Medicare 101: What you need to know

SHIBA counselors helped educate their audience on Medicare basics at a “birthday party” in Roseburg.

Annual open enrollment for Medicare has started and it’s important to know what that means for you.

Enrollment is open through Dec. 7. Any Medicare Advantage (Part C) or prescription drug plan (Part D) changes must be made between those dates so that coverage begins without interruption on Jan. 1.

“It is important to compare Medicare Advantage and Prescription Drug plans every year,” says Lisa Emerson, Senior Health Insurance Benefits Assistance (SHIBA) coordinator with the state of Oregon. “Plans change year to year, as do your individual health care needs, including prescription medications. You could potentially save money by shopping for a new plan.”

Retiring employees who no longer have health insurance available through their workplace instead must buy it through the federal government. But which plan should you buy, how often should you review it, and how do you know whether it’s the best plan for you?

There aren’t always easy answers to these questions, but there is free assistance. SHIBA counselors provide unbiased, personalized phone and in-person counseling. Private health insurance agents provide assistance in reviewing plan options at no out-of-pocket cost to beneficiaries. has a “plan finder” tool to aid in comparing plans and completing online enrollment. And even the health insurance companies themselves have agents who assist in describing benefits of their specific plans.

Much of that information is available in this issue of NW Boomer and Senior News, where our Medicare guide provides plan descriptions and benefits.

Medicare was created by the federal government in 1965, and is health insurance for Americans age 65 years or older, those under age 65 receiving Social Security Disability Insurance for more than 24 months, and those with end-stage renal disease or amyotrophic lateral sclerosis (ALS). There are more than 760,000 Oregonians with Medicare. Nationally, Medicare enrollment is increasing at a rate of more than 10,000 beneficiaries per day.

To enroll in Medicare and its other plans, begin signing up three months before you turn 65. You have seven months to sign up.

If you are already enrolled in a plan, but want to make a change, you have until Dec. 7.

Medicare Part A and Part B cover basic hospital and medical services at approximately 80 percent. Medicare allows private insurance companies to sell Medicare-approved policies.

The first is Medigap, jointly regulated by the state, and which pays the out-of-pocket costs after Medicare pays its portion. It is available with or without drug coverage and a stand-alone prescription drug plan can be purchased for those who choose to enroll in a Medigap plan.

Some of the items not covered by Parts A and B include long-term care, dental care and dentures, outpatient prescription drugs, alternative care, hearing aids and exams for fitting hearing aids, routine vision and eyeglasses, routine annual physicals with lab tests, and most travel outside the United States.

Medigap helps cover the “gaps” in insurance that Original Medicare (Parts A and B) do not cover, such as deductibles and co-insurance. The plans are named by letter, Plan A through Plan N. The plan benefits are standardized, meaning Plan A in one private insurance company is exactly the same as Plan A in another company.

During the enrollment pro-cess, health insurance companies may consider your medical history, and may refuse your application if you do not enroll within the required time period. They also may offer you a lower initial rate for the first 12 months, and then rates may increase overtime.

To view a company’s rate history, visit Pages/medigap.aspx.

Medicare Advantage (Part C) was approved in the 1990s as another way to receive your Medicare benefits.

Medicare Advantage plans are sold by private health insurance companies that contract with Medicare and offer “coordinated care.” Medicare pays these plans to provide all your Medicare-approved services. When you join a Medicare Advantage plan, you agree to that plan’s terms and conditions. Where you live often determines which Medicare Advantage plans are available to you.

Note that it is unlawful for you to be enrolled in a Medigap plan and a Medicare Advantage plan at the same time.

SHIBA is a state-sponsored Medicare information and assistance program and receives federal grant funding from the Administration for Community Living to provide community-based counseling services to thousands of Oregon Medicare beneficiaries in an effort to help them understand their Medicare benefits and enrollment options.

SHIBA counselors help beneficiaries compare plans and enroll by using the Medicare Plan Finder tool found online at Beneficiaries and their families can also use this tool to compare plans and complete their online enrollment.

Here are tips from SHIBA for comparing plans:

Find your insurance cards: You may need your red-white-and-blue Medicare card to review benefit details or enroll in a new plan. If you have a Medicare Advantage or prescription drug plan, you may also need that card.

Update your list of prescription drugs: Check with your doctor to make sure you understand each prescription. Is a generic available? Can you eliminate any unneeded medications? Based on your list, do you have the right plan for you?

Use the Plan Finder: The plan finder uses your prescription list to compare prescription drug and Medicare Advantage health plans in your area. Not all companies cover the same drugs so it’s important to have a complete list of your medications and dosages when using this tool.

Contact your doctor, hospital and pharmacy before making changes: Not all health and drug plans contract or work with the same providers. If you switch plans, make sure you understand which providers you can see for the best price.

Apply for help with drug costs: If you have limited income and assets, you may qualify for extra help with prescription drug costs. SHIBA counselors can help you apply for this benefit through Social Security.

In addition, SHIBA publishes an annual Medicare guide, which is available online and in print during the open enrollment period.

SHIBA counselors also schedule group presentations on Medicare and related topics.

For example, at a Welcome to Medicare “birthday party” in Roseburg in September, SHIBA counselors not only supplied a birthday cake, but also helped educate Oregonians age 64 and older on Medicare basics, including important enrollment deadlines, Social Security’s services, long-term care planning, and more.

“Many seniors miss the deadline to sign-up for Medicare,” says Cynthia Hylton, SHIBA education and outreach team member. “Depending on each person’s unique situation, enrollment periods vary, so we encourage everyone to contact a certified SHIBA counselor to get personalized help. We try to make it fun, educational and helpful. There’s no reason that learning about Medicare – or dealing with health care, in general – has to be difficult. We want to make this as easy for people as we can.” n

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