Dear Marci,

I sometimes worry that I’m not communicating well with my health care providers. What are some things I can do to get the most out of my doctors’ appointments?

Nelson (Worcester, MA)

Dear Nelson,

Communication is key in building good relationships with your health care providers and getting the best possible care. To help you communicate effectively with your doctors and other providers, take the following steps:

Be prepared.

• Before making an appointment, make sure that the doctors you are interested in seeing accept your health insurance.
• Think about what you would like to ask the doctor before your visit. You may want to write down your questions and take them with you to your appointment.
• Make sure to bring all relevant health insurance cards (for example, Medicare, Medicaid, Medigap, and/or Medicare Advantage cards) and documents to your appointment.
• Bring a copy of your health history to your appointment, especially if it is your first visit to a particular doctor. Your health history may include a record of the dates and results of past tests, major illnesses, hospitalizations, medications, chronic illnesses, allergies, and a family history of physical and mental illnesses.
• Bring a pen and paper to your appointment so you can write down what your doctor tells you. You can also ask your doctor if you can record your conversation.
• Decide if you want to bring another person, like a caregiver, to your appointment. It may be useful if you have extensive care needs or are used to someone managing your care.

Share information.

• Tell your doctor about any current symptoms or concerns during your visit. If there are several, consider ranking them in order of how much they are affecting/troubling you.
• Tell your doctor if you are having trouble with activities of daily living, such as bathing or dressing.
• Tell your doctor about other health care providers (like specialists or therapists) you have seen and any treatments they have prescribed or recommended.
• Health issues can be hard to talk about, but it is important that your doctor have as much relevant information from you as possible so they can recommend the best possible care.
• If your doctor does not specifically ask for information that you think is important, tell them.

Ask questions.

• If you do not understand something your doctor says, ask them to explain it.
• Ask the same question more than once, or ask if your doctor can explain something in a different way, if you need more time to process an answer. If you need further clarification, consider scheduling a phone conversation or speaking to a nurse or other provider.

Get it in writing.

• Ask your doctor to write down what you should do between now and your next visit. This may include instructions for how to take medications, specialists you should see, and/or lifestyle modifications you should consider.

Follow up.

• If you experience problems after your appointment, or if you have symptoms that get worse, call your doctor’s office to schedule a follow-up appointment. You may also need to make a lab/test appointment or find out how to access your lab/test results.
• Find out if your doctor uses any form of electronic communication, like email or an online portal. These can help you communicate questions and look up previous appointments and lab/test results without having to call the doctor’s office directly.

–Marci

Dear Marci,

I am feeling overwhelmed by Medicare plans trying to get me to enroll. Are there rules about how plans are allowed to market to me? What should I do if I think they’re breaking the rules?
-Beatrice (Savannah, GA)

Dear Beatrice,

During Fall Open Enrollment, which runs from October 15 to December 7 each year, Medicare Advantage Plans and Part D prescription drug plans will be marketing to people with Medicare. If you are considering changing your Medicare coverage during Fall Open Enrollment, it is important to verify all marketing information you see through credible sources, like 1-800-MEDICARE, your local State Health Insurance Assistance Program (SHIP), and websites that end in .gov. It is also important to remember the rules that are in place to stop plans from inappropriate marketing, and to know what to do if you think plans are breaking these rules.

Medicare has rules for how plans can contact you in different situations:

• By direct mail, radio, and print advertisements: Plans are allowed to market themselves by any of these means. They cannot, in these advertisements or in any other marketing situation, suggest that they are endorsed or preferred by Medicare. Plan names can include the word Medicare as long as it follows the name of the insurance company (for example, Acme Medicare Plan), and the usage does not suggest that Medicare endorses that particular plan more than any other plan.
• By phone or e-mail: A plan may not call or email you without your permission. They may only give you their contact information if you request it, and if this is the case, you must be the one to call them. If you give your contact information to a plan (like by putting it on a list at an event a plan is hosting), you may be giving them permission to contact you. If you do not wish to receive information about a plan in this way, do not give them your information. Plans must also follow federal and state regulations related to marketing over the phone – they cannot ignore the Do Not Call Registry and do not call again requests, and they cannot call late at night or early in the morning.
• In person: Plan representatives cannot approach you in public places or come to your home or nursing home uninvited. If you go to a plan’s educational or marketing event, or you agree to meet one-on-one with a representative, there are rules they must follow.
  • At plan events: Plans can hold educational or marketing events. At educational events, insurance companies cannot hand out marketing materials, plan-specific cost information, or a plan representative’s contact information. At a marketing event, an insurance company can provide information about a specific plan, but they cannot require you to provide contact information, give you a health screening, or create a situation that suggests they only want to enroll healthy people. Plans cannot offer gifts worth more than $15 at either kind of event, and they can only serve meals at educational events, not at marketing events. Additionally, any gifts that plans offer must be available to all attendees, not just those who enroll. Plans cannot offer benefits (such as a free checkup) as gifts.
  • At a one-on-one meeting:A plan representative can only schedule a meeting (at your home or in a public place) with your permission. At this meeting, the plan agent or broker is only allowed to talk to the person who has the appointment. Before the meeting, you must formally indicate the topics you would like to discuss, and the plan representative or broker cannot tell you about products or plans that fall outside of that scope, unless you give them further formal permission.

If you think a plan is engaging in a marketing violation, you should save any proof that you have. You can report violations to Medicare by calling 1-800-MEDICARE, or to your Senior Medicare Patrol (SMP) by visiting www.smpresource.org or calling 877-808-2468.

-Marci

Dear Marci,

Is it ever permissible to delay enrolling in Medicare altogether? I’m still a year off from turning 65, I’m working and covered by my workplace health plan, and I’d like to weigh all options open to me.

– Amanda (Olive Branch, MS)

Dear Amanda,

Anyone covered by current employee insurance thinking about delaying Medicare enrollment should consider which part of Medicare they want to delay: Medicare Part A (hospital insurance), Part B (medical insurance), or Part D (prescription drug coverage).

Before delaying Part A enrollment, consider the following questions:

1. Am I eligible for premium-free Part A? If you are eligible for premium-free Part A because you or your spouse worked more than 10 years in the United States, you can sign up for Part A at any time and will not have a late enrollment penalty for delaying enrollment. Many people are eligible for premium-free Part A. Many also choose to enroll when they first become eligible, even if their employee coverage pays primary, because they do not have to pay a premium.

2. I am not eligible for premium-free Part A. Will I have a Special Enrollment Period (SEP) to sign up for Medicare later? If you are not eligible for premium-free Part A, you should think carefully before delaying Part A enrollmentbecause you will need a Special Enrollment Period to sign up for the first time without penalty. If you are covered by insurance based on current work, you can use this SEP to sign up for premium Part A without penalty. If you do not qualify for an SEP, you will likely have a late enrollment penalty for delaying premium Part A enrollment. In addition, you will have to wait for the General Enrollment Period to enroll in premium Part A.

Before delaying Part B enrollment, consider the following questions:

1. Will I have a Part B SEP to sign up for Medicare later? If you are entitled to a Part B SEP, you will be able to enroll in Part B outside of your Initial Enrollment Period (three months before, the month of, and three months after your 65^th birthday month) or the General Enrollment Period (from January 1 through March 31 each year, with coverage becoming effective on July 1). If you have a Part B SEP, you will not have a late enrollment penalty for delaying Part B enrollment.

2. Will my other coverage pay primary or secondary to Medicare? If your employee health coverage will pay secondary to Medicare once you are eligible, it is usually not advisable to delay Medicare enrollment. Secondary insurance may take back any payments that it has made, or refuse to make future payments on health care costs until you enroll in Medicare.

Before delaying Part D enrollment, consider the following questions:

1. Is my current drug coverage creditable? Creditable drug coverage is coverage whose value is at least the same as the value of Medicare Part D. If your current drug coverage is creditable, you can delay Part D enrollment without penalty. You should receive a notice around September of each year informing you if your prescription drug coverage is creditable. If you have not received this notice, you should contact your human resources department. You should keep this notice for your records for each year that you have creditable drug coverage because you may need this paperwork to sign up for Part D later.

2. Will I have a Part D SEP to sign up for Medicare later?You will have an SEP to sign up for Medicare Part D later if you lose employer-based coverage (regardless of whether your employee drug coverage is creditable). You are also eligible for an SEP if you lose creditable drug coverage through no fault of your own. Both of these SEPs last for up to two months after the month that you lose your drug coverage. If your coverage was creditable, you will not have a Part D late enrollment penalty.

Amanda, to fully review your Medicare enrollment options, reach out to your State Health Insurance Assistance Program (SHIP). To find your SHIP’s contact information, you can go towww.shiptacenter.org or call 1-877-839-2675 for assistance. A SHIP counselor can help you understand your situation and discuss your specific health insurance needs.

– Marci   

Dear Marci,

How does Medicare coordinate with insurance from an employer?

– Zayden (Buffalo, NY)

Dear Zayden,

 Medicare and current employee insurance will work together in different ways under different circumstances. Without knowing your specific situation, a simple answer is not possible. Instead, let’s go over some of the most common instances where the two forms of health insurance coverage coordinate:

1. You are 65 or older. If you are 65 or older, current employee insurance from your or your spouse’s work paysprimary to Medicare if the employer has 20 or moreemployees. Current employee insurance from your or your spouse’s work pays secondary to Medicare if the employer has fewer than 20 employees.

2. You have received Social Security Disability Insurance (SSDI) for 24 months or more. If you have Medicare due to a disability, current employee insurance from your or your family member’s work pays primary to Medicare if the employer has100 or more employees. Current employee insurance from your or your family member’s work pays secondary to Medicare if the employer has fewer than 100 employees.

Note that if you have Medicare due to disability, the insurance based on current employment can be from your or your spouse’s current work or from your family member’s current work. For example, if you have are eligible for Medicare because of a disability and currently have coverage through your brother’s current employment at a company with 100 or more employees, his coverage will pay primary to Medicare. This is an important difference, because if you are eligible for Medicare due to age, the current employment-based coverage can only be from your or your spouse’s current work.

3. You have End-Stage Renal Disease (ESRD). If you haveMedicare due to ESRD, the Medicare coordination rules change depending on where you are in your 30-month coordination period. The 30-month coordination period begins the month you first become eligible for Medicare due to ESRD,even if you do not enroll.  

Medicare pays secondary to your employee coverage if you are still within your 30-month coordination period. Medicarepays primary to your employee coverage after the 30-month coordination period.

Remember, if you have ESRD, how Medicare works with your employee coverage depends on the coordination period instead of how many employees there are.

4. You are self-employed. If you are self-employed and provide coverage for yourself and at least one other person, Medicare considers you to have current employee insurance. (Medicare calls this a group health plan through current employment status, since you are offering coverage to at least one other employee.) A group health plan for a self-employed individual often pays secondary to Medicare, so you usually need to enroll in Medicare Parts A and B, which will pay primary. If you have coverage through an association, such as the local Bar Association, you are also considered to have current employee insurance.

Zayden, if your current employee insurance is supposed to pay primary, there are certain things that the employer and the plan cannot do. Once you are eligible for Medicare, the employercannot (a) offer different coverage than the coverage offered to employees who are not eligible for Medicare, (b) refuse to cover you, or (c) restrict your coverage.

The employer-based plan cannot (a) charge you more for your premium, deductible, coinsurance charges, and/or copays, (b) limit the benefits you receive, (c) give you misleading information to get you to disenroll, (d) pay providers less for services, (e) require you to wait longer for your coverage to begin, and (f) end your coverage because you become eligible for Medicare.

You should call the Social Security Administration (SSA) at 800-772-1213 to answer any questions you might have about whether or not you are considered currently employed or covered by current employee coverage. Write down the date and time of the call, the name of the representative you spoke to, and the outcome of the call. You should also speak with the human resources department of the employer that provides your coverage if you have questions about how your employee coverage works with Medicare. 

– Marci   

Dear Marci,

My mother is going to be eligible for Medicare soon. I want to help her choose a prescription drug plan, but I’m not sure where to start. What are some questions she should consider before signing up for a Part D plan?

– Erin (Clark, NJ)

Dear Erin,

Choosing a Part D plan can seem daunting because there are many points to think about. Depending on your mother’s needs, her financial situation, and her preferences, some of the following questions and guidelines may be more important than others.

One question to ask is: does this plan cover your mother’s drugs? If your mother takes a lot of prescription drugs, then choosing a plan that has her drugs on its formulary is an important first step. A formulary is a list of drugs that a plan covers. If a plan’s formulary does not include her drug or drugs, then she may end up paying out of pocket for the entire cost of the drug. You can help your mother create a list of the names of the prescriptions she takes, their dosages, and whether they are brand-name or generic. This can help you sort through plans and choose the ones that cover her drugs.

You should also ask about the costs associated with the plan. If your mother chooses a plan with a deductible, know that she will have to pay that amount out of pocket before her plan begins to cover her prescription drugs. She should also think about the most she can and wants to spend on the drug plan’s monthly premium.

The Medicare Plan Finder tool and the plan your mother is considering should provide information about the expected copays or coinsurances for the medications she anticipates taking over the next year. It is, however, difficult to estimate the exact cost of pharmacy copays and coinsurance amounts because these may change over the course of the year.

Another question to consider is, are my mother’s pharmacies preferred and in-network? Many drug plans include both preferred and non-preferred pharmacies in their networks. Your mother may pay less for her drugs at preferred pharmacies than at non-preferred pharmacies. If she goes to a pharmacy that’s close to home or easy to get to, it may be beneficial to look for a plan that categorizes that pharmacy as a preferred and in-network.

Also note that some plans have a mail-order option that may have cheaper prices than the pharmacy. If your mother is interested in mail-order, she can also look for a plan that includes that option.

Lastly, your mother will want to ask, what is the plan’s star rating?Medicare uses a star rating system to measure how well Part D plans perform in different categories, including quality of care and customer service. Ratings range from one to five stars, with one being the lowest and five being the highest rating. Medicare reviews plan performances each year and releases new star ratings each fall. You can find a plan’s star rating by using the Plan Finder tool onwww.medicare.gov.

Star ratings are not the only factor your mother should consider when looking for a plan. Even if a plan has a high star rating, it may not be right for her if it does not cover the drugs she needs. However, star ratings can be a factor to consider once your mother finds the plans that will provide the best coverage for her.

Knowing the right questions to ask can help you and your mother choose a Part D plan that works with her needs.

– Marci