A 5-step guide to Medicare options

A 5-step guide to Medicare options


The many changes happening in healthcare, like the opening of HealthSource RI, the new insurance exchange marketplace, are making headlines and may be causing some confusion. With the current Medicare Annual Enrollment Period coming to a close on Dec. 7, eligible seniors are urged to review all options to ensure that they make the best decision coverage in 2014. Whether a first time enrollee or an existing Medicare client, now is the time to reevaluate the plans in light of current and anticipated healthcare needs.

While individual needs vary, there are five steps everyone should consider when choosing a plan:

Know your options: There are two ways to get Medicare coverage — by choosing Original Medicare from the federal government (with optional supplemental coverage from a private insurer) or choosing a Medicare Advantage Plan from a private insurer.

Original Medicare includes hospital coverage, which is Part A, and medical coverage, which is Part B. With Original Medicare, you can add supplemental coverage from a private insurer for either a Prescription Drug Plan (Part D) or Medigap coverage to limit out-of-pocket expenses.

Medicare Advantage plans (also referred to as Part C) are available from private insurers and provide the same coverage as Original Medicare (hospital and medical) and can also include additional benefits or lower copayments — for example, Advantage plans frequently include prescription drug coverage (Medicare Part D) — while also including out-of-pocket limits to protect you in the event of costly care or treatment. Advantage plans may require you to get care within a network of doctors or other healthcare providers, but often include coverage for routine vision, hearing and dental care that is not covered by Medicare Original.

Make three lists: your healthcare needs, medications, and doctors and pharmacies.

• Healthcare needs: What healthcare services do you use regularly? How often do you see your primary care physician? How many specialists do you see each year? Are you anticipating any special needs, like surgeries? After you’ve made your list, check to see if these services are covered by the plans you’re considering and compare out-of-pocket costs such as copayments, coinsurance and deductibles.

• Medications: This list will help you determine which Medicare Prescription Drug Plan is best for you. Check each plan’s drug list (also known as a formulary) to make sure your drugs are covered and compare out-of-pocket costs. This is also a good time to check with your physician about whether there are new, generic versions of your prescriptions that may work equally well.

• Doctors and pharmacies: Check to see if they participate in the networks of plans you’re considering. Consider what types of doctors you may need to see next year and if a new pharmacy might be more convenient and offer better pricing.

Consider choosing a plan with out-of-network benefits if you travel. If you spend a significant part of the year in a second home, you need Medicare coverage that will travel with you. Check to make sure the plans you’re considering allow you to receive coverage outside of their network. If you plan to travel outside the United States, make sure that your plan provides coverage for emergency care outside the country.

Carefully Check to see if they participate in the networks of plans you’re considering. If you don’t anticipate many medical expenses, you may benefit from a plan with a low premium or no premium at all (also called $0 premium plans). It is important to note these plans often have higher out-of-pocket expenses than plans with premiums, but may be more cost-effective if you don’t use many services. Be sure to compare all the costs of the plans you’re considering, including copayments and out-of-pocket expenses.

Don’t forget about preventive and wellness services. With broader changes in healthcare reform, the focus is shifting to staying well, not getting better. More preventive services, including mammograms, colonoscopies and “wellness” visits, are now covered by Medicare without coinsurance or deductible charges. Some plans are offering additional covered benefits like $0 copays for generic drugs, $0 copays for doctor visits within coordinated care networks (also known as patient centered medical homes), low-cost fitness programs and allowances for vision hardware. Before making your decision, consider the benefits and value of these preventive and wellness options to help you stay healthy and active.

The benefit information provided here is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. [Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance] may change on Jan. 1 of each year. You must continue to pay your Part B premium. Blue Cross & Blue Shield of Rhode Island is an HMO plan with a Medicare contract. Enrollment in Blue Cross & Blue Shield of Rhode Island depends on contract renewal.

Stacey Paterno is the Assistant Vice President of Public Affairs for Blue Cross & Blue Shield of Rhode Island.

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