Each year, Medicare’s Open Enrollment Period runs from October 15 through December 7 for coverage beginning on January 1 of the next year. If your parent, family member, friend or loved one is Medicare-eligible, you might want to help them find the best healthcare coverage to meet their needs. Let’s discuss how to help a loved one enroll in Medicare. It starts with learning what Medicare is, how you can help determine what coverage or plan is best for them, how to pay Medicare costs and when they can enroll.
1. What is Medicare?
Medicare is a federal health insurance program for people 65 or older, people under age 65 with certain disabilities or people of any age with end-stage renal disease (ESRD). Medicare coverage is split into four parts, A through D. Each part covers a certain area of your loved one’s healthcare needs. We will break this down further:
- Medicare Part A (hospital insurance) covers inpatient healthcare costs including hospital stays, skilled nursing facilities (SNFs), hospice care and home health care. Note that long-term care such as nursing homes is not covered by Medicare. There is no monthly premium for Medicare Part A services.
- Medicare Part B (medical insurance) covers medically necessary doctors’ services, outpatient care, home health services and durable medical equipment (DME) and other medical services. It also covers many preventive services like diabetes screenings and flu shots. This is a monthly premium for Medicare Part B services. Medicare Parts A and B make up Original Medicare
- Medicare Part C (Medicare Advantage (MA) plans) cover everything that Medicare Parts A and B cover, plus emergency and urgent care. The difference between Medicare Part C is that you choose an MA plan from a private health insurer contracted through the government and you receive your coverage from the plan and not Original Medicare. MA plans also offer extra coverage like vision, dental, hearing and/or health and wellness programs. Most plans include prescription drug coverage (Medicare Part D). In addition to your Medicare Part B premium, you will usually have to pay a premium for an MA Plan.
- Medicare Part D (prescription drug coverage) coverage would need to purchased along with Original Medicare. Part D plans are available through private companies under contract with Medicare. Sometimes, your loved one might have creditable prescription drug coverage through a union or employer. In that case, they don’t need a Part D plan. If they have Original Medicare, they must also purchase Part D coverage when they are first eligible to avoid paying a late enrollment penalty. Note that many MA plans have Part D coverage built in. These are known as MAPD plans.
- Medigap (Medicare supplemental insurance, MedSupp) is coverage that can be purchased in addition to Original Medicare. Medigap plans are available through private insurance companies and can cover all of the payments that Medicare does not. These plans come with one monthly premium. You cannot have Medigap plus MA.
2. How can you help determine what Medicare coverage or plan is best for them?
It’s important to know what types of coverages are available to determine which type your loved one needs. This involves having a conversation with your loved one. We have a few points to help aid in that discussion:
- Look at what type of coverage they need. Original Medicare and MA plans have similar coverages, but MA plans cover a wider range of services. If your loved one needs frequent dental work or vision services, then an MA plan might be best.
- Put together a list of prescription drugs they take. From there, compare this list to potential prescription drug plans – either part D plans or MAPD plans. Also, make sure that the pharmacy that they get their prescriptions from accepts the chosen plan.
- Find out who their primary care physician (PCP) is. First, make sure that their PCP is covered by Original Medicare. Note that with Original Medicare, your loved one can go to any PCP that accepts Medicare, while their PCP needs to be in-network for an MA plan. However, a PCP is very important (and optimal), as they handle all care and referrals.
- Go over how much they (and you) can afford each month. This is an important part of the conversation. Make sure that you help your loved one research all plans and costs. MA plans have a premium (depending on the plan) that must be paid each month along with the Medicare Part B premium. But Original Medicare plus Part D coverage can also cost a lot due to deductible payments. Also, MA plans have lower out-of-pocket costs over time as there is an annual spending limit. This means that once you reach this limit, the plan pays for the rest of your coverage. Original Medicare does not have an out-of-pocket maximum.
3. When can they enroll in Medicare?
There are four time periods each year where your loved one can enroll in Medicare:
- The Initial Enrollment Period (IEP) when they first turn 65. This period of time is seven months – three months before, the month of, and three months after their 65th birthday.
- The General Enrollment Period which occurs if they miss the IEP. The General Enrollment Period runs from January 1 through March 31, but there will be a coverage gap (coverage begins July 1) and this could result in late penalties.
- The Open Enrollment Period (AEP) which lasts from October 15 to December 7. During this time, your loved one (who is likely already on Medicare) can choose to stay with Original Medicare, stay with their MA plan, apply for Medicare Part D coverage or switch to new coverage.
- A Special Enrollment Period (SEP) based on a number of qualifying events. We discuss this more in a previous blog post.
If you or your loved one are interested in learning more about the basics of Medicare or want to discover the benefits of Aspire Health plan, visit our Seminars page to learn more and sign up. There is no obligation to enroll at any of our events.