The world of Medicare can be a confusing place to navigate and can be difficult for those who are beginning their journey with Medicare coverage. eternalHealth is here to inform and empower you on your health care decisions and make your healthcare journey as easy as possible. We broke down Medicare into the different options you need to consider as you decide on the best coverage for you, and how to begin the process of enrollment! Start your journey on becoming a Medicare expert today!
What is Medicare?
Medicare, frequently referred to as Original Medicare, is a federal government health insurance program implemented in 1965 that plays an important role in managing medical costs as you get older. Typically, Medicare is for anyone 65 or older, but those younger than 65 may also qualify with certain disabilities, or for those with End Stage Renal Disease or ALS. Original Medicare is broken down into four parts:
Part A– Covers hospital care and inpatient related services such as inpatient hospital stays, surgery recovery costs, rehabilitation, hospice care, and skilled nursing care facilities.
Part B– Covers doctors’ appointments and other outpatient medical services such as ambulance services, clinical laboratory services, vaccinations, health screenings, and preventive services.
Part C– Covers Part A and B, but is offered by private insurance companies, often with extra benefits.
Part D– Covers prescription drug costs
It is important to note that while Original Medicare is a comprehensive program, there may be instances where Medicare does not offer enough coverage, and supplemental plans, called Medigap plans, will need to be added at an additional cost.
You Have Options
You may have noticed above that Part C, or Medicare Advantage, offers everything Original Medicare does (Part A and B), but with some added benefits. Private insurance companies will offer Medicare Advantage plans as another option to Original Medicare, and often have robust benefits that go above and beyond Original Medicare. These benefits can include benefits like vision, hearing, dental, and prescription drug coverage. eternalHealth curated four different Medicare Advantage plans with benefits that save you money and fit your lifestyle such as unlimited transportation to and from medical appointments and the pharmacy, quarterly healthy grocery* and over the counter allowances, in-home support, and a robust fitness benefit all at no extra cost to you. We even have a Give Back plan that puts $65 back into your social security check every month, which can go a long way especially during these uncertain times of inflation and rising costs of living.
Things To Consider When Deciding Which Plan Is Right For You
With all the options available between Original Medicare and Medicare Advantage, an already confusing process can become even more overwhelming. Luckily, there are a few things to consider when deciding which coverage plan would work best for you. One of the most important things to consider when choosing a plan is staying with your primary care provider or choosing a new one. Typically, with Original Medicare, you will be able to choose any doctor that accepts Medicare. With Medicare Advantage, you may have to determine whether your doctor is in network with the plan, or if you are willing to go to a new doctor that accepts your Medicare Advantage plan.
Next, it is important to consider cost when you are deciding on a plan. Original Medicare typically has $0 monthly premium for part A, but a $164.90 monthly premium for Part B. Many Medicare Advantage plans also offer $0 premiums, so the only premium cost you will be responsible for is your Part B premium, which you must be enrolled in, along with Part A, to qualify for a Medicare Advantage Plan. Additionally, with Original Medicare, there is no limit to out of pocket costs (unless you purchase additional supplemental coverage).
Medicare Advantage plans, on the other hand, have a yearly limit on how much you will spend in out-of-pocket expenses. Meaning, once you hit a certain limit, you will pay nothing out of pocket for the rest of the year. For example, with a Medicare Advantage plan through eternalHealth, you could have a yearly out of pocket maximum as low as $4,500 per year, with a $0 premium. This limit through Medicare Advantage plans acts as tool to protect you from unexpected, and sometimes catastrophic medical costs that can occur without warning.
Another important aspect when choosing between Original Medicare and a Medicare Advantage plan is prescription drug coverage. It is important to ensure that the prescriptions vital to your health are covered by whichever plan you enroll in. With Original Medicare, if you want prescription drug coverage, you will need to enroll in a Part D prescription drug plan which is on average an extra $33.37 on top of your Medicare coverage. Another consideration to consider when deciding on a coverage plan is the Medicare Part D “Donut Hole”. The “Donut Hole” is a coverage gap that occurs after you reach a total of $4,660 in total drug costs in 2023. Once this limit is reached, you will be responsible for 25% of the drug costs until you reach an out-of-pocket maximum of $7,400 in 2023. Medicare Advantage plans, on the other hand, will typically have a prescription drug benefit built right into the plan, often with $0 copays for Tier 1 and Tier 2 drugs. Coordination of care is also one of the most important aspects you can look for in a plan, and it is often overlooked. Coordination of care involves organizing patient care in a way that makes sharing information easily available to all participants involved in a patients care. This ensures the needs and preferences of the patients are known ahead of time and can lead to a safe and effective treatment plan. With an eternalHealth Medicare Advantage plan, we work to engage our team with all of our members’ care team, including doctors, nurses, and other healthcare professionals to improve the quality of healthcare our members receive.
How To Enroll
After taking the time and deciding whether to enroll in Original Medicare or a Medicare Advantage plan, you may be asking yourself, how do I enroll? There are a few different ways to enroll into Medicare, and each one has specific dates that you will need to keep in mind. Firstly, if you are receiving Social Security benefits when you turn 65, you will be automatically enrolled into Medicare (although you will need to actively enroll in Part D if you choose to do so). If you are not receiving Social Security Benefits when you turn 65, you will need to take action to enroll yourself into Medicare, either through the Social Security Administration website, or in person at one of their offices. This is when you must pay attention to specific dates. The Medicare Enrollment periods consist of:
Initial Enrollment Period– The initial enrollment period will be unique to you and is focused around your 65th birthday. This period will last for 7 months around your 65th birthday, and includes three months before your birthday, your birthday month, and three months after your birthday. If you miss signing up for Medicare during this time, you will need to wait for the general enrollment period, and may face late enrollment penalties
General Enrollment Period– Also called the Open Enrollment Period, The Medicare General Enrollment Period runs from January 1st to March 31st. During this time, you could enroll in a Medicare plan if you missed enrolling within your initial enrollment period. Additionally, if you are enrolled in a Medicare Advantage plan, the Open Enrollment Period is the time where you can enroll into a different Medicare Advantage plan or switch into Original Medicare. Note: you can only switch plans once during this period.
Medicare Advantage Annual Enrollment Period– if you decide to enroll in a Medicare Advantage plan (Part C), you will want to do so between October 15 to December 7 (Note: You must have enrolled in Medicare Parts A and B to be eligible for a Medicare Advantage plan. You can sign up for coverage here). During this period, you can add, drop, or change your Medicare Advantage plan if you decide to do so. You will also have another opportunity to make changes to your Medicare Advantage plan during the Open Enrollment period which runs from January 1st to March 31st
Special Enrollment Period- You have the opportunity to make changes to your Original Medicare or Medicare Advantage plan when certain events occur during your life. Some of these events can include losing an employee sponsored health plan, moving to a place not included in your plans service area, or Medicare terminates your plans contract.
It is important to note that prior to these enrollment periods, if you are previously enrolled in a plan, to review the Annual Notice of Change (ANOC) and the Evidence of Coverage (EOC) to ensure that your plan will continue to meet your healthcare needs for the following year. The ANOC notices will be mailed in late September and the EOC will be on the Plan’s website by October 15 of every year, so be sure to review them and confirm your plan will continue to give you the coverage you need.
Avoid Late Enrollment Penalties- It is important to set reminders for the date listed above, as late enrollment penalties can add up if you miss these dates. These fees increase the longer you wait to sign up and are added to your monthly premium costs. This means this penalty is not a one-time fee and are usually charged for the amount of time you have that coverage (for most people, it is a lifetime penalty). See below for a summary of Medicare Late Enrollment Penalties.
- Part A- While most people qualify for premium-free Part A, some may have to buy it. If you have to buy Part A coverage and are late to enroll, your monthly premium may go up as much as 10%, and you will have to pay for twice the number of years you didn’t sign up. Example: If you were eligible for two years but did not sign up, you will have to pay the Part A enrollment penalty for 4 years.
- Part B- Typically, you will not pay a Part B penalty if you qualify for a Special Enrollment Period, but if you do not qualify, you will pay an extra 10% for each year you could have signed up for Part B but didn’t. Example: If you waited two full years to sign up for Part B and did not qualify for a Special Enrollment Period, you will pay a 20% late enrollment penalty (or 10% for each full 12-month period that you could have signed up, but did not, in addition to the standard Part B monthly premium.
- Part D– Generally, you will not have to pay a Part D penalty if you have creditable drug coverage (like coverage from a current or former employer, the VA, or individual health insurance coverage) or if you qualify for Extra Help. If you do not fall under these two factors, you will pay a 1% penalty if you don’t join a Medicare drug plan when you first enroll into Medicare or go 63 days or more without creditable drug coverage. Example: If you waited 15 months after you were eligible to join Medicare to join a Part D plan, and you did not have creditable drug coverage, you will pay a 15% late enrollment penalty in addition to the Part D monthly premium.
Choosing a Medicare plan can be a difficult process, but with some careful planning, you can ensure that you will receive the best coverage possible that fits your needs. Assessing your needs, researching different plans, ensuring your doctors are in network, and considering coordination and continuum of care are great first steps to becoming well-versed in the coverage you deserve to live your best life!
To learn more about eternalHealth’s Medicare Advantage plans and speak to licensed agent, visit eternalHealth.com or call 1 (800) 831-9218 (TTY 711).
eternalHealth is an HMO plan with a Medicare Contract for HMO and PPO offerings. Enrollment in eternalHealth depends on contract renewal.
*The benefits mentioned are a part of a special supplemental program for the chronically ill. Not all members qualify