Medicare Advantage Open Enrollment Period Ends March 31

Most Medicare beneficiaries know they can make a change to their prescription drug coverage at the end of each year during the Annual Enrollment Period. However, many do not realize they can make one more change at the beginning of each year to the way they receive their Medicare benefits. This is called the Medicare Advantage Plan Open Enrollment Period and it runs from January 1 through March 31.

Why is this Open Enrollment Period Important?
There are several reasons. A Medicare beneficiary may have enrolled in a plan that they did not understand or that their doctor does not belong to, they may find that their costs under Original Medicare have increased and are seeking a less expensive option, or they wish to return to Original Medicare with a supplement that allows more freedom of choice. Furthermore, this is the last opportunity for most to make a change until the following year.

This Open Enrollment Period is only for changing in or out of Medicare Advantage plans.  During this time frame, one cannot enroll in Medicare Part D (prescription drug coverage) for the first time, drop Part D, or change from one Part D stand-alone drug plan to another.

What is a Medicare Advantage Plan?
A Medicare Advantage (MA) plan is one administered by an insurance company that enters into a contract with Medicare. The contract varies depending on the type of plan, but they all must follow certain terms and conditions set forth by Medicare. For example, they must accept applicants regardless of their age or health conditions (except for those that have End Stage Renal Disease or ESRD). In Alameda County in 2009 there are 47 Medicare Advantage plans. Many, but not all, include the Medicare Part D prescription drug coverage.

The type most people are familiar with is the Health Maintenance Organization or HMO. This MA plan contracts with a network of health care providers, generally does not cover care outside of the network other than emergency or urgent care services, and includes a plan premium and co-payments for most services. There are five HMOs offered in Alameda County in 2009—two by Health Net (one with the prescription drug benefit and the other without), two by Secure Horizons (one with the prescription drug benefit and one without), and one by Kaiser Senior Advantage (with the prescription drug benefit).

Another type of MA plan is the Preferred Provider Organization (PPO). A PPO also has a network of contracting providers but allows members to go outside of the network with higher out of pocket costs. In California there is one PPO offered by Anthem Blue Cross. The Freedom Blue plan has no premium, but there are co-payments until a $1,050 annual deductible is met. There is also a $4,000 annual out-of-pocket maximum and this plan includes the Part D benefit.

Note:  The Centers for Medicare and Medicaid Services (CMS) have temporarily suspended enrollment into this plan (and the Anthem Blue Cross Part D plans) due to contract compliance problems that adversely affect member services and coverage. The sanctions will be lifted when CMS determines the company has resolved these problems.

Special Needs Plans (SNPs) are a newer type of MA plan. They are geared towards certain populations: those with low incomes or chronic diseases, or those in nursing homes. SNPs aim to coordinate the care more closely based on the needs of their members and generally have lower premiums and co-payments. In Alameda County in 2009 there are six Special Needs Plans, one each offered by the Alameda Alliance, Health Net, and Kaiser, and three offered by Evercare (United Health Care). They all include prescription drug coverage.

Private Fee for Services Plans (PFFS) are a prolific kind of MA plan that has an open network of providers. In other words, its members can go to any doctor who is willing to accept the terms and conditions of that plan and to bill that plan directly. Prospective members should make sure their doctors are willing to do this. Premiums can range from $0 to over $100/month, with varying levels of coverage. Most, but not all, include prescription drug coverage. In Alameda County there are 33 PFFS plans in 2009.

Finally, a Medicare Saving Account (MSA) is another type of MA plan; however, the Open Enrollment rules do not apply here. If someone has already enrolled in an MSA during the Annual Enrollment Period, they must stay in it for the next calendar year. They are not allowed to make a change January through March. An MSA is similar to Health Savings Accounts offered by employers in that it involves a high deductible insurance plan and a tax-free savings account to be used for medical expenses until a $3,000 deductible is met. Medicare deposits an annual amount into the account; in 2009 it is $1,300. This MA plan does not include prescription drug coverage, but members may enroll in a stand-alone Part D plan. There is one MSA in California this year, and Advantra Freedom administers the insurance policy.

Note:  One other MA plan is approved by Medicare for Alameda County; however, it is not enrolling members yet. It is called Fresenius Medical Care Health Plan and will be geared specifically for people with End Stage Renal Disease (ESRD). Contracts with local dialysis providers in Alameda County have not yet been finalized.

What are the Open Enrollment Period Rules?
During the Open Enrollment Period, a person can enroll into one of these Medicare Advantage plans, disenroll from one and go back to Original Medicare, or change from one MA plan to another. To make a change, a beneficiary must only enroll in the new plan by March 31.  Disenrollment from the old plan should then happen automatically. 

If individuals wish to return to Original Medicare, they should decide how they are going to supplement their Medicare before disenrolling from the MA plan. Depending on their health condition, they may not be able to enroll in a Medigap (or Medicare supplement) policy of their choice.

Remember, there is one main caveat:
A Medicare beneficiary cannot enroll into or drop Medicare Part D, the prescription drug benefit during the Open Enrollment Period. If one has started the year with Part D, s/he must keep it for the remainder of the calendar year; likewise if one has not yet enrolled in Part D, s/he cannot do so during this time frame.

Are There Any Exceptions to the Open Enrollment Period?
People who qualify for the Low Income Subsidy (otherwise known as Extra Help for prescription drug costs) can change plans in any month of the year if they wish. This is known as a Special Enrollment Period. These beneficiaries may have full Medi-Cal benefits and therefore automatically qualify for the Extra Help, or they may qualify by applying separately through the Social Security Administration at www.socialsecurity.gov/medicareoutreach2 or by calling 1-800-772-1213. In general, if an individual earns less than $1,354/month in income and has less than $12,510 in assets, s/he can qualify for the Extra Help, which pays for most out of pocket prescription drug costs, including all or most of the Part D plan premium.

Others who may qualify for a Special Enrollment Period include those who lose eligibility for Medi-Cal or the Low Income Subsidy, those who lose their employer group prescription drug coverage, or those who move out of a Medicare Advantage plan service area.

For Further Information:

• on the enrollment periods and your rights under Medicare, visit the California Health Advocates website at www.cahealthadvocates.org and view the various fact sheets (A-008 is specific to enrollment periods).
• on the Medicare Advantage options available in Alameda County, call HICAP at Legal Assistance for Seniors and ask for our comparison charts. You may also request an in-person counseling appointment:  510-839-0393 or 1-800-434-0222.
• about Medicare Advantage plans in general, or specific to a certain region, or to enroll or disenroll, call 1-800-Medicare or visit www.medicare.gov.