Editor’s Note: Medicare open enrollment extends to Dec. 7 this year, but questions about this complicated program do not end then. Making Sen$e has turned to journalist Philip Moeller, who writes widely on health and retirement, to answer your Medicare questions in “Ask Phil, the Medicare Maven.” Send your questions to Phil.
Medicare rules and private insurance plans can affect people differently depending on where they live. To make sure the answers here are as accurate as possible, Phil is working with the State Health Insurance Assistance Program (SHIP). It is funded by the government but is otherwise independent and trains volunteers to provide consumer Medicare counseling in state and local offices around the country.
Kathy – Ore.: I am turning 65 in a week but not retiring from work until 66 1/2. Do I have to file for Medicare? I have good insurance through work. Thanks!
Phil Moeller: I am a great fan of “yes” or “no” answers – really I am! And I wish I could use them more often. But with Medicare (and most other government benefit programs), I have to begin my answer with, “It depends.”
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People with group health policies through their employer generally do not have to sign up for Medicare when they turn 65. They, or you in this case, can keep your employer coverage until you retire. You will then have eight months within which to sign up for Medicare without facing any penalties for late enrollment.
The “depends” part of my answer is linked to the size of your employer. If your employer has fewer than 20 employees and you are 65 or older, Medicare usually assumes what is called the “first payer” role. This means that you would need to sign up for Medicare. It would be your primary insurance and your employer plan would provide secondary coverage, kicking in where Medicare did not provide coverage. Your employer should be able to provide you more information on whether you need to do this and how to do so. Even at employers with fewer than 20 employers, there is an “it depends” aspect to this answer. Your employer may have pooled its coverage with other companies to form what’s called a multi-employer plan. This would permit you to avoid filing for Medicare when you turn 65. There are other “it depends” details here.
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And while you didn’t ask, the definition of signing up for Medicare in most cases means you need to sign up for Part B of Medicare, which covers certain doctor, outpatient and medical equipment expenses. If you’ve worked long enough to qualify for Social Security retirement benefits (at least 40 quarters of covered employment where you’ve paid Social Security payroll taxes) you automatically get Part A hospital coverage at no cost. You are not legally required to get Part D drug coverage, although you probably should get it or Medicare Advantage or Medigap.
Richard — Mass.: How can I find out what medicines my Part D plan covers? What is the monthly cost for myself and my wife?
Phil Moeller: To the Batcave, Robin. Or, in this case, to Medicare’s Plan Finder. You can find out which medications are covered by your Part D plan, and what they will cost, by looking at your plan’s formulary, or list of covered prescription drugs. You can also call your plan or 1-800-MEDICARE (TTY 1-877-486-2048).
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Once you’ve set up separate formularies for you and your wife, Plan Finder will tell you the projected out-of-pocket expenses for 2015 for all the plans offered in the ZIP code where you live. This is a powerful shopping tool but, yes, it will take some time.
You may already have a Part D plan that you like. And you may be able to view its formulary on your plan’s website or get a printed copy from your plan. But this is, after all, Medicare open enrollment season (until Dec. 7), so I am pushing comparison shopping today. You might be surprised at how much money you could save by switching to another plan.
Your monthly costs will depend, of course, on the precise drugs you and your wife need to take. There also could be what I call a convenience factor at work here. More and more drug plans are doing preferential deals with big drugstore chains. The insurer and, to a lesser extent, you, get better drug prices and the chain gets preferred access to consumers. Drug plans with these deals may charge higher prices if you get your prescriptions filled at a pharmacy that’s not part of its preferred network. Your favorite neighborhood pharmacy could be the odd man out here. You need to consider if that’s OK or if you’re willing to pay extra for convenience and to keep hearing your pharmacist laugh at your stale old jokes.
Diane – R.I.: Do all drug manufacturers sell their drugs to Medicare Part D plans at the same price, or do Part D plans negotiate drug prices with manufacturers? In other words, is it possible to pay less for what is generally considered a Tier 3 drug (very expensive) by shopping around for a Part D plan? My script generally increases in price by more than $2,000 every three months. My most recent script for a three-month supply cost my Medicare Part D insurer $20,000. Thank you.
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Phil Moeller: Your drugs are so expensive they must be generics! Just a bit of Medicare Maven humor given the skyrocketing prices of many generics. Hey, I feel your pain — literally. I also get to pay an outrageous amount of money so I can stick a spring-loaded injector into my body. But enough of such fun. Part D plans are able to negotiate drug prices with manufacturers. That means drug prices can vary by plan. However, it’s unusual for them to jump around a lot during a plan year. So, you might ask your insurer what’s up with that.
Prices can also vary depending on which pharmacy you use in a plan’s network. As I told the previous questioner, spending time on Plan Finder might be very worth your while, especially during open enrollment. It’s possible you may be able to save money and pay less by shopping around. And you also can call 1-800-MEDICARE (TTY 1-877-486-2048) to get personalized assistance and cost-comparison details.
Annie – Ariz.: I have just read your Oct. 15 NewsHour column, “Medicare’s open enrollment is health care’s Groundhog Day,” and I need clarification on Part A Medicare. This article states “the hospital deductible will be $1,260 for each benefit period… There is zero coinsurance for the first 60 days of a hospital stay.” I have a Medigap Plan G insurance with a policy from Columbian Mutual Insurance which picks up charges that Medicare does not pay. Does the above mean that my Columbian insurance will NOT pay that initial $1,260 charge should I have to have a hospital admit, and I would be responsible for it myself?
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Phil Moeller: Sorry for any confusion, Annie. You will not be on the hook for this deductible. The $1,260 figure assumes you have only Part A hospital coverage. But you have a Medigap policy; details of these plans were explained in an earlier Ask Phil column. In the case of Medigap Plan G, you won’t have to pay for the $1,260 Part A deductible if you’re admitted for inpatient care in a hospital. Your Medigap Plan G will pay that cost for you.