When can you apply for either Medicare Health Plan?
Medicare Health Plans — a special kind of insurance that works with MediCare!
More and more medical treatment is provided outpatient today. Thus Buying either a — Medicare Advantage or Medicare Supplement (developed by private companies) means you — protect your income & savings from what could be — a Very Big Risk of BIG medical expenses!
This page was developed to provide — highlights of Medicare Health Plans, how they work, & the times, MediCare calls them periods, when you can sign up:
First — a Medicare Advantage Plan (MA)
● MediCare rules say all MA plans must cover everything original MediCare Part A & Part B does. They also offer various, what MediCare calls, Supplemental benefits. *
( * Such as a full annual physical and other health-related benefits)
MA plans focus on coordinating each individual's overall health and individuals receive their medical treatment through MDs and other providers who participate in the company's network. [In SECT most MDs participate in the available MA plans]
Note: Plans usually cover an individual outpatient prescriptions and are then called a MAPD.
● This page has details to highlight and help you understand what individuals gain when they enroll!
CMS times to select a MAPD, called Election Periods, are described below in priority order .
Priority One — Initial Coverage Election Period (ICEP)
● The ICEP is a seven-month period for individuals turning 65 to apply for a MA plan! — people usually select a plan, which also includes prescriptions called a MAPD. The ICEP is at the same time as the seven-month IEP to sign up for MediCare.
● A person who enrolled in a MA or MAPD when they were first eligible for MediCare can, if dissatisfied, drop it at any time during the next 12 months and go back to Original Medicare.
Priority Two — Medicare Advantage Open Enrollment Period (MA OEP)
● The MA OEP is a unique once-a-year time, January 1st to March 31st, when anyone dissatisfied with their current Medicare Advantage (MA) or (MAPD), can make a change. They can:
-> Select a new MA or MAPD with the same or another company.
-> Return to original Medicare, select a Medicare Supplement, and a stand-alone Prescription Drug Plan.
● In addition, any person who enrolled in a MA or MAPD when first eligible for MediCare can also, if dissatisfied, use the MA OEP to drop it during the first three months on the plan and can change plans or go to Original Medicare.
Priority Three — Special Election Period (SEP)
● The SEP is when an individual with certain life events can change their MAPD. There are many situations, but a couple of typical Life Events would be:
-> moving to a different state.
-> learning that they qualify for Extra Help with prescription costs based on income level.
A SEP is also available to a person in a Medicare Supplement who changed to a MA/MAPD but became dissatisfied during the first 12 months. They can then:
-> Return to Medicare, apply for a Medicare Supp and a PDP.
Priority Four — Annual Coordinated Election Period (AEP)
● The AEP is the most common time for anyone with a MA or PDP to make a change. It happens each fall, and the new coverage is effective January 1st.
● They can change to a plan with their current or another company.
● The AEP currently runs from October 15th to December 7th.
Priority Five — Open Enrollment Period for Institutionalized Individuals (OEPI)
● The OEPI is for individuals in a long-term care facility and gives them the flexibility to meet their medical situation! They can make changes:
-> When entering,
-> While in,
-> within 60 days of leaving.
Why do Election Periods have a <—> Priority Order?
When a person's life situation results in being eligible for two SEPs at the same time, the date the plan they select will be effective is determined by the effective date rules for the period with the highest priority.
An example: A person who moves would qualify for a SEP but if the move happens during their seven month [ICEP] their effective date will be based on the ICEP' enrollment rules, which is Priority One.
The Second Medicare Health Plan — is a Medicare Supplement
Supplements were the first private company plans to work with MediCare.
They were named Supplements because the company works with Medicare's claims processing system to supplement the 80% of the approved amount * MediCare sent the MD or outpatient provider by sendng them 20%.
[ * MediCare's approved amount for treatments & services is often deeply discounted from what can be called the retail amount]
When you own a Supplement — frequently called a MediGap — you gain flexibility to receive treatment from any MD or provider in any state who accepts MediCare.
Why needed! — If you were just using Medicare Part A & Part B, called original MediCare, and had a complex medicate situation there is no limit on the amount you would be responsible for
Thus, you face — a very Big Risk of having to pay many outpatient provider(s) the — 20% MediCare did not pay for each treatment or service!
Details to increase understanding of how Medicare Supplement plans work, are regulated, and the eligibility and enrollment rules in CT are on this page.
What about medications? How are they covered?
Prescriptions received at a pharmacy are NOT covered by MediCare's Part B nor by a Supplement plan!
OK — what can you do? Individuals using original MediCare's Part A & Part B and a Supplement can:
-> Buy a Prescription Drug Plan (PDP) so part of the cost of the outpatient medications they get at the local pharmacy will be paid.
Information to help you understand PDPs, eligibility, and how to sign are on this link:
What about a person who does not take any medications? If they do not sign up and do not currently have "credible" prescription coverage, such as from an employer a monthly penalty of 1% of the average monthly cost of PDPs will be added for each month without a PDP.