As individuals retire or age into Medicare, their insurance situation can change dramatically. There are a multitude of options open to those with Medicare. The terms are different, the prices are different, the products offered are dramatically different each year.
The purpose of this column is to give those who are eligible for Medicare, or soon to be eligible for Medicare, some understanding of their insurance options and how it could impact their health and finances.
These questions and answers are meant as a guide to help you understand the complex questions you are now thinking about. Each individual's specific situation may create a different solution. You shouldn't necessarily do what your friends, family and neighbors do.
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Janell Sluga
Q: I did not switch my insurance by the Dec. 7 deadline. My insurance rolled over, so my plan will stay the same in 2013. Now I am not so sure that was smart. What chances for change do I have?
A: There are a number of Special Enrollment Periods that are available to all individuals with regard to Medicare Part D coverage. Today I am going to focus on two opportunities for switching plans, EPIC coverage and a Five Star Medicare Part D Plan.
EPIC is a New York State Pharmacy Assistance Program that provides very good prescription drug coverage to those who qualify. EPIC stands for Elderly Pharmaceutical Insurance Coverage. EPIC requires that you be 65 or older and a resident of New York state. The income guidelines require that a single person make less than $35,000 annually and a married couple make less than $50,000.
In 2013, there are changes to EPIC, making it much more comprehensive and useful. I recently did an article on all that EPIC will do for you. If you think you qualify for EPIC, please call their helpline at 1-800-332-3742. Their customer service department will answer your questions and send you an enrollment form. You can also get EPIC applications at your local pharmacy or New York State Office For the Aging locations. I have them in my office as well.
EPIC has no set enrollment period. It allows open enrollment all the time. That means that if you want to apply, you can apply anytime as along you meet the previously described criteria. EPIC uses your income figures from last year. Those figures can be obtained from your tax return, if you file; if you don't file, use your 1099 tax documents. You still receive these, even if you are not required to file taxes. You must also include your net Social Security Income (which is not always taxable). I encourage all seniors to review their income every year to see if they qualify for EPIC (if not already covered by EPIC).
EPIC will always be secondary to your Part D insurance coverage. If you have a retiree plan or VA coverage, EPIC will not help you pay for prescriptions. EPIC will only be secondary to Medicare Part D plans.
Another benefit to EPIC is that it may also help you to pay for that Medicare Part D coverage. If your income is $23,000 as a single person or $29,000 as a married couple and enrolled in EPIC, EPIC will pay for the Medicare Part D plan up to the monthly premium of $42.33. If your monthly Medicare Part D premium is more than that, you will only pay the difference. If your premium for Part D is less than $42.33, EPIC will pay the entire Part D plan premium. For a married couple this will hold true for both of you.
EPIC also has an additional benefit. This additional benefit may be more useful to you than any other benefit EPIC offers. If you are enrolled in EPIC, it gives you a Special Enrollment Period (SEP) each year. This means that every year you have EPIC you have an additional one-time opportunity to switch your prescription drug coverage from one product to another. This can be used at any time during the year, but only once each year.
For individuals in your situation, this gives you an opportunity to switch your insurance if you decide to. You can always evaluate whether switching your insurance makes sense. So if you missed the Dec. 7 deadline, you can use your EPIC SEP in December to switch plans and begin Jan. 1, or wait until after January to switch anytime you want during the year if necessary.
In counseling individuals with regard to their insurance, I have many times advised joining EPIC - not because an individual needs the additional drug coverage that badly, but because it gives them this SEP which we can use to make an advantageous insurance change.
If you don't qualify for EPIC, you have another SEP available to you. That is the SEP of a Five Star Medicare Part D Plan. This year we have one Five Star plan available to us in our region. This is a Stand Alone Drug Plan and would be used with original Medicare and ideally a Medicare Supplement Plan. The Five Star Plan is called Blue Cross Blue Shield Rx PDP. It is a Basic Plan, meaning it has a $325 deductible and a coverage gap.
It has a premium of $47.60 per month. If you enroll in an insurance product for 2013 and at some point during the year you need to make an insurance change, you can change into this Blue Cross Blue Shield Rx PDP, which will end your current prescription drug coverage. This is often used as way to leave a Medicare Advantage Plan and go back to original Medicare during the calendar year.
This Five Star Medicare Part D Plan means that now everyone has an opportunity to switch their insurance during 2013 if they need or want to. There are 16 SEPs available to individuals during the year. I will be covering these in an article early in 2013. The other 14 SEPs maybe useful to you and your situation as well.
Janell Sluga is a geriatric care manager certified and works for Senior Life Matters, a program of Lutheran Senior Housing, and has worked in Chautauqua County with seniors for more than 18 years. She is HIICAP (Health Insurance Information, Counseling & Assistance Program) counselor-trained by Office for the Aging. She does not sell insurance or represent any insurance company. She is an unbiased source of insurance and education to help seniors choose the best option for them.
You may submit questions to be answered in later columns to Janell Sluga at Senior Life Matters, 737 Falconer St., Jamestown, NY 14701, or call 716-720-9797, or by email at janells@lutheran-jamestown.org.
Please remember that not all questions can be answered in this format, but as many as can be, will be.