Navigating Medicare Enrollment

Brian Lehrer: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. Now I'll help you help yourself, or maybe help a parent or a grandparent in the Medicare open enrollment period for this fall, which closes later this week. Joining us is Louise Norris, health policy analyst for medicareresources.org, which helps people understand the pros and cons of traditional Medicare and Medicare Advantage and other things as they navigate open enrollment and different kinds of Medicare Advantage plans. We're doing this partly because forcing people onto Medicare Advantage plans has been such a hot-button issue for New York City municipal retirees this year, but many people who have a choice are interested in it but find that choice daunting. Let's see if we can help. Listeners, we can take your Medicare and Medicare Advantage open enrollment questions at 212-433-WNYC, 212-433-9692, call or text.

Louise, thanks for joining us. Welcome to WNYC.

Louise Norris: Thank you so much, Brian. It's a pleasure to be here.

Brian Lehrer: For those who haven't had to look this in the eye yet for themselves or an older loved one, this may sound like a stupid question, but what's Medicare?

Louise Norris: That's not a stupid question at all. Medicare is a federally run health insurance program for, it mostly covers folks who are 65 and older, but there are several million people under 65 who are on Medicare because of a long-term disability. It covers older folks and people with disabilities, providing health coverage.

Brian Lehrer: It comes in different parts. Bernie Sanders and others advocate Medicare for all as a path to all the holes in our current healthcare system for people under 65, but Medicare actually does not cover everything. Can you give us an overview of that?

Louise Norris: Right, exactly. Any lawmakers who have advocated for Medicare for all, they are careful to say that it would need to be enhanced from what we have right now, what the current Medicare program is. Basically, the way Medicare works is there's Medicare Part A, which is hospital coverage. If you're inpatient, that's for inpatient care. It also covers skilled nursing facility care and hospice care. Medicare Part B is outpatient care and physician services. It's basically everything else that's not inpatient hospital care. It's going to fall under Part B, but prescription drugs, outpatient prescription drugs, the kind that you get at a pharmacy, those are not covered under either Part A or Part B. They have Part D, which covers prescription drugs. It's entirely via private insurance companies, either a standalone just Part D plan that covers just prescription drugs, or a Medicare Advantage plan that includes Part D, and so covers prescription drugs, as well as other Medicare services. Then Medicare Part C is-

Brian Lehrer: Go ahead.

Louise Norris: -what they call Medicare Advantage. The other name for it is Medicare Part C. You've got the A, B, C, and D. Medicare Advantage takes the services that it would be covered under Medicare Part A and Part B, wraps them into one policy offered by a private insurance company, and most Medicare Advantage plans do include Part D as well.

Medicare Advantage plans can also include things like dental and vision, which is not included in either Medicare Part A or Part B. The benefits under a Medicare Advantage Plan don't exactly mirror Medicare Part A and Part B, but they do cover the services that are covered under Part A and Part B.

Brian Lehrer: Right. Hearing that answer, it's no wonder people's heads spin when they first have to confront this world. Listeners, again, we can take a few phone calls for Louise Norris from medicareresources.org if in this open enrollment period for this fall, which ends Thursday, am I right that Thursday is the last day?

Louise Norris: Yes, Thursday is the deadline for either switching your Medicare Advantage plan or your Medicare Part D plan, or switching over to one of those if you haven't had them in the past, Thursday is your deadline.

Brian Lehrer: If you have a question, 212-433-WNYC, 212-433-9692, call or text. From the way you just laid it out, it can sound, and I know you're not meaning to take a side there, but it can sound like Medicare Advantage plans, hey, let's go for that because that covers all the other things. That's going to include my regular doctor visits, Medicare Part B, not just the hospitalization in Part A. It's going to cover the prescription drugs in Part D, and it's maybe going to cover things like dental and vision, which none of the other parts of Medicare covered, but it's not that simple, right?

Louise Norris: It is definitely not that simple.

Brian Lehrer: What are the basic things that people should look for if they're entering the system for the first time and deciding whether to go for "regular Medicare or Medicare Advantage"?

Louise Norris: It's definitely not simple at all. I would say there's no one-size-fits-all all solution. New York is a unique situation just because in New York State, Connecticut and New York are the only two states in the country that work like this, but in New York, Medigap, which is your Medicare supplement that you buy if you choose to go with original Medicare, Medicare Part A and Part B, as opposed to Medicare Advantage,in New York, Medigap plans are guaranteed issue all year round, any time. In the rest of the country, outside of New York and Connecticut, that is not the case.

Everywhere else in the country, the way it works is if you have a six-month window when you first go on Medicare, when you first have Medicare Part B and Part A together, and you can enroll in any Medigap plan that's available in your area. After that six months is up, you can still submit an application, but it's not guaranteed issue. It's going to depend on your medical history. Which means that if you go with Medicare Advantage when you're first eligible for Medicare, and then say five years down the road, you decide you would rather have original Medicare instead, if you are not in New York or Connecticut, your medical history is going to determine whether or not you can actually get a Medigap plan. People can find themselves stuck and unable to-- technically they can go back to original Medicare during open enrollment, but if you can't get a Medigap plan, you could be faced with some pretty significant out-of-pocket costs when you use your original Medicare.

The thing that people in most of the country need to be cognizant of is thinking about their long-term needs as opposed to just what they need right now. The reason Medicare Advantage is so appealing to a lot of folks, and it does now cover about half of everyone with Medicare in the country, is on Medicare Advantage plan. The majority of folks with Medicare Advantage only pay the premium for Medicare Part B. They don't have any additional premium beyond that. Whereas if you have original Medicare plus a Medigap plan plus a Medicare Part D plan, you're going to be paying the premium for Part B, plus a premium for your Medigap plan, plus a premium for your Part D plan. Then also, like you said, the dental and vision, stuff like that, is appealing to folks with Medicare Advantage, but if you have Medicare Advantage, you are limited to the provider network of that plan, which can be localized or it can be a wider network, but it's not going to include all-- The way original Medicare works is any doctor nationwide who accepts Medicare, any hospital nationwide that accepts Medicare, you can just go there. You don't need to stay within a local provider network that your health plan has. The other thing is out-of-pocket costs. It depends on the Medigap plan you choose, but if you have Original Medicare and a Medigap plan, depending on how robust of a Medigap plan you pick, you could have very, very minimal out-of-pocket costs when you need to use your coverage if you have original Medicare.

Brian Lehrer: You'd be paying more for the premium up front to get that kind of coverage, right?

Louise Norris: Exactly.

Brian Lehrer: I guess one problem, for a lot of people, must be that a senior may be healthy today. You get to age 65, you have these choices in front of you that you've been laying out, and, "Hey, I feel pretty good." You're focused on the perks like dental and vision and that immediate savings that you were just describing, but when you're 75, when you're 85, when you're 95, you may need very specialized care from a doctor who's out of network, and you don't know what your medical situation is going to be, so you're rolling the dice one way or another.

Louise Norris: Exactly.

The nice thing about the approach that New York and Connecticut take is if you've been on Medicare for 10 years and all of a sudden you need more extensive care and you decide you'd rather go back to original Medicare and get a Medigap plan, you can do that. You just can't do it in most of the country if your medical needs at that point have become significant enough that the Medigap company is not interested in giving you a policy. That's why in most of the country it is so important to ask yourself both, what works for me now and what do I think I might need 20 years from now when obviously my healthcare needs are probably going to be much different than they are now. Assuming you're perfectly healthy at 65, you can't really assume that's going to continue to be the case forever, obviously.

Brian Lehrer: You laid out, Medicare Part A is basically hospitalization, Medicare Part B is basically most other doctor visits and a lot of other medical expenses. Medicare Part D is the prescription drugs. You said Medicare Part C is Medicare Advantage. Mary Ellen has a question about that category.

Mary Ellen, you're on WNYC.

Mary Ellen: Oh, hello. Thank you for taking my call. I had two questions. I think you pretty much answered the first one, which is whether the December 7th annual deadline applies to Medigap plans, to Medicare supplement plans. I think from what you're saying, at least in New York State, it doesn't, although it may in other states.

Louise Norris: In other states, there's no open enrollment period for Medigap. Outside of New York and Connecticut, if you're applying for Medigap after that initial six-month window, or there are some limited circumstances like your employer plan ended and you have a guaranteed issue and there's a trial for the first 12 months after you go on a Medicare Advantage plan. Outside of those circumstances, there's no such thing as an annual enrollment period for Medigap in the rest of the country.

Brian Lehrer: I think, Mary Ellen, your question was about calling Medicare Advantage Part C.

Mary Ellen: Part C. If you can just clarify, the first question is, in New York State, if you have a Medigap plan and there are different plans with different letters, you can change that at any point during the year?

Louise Norris: Yes.

Mary Ellen: In New York State?

Louise Norris: In New York State, Medigap is a guaranteed issue all year round, which is very different from the approach that's taken in most states.

Brian Lehrer: All right. Mary Ellen, thank you very much. Sonya in Lydon, New Jersey, you're on WNYC. Hi, Sonya.

Sonya: Good morning. My question is, is the price of Part B the same for everybody? Second question is, what kind of deductibles do these plans have? Are they affordable?

Louise Norris: The price of Part B is the same for most people. It's roughly $175 a month next year, and that is almost everybody pays that same price. If you have a high income, which is above $103,000 a year roughly, you will get a surcharge on your Part B premiums. If you delayed your enrollment in Part B without having other coverage in place other from an employer after you were 65, you might be paying a late enrollment penalty added to your Part B. Some folks do pay higher Part B premiums for those reasons.

Then some Medicare Advantage plans actually pay a portion of a person's Part B premiums. There are some folks who pay less for their Part B because their Medicare Advantage premium is refunding part of the cost. Then folks with very low incomes can qualify for programs that help to cover Part B. In general, it's roughly $175 a month for everybody.

Brian Lehrer: Do the Medicare Advantage plans evaluate your health and base a premium on their evaluation of your health, or even deny people because they're considered too high a risk?

Louise Norris: No. Medicare Advantage plans and Medicare Part D plans cannot use Medicare or medical underwriting. That's why we have this annual open enrollment period right now through December 7th. You can sign up for any Medicare Advantage plan that's available in your area, or any Medicare Part D plan, and your health is not a factor. I will note one caveat to that is there are special needs plans. There are Medicare Advantage special needs plans that are specifically tailored to folks with certain medical conditions. If you're looking at a Medicare Advantage plan for people with cardiovascular disease, obviously, you would have to have the medical condition that they are tailoring those plans to. Every other plan, no, you can join it and your medical history is not a factor.

Brian Lehrer: Steve in Manhattan, you're on WNYC. Hi, Steve.

Steve: Hey, can you hear me?

Brian Lehrer: Yes.

Steve: Hello. Hey. I just wanted to share a story about my parents' situational Medicare advantage. My father had a fall, broke a bunch of bones, was in ICU, and got discharged to a skilled nursing facility. Medicare comes with 60 days in a skilled nursing facility. What I found out when we got there was that if you're on Medicare Advantage which is being operated by the major insurance companies, they told me at the facility they're going to submit to discharge him every 5 to 10 days, and you can appeal but you're eventually going to lose the appeal and then you're going to have to pay out of pocket, which is what happened with us.

We went through two appeals. Eventually, they denied. They told us that was not the problem with people on regular Medicare. The impression was that if you're on Medicare Advantage and heaven forbid you need to file a claim for something, the Medicare Advantage folks are set up much more efficiently for deny and delay. Basically, it became a full-time job for me making calls, filing appeals, going through the legalese. This was months ago and I'm still in the process of battling them with that. From what I understood from the staff at the skilled nursing facility, this is the norm.

Brian Lehrer: This was with your Medicare Advantage provider?

Steve: Correct.

Brian Lehrer: You want to name the company.

Steve: United.

Brian Lehrer: Sound familiar, Louise? Does this come up a lot and with a lot of different plans?

Louise Norris: I'm so sorry you and your family had to deal with that. That is definitely an issue. Just to clarify, with original Medicare, if you have spent at least three nights in the hospital and you get discharged to a skilled nursing facility, original Medicare will cover the first 20 days in skilled nursing where you don't pay anything extra. Starting on day 21, you pay a daily rate. I believe it's around $400 a day, but don't quote me on that. Then up to 100 days total. After that, there is no more coverage for skilled nursing facility at all.

With Medicare Advantage plans, prior authorization and exactly what you're describing of constantly reevaluating, the coverage can definitely be a job and a process of keeping up with that as opposed to it just being as long as with original Medicare, if the doctors in the facility say that it is medically necessary for you to continue to be in there those first 20 days, you're not going to have any additional charges.

Brian Lehrer: Don't think that just because you're on Medicare now, your days of fighting with your insurance company are over.

Louise Norris: Right. The vast majority of Medicare Advantage plans, virtually all of them use prior authorization for medical services, which is very rarely used with original Medicare. Prior authorization is also used by virtually all commercial health plans in the individual market and the employer-sponsored market. People are accustomed to the idea of needing to get prior authorization for certain services. Once you go on Medicare, if you go the original Medicare route, prior authorization is very, very rare. It pretty much doesn't come up, whereas it will continue to be very much a part of your life if you're on Medicare Advantage.

Brian Lehrer: Steve was talking about his father in a skilled nursing facility. One of the biggest things that Medicare does not cover is home health care, home health aids, that sort of thing. Do Medicare Advantage plans offer that?

Louise Norris: Custodial care. Medicare can cover home health care if it's medical care they're providing. They're coming in and doing rehabilitation work like that. They won't cover just custodial care if that's all you need. You're not in need of actual skilled medical, you're just needing somebody to help you get up out of bed, get dressed, go to the bathroom, those sorts of things. Original Medicare does not cover that.

Medicare Advantage plans can incorporate some of those things into their plans. It can be for people with certain chronic medical conditions, the details do vary from plan to plan. As a general rule, if you need custodial care but not medical care, you are going to need something else besides Medicare, either Medicaid or long-term care policy or self-pay for that because it's really not part of Medicare.

Brian Lehrer: Last question from a listener and then we're out of time. This one comes via a text message, and this says, "Can you ask the guest to talk about the availability of insurance agents to help people go through this process? My friends and I all found them really helpful in sorting out some of the initial enrollment issues."

Louise Norris: Yes, absolutely. Brokers are a great place to start. You can contact your state insurance department because they license, and anybody who's selling Medicare policies, whether it's Medicare Advantage, Medicare Part D, Medigap, they're going to be licensed by the state insurance department. That's a place where they can direct you to. They'll probably have a search portal where you can look up licensed agents. The Medicare State Health Insurance Assistance program, there's one available in every state. It's SHIP, State Health Insurance Assistance Program, and you can go to shiphelp.org. You can find your state SHIP.

Those are not going to be brokers. Those are just going to be folks who can answer your questions and guide you, but a broker is who you're going to want in terms of somebody who's licensed by the state and can provide recommendations and then help you get signed up. That's where your state insurance department can help.

Brian Lehrer: Good place to end. There are people out there whose job is to help you navigate this, and we thank Louise Norris for doing some of that.

Louise Norris: You do not pay anything for that. [laughs] Just a heads up, that you don't pay for broker services.

Brian Lehrer: Yes, you don't pay the brokers. Louise Norris is a health policy analyst for medicareresources.org. Thank you so much.

Louise Norris: Absolutely. Thank you for having me, Brian.

 

 

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