Making sense of the annual election period

Medicare’s Annual Election Period began Nov. 15 and runs through Dec. 31. This is when people eligible for Medicare have the opportunity to re-evaluate their health care options and sign up for or switch their current coverage in Medicare Advantage and Medicare Prescription Drug plans.

In order to make certain the Medicare coverage you choose is best suited to you, there is helpful information available through many sources.

A first step: Be sure to look for your Annual Notice of Change, which will advise about upcoming changes to your existing plan. Review this document carefully so you can make an informed decision on remaining in your current plan or enrolling in a plan that may better meet your personal health care needs.

Even in today’s economy, when it comes to choosing health care and prescription drug plans, there are important things to consider beyond just the price.

In fact, it’s worth taking the time to learn the ABCs — and D’s — of choosing a plan.

Those letters stand for the four parts to Medicare:

1. Medicare Part A is hospital coverage and covers inpatient hospital care, inpatient stays in most skilled nursing facilities, Hospice and home health services.

2. Medicare Part B is medical coverage for doctor and clinical lab services, outpatient and preventive care, screenings, surgical fees and supplies, physical and occupational therapy.

3. Medicare Part C (also called Medicare Advantage) combines Parts A and B. It is an alternative to getting Medicare Part A and Part B coverage separately. Medicare Advantage plans combine hospital insurance (Part A) and medical insurance (Part B) into one plan, and can also be combined with Part D prescription drug coverage.

4. Medicare Part D is prescription drug coverage and can be a stand-alone plan (not joined with other insurance) or, they can be combined with a Medicare Advantage plan.

When choosing Medicare Advantage coverage, here are some things to consider:

Compare: Your health, finances or coverage may have changed since last year. Compare your current plan with other available coverage options to see if there is a better choice.

Cost: How much are your current premiums and deductibles? How much will you pay for hospital stays or doctor visits?

Doctor and hospital choice: Does your current doctor accept the health care plan you are considering? If considering a PPO (Medicare Advantage Preferred Provider Organization) or HMO (Health Maintenance Organization) plan, would you be limited to choosing your hospital and health care providers from a network? Would you need a referral to see a specialist? If considering choosing a new physician, call and find out if they are accepting new patients?

Prescription drugs: What are your prescription drug needs? Do you need to join a Medicare Advantage plan with prescription drug coverage or a standalone Medicare Part D prescription drug plan? What will your prescription drugs cost under each plan and does each plan provide coverage in the coverage gap (the “donut hole”)? Are your drugs covered under the plan’s formulary (drug list)?

Quality: Does the plan focus on prevention, as well as treating illnesses? Are your doctors and pharmacists working together to address your health care needs?

Convenience: Where are doctors’ offices located? What are their office hours? Which pharmacies are available and nearby? Do you know who to call when you have questions? Will you be able to talk with one person who understands your overall health needs?

There are many excellent insurance agents who can help answer your questions regarding the Annual Election Period. With so many choices available to people with Medicare, make sure you are educated on the subject and understand your options. You can also visit the Centers for Medicare and Medicaid Services (CMS) website for more information, visit www.medicare.gov.

Bob Downs is a vice president and general manager of Universal American in Maine.

Original Medicare vs. Medicare Advantage

During the Annual Election Period, people eligible for Medicare may change Medicare Advantage or prescription drug plans, return to the Original Medicare plan, or enroll in a Medicare Advantage or prescription drug plan for the first time.

The Annual Election Period — from Nov. 15 to Dec. 31 — for coverage effective Jan. 1, 2010 is the time when people with Medicare decide which plan best suits their health care needs.

Navigating through Medicare can be a challenge, but it’s important to take the time to understand your options. Asking the right questions and understanding plan options can help you make better decisions when selecting a plan.

There are important differences between Original Medicare and Medicare Advantage Plans.

Original Medicare

Original Medicare consists of Medicare Parts A and B. It is a fee-for-service plan and covers many health care services and certain drugs. With this kind of plan, people with Medicare can visit any doctor or hospital that accepts Medicare.

It’s important to know that, although Original Medicare pays for many health care services and supplies, it does not pay all health care costs. There may be gaps in some coverage and the patient is responsible to pay for such things as coinsurance, copayments and deductibles.

To cover these gaps in Original Medicare coverage, individuals may purchase Medigap or Medicare Supplement policies.

Medigap plans are private insurance plans that cover the coinsurance, copayments and deductible costs not covered by traditional Medicare. The person with Medicare pays a separate premium for Medigap in addition to their Medicare Part B payment.

With original Medicare, people with Medicare may also enroll in a stand-alone Medicare Part D Prescription Drug plan.

Medicare Advantage

Medicare Advantage plans provide the same coverage as Medicare Parts A and B and may also include prescription drug coverage. In addition, these plans usually cover services not provided by Original Medicare, such as preventive services, health and wellness programs, and extra value-added services.

Medicare Advantage plans are health plans approved by Medicare but facilitated by private health insurance companies. These plans may cover more services than Original Medicare alone and often have lower out-of-pocket costs.

Some Medicare Advantage plans also include prescription drug coverage. These plans are known as Medicare Advantage Prescription Drug Plans (MA-PD).

There are several types of Medicare Advantage plans, including: HMO (Health Maintenance Organization), PPO (Preferred Provider Organization), and PFFS (Private Fee-for-Service) plans. With Medicare Advantage HMO plans, members choose from a contracted network of doctors and hospitals to get covered services. Medicare Advantage PPO plans, allow you to choose doctors who are part of a particular network and also have benefits that can be accessed outside of the network usually at additional costs to the member. Medicare Advantage PFFS plans provide individuals the freedom to choose any doctor or hospital of their choice who accepts Medicare and the plans terms and conditions.

To join a Medicare Advantage plan, you must 1) live within the service area of a Medicare Advantage plan, 2) be eligible for Medicare Part A and 3) be enrolled in Medicare Part B. You must continue to pay your Part B premium and, in some instances, you might have to pay an additional premium for the Medicare Advantage plan. However, many Medicare Advantage plans do not require you pay an additional monthly premium and may offer plans with zero premium.

Bob Downs is a vice president and general manager of Universal American in Maine.