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In This Chapter

^ Changing plans during standard enrollment periods

^ Knowing when you can switch plans outside of standard enrollment periods ^ Dropping your plan — and being dropped

^ Deciding whether to change to another plan for next year or stay with the one you have

A\ Fter you’re in a Part D plan, and all the hard work of choosing one and ¥ \ signing up for it is behind you, probably the last thing on your mind is changing to another plan. But it makes sense to know When You can switch plans if you want to or need to, When You can drop out of a plan (yeah, there are rules about this too), and Whether You should compare plans all over again at the end of the year to see if you’d get a better deal with a different one.

You can switch plans during three time frames, depending on the plan you’re now in and your reasons for switching:

November 15 to December 31 each year: This is when anybody in a Part D plan (a stand-alone drug plan or a Medicare health plan that includes drug coverage) can change plans for the following year.

January 1 to March 31 each year: This is when you can change from traditional Medicare to a Medicare health plan, or the other way around; or you can change from one Medicare health plan to another — whether it provides drug coverage or not. However, you can’t change from one stand-alone drug plan to another. Also, you can’t use this period to Drop Or Add Drug coverage (if you haven’t already got it).

Special enrollment periods: These are allowed at any time of the year, but only in certain circumstances. They come with time limits.

This chapter focuses mainly on Switching Part D plans at certain times, according to the preceding situations. (For details about enrolling in a plan for the first time, go to Chapter 12.) I also explain the circumstances in which you can drop out of a plan — or be dropped by a plan. Finally, I cover the big end-of-year question — stay with the plan you have or switch to another? — and suggest points to keep in mind when you make that decision.

Switching Part D Plans at Standard Enrollment Times

You can understand why Medicare doesn’t allow everybody to switch Part D plans any time they feel like it — that would be chaos. And you can understand why Medicare allows special enrollment periods for special circumstances at any time of the year (I describe these special periods in detail later in this chapter). But why, oh why, does it have Two Open enrollment periods at different times? Wouldn’t it be simpler to have just one free-for-all once a year? Of course. But you’re stuck with two.

Table 17-1 lays out the possibilities for switching plans during the two standard time frames — eight possible combinations, depending on the health and drug coverage you have. (The shaded rows show options for people Without Drug coverage.) But it isn’t as complicated as it looks. Find your situation — the kind of plan you have now — in the left column, and then look across to see which type of plan you can switch to and at what time. In each situation, you have no more than two choices of plan types to switch to.

Table 17-1 Switching Plans: From Which, To What, When

If You’re in This Plan You Can Switch to: And Enroll at This

Now: Time:

If you Haven’t Already signed up for Medicare prescription drug coverage, you can use the January 1 to March 31 enrollment period only to switch to another health plan that Doesn’t Cover prescription drugs. I mention this as a warning because I’ve heard of some people (who’d missed their previous deadlines for getting drug coverage) joining a Medicare Advantage health plan during this period without realizing it wouldn’t cover their drugs. So if you want drug coverage, be sure to sign up at the right times — and if you join a Medicare health plan, always check that it actually covers prescription drugs.

After you figure out when you can switch to a new plan and what kind of plan you can switch to, all that’s left to do is enroll. In the following sections, I explain what you need to do to switch plans and the actions you can take if you change your mind about your newly chosen plan.

Enrolling in a new plan

When switching to a new Part D plan in either of the standard enrollment periods, all you have to do is enroll in it, following the process I describe in Chapter 12. You don’t have to disenroll from your present plan or even notify it. Your new enrollment is logged into Medicare’s computer system, and you’re automatically disenrolled from your previous plan as soon as your new coverage starts. If you enroll

U November 15 through December 31: Your old drug coverage finishes at midnight on December 31. Your new coverage starts January 1.

U January 1 through March 31: Your new drug coverage starts the first day of the month after you enroll — February 1 if you enroll in January; March 1 if you enroll in February; or April 1 if you enroll in March.

Figuring out how many times you can change your mind

What if you switch to another plan during one of the standard periods and then change your mind, either because you’ve found yet another plan you prefer, or because you decide you want to return to the plan you just switched out of? If the enrollment period hasn’t yet expired, these are your options:

U November 15 through December 31: Within this period, you can technically change Part D plans as often as you want. The last plan you enroll in by December 31 is the one you’ll have the following year. But be cautious of changing more than once — it can cause problems getting your information into the system, as described in Chapter 12.

U January 1 through March 31: You’re allowed to switch plans only once during this period, so you can’t change your mind, unless you qualify for a special enrollment period, as explained later in this chapter.

One exception is worth keeping in mind. Suppose you were in traditional Medicare and switched to a Medicare Advantage health plan in the January to March period and then regretted the change. You’ve already used up your single chance to switch. But If this is your first time ever in a Medicare health plan And You dropped a Medigap supplementary insurance policy when you joined the plan, you have the right to return to traditional Medicare and get back your Medigap policy at any time within 12 months of joining the plan, as explained in more detail later in this chapter.

Switching Plans during a Special Enrollment Period

Some people need to switch plans outside of the standard enrollment periods. So Medicare allows Special enrollment periods (SEPs) in certain circumstances. You can use these at any time in the year, but most have specific time limits. You have to switch plans within this allotted time — otherwise, you lose your chance and must wait until the next standard enrollment period to change plans. In some situations, this lag can leave you without coverage for several months.

In the following sections, I explain a number of circumstances in which you can obtain an SEP to change plans. I also tell you how to apply for an SEP (if you need to apply) and how to ensure your records are transferred safely. But I don’t include SEPs granted for situations that are covered in other chapters. Flip to the appropriate chapter if you’re

U Enrolling in a Part D plan when first joining Medicare (see Chapter 12) U Receiving Extra Help (see Chapter 5)

U Entering, leaving, or living in a nursing home (see Chapter 18)

U Joining or leaving a Special Needs Plan or a Program for All-Inclusive Care of the Elderly (see Chapter 18)

U Enrolling in Part D after returning from living abroad or being in prison (see Chapter 12)

U Joining or leaving Part D because of employment-related issues (see Chapter 6)

Knowing when you can use SEPs to change plans

Special enrollment periods cover a wide range of circumstances. The ones listed in the following sections are those you can use to switch plans. In each case, I explain the conditions for getting it, how long the SEP lasts, and when coverage in the new plan begins.

If you move permanently out of your plan’s service area

The time frame of your SEP for switching to another plan depends on when (and if) you notify your current plan of your move.

U If you tell your plan in advance, your SEP begins the month before your move and ends two months after the month of your move.

U If you tell your plan After You move, your SEP begins on the date you notify the plan and lasts for two months.

U If you don’t notify your plan of the move, your plan will disenroll you after six months. You then get an SEP that lasts two months.

In all of these cases, after switching to another plan, you can choose when your new coverage will begin — either on the first day of the month after enrolling in the new plan or up to three months afterward.

Even if the company that sponsors your old plan (whether a Medicare health plan or a stand-alone drug plan) offers the same or other plans in your new home area, you have the right to switch to a different one if new plans are available to you there. (But if you’re in a stand-alone drug plan that serves an entire state, and you move to a new house within the state, your coverage will continue and you won’t be entitled to an SEP.)

If you’re in a Medicare private health plan and Want to change to traditional Medicare

This SEP is available Only If both of the following conditions are met:

U You joined this Medicare health plan during your initial enrollment period when you first became eligible for Medicare at age 65.

U This is your first year in the same plan.

If these two conditions apply to you, you have the right to switch to traditional Medicare (and a stand-alone drug plan) at any time within 12 months from the time your coverage in the plan started. You also have a guaranteed right to buy Medigap supplementary insurance, but you must apply for it no later than 63 days after your coverage in the health plan ends.

If you dropped a Medigap policy to enroll in a Medicare private health plan for the first time

This SEP gives you a one-time guaranteed right to buy another Medigap supplementary insurance policy and switch back to traditional Medicare if

W You’ve been enrolled in this health plan for less than a year; And

U This is the first Medicare health plan that you’ve Ever Been in

You Can’t Obtain this SEP if you were enrolled in a Medicare health plan before, no matter how many years ago; see the later section "If you’re considering a switch to a Medicare private health plan."

If these two conditions apply to you, you have the right to be reinstated in the same Medigap policy you had before joining the Medicare health plan (or, if it’s no longer being sold, a policy from another insurer) at any time during your 12-month "trial period" with the health plan. You can use this SEP to disenroll from the plan and re-enroll in traditional Medicare, and you can also use it to enroll in a stand-alone drug plan. Your new coverage begins the first day of the month after you enroll. You can apply for the Medigap policy up to 60 days before, and no later than 63 days after, your plan coverage ends.

If your plan violates its contract With you

This SEP allows you to disenroll from your plan if it has broken its contract in some way — for example, it failed to provide promised benefits in a timely manner or in keeping with Medicare’s quality requirements, or it gave you erroneous information that led you to enroll in the plan.

You must apply to Medicare for this kind of SEP, as I explain later in this chapter. If Medicare determines that a violation has occurred, the SEP will begin when Medicare notifies you. You can then disenroll from the plan and enroll in another or switch to traditional Medicare. If you don’t immediately

Choose a new plan, your SEP lasts for 90 days after you disenrolled from your present plan. Your new coverage starts the first day of the month after you enrolled.

If you Were tricked or misled into joining a Medicare private health plan

This SEP allows you to switch out of a plan that you joined based on misleading or incomplete information of the kind covered in Chapter 11. You must apply to Medicare for this SEP, as I explain later in this chapter, and your case will be investigated. If Medicare determines that your claim is valid, you can immediately disenroll from the plan. You can choose to join another Medicare health plan or to switch to traditional Medicare and join a standalone drug plan. (In this case you also have a guaranteed right to buy a Medigap supplementary policy, regardless of when you joined the plan that misled you, as long as you apply for a policy no later than 63 days after your plan coverage ends.)

Your new coverage begins the first of the month after you enroll. But in certain circumstances — for example, if you incurred costs that your old plan wouldn’t pay for — you can ask for Retroactive (backdated) enrollment so that Medicare can cover those bills (see Chapter 11).

If a federal employee made a mistake when processing your enrollment or disenrollment in a plan

This SEP allows you to join or switch out of a Part D plan after an error has been made. It begins the month Medicare approves the SEP and continues for two more months.

If your plan withdraws from your service area, doesn’t renew its contract with Medicare, or is closed down

An SEP is given in each case, but the allowed periods for switching to another plan vary according to the situation. Medicare, your plan, or both will send you a letter that explains the circumstances, tells you how long your coverage will continue, and details when you can switch to another plan.

If you’re enrolled in a qualified State Pharmacy Assistance Program

This SEP allows you to change from one Part D plan to another at any time of the year but only Once A year. Your coverage begins the first day after the month you enroll in a new plan.

TBEfl Before making a switch, contact your State Pharmacy Assistance Program

(SPAP) for information because you’d need a plan that works with your SPAP coverage. If your SPAP automatically enrolled you in your current plan, you can’t get an SEP to change plans. (I cover SPAPs and which ones are "qualified" in Chapter 6.)

You also get an SEP if you lose your eligibility to be in an SPAP. This SEP begins the month you lose eligibility and lasts for two months afterward.

If you have any other exceptional circumstances

If none of the situations listed previously apply to you, you have the right to ask Medicare to allow an SEP based on your own "exceptional" situation. From time to time, Medicare introduces new SEPs, sometimes because a consumer draws its attention to an exception circumstance for which an SEP hadn’t existed before.

Applying for an SEP

You don’t need to apply for most SEPs. Just go ahead and enroll in a new plan of your choice. It’s the new plan’s responsibility to confirm that you’re entitled to an SEP. You’ll receive an enrollment form asking for information, just the same as for any enrollment (see Chapter 12). If your enrollment is accepted, it means the SEP has been granted. If the enrollment is denied, you’ll get a notice explaining why, as explained in Chapter 13.

You need to apply for an SEP if the reason for wanting one is that your plan violated your contract or you believe you were misled into joining the plan, as explained earlier in this chapter. Call Medicare at 800-633-4227, explain the situation, and say you want to apply for a special enrollment period to change to a new plan. Medicare will investigate and decide whether to allow an SEP.

Making sure your records are transferred

When you use an SEP to change plans during the year, the record of your drug usage and payments to date (from the beginning of the year) should be automatically transferred from your old plan to the new one.

It’s very important that this is done, because your records show

U The total cost of the drugs you’ve used since the beginning of the year, which determines your coverage level

U Your total out-of-pocket expenses since the beginning of the year, which count toward the limit that ends the doughnut hole (if you fall into it)

U How much of the deductible you’ve paid (if there’s a deductible)

How the deductible is transferred depends on whether the old and new plans have deductibles and the costs of the drugs you’ve used since the beginning of the year. These are possibilities:

• If your old plan had a deductible and you’ve already met it, you can’t be asked to pay a deductible under your new plan. For

Example, Plan X has a deductible of $295, and your total drug costs so far this year come to $350, so you’ve met your deductible and started receiving coverage. When you join Plan Y, which also has a $295 deductible, you don’t pay this amount but receive coverage at once.

• If your old plan had no deductible, but your new one does, you must meet this deductible before receiving coverage. For example, Plan X has no deductible, and you’ve received coverage for $250 worth of drugs (what you And Your plan have paid) so far this year. But Plan Y has a deductible of $295. So you must pay a balance of $45 ($295 – $250) in Plan Y before coverage begins.

• If your old plan had a deductible and you haven’t yet met it, it depends on whether the new plan has a deductible. For example, Plan X has a deductible of $295, but your total drug costs so far this year come to $100. Plan Y has a lower deductible of $200. Because you haven’t met your deductible in Plan X, you must pay the difference in Plan Y ($200 – $100 = $100). But if Plan Y has no deductible, you pay no more and your coverage starts immediately.

Medicare requires the old plan to transfer your payments record to the new plan within seven days of your coverage ending in the old plan. Still, checking is wise. When you receive the first Explanation of Benefits statement from your new plan, compare it with the last EOB from your old plan to ensure that your record has been transferred and that it correctly reflects the phase of coverage you’re in — the deductible, initial coverage period, coverage gap, or catastrophic coverage. If you’ve mislaid your last EOB, ask the old plan for a copy. If you think that the info hasn’t been transferred correctly, call Medicare

At 800-633-4227 and file a complaint.

Dropping a Plan without Joining Another (Or Being Dropped)

Most people are allowed to drop out of a Part D plan voluntarily Only During the standard enrollment periods or during some of the special enrollment periods specified earlier in this chapter. Clearly, if you switch plans, then technically you’re disenrolling from the old one and enrolling in the new one — even if disenrollment is automatic as soon as you join another plan — and that’s why the two actions are usually bundled together in Medicare’s eyes.

But there may be circumstances in which you need to drop out of a Part D plan Without Joining another. And in a few situations, your plan can drop You. This section considers both scenarios. I also cover a special situation in which you may or may not be dropped — being late with your premium payments — and explain what to do if you’ve been disenrolled from your plan unfairly.

Being a plan dropout

You can get a special enrollment period to drop out of a Part D plan without joining another in the following circumstances.

If you move to a new job that has health benefits

You may need to drop out of a Part D plan if you take a new job that comes with health benefits and drug coverage. Here’s what to do:

U Find out from your new employer’s benefits office whether your new drug coverage is creditable. (Creditable Means at least of equal value to Medicare drug coverage, as explained in Chapter 6.) If it’s not, you need to ask whether keeping your present Part D plan could disqualify you from receiving health coverage from your employer. (I cover this possibility in detail, too, in Chapter 6.)

U Call or write to your current Part D plan, explain the situation, and ask to be disenrolled. You’ll need to coordinate the date when your Part D coverage ends with the date when your new coverage begins.

Your new employer’s benefits office may make these arrangements for you — if so, it’ll tell you.

If you become eligible for TriCare or VA drug coverage

You can get an SEP to drop out of your current plan if you start qualifying for military or veterans’ benefits under the TriCare or Veterans Affairs programs. I describe benefits under these programs in Chapter 6.

If you move out of the United States

From your plan’s point of view, going to live abroad just means that you’re moving out of its service area. So the SEP is the same as if you were just moving somewhere else within the U. S., as explained in the earlier section "If you move permanently out of your plan’s service area." But in this case, you won’t be joining a new plan because Part D won’t cover you when abroad. When you return to live permanently in the U. S., you can apply for another SEP to enroll in a Part D plan again, as explained in Chapter 8.

If you decide you just want out of Part D

You do Not Get a special enrollment period for this purpose. You’re expected to wait until the November 15 to December 31 open enrollment period to do that. However, if you get an SEP to disenroll from a plan — for example, if you’re moving out of its service area — there’s no obligation to sign up for another plan. Similarly, there’s no obligation to sign up for another plan if you come to the end of the year and decide not to re-enroll. In this case, you need to deliberately request disenrollment from the plan — otherwise, your enrollment automatically continues the following year. And, of course, there’s no obligation to re-enroll if you stop paying premiums and get disenrolled by your plan.

If you drop out of a plan and don’t enroll in another, Medicare will probably send a letter warning that going without drug coverage would mean incurring a late penalty if you decide to enroll again in Part D in the future. But what you really need to think about — beyond the threat of a late penalty — is what it could mean to be without coverage for even a few months. Regardless of your reasons for dropping out of Part D, you may want to take a look at Chapter 7, which explains the implications of going without drug coverage.

^ Being dropped by your plan

A plan Must Disenroll you in any of these circumstances:

U You move permanently out of its service area. If you don’t let the plan know you’ve moved, it will eventually find out from Medicare or from returned mail. The plan must try to confirm that the move is permanent, but if it can’t contact you within six months, or receives no response, it must then disenroll you. (But if it confirms that your move is only temporary, it must continue your coverage.)

U You are imprisoned. The plan must disenroll you (because you can’t be enrolled in Part D when incarcerated) after confirming the situation from public records.

U You lose your eligibility for Medicare. This can happen in these specific circumstances:

• Your eligibility for Medicare is based on disability (including blindness or end-stage renal disease), but your disability ceases.

• You have Part A (hospital insurance) only because you’re buying it (as explained in Chapter 1). But you must also be enrolled in Part B (doctors’ and outpatient services) to qualify. So if you stop paying either Part A or Part B premiums (or notify Social Security that you no longer want this coverage) your eligibility for Medicare (and Part D) ends.

U You misrepresented other coverage you have. If the plan receives evidence that you intentionally withheld or falsified information about coverage you have from elsewhere (such as an employer) — in other words, double-dipping — it must disenroll you, but Only With Medicare’s approval. Your coverage stops on the first day of the month after you’re notified of the disenrollment.

U You die. At this point, you’re done worrying about Part D! But for the benefit of family members: They can inform the plan, but it won’t act until it’s received an official death notification from the Social Security Administration via Medicare. Disenrollment takes effect on the last day of the month of the death. The plan must refund any premiums paid

U You don’t pay your premiums in a timely manner. Because so many circumstances affect whether you’re dropped from a plan when you’re late with premium payments, I cover this possibility in more detail in the next section.

U You "engage in disruptive behavior." Medicare doesn’t define exactly what this phrase means, except to describe it as behavior that "substantially impairs" the plan’s ability to provide services to you or any other of its members. The plan can’t drop you for this reason without first trying to resolve the problem, submitting thorough documentation to Medicare, and receiving Medicare’s approval to disenroll you. The plan must also notify you of your right to appeal the decision (see Chapter 19 for details on appeals). Depending on the situation, Medicare may also grant a special enrollment period for you to switch to another plan without loss of coverage.

U You allow someone else to use your plan card to obtain services or prescription drugs, or the information on your enrollment form was fraudulent. The plan can terminate your coverage the first day of the month after it notifies you of disenrollment. The plan must inform Medicare, which will investigate the fraud.

A special case: Knowing what can happen when you don’t pay your premiums

If you stop paying your premiums, or get behind with them, what happens next depends on your plan’s policy. Under Medicare rules, your plan can choose to do any of the following:

A plan Can (at its discretion) drop you in these circumstances:

Beyond that date.

U Nothing — in other words, allow your coverage to continue U Disenroll you after giving you a grace period and notice

W Send you a letter inviting you to contact the plan if you receive Medicaid and/or Extra Help and are having difficulty paying the premium

Understanding when a plan can’t disenroll you

There are two situations in which you Can’t Be disenrolled from your plan for not paying premiums, regardless of its policy:

W If you’ve asked for premiums to be paid out of your Social Security check: The plan must work with Medicare to investigate why Social Security hasn’t deducted the premiums or, if it has, why the plan hasn’t received them. Whatever the reason, the plan can’t disenroll you while you’re considered to be in a state of Premium withhold — that is, your premiums are being taken out of your Social Security check Or You’ve asked for them to be deducted automatically in this way. Only if you change to being billed directly for your premiums can the plan ask you to pay the premiums and, if necessary, disenroll you if you don’t pay.

W If your full premium is paid by a State Pharmacy Assistance Program (SPAP) or another sponsor: The plan must work with the SPAP or the sponsor (such as an employer or union that pays Part D premiums) to receive the premiums.

Receiving a warning of disenrollment and a grace period

Part D plans can’t stop anybody’s coverage without warning. A plan must first send proper notice of its intent to disenroll you and inform you of its Grace period — a length of time that gives you the opportunity to pay the overdue premium(s).

The grace period must be at least one calendar month — though plans may choose to give longer periods, such as two or three months. The grace period begins on the first day of the month for which a premium is unpaid. Plans also have two options on how to deal with disenrollment after a grace period ends:

W Single grace periods: If one or more overdue premiums haven’t been paid in full during the grace period, the plan can terminate coverage at the end of that period.

For example, Harry is in a plan with a two-month grace period. He fails to pay a premium due June 1, ignores the warning notice from the plan, and fails to pay the next premium too. His grace period is June and July. Because he doesn’t pay the two premiums he owes by July 31, his coverage stops on August 1. (If he pays only one of the premiums by July 31, his coverage still stops on August 1. If he pays both premiums by that date, his coverage continues.)

W "Rollover" grace periods: These are more flexible arrangements that a plan can choose to provide. If more than one premium is owed, but you pay one premium during the grace period, this grace period stops,

And the plan sends notice of a new grace period. This process continues until Either You pay off all the owed premiums in full Or You fail to make any payment during a grace period, at which time the plan can dis-enroll you.

For example, Maureen is in a plan with a two-month rollover grace period. She fails to pay a premium due June 1 and ignores the warning notice from her plan. Her grace period is June and July. In July she pays the June premium, but not the one for July. She gets another warning notice and another grace period for July and August. In August, she pays the July premium, but not the one for August. Her next grace period is August and September. Despite warning notices, she doesn’t make a payment during this time, so her coverage stops on October 1. (If she pays for one premium during this time, her coverage and the rollover grace periods continue. If she pays both overdue premiums during this time, she’s no longer in default and her coverage continues intact.)

Your plan’s policy on disenrollment for not paying premiums and on grace periods must be clearly set out in your Evidence of Coverage. The plan is also required to inform you of these policies in its warning letters. If your grace period expires, the plan must send you a letter saying it’s disenrolling you and giving the date when your coverage will end. The plan has the right to take action to recover the premiums you haven’t paid — and/or the right not to re-enroll you until you’ve paid all premiums that you owe.

If you’re disenrolled from a Part D plan because you haven’t paid your premiums, you can re-enroll (or enroll in another plan) Only During the November 15 to December 31 enrollment period. So you may go without drug coverage for several months, which may incur a late penalty (as explained in Chapter when you sign up again.

If you and your spouse are enrolled in the same plan and pay your premiums by check, it’s best to send separate checks for each monthly premium or, if you send a single check, clearly indicate on it that the payment covers both premiums. Otherwise, one of you may be mistakenly disenrolled.

Taking action if you’ve been disenrolled unfairly

Mistakes happen. Here are some examples:

W They thought you were dead, and you’re not! This happens a bit more often than you’d think. It’s most often due to an error in the Social Security files — in which case, your Social Security check has likely stopped arriving, too. Sometimes it’s an error in Medicare’s records.

W They thought you lost your entitlement to Medicare, and you haven’t.

Again, this can be due to an error in the official files.

W They thought you’d moved away from your home area, and you

Haven’t. This may happen if you spend part of the year away from home, even if you’re enrolled in a Part D plan at your permanent address and have a plan that allows you to fill prescriptions at in-network pharmacies anywhere in the country. This is a mistake made by your plan.

W They disenrolled you by mistake. Computer systems can throw up wrong information in a number of situations, due to entry errors or time lags. For example, if you enroll in another plan during the November-December open enrollment period, and then change your mind and re-enroll in your old plan — and you do so, as allowed, before the end of that period — you shouldn’t be dropped from the old plan. If you are dropped, it’s a mistake.

4

If you think you’ve been dropped from your plan unfairly, call Medicare at 800633-4227 and say that you want to challenge the disenrollment. Medicare will investigate the situation. You should also call the plan and say that you want to remain enrolled. The plan must then tell you in writing that you should Continue to use its services While your case is being investigated. If Medicare approves your challenge, your enrollment will be reinstated and backdated to the time you were dropped, so your coverage is unbroken. If you had to pay out of pocket for any services (such as filling prescriptions) in the meantime, the plan must reimburse you.

Conducting a Yearly Plan Review to Decide Whether to Stay or Switch

November. Time for raking leaves, travel plans, and turkey. It’s a busy month as America prepares the pumpkin pies and gets ready for other holidays looming beyond the bustle of Thanksgiving. As if you didn’t have enough to do, November is also the time when another pressing question arises: Should you stay with your current Part D plan next year, or should you switch?

BBj Open enrollment from November 15 to December 31 allows everybody in Part D the opportunity to switch plans for the following year. But most people, in ] fact, don’t even consider it. Well, I’m going to push against that trend — not to persuade you to switch, but to recommend that you look carefully at the changes your plan will make in its costs and benefits for next year and then compare them with what other plans are offering. Why do I want you to go to this trouble? Because The plan that works best for you this year won’t necessarily be your best deal next year.

If you decide not to change plans, you don’t have to do anything — you’ll simply be re-enrolled automatically in your current plan for next year. But it’s in your interests to arrive at that decision After You’ve considered the alternatives and not just because doing nothing seems the easiest option.

In the following sections, I explain how your plan can change and how you’ll know about those changes, why it’s worth shopping around to see what other plans are offering next year, and factors to bear in mind if you consider making a switch.

Reading your Annual Notice of Change to understand plan alterations

Almost every plan makes some changes for the new year. So the costs and benefits in place on December 31 may well be different on January 1. Here are the changes that Could, Though not necessarily Will, Occur:

W The plan may not be there next year. Plans sometimes withdraw from certain service areas, don’t renew their contracts with Medicare, or, occasionally, go out of business or are terminated by Medicare.

W The insurance company that sponsors the plan may not offer this

Particular plan next year, but offers one or more different plans instead.

W The plan may alter its benefit design next year. For example, it may cease or start offering coverage in the doughnut hole (see Chapter 15), or it may change the structure of its tiers of charges for different drugs.

W The plan may change the amount it charges for premiums, deductibles, and co-pays — or switch drugs to different tiers so the co-pays change.

W The plan may alter its Formulary (the list of drugs it covers) by dropping some drugs or adding others.

W The plan may change the restrictions it places on some drugs (prior authorization, quantity limits, and step therapy; see Chapter 4) by lifting them from some drugs and imposing them on others.

How will you know if any of these changes will affect you? In the case of the first possibility — that your plan won’t exist next year — the plan (or maybe Medicare) will notify you in good time. And in that case, you’ll have to enroll in another plan to continue coverage. For other changes, the plan must send you details in a document called the Annual Notice of Change (ANOC). It’s arguably the most important mailing you’ll receive from your Part D plan each year, and you should definitely read it. (See the nearby sidebar to find out what happened to someone who Didn’t Read it.)

The plan must ensure that you get your ANOC no later than October 31. If you’re new to Medicare and, for that reason, enroll in a Part D plan for the first time between October 31 and November 30 during your initial enrollment period, the plan must send the ANOC together with its Explanation of Benefits in its enrollment packet. If you don’t receive an ANOC by the right date, call your plan and ask for it.

Beware of ignoring your Annual Notice of Change

It’s really important to read the ANOC! Here are two examples of what happened to someone who didn’t and someone who did:

W Suzie didn’t read her ANOC and stayed with the same plan. The full impact didn’t sink in until the following summer, and then she e-mailed me, very steamed. "I deliberately chose this plan because it covered me in the doughnut hole," she wrote. "Now I’m in it, and they won’t pay. I feel I’ve been tricked!" When I explained that her plan’s benefit design had changed at the beginning of the year — no longer giving gap coverage — and that the ANOC she’d received the previous October warned her of the changes, Suzie fessed up that she

Hadn’t read it. "I won’t make that mistake again," she said.

W Thomas began flipping through his ANOC without much interest, but then did a double-take when he saw that his plan’s premium would be raised by $15 a month the following year. That made him look more closely at the whole document. He found the co-pays for two of his brand-name drugs would also go up, from $52 to $60 a month. So Thomas used Medicare’s online plan finder to find out what he’d pay out of pocket for other Part D plans in the coming year, and switched to the one he felt would give him the best deal.

Comparing plans — yes, all over again!

I can hear the groans. No, no, not again! Of course, it’s your choice to go to the trouble of comparing Part D plans this year and every year. But in my opinion — and, actually, all consumer advocates agree on this — shopping around is well worth it. Here’s why:

W It’s not just Your Plan that may change its costs and benefits — so will all the others. A plan you decided against last year may offer a better deal next year — for example, a reduced premium, lower co-pays, fewer restrictions, or even better coverage in the doughnut hole.

W If most plans in your area change their costs, this may alter the equation of which plan will charge you least overall. As I emphasize in Chapter 10, the specific drugs you use determine your out-of-pocket expenses in any plan. Only running the numbers again will show which plan offers you the best deal Next Year.

W Your personal set of drugs may have changed during the past year. That too alters the equation of which plan offers the best deal next year.

W If you don’t take any drugs and have opted for the plan with the lowest premium (as suggested in Chapter 7), check whether your current plan or another will have the lowest premium next year.

W If you compare plans and decide to stay with the one you have, you’ll have the reassurance of Knowing That it’s still the best one for you.

I’ll throw in another reason why comparing plans every year is worthwhile if you use the online Medicare Prescription Drug Plan Finder. The more often you do it, the easier it gets. After you have the routine down, it may take only a few minutes to decide that your current plan is still the one for you or that another is better.

Convinced? If so, turn to Chapter 10 for a step-by-step guide to comparing Part D plans online, or for other ways of getting the same information.

Making your decision

If you’re reading this section, I’m assuming that you’ve compared plan offerings for next year and are considering one or two alternatives to your current drug plan. Chapter 10 offers several suggestions for making a final choice among a shortlist of options — for example, checking convenient pharmacies, evaluating customer service, and being able to get prescriptions filled when you’re away from home — which all apply here, too. But when you’re deciding whether to switch plans, rather than choosing one for the first time, you need to consider a couple other points.

If you’ve won exceptions from your current plan

Did your current plan grant you an exception by covering a drug that isn’t on its formulary? Or waive a restriction for any of your drugs because your doctor convinced the plan that it was necessary for your health, without the need for prior authorization quantity limits, or step therapy? If so, you need to find out whether your plan will allow these same exceptions to carry over into next year. Some plans do. Others may require you to apply for them again in the new year. The plan’s ANOC should clearly say what its policy is on this point. If it doesn’t, call the plan and ask for it in writing.

Of course, if your plan allows your exceptions to be carried over, that would save you hassle and be a big factor in deciding to stay with this plan next year. If it doesn’t, you have nothing to lose by changing to another plan. But in considering another plan, be sure to check its restrictions. They may be imposed on the same drugs — or on different ones you take.

If you’re considering a switch to a Medicare private health plan

If you’re thinking of switching from traditional Medicare and a stand-alone drug plan to a Medicare Advantage plan, you need to compare its medical costs and benefits as well as its drug coverage (see Chapter 9).

What about your Medigap supplementary insurance policy, if you have one? When you’ve dropped Medigap insurance to join a Medicare heath plan for the First time, Your first 12 months in the plan is regarded as a trial period. During this time, you can get a special enrollment period to switch back to

Traditional Medicare and buy a Medigap policy with the same company, on the same terms you had before. Otherwise, you can still buy a new policy, but it will likely cost more than your previous one. Here are some examples:

W Erica turned 65 in 2005, enrolled in traditional Medicare, and bought a Medigap policy. But in 2007, she joined a Medicare private health plan and gave up her Medigap insurance. After several months, she decided this was a mistake. Because she’d been in the health plan only a year — and because this was the only one she’d ever been enrolled in — she got back her Medigap insurance with the same company, on the same terms she had before.

W When he turned 65 in 1996, Enrico signed up for traditional Medicare and bought a Medigap policy. In 1999, he joined a Medicare health plan and gave up his Medigap. But at the end of the year, the plan stopped doing business in his area and he had to return to traditional Medicare. Because he’d been in the plan only a year, he was able to get back his Medigap policy on the same terms. In 2006, Enrico decided to try a health plan again. But this time he wasn’t happy with it and returned to traditional Medicare for 2007. Because he’d been enrolled in a Medicare health plan back in 1999, he wasn’t able to get back his old Medigap policy on the same terms. He took out a new policy, but because he was older now with more health problems, it cost him more.

Chapter 18