Top 7 Tips to Help You Navigate Medicare Plans and Benefits

Medicare Benefits Solutions
Jun 10, 2022

If you’re turning 65 soon or qualifying for Medicare due to disability, you may already know about the choices you’ll get to make once you’re eligible. It’s likely that you’ll have options to choose from, depending on where you live, what benefits you need, and your budget requirements.

Medicare is individual insurance, and you deserve access to coverage that meets your needs and preferences. Learning how to navigate Medicare plans and benefits may help you find a plan that’s right for you.

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Help Navigating Medicare

Given the rising medical costs expected with aging, choosing a Medicare plan is often the first step in preparing for current and future healthcare needs. But many people find navigating Medicare to be stressful and confusing.

It helps to break down the process with Medicare tips for seniors. This includes how to navigate Medicare choices, why you should compare Medicare plans, and where to get help with Medicare.

TIP: Find out which Medicare plans offer the most benefits and compare them against your existing coverage.

Insurance Navigation Tips

1. Enrollment dates

The following are the enrollment periods for newly eligible Medicare beneficiaries. Remember these dates to avoid having to pay a late enrollment penalty.

Initial Enrollment Period

The Initial Enrollment Period happens when you can first register for Part A (hospital insurance) and/or Part B (medical insurance, including outpatient physician services). The time frame revolves around your 65th birthday, beginning three months before and ending three months after the month of your birthday.

Tip: Although this period lasts seven months, it is best to enroll during the first three months to ensure coverage begins no later than your 65th birthday. If you enroll during the last three months, the Part B start date may be delayed.

You may qualify for Medicare if you’re under 65 years of age if you’ve been diagnosed with certain disabilities, such as ESRD, or have been receiving benefits from the Social Security Administration or Railroad Retirement Board for 24 months.

Special Enrollment Period

Some people are allowed to delay enrollment in Part B if they have other creditable insurance through a group, employer, or union. Most people get Part A premium-free when they turn 65 due to taxes paid while working. If you have to pay a premium for Part A (not the norm), the Special Enrollment Period includes Part A too. Eligibility applies to people who have group health insurance based on active employment. The period spans eight months from the end of employment or coverage, whichever event occurs first.

Tip: If you are eligible for a Special Enrollment Period, you can sign up at any point while covered under the group plan rather than waiting until employment or coverage ends.

General Enrollment

Suppose you are not eligible for the aforementioned Special Enrollment Period and did not sign up during your Initial Enrollment Period. In that case, you can enroll during the General Enrollment Period, which takes place between January 1 and March 31 every year.

Tip: Be aware that coverage will not start until July 1, and you may have to pay a late enrollment penalty.

2. Medicare enrollment options

Once you sign up for Original Medicare, you have the following options:

  • Add a Medicare Prescription Drug Plan (Part D).
  • Purchase a Medicare Supplement (Medigap) plan.
  • Drop Original Medicare and enroll in a Medicare Advantage plan (known as Part C or MA). MA plans are required to cover both Part A and Part B, but many plans include additional benefits, such as Part D prescription drug coverage, vision care, dental care, hearing exams, and more.

When choosing among these options, consider your comfort level with paying premiums and cost-sharing. For example, many MA plans offer a zero premium, but you are responsible for co-insurance, co-payments and deductibles. You’d still be responsible for your Part B premium, though.

Medicare Supplement plans cover some of these out-of-pocket expenses, but premiums can be high based on the carrier and your location. Please note that you may only purchase a Medicare Supplement if you have Original Medicare. You can’t have both a Medicare Supplement and Medicare Advantage plan.

3. Provider Network

MA plans typically require that you use a provider in the plan’s network either to lower your cost-sharing or to get coverage for the provider’s services. Some MA plans also require a referral from your primary care doctor to see a specialist. With Original Medicare, you can go to any physician or hospital in the U.S. that accepts Medicare, and a referral is usually not needed.

According to Medicare, “participating providers have signed an agreement to accept assignment for all Medicare-covered services.” Assignment means that your healthcare provider or supplier has agreed to accept Medicare’s payment as payment in full, charging you only when deductibles and coinsurance payments apply.

Tip: Medicare provides an online provider comparison tool where you can check if your doctor is a participating provider and accepts assignment. MA plans give you access to plan-specific provider network directories.

4. Out-of-pocket expenses

To avoid surprise expenses, Medicare is forthcoming about out-of-pocket costs. These amounts typically change annually and are announced in the last quarter of the year prior to any changes.

The following are 2022 cost-sharing amounts for Original Medicare. Out-of-pocket costs under MA plans vary.

  • Part A premium: If you don’t get premium-free Part A, you’ll pay from $274 per month to $499 per month, depending on how long you have worked and paid Medicare taxes
  • Part B premium: $170.10 per month standard (may be higher based on income)
  • Part A deductible: $1,556 per benefit period
  • Part B deductible: $233 per year
  • Part A coinsurance: $0 for the first 60 days of inpatient hospital care
  • Part B coinsurance: 20% of the Medicare-approved amount

Medicare Advantage plans have an annual out-of-pocket maximum limit. Once you’ve paid this amount, you will not have to pay anything more for covered services for the remainder of the year. Original Medicare does not have a cap to out-of-pocket costs, so depending on how often and what type of care you require, costs can add up.

Tip: Most Medicare beneficiaries pay no premium for Part A, referred to as premium-free Part A. Your Social Security statement informs you of your eligibility.

5. Maximizing benefits

The Medicare plan that is right for you is the one that offers the benefits you need and will take advantage of. For example, enrolling in a Medicare Supplement plan that includes emergency healthcare services during foreign travel may sound appealing. Still, it may not be worth the extra premium if you are not a traveler.

Medigap plan costs will be based on the plan you choose. The more coverage included will likely equate to a higher premium for the plan.

If Medicare Advantage appeals to you because of extra coverage like gym membership and over-the-counter medications, but you don’t use these services or products, you would not be optimizing your plan’s benefits.

6. Being open to change

You’ll likely get the most out of your search for Medicare options if you are open to change. If you currently use doctors or a pharmacy not in the network, consider switching to a new plan for cost savings. If you have trouble finding a plan that covers your medication, you can ask your doctor if there is a comparable drug on the market that treats your condition.

7. Getting help with Medicare

Navigating Medicare can take a lot of effort, and finding agents with expertise in helping you navigate the Medicare maze can ease your burden. Speak with an insurance agent who will ask questions to help them understand your current and projected healthcare requirements. This will help them filter and find available plans offered in your area.

For basic Medicare information, you can visit the official government website. But you should also take advantage of online plan comparison tools to help you narrow down your options and answer any questions you may have. Licensed sales agents can help provide an unbiased comparison of the plans available in your area and help you find the plan that will get you the benefits you need at a cost you are comfortable with.

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Shopping for Medicare Plans

If you’re starting to compare Medicare plans, consider using a location-specific online plan finder tool. By entering your zip code, you can find the best Medicare plan for coverage of your medications, doctors and benefit preferences. Have a list of medications you currently take on hand to compare prescription drug coverage options.

Once you’re signed up for Medicare, you will have an opportunity to make changes to your coverage during the Annual Enrollment Period that runs from October 15 through December 7. Choosing Medicare doesn’t have to be a complicated process. Use the tools available to explore your options and enroll in a plan that’s going to meet your needs now and in the future.

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