Enrolling in Medicare Over 65 with Health Issues
Hello Toni,
I’m retiring on January 1st, 2025, and am beginning to search for the right Medicare option for my wife and me. My wife is getting treatment at a local cancer center. Sadly, her treatment drugs are expensive, and I’m concerned about the Medicare Part D out-of-pocket costs. I, myself, am a diabetic who uses a flex pen and takes high blood pressure medications. Most of my prescriptions are generic, except for the diabetic prescriptions.
Our Medicare Part B will begin January 1 as my company benefits end December 31st, 2024. What should I do to prepare for this medical insurance change? I’m turning 71, and my wife will be 65 by the time I retire. I want to make sure that I enroll correctly!
Thanks,
Scott from San Diego
Great question, Scott!
When we meet with clients during a Toni Says® Medicare consultation, we emphasize that Medicare isn’t cookie-cutter; one size does not fit all! Everyone’s finances, health, and prescriptions are different! All these factors should be considered in finalizing your Medicare choices.
The cornerstone of Medicare planning at our offices is discussing Medicare Part D prescription drug planning. Make sure that you research the most cost-effective Medicare Part D prescription drug plan that covers all the prescriptions that you and your wife have!
More on Medicare Part D
Many people simply don’t practice proper Medicare Part D planning. They are more concerned about their doctors and fail to notice whether their prescriptions are covered under their new Medicare Part D or Medicare Advantage prescription drug plan. (To understand Medicare Part D and the famous “donut hole,” read chapter 5 of Toni’s Medicare Survival Guide Advanced edition.)
2024 Medicare Part D Costs Are:
- The initial Deductible is $545.
- The initial Coverage Limit is $5,030 when the “Donut Hole” begins.
- Donut Hole (Coverage Gap) begins once the Medicare beneficiary reaches the Medicare Part D plan’s initial coverage limit of $5,030 and ends when a total of $8,000 is out-of-pocket. The Medicare beneficiary will then be responsible for only 25% of the prescription drug cost while 70% is paid by the brand name/generic drug manufacturer and 5% is paid by the enrolled Medicare Part D plan until the Donut Hole ends when the $8,000 exit point is reached.
- Catastrophic Coverage of $0 out of pocket begins January 1, 2024: when a Medicare recipient enters Catastrophic Coverage. Medicare will pick up all costs of the prescriptions whether brand name or generic and those with a Medicare Part D plan pay $0.
On January 1 of each year, the process starts all over again with a new Medicare Prescription Drug plan and different costs, deductibles, and a new Donut Hole.
Every Medicare Part D plan has a formulary, whether it is a stand-alone Part D plan or Medicare Advantage (Part C) with a prescription drug plan. If your drugs are not on that formulary, you will pay 100% out of your pocket.
The 2025 Medicare Part D plans will be released this fall on October 1st! Scott, I recommend that you and your wife begin researching which Medicare Part D plan covers all your prescriptions and has the best price. Make sure you have one picked before you retire on January 1st!
What About Part B?
Medicare Part B is valuable as gold because of what it offers. Those receiving Medicare Part B for the first time need to understand the value of the Medigap/Medicare Supplement Open Enrollment Period. The Medicare & You Handbook discusses when to buy a Medicare Supplement: “The best time to buy a Medigap policy is during your Medigap Open Enrollment Period. This 6-month period begins the first month you have Medicare Part B (Medical Insurance), and you’re 65 or older.”
During this 6-month window, you can enroll in any Medicare Supplement plan without having to answer any health questions. Additionally, you cannot be denied coverage. After the 6-month window, then medical underwriting takes place, and those with existing health problems may not qualify for a Medicare Supplement Plan.
Many new Medicare beneficiaries explore the option of a Medicare Advantage plan (Part C). That can be a good option for someone with health conditions, like Scott and his wife. Be sure to discuss with all your doctors which Medicare Advantage HMO or PPO plans they accept!
What’s the Difference Between Medicare Supplements and Medicare Advantage Plans?
Medicare Supplement:
- Medicare Supplements work directly with “Original” Medicare. Medicare pays its share of the Medicare-approved amount for “medically necessary “covered healthcare costs.
- The supplement will pay its share. You choose – not the insurance plan – which doctor, hospital, home health agency, skilled nursing facility, etc., so long as the provider accepts Medicare assignment for your healthcare. You and your healthcare providers are in control of your healthcare.
- The downside to a supplement is that you have a monthly premium that may increase each year.
- Medicare prescription (Part D) drugs plans are not included, so you may need to enroll and will pay separately for a “stand alone” Medicare (Part D) Prescription drug plan.
Medicare Advantage PPO Plan:
- To qualify for any Medicare Advantage plan: a) You must be enrolled in both Medicare Parts A & B. Must live in the service area 6 months out of the year.
- Medicare pays the insurance company a certain dollar amount every month for your care with the Medicare Advantage Prescription Drug (MAPD) plan you are enrolled in. Your Part A and Part B must always remain in effect.
- When you go to the doctor, or hospital or visit your pharmacist, you must only use your Medicare Advantage Plan insurance card, not your Medicare (red, white, and blue) card. You must verify that your specific medical provider is still accepting the MAPD plan you are enrolled in.
- A Medicare Advantage Plan must provide all your Part A and Part B benefits and some Medicare Advantage Plans have Part D prescription drug plans included. The plan may also have “extra” benefits such as gym membership, dental, and vision.
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Originally published June 13, 2024
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