Medicare Overview

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.

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 they need 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.

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.