Open enrollment starts Monday for thousands of area seniors and disabled residents who rely on Medicare prescription drug or managed-care plans to help pay for their medications and medical care.
Consumers have until Dec. 7 to enroll in the optional plans or switch coverage. Changes are effective Jan. 1.
The nearly 2 million Ohio residents covered by Medicare can select from among 33 Medicare prescription drug plans, also known as Medicare Part D plans.
Dozens of Medicare Advantage managed-care plans also are available that provide help paying for doctor visits, hospital stays and other medical services.
The Medicare Part D prescription drug plans are offered statewide; the Medicare Advantage managed-care plans vary county-by-county.
Both types of plans are available — but not required — for everyone covered by Medicare, the federal health insurance program for people 65 and older and some younger disabled Americans.
To avoid surprises come Jan. 1, everyone should carefully review notices from their plans about changes in 2013, said Francine Chuchanis, ombudsman supervisor for the Greater Akron/Canton Area Agency on Aging.
According to a recent survey by the nonprofit Kaiser Family Foundation, a third of seniors don’t review and compare their Medicare options annually.
“Nobody should be taking health-care costs for granted anymore,” Chuchanis said.
She estimates the average limit on out-of-pocket spending for enrollees is increasing from $3,778 this year to $4,307 in 2013 among the Medicare managed-care plans available in Summit County, even though premiums are relatively flat.
“For people who have high medical costs, they need to pay attention to that out-of-pocket maximum,” she said.
Officials with SummaCare, Summit County's largest Medicare managed-care provider, said although premiums are increasing for two of its three plans available in the county, some benefits are improving, such as lower out-of-pocket costs for hospital stays.
Consumers who sign up for Medicare prescription drug coverage need to make sure the drug store they use is considered a “preferred” pharmacy by the insurer to avoid higher drug costs, Chuchanis said.
In addition, enrollees should review plan details to determine whether co-pays, co-insurance and covered drugs (known as the formulary) are changing.
Rating system ranks plans
The Medicare program is taking more aggressive steps to encourage consumers to pick plans that rank higher on a 5-star quality rating system, said John Hammarlund, administrator for the Centers for Medicare and Medicaid Services (CMS) region that includes Ohio.
The rating system considers patient experience and complaints, as well as drug pricing and patient safety for the prescription drug plans and efforts to manage chronic illnesses and promote preventive care for the managed-care plans, Hammarlund said.
If a plan has earned fewer than three stars on the quality-rating system for three consecutive years, consumers won’t be able to sign up for the plan online through Medicare’s website (www.medicare.gov). Instead, they will need to call the plan to enroll.
The Medicare program also is notifying everyone enrolled in a “low-performing” plan about the designation and encouraging them to review other options, Hammarlund said.
To encourage enrollment in high-performing plans, the federal government is allowing consumers to switch to a plan with a 5-star quality rating once at any time during the year. Typically, enrollees can only move to different plans during the open enrollment period, except in some special circumstances.
“In all cases,” Hammarlund said, “we want to make sure the plans are the highest quality possible.”
Kaiser Permanente’s Medicare managed-care plans in Summit County earned the top 5-star rating. A Medicare managed-care offering from WellCare was ranked as low-performing. None of the Medicare Part D drug plans in Ohio earned five stars or rated as consistently low-performing.
Enrollees in a majority of plans will face a gap in coverage that could force them to pay for thousands of dollars worth of medicine on their own before more comprehensive coverage begins. However, the federal health-care reform law is slowly shrinking the so-called “doughnut hole” in the coming years until it disappears in 2020.
Drug discounts
Enrollees will get a 52.2 percent discount on brand-name drugs and 21 percent on generic drugs during the gap in coverage in 2013 — an improvement from 50 percent off brand names and 14 percent off generics this year.
The federal government contracts with private insurance companies to provide drug coverage to Medicare recipients who sign up for the plans. Everyone but the poorest enrollees pay a portion of the monthly premium; the government picks up the rest.
Retirees who get their coverage from a former employer or union should have received a notice indicating whether their plan is considered “creditable coverage,” or at least as good as Medicare Part D plans. Anyone who loses creditable coverage can sign up for a Medicare prescription drug plan within 63 days after losing coverage without paying a late-enrollment penalty.
Cheryl Powell can be reached at 330-996-3902 or cpowell@thebeaconjournal.com. Follow Powell on Twitter at twitter.com/abjcherylpowell.