OPPORTUNITIES TO CHANGE YOUR MEDICARE ARRANGEMENTS

Here are the several opportunities which are open or will open for Medicare beneficiaries to enter, leave, and change Medicare Advantage plans (Medicare managed care, also known as Part C) and Medicare Part D prescription drug plans. And, even if a beneficiary doesn’t have Part B, to get it (and even Part A). Some of these opportunities are quite time limited, and you need to use them to make sure you are in the very best Medicare arrangement for you.

The 2013 Annual Election Period (Open Enrollment)

Medicare beneficiaries have received their Medicare & You 2013 booklets, and this signals the beginning of the Open Enrollment period where beneficiaries can make changes which will go into effect on January 1, 2013. (This is sometimes also called the Annual Coordinated Enrollment Period.)

Of extreme importance is that the open enrollment period will begin on Monday, October 15 and run only until Friday, December 7 of 2012 – this is the different and earlier time frame that started last year, so remember, you generally have only until December 7 to make a change to how you get your Medicare and / or which Medicare Advantage and / or Part D Drug plan you use. Remember that you can, beginning October 15:

If you are in Original Medicare, you can join a Medicare Advantage plan. If that plan does not have a Part D benefit, you can join a Part D stand-alone prescription drug plan, or, if you are already are in Medicare Advantage plan, you can stick with it (if it is staying in Medicare) or switch to a different one.

If you are in Original Medicare, and you want to stay in it, you can join a Part D stand-alone prescription drug plan, or, if you are already are in one, you can stick with it (if it is staying in Medicare) or switch to a different one.

If you are in a Medicare Advantage plan, you can go into Original (fee-for-service) Medicare, or a switch to a different Medicare Advantage plan or stay in the plan you have (if your plan is continuing into 2013). If the Medicare Advantage plan you join or stick with has a Part D prescription drug benefit, you will use it for your Part D. If it does not, or if you go into Original Medicare, you can join a stand-alone Part D plan.

So there are lots of options. And you should take the time to seriously consider each of them. The Centers for Medicare & Medicaid Services (CMS) tell us that both Medicare Advantage and drug plan premiums will be, on the whole, holding about steady in 2013 from 2012. But this does not mean that the Medicare Advantage plan or drug plan you are with won’t change its premium. And it may be that there is another Medicare Advantage plan or drug plan available for 2013 that’s a better deal, benefits, premiums, and quality all considered, than what you have now. And for those not in a Medicare Advantage plan or drug plan, this is the time for you to see if joining one or the other is best for you. And although many of the news articles and advertising for plans are directed at seniors, disabled beneficiaries should strongly consider a Medicare Advantage plan, especially considering the generally large Medigap premiums you otherwise might face.

And a couple of quick notes about Medicare Advantage plans. For one, almost all types of these will have out-of-pocket limits. That is, after you reach a certain amount of medical expenses (Part A and B) that you have had to pay yourself, you won’t have to pay anything. (This does NOT apply to Part D.) This catastrophic protection feature became mandatory last year and continues in 2013; this requirement is a safety valve available to you that is not present in Original Medicare. Also, Medicare Advantage plans will not be able to charge you deductibles or co-payments for any preventive services that are free in Original Medicare, that is, they will be free to you also.

And two minor improvements have been made to Part D in 2013. If you hit the donut hole, your plan will now pay 52½ percent of your coinsurance on brand-name drugs (up from 50 percent in 2012), and it will now pay 21 percent of the cost of your generics (up from 14 percent in 2012). So if you are not in Part D, these are reasons to think about joining it now.

So take action to review what’s available to you for 2013. Go onto www.Medicare.gov and go to the “Plan Finder;” (look for “Find health and drug plans.”) If you’re not good with computers, have a child, grandchild or friend help you. Or call 1-800-MEDICARE, or call your State Health Insurance Counseling Program (SHIP); their toll-free number will be on the back of your Medicare & You 2013 booklet.

Special Enrollment Period (SEP) for Beneficiaries in Non-Renewing Plans

If your Medicare Advantage plan (Part C) or Part D prescription drug plan decided to terminate its relationship with Medicare, that is, it did not renew its contract with Medicare for 2013, remember that you have a “special enrollment period” (SEP) to enroll in a new Medicare Advantage plan or prescription drug plan. Specifically, beginning on Saturday, December 8 (the day after the end of the Annual Enrollment Period), and continuing to Thursday, February 28, you can choose a Medicare Advantage plan or a Part D prescription drug plan. If you enroll in one on or before December 31, 2012, your enrollment will be effective January 1. If you enroll any day in January 2013, your enrollment will be effective February 1. If you enroll any day in February 2013, it will be effective March 1.

But the best strategy is to either enroll during the regular Open Enrollment period, or using this special enrollment period during December. This way, you will be continuously covered, and you can start burning through any annual deductible(s) you may be subject to beginning January 1. So get going and make your choice. If you are enrolling in a new Medicare Advantage plan, be sure to talk to your physician(s) and other heath care providers to see if they will “take” your plan before you enroll.

And there is a restriction on this. If you are in a stand-alone Part D drug plan, you can only join another such plan or a Medicare Advantage plan with drug coverage.

And if you are in a Medicare Advantage plan, and decide that you want to go back to Original Medicare, you can join a stand-alone Part D drug plan. And if you don’t enroll in a Medicare Advantage plan, you will automatically be put back into Original Medicare on January 1, 2013. And if you are 65 or older, you will have a right to purchase a Medigap policy (Medicare Supplement policy). Specifically, you will have the right to buy a policy A, B, C, F, F-High, K or L. But your opportunity to exercise this right to a “guaranteed issue” to such a policy only exists from November 4 until March 4. (Your state may have more expansive rules about your Medigap opportunities.)

The 2013 Special Enrollment Period (SEP) for 5-Star Plans

As soon as the Annual Coordinated Enrollment Period ends, a special enrollment period (SEP) will open on December 8 and will be continuously open from then and throughout 2013. This will allow a Medicare beneficiary to sign up for a 5-Star Medicare Advantage and / or a 5-Star Part D drug plan.

Medicare assigns quality ratings to all Medicare Advantage plans and Part D drug plans. These ratings, which are shown in the Plan Finder on www.Medicare.gov, are based on a number of factors, but the highest ranked plans, those with five stars, are considered the best. In order to reward these outfits for striving to serve beneficiaries most effectively, a beneficiary can enroll in a 5-Star Medicare Advantage and / or a 5-Star Part D drug plan whether they are in Original Medicare or are already in a Medicare Advantage and / or a Part D drug plan. A beneficiary can enroll beginning on December 8 and any day thereafter, and their enrollment will be effective with the first day of the month following their enrollment. A beneficiary can do this only once for an enrollment effective in 2013.

Note that achieving this rating is not easy, so it well may be that you won’t have a 5-Star option available to you. And, s always, if you are enrolling in a new Medicare Advantage plan, be sure to talk to your physician(s) and other heath care providers to see if they will “take” your plan before you enroll.

The 2013 Annual Medicare Advantage Disenrollment Period (MADP)

In 2013 the Annual Medicare Advantage Disenrollment Period will run only from Tuesday, January 1 to Thursday, February 14. The changes you can make during this short, 45 day period are these:

You may leave your Medicare Advantage (Part C) plan with Part D prescription drug coverage (an MA-PD plan) and go to Original (fee-for-service) Medicare and, if you wish, join a stand-alone Part D prescription drug plan (PDP). The change to Original Medicare will be effective the first day of month following the date you disenroll from your Medicare Advantage plan. (It will be either February 1 or March 1, 2013.) If you enroll in a Part D drug plan, your enrollment will be effective on first day of month following the date the plan gets your enrollment request. (Again, it will be either February 1 or March 1, 2013.)

And you do this either by:

Disenrolling from your Medicare Advantage plan. This will put you in Original Medicare without any Part D drug coverage.

Or by enrolling in a stand-alone Part D drug plan. This will automatically
disenroll you from your Medicare Advantage plan and put you into Original Medicare and enroll you in the Part D drug plan.

And you may disenroll from your Medicare Advantage plan and later enroll in a stand-alone Part D drug plan, as long as you enroll by February 14, 2013.

And, if you are in a Medicare Private Fee-for-Service (PFFS) Medicare Advantage plan that does not have Part D prescription drug coverage, and in a stand-alone Part D prescription drug plan (a PDP), you may change to Original Medicare, but you must keep your current Part D prescription drug plan. Your change to Original Medicare will be effective first day of month following the date you disenroll from your Medicare Advantage plan. (It will be either February 1 or March 1, 2013.)

You may NOT join a Medicare Advantage plan nor switch from one Medicare Advantage plan to another. And, of course, there is always an exception in Medicare: if you are in a Medicare Advantage Medical Savings Account plan (MSA), you can’t drop it at this time.

So, in effect, during this Annual Disenrollment Period, a beneficiary in Medicare Advantage (Part C) who does not like their plan and is willing to go back to Original Medicare (“fee-for-service” Medicare, also known as “plain vanilla” Medicare) may do so. And if a beneficiary has prescription drug coverage with their plan, they can just drop it or they can join a stand-alone Part D drug plan. But remember that all of these Part D plans charge a premium (and not every Medicare Advantage plan does, even if it has drug coverage), you need to think of that. And, of course, if you need or want a Medigap insurance policy (Medicare supplement) to go with your Original Medicare, you better be sure you can get one (and price it to see if you can afford it) before you jump back into Original Medicare.

Special Enrollment Period for Beneficiaries in Low Performing Plans

This is new in 2013. To facilitate beneficiary enrollment into higher quality plans, a special enrollment period (SEP) will be given to beneficiaries who are enrolled in “low performing” Medicare Advantage and Part D drug plans. By “low performing” is meant any plan which has had an overall star rating of less than three stars for three years in a row. (You can tell if a plan is a low performer as it will have a low performer icon in the Medicare Plan Finder.  It looks like a red triangle with an exclamation point in it.) Specifically, the Centers for Medicare & Medicaid Services (CMS) will send notices to individuals enrolled in these plans informing them of their plan’s low rating and offering them an opportunity to request a special enrollment period (SEP) to move into a higher quality plan for 2013. Beneficiaries can take advantage of this opportunity any time after the Annual Election Period (Open Enrollment), that is, beginning with December 8, 2012 and going through November 30, 2013.

These requests must be made directly to 1-800-MEDICARE and not to either your current plan or the plan you wish to join. The beneficiary will have to enroll in a plan which currently has a rating of three or more stars. The change will be effective the first of the month following the month in which the enrollment request is made. And again, if you are enrolling in a new Medicare Advantage plan, be sure to talk to your physician(s) and other heath care providers to see if they will “take” your plan before you enroll.

Part B General Enrollment Period with an Initial Enrollment Period

And we must not forget, for those of you who are not enrolled in Medicare Part B, that every year you have the opportunity to sign up for it between January 1 and March 31 of that year. So you can do this beginning Tuesday, January 1 and ending with Sunday, March 31, 2013. You can call Social Security to do this, but remember that their toll-free line (1-800-772-1213) is not fully available on weekends. If you enroll, you will get Part B on July 1, 2013. (For those extremely few of you who don’t have Part A, and wish to buy premium Part A, you can do so in these same timeframes. If you don’t have Part B, you will have to sign up for it, too.)

And what’s very important here is that, if you will now have both Parts A and B effective with July 1, you now may join a Medicare Advantage plan and / or a Medicare Prescription Drug plan. And if you will now have just Part B effective with July 1, you can join a Medicare Prescription Drug plan. But you have only between Monday, April 1 and Sunday, June 30, 2013 to do so. Note that these dates follow and do not coincide with the dates you have to enroll in Part B, and you have to enroll before you actually get your Part B on July 1.

And if your sign up for Part B, go ahead and start making your appointments no earlier than July 1 for the many preventative services you will now be able to get for free; as well as for the counseling and educational services which apply to you (some of which are not free). Don’t wait until July 1 to start making these. This is both because it may take some time for you to get an appointment, and because, now that you have Part B, you need to use it to take the very best care of your health you possibly can.

Notices to Low Income Subsidy (LIS) “Extra Help” Beneficiaries

Beginning this month (October 2012) the Centers for Medicare & Medicaid Services (CMS) will send out a variety notices to those Medicare beneficiaries that have the Low Income Subsidy (Extra Help) about changes that affect them.

One such notice is the “Change in Extra Help Co-payment” notification letter. This letter, mailed early in the month, is on orange paper, and informs beneficiaries who have the Low Income Subsidy, and who will continue to have it in 2013, that their co-payment level will change beginning January 1, 2013, and what the new level (up or down) will be. (This is CMS Product No. 11199.)


The following affect those Low Income Subsidy beneficiaries who are in stand-alone drug plans (PDPs).

In late October CMS will send letters on blue paper to those beneficiaries that it has reassigned to a new drug plan in 2013. Two different events cause these reassignments.

First. If a Low Income Subsidy beneficiary’s current drug plan is leaving the Medicare program in 2013, CMS’s “Reassignment Notice – Plan Termination” notification, which is printed on blue paper, will tell them this, and will also tell them which plan they have been reassigned to. While they have already been informed by their plan that it will terminate, this is the first notice they receive telling them what their new plan will be. They are also told that they can join a different plan if they wish. These beneficiaries should indeed use the Plan Finder to make sure that the plan they have been reassigned to is the best one for their individual circumstances, which mostly depend on which prescriptions they routinely take. (This is CMS Product No. 11208.)

Second. If a full subsidy Low Income Subsidy beneficiary’s current drug plan is raising its monthly premium to an amount over the benchmark premium amount, and they were automatically enrolled in their current plan by CMS, they will receive a “Reassignment Notice – Premium Increase” notification letter. It is also printed on blue paper, and will tell them that, on January 1, 2013, they will automatically be reassigned to a plan whose premium is at or below the benchmark, and which plan this is. They are also given the option of calling their current plan if they wish to stick with it and pay the premium difference. Finally, they are reminded that as a Low Income Subsidy beneficiary they may change their plan at any time. This notice also includes a list of all plans in their state with premiums at or below the benchmark. These beneficiaries should also use the Plan Finder to make sure that the plan they have been reassigned to is the best one for their individual circumstances, which, again, mostly depend on which prescriptions they routinely take. (This is CMS Product No. 11209.)

Finally, in early November, CMS will send out a notification to those Low Income Subsidy beneficiaries who chose a drug plan on their own, and whose plan is raising the premium over the 2013 benchmark amount, that they will now have to pay a portion of their monthly Part D premium. This “LIS Choosers Notice” is printed on tan paper. These beneficiaries should also use the Plan Finder to determine if the plan they are in continues to be the best one for their individual circumstances, which, again, mostly depend on which prescriptions they routinely take, but in this case will also depend on their new premium liability. (This is CMS Product No. 11267.)

And something new this year: In December those Low Income Subsidy beneficiaries who were reassigned (either because their drug plan left the program or their plan’s premium went over the benchmark) will be sent a letter called the “Reassign Formulary Notice” printed on blue paper. It will tell them which the drugs they have been taking are on their new plan’s formulary, that is, the plan they were reassigned to. This will give them a good idea of how well the new plan’s formulary covers the drugs they take.

Two items of interest. One is that the drug information is from the period January 1 to August 31, 2012, so if the beneficiary has added or dropped prescriptions since then, this information will be a bit out-of-date. (Up to 30 drugs will be displayed.) The other is the letter will also tell the beneficiary whether or not their new plan has any rules which apply to the specific drugs they take, for example, prior authorization. The beneficiary is also told that they can change plans and even do this after the annual enrollment period has ended as Low Income Subsidy beneficiaries can do so at any time. In light of this information, if the beneficiary has any concerns, they should use the Plan Finder to see if another plan would work better than the one they have been reassigned to. (The letter will have a list of all the plans with premiums below the benchmark available to the beneficiary. These letters are CMS Product No. 11475 (for reassignments) and 11496 (for terminations).)


And the following applies to those Low Income Subsidy beneficiaries whose will continue to be eligible for the subsidy in 2013 and who are in a Medicare Advantage Plan which is non-renewing or undergoing a service area reduction, and who are being reassigned to a stand-alone drug plan (PDP). (See my posting of October 26 for more details on these reassignments.) They will, in late October or early November, be sent an “MA Reassignment Notice.” This notification, printed on blue paper, will tell them about the reassignment and identify their new drug plan. It will also tell them they have the option of joining a Medicare Advantage Plan (with or without drug coverage) or of changing to a different stand-alone drug plan. This notice also includes a list of all stand-alone drug plans in their state with premiums at or below the benchmark. Beneficiaries who receive this need to carefully think about joining a Medicare Advantage Plan if they have had success with this approach, especially because with their low incomes they may not be able to afford a Medicare Supplement policy (Medigap). And they can use the Plan Finder to find a Medicare Advantage Plan, using the specific prescriptions they currently take. And if they opt for Original Medicare (that is, they do not enroll in a Medicare Advantage Plan), they can use the Plan Finder to locate the best stand-alone drug plan for them. (This notice is CMS product No. 11443.)

These beneficiaries will also be sent a letter (the "Reassign Formulary Notice," on blue paper, in December) telling them which the drugs they have been are taking are on their new plan’s formulary, that is, the plan they were reassigned to. See the paragraph beginning “Two items of interest:,” above, for other details on this letter.

Prior Authorization of Power Mobility Devices (PMDs) Demonstration

Beneficiaries in Original Medicare (also known as fee-for-service Medicare) and living in the states of California, Florida, Illinois, Michigan, New York, North Carolina and Texas have been, beginning with September 1, 2012, included in a “demonstration project” which is designed to curb the fraudulent supplying of power mobility devices. A demonstration project is a temporary effort in which Medicare can try new and different but limited approaches to the Medicare program, such as delivering care in new ways, testing different reimbursement methodologies, seeing if a new type of Medicare Advantage Plan will work, and so forth.

The devices involved in this demonstration include almost all power wheelchairs and power operated vehicles such as scooters. Medicare believes that in some areas of the country these types of items are at times improperly or fraudulently supplied. So if you are an Original Medicare beneficiary and live in one of these seven states, and are thinking of acquiring one of these devices, read on. (And by “live in,” we mean that your residence address on the Social Security Administration (SSA) records is in one of these states. Medicare does not keep up on your residence address, but uses SSA’s records. You can check on your SSA address or change it by calling 1-800-772-1213. Railroad (RRB) beneficiaries should call 1-877-772-5772).

Under this demonstration, physicians or practitioners who prescribe these devices or the suppliers of these devices may submit a prior authorization request to the appropriate Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) requesting prior authorization of the equipment. (These “DMEMACs“ are the companies Medicare contracts with to process Medicare DME claims.) Prior authorization, sometimes known as “prior approval” or “pre-certification,” exists in many other public and private health care programs, and is not uncommon in some Medicare Advantage Plans, but is almost unheard of in Original Medicare. And whether or not they submit the prior authorization, your physician or practitioner will have to have a face-to-face examination of you, and they can even get some reimbursement from Medicare for submitting the prior authorization request paperwork.

If such a prior authorization request is submitted, the contractor will try to make a decision on the request within 10 business days. And if you have an unusual but extremely urgent need for the equipment, your physician or practitioner can ask for a 48-hour decision.

If the prior request is approved, and the supplier delivers the equipment to the beneficiary, the contractor will approve and pay the claim at the normal reimbursement amount. If the request is not approved, it can be resubmitted with additional information, but cannot be formally appealed.

If the request is not approved, the supplier can deliver the equipment to the beneficiary and submit a claim. These claims will all be formally denied, and all the normal appeal rights will kick in.

If, on the other hand, the supplier submits a claim for such a device without first seeking prior authorization, the contractor will suspend the claim and send a request to the supplier asking for information to show whether or not it should be covered. If this information is not submitted, or if it shows the device is not medically necessary, the claim will be formally denied. In this case the beneficiary’s normal appeal rights will kick in. If the information is submitted and it shows the device is necessary, the claim will be approved BUT PAID AT 25 PERCENT LESS than the normal approved amount if it is submitted by a “non-competitive bid supplier.”

(This 25% reduction provision does not go into effect until December 1, 2012. And not to get overly detailed, but Medicare is also running a different demonstration project in a number of metropolitan areas, including some in Florida, North Carolina and Texas, which generally require beneficiaries to use those suppliers who have won the competitive right to supply Medicare beneficiaries with certain items of durable medical equipment and supplies. Certain power mobility devices are included, so there is some overlap. If you reside in one of the three states just mentioned, you can call 1-800-MEDICARE to find out if you are in one of the metropolitan areas where the competitive bid supplier demonstration is running.)

Beneficiaries should be aware that if either the prior authorization is not given, or the physician, practitioner or supplier does not seek this, and the supplier asks the beneficiary to sign an Advance Beneficiary Notice (ABN) indicating that the item is not covered, the beneficiary will be liable for the cost of the item. And while the beneficiary may ask for delivery of the item and then appeal the denial, beneficiaries should be aware that unless they win the appeal, they will be fully liable for the cost of the item.

As demonstrations are limited, this prior authorization demonstration will expire on September 1, 2015.