Introduction to Medicare Program Recap

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Thank you to Kelly Ott from the State Health Insurance Assistance Program for Mercer County presenting on the different aspects of Medicare and diving into some of the complexities that exist within each part.  Each part of Medicare covers different aspects of physical medical care and as such, has different premiums, deductibles, cost sharing for services, and rules for enrollment.  Therefore, it is important to be familiar with your options, as well as organizations that can help you ensure that you are properly enrolled and getting the best coverage for your personal medical needs.

Eligibility and Enrollment

Medicare is a federally funded medical insurance program that is funded by income taxes.  Medicare eligibility begins at age 65 or if an individual has been receiving Social Security Disability payments for 24 consecutive months.

There are 4 enrollment periods that you can take advantage of:

  1. Initial Enrollment Period – This is a 7-month period that starts 3 months before turning age 65. You will receive a mailed document in which you can enroll in Part A and B or, if you are currently employed and under an employer-sponsored medical insurance plan or under your spouse’s, you can delay enrollment.  If you enroll after the month you turn 65, there will be a delay in Part B.
  2. General Enrollment Period – This occurs every year from January 1 – March 31. If you enroll during this period, the coverage starts one month after you sign up.
  3. Special Enrollment Period – This period is designed for individuals who were on a different medical plan at age 65 and deferred enrollment. If you fall under this category, you can enroll in Medicare without a penalty if you enroll within 8 months of the termination of your previous coverage.
  4. Open Enrollment – From October 15th – December 7th, individuals enrolled in Original Medicare or a Medicare Advantage plan can change their coverage options.  This includes switching Medicare Advantage plans or switching from Medicare Advantage to Original Medicare.

If you are collecting Social Security benefits, you will automatically be enrolled in Medicare.

Medicare Part A

Part A of Medicare is your hospital insurance and covers things like hospital stays (bed, board, general nursing care), skilled nursing care at an approved facility (rehab), home health care services, hospice care, and blood transfusions.  There is a monthly premium for Part A, but that is waived if you or your spouse has “paid” into Medicare for at least 10 years (40 quarters) through federal tax withholding.  There is not late enrollment penalty should you refuse to enroll in Medicare when your turn 65.  There is a deductible of $1,600 for hospital stays if you do not have supplemental or Medigap insurance.  There are also copays for each hospital stay after 60 days as well as for inpatient rehab stays after 20 days.  It is worth noting that if you receive inpatient care at a hospital that can be provided elsewhere, that will be covered under Medicare Part B.

Medicare Part B

Part B of Medicare is often referred to as the medical insurance part.  Part B covers doctor’s services, outpatient medical services, diagnostic testing, preventative health care services, and other services.  It will also cover ambulance services only if other transportation would endanger your health.  The monthly premium for Part B has yet to be released, but was $174.700 for 2024 and is based off of your last income tax return.  If your annual gross income is more than $103,000 (single) or $206,000 (joint), you will pay a higher premium.  If your monthly income is less than $1,695 (single) or $2,300 (joint) and assets less than$9,430 (single) or $14,130 (joint), you may be eligible for the SLMB program that will pay your Part B premium.

There is an annual deductible for Part B that has yet to be released but was $240 in 2024 and once that deductible is met, Medicare will pay 80% of the Medicare approved rate for covered services.  If a provider accepts Medicare assignment, they cannot charge more than the Medicare approved rate; if a provider does not accept Medicare assignment, they may charge up to 15% over the Medicare approved rate.

Once you become eligible for Medicare, you must enroll in Part A, but you can defer Part B enrollment if:

  • You are still working and covered by health benefits from a large employer (20 or more employees)
  • Covered by your working spouse’s large employer

However, you MUST enroll in Part B if you:

  • Are on COBRA
  • Covered by a small employer
  • Have retiree coverage only
  • Have Marketplace coverage
  • Have no other healthcare coverage

Medicare Part C

Part C is often called Medicare Advantage and oftentimes includes a prescription drug plan (Part D).  Medicare Advantage plans are offered by insurance companies contracted by Medicare.  These plans are either HMO, which requires you to stay within a network, or PPO, which allows you to go out-of-network for a fee.  Within these plans, specific doctors, hospitals or labs may be required, pre-approvals or referrals may be needed, and co-pays will differ.  Be aware that doctors may leave a network at any time so be sure to verify that they are covered under the plan.  All medical claims will be process through the insurance company rather than Medicare and you only need your Medicare Advantage card when visit a doctor or hospital.  These plans may also offer additional benefits not found in traditional Medicare, including vision, dental, and hearing coverage as well as gym memberships.

Premiums with Medicare Advantage plans ranged anywhere from $0 to $157 per month in 2024; numbers for 2025 plans are still being finalized.  Additionally, primary doctor co-pays ranged from $0 to $35 and specialist co-pays ranged from $5 – $50 in 2024; numbers for 2025 plans are still being finalized.  The maximum amount of out-of-pocket expenses on medical for in network care is capped at $9,350 – $14,000 per year, depending on the plan, and after that, the Advantage plan will pay all medical costs.  Each county will have different approved plans so it is important to review all available plans, especially during annual enrollment (October 15 – December 7) and use the Medicare Plan Finder tool to check your medications.

Medicare Part D

Part D is the prescription drug coverage of Medicare and although it is optional, once you become eligible for Medicare, you must have creditable drug coverage.  Creditable drug coverage includes any Medicare Advantage plan or employer, union, or retiree coverage.  Things such as prescription discount cards (Good RX), drug manufacturer programs, and pharmacy or supermarket programs are not considered credible drug coverage.  All insurance companies contracted by Medicare include a prescription drug plan that covers at least 2 prescription drugs in each treatment class, covers insulin and supplies for injection (does not cover test strips), and covers most vaccines, including the vaccine and fee to administer.  However, if a drug is not on formulary, you will have a pay the full cost of the drug.

Drugs on the formulary vary by tier and each tier comes with a different cost.  The tiers are as follows:

  • Tier 1 and 2 – Generic medications
  • Tier 3 and 4 – Brand name medications
  • Tier 5 – Specialty medications
  • Tier 6 – Clinically effective, low cost medications, but not offered by all plans.

There is a penalty associated with late enrollment for Part D.  If a Medicare eligible individual does not have credible drug coverage for any period over 2 months, that person will be charged a monthly penalty of 1% of the national Part D premium ($0.33 in 2020), recalculated annually, for as long as the individual remains without coverage.  This penalty will be added to the monthly premium of a Part D plan and continues for the lifetime of the individual or as long as the individual is enrolled in any drug plan.

Premiums for Part D plans in NJ in 2024 will range from $0 to $130.80 per month, depending on the plan; the average premium is $62.  Additionally, there may be a deductible, up to a maximum of $590 that must be met before any financial contribution from the prescription drug plan.  After the initial deductible period, there are 3 different coverage period with different corresponding coverage amounts:

  • Deductible – Up to $590
  • Initial Coverage Period – You pay the percentage of the drug costs as defined in your plan until the total cost of your medication, including money paid by the plan, reaches $2,000. Things that do not count toward this cap include plan’s monthly premium, any drugs not on the plan’s formulary, and any drugs filled at a non-network pharmacy.
  • Catastrophic Benefit – You pay $0 for the remainder of the year; everything is covered by your plan.
  • Coverage Gap/Donut Hole has been eliminated!

It is important to make sure you find the most affordable plan based on your medications and financial situation, so it is highly recommended to use the Medicare Plan Finder tool to compare your options.  Remember to look out for quantity limits, prior authorizations, and step therapy requirements that may require you to try other medications before the plan will approve and pay for one recommend by your doctor.  It is  recommended that you review your plan every year during the annual enrollment period between October 15 and December 7.

New Benefits

There are some new benefits that have come out of the pandemic and the Inflation Reduction Act.  In regards to COVID, all initial vaccine and booster shots are completely covered.  Testing for COVID is covered as well, but a prescription is needed for each test after the initial test; this occurs for each instance of COVID.  Antibody testing is also covered as well as all related treatment.  At home tests are NO LONGER covered by Medicare.

There is a new prescription payment program available called the Medicare Prescription Payment Plan that will allow prescription payments to be paid on variable installments throughout the year.  This will not reduce the cost of any prescriptions, but will assist enrollees with high cost sharing early in the calendar year.  However, the MPPP will not be available to those who are currently receiving assistance through any prescription assistance programs from the state of New Jersey, such as PAAD or Senior Gold.

Continuing Benefits

Starting January 1, 2023, all brands of injectable insulin were capped at $35 a month; insulin through DME pumps will be capped at $35 starting July 1, 2023.  The $35 cap does not apply to disposable insulin pumps (ex Omnipod) or to non-insulin diabetic drugs such as Ozempic or Januvia.

All approved adult vaccines must be on the plan formulary with $0 cost sharing, which includes the shingles (Shingrix), flu and Tetanus-Diphtheria-Whooping Cough vaccines.

Extra Help

There are some programs, at both the federal and state levels, that can help pay for some or all of the costs of your Part D plan.  At the federal level, there is the Federal Extra Help program, which you are automatically enrolled in if you are on Medicaid or receive assistance with your Part B premiums.  At the state level, there is PAAD and the Senior Gold prescription discount program.  PAAD will enroll you in a Part D plan and pay all premiums and any late enrollment penalties.  There is a cap of $5 for generic and $7 for brand name covered medications, but you must meet certain income limits to qualify: less than $52,142 per year if single and less than $59,209 if married.  The Senior Gold prescription discount program, while less comprehensive than PAAD, will enroll you in a Part D plan at any point in the year, but does not cover any penalties or premiums.  You will only be required to pay $15 and then 50% of the remaining balance of your medication and the income requirements are less restrictive: $62,142 per year if single and $69,209 if married.  You can apply for all of these programs by filling out the NJ Save application, available at https://www.state.nj.us/humanservices/doas/home/ap2.html.

Final Thoughts

Medicare can be a complex and difficult issue to navigation, especially when you add in Medicare Advantage plans that can change from year to year.  It is highly recommended to review all of your Medicare information each year as the annual enrollment period approaches (October 15-December7).  If you need help with enrolling in Medicare, Medicare Advantage plans, or government assistance programs, please reach out to your county State Health Insurance Assistance Program office.  If you are having trouble locating your county SHIP office or live in Mercer County, please reach out to Kelly Ott at mercercountyship@gmail.com or 609-273-0588.  You can find your county SHIP office by visiting https://www.nj.gov/humanservices/doas/services/q-z/ship/.

You can download a copy of the presentation slides at https://www.njstatelib.org/wp-content/uploads/2023/11/Presentation-Slides.pdf and view a recording of the webinar at https://youtu.be/inIuHjFQAwU.