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What to Consider When Helping an Older Loved One Choose a Medicare Plan

With Medicare’s Annual Open Enrollment ongoing from October 15 to December 7, you may have already begun discussions with your loved one on the basics of Medicare, such as differences from Medicaid and what the different plans and options are. But before such an important decision is made, it’s important to go more in depth by preparing the right questions with your loved one to guide the conversation and exploring the different points of consideration that will help determine which plan is best for your loved one’s individual needs.
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“How can I prepare for Medicare Enrollment with my loved one?”

Before beginning the process of Medicare enrollment, consider taking these steps:

  • Review your loved one’s current coverage
    • Consider asking the following questions:
      • Are they happy with their doctor(s), or would they be open to switching?
      • What health concerns do they worry about?
      • Would they like to make any coverage changes?
  • Open communication
    • Talk to your loved one about their health needs. It’s helpful for you to understand as much as possible so that, in the event you must act on their behalf, you may comfortably do so.
    • Speak with your loved one’s health care professionals to better understand your loved one’s condition. Ask clarifying questions about their health care, and get information about screenings and treatment strategies.
  • Consider legal needs
    • If your loved one wishes you to make decisions on their behalf, consult your State Health Insurance Assistance Program (SHIP) to begin the process of getting authorized to make Medicare decisions for your loved one if you have not already done so.

  • Make a budget
    • Review your loved one’s health care costs each month and weigh that against their income sources.
    • Participate in benefits checks for programs in your area that can help cover some of your loved one’s health-care costs. 

“What things should I consider when choosing between plan options?”

Before selecting a plan, you and your loved one should discuss the cost, coverage, convenience, and quality of each plan:

  • Cost: The monthly fee you will need to pay varies by plan. Some drug plans also have a yearly deductible—the amount that must be spent before a drug plan begins to pay its share of covered drugs—or prescription copayment, while others don’t. If your loved one doesn’t have many drug costs now, but they want coverage for peace of mind and to avoid future penalties, consider looking at plans with a low monthly premium for drug coverage to maximize on savings.

    You should also be aware of a plan’s coverage gap or “donut hole,” a temporary limit on what the drug plan will cover for drugs once $4,430 has been spent on covered drugs in 2022 ($4,660 in 2023). If this happens, your love one will need to pay 25 percent of the plan’s cost for covered brand-name drugs and for covered generic drugs.

    Once your loved one has spent $7,050 out-of-pocket in 2022 ($7,400 in 2023), they will be out of the coverage gap and will automatically get “catastrophic coverage.” Catastrophic coverage means that your loved one will only pay a small coinsurance amount or copayment for covered drugs for the rest of the year.  
  • Coverage: Each drug plan has its own “formulary,” a list of the generic and brand-name drugs that a drug plan covers. This list includes the cost of each drug, and, if the plan uses tiers, which drugs are in each tier. Because your loved one’s prescriptions may not be covered by a drug plan’s formulary, you should look into this information before committing to a plan. If your loved one takes many generic prescriptions, plans with tiers that charge low or no copayments for these prescriptions may be the best option.

    Drug plans may require “prior authorization.” This means that before the drug plan will cover certain prescriptions, your loved one must show that they meet certain criteria to have that particular drug. Your loved one’s doctor may need to provide additional information about why the drug is medically necessary before they can fill the prescription.

    Plans may also require “step therapy” on certain drugs. This means your loved one must try one or more similar, lower cost drugs before the plan will cover the prescribed drug. Quantity limits on how much medication your loved one can get are also common. To find out the specific drug coverage rules for a plan, visit Medicare.gov.
  • Convenience: You should make sure your loved one’s current pharmacy is in the plan’s network, or that the alternate pharmacies offered are within a convenient distance. Some drug plans charge lower copayments or coinsurance amounts at certain pharmacies in their network and not others, so in some cases, it may be better for your loved one to switch pharmacies. 

    Some drug plans may offer a mail-order program that will allow your loved one to have their prescriptions sent directly to their home. Discuss with your loved one if they would like to have this option.
  • Quality: Each plan has a quality rating. Medicare uses information from member satisfaction surveys, plans and health care providers to give overall performance star ratings to plans. A plan can get a rating between 1–5 stars. A 5-star rating is considered excellent. These ratings are listed on the Medicare Plan Finder.
Content licensed from the Benjamin Rose Institute. Article by Cynthia Walker