Life After 50 Expo

Dear Marci,

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I have a Medicare Advantage plan, but I think I want to disenroll and switch to Original Medicare during the Medicare Advantage Disenrollment Period. I know I can also enroll in a stand-alone Part D plan if I switch to Original Medicare. Can I also purchase a Medigap policy during this time?

– Eric (Chicago, IL)

Dear Eric,

Disenrolling from a Medicare Advantage plan during theMedicare Advantage Disenrollment Period (MADP) does not necessarily give you a protected right to purchase a Medigap. Remember, a Medigap is a supplemental insurance policy that is sold by private insurance companies to help pay Medicare copays, coinsurances, and deductibles. For a full list of what Medigap plans typically cover, click here. This insurance policy is usually available in the form of twelve different plans labeled A through L and works only with Original Medicare.

Under national law, you only have the right to buy a Medigap policy if you are 65 years old and enrolled in Medicare, and if you buy your policy during a protected enrollment period. When you turn 65 and enroll in Medicare Part B, you have a six-month open enrollment period during which Medigap companies must sell you a policy at the best available rate, regardless of your health status and cannot deny you coverage.

If you are age 65 or over, national law also gives you a protected enrollment period to buy most Medigap policies within 63 days of when you lose or end certain kinds of health coverage. This includes:

  • If you lost group health insurance (through either current or previous employment) through no fault of your own;
  • If you joined a Medicare Advantage plan when you first became eligible for Medicare and disenrolled within 12 months; or
  • If your previous Medigap policy, Medicare Advantage plan, PACE program ends its coverage or commits fraud.

Finally, if you have a Medicare Advantage plan, Medicare SELECT policy or PACE program and you move out of the plan’s service area, you have the right to buy most Medigap policies. Note that national laws regulating Medigaps do not apply to people under the age of 65 who are eligible for Medicare due to disability or ESRD diagnosis.

If you do not meet the criteria listed above, you may encounter problems when trying to purchase a Medigap during the MADP. Companies can refuse to sell you a policy, or may only sell you one if you meet certain medical requirements. You also may need to pay ahigher premium and wait six months before the Medigap will cover pre-existing conditions.

Keep in mind, many states follow the national rules explained here for Medigap policies, but some allow people to more flexibility to enroll in Medigaps. Some states also apply Medigap protections to people under age 65 who qualify for Medicare based on a disability. Check out the rules in your state before purchasing a Medigap by, calling your State Health Insurance Assistance Program (SHIP). To find the contact information for you SHIP, visit www.shiptalk.org.

-Marci

Transitions from Expansion Medicaid into Medicare Examined !

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A new report from AARP Public Policy Institute (PPI) examines the challenges faced by low-income adults who enroll in expanded Medicaid coverage and later must transition into coverage under Medicare. Under the Affordable Care Act (ACA), states can expand Medicaid coverage to adults ages 19-64 earning up to 138% of the Federal Poverty Level (FPL). The Supreme Court ruled in 2012 that Medicaid expansion is a state option. To date, 28 states and the District of Columbia have chosen to expand the program to adults under age 65 who in most cases would not have qualified before the expansion.

Individuals enrolled in expansion Medicaid have little or no out-of-pocket costs when accessing covered health care, prescription medications, and other Medicaid-covered services, and these individuals rarely pay a premium. When a person turns 65 or becomes eligible for Medicare under the age of 65, however, that person generally can no longer qualify for expansion Medicaid and must instead be covered under Medicare.

The AARP PPI report highlights additional costs for low-income adults transitioning from expansion Medicaid into Medicare, and discusses restrictive income and asset limits associated with programs available to help low-income Medicare beneficiaries with their Medicare premiums and cost sharing. Specifically, the report highlights the Medicare Savings Programs (MSPs), all of which pay a Medicare beneficiary’s Part B premium, and automatically qualify that individual for assistance with Medicare prescription drug costs, through the Extra Help program. Eligibility for full Medicaid benefits and for MSPs for individuals age 65 or older (and those with Medicare who are under 65) are often stricter and can count a person’s assets, whereas assets are not counted to determine eligibility for expansion Medicaid.

AARP Public Policy Institute Highlights Medicare ACOs

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In December, the AARP Public Policy Institute published an article on Medicare Accountable Care Organizations (ACOs). Established by the Affordable Care Act, ACOs are networks of hospitals, doctors, and other health care providers. These networks share a primary goal— to coordinate and improve the quality of, expand access to, and reduce the cost of care for beneficiaries with Original Medicare.

Medicare ACOs are unlike Medicare Advantage (MA) plans in two important ways. First, MA plans have defined provider networks and may impose utilization controls, like prior authorization, on access to particular services or prescription medicines, but ACOs do not. Beneficiaries who receive care from an ACO are encouraged to see doctors within their ACO, but have the option to seek care from any doctor that is part of Original Medicare. Second, Medicare beneficiaries proactively enroll in an MA plan. Original Medicare beneficiaries who are “attributed” to an ACO, however, may not know they are part of the ACO.

Medicare beneficiaries’ quality of care measures appear to have improved for those beneficiaries receiving care from ACOs. Citing empirical research, AARP notes that quality of care improved on multiple measures, including timely access to care, coordination between specialty and primary care, and whether the patient was offered the doctor’s visit notes at the end of an appointment.

U.S. Senators Reflect on the Continued Importance of Medicare and Medicaid after 50 Years

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Last week, Senator Ron Wyden, on behalf of 45 fellow Senators, submitted to the Congressional record a resolution commemorating the 50thanniversary of the Medicare and Medicaid programs. The resolution states, “…as a result of President [Lyndon] Johnson’s call to action and Congress’ bipartisan initiative that created the Medicare program, 54,000,000 seniors and people with disabilities have access to guaranteed health care benefits.”

The resolution also highlights 50 years of work in Congress to protect and improve the Medicare program for all current and future beneficiaries, and states that all future efforts should “build upon President Johnson’s vision ‘to assure the availability of and accessibility to the best healthcare to all Americans, regardless of age or geography or economic status.’ ”

Sen. Wyden reflects on the importance of Medicare and Medicaid and recalls why these programs were created. Fifty years ago less than half of older Americans had health insurance, and “many aging Americans without family to care for them ended up destitute, without necessary health care, or on the street.”

Sen. Wyden concludes, “…that despite sharp differences and partisanship, the Congress of Johnson’s day was able to rise above that culture and those challenges to find agreement and make America a much better place. As this new Congress begins, I hope we can use that 50-year-old spirit to strengthen, protect and improve Medicare and Medicaid to keep the guarantee strong and ensure health care to those who need it most.”

Dear Marci,

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Dear Marci,

Can you give me a brief summary of any major changes to Medicare in 2015? I have read information in a few different places, but I want to make sure I am not missing anything at the start of the New Year.

– Ruth (Wilmington, DE)

Dear Ruth,

In 2015, Medicare benefits and costs will remain stable, although some small changes occurred when the year began. For example, Original Medicare costs mostly stayed the same. For Part B, the monthly premium and deductible will remain the same in 2015. You can expect to continue paying $104.90 per month for your Part B premium. The deductible remains at $147. Additionally, if you pay a higher Part B premium due to income adjustments (called IRMAA), these premiums remain the same as well.

For Part A, most people do not need to pay a monthlypremium because they have or their spouse has worked in the United States for 10 years or more. If you have worked in the U.S. for 7.5 to 10 years, you pay a premium of $224 per month for Part A in 2015. If you have worked in the U.S. for less than 7.5 years, you pay a premium of $407 per month for Part A. The Part Adeductible is $1,260 in 2015. Once you meet this deductible, days 1-60 spent as a hospital inpatient in each benefit period still have a $0 copayment in 2015. Remember, a benefit period begins the day you enter the hospital as an inpatient. It ends when you have not received inpatient hospital or skilled nursing facility care for 60 days in a row. Days 61-90 as a hospital inpatient have a daily copayment of $315. Your copayment during your 60 lifetime reserve days is $630. Remember, these days can only be used once in your lifetime; they are non-renewable.

It is important to know that to the costs listed above relate to Original Medicare. Medicare Advantage planscan change their premiums, copayments, and deductibles, as well as their plans, from year to year. If you have a Medicare Advantage plan, confirm your cost sharing amounts for 2015 directly with your plan. Remember, your Medicare Advantage plan’s networks and list of covered drugs (formulary) may have changed in the new year as well. You should also confirm these changes with your plan. If you find that you are dissatisfied with any changes in your Medicare Advantage plan for 2015, you can use the Medicare Advantage Disenrollment Period (MADP) to switch to Original Medicare with a stand-alone Part D plan. Going from a Medicare Advantage plan to Original Medicare with a stand-alone Part D plan is the only change you can make during this time. Remember, the Medicare Advantage Disenrollment Period occurs each year from January 1 to February 14.

As with Medicare Advantage, make sure you understand any other changes to your Part D plan’s costs, pharmacy networks, and formulary. Contact your plan directly to get their information. If your plan changes its coverage of a drug you took in 2014, it must provide you with a 30-day transition supply of this medication during the first 90 days of 2015.

In 2015, your costs and coverage for your Part D plan may have changed. Medicare beneficiaries with Part D plans pay less in 2015 when they hit the coverage gap, also called the doughnut hole. In 2015, you enter the doughnut hole after your total drug costs reach $2,960. Once you are in the doughnut hole, you pay 45% of the cost for brand-name drugs, and 65% of the cost for generic drugs. You exit the doughnut hole and enter catastrophic coverage once you have spent $4,700 in out-of-pocket costs. Remember, the Affordable Care Act is closing the doughnut hole in Medicare Part D plans and ensures that beneficiaries pay no more than 25 percent of the costs of their prescription drugs throughout the year by 2020.

-Marci