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medicare open enrollment webinar: questions and answers

The following are questions and answers from the webinar held by Acentra Health on November 12, 2024.

Is it correct that if you switch from Medicare Advantage to Original (Traditional) Medicare and want to get a Medigap plan, you will then be subject to underwriting (looking at pre-existing conditions)?

If you switch from a Medicare Advantage plan to Original Medicare and want to get a Medigap (Medicare Supplement) policy, there may be medical underwriting. This means that insurers could look at your health history. Then, they may deny coverage or charge higher premiums based on your existing medical conditions.

However, there are exceptions:

1. Guaranteed Issue Rights: In certain situations, you have guaranteed issue rights. This means that you can buy a Medigap policy without medical underwriting. For example, if you are switching within the first 12 months of enrolling in Medicare Advantage (known as a "trial right"), you can switch to Original Medicare and get a Medigap plan without underwriting.
2. Open Enrollment Period: If you are in your Medigap Open Enrollment Period (usually the six-month period starting the month you turn 65 and are enrolled in Medicare Part B), you can also purchase a Medigap policy without underwriting.

Outside of these periods or exceptions, changing to Original Medicare and trying to get a Medigap plan could have underwriting. The rules for Medigap vary by state. It is important to check with the State Insurance Department to see if you can buy a Medigap policy outside of your Medigap Open Enrollment Period. You may have additional rights under state law.

Please visit the medicare.gov site to see the various scenarios and which rules would apply: https://www.medicare.gov/health-drug-plans/medigap.

For those who do not have access to the internet, please call 1-800 MEDICARE (633-4227) or request the phone number for the State Health Insurance Assistance Program (SHIP) for guidance.

What is the phone number for the State Health Insurance Assistance (SHIP) in Tennessee?

The phone numbers for all the SHIP organizations are listed at www.shiphelp.org.

I am receiving a lot of mail and seeing lots of commercials. What do I need to think about when making a decision about my Medicare for next year?

The mailings and commercials are shown to you because now is the time for everyone on Medicare to consider their health plan option for next year. Please keep in mind that these commercials have paid spokespeople. When you see the Jimmy JJ Walker or the Joe Namath commercials, know that they are paid to endorse certain products.

Here is a helpful hint: If you pause the TV screen at the bottom, you will see a message that if you contact them, you will speak with a licensed insurance agent. It will note that this plan may or may not be available in your area. They are not linked with Medicare.

An option would be to get the facts in writing. Then, do a comparison with someone that you trust. Medicare stays neutral and unbiased. SHIP is also neutral and unbiased. Look at what you are currently enrolled in and see if it will work again for you next year. If not, compare the plans. We at 1-800-Medicare or the SHIP can help with that.

If I am married, should my husband and I select the same plan during Open Enrollment? 

With Medicare Part D, we look at you as individuals. Please know that Medicare is not a family plan. When using the medicare.gov decision tool, you are looked at separately because your health needs may be different. The prescriptions that you take may be different.

Of note: Some of you may have what's known as creditable coverage. Creditable coverage means that your coverage is equal to or better than a Medicare Part D plan.

Some employers, Veteran’s Affairs, Federal Employee Health Benefits Plan, Indian Health Service, and TRICARE are considered creditable forms of coverage. If you have this, your employer will send you a notice that what you have is equal to or better than a Medicare Part D plan. You do not have to sign up for a Medicare Part D plan. However, if that coverage ends, you will have a special election period. You could sign up for a Part D plan at that time. If you are in that situation, that is a little bit different.

If I am pleased with my current plan, do I need to do anything?  

If you are pleased with your current plan, you do not need to do anything. You can stay in that plan. We still suggest that you look to see if there may be changes next year, and make sure that your plan is staying. Some of the plans are leaving next year. There may be changes with cost or what they cover, and it may not be the best fit for you.

What is the difference between Medicare & Medicaid?

Medicare is the national health insurance for people over the age of 65 or under 65 with a disability. You enroll in Medicare through the Social Security Administration.

Medicaid is a joint federal and state program that helps people with limited income and resources. Medicaid also covers services that Medicare may not or may partially cover. These can include a nursing home, personal care, and home and community-based services. Each state has its own rules for eligibility and what they will cover. It also covers people 65 and older, children under 19, women who are pregnant, people living with disabilities, parents or adults caring for children, and children without dependent children in certain states. Those are the main differences.

It is possible for a person to have both Medicare and Medicaid coverage if they meet the requirements. We call these individuals dual eligible.

What is the difference between a Medicare supplement (Medigap) and Medicare Advantage?

The Medigap plan works with original Medicare. With original Medicare, you show your red, white, and blue card to any doctor or healthcare provider. Usually, Medicare pays  80 percent, and you pay 20 percent. This includes any deductibles, coinsurance, or copayments, depending on the service. Medigap fills in those gaps after Medicare has paid its part. Medigap plans are supplemental insurance policies that you can purchase to fill in the gaps.

With a Medicare Advantage plan, you're agreeing to receive all your health care through the plan’s network of doctors and providers.

You may hear terms such as HMO or health maintenance organization, PPO or preferred provider organization, and PSO or provider-sponsored organization. With these, you are agreeing to receive all your care through that network of doctors and providers.

It's going to cover your Part A hospital services, your Part B medical services, and many times, it'll cover your Part D services. Many people like these options because they offer benefits over and above what original Medicare covers. The most common benefits are dental, hearing, gym memberships, transportation, and money for over-the-counter items.

It is important to know that if you want a Medicare Advantage plan, you must be enrolled in both Medicare Part A and Part B. You will continue to pay the Part B premium, but when you're in a Medicare Advantage plan, you do not need a secondary insurance or a supplement.

Before you enroll in a Medicare Advantage plan, make sure that your preferred doctors and providers will take that insurance. There have been times when people are not happy with their selection and that is the main reason. When you have original Medicare and you have a supplement, you can see any doctor or provider who accepts Medicare. Medicare pays, and then the supplement pays.