SECOND OF TWO PARTS

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PHILADELPHIA >>Medicare’s open enrollment runs to Dec. 7, so it is time to review your benefits and make necessary changes for 2025.

It’s important that you enroll in the best plan for your needs, so the Inquirer has created a Medicare primer to make the process less intimidating, based on questions sent in by readers.

The information below is the second of two parts published on this Live Well page.

Enrolling in coverage

Question: How do I choose supplemental coverage?

Answer: Pick a plan to address the coverage gaps that concern you the most. Supplemental coverage is for people with original Medicare; it cannot be used to cover Medicare Advantage out-of-pocket expenses.

Supplemental coverage, also called Medigap, covers “gaps” in original Medicare plans, such as health expenses while traveling abroad, excess charges and copays. It is sold by private insurance companies. Look for a letter system to assemble your benefits package; plans with the same letter offer the same coverage.

Be aware that prices can vary widely between companies, even for the same coverage.

Q: How do I figure out which prescription plan will be the lowest cost to me?

A: Make sure it covers the drugs you need.

Most people focus on the monthly cost, known as the plan premium. But a plan with a low premium could end up costing more than another with a pricier premium if it does not cover your specific medications. Also review cost-sharing details — how much you will pay versus how much the plan will pay — and whether you will be required to fill prescriptions at select pharmacies. Medicare’s Plan Finder allows you to search based on the medications that you need.

Q: Where can I go for help?

A: Don’t be surprised if you need advice. The options can get complicated and scams abound during enrollment season.

Every state has an agency offering free Medicare help. These impartial programs do not offer legal advice, endorse plans or sell insurance.

Hawaii State Health Insurance Assistance Program, known as Hawaii SHIP, offers free, local, one-on-one Medicare counseling. To get started, visit hawaiiship.org, or call 808-586-7299 or toll free at 888-875-9229.

Drilling down

Q: What if I don’t sign up during my ‘new to Medicare’ period?

A: You could face penalties.

Most people qualify for Medicare at 65. There’s a seven-month period to sign up — your birth month plus three months before and after. Sign up early if you want coverage to start as soon as you turn 65. Missing this enrollment period could lead to penalties for the duration of your Medicare coverage.

The penalty for signing up late to Plan B is 10% of the premium for every 12 months you were not enrolled. Part D prescription coverage has a penalty of 1% of the premium for every month missed. If you miss your “new to Medicare” enrollment period, you could end up temporarily uninsured.

Q: What if I plan on working past 65 and have employer-sponsored coverage?

A: You can usually keep your health plan and delay enrolling in Medicare without penalty.

People who have health insurance through a large employer — and are actively working — can delay signing up for Part B until they retire without penalty. If you have coverage through a small company with fewer than 20 people, you’ll have to move to Medicare.

Talk to your human resources department about your options. If you keep your employer-sponsored health plan beyond age 65, your employer will need to fill out a form verifying you had continuous coverage when you retire.

The same rules apply if you are covered under a private health plan through a spouse who is still working.

Q: How do I decide whether to keep my employer-sponsored health plan or transition to Medicare?

A: Consider the premium, deductible and other cost-sharing expenses. Compare how prescriptions are covered and the doctor networks offered. If you are covered under a spouse’s plan, look at how the employer handles dependent coverage.

Companies may pay for a large share of the employee’s health insurance but not the cost of insuring spouses and children. In this case, it may be more cost-­effective for an over-65 spouse to move to Medicare.

Q: Can a spouse’s health savings account, or HSA, from an employer-sponsored health plan cover my Medicare expenses?

A: Yes — with limits.

An employee’s HSA can be used to pay eligible medical bills for a spouse covered by Medicare. Eligible medical expenses include copays for prescriptions and services applied to your plan’s deductible, as well as Part A and Part B premiums. An HSA cannot be used to pay for supplemental policy premiums. Once you sign up for Medicare, however, you will no longer be allowed to contribute pretax funds to an HSA.

Q: What if I have an individual health plan through the Affordable Care Act, or ACA, marketplace?

A: People with ACA marketplace health plans almost always transition to Medicare when they turn 65. You may be able to keep your individual health plan, but you won’t be eligible for a tax subsidy after 65 and could face penalties if you don’t sign up right away.

The cost and coverage could be very different from what you’re used to. The Medicare Part B premium may be less than what people in their 60s pay for an individual marketplace plan. But people who have been receiving an income-based tax subsidy for an ACA marketplace plan may find that their costs rise under Medicare.

Consider discussing options with an enrollment adviser, or visit the National Council on Aging’s BenefitsCheckUp website (benefitscheckup.org) to find out if you’re eligible for financial assistance.

Q: What are zero-dollar premium Medicare Advantage plans, and are they really free?

A: No. Everyone pays a monthly premium for Part B, regardless of whether you have original Medicare or Medicare Advantage.

Medicare Advantage plans often include extra services, such as prescription drugs, vision or dental — for an extra charge. When a plan advertises a “zero-dollar premium,” it is referring to these additional, plan-specific benefits. You will still pay the Part B premium.

Keep in mind that premiums are only one source of out-of-pocket costs. Plans with low premiums may have high deductibles, copays and coinsurance. You should also consider how much your medications will cost under the plan and whether your doctors are in network. Medicare’s online plan finder can help you compare options.

Q: What is Silver Sneakers?

A: A fitness program offered by some Medicare Advantage plans that gives members access to free gym memberships, fitness classes and health education resources. It is not part of original Medicare. Plans that don’t offer Silver Sneakers may have a similar fitness program. Ask your plan administrator.

Although the program can be a valuable benefit, also consider whether the plan will meet your health care needs, how it covers the medications you take and whether you can continue seeing the same doctors. And, as with any fitness membership, make sure that the facility fits your physical needs, schedule and location.

Glossary of terms

>> Premium: The base cost of the health plan, paid monthly. Regardless of whether you choose original Medicare or Medicare Advantage, you will pay the Part B premium monthly. Most people paid $174.70 a month for the Part B premium in 2024.

>> Deductible: The amount of money you spend out-of-pocket before the plan begins paying a larger share of medical expenses. For 2024, the Part B deductible was $240.

>> Copay: A flat fee you pay for certain services, such as a doctor’s visit or medication.

>> Coinsurance: The portion of a medical bill you must pay even after you meet your deductible. Original Medicare has 20% coinsurance after meeting the deductible, which means you will pay 20% of any medical bill.

>> Drug formulary: The list of prescription medications covered by your plan. Formularies rank medications into tiers, with lower-tier drugs being the preferred and least-expensive options. Higher-tier versions of the same medication will cost more. Health plans frequently switch their preferred choices and may even drop medications from the formulary.

>> In-network: Doctors who accept your health plan are in-network. The vast majority of doctors accept original Medicare. Medicare Advantage plan networks vary.

>> Out-of-network: Doctors who do not accept your health plan are out-of-network. You may have to pay more for their services, or the visit may not be covered at all by your plan.

>> Original or traditional Medicare: A federal health program for people who are 65 or older, or who have a qualifying disability. People who choose original Medicare will enroll in Part B, with choices for optional supplemental and drug plans.

>> Medicare Advantage: Medicare plans sold and operated by private insurers. These federally approved plans must cover all Plan B benefits. They can offer extra services, such as coverage for prescription drugs, and may limit the number of in-network doctors.

>> Part A: Covers hospital visits and medications administered in a hospital setting, such as infused drugs. Most people receive Part A coverage when they turn 65 at no additional cost.

>> Part B: Covers doctor’s visits, labs and other non hospital services. People who choose original Medicare will enroll in Part B.

>> Part C: Also known as Medicare Advantage.

>> Part D: Prescription drug plans that people who opt for original Medicare can buy.

>> Medigap: Supplemental plans that people who opt for original Medicare can buy to cover out-of-pocket costs, such as copays. Medigap plans do not pay for the Plan B premium.