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Seniors: Prepare for Medicare annual enrollment

Dr. Alfred Casale

Health insurance is not really a fun and interesting topic for most normal people, but it is a topic I think important to cover once or twice each year as we get close to the end of summer and into the fall season.

In just about a month, the Medicare Annual Enrollment Period will begin — on Oct. 15 to be exact — and through Dec. 7, people over 65 will be able to choose the Medicare plan that best fits their needs.

With so many insurance companies competing for customers and so much information that can often be confusing swirling around during this time of year, it’s helpful to take a step back and start with the basics.

Medicare, which is commonly referred to as Original Medicare, is government-issued health insurance for those 65 and older. It consists of two main parts, Part A and Part B, which cover different things.

Part A helps cover things like:

— Hospitalization

— Care in a skilled nursing facility

— Hospice care

— Home health care (in certain circumstances after you’re in a hospital or skilled nursing facility)

Part B helps cover routine care, such as:

— Appointments with your primary care physician

— Outpatient care

— Preventive services

— Occupational/physical therapy

— Home health care

Original Medicare does not limit the amount of out-of-pocket expense a patient might pay each year. It covers 80% of Part B expenses, and the patient is responsible for the remaining 20%. If a patient has an expensive course of treatment, like chemotherapy, that bill can be quite high.

Original Medicare also does not cover prescription drugs, dental care, hearing aids, eyewear or fitness programs.

Medicare Advantage is an insurance plan available through private companies that are paid by the Medicare program to cover eligible seniors. These Medicare Advantage programs typically offer more benefits than Original Medicare. Created in 2003, Medicare Advantage has become a popular alternative to Original Medicare with more than 20 million older adults enrolled in plans.

Also called Medicare Part C, Medicare Advantage plans offer a variety of benefits in addition to traditional Medicare coverage. Medicare Advantage plans cover hospitalization and medical care typically handled under Parts A and B. But while doing so, they limit out-of-pocket expenses, have little to no monthly premiums, and include extra benefits, like prescription drugs (also called Medicare Part D), eyeglasses and eye exams, hearing aids, dentist visits, gym memberships and fitness classes.

When choosing the right plan for you, you’ll want to consider the four Cs: coverage, cost, convenience and customer service.

Coverage — Seek out plans that limit out-of-pocket expenses, and consider the added value of plans that offer preventive services and dental and vision benefits. Request a list of covered drugs and make sure your prescriptions are included. Some plans even include coverage in the Medicare Part D coverage gap (known as the “donut hole”), which means you won’t have to pay additional out-of-pocket costs for prescriptions after your drug plan has reached its annual limit for your covered drugs.

Cost — Find the right balance between monthly premiums and out-of-pocket expenses. Pay close attention to the cost of both brand name and generic drugs.

Become familiar with these important cost-related terms:

— Monthly premium: the amount you pay each month to cover your cost of membership in the plan

— Deductible: the amount you must pay for health care before the plan begins to pay

— Copay: the amount you pay for each medical service, like a wellness visit with your doctor

— Coinsurance: the percentage of a charge for services you may have to pay after you pay your deductible

Convenience — Select coverage from a health plan with a network that includes the doctors and pharmacies you know, and consider telehealth options.

Customer service — If you need help, you want to make sure your insurance company will be there. To find a health plan that offers excellent customer service, look for independent reviews and discuss options with friends and family.

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Dr. Alfred Casale, a cardiothoracic surgeon, is chief medical officer for surgical services for Geisinger and chair of the Geisinger Heart Institute.

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