Making a Part D plan decision
If you have decided to enroll in Medicare Part D, how do you decide which plan to join? No matter where you live in the United States (including Puerto Rico), you have a wide range of choices.
First, you need to decide whether to
- Stay with standard Medicare (Part A and Part B, which cover your doctor, hospital, and some other services) and enroll in a stand-alone Medicare Part D plan
- Enroll in a private health insurance plan that has contracted with Medicare to provide the full range of Medicare covered health care, including drug benefits (this is called Medicare Advantage)
In a Medicare Advantage plan, you get all of your Part A and Part B coverage, as well as your prescription drug coverage (Part D). Medicare Advantage plans may be health maintenance organizations (HMOs), preferred provider organizations (PPOs), or private fee-for-service plans. There are also some Medicare Advantage Plans designed for people with special needs, such as long-term care needs. The Part D drug benefit offered with a Medicare Advantage plan is known as a Medicare Advantage Prescription Drug Plan or MA-PD.
You can learn more about Medicare Advantage in Medicare & You which you can find at www.medicare.gov. To get a copy of this handbook sent to you, call 1-800-633-4227 (1-800-MEDICARE)
Before you choose a stand-alone Part D plan or a Medicare Advantage Plan that includes Part D prescription drug coverage, you should look at all your options. Your coverage will be different based on who you are insured through.
Your drug coverage options
The options you have when looking at Medicare Part D and other types of drug coverage depend on the type of medical plan you have.
If your current plan is through an employer, a union, or the military
- Check with your benefits administrator about your options.
- The plan you have must be “as good as or better than” the standard Part D plan.
If you decide to keep your current coverage, be sure to get and keep a letter as proof of creditable coverage (proof that your coverage is as good as or better than Medicare Part D). You will need this letter to avoid future penalties if you later enroll in Part D.
If you lose your coverage, or decide to switch to Part D, you must join a Part D plan before going 63 continuous days without coverage. If you lose creditable coverage, you can join a Part D plan even if it’s not during open enrollment time. But if you go more than 63 days, you may have to pay a late enrollment fee. The late enrollment penalty is not a one-time fee; it will raise the cost of your coverage for as long as you have it.
If you have Medicare Part A, Part B, or both
If you are new to Part D, you must enroll during your first enrollment period unless you have “as good as or better” coverage as discussed above. You have 7 months to join Part D: 3 months before you turn 65, the month you turn 65, and the 3 months after you turn 65. If you do not join when you are first eligible, you will have to pay a late enrollment penalty for as long as you have Medicare. This penalty raises your premium for the rest of your life.
If you already have Part D, review your coverage every open enrollment period (October 15 to December 7). If you want to switch plans you must do so during this time except in certain situations (if you move or go into a nursing home, for instance). If you are happy with your coverage and its premium, and the plan is still offered in your area, you don’t have to do anything to keep the same coverage.
If you have a Medigap policy, in most cases drug coverage under Medigap is not as good as coverage under Medicare Part D. If you don’t join a Part D plan when you are first eligible you may have to pay late enrollment penalties if you choose to join later. You can’t have Medigap prescription drug coverage and Medicare prescription drug coverage at the same time.
If you have a Medicare Advantage Plan
These may be HMOs, PPOs, private fee-for service, and Medical Savings Account (MSA) plans.
- If you belong to a Medicare Advantage HMO or PPO, you can only get prescription drug coverage from that plan. If you join a Part D plan you will automatically be removed from your Medicare Advantage HMO or PPO.
- If you have a private fee-for-service plan or a Medicare MSA plan that doesn’t offer drug coverage, you may join a Part D plan.
Be aware that you can join or switch Medicare Advantage Plans:
- When you first become eligible for Medicare (this 7-month period starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65).
- If you get Medicare due to a disability, then you can join during the 3 months before to 3 months after your 25th month of disability.
- During annual open enrollment (October 15 to December 7)
If you’re in a Medicare Advantage Plan (MAP), you can make one type of change after December 7. Between January 1 and February 14, you can leave your plan and switch to standard Medicare. If you switch to standard Medicare during this period, you will have until February 14 to join a Medicare Prescription Drug Plan. Your coverage will begin the first day of the month after the plan gets your enrollment form. This is the only change you can make after December 7.
As with other Medicare coverage, in certain situations (such as if you move or go into a nursing home), you are allowed to join, switch, or drop a Medicare Advantage Plan.
There’s also a 5-Star Special Enrollment Period. Starting December 8, 2013 through November 30, 2014, you can switch to a 5-star Medicare Advantage Plan (MAP) at any time during the year. A 5-star rating is considered excellent. The star ratings can help you compare plans based on how good they are and how well they perform. (Plan ratings can be found online at www.medicare.gov/find-a-plan.) You can only use this special enrollment to switch to a 5-star MAP once a year, and you can only join a 5-star MAP if one is available in your area. Note that if you move from a MAP that has drug coverage to a 5-star MAP that doesn’t, you may lose your prescription drug coverage. Then you’ll have to wait until the next open enrollment to get coverage, and you may have to pay late enrollment penalties.
If you have Medicaid
- If you have both Medicaid and Medicare, you are said to be dual eligible. If you do not join a Part D plan, Medicare will automatically enroll you in a plan. You will get a letter telling you about the plan you have been enrolled in and when your coverage begins.
- If Medicare enrolls you in a plan, you may switch Part D plans at any time. It’s a good idea to look at the plans available to you and be sure you are in the one that best meets your needs.
- Medicare Part D prescription drug coverage
- Special things people with cancer need to think about
- Who should enroll in Medicare Part D?
- Making a Part D plan decision
- Getting help to pay Medicare Part A and/or Part B premiums (the Medicare Savings Programs)
- Formularies and drug coverage
- Where can I use my Part D drug coverage to fill my prescriptions?
- How much will the Part D drug plan cost?
- Things to know once you’ve chosen a Part D drug plan
- Switching drug plans in the future
- Frequently asked questions
- Where can I get more help?
- Are you ready to get started?