Learning Center > 5 Common Medical Procedures for Seniors

5 Common Medical Procedures for Seniors

Medicare spending is trending upward. In 2018, Medicare benefit payments totaled $731 billion - an increase from $462 billion in 2008.

And Medicare-aged people can sometimes have chronic conditions and limitations, which can lead to costly medical services and treatment - all while living on a modest income. So it might be important for you to know the cost of an impending medical procedure to treat your condition.

But finding the true cost of a medical procedure can be tricky, so we used Medicare's procedure price lookup tool to find rough costs of every procedure covered under Medicare.

It's not a perfect science though: The average costs found on Medicare's procedure price lookup tool are based on Original Medicare. That said, the prices do not account for physician fees and Medicare Advantage or Supplemental plans. Still, the tool can give you a ballpark estimate for medical procedures so you can plan ahead and budget accordingly.

With this in mind, let's take a look at five common procedures for Medicare recipients and the costs associated with each procedure.

(Note: All costs are based on Medicare's procedure price lookup tool. Current Procedural Terminology (CPT) is a medical code used to report medical, surgical and diagnostic procedure codes for tracking and billing purposes.)

1. Cataract surgery

Cataract surgery is a common surgery procedure designed to correct blurry vision and reduce glare from lights. During the procedure, an ophthalmologist removes the lens of your eye and replaces it with an artificial lens.

How much does cataract surgery cost?

According to Medicare’s tool, the average out-of-pocket cost of cataract surgery is between $51 and $101 for CPT 66821, but the treatment may involve more than one procedure so the final cost could be more. And there may be additional costs from the facility where the procedure is performed.

Who typically needs cataract surgery?

The need for cataract surgery increases with age. In fact, one in five people ages 65 and up need the procedure, and that ratio increases to three in five people by age 80.

Not everyone with cataracts will need surgery to correct the problem, though. Only those having trouble doing everyday activities because of their cloudy, blurred vision will need the surgery.

Is cataract surgery covered by Medicare?

Yes.

2. Upper GI endoscopy

An upper GI endoscopy involves inserting a small camera into the esophagus, so your doctor can see the inside of your stomach and small intestine. This procedure is often performed to diagnose the cause of persistent heartburn.

If abnormalities are found, additional procedures may be performed at that time or scheduled for a later date.

How much does an upper GI endoscopy cost?

The average cost to the patient for this procedure is between $57 and $112 for CPT 50572, depending on the type of facility used.

Who typically needs an upper GI endoscopy?

People who suffer from acid reflux. Their symptoms often include abdominal pain, difficulty swallowing, nausea, or stomach bleeding.

Is an upper GI endoscopy covered by Medicare?

Yes.

3. Colonoscopy and biopsy

Like an endoscopy, a colonoscopy involves inserting a small camera attached to a tube into the intestinal tract — in this case into the colon. The main purpose of a colonoscopy is to check for colon cancer.

During this procedure, it’s not uncommon to find polyps, which are removed and sent for a biopsy. A biopsy is a lab test to determine whether tissue is cancerous.

How much does a colonoscopy cost?

It can be tricky to calculate the cost of a colonoscopy because there are several variables involved. For example, there's no need for a biopsy if polyps aren't found. But if something else is found, like a tear in the lining of the colon, an on-the-spot procedure might be performed.

Generally, the patient cost for a colonoscopy with no complications is between $100 and $195 for CPT 45380. And there may be additional costs from the facility where the colonoscopy is performed.

Who typically needs a colonoscopy?

Colonoscopies are recommended for anyone with a family history of colon cancer or over the age of 50, making this one of the most common procedures for seniors.

Your doctor is likely to order a colonoscopy if you have such symptoms as:

  • Rectal bleeding
  • A change in bowel habits including constipation or diarrhea
  • Narrow or thin stools
  • Abdominal discomfort including gas pain and bloating
  • Chronic fatigue
  • Unexplained weight loss
  • Unexplained anemia

Is it covered by Medicare?

Yes.

4. Arthroplasty knee (knee replacement)

”Arthroplasty knee” is a fancy way of saying “knee replacement.” No matter the term you use, this procedure repairs worn knee sockets, which can include complete or partial knee replacement.

Two out of three seniors will need knee replacement surgery at some point, making this the most common medical procedure for those over 65.

How much does a knee replacement cost?

It can be difficult to estimate the exact cost in advance because the surgeon may not know exactly what's needed until taking a look inside the joint. The cost can also vary depending on whether the knee replacement is performed in a hospital or at an ambulatory surgical center.

In many instances, knee replacement procedures might cost less in a hospital setting. The costs for arthroplasty knee surgery range from $524 to $1,364 (CPT 29879) when performed as a hospital outpatient. But it may be higher if it's performed in a clinical setting. Look into costs associated with the facility where the knee replacement will be done.

That's because hospital outpatient departments must cap Original Medicare patient costs at $1,364.

Who typically needs knee replacement?

Osteoarthritis is the most common reason for knee replacements, but other factors may lead to the deterioration of the knee joints, including:

  • Rheumatoid arthritis
  • Gout
  • Knee injuries
  • Knee deformities
  • Hemophilia
  • Bone disorders

Is it covered by Medicare?

Yes.

5. Total or partial hip replacement

A hip replacement, also known as hip arthroplasty, is a surgical procedure in which a damaged hip joint is removed and replaced with an artificial joint, often made of titanium and ceramic. During the procedure, the entire hip joint is surgically opened to remove the damaged head of a thigh bone and replace it with man-made materials, which eventually fuses with the bone. At the same time, the eroded lining of the hip socket is also removed and replaced, restoring mobility and resulting in pain-free movement.

Hip replacements are typically caused by osteoarthritis, a degenerative condition that erodes the surface of a joint. More than 10 million American seniors suffer from osteoarthritis.

How much does a total or partial hip replacement cost?

As with any medical procedure, pricing varies by your location and provider. On average, the patient's cost of a total hip replacement ranges from $548 to $1,139 for CPT 29862.

But remember: If a surgery like this is performed in a clinic setting, the Original Medicare cap of $1,364 doesn’t apply — which could increase the cost to you. Always look into costs associated with the facility where the hip replacement will be performed.

Who typically needs a hip replacement?

People over age 60 with osteoarthritis or other degenerative joint conditions of the hip.

Is it covered by Medicare?

Yes. Both partial and full hip replacement surgery is covered under Medicare.

Don't get surprised by medical procedure costs

Remember: Though the projected costs of these common medical procedures may help you prepare your wallet for the given procedure, they're just ballpark figures. Procedure costs can vary by your location, so it's always wise to check with your Medicare provider to get additional procedure cost estimates.

It's also worth noting that your doctor may order tests or additional procedures that may not be covered by Medicare. And if your procedure requires a hospital stay, there are plenty of ways to avoid costly hospital bills.

Also keep in mind that you may need additional services after your procedure, such as physical therapy, so you may need to factor rehabilitative services into the equation.

Choosing a Medicare plan

Having a general idea how much common medical procedures cost is a good first step to be prepared for them. But choosing the optimal Medicare plan for you is also important because coverage for some procedures may depend on whether you have Original Medicare or Medicare Advantage.

Medicare Advantage and Medicare Supplement are two common ways to replace or supplement Original Medicare, but they serve different purposes:

  • Medicare Advantage plans also known as Part C usually cover Parts A, B, and D with one bundled insurance policy for all Medicare coverage.
  • Medicare supplement insurance is not comprehensive medical coverage. Instead, it provides extra coverage to help pay for some of the healthcare costs and services that Medicare doesn’t cover. These plans, also known as Medigap, can offer protection from large out-of-pocket medical costs that result from numerous doctor or hospital visits. Additionally, a standalone prescription drug plan must be purchased to get prescription drug coverage.

If you need help choosing the right Medicare plan for your specific medical needs, you can compare Medicare plans through our online Medicare plan finder or by calling 800-620-4519 to reach one of our licensedd insurance agents.

We've also put together Medicare FAQs for more information.

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What you should read next

The popularity of Medicare Advantage plans is growing at a rapid pace. In 2020, more than 36% of all Medicare beneficiaries were enrolled in Medicare Advantage health care plans. Whether you’re already in a Medicare Advantage plan, you’re curious about them, or you’ve never heard of them, this Medicare Advantage guide is for you. In this in-depth Medicare Advantage guide, we’ll provide a Medicare Advantage overview that will answer your frequently asked Medicare questions and cover the following topics: What is Medicare Advantage and who qualifies for it The different types of Medicare Advantage plans and how they work The difference between Original Medicare and Medicare Advantage What Medicare Advantage plans cover Who should consider getting Medicare Advantage How much Medicare Advantage costs Medicare Advantage and special scenarios Medicare Advantage plan ratings When to enroll in Medicare Advantage How to enroll in Medicare Advantage What Is Medicare Advantage? Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. The Medicare Advantage program is a way for beneficiaries to access their benefits and rights under Original Medicare, but through a private insurance company instead of the Federal Government. A Medicare Advantage plan is a contract between a private insurance company and the Medicare program. By law, every Medicare Advantage plan must cover everything covered by Original Medicare (Medicare Part A and Medicare Part B). This means that if you choose to enroll in a Medicare Advantage plan, you can be confident that you’ll receive all the benefits you’re entitled to under Original Medicare. Who Qualifies For Medicare Advantage? To qualify for Medicare Advantage, you must be enrolled in Original Medicare Parts A and B. You also must continue to pay your Part B premium in order to keep your Medicare Advantage coverage. There are no age restrictions for Medicare Advantage plans. If you’re enrolled in Part A and B before age 65 due to a disability or chronic condition, you’re still eligible for Medicare Advantage coverage. How Do Medicare Advantage Plans Work? Medicare Advantage health care plans work like the employer-sponsored health insurance plans you may be used to from your previous or current job. Medicare Advantage plans provide comprehensive coverage, and you usually need to stay in-network to receive care. You’ll typically have some out-of-pocket expenses when you receive services and procedures under your Medicare Advantage policy. These costs typically come in the form of copayments or coinsurance that you’ll pay to your provider when you receive care. An important point to remember is that all Medicare Advantage plans have an annual out-of-pocket (OOP) maximum that limits the total amount you can spend in any year. But you do not have an OOP with Original Medicare. What Types Of Medicare Advantage Plans Are Available? There are 6 types of Medicare Advantage plans, including: Medicare Advantage HMOs (Health Maintenance Organizations) Medicare Advantage PPOs (Preferred Provider Organizations) Medicare Advantage PFFS (Private Fee-For-Service Plans) Medicare Advantage SNP (Special Needs Plans) Medicare Advantage HMO-POS (HMO Point-Of-Service Plans) Medicare Medical Savings Plans (MSPs) In this Medicare Advantage guide, we’ll focus on Medicare Advantage PPO plans and Medicare Advantage HMO since they’re the most common types of MA plans. The Difference Between Original Medicare and Medicare Advantage The primary difference between these programs is that Medicare Advantage is an alternative to Original Medicare. When you join a Medicare Part C plan, you no longer receive your Medicare benefits through Original Medicare. Medicare Advantage plans are offered and administered by private insurance companies. But these private insurance companies must comply with many rules and regulations set by the Medicare program. Pros And Cons Of Medicare Advantage Plans vs. Original Medicare Medicare Part C plans have many advantages when compared to Original Medicare. The 3 biggest pros of Medicare Advantage plans are: Annual Out-of-Pocket Maximum spending cap Availability of prescription drug coverage* Extra benefits for things not covered by Original Medicare *Note: Some MA plans are available without prescription drugs. These additional benefits from Part C make Medicare Advantage a more complete coverage option than Original Medicare. MA plans can have their drawbacks in comparison to Original Medicare, depending on your healthcare needs. The 3 biggest pros of Original Medicare are: #1. You can see any doctor or go to any facility anywhere in the country, as long as they accept Medicare. #2. There are no networks. Most Medicare Advantage plans have some kind of network restrictions. #3. You don’t need referrals to see specialists. With some Medicare Advantage health care plans, such as HMOs and Special Needs Plans, you usually need referrals from your primary care physician to visit a specialist. What Does Medicare Advantage Cover? Medicare Advantage plans provide coverage that matches Original Medicare Parts A and B. Generally speaking, your Medicare Advantage plan will cover the same service or procedure as Original Medicare. But there is one exception to this rule, which we’ll cover below. Medicare Advantage plans cover the following services. Medicare Part A Services Medicare Part A covers services that take place in healthcare facilities or institutions like: Inpatient hospital stays Skilled nursing services (not room and board) Hospice care In-home care Note: Hospice care is usually not covered by Medicare Advantage plans. Instead, hospice care is covered under Original Medicare, even if you’re enrolled in a Medicare Advantage plan. However, a new test program in 2021 will explore Medicare Advantage plans providing hospice benefits. Medicare Part B Services Medicare Part B services and procedures are considered more routine and non-emergency in nature than Part A. Common Medicare Part B services include: Doctor’s visits, including specialists Physical and occupational therapy Lab and diagnostic testing services like blood work and x-rays Durable medical equipment Mental health services Ambulance services Some cancer treatments, including chemotherapy As mentioned, Medicare Advantage plans cover all of these services with the exception of hospice care. Medicare Advantage And Prescription Drugs Most Medicare Advantage plans offer prescription drug coverage. These plans are also known as Medicare Advantage Prescription Drug Plans (MAPDs), and they include Medicare Part D. Medicare Advantage Extra Benefits When considering Medicare Advantage pros and cons, it’s essential to take extra benefits that Medicare Advantage could offer to you. Many of these benefits are not provided through Original Medicare. Medicare Advantage benefits may include: Fitness programs: SilverSneakers, gym memberships, and fitness trackers. Vision care: Eye exams, contact lenses, and sometimes eyeglass frames. Hearing care: Exams and often discounted hearing aids. Dental coverage: Some plans have basic dental benefits built in, others offer dental coverage for an extra premium. Transportation: Rides to and from medical appointments. Meal Deliveries: For qualified people returning home from the hospital or skilled nursing facility Telemedicine services and virtual healthcare. Note: Medicare Part C plans have the ability to choose which, if any, extra benefits to offer. These insurance companies may also make changes to their Medicare benefits and offerings each year. Who Is Medicare Advantage Good For? You should consider enrolling in Medicare Advantage if: You want to put a cap on your total out-of-pocket spending under Original Medicare. You want prescription drug coverage without paying for a separate Part D drug plan. You need some of the extra benefits (vision, hearing, private home aides) that come with many Medicare Part C plans. You don’t want to pay for Medicare Supplement (Medigap) plans. You don’t mind using a network of doctors and facilities. You don’t mind needing referrals to see specialists. You don’t mind paying small copays each time you see a doctor. How Much Does Medicare Advantage Cost? Medicare Advantage plans have several costs associated with them. Before we dive into each cost, it’s important to remember that you always have to pay your Part B premium in order to have Medicare Advantage. Now, some Medicare Advantage plans offer a benefit that covers part, or all, of your Part B premium. But check the plan benefits closely to see if this is offered by a specific Medicare Advantage plan. Beyond this Part B premium, you might face the following Medicare Advantage plan costs: Monthly premium Annual deductible Copayment Coinsurance You might have a monthly premium for your Medicare Advantage plan, but these premiums tend to be low. For example, the average Medicare Advantage premium was $23.63 per month in 2020. However, many Medicare Advantage plans do not have a monthly premium. In 2020, 60% of people enrolled in Medicare Advantage didn’t pay a monthly premium. Some Medicare Part C plans have an annual deductible, but again, many do not. If your plan does have an annual deductible, this means you’ll have to pay a certain amount before the plan begins paying benefits. Note that there may be separate deductibles for drug coverage and medical benefits. Beyond premiums and deductibles, the most common expenses you’ll have with Medicare Advantage plans are copayments and coinsurance. These two terms are referred to as “cost-sharing.” This is what you’ll pay out of pocket when you receive covered services. All the amounts you pay during the year count towards your annual out-of-pocket cap. Examples Of Medicare Advantage Costs Let’s look at 3 examples of how these Medicare Advantage costs work in a Medicare Advantage HMO plan. (Note: These costs are not the actual costs for any specific plan, but rather, in the range of costs for plans that you may have access to.) Scenario 1: Medicare Part B Services You injure yourself shoveling snow on your property, and you go to the doctor for an examination. You’ll pay a copay of $20 to see your primary care physician who then refers you to an orthopedic specialist. Your orthopedic specialist charges you a $35 copay for the office visit and wants you to get x-rays. You pay a $50 copay for the x-rays. Fortunately, nothing is broken or torn, so your specialist refers you to physical therapy. You pay a copay of $40 for four physical therapy sessions. Your total out-of-pocket spending for this injury is $265, spread out over a month-long period. All of these costs count towards your Medicare Advantage out-of-pocket maximum. Scenario 2: Medicare Part A & B Services You experience the symptoms of an irregular heartbeat, so you’re admitted to the hospital as an inpatient. You spend two nights in the hospital. You pay a copay of $300 per day, which amounts to a total of $600. After you’re released from the hospital, you continue to see a cardiologist, and you pay a $35 copay to see this specialist each time you visit. Scenario 3: Cancer You’re diagnosed with a treatable cancer, and you’re given chemotherapy. The copay for this treatment is 20% of the Medicare-approved cost. Although 20% amounts to more than $20,000, you hit your annual out-of-pocket maximum, so your costs are capped at $5,900 for the year. When Can You Enroll In Medicare Advantage? You can normally enroll in or change your Medicare Advantage coverage during 3 periods of time: Your Initial Enrollment Period (IEP) when you’re first eligible for Medicare. The Medicare Annual Enrollment Period (AEP), which runs from October 15 to December 7 each year. The Medicare Advantage Open Enrollment Period from January 1 to March 31 each year - however, this MA open enrollment is only for those already in a Medicare Advantage plan. Enrolling In Medicare Advantage For The First Time If you’re turning 65, you can enroll in Medicare Advantage during your Initial Enrollment Period (IEP). Your IEP lasts for 7 months, which begins 3 months before your 65th birthday, includes that birthday month, and ends 3 months after you turn 65. If you’re under 65, your first chance to enroll in Medicare Advantage starts: After your 24th month of receiving Social Security disability benefits, or At any age if you have Amyotrophic Lateral Sclerosis (ALS), also called Lou Gherig’s Disease, or if you have End-Stage Renal Disease (ESRD). Changing Your Medicare Coverage During AEP The Medicare Open Enrollment Period, also called the Medicare Annual Enrollment Period or Annual Election Period, is a good time to decide whether Medicare Advantage or Original Medicare is right for you. Also keep in mind that Medicare Advantage plan benefits can change annually. So if you have a MA plan, you should check to make sure the plan still meets your needs. Here are the actions you can take during AEP: Change from Original Medicare to a Medicare Advantage plan. Change from one Medicare Advantage plan to another. Disenroll from your Medicare Advantage plan and go back to Original Medicare. Change from one prescription drug plan (Medicare Part D) to another. Enroll in a prescription drug plan. Cancel your prescription drug coverage. If you enroll in, or switch your Medicare Advantage insurance during AEP, your new coverage will be effective on January 1st of the following year. You may also be able to enroll in a Medicare Supplement plan if you drop your Medicare Advantage coverage during AEP. The Medicare Advantage Open Enrollment Period If you’re enrolled in a Medicare Advantage plan, you have access to another enrollment period beyond AEP: The Medicare Advantage Open Enrollment Period (MA-OEP). MA-OEP runs from January 1 to March 31 of each year. During the MA-OEP, you can: Change from one Medicare Advantage plan to another. Drop Medicare Advantage, and return to Original Medicare. Add a Prescription Drug Plan if you return to Original Medicare. It’s important to keep in mind that the MA-OEP is only for people who already have a Medicare Advantage plan. If you change plans during the MA-OEP, your new coverage will be effective on the first day of the month after you enroll. Medicare Advantage & ESRD Coverage For all years before 2021, there was an exclusion for people with permanent kidney failure, known as End-Stage Renal Disease (ESRD). ESRD patients could not get new Medicare Advantage coverage. However, beginning January 1, 2021, ESRD patients will be able to enroll in or switch Medicare Advantage plans. Now the eligibility for Medicare Advantage and Original Medicare will be perfectly aligned. Medicare Advantage And Other Special Scenarios We mentioned earlier that Special Needs Plans (SNPs) are a type of Medicare Advantage insurance. Let’s take a look at some common types of SNPs, and how Medicare Advantage health plans are also helping people to get access to care and benefits during the coronavirus pandemic. Medicare Advantage And Chronic Conditions There are Medicare Advantage plan options for people with chronic conditions like diabetes and heart disease. These plans are known as Chronic Special Needs Plans (Medicare C-SNPs), and the benefits are tailored to help you treat and manage your chronic condition. These health plans often provide you with a care coordinator to make sure your needs are being met. These Special Needs Plans have Special Enrollment Periods (often called SEPs), so if you qualify for a C-SNP, you can enroll in it at any time. You won’t have to wait for an annual enrollment window. Medicare Advantage And Medicaid Another kind of Special Needs Plan exists for “Dual Eligibles” – people who are eligible for both Medicare and Medicaid. These plans, called Dual Eligible Special Needs Plans (D-SNPs), have cost-sharing that conforms to the Medicaid program, which means that most costs are $0. D-SNPs incorporate various prescription drug discount programs, depending on your income level - so you’ll save money on your prescriptions if you qualify. D-SNP plans also have more favorable enrollment windows, which allow you to access the benefits once you become eligible for Medicaid or extra help and at certain times during the year without waiting for an annual enrollment window. Medicare Advantage And COVID-19 Medicare provides Coronavirus coverage to help people combat the virus, which includes: No-cost lab testing. Antibody testing. All medically-necessary services and procedures, including hospitalizations and doctor’s visits. Coronavirus vaccine coverage, when one becomes available. Many Medicare Advantage health plans are waiving cost-sharing for these services. In this case, you wouldn’t pay a copayment or coinsurance for seeing a doctor or going to the hospital if you have COVID-19. Medicare has also approved an expanded role for telehealth and virtual doctor’s visits. And many Medicare Advantage health care plans offer these no-contact services with no out-of-pocket cost to you. Medicare Advantage Plan Ratings Every established Medicare Advantage plan is given a Medicare Start Rating by the Centers for Medicare & Medicaid Services (CMS). Star ratings range from 1 to 5, with 5 stars being the highest. Here’s a breakdown of what each rating means: 5-star rating: Excellent 4-star rating: Above Average 3-star rating: Average 2-star rating: Below Average 1-star rating: Poor Medicare Advantage plans are rated on several different metrics and are given an overall rating. This Medicare star ratings system is designed to help you get a feel for the level of quality and satisfaction a MA plan offers. Star ratings also give you an idea of how well a plan treats its members. Plans are rated on how quickly it responds to appeals and complaints and how they cover health screenings and preventative services. Plans are also rated for both medical benefits and prescription drug benefits, if the plan has drug coverage. How To Enroll In A Medicare Advantage Plan If you want to enroll in a Medicare Advantage plan, you’ll want to consider 3 things before joining: Make sure you find a plan that’s available in your area. Most Medicare Advantage plans are restricted to specific counties or states. Make sure your current doctors and medications are covered. This is especially important if you’re looking at a Medicare Advantage HMO plan. You’ll have to use the doctors that are in-network, and you’ll only get coverage for medications that are on the plan formulary. So make sure you investigate these before enrolling. Pay attention to star ratings. This can help you compare the overall quality among different plans. But keep in mind that new plans are not given star ratings until enough data has been collected for CMS to calculate a rating. Once you’ve found a plan, you have a few options to enroll, including: Online, by phone, or paper enrollment directly with the insurance company. Working with a licensed health insurance agent who can help you find, compare, and enroll in a Medicare Advantage plan of your choice. Medicare Advantage Guide Conclusion Medicare Advantage plans can be a great way to manage your out-of-pocket spending while enjoying extra benefits we covered, if you qualify. And they can offer some compelling advantages over Original Medicare, depending on your healthcare needs. So if you'd like to learn more about Medicare Advantage plans in your area, call 800-620-4519 to reach a licensed insurance agent who may be able to guide you to the right plan for your needs. You can also try online Medicare plan comparison tool.
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The transition from 2020 to 2021 offers many opportunities for people on Medicare. Whether you use Original Medicare, Medicare Advantage, or Medicare Supplement Insurance, you’ll find plenty of changes on the horizon. In this guide to 2021 changes to Medicare, we’ll review what happened during 2020, and dive into the Medicare changes and opportunities for 2021. Review of 2020 Medicare Changes To say that a lot happened in 2020 is a cosmic understatement. The big disruptor, of course, was COVID-19. The pandemic led to some sizable changes in the Medicare program. Some of the highlights from 2020 include: Medicare Supplement (Medigap) Plans C, F, and High Deductible F (HDF) were no longer available to newly-eligible beneficiaries as of 1/1/2020. For the second year in a row, the infamous “Donut Hole” was closed for Part D drug plans. Medicare expanded access to telehealth/virtual doctor appointment services. Many insurance companies, including the major Medicare Advantage plan sponsors, reduced or waived copayments for COVID-19-related care. Other than the COVID-19-related changes, the loss of Medigap Plans C, F, and HDF was probably the biggest change to Medicare for 2020. Those plans became unavailable for beneficiaries who first became eligible after 12/31/2019. This leaves Plan G as the most comprehensive Medigap plan available to all new Medicare beneficiaries. This plan will cover 100% of your Medicare deductibles, copayments, and coinsurance except for the Part B deductible. You’re responsible for the first $198 in Part B expenses for 2020. 2021 Changes To Medicare Some cost-sharing amounts for 2021 are not yet known - and it could be due to the uncertainty that COVID-19 created. As of now, it’s expected that 2021 Medicare Part B premiums, and Part A and B deductible amounts will be announced in November 2020. What we do know is that any 2021 Part B Premium increase will be capped by Congress. As part of a budget deal, Congress and the President limited any increase in Part B premium to no more than 25% of the calculated amount. This is designed to help prevent a dramatic increase in premium cost due to the effects of COVID-19. In general, you can expect relatively small increases in premiums. For historical context, here are the increases from 2019 to 2020: Part A deductible increased from $1,364 to $1,408 ($44 increase) Part B deductible increased from $185 to $198 ($13 increase) Part B base premium increased from $135.50 to $144.60 per month ($9.10) Keep in mind: The 2021 Part B premium increase will once again be capped by the Social Security cost of living adjustment for qualified Medicare beneficiaries on Social Security. This provision protects your Social Security check from shrinking due to Medicare premium increases. So, for 2021, you’ll have a double-protection against Part B premium increases. Medicare Advantage Plan Changes For 2021 Many of the most exciting and notable 2021 changes to Medicare encompass Medicare Advantage plans. These plans, which are also known as Part C plans, are a private insurance alternative to Original Medicare. Medicare Advantage And ESRD The single biggest piece of news about Medicare Advantage for 2021 relates to those with End Stage Renal Disease (ESRD), also known as kidney failure. Beginning 1/1/21, Medicare beneficiaries with ESRD will be able to get coverage through Medicare Advantage plans. Prior to 2021, Medicare Advantage plans were generally able to exclude people with ESRD. This left ESRD patients in a tough spot, since under Original Medicare Part B, they paid 20% of the cost of dialysis. And this can get expensive very quickly since there was no out-of-pocket cap on their expenses under Original Medicare. Everyone with ESRD will now be able to get Medicare Advantage coverage. This may not reduce the amounts ESRD patients pay early in the year, since many Medicare Advantage plans charge a 20% coinsurance for dialysis as well. However, the great news for ESRD patients is that every Medicare Advantage plan has an annual out-of-pocket maximum. So once ESRD patients hit their annual spending caps, they’re not required to pay for any more medical expenses the rest of the year. Medicare Advantage And Hospice Benefits Another 2021 change to Medicare Advantage is a small test program for delivering hospice benefits. Historically, hospice coverage was provided by Original Medicare, even if you were in a Medicare Advantage plan. Starting in 2021, 53 Medicare Advantage plans across the country will provide hospice and palliative care. This is a very small number of plans, so it won’t affect most people at this point. However, if the test program works, you may see more Medicare Advantage plans offering this benefit in the future. Extra Benefits Through Medicare Advantage Plans Medicare Advantage is the subject of other big 2021 changes to Medicare. Beginning in 2021, additional benefits will be available. Extra benefits are benefits offered by Medicare Advantage plans that are not covered by Original Medicare. Examples may include: Dental coverage Vision and hearing coverage Chiropractic care For 2021, new Medicare benefits will be available. Many of them are designed to help you get care at home, and lend some support to caregivers. The new extra Medicare benefits in 2021 available through some Medicare Advantage plans include: Caregiver support Adult day health services In-home support services Therapeutic massage Acupuncture (for chronic low back pain only – this is also now covered under Original Medicare) But these extra benefits are not required or guaranteed. Instead, they are optionally provided by Medicare Advantage plans, and they can be changed or discontinued from year to year. Still, the availability of adult day health services and caregiver support will be beneficial for many of those on Medicare who struggle to care for themselves. For 2021, Medicare Advantage plan premiums are lower on average than in the past. In fact, the average Medicare Advantage plan premium is expected to be 11% lower in 2021 than in 2020. For 2021, the average Medicare Advantage plan premium will be $21 per month. On the other hand, the annual out-of-pocket maximum for in-network services is rising to $7,550. This is the highest it can be. Many plans will continue to offer lower out-of-pocket maximums. 2021 Changes To Medicare Drug Plans The other big news in 2021 changes to Medicare is the Part D Senior Savings Model. This model program, which is essentially a five-year test, will cap the price beneficiaries in participating to no more than $35 copays for a 30-day supply for many types of insulin. Under this new program for 2021, beneficiaries will have access to about 1,700 MAPDs (Medicare Advantage plans with Part D drug benefits) and stand alone Prescription Drug Plans that cap the cost of insulin. Another great detail about this program is that the cost for insulin won’t change, even if you enter the coverage gap during the year. You’ll still pay the same capped copayment. In addition, you won’t have to meet a deductible to get the $35 copay price. While not every plan has chosen to participate, CMS expects there to be at least one plan in all 50 states, the District of Columbia, and Puerto Rico. Given the effect of diabetes on the kidneys, patients with ESRD are in position to grab some great new benefits for 2021 and beyond. How To Prepare For 2021 Changes To Medicare For starters, you should make note that we expect a slight increase in Original Medicare costs, for 2021. Though we still don’t know what they’ll be, we expect there to be some increase in the Part B premium, even with the caps that will limit the total rise in costs. You can expect the same thing with deductibles. As with a normal Medicare Open Enrollment Period, also called the Medicare Annual Election Period (AEP), you should review your current coverage to see if switching plans for 2021 makes sense. New plans are available each year, so Medicare beneficiaries have until December 7, 2020 to make a change to their plans for the 2021 plan year. When comparing plans during the Medicare Open Enrollment Period, be sure to look at: The monthly premium (if any) Annual deductibles (if any) Cost structure, like copays and coinsurance amounts for Medicare Advantage and Prescription Drug Plans Out-of-pocket maximum amounts for Medicare Advantage plans Networks of doctors and medical facilities for Medicare Advantage plans Tip: It’s important to not just jump into a new plan because it has one appealing feature. You want to make sure that your doctors accept any new plan and that your current medications will be covered. If you use insulin, you may want to consider one of the standalone Prescription Drug Plans or MAPD plans participating in the Senior Savings Model program, if available. It’s estimated that those on insulin could save more than $400 per year on average. Besides savings on insulin through the Senior Savings Model program, ESRD patients who don’t currently have Medicare Advantage plan coverage should consider it for 2021. Moving to Medicare Advantage could help ESRD patients in 2 different ways: Moving from Original Medicare to Medicare Advantage Moving from Medicare Supplement Insurance to Medicare Advantage In the first case, you can take advantage of the out-of-pocket spending cap that a Medicare Advantage plan can offer. The out-of-pocket cap could be a real benefit for ESRD patients since it’s not only dialysis treatments that could count against the Medicare out-of-pocket maximum (OOPM). All spending on Medicare-approved services and procedures count towards the OOPM, so an ESRD patient might “max out” their spending during 2021 and get substantial relief the rest of the year. On the other hand, if you have ESRD and are currently covered by a Medigap (Medicare Supplement) plan, you might be able to save money on your monthly premium by switching to Medicare Advantage. And you might save money or come close to breaking even by switching from Medigap to Medicare Advantage, depending on the premiums and out-of-pocket maximums for plans in your area. Just be sure you run the numbers before making this move. Note: It can be difficult to get Medicare Supplement insurance coverage back after you move away from it. You might have to go through medical underwriting, which means you may be declined coverage as an ESRD patient with a pre-existing condition, unless you qualify for a guaranteed issue period. Due to the complexities of Medigap coverage, it’s a great idea to talk to a licensed insurance agent to see if switching to Medicare Advantage is a good idea. Get Help With Medicare If you still have questions about 2021 changes to Medicare and how they impact you, call 800-620-4519 to get help from one of our licensed insurance agents. Or you can try our free Medicare plan comparison tool to find Medicare plans in your area. There is no obligation to enroll in a plan.
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The Medicare Annual Enrollment Period (AEP), sometimes called Medicare Open Enrollment or the Medicare Annual Election Period, starts on October 15. If you’re eligible for Medicare, you’ll probably receive lots of information over the next few weeks and throughout AEP. And this information can be overwhelming. But we’re here to help you with this useful Medicare guide. So let’s dive into the Medicare Annual Enrollment Period, what it is, how to prepare, and what you can do during AEP. Then, we’ll cover some tips for choosing the right Medicare plan for your healthcare needs. What is the Medicare Annual Enrollment Period? The Medicare Annual Enrollment period happens each year from October 15 to December 7. During this time period, you have the option to make changes to your Medicare coverage. Your new coverage would then take effect January 1. But if you’re satisfied with your current Medicare coverage, you don’t have to take any action during Medicare AEP. There are no penalties involved if you do nothing. Medicare plan details can change annually, though, so it’s wise to review your Medicare coverage each year. We’ll cover more on this shortly. What’s the Difference Between Medicare AEP and the Medicare General Enrollment Period? The Medicare Annual Enrollment Period is sometimes confused with the Medicare General Enrollment period, which is January 1 to March 31 each year. It’s important to understand the differences between the two enrollment periods. The Medicare General Enrollment Period is for Medicare beneficiaries who didn’t sign up for Medicare Part A or Part B when they first became eligible and aren’t eligible for a Medicare Part B special enrollment period. The AEP, however, is for beneficiaries who are already enrolled in Medicare and want to change their Medicare coverage. What Changes Can I Make During the Medicare Annual Enrollment Period? The first thing to know is that you cannot use the Medicare Annual Election Period to enroll in Medicare Part A or Part B for the first time. But if you’re enrolled in Medicare Part A and Part B and you’d like to change your Medicare coverage, here are some things you can do during the Medicare Annual Election Period: Change from Original Medicare to a Medicare Advantage plan. Change from one Medicare Advantage plan to another. Disenroll from your Medicare Advantage plan and go back to Original Medicare. Change from one prescription drug plan (Medicare Part D) to another. Enroll in a prescription drug plan. Cancel your prescription drug coverage. 5 Tips to Prepare for the Medicare Annual Enrollment Period There are many Medicare insurance carriers and plan options, but there are several steps you can take to be a savvy shopper and choose the right plan for your unique needs. 1. Mark Your Calendar This may seem like an obvious tip, but it’s worth mentioning: Mark your calendar for October 15 through December 7 if you’d like to make a change to your Medicare plan. You might even set aside a few hours to research and compare Medicare Advantage plans and Prescription Drug plans ahead of October 15. These plans announce their benefits for the next year starting on October 1. Writing down these Medicare AEP dates and to-dos will help you to commit to these priorities. 2. Review Your Medicare Annual Notice of Change You’ll receive lots of information over the next month or so, so if you’re currently enrolled in a Medicare Advantage or Prescription Drug Plan, the Annual Notice of Change (ANOC) is one piece of mail you’ll want to read. Your Medicare plan will mail your Annual Notice of Change letter to you by September 30. The ANOC letter will inform you of most changes to your Medicare health plan, including coverage and benefits that will take effect on January 1, 2021. Each year, your Medicare health plan sets the amounts it will charge you for premiums, deductibles and other services. Medicare doesn’t set these rates - but your insurance company does. With this in mind, the amounts you pay could change each year. While evaluating your current Medicare plan, you may want to ask yourself questions like: Did the plan cover the services I needed? Did I use out-of-network providers? Did I spend more out of pocket than I originally anticipated? Has something changed with my health (new diagnosis, new prescriptions, etc.)? The ANOC will also provide a side-by-side comparison of your current plan and next year’s plan benefits, costs and other changes (if any). Moral of the story: Don’t toss this piece of mail aside. Always review your ANOC to ensure your plan continues to meet your needs on an annual basis. And if you don’t receive your ANOC by September 30, contact your Medicare insurance company. 3. Make A List of What’s Important To Your Health Keeping a list of what’s important to your health is an invaluable way to prepare for the Medicare Annual Enrollment Period. Start by writing down all of your doctors, preferred health care facilities and hospitals, and prescription drugs, if you take any. We also recommend making a list of value-added benefits that may fit your health, lifestyle and budget. For example, you may be someone who likes to keep active and have social interaction. So a fitness program like SilverSneakers, which gives you access to a network of gyms and other programs, might be a good fit for you. A Medicare Advantage plan may provide these types of fitness or wellness programs. Another thing to consider is whether or not you have an elective surgery planned for 2021. If so, you’ll want to check your hospital-specific benefits under your current Medicare Advantage plan. 4. Check Your Plan’s Drug Formulary Your Medicare plan’s drug formulary will not be included in your Annual Notice of Change, so be sure you call your insurance customer service representative to see if your prescription drugs will be covered for the 2021 plan year. If your prescription drugs aren’t covered, it’s wise to use the Medicare Annual Enrollment Period to find a plan that does cover them. 5. Talk To Your Doctor Another “Medicare must-do” is to make sure all of your doctors and healthcare facilities will remain in network with your current Medicare plan. If they aren’t, you may want to take advantage of the Medicare Annual Enrollment Period. So be sure to ask your doctor if he or she plans on changing health plan affiliations over the next year. What Are The Benefits of A Medicare Advantage Plan? Understanding your Medicare plan options - starting with a Medicare Advantage plan - is a smart first step to take because you can switch, enroll into or disenroll from Medicare Advantage plans during AEP. Medicare Advantage plans, otherwise known as “Medicare Part C” or “MA Plans,” bundle Original Medicare (Parts A and B) services into one plan. While Original Medicare offers you a number of benefits, it may not cover health and medical services you might need. Medicare Advantage plans might be an attractive option because some plans include extra benefits that could save you money. These benefits may include: $0 monthly plan premiums Prescription drug coverage Dental, vision and hearing coverage Access to fitness programs Rides to medical appointments Help managing certain chronic conditions (congestive heart failure, COPD, diabetes) Medicare Advantage plans may also cover a number of in-home services to keep you safe and healthy at home, especially during these uncertain times due to the coronavirus pandemic. These benefits may include: Telemedicine services (also known as telehealth) Home-delivered meals Home-delivered prescriptions Private home aides Another potential perk of Medicare Advantage plans is that they include annual out-of-pocket maximums, which means your costs will be capped. But it’s important to note that Medicare Advantage plans vary by county and zip code. One way to compare Medicare Advantage plans and get Medicare quotes is through our easy-to-use quoting tool. Just enter your zip code to see Medicare Advantage plans that are available in your area. More Medicare Options for People With Kidney Failure One major change happening for the 2021 plan year is that people with End Stage Renal Disease (ESRD), also known as kidney failure, will now have the option to enroll in a Medicare Advantage plan. The Centers for Medicare & Medicaid Services (CMS) estimates that more than 80,000 people living with ESRD will enroll in a Medicare Advantage plan by 2026 - a significant increase of 63%. Medicare Advantage plans may provide ESRD patients with better coverage compared to Original Medicare. Many Medicare Advantage plans include access to coordinated care, which helps ensure all your doctors are on the same page regarding your treatment. What Are Medicare Advantage Special Needs Plans? Medicare beneficiaries also have access to Medicare Advantage plans designed for unique needs. These are called Special Needs Plans (SNPs). Like other types of Medicare Advantage plans, SNPs vary based on location. You may be able to switch to a Special Needs Plan during the Medicare Annual Enrollment Period if one of these situations apply: You’ve been diagnosed with a serious medical condition by a doctor. There are SNPs for certain chronic conditions, such as kidney and heart failure, diabetes and dementia. Services are tailored to the specific condition the plan covers. You need or have received skilled nursing care for at least 90 days at your home or at an institution, such as a nursing home or long-term care facility. You qualify for both Medicare and Medicaid. Medicaid eligibility is based on your income and assets. If you qualify, Medicaid will pay most of the costs for your Medicare Special Needs Plan. Special Needs Plans include all the same benefits as regular Medicare Advantage plans, plus some expanded coverage. For example, all Special Needs Plans must include prescription drug coverage, which is usually tailored to the specific condition the plan covers. Although most regular Medicare Advantage plans include prescription drugs, some do not. Some SNPs also provide a care coordinator to help you stay on track with your doctor appointments and treatment plan. What If My Income Has Changed in 2020? The coronavirus crisis has affected the financial well-being of many Americans, including those on Medicare. If you’ve experienced a decrease to your income or assets, the Medicare AEP 2020 season is a great time to switch to a more affordable plan. If you have limited income, you might qualify for extra savings on Medicare costs through these programs: Medicare Savings Programs. These programs help pay for some of your Medicare Part A and Part B out-of-pocket costs, such as copays, deductibles and premiums. Most programs are for Medicare beneficiaries who also qualify for Medicaid. And as mentioned, Medicaid covers the majority of your costs when you join a Medicare Advantage Special Needs Plan. You can check if you qualify through your local Medicaid office. Medicare Extra Help. Extra Help reduces your Medicare prescription drug plan costs. You should contact Social Security to check your eligibility for Extra Help if you have an existing Medicare drug plan or you join one during AEP. How To Enroll During the Medicare Annual Enrollment Period To enroll in an eligible plan during the Medicare Annual Enrollment Period, you can visit Medicare plan comparison websites like healthinsurance.com or Medicare.gov. Or, you might prefer to talk to a licensed insurance agent to get help enrolling in Medicare. Whatever option you choose, be sure to have 3 items handy before you enroll in a plan or make changes to your current plan during AEP: Your Medicare card Your list of doctors, prescriptions and what is important to your health Pen and paper to take notes More on Medicare Eligibility Medicare is a federal health insurance program developed in 1965. To be eligible for Medicare you must meet one of the following criteria: You are age 65 or older You are under age 65, disabled, and have been receiving Social Security disability benefits for at least 24 months. You have End Stage Renal Disease or Lou Gehrig’s Disease (also known as Amyotrophic Lateral Sclerosis or ALS). You can visit Medicare.gov to see if you’re eligible for Medicare and calculate your estimated premiums for certain plans. How To Find A Medicare Advantage or Prescription Drug Plan You don’t have to go it alone when choosing a Medicare Advantage plan or Prescription Drug Plan. We’re here to help you navigate the Medicare Annual Enrollment Period through a number of ways, including: Our Medicare plan comparison tool Our online Medicare resources You can also call 800-620-4519 to speak to a licensed insurance agent about your options. You can also read through some of our articles to learn more about Medicare. Medicare 101 Guide Top Medicare Frequently Asked Questions Understanding Original Medicare vs. Medicare Advantage
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