Medicare gets a checkup

Written by Chris Gerbasi

New Advantage plan enrollment period and more care options are part of 2019 changes.

When Mary Richichi enrolled in  Medicare for the first time last fall, her top priority was keeping her doctors. Mary had successful surgery for a brain tumor, and she and her husband, John, travel to Orlando for her follow-up care.

“I want to find out what is best for me,” says Mary, of Fruitland Park. “I need to be able to stay with my doctors. It’s very important because I trust my doctors.”

John has been enrolled in Medicare for two years and he’s satisfied with his coverage. But he acknowledged the couple was “totally lost” in finding the right plan for Mary.

Fortunately, they chose to get a consultation at Leesburg Public Library with a representative from SHINE, or Serving Health Insurance Needs of Elders. SHINE is a program within the state Department of Elder Affairs, and volunteers provide free, unbiased information—not recommendations—to seniors.

Education about Medicare is especially important this year as a host of legislative changes have been made for 2019, and more are expected in 2020. Some changes will alter premiums, deductibles, and co-payments slightly depending on an enrollee’s chosen plan. But overall, the changes are expected to lower out-of-pocket drug costs and allow insurers to offer more options for care, according to the Centers for Medicare & Medicaid Services (CMS).

While the open enrollment period for Medicare ended in December, a new enrollment period for Medicare Advantage plans has been added for 2019.

Medicare consists of four parts. Parts A and B, known as original Medicare, provide government insurance. Part A covers hospital, rehabilitation, and hospice costs; Part B covers doctor visits, lab tests, screenings, and outpatient services. Supplemental plans are private insurance that helps pay out-of-pocket costs for people with Parts A and B.

Part C, or Medicare Advantage, is private insurance for comprehensive health coverage in a network of providers. Part D is private insurance covering outpatient prescription drugs. 

During the new enrollment period, Jan. 1-March 31, participants can “test drive” a Medicare Advantage plan for three months and then change to another Advantage plan or an original Medicare plan if they choose. Participants can make only one change during this period.

Among the other changes:

Doughnut hole: The Part D “doughnut hole” will shrink for brand-name drugs in 2019 and for generic drugs in 2020. The doughnut hole refers to a gap in coverage. Once enrollees’ out-of-pocket spending reached a certain level, the plan covered less and patients paid more until a second threshold was reached, and then plans paid more and patients paid less. Now, participants still will need to pay a portion of their drug costs, but less than before. After the total cost for drugs reaches $3,820, they’ll pay up to 25 percent of the cost of brand-name drugs and 37 percent of the cost of generics until they spend $5,100. Then they will pay whichever is higher: 5 percent of the drug cost or $8.35 for brand-name drugs and $3.35 for generics.

Lifestyle needs:Medicare Advantage plans added options for insurers to cover needs such as home-delivered meals; transportation to doctors’ offices; home safety features like wheelchair ramps, stair rails, and grab bars; home health aides; and home-based hospice care.

Insurers are not required to offer these options but likely will as about 600 new Medicare Advantage plans have flooded the market, according to CMS.

“Medicare Advantage plans are becoming very competitive,” says Robert Whitaker, an insurance agent in Lady Lake who has 30 years of experience with Medicare plans. “They’re able to add those (options), like transportation. In-home help is something that’s never been offered before.”

Therapy:Congress repealed a cap limiting coverage on outpatient physical, speech, and occupational therapy, so original Medicare participants have the opportunity for more benefits, Robert says. 

Diabetes: For people with prediabetes who have Part B coverage and meet other criteria, Medicare covers a program for health behavior changes that can sometimes delay or prevent type 2 diabetes. For people with diabetes, Medicare will pay for devices that deliver continuous insulin based on individual settings, and devices that allow patients to use smartphones to continuously monitor blood-sugar levels.

Whether participants are looking for Medicare Advantage plans during the new enrollment period or looking ahead to next fall’s enrollment, they can get help at medicare.gov, Robert says. The site’s “coverage wizard” allows people to compare multiple plans side by side.

SHINE also conducts consultations throughout the year at about a dozen sites in Lake and Sumter counties. (For times and details, visit floridashine.org.)

John DeMarse, a SHINE volunteer and Villages resident, says Medicare enrollees have plenty of opportunities in this area to shop around for plans based on their needs.

“It’s important that people make a good, informed decision when they start Medicare, so they’re comfortable with what they have,” John says.

Sources: Medicare & You 2019 guidebook, cms.gov, medicare.gov, AARP

About the author

Chris Gerbasi

Chris Gerbasi has been a journalist for more than 30 years, writing and copy editing for newspapers and magazines throughout Michigan and Florida, and covering everything from city hall to spring training.

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