Every Part D plan has something called a formulary, which is a list of drugs covered under the plan. Each formulary has a set of tiers, and in most cases, Part D plans have between three and six tiers. A lower-tier drug usually has lower copays or coinsurance than a drug in a higher tier. For example: Tier 1 – Lowest copay, usually generic drugs Tier 2 – Medium copay includes some low-cost brand-name drugs Tier 3 – Higher copay includes brand-name drugs that have generic versions also available Tier 4 – Higher-co-pay brand-name drugs, and some specialty drugs Tier 5 – Highest copay includes high-cost specialty prescription drugs Suppose you are prescribed a drug in a high tier, and a drug that is similar or therapeutically equivalent is also available in a lower tier at a lower price. In that case, you can ask your insurance company for an exception to get the lower coinsurance or copay. Call Kevin Leinum Medicare Agent – your local Medicare Expert about what Medicare covers or how enrolling in a Medicare Advantage or Medicare Supplement plan can improve your coverage and reduce your out-of-pocket costs.

There is nothing that requires you to enroll in a Part D prescription drug plan when you become eligible for Medicare. However, suppose you do not enroll when you first become eligible. In that case, even if you don’t take any prescription drugs, you will be assessed a Part D late enrollment penalty when you eventually enroll in a Part D plan.

The penalty is assessed if you don’t have Part D coverage or other creditable prescription drug coverage for 63 or more days in a row after you become eligible for Medicare.

How much the Part D late enrollment penalty is will depend on how long you did not have Part D or creditable prescription drug coverage. The penalty is calculated by multiplying 1% of the “national base beneficiary premium” ($33.37 in 2022) times the number of full, uncovered months you did not have Part D or creditable coverage.

If you don’t take any prescription drugs and do not enroll in a Part D plan for several years after becoming eligible for Medicare, the Part D penalty can be a significant amount of money, and once assessed, it never goes away. There are many Part D plans with low or even $0 premiums(for some MAPD plans), so you would be wise to enroll in one even if you do not take any prescription drugs to avoid what could be a costly penalty down the road.

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Covered benefits and cost-sharing for Medicare Advantage plans are two very different things. Covered benefits are a list of specific services, tests, etc., that are covered by your Medicare Advantage plan. All Medicare Advantage plans must cover at a minimum the same benefits provided by Original Medicare Parts A & B. They also frequently include supplemental benefits. These can include things like Dental, Vision, Hearing, Fitness memberships, over-the-counter drug benefits, transportation, and more. Every Medicare Advantage plan is required to provide you with a Summary of Benefits that outlines all of the covered benefits under the Medicare Advantage plan. Cost-sharing is a financial aspect of your Medicare Advantage plan and includes deductibles, copays, and coinsurance. These out-of-pocket costs are then applied to the various covered benefits provided by your plan. Each covered benefit has an associated deductible, copay, or coinsurance applied to it. Some services like preventative service may have a $0 cost-sharing amount associated with that particular benefit. You plan Summary of Benefits will also include the cost-sharing that is applied to each covered benefit. Call Kevin Leinum Medicare Agent about what Medicare covers or how enrolling in a Medicare Advantage or Medicare Supplement plan can improve your coverage and reduce your out-of-pocket costs.

Those that are new immigrants to the United States are not eligible for Medicare. Only residents of the United States (citizens, permanent residents) are eligible for Medicare. If an immigrant is a permanent resident for five years and has continuously resided in the United States for that entire time, they can purchase coverage once they turn 65. In most cases, you will have to pay a premium for Medicare Part B. If you or your spouse worked and paid Medicare taxes for at least ten years (40 quarters), you will not have to pay a premium for Medicare Part A. These rules also apply to Medicare Advantage plans as well as Part D prescription drug plans and Medicare Supplement plans.
If an immigrant is eligible for Medicare coverage, they should also consider the other coverage options available, including Part D Prescription Drug plans, Medicare Supplement Plans, or Medicare Advantage plans. These plans supplement their Original Medicare benefits and may be required to avoid paying any late enrollment penalties. You can find many of the materials available from Medicare and other insurance companies in languages other than English. However, not all materials are always available in all languages, but translation services are available if you call the toll-free Medicare number or any insurance companies customer service phone number.

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The short answer is no. If you like Original Medicare, you don’t have to make any changes. However, it would be wise to talk to an independent agent who is an expert in Medicare to ensure that original Medicare is the most appropriate choice for your specific situation. At a minimum, you should also consider enrolling in a Part D Prescription Drug plan since prescription drugs are not covered under Original Medicare. You could also be assessed a penalty if you don’t enroll in a Part D plan when initially eligible for Medicare.

There are several factors that may impact which Medicare plan is right for you. They include things like your health, financial situation, travel plans, and more. Enrolling in a Medicare Advantage plan can be very affordable, and often Medicare Advantage plans include significant additional benefits not covered under Original Medicare. These include things like transportation to doctors’ visits, dental, vision, hearing, over-the-counter drug benefits, and more. Medicare Supplements (Medigap) plans can also reduce the amount of out-of-pocket costs associated with Original Medicare.

Kevin Leinum Medicare Agent – your local Medicare Expert – can help you understand the many parts of Medicare and determine what the right fit is for you. Give us a call to discuss the options available to you.