There are more than 2 million North Carolinians who get their health care coverage through Medicare, the government health insurance program for senior citizens and the disabled. This is the time of year when all Medicare enrollees can check that their coverage still works for them, and make changes if it doesn’t. Medicare open enrollment occurs now through Dec. 7, and the process can be complicated. So here are a few questions and answers to help you dig in.
1. Why do I need to review my policy during open enrollment?
You’re not required to do anything. But Medicare plans can and do change from year to year, including premiums, deductibles, copayments, benefits, drug formularies, and provider network. It’s important to review your coverage to make sure it still meets your needs.
If your circumstances have changed, that could also trigger the need for different coverage. You may be traveling out of state a lot more to spend time with a new grandchild and no longer have regular access to your doctors. Or maybe you anticipate higher than usual medical bills next year. All those things can change your coverage needs.
2. How do I know if I need to change my coverage?
The first decision you need to make is whether you want to be on the original Medicare plan, which is typically an 80/20 plan, or whether you want a managed care plan. About 40% of North Carolina beneficiaries are enrolled in managed care plans. These are called Medicare Advantage plans. There are 145 Medicare Advantage plans in North Carolina. They’re run by private companies but regulated by the government.
Melissa Munden, director of the State Health Insurance Information Program, says those most concerned about costs might want to consider a Medicare Advantage plan. The average monthly premium is about $15.22, and some plans have no premium. Some may cover some or all of your medications. Some may even offer other benefitslike vision care.
3. Why do some people prefer original Medicare?
Medicare Advantage plans typically offer a limited network of doctors. So if you want to see a doctor outside of that network, you’ll have to pay the full cost. And they may require you to get a referral from a primary care doctor in order to see a specialist. Munden said those who need more flexibility, or who travel a lot, may be better off with original Medicare.
But those with original Medicare often buy additional coverage called a Medigap policy. That could be tricky if you’re already enrolled in Medicare and haven’t purchased one before.
4. What’s a Medigap policy?
These are policies that cover some or all of your out-of-pocket costs from original Medicare. Premiums vary depending on the coverage, your age and your use of tobacco. One of the most popular plans cancost anywhere from less than $100 a month to more than $1,000 a month.
If you apply for a Medigap policy when you first become eligible for Medicare, you’re guaranteed to get one. But if you didn’t buy a Medigap policy when you first signed up and subsequently decide you want one, in most circumstances you’ll have to apply and answer questions about your health. And you might not get approved.
So you may want to shop around for a Medigap policy to make sure you’re fully covered before you decide to move from a managed care plan to original Medicare.
5. Do the plans cover prescription drugs?
Original Medicare doesn’t cover prescription drugs, and any given managed care plan may not cover the specific drugs you take.
But you can buy a separate policy for prescription medicines. This year, North Carolinians have a choice of 23 different Medicare prescription drug plans. You can purchase them through the same site, Medicare.gov, where you can review your other coverage.
6. This is complicated. How do I sort it out?
One way is to go on the Medicare.gov website. It actually includes a plan finder that walks you through a decision tree and helps you shop for a plan.
The finder will also direct you to the best Medicare drug coverage for you, based on the medications you take.
You can also talk to someone at the State Health Insurance Information Program. Volunteers there can walk you through your options, and help you decide which coverage is best.
7. What if I need additional financial assistance to pay my Medicare premium?
Some low-income enrollees may qualify for both Medicaid and Medicare. And even if your income is too high to qualify for Medicaid, you may be allowed to subtract medical bills from your income, allowing you to "spend down" to become eligible for Medicaid.
Others may qualify for a government-run Medicare Savings Program to pay some expenses. More information on these programs is available here.
