Diabetes in Medicare Open Enrollment

Type 2 diabetes is one of the biggest health problems facing the aging population, and many baby boomers with diabetes are wondering which Medicare plan is best for their health condition. As we have less than a month left to Medicare open enrollment, you might be wondering if there are better options than what you currently have. Park Crescent has prepared this guide for you during National Diabetes Month to help with your decision making.

Medicare Basics

As we’ve discussed before, Medicare has four parts. Part A covers hospital and nursing home stays, while Part B covers medical expenses like doctor visits, outpatient therapies, medical equipment like insulin pumps and glucose meters, and preventive screenings. Both parts together are called Original Medicare, and are the basic coverage that most people are automatically enrolled in at age 65.

Medicare Part C is also known as Medicare Advantage. These plans are private plans who administer your Medicare benefits. Each plan offers different “extras” as well as varied price points, enabling you to shop for the plan that best suits your specific situation. Part D stands for prescription drug coverage, private plans you can purchase to supplement your Original Medicare plan, which doesn’t cover medication costs.

Medicare supplement plans, also known as Medigap, are standardized health plans you can use to supplement your Original Medicare coverage. You have six months after your 65th birthday to freely enroll a Medigap plan. After that, insurers will be allowed to take your health history, including your diabetes, into account when deciding whether or not to issue coverage to you.

Pre-existing Conditions

Pre-existing conditions are when you have a known medical condition when you apply for a new insurance plan. In the past, insurers were able to deny coverage or charge significantly higher premiums for customers with pre-existing conditions. The Affordable Care Act put a stop to that, and now insurers are required to take all individuals regardless of their medical history.

Original Medicare and Medicare Advantage always covered pre-existing conditions. There are a list of services that Original Medicare—and by extension, Medicare Advantage—always covers, even if you have an extensive medical history. The one exception to that is end-stage renal disease. ESRD is chronic kidney disease, a not uncommon complication of diabetes. Most Medicare Advantage plans do not cover services related to ESRD, so if you have the condition, you may not be able to switch to a Medicare Advantage plan.

Medicare Advantage Special Needs Plans

These plans offer benefits for three specific groups of people:

  • Nursing home residents
  • People with dual Medicare/Medicaid eligibility
  • People with certain chronic medical conditions

Medicare SNPs are not available in all areas of the country, but fortunately, New Jersey-ites with ESRD and dual eligibility do have the option to enroll in an SNP plan. For more information, check out the NJ’s Department of Human Services page at www.state.nj.us.

Choosing Between Original Medicare or Medicare Advantage

As an older person with diabetes, you have to make a lot of healthcare decisions. Here are the main benefits of each option. You may find specific pros or cons to either option based on your personal situation.

Original Medicare

  • On Medicare you have the widest possible selection of doctors. Going with an advantage plan often limits your available healthcare providers to a much smaller network, so you’ll have to find a new one if your preferred endocrinologist is not on your insurance’s network.
  • The Part A premium is free as long as you’ve worked at least 10 years, and Part B has a relatively low premium. If your diabetes is well-controlled and you don’t need regular medical intervention, you may come out ahead financially by sticking with Original Medicare.
  • If you started your Medicare coverage with Original Medicare and enrolled in Medigap within the first six months, it may not be worth switching to Medicare Advantage. That’s because if you ever want to switch back to Original Medicare, you could be denied Medigap coverage because of your medical history.

Medicare Advantage

  • Private plans have much higher deductibles than Original Medicare, but they also have an annual max of out-of-pocket expenses. After that, all your medical needs are covered at 100 percent. If you anticipate needing a lot of medical care due to your condition, this may make more financial sense.
  • Most Medicare Advantage plans have built in drug coverage, so you wouldn’t have to get a separate Part D drug plan.

If you have any questions about medicare coverage or open enrollment, call 1-800-MEDICARE (1-800-633-4227) or visit medicare.gov.


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