No news to anyone with Medicare, AEP is here. Medicare’s annual open enrollment officially launched Thursday October 15th. AEP (Annual Election Period) is the time each year CMS (Centers for Medicare and Medicaid Services) has allotted for Medicare members to make a one-time* decision regarding their Medicare coverage for the upcoming year. Beneficiaries can compare their current health and drug coverage with other Part D prescription drug plans including MA/MAPD (Medicare Advantage or Medicare Advantage with Prescription Drug) options and make changes which are effective January 1. Coverage options through Medicare Advantage, Part C of the Medicare program, has been a viable option to the general Medicare population since the early 2000’s notwithstanding any current or pre-existing health conditions except one —a current or prior diagnosis of ESRD (End Stage Renal Disease). ESRD was an automatic ineligibility sentencing for a prospective member’s enrollment in an MA/MAPD health plan with few, if any, applicable disclaimer. At an affirmative response to this one and only program allowed general health related eligibility question, discussion of probable enrollment in Medicare Advantage must cease regardless of the individual’s asserted needs or preference.
Enter 2021, and change has come.
Effective this AEP, ESRD no longer disqualifies members from choosing coverage via enrollment in Medicare Advantage. You can now compare plans and choose to enroll in an MAPD, or an MA with PDP when/if applicable, or continue original Medicare with PDP regardless of health status. It is your choice. Weigh your options carefully. Due diligence is most important. Thoroughly check service and facility providers’ availability and acceptance of any considered plan’s terms and conditions. Some questions to ask at minimum are:
What will be my out-of-pocket costs? Are there network considerations? What plans do my primary care doctor and, or specialists currently work with? Are my current prescriptions covered, or can be covered? What deductible and tier levels apply? Is my current, or alternative preferred pharmacy already available? Does the plan present it at preferred or standard prescription pricing? What added benefits do I need or would like to have, i.e., dental, vision, over-the-counter health related items and supplements, hearing, fitness, transportation, et. al.? Which plans offer all or a majority of these benefits and, or at the most value to me?
You can also find general answers to these and many other questions in your Medicare and You Handbook. For more specific information, you can find and compare plans via search engines, and government or carrier assisted websites and telephone assistance. When needed, it is important to get assistance in the quest to find the right coverage for you in 2020. Seek qualified help. Working with a licensed health, trained and certified agent can readily answer your questions, affirm your understanding, and significantly decrease any confusion as you are personally guided in navigating the seemingly daunting and complex maze of Medicare related options, coverages and products of AEP.
“Medicare” generally refers to the structured program of collective Parts designed to provide recipients comprehensive overarching healthcare coverage and services. It includes Parts A-Hospital, B-Medical, C-Medicare Advantage, and D-Prescription Drug coverage. During AEP, members can opt to continue or return to original Medicare; add, drop, or change their Part D prescription drug coverage; or to enroll in a Part C Medicare Health Plan with or without drug coverage (MAPD or MA) depending upon their individual circumstances and, or preferences. Now, new for 2021, ESRD members are fully afforded opportunity to take advantage of all coverage options as well. For more information on ESRD and the Medicare program see
“Original Medicare” typically refers to the Generic Fee for Service program which provides Part A (Hospitalization and Skilled Inpatient Care) and, or Part B (Physician and other outpatient professional medical services) through the member’s utilization of the government issued MBI or “Red, White & Blue” card. These services can be accessed from any provider or facility who accepts Medicare. Both Parts A and B have related annual or benefit period deductibles, coinsurances and, or copays which are the responsibility of the beneficiary. With exception of the yearly Part B deductible, there are no annual or out-of-pocket maximums or limitation guarantees with Original Medicare. Beneficiary costs can and do vary depending upon the applicable benefit used, services received, and provider type or facility (primary, general or specialist care) and status (participating or non-participating. Members can purchase Medicare supplemental insurance policies, or Medigaps, to help with the costs of original Medicare. Unlike Medicare program and plans, Medicare supplement policy premiums and issuance are usually premised on age and other underwriting requirements unless the member can be associated with a qualifying guaranteed issue event at the time of purchase.
Part D provides beneficiaries access to pharmacy and prescription drug coverage under the Medicare program. CMS contracts with various private insurers to give each Medicare member opportunity and options to obtain Part D coverage. Coverage can be obtained as a standalone PDP plan or included in a Part C MAPD or other Medicare Health Plan.
Part C of the Medicare program is known as Medicare Advantage. Also called “bundled” benefit plans, Medicare Part C provides Medicare beneficiaries the alternative to access their Medicare Part A and B health benefits and with Part D options as well by enrolling in approved Medicare health insurance plans. Medicare Advantage plans are available from private insurers with whom CMS has contracted for this purpose and are offered in CMS specified designated service areas. These plans must provide all the benefits of Original Medicare; however, are not limited to medically necessary coverage only. MA plans can provide members with prescription drug coverage and may even add routine benefit coverage i.e., dental, vision, hearing, OTC and much more. Plan premiums are usually low, and in some areas, no premium pricing plans may be available. You must be entitled to Part A, enrolled in Part B, and be a resident of the desired plan’s service area to qualify for enrollment. ESRD is no longer a disqualifying factor for enrollment into an MA or MAPD starting January 1, 2021.
*New to Medicare beneficiaries who are aging in, or delayed Part B enrollment due continued employment and have employer group coverage, or any other valid SEP (Special Election Period) will or may have additional option for making changes aside from the AEP deadline.
Continue reading...