USA/Health—
(StatePoint) Each fall, the Annual Enrollment Period (AEP) for Medicare, which runs from Oct. 15 to Dec. 7, is an opportunity for people eligible for Medicare to choose the health plan that will work best for them in the coming year.
While Original Medicare provides broad coverage, there are some services that aren’t covered, including many that people are likely to need as they age, according to Jane Funk, vice president of Medicare Market Growth with HealthSpring, which offers Medicare and supplemental policies across the country.
For starters, it’s important to know that people who choose Original Medicare generally remain responsible for deductibles and coinsurance, and there is no annual out-of-pocket maximum. Either Medicare Supplement or standalone Supplemental Health & Life policies can help with some of those costs. Medicare Advantage (MA) plans have annual limits on out-of-pocket spending for covered services, but costs, networks and authorization requirements vary.
Funk points to the following areas that can be particularly tricky for those looking to secure their coverage for the year ahead.
Routine dental, vision and hearing care. Original Medicare generally doesn’t cover routine dental care or dentures, routine eye exams for glasses or contacts, or hearing aids. Many MA plans or standalone dental, vision and hearing policies offer additional benefits in these areas. Services, provider networks, frequency limits and member costs vary so make sure you know exactly what is covered.
Hospital status. Hospital services can also trip people up. Someone may spend several nights in a hospital but still be classified as an outpatient receiving observation services rather than as an inpatient. Under Original Medicare, that distinction can affect both the hospital bill and whether a subsequent skilled nursing facility is covered. Patients or their caregivers should ask directly: “Am I admitted as an inpatient, or am I here under observation?”
Annual wellness visits. An annual wellness visit is not the same as a traditional comprehensive physical. The wellness visit focuses on preventive planning and assessing health risks. If the provider performs additional tests or addresses medical concerns, deductibles or coinsurance may apply. Some MA plans offer more comprehensive annual exams at no additional cost to the member.
Prescription drugs. Many people assume they have outpatient drug coverage under Original Medicare, but they do not. Original Medicare doesn’t include outpatient prescription drug coverage; beneficiaries need a separate drug coverage plan, called a Part D plan, or they need an MA plan with Part D included (MAPD) for that. Each plan has its own formulary, pharmacy network and coverage rules, such as prior authorization, step therapy or quantity limits. Just because a medication is prescribed doesn’t mean it will be covered by a specific plan.
International care. Original Medicare provides very limited foreign travel coverage. Medicare Supplement and plans may offer certain emergency benefits abroad, but Medicare beneficiaries with any Medicare plan should verify those provisions before traveling, rather than assume their usual coverage will follow them.
Watch out for fraudsters
One last note. Being wary of unsolicited calls from fraudsters about Medicare plans is important. Do not provide insurance or personal information without verifying that you are speaking to a legitimate Medicare provider. If you are not sure who you are speaking with, hang up and call back using a number from a verified source, such as the back of your Medicare card or a website. Credible sources of information include Medicare.gov and HealthSpring’s website at https://HealthSpringMedicare.com/LearnMore.
“Plan benefits, formularies and networks can change, and so can one’s health, so people should never assume that last year’s plan will still fit their needs best,” says Funk. “Spending time doing research can prepare people to make an informed decision during AEP.”
HealthSpring products and services are provided exclusively by or through operating subsidiaries of Health Care Service Corporation, a Mutual Legal Reserve Company.
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