Latest news and updates about the Medicare and pharmacy industries.

5 Medicare Myths, Debunked

Posted on in Industry Updates by Amplicare Team

For a good portion of the population, Medicare is a necessity. But its complexity often leads to confusion. Patients look to healthcare professionals, including pharmacists, for help to understand their options. It is, therefore, important for you to know some common misconceptions and be prepared to address them. To help, here’s a look at the reality behind five Medicare myths.

Myth: Medicare — including Part D — is free and all-inclusive
Reality: Medicare benefits Americans do or will receive are funded by their money. All tax-paying citizens pay a percentage of their income to the Center for Medicare and Medicaid Services (CMS). Patients who know this may also believe another common myth: once you are enrolled in Medicare, all medical services are covered indefinitely. However, many parts of Medicare, including Part B and Part D, must be paid for monthly. Plus, plans offer different benefits that may change year-over-year.

To alleviate Part D costs, many patients enroll in a Medigap plan or a Medicare Advantage (MA) plan. Medigap is supplemental to a Medicare plan, meaning patients must also be covered by a traditional Medicare plan. A Medicare Advantage plan, on the other hand, replaces traditional Medicare and offers its own prescription drug coverage.

Pro Tip: Help your patients compare Medicare plans before they enroll. This is a great way for them to decide what works best for their situation.  

Myth: Once you are eligible for Medicare, you can enroll whenever you want
Reality: It’s likely that many of your patients know they are eligible for Medicare on their 65th birthday. What they may not realize is that not enrolling within a designated period of time can result in financial penalties. Patients have a seven-month Initial Enrollment Period, which includes the three months before their birthday, their birth month, and the three months after. If they don’t enroll during this time, a 10% increase will be applied to their Part B premium. This increase is then added to the premium for every year they weren’t enrolled and remains as long as they are in the program.

Similarly, for every month a patient does not have creditable drug coverage (i.e., coverage that is comparative to Med Part D plans), a penalty is added to their monthly premiums once they enroll. This is calculated with the following equation:

1% x $33.19 x # of months eligible for Part D = additional cost to the monthly period

Pro Tip: Reach out to your patients before and during their Initial Enrollment Period to help them avoid penalties and reinforce your role as a healthcare provider.

Myth: You don’t have to sign up for Medicare if you have insurance
Reality: This misconception can be just as costly as the previous. In this case, your Medicare-eligible patient likely has insurance from their employer. If that employer has more than 20 employees, this insurance is considered primary and the patient doesn’t have to enroll in Medicare. However, if the employer has fewer than 20 employees, their insurance is secondary. Secondary insurance is not considered comparable to Medicare coverage. This means the patient must enroll in Medicare or they will be subject to the same penalties as someone without coverage.

Pro Tip: Provide educational materials at your pharmacy targeted toward patients 65 and older to help them know what to expect. 

Myth: Once a patient chooses a plan, they are stuck with it for life
Reality: In a 2018 Nationwide Retirement Institute survey, more than a third of participants thought they must keep the Medicare plan they first chose. This is concerning because as a patient’s health changes, the plan that best fits them may not be their original one. In reality, patients enrolled in traditional Medicare and Medicare Advantage have the opportunity to switch plans during Medicare Open Enrollment (October 15 to December 7). MA plans also have an Extended Enrollment Period that runs from January through March. Plus, patients can switch plans when they meet certain qualifying factors. During these times, patients can reevaluate their coverage to make sure it is meeting their current needs.

Pro Tip: Use a plan comparison tool to save you time as you help your patients make an informed decision. For instance, our platform integrates with your pharmacy system to pull and analyze patient, pharmacy, and plan data to deliver plan comparisons in seconds.

Myth: Being a preferred pharmacy is always better
Reality: Being a preferred pharmacy seems like a positive thing — after all, many of your patients’ copays will be lowered. However, it is also true that your preferred status can be accompanied by DIR fees. These fees may be applied for a variety of reasons and add to your pharmacy’s costs. Even pharmacies who meet high performance metrics are subject to these additional charges (learn more about the complicated relationship between performance and DIR fees).

Pro Tip: Low income subsidy patients face low out-of-pocket drug costs, regardless of a pharmacy’s preferred status. Focusing on your dual eligible patients could be beneficial to your pharmacy. These patients also have the option to switch plans outside of Open Enrollment once per quarter.

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