare to have the enrollment documentation in case any problems arise.

Once your new plan starts, you are automatically disenrolled from your old plan. You do not need to contact your old plan to disenroll.

I hope this helps!

-Marci

Dear Marci,

I have Original Medicare and a Part D plan. I’m considering changing my Part D plan this Medicare Open Enrollment Period. How can I compare Part D plans?

-Mina (Walla Walla, WA)

Dear Mina,

I’m glad to hear you’re comparing your Medicare coverage options this fall! Research shows that many people with Part D could lower their costs by shopping among plans each year. There could be another Part D plan in your area that covers the drugs you take with fewer restrictions or with lower costs, so it’s great that you are trying to compare plans.

I would recommend using Plan Finder to compare Part D plans. Medicare Plan Finder is an online tool at www.medicare.gov that can be used to compare stand-alone Part D plans or Medicare Advantage Plans. Plan Finder provides information about costs, which drugs are included on the plan’s formulary (list of covered drugs), and the star rating of the plan.

To use Plan Finder, follow these steps:

Go to www.medicare.gov and click on the button that says, “Find Plans Now.”
You can do a general search on the right side of the page, under the title “Continue without logging in” button. If you wish to save your drugs and pharmacy information, you can log into or create your Medicare account on the left side of the page.
Next, put in your zip code and use the drop-down list to choose whether you are looking for a Medicare Advantage or Part D plan. Make sure you click “Apply” and then click on “Start” to begin your search.
Then you can enter the drugs you take, choose the pharmacies you use, and indicate whether you are interested in a mail order option.
Plan Finder will display results for plans in your area. Note that a plan may not cover all of the drugs you take, but it may have alternatives on its formulary. Speak to your provider about whether these alternatives would be appropriate for you. Plan Finder also tells you if the plan has a deductible and how much the monthly premium is.

Initially, the plans will be sorted by “lowest drug + premium costs.” This is the closest estimate to what you may pay out of pocket for your Part D coverage for the year. You can select “Plan Details” to find out more specifics about coverage, including any coverage restrictions that might apply to your drugs.

Before enrolling, it is a good idea to call the plan directly to confirm any information you read on Plan Finder, as information may not be completely up to date. Here is a list of questions you can ask when calling a company about their prescription drug coverage. You can enroll in a plan online, by calling 1-800-MEDICARE, or by calling the plan directly.

Note that this year, there are some additional things that people who take insulin should consider when using the Plan Finder tool. Beginning in 2023, cost-sharing for insulin is capped at $35 per prescription. However, the Plan Finder tool does not reflect this price change. If you take insulin, do your Plan Finder search without your insulin included in your drug list. This will show you the lowest cost plans for your other medications. Then separately check with a plan to see if your insulin is on the plan’s formulary.

You can make as many changes as you want between October 15 and December 7, but only the last change you make will take effect on January 1. If you choose a plan and realize that it is the wrong plan after Fall Open Enrollment is over, in most cases you will not be able to change your coverage until the next Fall Open Enrollment Period. For this reason, it is important to carefully consider all of your options and take the time to research each plan in order to make a decision that fits your health care needs.

Good luck choosing the best Part D plan for your needs!

-Marci