by: Margie Johnson Ware, Aging and Health Specialist.
So you made it through Open Enrollment and crossed “re-evaluate my Medicare options” off your to-do list. You had your Medicare card. You were feeling good, accomplished even. Then you tried to make a doctor’s appointment, and it went a little something like this:
“Has your insurance changed?”
“Yes, I have the new XYZ plan. It has a zero premium and I’m so glad I’m saving money!”
“Well, we don’t take Plan XYZ. Sorry!”
The news might come in a different form. Your pharmacist might tell you that the new plan doesn’t cover one of your important medications. Or it covers all your medications, but the copay is WAY higher than last year. No matter what the case, your perfect Medicare plan isn’t looking so perfect anymore. Luckily, there may be a way to address these problems—depending on your situation. Let’s examine them.
1. You switched to a Medicare Advantage (MA) plan that you don’t like.
Don’t like your new Medicare Advantage plan? Good news! You have from January 1 to February 14 (the Medicare Advantage Disenrollment Period) to drop out of your new MA plan. However, you cannot join another MA plan this year, and your coverage will go back to Original Medicare (Parts A and B). You should also add a Part D plan if the MA plan you’re leaving included drug coverage—you have until February 14th to do so.
Additionally, be aware that you might not be able to get a new Medigap policy to help cover the cost gaps from returning to Original Medicare (many beneficiaries cannot afford Original Medicare without a Medigap policy). Some states have “continuous open enrollment” for Medigap, or have liberal rules about underwriting new policies. Other states have much stricter policies. You can learn more about how switching out of Medicare Advantage may affect your Medigap enrollment opportunities here.
Missed the February 14th Medicare Advantage Disenrollment Period deadline? You’ll have to wait until next year’s Medicare Open Enrollment Period (OEP) to make changes to your plan.
2. Your doctor won’t take your new MA plan.
Whether this is your first time joining a Medicare Advantage plan—or you’ve recently switched from one MA plan to another—it is important to have coverage that works with your local care options. If you find out that your doctor doesn’t take your new plan, you can still drop your MA plan and revert to Original Medicare during the Medicare Advantage Disenrollment Period.
But before you do that, call the plan and ask to speak to someone in Provider Relations. It’s possible that your plan has never reached out to your physician group and asked them to join. Before leaving your new MA plan altogether, it’s worth finding out whether your current provider is willing to join your plan’s coverage network.
3. You can’t use your new Part D plan at your pharmacy, it doesn’t cover your drugs and/or the copays are more than you anticipated.
First of all, it’s always a good idea to shop pharmacies for both price and convenience. Does your new plan not cover the drugs you need? Before rushing to change your plan, try taking the list of covered drugs (called a “formulary”) to your doctor—they can help you figure out if an alternative medicine (that is covered by your new plan) would work.
If your Part D plan still doesn’t work for one or more of your medications (or the medications are prohibitively expensive), ask the prescribing physician whether they have samples you can use until your coverage problem is resolved. Do they know of a program from the drug manufacturer that will allow you to purchase the medication at a reduced rate? There may be a way to work with your existing plan by asking for a tiering exception or coverage determination. You can also check out NeedyMeds.org, a nonprofit site dedicated to helping people find ways to afford their medications.
If none of the above fits your situation—and you are outside of the enrollment period for switching your Part D coverage—you might still have some options, depending on your situation. If your state has a State Prescription Assistance Program (SPAP) and you belong to that program, you may have the option of making one extra change in your prescription coverage during the year. If you don’t belong, find out if they have open enrollment or what the rules are for you to join.
There are other special situations that may allow you to switch your Part D coverage outside of the Medicare Open Enrollment Period (OEP). If there’s a 5 star Part D plan available in your area, you can join it any time during the year. You can see star ratings on the “Medicare Drug and Health Plan Finder” at Medicare.gov. Additionally, if you receive Extra Help with your Medicare prescription drug costs, you can switch plans as often as once a month. Moving between states or entering a nursing home may also allow you to change plans. However, if none of these exceptions apply to you, you may have to stick with your current Part D plan until next year’s OEP.
4. You’re unhappy with your coverage–but you’re not sure what to do next.
Not sure what the right course of action is? We recommend you start by trying the Medicare Questionnaire tool, created by the non-profit National Council on Aging. The tool can help you compare coverage options, and provides access to free, trustworthy Medicare advice from a licensed benefits advisor. You can also find excellent advice from your local State Health Insurance Program (SHIP), a federally funded program that provides free Medicare counseling from trained staff members. Medicare advisors have a variety of resources that they can tap into to try and solve your problem in the short-term while a longer-term answer is being researched.
Picking the right Medicare plan can be incredibly complicated, and many beneficiaries run into problems they didn’t anticipate. The important thing is to address your concerns immediately. Get good advice about exactly what you can and cannot do, and what costs might arise for you in the future. Only by having accurate information can you make an informed choice about your next steps.