Get Medicare Health Plan Options

We can help you get products such as Medicare Supplement Insurance (Medigap), Medicare Advantage and Medicare Part D prescription drug plans by referring you to health insurance companies in your area.

Medigap Supplemental Plans

What is Medicare Supplement?
Need help paying your Medicare deductibles, copayments and coinsurance? A Medigap insurance policy (also called Medigap supplemental insurance or Medicare supplemental plans) helps pay the "gap" between what Original Medicare (Medicare Parts A and B) pays for your health care and what you pay out of your own pocket.

You can get a Medicare supplemental plan only if you have Original Medicare. Medigap covers Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). It does not cover Medicare Part C (Medicare Advantage Plans), Medicare Part D (prescription drug plans) or any other private health insurance, Medicaid, Veterans' Administration benefits, or TRICARE.

You can get a Medicare supplement through private insurance companies. The Medigap policy must be clearly identified as "Medicare supplement insurance." There are 10 different Medigap coverage options to choose from. Plans are labeled A, B, C, D, F, G, K, L, M and N to signify the plan differences. Plans E, H, I and J are no longer available.

Because Medigap policies are regulated by state and Federal laws, all benefits for all options are the same regardless of insurer. The differences will be in the price, who administers the plan, and which of the ten options the insurer chooses to offer. You may want to choose a health insurer that you already feel comfortable with. Or you can shop around for the best prices.

Open enrollment for Medicare supplemental plans Your open enrollment for Medigap supplemental insurance begins the first month you are covered under Medicare Part B. You have six months to enroll. If you are under 65, check with your state's Social Security Administration to see if they offer additional open enrollment periods.

As long as you enroll during this six-month open enrollment period, the insurance company cannot refuse to sell you a Medigap policy, charge you more because you have health problems, or make you wait for coverage to begin. You may, however, have to wait up to six months for coverage of a pre-existing condition. That means, if you have a specific health problem when you enroll, you may have to wait up to six months to be covered for medical services associated with that health problem. Original Medicare will still cover that health problem even if your Medicare supplement plan doesn't cover your out-of-pocket costs.

If you do not enroll in a Medicare supplemental plan during your open enrollment period, then the private insurance company may "underwrite" the plan. That means you may be subject to a physical, and the insurance company can either refuse to sell you the plan or they can adjust your premium based on your health status.

If you enroll in a Medicare Advantage Plan, you should cancel your Medigap policy. However, if you later return to Original Medicare (Parts A and B), you have a twelve-month special enrollment period to sign up for a Medigap supplemental plan.

How insurance companies set Medigap premiums There are three ways an insurance company can set Medigap premium rates:

• "Community-rated" (or "no-age-rated") premiums are the same for everyone, regardless of age.
• "Issue-age-rated" (or "entry-age-rated") premiums are based on your age when you first buy the policy. The sooner you enroll, the less you will pay.
• "Attained-age-rated" premiums are based on your current age, meaning it goes up as you grow older.

Other factors impacting the premium rates can include inflation, geography and medical underwriting (if you did not enroll when first eligible) and other discounts. You should check with each specific health insurer to see how it sets Medigap prices before you buy.

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Medicare Part C – Medicare Advantage Plans

What is Medicare Part C?
If you qualify for or already have Original Medicare, you can choose to instead enroll in a Medicare Advantage Plan from a qualified private health insurance company. You would never need all three. You also have no need for a Medigap policy if you enroll in a Medicare Advantage Plan.

A Medicare Advantage Plan generally covers everything that Original Medicare covers, but with some differences. Those differences can be in how much you pay out of your own pocket when you receive health care. For example, you might have lower copays or a smaller deductible, or you might pay a different percent share of the bill (coinsurance).

All Medicare Part C coverage includes emergency and urgent care. Some plans may even include routine vision, routine dental and/or wellness programs. Most include prescription drug coverage under Medicare Part D. Medicare Part C coverage does not include hospice care; that benefit remains with Original Medicare even if you have a Medicare Advantage Plan.

Types of Medicare Advantage (Part C) Plans
It's important to review the differences between the types of plans to see which works best for you. There are several different types of Medicare Advantage Plans:

• HMO (Health Maintenance Organization Plan) - allows you to see doctors and other health professionals that participate in its network. If your doctor is already in that network, it could be a good option because you tend to pay less out of your own pocket with network doctors.
• PPO (Preferred Provider Organization Plan) - gives you the freedom to choose any doctor, which can work for you if you prefer that kind of flexibility.
• PFFS (Private Fee-for-Service Plan) - pays a specific amount for health care services and the treating doctor has to accept that amount, even if it is less than his or her usual charge. If the doctor does not agree to those terms, then Medicare will not cover services through that doctor.
• SNP (Special Needs Plans) - is especially for people who have - as its name implies - special needs. That includes (but is not limited to) those living in a nursing home, Medicaid-eligible individuals, and people with chronic diseases or disabling conditions, like diabetes, ESRD or HIV/AIDS. This type of plan always includes prescription drug coverage while other types of plans may or may not.
• POS (Point of Service Plan) - covers both in- and out-of-network health services, but at different rates. You pay less out of pocket when you go to in-network doctors, labs, hospitals and other health care providers.
• MSA (Medical Savings Account Plan) - includes both a high deductible and a bank account to help you pay that deductible. The amount deposited into the account varies from plan to plan. The money is tax free as long as you use it on IRS-qualified medical expenses, which includes the health plan's deductible.

Eligibility for Medicare Part C
Medicare Part C eligibility is based on your membership in or eligibility for Medicare Parts A and B (except if you have End Stage Renal Disease (ESRD)). Generally, if you have Medicare Parts A and B, you are eligible for Medicare Part C. However, you must live in the service area for the Medicare Advantage Plan that you're considering. The service areas may be more limited than Original Medicare.

If you have other health insurance coverage, for example through an employer or union, find out their rules before you enroll in a Medicare Advantage Plan. You may lose your other coverage if you enroll in the Medicare Advantage Plan. But that's not a hard and fast rule. It's best to talk it over with the other plan's benefits administrator. If you drop the other plan, you might not be able to get it back if you change your mind later.

Enrollment in Medicare Part C
Medicare Part C enrollment processes differ depending on which private insurer you chose. But the enrollment periods are the same everywhere. You can enroll in a Medicare Advantage Plan (Part C) when you first become eligible for Medicare. It's a seven-month period that starts three months before your 65th birthday through four months after your birthday. If you are under age 65 and you receive Social Security disability, you qualify in the 25th month after you begin receiving your Social Security benefits.

If you are already enrolled in Original Medicare, then you must wait until the next enrollment period to sign up for Medicare Advantage. The annual enrollment period is October 15 through December 7 Coverage begins on January 1 of the new year.

If, after enrolling in a Medicare Advantage Plan, you change your mind, you can switch back to Original Medicare from January 1 through February 14 each year. If you would be losing prescription coverage as a result of the switch, you can also sign up for Medicare Part D during this time.

Generally, once you enroll, you stay enrolled until the next annual election period becomes available. However, there are some situations that might qualify you to make a change during the rest of the year. An example of the situations include(this is not an all inclusive list):

• You move outside your Medicare Advantage Plan's service area
• You qualify for Extra Help (a program to help you afford prescription drugs)
• If you move into an institution (such as a nursing home)

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Medicare Part D Prescription Drug Coverage

What is Medicare Part D?
Medicare Part D prescription drug coverage, often referred to as Part D, is available to anyone who is also eligible for Original Medicare. You have to get Medicare Part D through a private insurance company that is contracted with Medicare to offer these plans. Different insurers offer different types of plans, so your cost for the plan (premium) and your out-of-pocket expenses for prescription drugs (copayments, coinsurance and deductible) will vary. You'll have to shop around to decide which plan is best for you.

Part D coverage typically works like this:

1. You pay a monthly premium to be covered under the plan

2. If the plan has a deductible, you pay the full amount of your prescription drug purchases until the deductible is met.

3. After you satisfy the deductible, you will pay a share of the costs according to your specific plan. That could include a flat amount (copayment) or a percentage of the total amount (coinsurance). You typically pay this amount directly to the pharmacist at the time of purchase.

4. After your Part D coverage has paid a certain amount for prescription drugs, you may have to pay all costs yourself up to a yearly limit. This is sometimes called a "coverage gap" or "donut hole." Read your Medicare prescription drug plan documents carefully to see if this applies to your plan. Not all plans have a coverage gap, and there are ways to help you fill this hole. See "Filling the donut hole" below for more about that.

5. Once you have paid $4,700 (in 2012) out of your own pocket for prescription drugs, you automatically get "catastrophic coverage." This means for the rest of that particular year, you would only pay a small copayment or coinsurance amount for prescription drugs.

Note that Medicare Part D coverage may differ from plan to plan. Some drugs (for example brand-name drugs vs. generic drugs) are covered at different levels. Each insurance company determines what drug is covered at which levels. The insurer will publish a prescription drug "formulary" that lists this information.

Who can get Medicare Part D coverage? Everyone who is eligible for Original Medicare can get a Medicare prescription drug plan. You must live in the service area for the particular plan that you are considering and continue to pay your Part B premium, if applicable.

When to enroll in a Medicare Part D plan Enroll in a Medicare prescription drug plan as soon as you are eligible. Be sure to enroll early so you have your ID card as soon as your coverage begins. If you don't join a Medicare Part D plan when you are first eligible, you may have to pay a late enrollment penalty when you do join. The penalty is waived if you qualify for and get "Extra Help" for low income individuals.

Your initial enrollment begins three months before you turn 65 years old and continues for seven months. After your initial enrollment, general enrollment occurs during the Annual Enrollment Period (AEP). In 2011 (for 2012 plans), this period will begin October 15 and last through Dec 7.

Do not let your prescription drug coverage lapse for 63 days or more. If you do, you may have to pay the penalty. You don't need prior prescription drug coverage to get Medicare Part D if you enroll when first eligible. But once you enroll in Medicare Part D, you must continue to have some form of "creditable" prescription drug coverage without a lapse.

Creditable coverage means you could have a prescription drug plan through any of the following:

• An employer or union group
• TRICARE
• Indian Health Services
• Department of Veterans Affairs
• A private health insurer

Medigap policies and discount drug cards are not considered creditable coverage.

When you leave a creditable prescription drug plan, you should receive a letter or certificate showing the dates of your coverage. Keep this letter somewhere safe because you may need to prove that you did not have a lapse in coverage later.

How to get Medicare Part D coverage If you have Original Medicare and want to keep it, you can get a Medicare prescription drug Plan (PDP) through a private insurer. This can be through a Medicare insurance agent or through an employer or union group.

If you have a Medicare Advantage Plan (Part C) or are considering this option, review the plan to see if it includes prescription drug coverage. If not, you may want to determine if you would like to obtain another coverage option that provides for both medical and prescription drug coverage.

Getting "Extra Help" for Medicare prescription drug plans Generally for 2012, if you earn less than $16,335 (single) or $22,065 (married with no other dependents) you may qualify for the Medicare prescription drug low-income subsidy. Check the rules in your state as these amounts may be different for you. There are also restrictions on other cash resources, such as how much you have in checking or savings.

The Extra Help program helps you pay your monthly Medicare prescription drug plan premium and your out-of-pocket costs, such as copayments, coinsurance and deductibles. There is also no coverage gap or late payment penalties for those who qualify.

Some people automatically qualify for Extra Help. For example, if you have full Medicaid coverage, get help from your state Medicaid program for your Medicare Part B premium, or if you get Supplementary Security Income benefits. If you automatically qualify, you will receive a letter from Medicare and will not have to apply.

Filling the donut hole The recent federal Health Care Reform legislation will reduce the doughnut hole gap over several years to make prescription drugs even more affordable. If you reach the coverage gap in 2011, you may get a 50% discount on brand-name prescription drugs when you buy them. There will be additional savings in the coverage gap each year through 2020, when the donut hole is closed completely. Medicare is planning other ways to fill the coverage gap in future years, so watch for other news about this. For more information, see "Bridging the Coverage Gap," available at http://go.usa.gov/loF or by calling 1-800-MEDICARE (1-800-633-4227), TTY users should call 1-877-486-2048.

Be sure to talk to your doctor to see if you are taking the lowest cost medications available to you.

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