By Carol A. Cates, MSN, MBA, RN
Chief Nursing Officer
Odessa Regional Medical Center
There are some things I write about at least once a year like stroke, heart disease, cancer, and injury and accident prevention. I write about them because they are conditions that take far too many lives, and I hope that by talking about them, it might help someone catch something early or prevent something awful.
There is one more thing I write about every year, and it’s not a heath condition per se’, but it sure affects how many people deal with their health care, and that is Medicare open enrollment. I write about that because far too frequently I see people struggle with conflicts between the plan they have and the services they need. Open enrollment is the time when you can look at the available options and make sure the plan you have fits the needs you expect to have next year.
Medicare open enrollment started on October 15th and ends on December 7th. Medicare is available under 4 separate plans: A, B, C, & D, each of which covers very specific things. You may also need to consider additional coverage like Medicare Supplement Insurance, also known as Medigap insurance. One very important point about Medicare Part D and Medigap insurance is if you don’t get them when you are first eligible for Medicare, they may cost more later.
Medicare A & B are also known as “traditional Medicare.” Part A covers inpatient stays in a hospital, skilled nursing facility care, skilled nursing care in a nursing home that is not custodial or long-term care, hospice and home health care. Part B covers medically necessary services and preventative services. According to the Medicare.gov website, medical necessity means “services or supplies that are needed to diagnose or treat your medical condition and meet accepted standards of medical practice.” A little more simply, that means part B covers things like ambulance services, some mental health services, and durable medical equipment (DME). Medicare A&B don’t cover long-term (custodial) care, dental care, eye exams, dentures, cosmetic surgery, massage therapy, routine physicals, hearing aids or hearing exams to fit hearing aids, or concierge medical care.
Medicare part C is also known as a Medicare Advantage plan. Those plans are managed by a private insurance company and often include coverage for some of the things Medicare does not, like dental care. But they can also vary widely between plans on the services they do cover. Medicare.gov recommends considering several points when you are deciding on traditional Medicare versus Medicare Advantage plans.
First is cost. Traditional Medicare does not have a limit on your out-of-pocket costs unless you have supplemental coverage (Medigap). Medicare Advantage plans have limits on out-of-pocket expenses.
Second is coverage. This is where you will need to do your research on what is covered, the limits on that coverage and what you think you might need in the future. There are pros and cons to each option and only you and your loved ones can decide which plan best meets your individual needs.
Third is other coverage options. Make sure you understand how other insurance coverage (such as insurance or prescription coverage from a pension plan) interacts with the Medicare plan you choose. Look at Medigap coverage as well and how it interacts with the plan you choose.
Fourth is prescription drug coverage. Prescription coverage can either be through Medicare part D or in conjunction with a Medicare Advantage plan. Some Medigap plans also have prescription coverage. Again, this is a place you want to do some research. I have known more than one person who has had to choose between their medications and the basics of life like food and shelter. Make sure the plan you choose covers the medications you need to stay healthy.
Fifth, look at your options for choosing your doctor and hospital so you get the providers you want. Sixth, look at the quality of the plan you choose. Research ratings on plans and talk to friends and loved ones about their experiences with that plan. Don’t be swayed by an ad on TV.
Finally, consider travel. Traditional Medicare only covers you in the US, some Medigap plans may cover international travel. Some Medicare Advantage plans only cover in certain regions as well. If you are planning on traveling in the US or internationally in the next year, make sure your Medicare plan has you covered for that trip.
Your choices during Medicare open enrollment can have a major impact in your life during the next year, and in the case of Medigap and Part D coverage, if it’s your first year to enroll, on your costs for those plans moving forward. This is one decision where you really want to take the time to do your research on the best options for you. Start considering that decision now, so you have plenty of time to make a decision before the December 7th deadline.
