Everything you need to know about Medicare open enrollment for 2023 [The Philadelphia Inquirer]

Oct. 13—Medicare's fall open enrollment, which runs Oct. 15 through Dec. 7, is an opportunity to review your benefits and make changes for 2023.

Signing up for Medicare or changing plans can seem daunting, but it's important to make sure you're enrolled in the best plan for your medical needs.

To help make the process easier, The Inquirer has curated a Medicare primer based on questions sent in by readers. Now updated for 2023, it can help you select the best Medicare plan for you.

Click around to find your answers:

—What to know about annual open enrollment

—Medicare 101

—Programs to help you pay for Medicare

—How to enroll in Medicare coverage

—Looking at some specific situations

Glossary of Terms

Premium: The base cost of the health plan, paid monthly. Regardless of whether you choose original Medicare or Medicare Advantage, you will pay the Part B premium monthly. Most people will pay $165 a month for the Part B premium in 2023.

Deductible: The amount of money you spend out-of-pocket before the plan begins paying a larger share of medical expenses. For 2023, the Part B deductible is $226.

Copay: A flat fee you pay for certain services, such as a doctor's visit or prescription medication.

Coinsurance: The portion of a medical bill you must pay even after you meet your deductible. Original Medicare has 20% coinsurance after meeting the deductible, which means you will pay 20% of any medical bill.

Drug formulary: The list of prescription medications covered by your plan. Formularies rank medications into tiers, with lower-tier drugs being the preferred and least-expensive options. Higher-tier versions of the same medication will cost more. Health plans frequently switch their preferred choices and may even drop medications from the formulary.

In-network: Doctors who accept your health plan are in-network. The vast majority of doctors accept original Medicare. Medicare Advantage plan networks vary.

Out-of-network: Doctors who do not accept your health plan are out-of-network. You may have to pay more for their services, or the visit may not be covered at all by your plan.

Original or traditional Medicare: A federal health program for people who are 65 or older, or who have a qualifying disability. People who choose original Medicare will enroll in Part B, with choices for optional supplemental and drug plans.

Medicare Advantage: Medicare plans sold and operated by private insurers. These federally approved plans must cover all Plan B benefits. They can offer extra services, such as coverage for prescription drugs, and may limit the number of in-network doctors.

Part A: Covers hospital visits and medications administered in a hospital setting, such as infused drugs. Most people receive Part A coverage when they turn 65 at no additional cost.

Part B: Covers doctor's visits, labs, and other non-hospital services. People who choose original Medicare will enroll in Part B.

Part C: Also known as Medicare Advantage.

Part D: Prescription drug plans that people who opt for original Medicare can buy.

Medigap: Also known as supplemental plans that people who opt for original Medicare can buy to cover out-of-pocket costs, such as copays. Medigap plans do not pay for the Plan B premium.

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Annual Open Enrollment questions

What is Medicare's annual open enrollment?

A time to review your Medicare coverage — whether you have original Medicare with prescription and supplement plans or Medicare Advantage. During the fall enrollment period, you can sign up for new coverage or change your plan. You can switch from original Medicare to Medicare Advantage (or vice versa), add a prescription drug or supplement plan to original Medicare coverage, or choose a new Medicare Advantage plan.

Do I need to do anything during the fall enrollment period if I'm happy with my current plan?

Yes. Plans may change slightly from one year to the next, so it is important to review your coverage, even if you're happy with it. For instance, the list of prescription medications covered by Medicare Advantage and Part D plans change every year. Your preferred medication may no longer be covered or the cost may have changed. Also consider how your health needs have changed: Did you start taking a new medication? Will you be traveling more? Be sure that your current plan is still the best fit.

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Medicare 101

What's the difference between original Medicare and Medicare Advantage?

Original Medicare is managed by the federal government and offers coverage for hospital services (Part A) and outpatient services, such as primary-care doctors, specialists, and routine care (Part B).

Medicare Advantage plans are run by private insurance companies approved by the federal government. These managed-care plans must cover all the same benefits as original Medicare (though you'll be limited to their provider networks) but may offer extras, such as dental, vision, or hearing services. Medicare Advantage plans also typically include prescription medication coverage. People who opt for original Medicare can buy supplemental plans to help cover more health care costs or a Part D drug plan for medications.

How do I know which plan is right for me?

It depends on your medical needs and financial resources.

Original Medicare is accepted by most doctors, which could be important if you need care while traveling out of state. Similar to many employer-based insurance plans, Medicare Advantage plans have provider networks. If you go to an out-of-network doctor or hospital, the visit may not be covered or may cost more. Medicare Advantage may also include prescription drug coverage, whereas original Medicare does not. People who opt for original Medicare will have to buy a separate drug plan (Part D) if they want medications covered.

Use Medicare's online Plan Finder tool or talk to a volunteer counselor (more details on where to get help below) to decide which plan best meets your needs.

What type of plan should I choose if my biggest concern is cost?

It depends. Your total out-of-pocket expense will depend on how the plan you choose covers the services you use most. Both types of plans have a premium for Part B (doctor's services) — about $165 a month for most people in 2023, as well as a deductible, which will be $226 in 2023.

Original Medicare beneficiaries pay 20% of the Medicare-approved rate for most doctor services after meeting their deductible. Supplemental plans can help cover some of these extra expenses for original Medicare members.

Copays, coinsurance, and deductibles will vary for Medicare Advantage plans, which may charge additional premiums for its prescription drug coverage and extra services.

Does Medicare restrict which doctors I can see? Can I change doctors?

Always ask before making an appointment, but most doctors accept original Medicare.

Medicare Advantage plans have a more limited network of doctors. Call your plan to ask for a list of in-network providers. Or ask if a doctor you already see is in network. You can switch doctors at any time, but make sure your new doctor is covered by your plan to avoid unexpected bills.

Are there any programs to help people pay for Medicare?

Yes. People who meet income and asset qualifications may be eligible for one of Medicare's financial assistance programs.

The Qualified Medicare Beneficiary program offers the highest level of assistance, helping pay for Part A and B premiums, deductibles, coinsurance, and copays for people with $1,153 or less in monthly income and no more than $8,400 in assets. Income and assets requirements may vary by state and are higher for couples.

The Specified Low-Income Medicare Beneficiary helps people who earn too much to be eligible for the QMB program to pay for their Part B premiums.

The Qualifying Individual program also helps cover Part B premiums, has an even higher income threshold, and is available on a first-come, first-served basis.

The Qualified Disabled and Working Individuals program helps cover Part A premiums for people younger than 65 with a disability who are currently working.

Medicare beneficiaries in New Jersey may also be eligible for state-run assistance to make prescription drugs more affordable.

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The National Council on Aging has a website called BenefitsCheckup to help people research these options.

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Enrolling in coverage

How do I choose supplemental coverage?

Pick a plan to address the coverage gaps that concern you the most. Supplemental coverage is for people with original Medicare; it cannot be used to cover Medicare Advantage out-of-pocket expenses.

Supplemental coverage, also called Medigap, covers "gaps" in original Medicare plans, such as health expenses while traveling abroad, excess charges, or copays. It is sold by private insurance companies. Look for a letter system to assemble your benefits package; plans with the same letter offer the same coverage.

Be aware that prices can vary widely between companies, even for the same coverage.

How do I figure out which prescription plan will be the lowest cost to me?

Make sure it covers the drugs you need.

Most people focus on the monthly cost, known as the plan premium. But a plan with a low premium could end up costing more than another with a pricier premium if it does not cover your specific medications. Also review cost-sharing details — how much you will pay versus how much the plan will pay — and whether you will be required to fill prescriptions at select pharmacies. Medicare's Plan Finder allows you to search based on the medications that you need.

Where can I go for help?

Don't be surprised if you need advice. The options can get complicated and scams abound during enrollment season.

Every state has an agency offering free Medicare help. These impartial programs do not offer legal advice, endorse plans, or sell insurance.

Pennsylvania Medicare Education and Decision Insight (PA MEDI), formerly called the APPRISE program, has a helpline and locations across the state providing personalized assistance. Learn more at aging.pa.gov, or call 800-783-7067.

New Jersey State Health Insurance Assistance Program also has a helpline and local offices with volunteer counselors. Find locations at state.nj.us/humanservices, or call 800-792-8820.

Nonprofit organizations such as CARIE (Center for Advocacy for the Rights and Interests of the Elderly) also provide assistance. Independent brokers, who are not bound to sell just one insurer's products, can also be a good resource.

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How do I find a reputable independent broker?

Find licensed brokers using the online database maintained by the National Association of Insurance Commissioners.

Independent brokers must be licensed by the state and follow strict rules about selling private Medicare plans (Medigap, drug, and Advantage plans). Search for a broker who lives in your community, rather than several states away, if you wish to meet in person.

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