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Marci’s Medicare Answers

November 2013

 

Dear Marci,

I want to make changes to my Medicare coverage during Fall Open Enrollment. What is the difference between Original Medicare and a Medicare Advantage plan? 

—Lyndsay 

Dear Lyndsay,

That’s a great question to ask, particularly during Fall Open Enrollment. If you have Medicare, you can receive your Medicare benefits through either Original Medicare or a Medicare Advantage plan.

Original Medicare is the traditional Medicare program administered directly through the federal government. Original Medicare consists of Part A (hospital insurance) and Part B (medical insurance). If you have Original Medicare, you can get Medicare prescription drug coverage by signing up for a stand-alone Part D plan. Listed below are some important things to know about Original Medicare.

Original Medicare:

  • Lets you see any doctor in the country, as long as the doctor accepts Medicare.
  • Does not require you to get a referral from your primary care doctor before seeing other doctors or specialists.
  • Pays 80 percent of the cost of most outpatient medical services you receive. You are generally responsible for paying the remaining 20 percent coinsurance.
  • Does not cover certain services such as vision, dental and hearing care.

On the other hand, Medicare Advantage plans generally offer hospital, medical and prescription drug coverage under one private insurance plan. These plans must offer at least the same benefits as Original Medicare; however, each plan may have different costs and rules. Listed below are some important things you need to know about Medicare Advantage plans.

Medicare Advantage plans:

  • Typically require you to see a doctor or health care provider who is in the plan’s network.
  • May require you to get a referral from your primary care doctor before seeing other doctors or specialists.
  • May have different costs and rules, depending on the plan.
  • May cover limited health care services that Original Medicare does not cover.
  • Must have a maximum limit on out-of-pocket costs, meaning that once you spend a certain amount for covered health care services out of your own pocket, you pay little to nothing for services thereafter.

Keep in mind that knowing the difference between Original Medicare and Medicare Advantage plans is especially important during Fall Open Enrollment. Fall Open Enrollment occurs each year from October 15 to December 7. During this time, people with Medicare can make changes to their Medicare coverage with their new coverage taking effect January 1 of the following year. Outside of this time, people with Medicare generally cannot make changes to their Medicare coverage unless certain circumstances qualify them for a Special Enrollment Period. If you want to switch from a Medicare Advantage plan to Original Medicare or vice versa during Fall Open Enrollment, it’s best to call 800-MEDICARE to make this change in order to avoid enrollment errors.

—Marci

Dear Marci,

I received a notice in the mail that said my Medicare Advantage plan would not be offered in 2014. I do not qualify for any assistance programs. What are my options?

—Jason

Dear Jason,

If your Medicare Advantage plan is ending on December 31, 2013 and you do not qualify for any assistance programs that may entitle you to a Special Enrollment Period, you need to make decisions about your Medicare coverage before the end of the year. If your plan will not be available in 2014, your plan should send you a notice informing you of this change by October 2, 2013. This notice may also include a list of other Medicare Advantage plans in your area. Remember, you can get your Medicare benefits either through Original Medicare, the traditional Medicare program administered directly through the federal government, or a Medicare Advantage plan, also known as a Medicare private health plan.

If you want to join another Medicare Advantage plan, you can sign up for a new plan at any time between October 15, 2013 and February 28, 2014. You can learn about the different plans offered in your area by going online and visiting www.medicare.gov or by calling 800-MEDICARE. Keep in mind that it’s best to sign up for a new plan by December 31, 2013, so you can get plan coverage beginning January 1 of the following year. If you wait until January or February to enroll, your coverage will start the first of the month after you enroll. You will have Original Medicare with no drug coverage until your Medicare Advantage plan coverage starts.

Keep in mind that if you decide to have Original Medicare in 2014, you will most likely need to sign up for a Medicare Part D plan. While you have until February 28, 2014 to sign up for a Part D plan, you should sign up before December 31, 2013 so that you can get drug coverage beginning January 1, 2014. If you wait until January or February to enroll into a Part D plan, your coverage may not begin until the first of the month following the month of enrollment.

—Marci

Dear Marci,

I received a tan notice in the mail that said I would need to pay a Part D plan premium in 2014 unless I join a plan with a cheaper Part D premium. What does this notice mean?

—Ben

Dear Ben,

This tan notice is sent out to people who have Extra Help, the federal assistance program that helps people with Medicare pay their prescription drug costs. You will receive this particular notice if you were awarded the Extra Help benefit and you chose your own Medicare prescription drug plan (Part D plan) in the past.

This notice tells you that your Part D plan premium is increasing above the Part D regional benchmark amount. If you have Extra Help, you will not have to pay your plan’s premiums, as long as they are below the yearly determined regional benchmark amount. If you get this notice, you can do one of two things:

  • You can keep your plan and pay for some of your Part D plan premium in 2014; or
  • You can switch to a Part D plan that has a premium below the regional Part D benchmark amount.

In order to pay $0 premiums for your Part D coverage in 2014, you can look for other Part D plans in your area by calling 800-MEDICARE or by going online and using the Plan Finder tool at www.medicare.gov. Keep in mind that it’s best to make this change in early December, so that you will not have to pay any premiums to have Part D coverage in 2014.

—Marci

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Marci’s Medicare Answers is a service of the Medicare Rights Center (www.medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare. To subscribe to “Dear Marci,” MRC’s free educational e-newsletter, click here.

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Last Modified: 09/19/2013 14:08:42
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