Dr. Marsha Lavoie, a family medicine specialist at Harrington Memorial Hospital in Southbridge, knows more about Medicare than most people because she routinely bills the federal health insurance program on behalf of her older and disabled patients.
But when it came time to sign up for the program herself this year, Lavoie, 65, faced the same concerns and uncertainties as anyone else navigating the maze of Medicare options, regulations, supplemental plans, and potential land mines.
“It’s time-consuming trying to sort through it,” Lavoie said. “You’ve got to look at coverage, premium, network, drugs, how much it’s going to cost and what the restrictions are. There’s so many different plans, and they all have their own rules and regulations.”
With roughly 10,000 baby boomers turning 65 each day, according to the Pew Research Center, the Medicare enrollment odyssey has become a generational rite of passage. Some welcome it as a godsend, enabling them to retire or pursue new ventures without fretting about health insurance. Others dread confronting the program’s myriad complexities.
And the decisions don’t end with your initial enrollment. Medicare has annual open enrollment periods each fall, including one ending this Friday, in which beneficiaries can make changes to some of their coverage.
For those soon to be eligible for Medicare, the issues to grapple with are as individual and varied as they are unavoidable.
“Everyone’s situation is different,” said Carole Malone, assistant secretary of elder affairs in Massachusetts, which has about 1.3 million Medicare beneficiaries. “Their health is different, the medicines they take are different, their marital status is different. Some are still covered by their husband’s or wife’s health insurance.”
Lavoie, for example, lives across the border in Connecticut with her husband, and many of the Medicare Advantage plans she could buy there — to enhance basic Medicare — wouldn’t cover their doctors in Massachusetts. Since she planned to work for at least another year or two, she ultimately decided to enroll in Medicare Part A for hospital coverage but opted to stay on her employer’s insurance for physicians visits, prescription drugs, and other needs.
If you’re approaching Medicare with trepidation, here are some basics to get you started:
When to enroll: You can sign up for Medicare as early as three months before the month you turn 65, or as late as three months after. The exception: If you’re still covered by your employer, or your spouse’s, you can delay enrolling without penalty. But you should enroll in Medicare Part A even if you’re still on an employer’s plan because it sets you up in the Medicare system. And because you’ve contributed throughout your work life, there’s no premium for hospital coverage.
Here’s a sign-up link: www.medicare.gov/sign-up-change-plans/getting-started-with-medicare.
Beware late sign-up penalties: Since there’s no premium for Part A, there’s no penalty for missing the Medicare enrollment deadline. But if you’re late to enroll in Part B, which covers doctors’ visits and tests, you’re subject to a late penalty premium for the rest of your life of 10 percent for each year you delay. That’s right: for the rest of your life.
Similarly, missing the deadline for Medicare Part D, prescription drug coverage, invites a late penalty premium of 1 percent a month, amounting to 12 percent for the first year. Again, if you’re still getting your insurance through work, you can delay enrollment without incurring a fine.
More than 750,000 beneficiaries were paying late sign-up penalties in 2014 and were saddled with premiums 29 percent higher on average than those who enrolled on time, according to a Congressional Research Service report published last year. Medicare assesses these penalties because it relies on premiums to help fund 25 percent of the program, and it needs relatively young and healthy people to support older and sicker participants.
To avoid the Medicare charges, “the most important thing is to deal with the [enrollment] issue at 65,” said Norfolk consultant Kurt Czarnowski.
The basics: Medicare has four parts. Part A pays for in-patient hospital care, skilled nursing, and home health care; there’s no monthly premium for those who paid in for at least 10 years through paycheck deductions. Part B covers outpatient medical services, such as visits to doctors and emergency rooms, tests, and procedures. You’ll be billed quarterly for Medicare premiums until you start receiving Social Security; after that, premiums are deducted from your Social Security check.
The monthly premium for Part B is set annually; for most people, it’s $134 in 2018 but will climb to $135.50 in 2019.
Parts A and B, which date back to 1965, are sometimes called basic or original Medicare, covering 80 percent of medical costs.
Many enrollees supplement original Medicare with private Medigap plans that cover the other 20 percent of costs but also carry premiums, which vary depending on the plan, or opt for private managed care plans that provide insurance through physician and hospital networks.
Managed care option: Enrollees have the option of buying a wide range of Medicare Advantage plans from Medicare-approved private insurers under Medicare Part C, which took effect in 1997 and was intended to provide more efficiencies and cost savings to retirees.
Folks opting for Advantage get their hospital and medical insurance — and often other benefits such as medicines, eyeglasses, or dental coverage — through plans typically administered by health maintenance or preferred provider organizations. The plans vary widely by state, benefits, and cost. Many are seen as cheaper alternatives but restrict members to a network that may or may not cover some medical specialists or out-of-state doctors. Members must still pay their Part B premiums, even though doctors’ visits are covered through their Advantage plans.
Drug coverage: Medicare Part D, which started in 2006, allows beneficiaries to purchase prescription drug plans, also from private insurers. These plans also carry premiums.
Medigap or Medicare Advantage? Both types of plans are options for plugging the holes, or gaps, of what isn’t covered by basic Medicare. Medicare Advantage plans roll together hospital, health insurance, and, usually, drug coverge. They typically have lower monthly premiums than Medigap plans but limit members to a network of doctors and hospitals. They can be a good option for people who don’t use a lot of medical services. Depending on the plan, they could also pay for services, such as gym memberships and hearing aids, not covered by basic Medicare.
Those with chronic health conditions who need a lot of health services may want to buy a Medigap plan. While such plans carry higher monthly premiums, they have fewer restrictions, and members don’t have to pay co-pays to see doctors or specialists.
Unlike most Medicare Advantage members, though, Medigap buyers have to purchase a separate drug plan. Because most Medigap plans work across state lines, they are also a good option for “snowbird” retirees who spend part of the year down south, or people who live in one state but see doctors in a neighboring state.
When to shop around: Medicare has an open enrollment period that started Oct. 15 and ends Dec. 7, for beneficiaries wanting to switch from basic Medicare to Medicare Advantage, or vice versa, or buy or change prescription drug plans.
Next year, for the first time, there will be a separate open enrollment period running from January through March just for Medicare Advantage. This will be geared to beneficiaries who’ve already purchased a Medicare Advantage plan but want to change it, drop it, or switch to a Medigap plan along with a separate prescription drug plan.
Where to get personalized help: For new enrollees, and those seeking to change coverage during annual open enrollment periods, there’s a valuable source of independent advice on finding a Medicare Advantage or Medigap plan that suits your specific needs: federally funded programs offered free of charge at regional offices, senior centers, and other sites. In Massachusetts, the program is called SHINE, or Serving the Health Information Needs of Everyone, and its corps of trained, certified volunteers stand ready to help.
Here’s a link to SHINE’s website: www.mass.gov/service-details/find-a-shine-counselor.
At the Center on the Heights in Needham last week, seniors waited to see counselors for the MetroWest SHINE program during the Medicare open enrollment.
Ashland resident Stanford Shane, 75, who works in the wholesale produce business and has had the same Medicare Advantage plan for the past 10 years, came to talk to counselor Ed Levin about whether there were other options with better coverage or lower cost.
“If Ed finds something that makes sense for me, I’m open to checking it out,” Shane said.
Across the room, counselor Margaret Leidler was on a computer scrolling through potential options for Phyllis Bernstein, 69, a clinical social worker who enrolled in Medicare four years ago and has changed her prescription drug plan every year. Last year, she was able to cut her monthly premium from $99 to $19.
“It’s tricky,” Bernstein said, surveying the panoply of medication and cost options populating Leidler’s screen. While she could shop for plans on her own, Bernstein said, “I have tremendous confidence in the advice I get here.”Robert Weisman can be reached at firstname.lastname@example.org. Follow him on Twitter @GlobeRobW.