Each fall from October 15 through December 7, the Medicare Open Enrollment Period (OEP) gives seniors the opportunity to adjust their Medicare coverage for the coming year. But what happens if you miss the December deadline? Do you have to wait until next year’s OEP to make changes?
If you haven’t modified your existing Medicare coverage during the OEP, it will roll over automatically and remain in effect through the new year as long as you continue paying any necessary premiums. However, private Medicare plans can and often do change their costs and benefits each year, so your existing coverage may no longer meet your needs or budget come January 1.
Fortunately, beneficiaries can join, switch or drop Medicare health and/or drug plans outside of the annual OEP under a few different circumstances. Use these tips to maximize your Medicare benefits in the coming year and learn about lesser-known opportunities for switching up your coverage.
Options to Consider if You Missed Medicare Open Enrollment
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Make changes during the Medicare Advantage Open Enrollment Period.
In 2019, the Centers for Medicare & Medicaid Services (CMS) introduced the Medicare Advantage Open Enrollment Period (MAOEP), which runs each year from January 1 through March 31.
During the MAOEP, beneficiaries who already have a Medicare Advantage Plan (aka Part C or MA Plan) can switch to another or disenroll and revert to Original Medicare (Part A and Part B) with the option to enroll in a Medicare Part D drug plan.
Keep in mind that, if you drop a MA Plan, you’re giving up benefits, such as the network of providers who participate in that plan and a cap on your out-of-pocket spending for approved medical bills. These are two benefits that Original Medicare doesn’t provide. So, before you switch or disenroll, do some research to ensure you’ll still have the coverage you need, the network you want and premiums you can afford. -
Investigate Medicare Special Enrollment Periods (SEPs).
Medicare also provides SEPs for seniors who need to change their coverage outside of the OEP due to certain qualifying life events. While there are some additional guidelines for SEPs, basic qualifying events include moving to a new address, losing current health insurance coverage, gaining the ability to enroll in new health insurance coverage, and a current Medicare plan changing their coverage. For a full list of all SEPs and their rules, visit Medicare.gov.
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Research Medicare Supplement Insurance (Medigap) policies.
Medigap policies are sold by private insurance companies and offer supplemental coverage to be used in conjunction with Original Medicare. Most people purchase a Medigap policy during their individual six-month Medigap Open Enrollment Period. Unlike the annual OEP, the enrollment timeframe for Medigap is different for each person. It automatically begins the month that a person is BOTH age 65 or older AND enrolled in Medicare Part B. During this window, private insurance companies cannot charge more for, deny or restrict your coverage based on medical underwriting and pre-existing conditions. This is not the case after a person’s six-month Medigap Open Enrollment Period ends, except in certain guaranteed-issue circumstances. You may still try to buy a Medigap policy outside of your enrollment period, but insurers may charge more for a policy or refuse to sell you one if you do not meet their medical underwriting requirements. You can search for and compare Medigap plans that are available in your area at Medicare.gov.
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Look for 5-star Medicare plans.
In 2010, the comprehensive Patient Protection and Affordable Care Act created a star rating system for Medicare Plans (one star being poor and five stars being excellent in terms of quality and performance), and Medicare updates its ratings every fall. Beneficiaries can switch to a five-star MA Plan, Medicare Cost Plan or Medicare Prescription Drug Plan only once during each “5-star special enrollment period” between December 8 and November 30. You cannot change to any plans that are not rated five stars, however. Beneficiaries can use the Medicare Plan Compare tool to search for high-rated plans, which are identified with a special 5-star icon.
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Find ways to maximize your existing drug coverage.
If you missed the OEP and can’t (or don’t) want to use the techniques above, look for ways to minimize your out-of-pocket health care costs in the meantime. Even with health and drug coverage, prescription drugs tend to be a significant expense for seniors. Optimizing your regimen to better fit your current coverage is one of the best ways to reel in medical spending.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 requires every Medicare plan with prescription drug coverage to include at least two drugs in the most commonly prescribed categories and classes in their formulary. Even if your plan doesn’t cover the drug you take, it must cover another similar drug designed to treat the same problem. Talk to your doctor to find what other medications exist to treat your condition and discuss the possibility of switching to a generic version or a drug that is part of your plan’s formulary. If you and your doctor decide that you cannot take an alternative drug due to limited effectiveness, adverse effects or other issues, consider filing an exception request with your plan for coverage of the preferred medication(s).
Don’t feel as though you’re trapped in a plan that doesn’t meet your needs. If the cost of medications, premiums or key benefits becomes unaffordable, there may be opportunities to make coverage changes and reduce out-of-pocket costs. The key is to be proactive. Reach out to the State Health Insurance Assistance Program (SHIP) at your local Area Agency on Aging for help figuring out what options are available to you.
Sources: Joining a health or drug plan (https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan); When can I buy Medigap? (https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap); Summary of the Affordable Care Act (https://www.kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/); 5-star special enrollment period (https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/5-star-special-enrollment-period); H.R.1 - Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (https://www.congress.gov/bill/108th-congress/house-bill/1); How Medicare Drug Plans Use Pharmacies, Formularies, & Common Coverage Rules (https://www.medicare.gov/Pubs/pdf/11136-Pharmacies-Formularies-Coverage-Rules.pdf)