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Boomers, seniors need to review their Medicare health and drug coverage during Fall Open Enrollment

Everyone with Medicare who is enrolled in a private health or drug plan should review their choices during the Fall Open Enrollment Period, the Medicare Rights Center, a consumer service organization, recommends.

MRC_1502Even people who are currently satisfied with their plan should examine it, because plans change benefit packages every year. Those enrolled in Original Medicare can also decide at this time to switch to a private plan.

The Fall Open Enrollment Period runs from Oct. 15 through Dec. 7. During this time, Medicare beneficiaries can make changes to their health and drug coverage options without restriction. They have the right to make as many changes as they need, and the last change they make by December 7 will go into effect on Jan. 1.

“Medicare beneficiaries need to be aware of any changes to their current plan and carefully review all of their options in time to make a decision by Dec. 7,” said Joe Baker, president of the Medicare Rights Center. “While reviewing your options, it is important that you contact the plan to confirm any information you find. Once you have made your decision, you can enroll in the plan by calling 800-MEDICARE.”

Everyone with a Medicare Advantage plan, also known as a Medicare private health plan, or Medicare drug plan should have received their Annual Notice of Change by Sept. 30. The notice lists the changes in the plan, such as the premium and copays, and compares the benefits in 2014 with those in 2013.

Medicare health coverage

The Medicare Rights Center urges people to consider the following questions before enrolling in a Medicare Advantage plan:

  • Will I be able to use my doctors? Are they in the plan’s network and are they taking new patients who have this plan?
  • Have my doctors’ experiences with this plan been positive? What problems have my doctors seen with patients in this plan?
  • Which specialists, hospitals, home health agencies, and skilled nursing facilities are in the plan’s network?
  • Who can I choose as my primary care physician?
  • How much is my monthly premium?
  • How much will it cost to see my primary care physician? A specialist?
  • Do I need a referral to see a specialist?
  • Are my prescription drugs on the plan’s list of covered drugs?
  • Does the plan require that I get “prior authorization” before my prescription will be covered, or impose other restrictions, such as limiting the quantity or requiring that I try a cheaper medication before it will cover a more expensive one?
  • How much will I have to pay out of pocket before coverage starts?
  • How much will I pay for brand-name drugs? How much for generic drugs?
  • What service area does the plan cover?
  • What kind of coverage do I have if I travel outside of the service area? 

Use the Medicare Plan Finder tool at www.medicare.gov or call 800-MEDICARE to review your options and get details.

For a list that includes these and more questions to ask, go to Medicare Interactive

People with Medicare who are unsatisfied with the Medicare Advantage plan they chose are able to switch to Original Medicare and a stand-alone prescription drug plan during the Medicare Advantage Disenrollment Period or MADP, which Jan. 1 to Feb. 14.

They’ll also have the right to add a Part D prescription drug plan during the MADP. They won’t, however, be able to switch from one Medicare Advantage plan to another. People with Original Medicare won’t be allowed to make changes during the MADP.

People with Medicare will also have a Special Enrollment Period or SEP to enroll in a Medicare Advantage or Part D plan with a five-star rating. The SEP can be used at any time during the year, but only once per year, and to make only one change.

Learn more about the new SEP on page 3 of Fall Open Enrollment Period: A Resource for Journalists

Although people who are unsatisfied with their Medicare Advantage plan will have a chance to switch to Original Medicare during the MADP, they may not be able to get a Medigap plan to fill the gaps in coverage, or their Medigap choices may be limited. This is another reason that Medicare Rights urges beneficiaries to ask questions before making their health coverage choices during the Fall Open Enrollment Period. 

Medicare prescription drug coverage

Medicare beneficiaries who have a Part D prescription drug plan should not only find out if a plan covers their drugs, but also pay particular attention to coverage restrictions, such as quantity limits, prior authorization, and step therapy, trying lower-cost medications first.

To choose the Part D Plan – either a stand-alone drug plan or a drug plan that is part of a Medicare Advantage plan – that best meets your needs, first:

  • Make a list of the medicines you take, the dosages, and how much you currently pay.
  • Make a list of pharmacies you use regularly.

Second, decide what type of drug plan you need. If you have:

  • Original Medicare: Choose a stand-alone prescription drug plan or PDP if you want to continue to receive your other health benefits through Original Medicare.
  • A Medicare Advantage plan, such as an HMO or preferred provider organization: Generally, you must get Part D drug coverage as part of your Medicare Advantage plan’s benefits package.

Third, use the Medicare Plan Finder tool at www.medicare.gov or call 800-MEDICARE to review your options and get details.

Fourth, ask questions, such as:

  • Does the plan cover all the medications I am taking?
  • If the plan doesn’t cover a medication I take, does it cover one that will work for me? Ask your doctor.
  • Does the plan require that I get special permission before it will cover the medication I need, such as prior authorization or step therapy?
  • How much will I pay at the pharmacy – copayments or coinsurance – for each drug I need? Be aware that certain drugs may cost a lot even if they’re covered.
  • How much will I pay in monthly premiums and annual deductible?

The Medicare Rights Center recommends that beneficiaries call the plan to confirm the information they find, and keep a record of the conversation with the plan representative. It also recommends enrolling in a plan by calling 800-MEDICARE rather than the plan itself.

For more detailed information about the Fall Open Enrollment Period, see www.medicarerights.org/pdf/2013-fall-open-enrollment-resource-for-journalists.pdf

For more detailed information about the Fall Open Enrollment Period, see www.medicarerights.org/pdf/2013-fall-open-enrollment-resource-for-journalists.pdf

For a list that includes these and more questions to ask, go to Medicare Interactive.

Copyright 2013, Rita R. Robison, Consumer Specialist


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Tom Sightings

Good post. I just signed up for Medicare, and it seems like a great program. But boy, oh boy, is it complicated!


Hi Tom,

Yes, Medicare is complicated. But you're a good researcher as well as a great writer. I'm sure you compared plans carefully.


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