Fall Season Means It’s Time to Tune Up Your Medicare Coverage

A person holds pharmaceutical tablets and capsules in this picture illustration taken in Ljubljana Sept. 18, 2013. (Reuters/Srdjan Zivulovic)

CHICAGO—If you are not happy with your Medicare coverage, now is the time to make a change.

The annual Medicare fall enrollment period for 2019 begins Oct. 15 and runs through Dec. 7. This is the time to make changes to your basic coverage and your prescription drug insurance. Fall enrollment presents an opportunity to save money—but more importantly, the chance to make sure your insurance coverage provides the best match of health care providers.

The basic choice is between traditional fee-for-service Medicare and a Medicare Advantage plan, the all-in-one managed-care alternative offered by private insurance companies. Advantage plans usually include prescription-drug coverage, and cap out-of-pocket expenses.

Advantage can save you money in some instances, but the trade-off is being tied to a narrower network of health care providers. Traditional Medicare still provides the widest, most flexible access to providers. Seniors who choose traditional Medicare usually add a standalone Part D drug plan; many also add a Medigap supplemental policy.

Even if you like your current coverage, it can pay to take a careful look. The design of your prescription-drug plan coverage can change annually, and Advantage plans can make changes to their networks of health care providers at any time.

The shopping process should begin with a review of a letter that arrives each autumn from your Medicare prescription drug or Advantage plan provider. Called the Annual Notice of Change (ANOC), this letter details any changes in rules for cost-sharing, coverage of specific medications—and even whether a specific drug will be covered.

“The ANOC gives the simplest overview of what is changing in the plan you currently have for next year,” said Casey Schwarz, senior counsel, education and federal policy at the Medicare Rights Center.

Pay careful attention to the network of providers in your current plan for the coming year—pharmacy-delivery options in the case of stand-alone drug plans, and health care providers if you have an Advantage plan. Also read carefully the so-called formulary, which describes the rules for coverage of a medication, including whether any quantity limits are imposed, or if the red tape of “prior authorization” will be invoked.

New in Medicare Advantage

Advantage plans provide all-in-one coverage of hospitalization and outpatient services, sometimes for the same monthly premium you pay for traditional Medicare ($134 this year). Most plans offer extra benefits such as dental and vision coverage; many also wrap in prescription drugs. Just over half of plans (55 percent) will charge a supplemental premium for those extras, averaging $34 next year, according to the Kaiser Family Foundation (KFF).

For next year, the Centers for Medicare & Medicaid Services (CMS) have given insurers the option to add new services, such as adult daycare and home-based palliative care or home health aids. Equipment that helps frail seniors stay in their homes also can be covered, including grab bars and stair rails.

But few plans will offer the expanded services for 2019, since CMS just announced the new rules in April, according to Gretchen Jacobson, associate director of the KFF Medicare program.

“Plan providers didn’t have much time this year to incorporate these new services,” she said. “We could see more plans offering them in 2020.” (None of the new benefits will be available to enrollees in traditional fee-for-service Medicare.)

Another change this year: Enrollees in Medicare Advantage will have an expanded “do-over” opportunity. A new Advantage open enrollment and dis-enrollment will run from Jan. 1 through March 31. During this period, you can switch between Advantage plans or switch to traditional Medicare. (Previously, it was possible only to disenroll from an Advantage plan.)

Prescription-Drug Plans

The average Medicare prescription-drug plan premium is projected to remain stable in 2019 at about $32.50 per month, down from $33.50 in 2018, according to the Medicare Rights Center. But premiums for specific plans can fluctuate widely from year to year, so pay attention to whatever rate is announced in your ANOC.

If you have expensive prescriptions, you will benefit from the continued shrinking of the notorious “doughnut hole”—the gap in plan coverage that begins when combined spending by you and your insurer reaches a certain amount. In 2019, you enter the gap when your own spending, including discounts by any drug manufacturer, hits $3,820; you exit when spending reaches $5,100.

The gap has been closing gradually due to changes in federal law. Next year, the gap is closed completely for brand-name drugs, which means that enrollees will pay Part D’s standard 25 percent cost-sharing fees. The gap continues for one more year for generic drugs, with cost-sharing of 37 percent.

Shopping Resources

Medicare Plan Finder: Use Medicare’s official plan shopping site (https://bit.ly/2IDFHEJ) to identify good-fit plans. Plug in your Medicare number and drugs (you will need each drug’s name and dosage), and the plan finder then displays a list of plans that match your needs, including their estimated total cost (premiums and out-of-pocket expenses); which drugs are covered; and customer-satisfaction ratings. The finder also will give you advice about drug utilization and restrictions.

Medicare & You: CMS mails out this free handbook in late September; it contains plenty of useful information about Medicare coverage and programs. If you haven’t received it, call 1-800-Medicare to get a copy, or download it (https://bit.ly/2NYP1su).

State Health Insurance Assistance Programs (SHIPs): Each state has a federally funded SHIP that provides free counseling on coverage options. Click here to find your local SHIP: (bit.ly/1OU0sfN). The Medicare Rights Center also offers free counseling by phone [phone]).

By Mark Miller