CDISNM Blog
Original Medicare (Part A and Part B) does not include benefits for prescription drugs. While you are not required to have drug coverage if you need it, there are only two ways to get it—purchase a standalone Part D plan or get it as part of a Medicare Advantage plan. Enrollment in Part D is voluntary, unless you receive benefits from Medicaid, in which case, you are enrolled automatically.
Costs
If you choose to purchase a plan separately to add to your Medicare coverage, you should expect to pay for a few different things.
Monthly Premium. There is a monthly premium for drug benefits that are in addition to your Part B premium. The exact amount varies and is based on the plan you choose. High-income Medicare beneficiaries can also expect to pay an income-related monthly-adjusted amount, in addition to the premium. However, most seniors pay only the standard premium. If you do not sign up for Part D coverage when you are first eligible, you may have to pay a late enrollment penalty.
Deductible. In addition to a premium, most plans include a yearly deductible. The good news is, that there is a maximum deductible amount—a limit to how much you pay out-of-pocket before your Medicare drug plan starts contributing. Note: some Part D plans offer “first dollar coverage”, meaning you do not pay a deductible, and coverage starts immediately.
Copayments and Coinsurance. While your plan will likely pay for a good amount of your medications, you are responsible for the remaining amount, which is called copayment or coinsurance. Medicare standards ensure that copayments are no more than 25 percent of the full cost of a prescription, and plans are required to pay no less than 75 percent. In some cases, copayments are waived completely.
Copayments for prescriptions may be waived if:
You live in a long-term care nursing facility and are enrolled in both Medicare and Medicaid.
Your plan waives the copayment for certain drugs.
Your pharmacy opts to waive the copayment for specific drugs.
Coverage Gap
The coverage gap is a little different. Once you and your plan reach a predetermined amount for prescription drugs, you enter the coverage gap, or “donut hole”. Medicare stops paying while you are in the gap, leaving you responsible for 100 percent of your medication cost. However, once you reach catastrophic levels, Medicare pays for 95 percent of your medication cost.
Need to Know
Understanding the costs surrounding Part D coverage can be complicated. Here is an easy summary with just the facts.
Enrollment is voluntary unless you receive Medicaid benefits.
There are only 2 ways to get prescription drug benefits: a Part D plan or Medicare Advantage.
Plans include a monthly premium, deductible, copayments, or coinsurance and costs while in the donut hole.
Remember, different Medicare drug plans have different rules. Some require prior authorization from your doctor before certain medications can be filled. Others impose limits on how much medication you can get at one time. In some cases, certain plans require you to try lower-cost drugs before a prescribed drug will be covered. In addition, each plan’s formulary, or list of covered drugs may be different. Be sure to look carefully at the plan you choose to make sure any medications you use regularly are on the list and your preferred pharmacy is a participating pharmacy.
References:
https://www.medicare.gov/part-d/costs/part-d-costs.html
https://www.medicare.gov/part-d/coverage/rules/drug-plan-coverage-rules.html
https://www.medicare.gov/sign-up-change-plans/get-drug-coverage/get-drug-coverage.html
http://www.kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet/
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CDISNM Blog
9 to 12 months before you turn 65
Confirm that you are eligible to receive Medicare benefits by calling the Social Security Administration at 800.772.1213.
Review your current health insurance policy to find out what happens with that coverage when you turn 65.
Research options for coverage to help protect yourself from costs not included in Medicare coverage.
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4 to 8 months before you turn 65
Become familiar with Medicare parts: A, B, C, and D.
Ask your doctor if they accept Medicare or participate in other Medicare plans.
Sign up for coverage to help protect yourself from costs not included in Medicare coverage.
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1 to 3 months before you turn 65
Enroll in Medicare Parts A and B – if you do not receive your automatic enrollment information in the mail, contact the Social Security Administration at 800.772.1213.
Sign up for Social Security if you have decided to take early Social Security benefits (Note: it usually takes three months after you sign up before you begin receiving benefits).
If your spouse and/or dependent are covered under your employer’s plan, make arrangements for him or her to have coverage after you have Medicare.
Happy 65th Birthday!
If you have not received your Medicare card in the mail, call the Social Security Administration at 800.772.1213.
Make sure your physician’s office has a copy of your Medicare Card and any supplement plan you may have signed up for.
References:
https://www.medicare.gov
MUC25-2016-BCBS
CDISNM Blog
Medicare plan deductibles are charged not at the beginning of the plan year, but at the beginning of each benefit period. Understanding your benefit period and when it is can help you estimate your costs in the event you need care.
Benefit Period
The benefit period is simply the way Medicare measures your use of inpatient hospital and skilled nursing facility (SNF) services. Your period begins the day you’re admitted as an inpatient into a hospital or SNF and ends when you have gone 60 days in a row with no inpatient hospital or SNF care. The benefit period has nothing to do with the calendar year but is based on your medical care needs. It begins on the first day you are admitted into the hospital or SNF and ends 60 days after the last day you receive treatment. For example, if you are admitted into the hospital on May 1 and receive 15 days of treatment, your benefit period would begin on May 1 and end on July 15.
If you need to return to the hospital before the 60 days have expired, you will still be in the same benefit period. However, as soon as 60 days have passed with no care, if you return to the hospital, you will start a new period. While there is no limit to the number of benefit periods you can have or how long each benefit period can last, you must pay the inpatient hospital deductible.
Benefit Period Determines How Much You Pay
When your benefit period begins, you are responsible for paying your Part A deductible. In 2024, Medicare recipients will pay a $1632 deductible for each benefit period. For days 1-60 in the hospital, the coinsurance for each benefit period was $0. That means for the first two months in the hospital, you are covered with no daily coinsurance due. For days 61-90 of a hospital stay, coinsurance is $408 per day. For days 91 and beyond, coinsurance for each “lifetime reserve day” after day 90 for each benefit period is $816. With a skilled nursing facility, coinsurance was $0 for the first 20 days of each benefit period and $204 per day for days 21-100. To find out where you are in your benefit period, refer to your Medicare Summary Notice (MSN). This document details all health care services you received in the past 3 months.
References:
https://www.medicare.gov/glossary/b.html
https://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html
https://www.medicare.gov/coverage/skilled-nursing-facility-care.html
https://blog.medicarerights.org/what-is-a-benefit-period/
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CDISNM Blog
Initial Enrollment Period
At the age of 65, most individuals are automatically enrolled in Medicare Part A and Part B. As long as you are eligible to receive Social Security or Railroad Retirement Board benefits, you qualify for Medicare coverage. Everyone who has worked for at least 10 years will receive Part A benefits premium-free. You do not need to do anything at all and you will automatically be enrolled in Medicare Part A coverage. However, Part B is not premium free and you will need to pay monthly. Like Part A, enrollment is automatic – if you choose not to accept Part B coverage, you can “opt-out”. If you are still working at age 65 and receive employer-sponsored health care, you may still enroll in Part B coverage and would need to sign up during your Initial Enrollment Period. If you choose to continue receiving coverage through work, it is acceptable to delay enrollment in Part B benefits. In this case, there is a Special Enrollment Period that typically begins when employer-based coverage ends.
Medicare Enrollment Periods
Initial Enrollment Period:
Medicare offers those who are turning 65 7 months to enroll called the Initial Enrollment Period. Initial Enrollment begins three months before your 65th birthday and ends three months after you turn 65.
General Enrollment Period:
For those who miss the Initial Enrollment Period, there is a General Enrollment Period, which extends from January 1st through March 31st each year. Keep in mind, that enrollment begins on January 1st for coverage that begins on July 1st.
Open Enrollment Period:
Changes can be made during this period to switch from a Medicare Advantage Plan to Original Medicare plus a Part D Plan or to switch from one Medicare Advantage Plan to another. This period is from January 1st to March 31st. Plan changes take effect the month after it is submitted.
Special Enrollment Periods:
Special Enrollment Periods are available for people who are undergoing special life events or circumstances that make it difficult to enroll during designated enrollment periods.
Making Changes to Your Medicare Coverage
Medicare realizes that sometimes people want to change their Medicare plan. An Annual Election Period is available from October 15th through December 7th. During this time, anyone is entitled to do the following:
If you receive Original Medicare:
Leave Original Medicare for a Medicare Advantage plan (with or without prescription drug coverage)
Join or drop Medicare Prescription Drug coverage
Switch between Medicare Prescription Drug plans
If you are enrolled in Medicare Advantage:
Switch to Original Medicare
Switch between Medicare Advantage plans with prescription drug coverage
Switch between Medicare Advantage plans without prescription drug coverage
With all changes to your Medicare plan, as long as your enrollment request is made by December 7th, new coverage begins January 1st of the following year.
References:
https://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/when-sign-up-parts-a-and-b/when-sign-up-parts-a-and-b.html
https://www.medicare.gov/sign-up-change-plans/get-parts-a-and-b/when-how-to-sign-up-for-part-a-and-part-b.html
MUC10-2016-SSI/CDIS
CDISNM Blog
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