Shopping for a Medicare plan for the first time? There are so many decisions to make, and they can be so confusing. Do you go with Original Medicare and add a prescription drug plan (Part D) and Medigap plan? What’s the difference between one Medicare Advantage plan and another? Should you get Part D (prescription) coverage now or later? This section helps explain how it all works so you have a better understanding of your options before you explore our plans to find the one that fits the way you live. Request A Quote
Annual Election Period – October 15th to December 7th
Initial Coverage Election Period – 65th birthday month + the 3 months prior and after
What is Medicare?
Medicare is a health insurance program introduced in 1965. It is administered by the United States government through the Centers for Medicare and Medicaid Services (CMS) and provides health insurance coverage to people who:
• Are age 65 and over
• Are under 65 with certain disabilities
• Have end-stage renal disease
• Meet other special criteria
Key Enrollment Dates
Initial Coverage Election Period (ICEP)
ICEP is when you first become eligible for Part B, and occurs on or around the time you turn 65. You may join:
• Three months prior to your birthday month
• During your birthday month
• Three months after your birthday month
Annual Enrollment Period (AEP)
During AEP you can change or drop a Medicare Advantage plan or Part D prescription drug plan.
• This period occurs during the fourth quarter of the year. For the upcoming year, it is from October 15 to December 7.
• You may take more than one election during this period, but the last one you choose during that period is the one that counts.
• Coverage changes are effective January 1.
Medicare Advantage Disenrollment Period (MADP)
This period allows beneficiaries to disenroll from their Medicare Advantage plan and return to original Medicare.
• This period is from January 1 to February 14.
• You cannot switch from one Medicare Advantage Plan to another or enroll in a Medicare Advantage plan during this period.
• If you move from a Medicare Advantage plan back to Original Medicare, you may enroll in a stand-alone Part D prescription drug plan during this time.
Special Enrollment Periods (SEP)
Special Enrollment Periods exist for beneficiaries with Medicare Advantage or Part D prescription drug plans who may lose coverage because of certain qualifying events. These beneficiaries can enroll outside of the AEP if they experience one of the following:
• A loss of group coverage.
• A move from the plan service area.
• Dual eligibility.
5-Star Special Enrollment Period (SEP)
CMS measures health plan quality on a scale of 1 to 5 stars to help you make an informed decision. You can switch to a 5-Star-rated plan under these guidelines:
• You can only switch once between Dec. 8–Nov. 30.
• Your current plan must be Original Medicare (with or without a Medigap plan), or a Medicare Advantage plan.
What is Part A?
Part A is inpatient hospital insurance and eligible individuals are automatically enrolled in Part A with no premium. Others apply to the program when they are eligible or pay a monthly premium if they have worked less than 40 quarters in their lifetime.
- Inpatient care in hospitals (includes critical access hospitals, inpatient rehabilitation facilities and long-term care hospitals)
- Skilled nursing facilities (not custodial or long-term care)
- Hospice care
- Home health care services
- Part A of Medicare does not cover non-skilled or custodial services including assistance in Activities of Daily Living (ADL), nor does it cover benefits that are covered under Part B of Medicare.
What is Part B?
Part B is outpatient/physician insurance. It’s voluntary, has a monthly premium, and is designed to cover doctor’s services, outpatient care, and some other services not covered by Part A. The monthly premium is either deducted from monthly Social Security or billed quarterly if not yet drawing on Social Security. Eligible individuals should be automatically enrolled in Part B when they elect Medicare, unless they choose to defer because they continue to work or have other coverage. If an individual does not enroll during that period he/she may pay a penalty when he/she does enroll.
A deductible and coinsurance apply when using Part B, and is limited to Medicare allowable charges.
Examples of Services Not Covered:
- Routine vision, alternative health care, routine hearing screening exams, routine chiropractic care, prescription drugs, first three pints of blood
- Chiropractic services (except to correct a subluxation using manipulation of the spine)
- Cosmetic surgery
- Custodial care
- Dental care (in most cases) and dentures
- Eye care (routine exam), eye refractions, and most eyeglasses
- Routine foot care (with a few exceptions)
- Health care while travelling outside the U.S., except in limited cases
- Hearing aids and exams for the purpose of fitting a hearing aid
- Hearing tests that haven’t been ordered by a doctor
- Long-term care
- Orthopedic shoes (with few exceptions)
- Prescription drugs (most outpatient drugs aren’t covered)
- Syringes or insulin, unless the insulin is used with an insulin pump
What is Part C?
Part C are Medicare Advantage plans offered through private companies and provide Part A and Part B Medicare coverage. They usually offer extra benefits such as vision, hearing, dental, and/or health and wellness programs and many include prescription drug coverage. Beneficiaries may have to see doctors in the plan’s provider network or go to certain hospitals to get services. If not, they may have to pay the entire cost of the service. Part C does not cover hospice care (still provided by Original Medicare).
Usually Covers/Offers
- No or minimal medical deductibles
- Simple copays for most covered services
- An out-of-pocket maximum
- Optional dental benefits
- Coverage for urgent or emergency care when travelling outside the U.S.
- Fitness benefits
- Chiropractic care
- Optional prescription drug coverage with mail-order services
- Vision and hearing benefits
Enrollment in Part C – Medicare Advantage Plans
In order to join a Medicare Advantage plan, beneficiaries must:
- Be entitled to Part A and enrolled in Part B (note: beneficiaries must continue to pay their Part B premium)
- Must maintain a permanent residence for six months or more in the service area of the Medicare Advantage plan
Beneficiaries may choose not to enroll in a Medicare Advantage drug plan, however penalties may apply for late enrollment. And enrollees may have to pay an extra monthly premium in addition to the monthly Part B premium (note: enrollees will still be responsible for the Part B premium).
What is Part D?
Part D is prescription drug coverage and was first offered in 2006. Plans are available through private companies that contract with Medicare to provide coverage. Each plan can vary in cost and drugs covered. If an individual does not enroll during a specific period he/she may pay a penalty when he/she does enroll—unless they have continuous creditable prescription drug coverage offered through another plan (e.g., employer or individual). Original Medicare alone does not cover the cost of prescription drugs.
Costs Associated with Part D Coverage
Part D is voluntary and is designed to provide prescription drug coverage with Medicare Part A and B coverage. Like Part B, there is a monthly premium, which can be automatically deducted from your Social Security benefits. And like many insurance plans, Part D plans have differing levels of coverage before and after an out-of-pocket expense limit is reached. Unlike most insurance plans, Part D has a “coverage gap” or “donut
hole”, which begins once you and your drug plan have spent a certain amount for covered drugs. Once the out-of-pocket limit is reached, the gap closes and prescription benefits begin again.
Enrollment in Part D
Anyone who has Part A and/or Part B and lives in a plan’s service area is eligible for Part D.
Individuals with limited income or resources may qualify for Extra Help, a Medicare program to help pay prescription drug program costs. For more information about Extra Help go to medicare.gov
People with Medicare (who do not already have prescription drug coverage through an employer or union, COBRA, or other means) can obtain prescription drug coverage by either:
- Joining a (stand alone) Medicare Part D prescription drug plan; or
- Joining a Medicare Advantage plan that includes Part D prescription drug coverage. Costs can be different for each plan, but all Medicare drug plans must provide at least the standard level of coverage set by Medicare.
Beneficiaries who don’t enroll in a Medicare prescription drug plan when they are first eligible may have to pay a late enrollment penalty to enroll in a plan later if they don’t maintain creditable coverage. Most people who wait until after the end of their Initial Enrollment Period (IEP) to join a plan will have their premiums go up 1 percent of the national base beneficiary premium for every month they waited to enroll. These individuals will usually have to pay this penalty as long as they have Medicare prescription drug coverage.
Before selecting a Medicare Part D plan, you should determine if the prescription drugs you currently take are on their formulary, and what the costs are. You can visit www.medicare.gov to compare Medicare Part D prescription drug plans.
Medicare Supplemental Plans
These health insurance plans are sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover. There are 10 standard Medicare supplement health care policies – plan A thru N. With companies offering the same standardized insurance plans, your Medicare supplement choice comes down to price and a company’s service, reputation and experience with Medicare supplement insurance policies. You can also add prescription drug coverage by purchasing a Medicare Prescription Drug Plan.
Regence BlueShield Medicare Supplemental
Premera Blue Cross Medicare Supplemental
