Navigating Medicare Open Enrollment: What’s the right plan for you?

Medicare’s annual open enrollment period for health and drug coverage has begun and will continue through December 7, 2020. This time period allows those eligible to sign up, and those enrolled to change their selected Medicare health/prescription plan for the following year. It can be difficult to navigate, but the decisions you make during this period are critical, and you deserve to understand exactly what’s available.

As we approach the open enrollment deadline, we want to cover some Medicare basics, what this period means for people living with ALS, and resources available to select the right plan for you.

What Is Medicare?

Medicare is the federal health insurance program, available for those over the age of 65, those younger than 65 with disabilities, and individuals diagnosed with End Stage Renal Disease. A person diagnosed with ALS is eligible for Social Security Disability Insurance (SSDI) benefits, thereby making them Medicare eligible as well.

There are two Medicare options for those eligible: original Medicare and Medicare Advantage plans. Original Medicare consists of parts A & B, which are hospital insurance (A) and health insurance (B). Original Medicare includes a yearly deductible which must be paid before the plan kicks in; once the deductible is met Medicare covers 80 percent with the patient covering the remaining 20 percent. Original Medicare does not include prescription drug coverage. Prescription coverage is known as Medicare Part D and includes a separate monthly premium. Drugs are classified by tiers, and you can estimate your cost before selecting a plan based on your anticipated prescription needs for the upcoming year. There are additional policies available called Medigap coverage that can help to offset the cost of original Medicare. These plans are standard, and are sold privately as “Medicare Supplement Insurance.” The plans vary, and can cover costs such as the yearly deductible, copays/coinsurance, and skilled nursing facility coverage. These plans have a separate monthly premium in addition to your standard Medicare premium.

Rather than pay multiple premiums separately, those that are interested in complete coverage do have the option to go with a Medicare Advantage Plan. These plans typically bundle parts A, B and D for one monthly premium, paid to an insurance company that has contracted with Medicare. These plans also sometimes include coverage for needs that are not covered by original Medicare, such as dental, vision and hearing. These plans can also be tailored more to meet an individual’s needs; for example, some plans offer coverage of transportation to and from appointments or some coverage of in-home care. One notable difference between Original Medicare and an Advantage plan is that with Original Medicare, there is no out of pocket limit for premiums, deductibles or copays. Medicare advantage plans are typically capped annually.

What Does This Mean for a Person Diagnosed with ALS?

Medicare coverage starts for a person with ALS when Social Security Disability Benefits kick in. Right now, there is a five month waiting period for a person diagnosed with ALS (younger than 65) before SSDI benefits start. While there is legislation pending in congress to have this five month period waived due to the progressive nature of the disease, right now a person with ALS does have at least that five month period before becoming Medicare eligible. ALS is very individualized, and you should work with your provider early and often in the disease progression to adapt and make sure you are getting the right care for your particular situation. This is also true for your insurance.

ALS is an expensive disease from the start, and having medical coverage is absolutely essential to help offset the cost of needs that come up. When considering a plan, a person with ALS should keep in mind the increase in healthcare needs as the disease progresses. Keeping things like durable medical equipment, prescription coverage, nutrition support, and any in-home or nursing facility assistance in mind when selecting a plan can help offset the long term and out of pocket cost of your care.

Resources Available to Help Find the Right Plan

The good news is, Medicare’s website is relatively easy to navigate to compare plans and find the right one to fit your needs. Whether you are choosing an Original Medicare plan or Medicare Advantage option, the website will show you details about availability in your state, monthly and annual costs, benefits coverage, and where plan limitations apply.

There are also resources available in most states through the local Area Agency on Aging that will help answer questions and guide those that are either newly Medicare eligible or looking to change plans. Here in St. Louis, Aging Ahead is a great organization that can connect you with a community options specialist and again, answer questions related to choosing the right coverage. And as always, you can contact your local Care Services Coordinator for assistance in getting connected to one of these organizations.

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