Column 4: Medicare

I am over 65 and on Medicare?  How does the Affordable Care Act affect me?


Since the implementation of the law, you get more preventive services, for less. Medicare now covers certain preventative services like mammograms or colonoscopies without charging you coinsurance or deductibles. You also get a free yearly wellness visit.  In addition, you now get a 50% discount on brand name drugs while in the donut hole.  You will also be encouraged to use an ACO (Accountable Care Organization). 


The Medicare website defines an ACO as this:  Local health care providers and hospitals volunteer to work together to provide you with coordinated care. The doctors and other providers who are helping care for you will communicate with each other, and partner with you in making health care decisions. It is my understanding that Dignity Health is forming an ACO.


I am hearing that some doctors are not accepting Medicare.  Does that mean I can't see my doctor any more?

It is important to understand the difference between not accepting Medicare assignment and opting out all together.  You may see any physician you choose. If a physician does not accept Medicare assignment that means they will not bill Medicare for you.  But you can see that physician, pay the provider and bill Medicare yourself.  You will be reimbursed at the Medicare allowable amount. In addition if you have a supplement that covers the "Part B Excess" then you will likely be covered for most of the amount.

However if your provider has totally opted out of the Medicare program, then you may not bill Medicare or your supplement because the claim won't be allowed. The following prodders must accept Medicare assignment: Hospitals, Skilled nursing facilities, home health agencies, outpatient physical therapy, occupational and speech pathology services. Clearly it saves money and time if you go to a provider who accepts Medicare assignment.

Will there still be open enrollment for my Part D Prescription Drug benefit?

Yes, the open enrollment period will begin October 15 and end December 7.  You can change Rx plans during that time.  The Medicare website has an excellent comparison calculator that can show you the total costs of the plan, including premiums, deductibles and copay based on the prescriptions you are taking and the pharmacy you choose. Of course we are all one doctor visit away from a new medication, but this is the best way that I know of to look at the plans.



I am over 65 and still on my employer's health plan. Do I have to enroll in Part D?

If your employer's plan provides "creditable coverage" that is coverage that is deemed to be as good as Medicare Part D, you do not need to enroll in another plan.  You should be given a notice that states if your plan is "creditable" or not. 

In fact, you are never required to enroll in an Rx plan.  However, if you do not enroll or have creditable coverage when you become eligible, you then must wait until an open enrollment period to enroll.  You also may be subject to a penalty when you enroll later.  That penalty is 1% of the average premium per month that you delay.  Currently this is about $.40 per month.

If you come off of the employer plan at a later date and have had creditable coverage, you are eligible for a Special Enrollment Period (SEP) and will not have to wait for open enrollment.