Being an active walker, John has led a healthy life. However, now at age 68, he has found that he will need major surgery and rehab in the first few months of 2013. He enrolled in a Medicare Advantage Plan (MA) when he was 65 and it has served him well by keeping his premiums low, providing predictable co-pays and out of pocket limit for covered expenses. With the pending surgery he is now looking for the best options to cover these medical expenses.

If John were to stay the course with his current plan, he would pay about $200 co-pay a day for his hospital stay, about 20% co-pays for the surgery and for each rehab session. It is prudent and important for John to review his current coverage and calculate an estimate of out of pocket expense. The MA plans have a maximum out of pocket amount that John would pay for 2013, but it is well over $3,000.00. While John may not reach the out of pocket maximum, he can essentially add the money spent on co-pays to his premiums to come up with his total out of pocket medical costs.

John has an option is to move back to Original Medicare and buy a Medicare supplement and Part D Plan for drugs. Some Medicare Supplement plans, but not all, require underwriting. The Plan F Medicare supplement pays all of Medicare‘s co-pays, so John would have little to no out of pocket cost for expenses covered Medicare supplement. In his case, he would pay about $170 more a month in premiums. Therefore, if his projected out of pocket costs with the MA Plan are far greater than $2,000 in 2013, the Medicare supplement may be a good option for John. So, what is the rule:

A person can only leave a Medicare Advantage and return to Original Medicare plan during the Medicare Advantage Disenrollment Period (MADP). Except for other special circumstances, a person cannot join or switch MA plans during this time. The MADP is from January 1- February 14 each year.

If you want to disenroll from an MA-only or an MAPD (includes prescriptions) plan and return to Original Medicare during this time, you have a special election period (SEP) to join a Part D prescription plan.

• If you’re in an MAPD, you can either 1) submit a disenrollment request to your MAPD plan and then enroll in a Part D plan, or 2) enroll in a Part D plan first, which then automatically disenrolls you from your MAPD.
• If you’re in an MA only plan, you must first request disenrollment from your MA plan to trigger your SEP to join a Part D plan.

You can only enroll into one Part D plan during your SEP, and this SEP is only available during the MADP, January 1 – February 14. Your enrollment into your new Plans are effective the first of the following month. In John’s case, it is advisable to seek professional help if he wishes to compare his outcomes or consider making this change.

I would like to wish all a Happy and Healthy New Year.