Medicare Overview

Video explanation of Medicare

Understand Your Medicare Options

Medicare Glossary

Medicare Drug Benefit FAQ – 2018

Most Medicare beneficiaries will add a Part D medication benefit to their traditional Medicare A (primarily hospital) and B coverage (primarily physician visits and outpatient services). You may opt, instead, to leave original Medicare and join a Medicare Advantage plan (Part C) to obtain your health and drug benefits. Click here to read a basic framework for understanding Medicare.

Medicare Advantage plans are approved by Medicare and administered by dozens of private insurance companies. These plans provide Medicare Part A and B benefits and MAY include extras such as prescription coverage. They come in many forms, including Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) that have provider networks, and also Private Fee-for-Service (PFFS) plans that do not have provider contracts.

These plans work especially well for people who don’t need many services or for those who cannot afford a Medicare supplement to fill in the gaps in original Medicare. However, a number of these plans are not widely accepted by healthcare providers (physicians, hospitals, home health agencies, rehabilitation facilities, etc.) in North Carolina. Selecting the wrong Medicare Advantage plan can mean denial of services or more costly medical care. In addition, the payment structure for policyholders is very different than traditional Medicare. Frequently, we see people who have enrolled in these health plans without truly understanding the pros and cons.

Senior PharmAssist is the coordinating site in Durham County for the N.C. Seniors’ Health Insurance Information Program (SHIIP). Our staff works closely with the state SHIIP office (1-855-408-1212) to furnish any age/income Medicare beneficiary in Durham with the information she or he needs to make informed judgments about Medicare Advantage and Part D plans, Medicare A & B, employer-sponsored retiree coverage and supplemental insurance.

While Senior PharmAssist provides Medicare insurance counseling year-round to those who are new to Medicare or who have questions, most beneficiaries can only change their coverage during the annual open enrollment period (OEP), Oct. 15 – Dec. 7. All Medicare beneficiaries are encouraged to examine their options each year, as policies and prices change – not to mention that the medication needs of an individual can change from year to year.

During the OEP for 2018, our staff and 17 SHIIP volunteers provided one-on-one counseling to 1,387 individuals, a 9% increase from last year. For the ninth consecutive year, more than half of beneficiaries who had a stand-alone Part D drug plan needed to switch coverage to save money. We helped “switchers” obtain an average projected savings of $1,009 (median of $430) on prescriptions for 2018. Those we had never seen before who switched saved an average of $1,124 (median of $536), and switchers with the most limited income – who had Medicare’s low-income subsidy or “extra help” – saved an average of $2,494 (median of $543).

Part D savings figures do not include those we helped who had employer-sponsored coverage, were new to Medicare or had their drug benefits as a part of their Medicare Advantage plans. A quarter of the individuals we helped during OEP were enrolled in one of the two Medicare Advantage plans that ended contracts in Durham for 2018. This was particularly bad news for people with diabetes who rely on insulin, as one of the plans had covered insulin with small co-payments in 2016 and 2017. The silver lining for Medicare Advantage enrollees whose plan left the area is that it triggered a special enrollment period so they could switch to original Medicare and purchase a supplement without underwriting (charging more for pre-existing conditions). This opportunity was a huge relief to some older adults and literally will save them thousands of dollars per year on medical costs.

If you miss the annual OEP, you may still have the opportunity to sign up for or switch your Medicare-approved drug coverage during the year, depending upon your income and other factors. If you have questions about Medicare and live in Durham, call us at 919-688-4772.