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Medicare Enrollment: Doing Nothing Can Be Costly!

If you will become age-eligible for Medicare in 2011, you may be tempted to let your Medicare enrollment slip. Perhaps you’re still employed or you have health care coverage through your spouse. Regardless of the reason, if you don’t enroll in Medicare within three months of your 65th birthday, you could end up paying a premium penalty for the rest of your life, based on when you finally enroll in the plan.

When you become age-eligible for Medicare, you have a “special enrollment period” during which you can enroll in Medicare for the first time. The special enrollment period begins three months before your 65th birthday and ends three months after your birthday.

If you don’t enroll in Medicare during the special enrollment period, you’ll be paying a permanent penalty in the form of increased monthly premiums on Medicare coverage. The penalties can vary, and they apply to all Medicare coverages for which you pay premiums. In other words, the penalty will apply to Medicare Part B, Medicare Part C and Medicare Part D premiums.

This is especially important to understand for Medicare Part D coverage. Medicare Part D coverage is optional. If you opt out for a year or two, even if you enrolled in Medicare Part A and Part B plans, you’ll still pay the premium penalty for your prescription drug coverage when you enroll in a Part D plan.

To avoid the premium penalty, many Medicare-eligible beneficiaries enroll in the lowest cost plans possible when they first become eligible. This strategy may have you spending some additional cash up front, but it will prevent you from paying potentially large non-enrollment penalties later.

One other caveat: your eligibility to enroll in Medicare Supplemental Insurance plans begins when you first become eligible for Medicare. If you choose not to enroll in Medicare at that time, you may forfeit your opportunity to enroll in a supplemental insurance plan later. If you eventually want traditional Medicare Part A and Part B coverage, examine the Medicare Supplemental Insurance plans carefully during your special enrollment period.

2011 Medicare Part D Choices Require Research Says Firm

Avalere Health, a healthcare policy research firm, says that Medicare beneficiaries must do some research before making their Medicare Part D plan election for 2011.  The company says that significant changes await some enrollees, even if they elect the same Part D provider they had in 2010.  According to the company, many Medicare Part D providers have changed their formularies and co-pay costs, meaning that some drugs that were covered in 2010 may not be covered in 2011.

One of the more noticeable changes may be in the way providers structure co-pays.  According to Avalere Health, more providers are structuring their Part D plans with five or more tiers, which will allow providers to charge different co-pays for drugs in different plan tiers.  The number of tiered plans has risen from 27% in 2009 to more than 40% in 2011.  Some plans that already use tiered payment structures have two different tiers for generic drugs.

Another major change for consumers will be in their choice of pharmacy.  Some Part D plans will use preferred pharmacies and will base consumer out-of-pocket costs not only on the prescribed drugs, but also on whether or not prescriptions are filled at a participating pharmacy.  Consumers who use non-plan pharmacies may find themselves paying up to 50% more in out-of-pocket costs for prescription drugs.

More Part D plans are also using pre-authorization and limiting the quantity of medications that can be dispensed at one time, creating an overall higher cost to the consumer for pharmaceuticals in the form of additional co-pays.  The end result of these changes is a net decrease in the number of drugs covered by the top ten prescription drug plans (PDP) for 2011.

Among the top ten plans, the 2011 formularies cover between 50% and 87% of prescription drugs.  To illustrate the potential impact of changes among drug plans, Avalere’s analysis shows that while the AARP’s 2011 formulary covers four popular rheumatoid arthritis drugs with a 33% cost-share, Humana-WalMart’s 2011 formulary covers only two of the four drugs and has a 35% cost-share on the covered formulations. In addition, the cost-share at non-preferred pharmacies is significantly higher.  Enrollees must pay out-of-pocket for drugs not covered by their provider’s formulary. More information about the Avalere Health study can be found at

Doctor Survey Shows More Than 10 Percent May Close In 2011

Arizona Medicare DoctorA survey conducted by the American Academy of Family Physicians (AAFP) shows that about 13% of family physicians who have an ownership stake in their practices may close their practices if Congress does not halt planned drastic cuts in reimbursements in January 2011.  Congress has announced planned cuts of 30% in the Medicare reimbursement rate beginning January 1, 2011.  Initially the cutbacks were set to take effect December 1, but Congress recently voted to delay implementation by one month.

Nearly two-thirds of survey respondents said they would have to stop accepting new Medicare patients and nearly three-fourths said they would have to reduce the number of appointments available to Medicare patients if the cuts are enacted. According to the AAFP, more than one-quarter of rural family physicians depend on Medicare reimbursements to keep their practices open, and the closure of a medical practice would affect not only Medicare recipients, but also healthy adults and children who require routine healthcare services.

The proposed cuts are the result of the application of the sustainable growth rate (SGR), which ties Medicare reimbursements to economic growth. In periods of negative economic growth, the SGR formula calls for payment reductions.  Since its inception in 2002, the SGR has indicated reimbursement reductions, but Congress has voted to override the SGR in favor of modest increases in reimbursements.  Without continued Congressional intervention, the accumulated reductions, which now total nearly 30%, will take effect January 1.

In the past, Congress has briefly allowed the SGR to take effect. During the brief lapses, CMS withheld Medicare and Medicaid reimbursements while waiting for Congress to act. The resulting reductions of as much as 20% required practices to take loans to make their payroll and continue providing services to patients.

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