When we think of October, candy corn, jack-o'-lanterns and cooler, dry weather are top of mind.
But for Floridians looking for health care coverage, early October also signals that Medicare enrollment is just around the corner.
Oct. 15 marks the start of the annual enrollment period for Medicare, the federal health insurance program for seniors 65 and over. The traditional window to shop around for plans runs through Dec. 7 this year. But that period has been extended to Dec. 31 for people who qualify who may have been impacted by the recent slew of hurricanes, Harvey, Irma and Maria.
Florida is one of the biggest players in Medicare, with more than 2.4 million people enrolled, according to the Centers for Medicare & Medicaid Services. While most enrollees tend to stick with the plans they know and have used before, there are some subtle changes to Medicare Advantage plans this year that could affect some benefits. For the most part, though, it seems that those changes are slight ones — with some reduced and rising premiums and some expanded coverage. However, any change could mean some doctors may no longer be part of the network, or specific prescription medication may become more expensive or not be covered at all.
But don't fret. The Tampa Bay Times is here to help navigate the range of programs and options.
How Medicare works
Part A and Part B tend to be the most popular programs, which generally offer the most free services for consumers who qualify.
• Part A covers inpatient hospital care, nursing home care, hospice and a few other services like at-home care. These services are free, which means there's no premium to pay.
• Part B covers outpatient hospital care, doctor bills, physical therapy and more services. Part B is optional and costs most people a monthly premium, which was $134 (could be higher, depending on income) for most enrollees in 2017, or $109 a month if deducted from their Social Security check. These premiums will rise in the upcoming enrollment cycle, experts say. Cost-of-living adjustments that are expected to slightly inflate Social Security payouts next year will likely be eaten up mostly by seniors' rising Part B premiums. Experts estimate that premiums paid through Social Security will likely be around $20 or $30 more a month in 2018.
Despite the increased cost, you should still probably sign up for Part B when you first become eligible for Medicare, no matter how healthy you are — unless you are still working and included on an employer's health plan. Otherwise, you will face a stiff penalty when you do need this coverage. Even if you choose a private Medicare HMO for your coverage, you have to sign up for Part B. New income brackets will also debut in 2018 for Part B enrollees. Due to legislation passed in 2015, "high income" enrollees begin at $85,001 for an individual and $170,001 for a couple. That means you'll pay a higher premium if you now fit into this bracket.
• There is another alternative: Medicare Advantage health plans, or Part C. This is privately managed care — usually an HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) — in which you often must choose your medical providers from a plan's predetermined list. As of this year, 33 percent of Medicare beneficiaries in the United States are enrolled in an Advantage plan, according to the Kaiser Family Foundation. You will pay copays or coinsurance for covered services. Medicare Advantage plans are subsidized by taxpayers. And, if you are satisfied with the doctors and hospitals in their network, they usually turn out to be less expensive than Original Medicare, though not always. Most Advantage plans also provide drug coverage, so you do not need a separate Part D drug plan.
It's worth noting that Part A and Part B services under Original Medicare come with deductibles and copays, too. Many people cover these costs by buying private Medicare supplement policies, also known as Medigap. This is not required and premiums tend to be high, but if you suffer a catastrophic illness, Medicare supplement policies will pay off. Also, a few Medicare supplement policies offer coverage outside the country, which Original Medicare does not. People who travel abroad might consider one of these plans.
• Part D covers prescription drugs. This year, more than 42 million Medicare beneficiaries are enrolled in Medicare Part D plans, according to the Kaiser Family Foundation. Plans are expected to expand by 5 percent in 2018, which means you will have more options. You buy these plans from private insurance companies for an average premium of $33.50 a month, which is about $1.20 cheaper than 2017. The plan then defrays the cost of your medications. These plans have deductibles and copayments but are subsidized by taxpayers and usually a good deal.
How do I get a Medicare Advantage plan?
There is some good news about Medicare Advantage plans this year. The Centers for Medicare & Medicaid Services says that the average monthly premiums for Advantage plans will drop by $2 next year to about $30. About 77 percent of Advantage enrollees who choose to stay in their current plan will have the same or a lower premium next year.
You must sign up for Part B Medicare to qualify for a Medicare Advantage plan. Some insurance companies will pay all, or part, of your premium. Some plans offer vision, hearing and dental benefits that Original Medicare does not, though sometimes these benefits are minimal.
The tradeoff is that Original Medicare lets you pick any doctor or hospital in the country, whereas Advantage plans often restrict you to a network or charge a hefty fee if you get service outside the network. If access to a particular hospital or doctor is important to you, make sure they are on the Advantage plan you are considering.
Also, plans can and do drop providers from their networks. Advantage plans always carry a risk that you can end up losing the doctor you want to see. Worse, some Advantage plans have gone bankrupt or have been shut down by authorities midyear, sending you and thousands of others scrambling for new doctors. If that happens, Medicare will give you a chance to find a new plan.
What's more, some Advantage plans skimp on coverage for hospital visits, skilled nursing care or other services. Pay close attention to the benefits offered when picking a plan. Don't just choose the plan with the cheapest premium.
Many Advantage plans include drug coverage.
Unless you already have prescription drug coverage through the Department of Veterans Affairs, the union you belong to, an employer or through some other source, it's important to get some kind of drug coverage — either a Part D drug plan if you are on Original Medicare or a Medicare Advantage plan that covers drugs.
You should get coverage even if you don't use any prescription drugs.
Many Advantage plans offer drug coverage without any extra charge. If you get sick and need expensive drugs, you will be happy you bought coverage. More important, if you decline drug coverage now, the government will impose a stiff penalty every year if you try to sign up.
Your costs could vary widely depending on the drugs you take and services you use.
The best way to compare costs tailored to your circumstances is with Medicare's online Plan Finder (medicare.gov/find-a-plan), which allows you to factor in your health conditions and the drugs you take.
Mind the gap
You reach the coverage gap, also known as the "donut hole," when the total cost of all your drugs for the year reaches $3,750, an amount set by Congress. That amount is the total paid — by the insurance company and your deductibles and copays. For example, if your plan pays $600 a month for your drugs, but charges you only $100, you will hit the coverage gap in less than six months because the total paid will have reached $3,750.
Then, the onus is on you to pay until your out-of-pocket drug expenses for the year reach $5,000 and you are eligible for "catastrophic" coverage. At that point you are out of the "gap" and only responsible for a small coinsurance amount or copayment for covered drugs for the rest of the year.
You will get a discount on brand-name and generic prescription drugs while you are in the coverage gap. Some plans offer limited coverage in the gap.
Medicare's Extra Help program, for people with limited income and resources, can reduce out-of-pocket costs for a Part D drug plan or a Medicare Advantage plan that covers drugs.
To qualify, a person must not have combined savings, investments and real estate that are worth more than $27,600, if you are married and living with your spouse. An individual must not have a net worth of more than $13,820 if unmarried. Applicants must already be enrolled in Medicare Part A or Part B.
If you think you qualify, contact the Social Security Administration toll-free at 1-800-772-1213 or apply online at socialsecurity.gov.
The federal government also offers Medicare Savings Programs for low-income people. The lower your income, the more you stand to gain.
For all these programs — called QI, QMB and SLMB — your liquid assets cannot exceed $7,280 for a single person or $10,930 for a married couple. (Liquid assets include stocks, cash and savings accounts. They do not include your home or car.)
The monthly income limits are:
• QI: $1,377 for a single person or $1,847 for a married couple. This program pays your Part B premium but has a fixed budget. When its money is exhausted, nobody else can qualify that year.
• QMB: $1,025 for a single person or $1,374 for a married couple. This program pays your Part A and Part B premiums and Medicare's copayments and deductibles.
• SLMB: $1,226 for a single person or $1,644 for a married couple. This program pays your Part B premium and has no fixed budget. Everyone who qualifies can get the benefit.
• Note: To see if you qualify or to find out how to apply, call Florida's Medicaid office toll-free at 1-866-762-2237, apply online at socialsecurity.gov/i1020 or call Social Security toll-free at 1-800-772-1213. Ask for information about Medicare Savings Programs.
Florida's SHINE program is made up of volunteers who can navigate Medicare's website and help find the plan best suited to you. Call the Florida Senior Hotline toll-free at 1-800-963-5337.
• Note: Before you contact SHINE, make a list of all your drugs, dosages and monthly usage.
• Another note: You also can get help from Medicare by calling toll-free 1-800-633-4227, but the government workers there generally have less time to spend with you than SHINE volunteers do.
Times staff writer Kathleen McGrory contributed to this report. Contact Justine Griffin at [email protected] or (727) 893-8467. Follow @SunBizGriffin.