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Mysteries of Medicare

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1. What is Medicare's Annual Open Enrollment Period?

You will receive mailings about your current plan

You will receive, or have already received, a notice called an Annual Notice of Change (ANOC) from your Medicare Advantage Plan or your Medicare Part D Prescription Drug Plan.  This notice is intended to make you aware of any changes for your plan starting January 1, 2023.  These changes can include increases or decreases in monthly premium and co-pay costs, formulary changes in drugs covered, tier levels and pharmacy network.     If you have not received this ANOC by September 30, call your plan and request it.  Do not assume that what you selected for 2022 will remain the same and do not assume that it will be the best option for you in 2023.

You may switch your Medicare plans during the AOEP

You have received your ANOC, with plan information, because Medicare gives beneficiaries a chance to review and change Medicare Advantage Plans and Part D Prescription Drug Plans during the Annual Open Enrollment Period (AOEP).  The AOEP is from October 15^th - December 7^th.  Comparison can be done using the Medicare website, www.medicare.gov, under the option “Find Health and Drug Plans.”  This site has information on all available plans.  If, after your review, you find a plan with a better fit for your needs, you can change plans and enroll online.  Your new plan would be effective January 1, 2023.

Medicare beneficiaries who have access to a computer would benefit from setting up a Medicare account on the Medicare.gov website.   This account with a username, password and security question will allow you to add your drugs once and then add new drugs, change doses or remove drugs no longer needed. The comparison of plans becomes quicker and easier.  

The Medicare account can also give you information about processed claims from your providers should you have any concerns.

Retiree coverage from a former employer may have different dates and different instructions for making changes

If you have retiree coverage from a former employer, you will also be provided with benefit and cost information for the next year, including instructions for making changes to your coverage.   Retiree Option Selection Period and Federal Open Season are terms meaning the same as Annual Open Enrollment Period, but may have different rules and dates for making changes.  Even with a retiree plan, you will receive an ANOC by September 30.   The ANOC must state that your retiree prescription coverage is "creditable", meaning that it is as good as, or better than, the Medicare Part D Plans.  This is an important letter, so keep it with your plan information.

Other important mailings you may receive during AOEP

Other mailings that you may receive during the AOEP could include information regarding "Extra Help" (Part D assistance for qualifying beneficiaries), Medicare Part B and Medicare Part D "Income-Related Medicare Adjustment Amount" (IRMAA), PACE/PACENET, and a new "Medicare and You" handbook.  If you receive forms to be completed that will continue your benefits, complete them promptly and return them so that your help does not end due to failure to respond.

Plans that are NOT affected by the AOEP

Medicare Supplement Plans, also known as Medigap Plans, are not affected by the AOEP.  You would probably be subject to medical underwriting for changes to one of these plans if you are not in a "guarantee issue" period.   However, beneficiaries with a Medigap Plan may have a Part D Prescription Plan that needs to be reviewed annually during AOEP.

How can you get help navigating these options?

If you are wondering how you can understand your mailings, evaluate your coverage, enroll in new plans or apply for assistance programs, PA MEDI counselors can help with any of those tasks.  PA MEDI counseling is free, unbiased, personal, informative and confidential.  The counseling sessions are by appointment and most occur at area Senior Centers and libraries.  To schedule an appointment at a senior center, call the center directly.  To schedule at another location, call 610-344-5234 (after September 15^th), and leave a message.  A volunteer will pick up the message and return the call within one business day.  The volunteer can give you dates and times of available appointments.  You can also call and leave a message on our Help Line at 610-344-5004, option 2, requesting information on Open Enrollment Events.  

During AOEP counselors are still available to schedule appointments with beneficiaries who are becoming eligible for Medicare.  PA MEDI counselors can help you with your Medicare enrollment and give you information on all the options that go with Medicare.

2. How and when do I enroll in Medicare?

This newsletter will provide information on enrolling in Medicare, with detailed instructions for completing an enrollment during a Special Enrollment Period (SEP).  You are automatically enrolled in Medicare Parts A and B at age 65 if you begin getting benefits from Social Security or Railroad Retirement Board before your 65^th birthday; or you have reached the 25^th month of being deemed disabled.    Otherwise, you must facilitate your own enrollment.  You have the choice to enroll in Medicare when you have an End Stage Renal Disease diagnosis. 

For most people, the first opportunity to enroll in Medicare Parts A and B would be when you turn 65 years of age. This would be your Initial Enrollment Period (IEP).  Your IEP begins three months before the month when you turn 65, and continues through the month when you turn 65, and three months after the month when you turn 65.   It is a seven-month window allowing you to enroll without penalty.  If you enroll in Medicare during the first three months of your IEP, your coverage will be effective the first of the month when you turn 65.  If you enroll in any of your other IEP months, coverage will begin the first of the following month.  You will pay no premium for Part A if you or your spouse paid Medicare taxes for 40 quarters, or more.  Part B will have a monthly premium. Apply online at www.ssa.gov/medicare/sign-up or by calling Social Security at 1-800-772-1213.

If you will have continued coverage past your IEP by your, or your spouse’s Employer Group Health Plan (EGHP), with more than 20 employees, based on active employment, you can delay enrollment in Medicare because the EGHP will continue to be your primary coverage. However, if you are eligible for “free” Part A, it would be to your advantage to enroll in Part A during your IEP.  Since Part B has a premium, you may want to delay this enrollment until your, or your spouse’s employment ends.  Your EGHP will be your primary coverage, with Medicare Part A secondary.  If the EGHP has fewer than 20 employees, Medicare will be your primary coverage and the EGHP will be secondary.  In this case, you should not delay Medicare enrollment; you need both parts of Medicare to be fully covered. The end of the EGHP triggers an eight-month Special Enrollment Period (SEP) to enroll in Medicare.  Enrollment at this time, adding Part B, is easier if you enrolled in Part A during your IEP.

If you already have a Medicare card with an effective date for Medicare Part A, the process for online enrollment in Medicare Part B has recently been simplified by the Social Security Administration.  You need two forms for Part B enrollment.  At the bottom of the ssa.gov home page, click on the word “Forms”.  This is a listing of all the forms available from SSA.   You will need to find form CMS 40B (which is fifth on the list) and CMS L564 (sixth on the list).  If you wish to enroll online, download CMS L564 and save it in your document file.    This form is used to verify your continuous employment and must be completed by your employer.  Send form CMS L564 electronically to your employer to be completed by the HR department and returned to you electronically.  Save it in your document file.  Once you have done this, the form will be ready to upload into your online Part B application when you get to that part of the application.   The form CMS 40B is already embedded in the online application.   You will complete the information on form CMS 40B.  Here are step-by-step instructions for online and manual enrollment.  

Online enrollment for Medicare Part B:

• Go to www.ssa.gov/medicare/sign-up  
• Click on “Sign up for Part B only”
• Click on "Start application”
• Once the application is on your screen, click “continue”
• Work through the application which begins with form CMS 40B and progresses to the point where you must upload some type of employment verification.  The uploaded form CMS L564 will be that verification.  If, for some reason, you are not able to provide CMS L564, the form instructions list other accepted types of employment verification.
• In section A7 be sure to enter when you want Part B to begin

Enrolling in Medicare Part B Manually 

• Go to www.ssa.gov Homepage
• Locate and print Forms CMS 40B and CMS L564
• Complete CMS 40B yourself, indicating in the “remarks” section, when you want Part B to begin    
• Ask your employer to complete CMS L564 to verify your continuous employment
• When both forms are completed, mail or fax them to your local SSA office (remembering to keep a copy of the forms and get a receipt at the post office if you mail them).  It may be possible to personally deliver them to the local SSA office if the office is open to the public.
• If West Chester SSA office is your local office, the mailing address is:

            1101 West Chester Pike, West Chester, PA 19382

            Fax #:  1-833-787-1782

• If you are doing applications for you and your spouse, make sure you each have these forms and send each spouse’s documents separately

Once you receive a new Medicare card with effective dates for Part A and Part B indicated on the card, you can enroll in a Medicare Advantage Plan or a Medigap.  If you choose Original Medicare, alone, or with a Medigap, prescription coverage is delivered by a stand-alone Part D Plan.  If you choose a Medicare Advantage Plan, it should include prescription coverage, unless you have other creditable coverage, such as VA, retiree, or PACE prescription coverage.  You have two months from the end of your EGHP to add prescription coverage without incurring a penalty and a delay in the start of coverage. Enrollment in a Part D plan can be facilitated when one, or both parts of Medicare are effective.  The Part D plans can become effective the first of the month after you apply.  

If you do not enroll during your IEP and you do not qualify for an SEP, you will have to wait for the Annual General Enrollment Period (GEP) from January 1 – March 31.  This enrollment will be completed by phone with SSA.  You may have to pay a penalty for delayed enrollment.

Some of these rules will be different if you do not qualify for free Part A.  A PA MEDI counselor can explain these situations to you.

Contact PA MEDI to talk to a counselor if you need more information on either of these enrollment periods, or if you have other Medicare-related questions.  PA MEDI is Pennsylvania’s program of free insurance consultation under the auspices of the Department of Aging.    Call our Helpline 610-344-5004, Option 2, and leave a message; or send an email to [email protected].  

 

3. How does Medicare work with employer based insurance?

If you are covered by a group health plan (GHP) at the company where you or your spouse are actively employed at the time you become eligible for Medicare, it is important to understand how Medicare and employer-based insurance plans share costs. 

For those becoming eligible for Medicare because of age, if your GHP coverage is through a company with 20 or more employees, that plan is your primary insurer until you (or your spouse if the source of your coverage) retire or otherwise lose coverage. This means that you do not need to sign up for Medicare until the GHP coverage ends, at which time you will have a Special Enrollment Period when you can enroll in Medicare, a Medigap or Medicare Advantage plan, and Part D (prescription) plan. However, if your coverage comes through a company with fewer than 20 employees, your GHP is usually secondary to Medicare. You must have a primary insurer to be assured of coverage, so if this is your situation, it is important to enroll in Medicare when you turn 65. If you become eligible for Medicare because of disability, the only difference is that if the company has 100 or more employees, the GHP coverage is primary, under 100 employees, it is secondary. Always confirm the type of coverage you have with your employer. To find out more, contact a PA MEDI counselor by calling your local senior center to set up an 

4. Am I covered by Medicare if my spouse or I is employed?

If you are covered by a group health plan with 20 or more employees, that plan is your primary insurer until you (or your spouse if the source of your coverage) retire or otherwise lose coverage. This means that you do not need to sign up for Medicare until the group health plan coverage ends, at which time you will have a special enrollment period when you can enroll in Medicare, a Medigap or Medicare Advantage plan, and Part D (prescription) plan. However, if your coverage comes through a company with fewer than 20 employees, your group health plan is usually secondary to Medicare. You must have a primary insurer to be assured of coverage, so if this is your situation, it is important to enroll in Medicare when you turn 65. If you become eligible for Medicare because of disability, the only difference is that if the company has 100 or more employees, the group health plan coverage is primary, under 100 employees, it is secondary. Always confirm the type of coverage you have with your employer. 

5. When can I switch my Medicare plan?

In September each year, you will receive a notice called an Annual Notice of Change (ANOC) from your Medicare Advantage Plan or your Medicare Part D Prescription Drug Plan. This notice is intended to make you aware of any changes for your plan starting January 1. These changes can include increases or decreases in monthly premium and copay costs, formulary changes in drugs covered, tier levels and pharmacy network. If you have not received this ANOC by September 30, call your plan and request it. Do not assume that what you selected for the current year will remain the same and do not assume that it will be the best option for you in the following year. 

Medicare gives beneficiaries a chance to review and change Medicare Advantage Plans and Part D Prescription Drug Plans during the Annual Open Enrollment Period (AOEP). The AOEP is from October 15th - December 7th . Comparison can be done using the Medicare website, medicare.gov, under the option “Find Health and Drug Plans.” This site has information on all available plans.If, after your review, you find a plan with a better fit for your needs, you can change plans and enroll online. Your new plan would be effective January 1 of the next year.

Medicare beneficiaries who have access to a computer would benefit from setting up a Medicare account on the medicare.gov website. This account will allow you to add your drugs once and then add new drugs, change doses or remove drugs no longer needed. The comparison of plans becomes quicker and easier. The Medicare account can also give you information about processed claims from your providers.

Retiree coverage from a former employer may have different dates and different instructions for making changes
If you have retiree coverage from a former employer, you will also be provided with benefit and cost information for the next year, including instructions for making changes to your coverage. Retiree Option Selection Period and Federal Open Season are terms meaning the same as Annual Open Enrollment Period, but may have different rules and dates for making changes. Even with a retiree plan, you will receive an ANOC by September 30. The ANOC must state that your retiree prescription coverage is "creditable", meaning that it is as good as, or better than, the Medicare Part D Plans. This is an important letter, so keep it with your plan information. 

Other important mailings you may receive during AOEP 
Other mailings that you may receive during the AOEP could include information regarding "Extra Help" (Part D assistance for qualifying beneficiaries), Medicare Part B and Medicare Part D "Income-Related Medicare Adjustment Amount" (IRMAA), PACE/PACENET, and a new "Medicare and You" handbook. If you receive forms to be completed that will continue your benefits, complete them promptly and return them so that your help does not end due to failure to respond. 

Plans that are NOT affected by the AOEP
Medicare Supplement Plans, also known as Medigap Plans, are not affected by the AOEP. You would probably be subject to medical underwriting for changes to one of these plans if you are not in a "guarantee issue" period. However, beneficiaries with a Medigap Plan may have a Part D Prescription Plan that needs to be reviewed annually during AOEP. 

6. Does Medicare Cover COVID-19 Costs?

Original Medicare

• Lab tests for COVID-19 are covered at no cost if ordered by a health care provider. Note that free over-the-counter test kits are no longer covered by Medicare but are available for purchase.
• Treatment for patients exposed to COVID-19 are covered but there may be copays and deductibles.
• COVID-19 vaccines (no out-of-pocket expenses)
• All hospitalizations and related services that are medically necessary. Those with Original Medicare could have deductible and/or copay charges unless they also have a Medicare supplement or Medigap policy that covers these charges.

Medicare Advantage Plans may include additional benefits; however, there may also be additional cost sharing. Check with your MAPD plan about coverage and costs.

7. Do I need Medicare Part D?

Medicare Part D is prescription drug coverage that is offered to everyone with Medicare. The purpose of Part D is to help you pay for prescriptions. Premiums, copays, and drugs coverage vary from plan to plan, but all must meet basic requirements set out by Medicare. Drug coverage is generally built into Medicare Advantage plans. There are also plans without the medical component.

I don’t take any drugs, or only inexpensive drugs. Why should I pay for a plan?
Two reasons: 

1. Your situation may change and you may need to start taking prescription drugs or need more expensive drugs. Most people can only sign up for a plan when they first get Medicare Parts A and B, or during annual ernrollment, from October 15 to December 7 each year. So, if your doctor wants you to go on a new medication in January, you may not be able to get any coverage until the end of the year.
2. There is a penalty if you don’t join a plan when first eligible. That penalty is 1% of the “national base beneficiary premium” for each full month when you were eligible but did not have creditable coverage. This penalty sticks with you as long as you have Part D, and will change when the base premium changes.

How can I avoid the penalty and the risk of not having coverage when I need it?

1. Get coverage during your initial enrollment period, which starts the third month before the month of your 65th birthday and ends the third month after your birth month.
2. If you have employer or union-based coverage, you have a special enrollment period of two months after that coverage ends.
3. Don’t go more than 63 days without a Part D plan or other creditable coverage. Examples of creditable coverage include retiree plans from a former employer or union, Pennsylvania’s PACE program for seniors with low incomes, and VA drug coverage. If you have one of these and lose it, you have 2 months to get a new plan without penalty. 
4. If you qualify for assistance through Extra Help or Medicaid, you can join a drug plan without penalty at any time

8. Does Medicare cover vaccines?

As of January 1, 2023, co-payments or deductibles for any of the vaccinations recommended by ACIP (Advisory Committee on Immunization Practices) were eliminated for those with Medicare Part D. This is a significant change, because vaccines covered under Medicare Part B have been handled differently than those under Part D.

Part B vaccines have had and will continue to have no out-of-pocket costs for Medicare beneficiaries. These include influenza vaccine, COVID-19 vaccines, vaccines for pneumococcal infections, and, for people at risk of contracting the disease, Hepatitis B shots.

Part D-covered vaccines, on the other hand, have generally had copayments or deductible costs that had to be paid by the insured. Now, those vaccines will also be available at no charge when prescribed. This category includes Tdap (tetanus, diphtheria and pertussis), and Shingrix (for prevention of shingles). In addition, those with special risk factors are eligible for no cost vaccination  against Hepatitis A, varicella, meningococcal A, C, Y; meningococcal B, and haemophilus influenzae type b.

9. What if one or more of my drugs is no longer covered by my Medicare drug plan?

During the last Medicare Annual Open Enrollment Period (AOEP), you might have made changes to your Medicare Prescription Drug Plan (Part D) or your Medicare Advantage Plan (Part C) without realizing that one of your drugs was not covered. If a drug you are taking is no longer covered because Part D plan changed its formulary or if you changed to a new plan that does not cover the drug, you may need a transition fill. This gives you time to switch to another drug that is in the formulary or to request a formulary exception. Plans are required to provide a one-time "transition fill" (up to a 30-day supply) within the first 90 days after your plan or its formulary changes. Transition fills also apply if your plan covers the drug but quantity limits or prior authorization prevent you from getting the prescription filled. If you are eligible for a transition fill, the pharmacy will fill your prescription and will receive an electronic notice from your plan that this is a transition fill. In some cases, the pharmacist may need to call the drug plan to get permission to dispense the drug. You will receive a letter from the plan that includes instructions on how to find an appropriate substitute, how to file an exception request or how to manage quantity limits. If you have a problem getting a transition fill, your first step should be to contact your drug plan. 

10. What happens if you lose your Employer Group Health Plan when you are eligible for Medicare?

Some people choose to work past their age of eligibility for Medicare. As long as you have coverage with an employer group health plan (EGHP) larger than 20 employees through you or your spouse’s employment, you do not need to enroll in Medicare when you turn 65. Many people in this situation enroll in Medicare Part A and defer Part B until the EGHP ends.

What happens if you suddenly lose your job and employer medical benefits?

Even though your Medicare special enrollment period continues for eight months after losing your EGHP, enrolling in both parts of Medicare should be the first item on your immediate action plan. The enrollment period for enrolling in a new prescription drug plan is only 63 days and is dependent on having at least one part of Medicare. You need both parts of Medicare to complete your coverage with either a Medigap plan or a Medicare Advantage Plan.

Medicare enrollment is facilitated by the Social Security Administration. If you are just adding Part B, Social Security has recently created a special portal on ssa.gov to allow for online Part B enrollment. On the website, look for the “Medicare Enrollment” window and then scroll down to “Apply Online for Medicare Part B During a Special Enrollment Period.” Medicare coverage begins the first of the month after you enroll, unless you specify a different date.

You can also submit your enrollment request during this SEP by doing one of the following:

1. Fax your forms CMS-40B and CMS-L 564 and documentation of EGHP to 1- 833-914- 2016. Forms are available on the SSA website under “Forms”. Send a cover letter with the forms and keep copies of everything.

2. Mail forms CMS-40B and CMS-L564 and documentation of EGHP to your SSA local field office

11. What's new for 2023?

• The Cost of Living Adjustment (COLA) for Social Security is 8.7%.  
• Part B premium is $164.90 per month and the yearly deductible is $226.
• The Part D drug deductible will range from $0-$505 depending on the plan you choose. 
• Income Related Medicare Adjustment Amounts (IRMAA) for high-income households-more than $97,000 for individuals and $194,000 for couples- have also changed.  IRMAA applies in addition to the standard Medicare premiums for Part B and/or Part D.

Discussions of offering coverage for dental, vision and hearing to those with Original Medicare continue but no decisions have been made in this year’s budget talks, so coverage if approved may come in later years.

For those in Medicare Advantage plans the maximum out-of-pocket (MOOP) limit for 2023 is $8300.  Note that this maximum is only for Part A and Part B deductible and co-pays.  Part D drug costs are not included. Studies have shown that even with MOOP and a $0 premium, Advantage plans can end up costing more than Original Medicare and a supplemental insurance policy.  So be sure to read and understand the coverage being offered and the costs to you.

PA MEDI counselors are trained and available to provide FREE, personalized, unbiased counseling.   If you have questions about your current Medicare coverage or are new to Medicare, counselors are available to help you.  Please call your local senior center to schedule an appointment or leave a message on  our Helpline 610-344-5004 to talk to a counselor. Calls will be answered in 24 hours.

12. When are the Medicare General Enrollment Period and the Medicare Advantage Open Enrollment Period?

There are 2 enrollment periods that run concurrently from January 1 through March 31: 

General Enrollment Period (GEP)
The GEP is primarily used by those who did not sign up for Part B during their Initial enrollment period and who do not have a special enrollment period. It also applies to those who must pay a premium for Part A and who did not sign up when first eligible for Medicare. This is the only time of year these individuals can enroll in Medicare. Coverage will start the month after enrollment. Also, they may have to pay a late enrollment penalty that lasts as long as they have Medicare (Part B) or twice as many years as they weren’t covered (Part A).

Medicare Advantage Open Enrollment Period (MAOEP) 
The MAOEP can be used only by those already enrolled in a Medicare Advantage Plan to: 

1. Change to a different Medicare Advantage Plan with or without drug coverage, or 
2. Drop their Medicare Advantage plan and return to original Medicare and enroll in a Prescription Drug Plan (PDP). 

Those with a Medicare Advantage Plan and a stand-alone prescription drug plan can drop the Medicare Advantage plan but cannot change the prescription drug plan. Those with Original Medicare with or without a Medigap plan or stand-alone prescription drug plan cannot use this enrollment period to change or join a prescription drug plan or join a Medicare Advantage Plan. Changes made during the MAOEP will go into effect the first day of the following month.

Before dropping a Medicare Advantage Plan, individuals should consider how they will handle the costs associated with Original Medicare, such as deductibles, coinsurances and copayments. The MAOEP does not include the right to purchase a Medicare Supplemental Insurance (Medigap) policy with guaranteed issue. This means that an insurance company may or may not accept an applicant with underlying medical conditions. It always pays to investigate this option before dropping a Medicare Advantage Plan.  

13. How do I avoid Medicare scams?

Things to remember:

• Medicare does not randomly call beneficiaries. If you called at a busy time, you may be asked for a call-back number.
• Medicare does not sell products or services.
• Scammers are frequently able to “spoof” a phone number so that it looks like someone you know.
• Do not give anyone you do not know your Medicare or credit/debit card number.
• If you are not comfortable with the person or request being made, you can always ask for a number to call the person back. If the call is a scam, the caller will usually hang up.
• Always review your quarterly Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) to determine that all services billed are for items and providers you recognize. It is advisable to save these documents for at least a year. If you have Original Medicare and a MyMedicare account, you can go online to review your claims history

14. What are 5-Star plans and when can I enroll?

Beneficiaries eligible for Medicare can take advantage of a special enrollment period if there is a plan in your service area that has been awarded a rating of five stars. To make this change, Medicare beneficiaries must currently be enrolled in one of the following:

• Prescription Drug Plan (PDP)
• Medicare Advantage Prescription Drug (MAPD) Plan
• Medicare Advantage (MA) Plan with no drug coverage
• Not enrolled in any plan

If there is more than one five-star plan in your service area, it's possible to switch from one of these plans to another. This special enrollment opportunity can be used once between December 8th and November 30th. Enrollment changes are effective the first day of the month following the month you submit your enrollment request.

There are risks involved in making this change. The key is that you understand the benefits of the plan that you currently have, and the benefits of the five-star plan that you may be considering. Consideration must also be given to any network changes, formulary changes and benefits of the new plan chosen. It is possible to lose your prescription drug coverage if you unintentionally join a five-star Medicare Advantage Plan that does not include prescription drug coverage. In this case, you would have to wait until the next Open Enrollment Period (October 15 - Dece mber 7) to join a drug plan. The new plan would be effective January 1st. You might have to pay a late enrollment penalty for being without Part D drug coverage.

The star ratings of Medicare plans are awarded to plans based on member satisfaction surveys and health care provider comments. The rating system for Medicare Advantage Plans uses five key criteria in their assessment. These criteria help evaluate member access to preventive services; how often members receive treatment for long-term health conditions; overall satisfaction; number and type of complaints against the plan; quality of customer service. The ratings range from 1 to 5 stars, with 5 stars considered excellent. Medicare updates these ratings annually. The ratings can change from year to year.

If the Centers for Medicare and Medicaid Services notifies you that your current PDP or MAPD has failed to achieve at least a 3-star rating for three years straight, you may switch to any 4- or 5-star plan. The switch can be made any time during the year following notification and at any time the following year. This switch must go through 1-800-MEDICARE. 

Medigap plans are not included in the five-star Medicare rating system. These plans are rated, but with different criteria, mostly dealing with financial stability; and by different agencies. There are several independent rating agencies, such as, A.M Best Company and Standard and Poor’s Insurance Rating Services. These rating agencies use letter grades to indicate a company’s financial stability. The letters A++ or A+ show a superior financial rating for the company. 

15. How can I get help paying for Medicare Part B and Part D?

If you have monthly income below $3,460 if married, or below $2,790 if single, you may be eligible for one or more of the following programs that help pay for Part D (prescription drug) coverage and in some cases Part B (medical) coverage:

• Low-Income Subsidy (LIS), also known as Extra Help, reduces the cost of prescription drug coverage by reducing or eliminating Part D plan premiums, deductibles, and copays. It also eliminates the “donut hole.”  Apply for Part D Extra Help
• The Medicare Savings Program (MSP) pays the Medicare Part B premium, and applicants in the lowest income and resource categories also get help with Part A and Part B deductibles and copays. Those eligible for any level of MSP are also automatically enrolled in LIS.  Application for Payment of Medicare Premiums, Coinsurance and Deductibles
• LIS and MSP have resource as well as income limits. For Pennsylvania residents with low income, but with resources too high to qualify for LIS or MSP, the PACE/PACENET program helps pay prescription drug costs. This program has a very broad formulary, low copays, and no donut hole.  PACE/PACENET Brochure and Application
• Certain low-income individuals covered by Medicare are eligible for a program called Low Income Subsidy (LIS), also known as Extra Help. LIS provides assistance paying for Medicare prescription drug plans (Part D) premiums and co-pays. To qualify for LIS, individuals must be covered by a Part D plan or Medicare Advantage plan with drug coverage. There may be a gap in time between a person being granted LIS coverage and the time when Part D coverage takes effect. To assist with drug costs during this gap, the LI NET (Low Income Newly Eligible Transition) program provides temporary drug coverage that lasts about 2 months. Note that if you do not enroll in a Part D plan, you will be auto-enrolled by Medicare. LI NET pays for all drugs covered under Part D and can be used at any pharmacy. Once your Part D plan becomes effective, LI NET will be discontinued and only those drugs that are in your plan's formulary will be covered.

  
  If you are covered by LI NET, you will receive a welcome letter from Medicare or Social Security including the effective date for your coverage, a membership card, and instructions. If you need a prescription, take all this information to the pharmacy. The pharmacist will know how to process the claim for coverage. Your level of assistance will determine co-pays. If you incurred out of pocket expenses on covered drugs while eligible for LI NET, you can apply for reimbursement.

16. What are the different parts of Medicare?

PA MEDI is Pennsylvania’s statewide program of Medicare counseling under the auspices of the Chester County Department of Aging in Chester County. This newsletter from the PA MEDI program will help you understand what each of the parts of Medicare provides. The four parts of Medicare are:

Part A (hospital insurance) helps pay for medically necessary inpatient hospital care, inpatient care in a skilled nursing facility, home health care and hospice care. The Part A premium is free

if you have worked ten years (40 quarters) and paid your FICA (Medicare) taxes. 

Part B (medical insurance) helps pay for medically necessary doctors’ services, outpatient services and other medical services and supplies that are not covered by Part A. There is a monthly premium for Part B.

Medicare Part C, also known as Medicare Advantage, covers all Medicare Part A and Part B services and may offer other services such as vision and dental assistance. Most Part C plans include prescription drugs. Premiums for Part C vary and most plans have co-pays when you receive medical services.

Medicare Part D offers prescription drug coverage for those not enrolling in a Medicare Advantage Plan. There is a monthly premium for Part D. 

17. How do I update my contact information if I'm moving?

One to two months before the move make sure that you update Social Security and your insurance carrier. If you are receiving any level of assistance from your state, such as Medicaid, notify the appropriate agency in your home area. 

The quickest way to change your address for Social Security and Medicare accounts is to go to ssa.gov. If you have a MySocialSecurity account, you can make the change through that account. If you don’t have one, it is easy to open one. Alternatively, you can call 1-800-772-1213 Monday-Friday 7am to 7pm or visit your local office. If you receive benefits through Railroad Retirement, call the Railroad Retirement Board at 1-877-772-5772 Monday-Friday 9am to 3:30pm. 

If you have a Medigap plan (officially called a Medicare Supplement), contact them to see how to change your address. You can usually keep that plan, even if moving out of state. However, your premiums may change; ask about this when speaking to the insurer. There are two exceptions to being able to keep your plan: 1) if moving in or out of Massachusetts, Wisconsin, or Minnesota, all of which have different Supplements than the other states, and 2) if you have a Medicare SELECT plan. These use hospital networks, thus limiting their service areas. They are not sold in Pennsylvania. If losing coverage for either of these reasons, you have a guaranteed issue right to buy certain Medigaps within about 2 months of your move. If you can keep your current plan, but find that the premiums at your new address will increase significantly, you may want to shop for a new Medigap. In this situation you have no guaranteed issue rights, which means you may be turned down if you have certain pre-existing conditions. Consult the State Health Insurance Assistance program (SHIP) in your new state (PA MEDI in Pennsylvania) for more details. 

Part D (Prescription Drug) plans have coverage areas. Check with your plan to see if it will still cover you in your new home. If not, you will have a Special Enrollment Period (SEP) to get a new plan that starts one month before your move and lasts 2 months after. To assure seamless coverage, pick a new plan the month ahead of your move. A SHIP counselor can help you. 

Similarly, Part C plans (Medicare Advantage) have coverage areas. Your current plan can tell you if you will be covered at the new address. If not, you can switch to a new plan or go back to Original Medicare. The SEP for getting a new Medicare Advantage plan is the same as that for Part D plans described above. Should you choose Original Medicare, you will have a guaranteed issue period to obtain certain Medigap plans without health questions, and an SEP to enroll in a Part D plan.

If you are receiving any level of assistance from your state, the appropriate agencies must be notified of your move. For Medicaid in Pa., call the Consumer Service Center for Health Care Coverage at 1-866-550-4355 or your County Assistance Office (The Chester Co. number is 610-466-1000.) Pennsylvania residents who have PACE or PACENet can call 800-225-7223. Since these programs are funded by the state, you will lose this coverage if you move to a different state and have to reapply. Note that the Extra Help program is federal, so it will follow you based on your change of address with Social Security.

18. Can I change my Medicare Advantage or Medicare Prescription Drug Plan anytime?

You can make changes to these plans when certain events happen in your life, such as moving or losing other insurance coverage. When these, or other changes occur outside the Medicare Annual Open Enrollment Period (AOEP), you are given a Special Enrollment Period (SEP). This newsletter will address the SEP that you have when you are eligible for Low-Income Subsidy (LIS) or Pennsylvania’s PACE or PACENET programs. 

Low-Income Subsidy is also called Extra Help which is a federal program that helps to pay out-of-pocket costs of Medicare prescription drug coverage. Eligibility for the program is based on income and certain available assets. Depending on your income and assets, you may qualify for either full or partial Extra Help. People eligible for any level of Medicaid automatically receive Extra Help.

When you are eligible for either level of Extra Help, you qualify for more than one Special Enrollment Period (SEP) in a calendar year. Medicare beneficiaries typically have a chance in the fall during

Annual Open Enrollment Period to make changes with Medicare plans that will become effective January 1 of the following year. Extra Help eligibility allows for a SEP each quarter during the first nine months of the calendar year. If you make a change, it will become effective the first of the following month. To make another change, you will need to wait for the next quarter. PACE or PACENET eligibility allows for one SEP during the calendar year.

You may wish to make a change if your preferred pharmacy is out-of-network for your current plan. Other reasons for making a change could include your plan’s formulary change mid-year, your medications may change during the year, your plan is not performing as you expected, or perhaps you were automatically enrolled into a plan that is not working for you. If you need help making a change, PA MEDI counselors or Medicare can assist you. You can contact PA MEDI counselors by phone on our Help Line (610-344-5004, option 2) or by email ([email protected]). Counselors pick up these messages daily and return calls within one business day. Most of the Chester County Senior Centers are opening for in-person visits. Call your Senior Center to see about meeting with a PA MEDI counselor.

19. How do I create a Medicare account?

A Medicare account is a helpful, online tool that you, as a Medicare beneficiary, can access easily. To set up an account, go to Medicare.gov, click on the “Log in/Create Account” button, then click “create an account now” and follow the instructions. Once you create your username and password, and a security question, put them in a safe place where you will find them easily when needed. 

An online Medicare account has many useful features:

• The ability to enter, save, and edit a list of your prescription drugs and preferred pharmacies. This simplifies using the Medicare Plan Finder to compare Part D (prescription) and Part C (Medicare Advantage) plans during the Annual Open Enrollment Period (Oct. 15 through Dec.7). Without an account, you must enter your drug list each time you want to check your coverage. Even if you aren’t a regular computer user, having this available will be a big help to a PA MEDI counselor or other person helping you shop for your next plan.
• Print a copy of your Medicare card if yours is damaged or lost.
• View your current plans, including the subscriber number.
• If you have Original Medicare, you can view the details of your claims as soon as they are processed, and view claims up to 36 months old. Your Medicare Summary Notices are also available, and if you want, you can receive them electronically rather than wait for paper copies in the mail. Any of this information can be downloaded and printed  (Those with Medicare Advantage Plans can get all claims information through the plan provider.) 
• Choose to receive email notifications from Medicare with information about preventive services and account alerts.

20. What are the benefits of the Inflation Reduction Act (IRA) of 2022 for Medicare beneficiaries?

This Act passed by Congress in 2022 is designed to save Medicare beneficiaries money on healthcare, especially the cost of prescription drugs.

Here are the main coverage/benefit changes:

• $35 per month insulin. One of the first benefits enacted was capping Part D covered insulin costs at $35 per month starting 1/1/2023. Part B covered insulins were added in July 2023. Under the new Act, there are no deductibles for insulin with Parts B or D.
• Drug costs capped at $2000 per year. Total out of pocket costs for Medicare drug plans will be limited to $2,000 per year starting in 2025.
• Vaccines fully covered. Additionally, there will not be a co-pay for Medicare approved vaccines that are on the beneficiary's drug plan formulary beginning 1/1/2023.
• Extra Help expanded. Low-income seniors who meet income limits can qualify for Extra Help with their drug costs. In 2024 Medicare Full Extra Help for low-income seniors will be expanded to 150% of the Federal Poverty Level ($20,385 for a single person). The category of Limited Extra Help will be eliminated. Asset limits have not changed.

There are also impacts to the drug companies. Those companies raising drug costs more than 6% will be penalized by CMS. Beginning in 2024, but not effective until 2026, CMS will begin negotiating drug prices. The initial negotiations will be for the top 10 most utilized and/or most expensive drugs. The list will be expanded in the years after 2026.

If you have questions or concerns about current Medicare coverage or are new to Medicare, PA MEDI counselors are trained and available to provide FREE, personalized, unbiased counseling. Please call your local senior center to schedule an appointment or leave a message on our Helpline 610-344-5004, Option 2, to talk to a counselor. Calls will be answered in 24 hours.