The New Old Age Blog: Q & A: Medicare and the Insurance Exchanges

Shirley Mierzejewski was "very upset" when she found out her Medicare health insurance premiums will nearly double next year.

"I cannot afford that, I cannot," said Ms. Mierzejewski, 77, who lives in Euclid, Ohio, and works part time as a receptionist at a local college. She has a private Medicare Advantage policy from Anthem, which provides drug and medical coverage.

"So I started thinking about the marketplaces," she said, referring to the online insurance exchanges created by the Affordable Care Act. "Maybe I could find something cheaper there."

But after attending a Medicare meeting this month at the Euclid Senior Center, she learned that the plans available on the exchanges are not intended for most people with health insurance — and that includes those with Medicare.

While thousands of Americans are trying to sign up for insurance on the exchanges, Medicare counselors like Semanthie Brooks, who spoke at the meeting Monday in Euclid, are trying to steer seniors away. They worry that Ms. Mierzejewski and other older adults may not realize that Medicare is a pretty good deal compared to exchange policies and may try to buy one anyway.

Exchange plan enrollment began on Oct. 1 and runs through March. The enrollment period for next year's Medicare Advantage and prescription drug plans — many offered by the same companies selling marketplace coverage — starts Tuesday and ends Dec. 7.

"People are going to be inundated with marketing materials and commercials around both," said Ms. Brooks, director of community advocacy at the Benjamin Rose Institute on Aging, a social service agency in Cleveland. She has been crisscrossing northeastern Ohio, helping elderly residents sort out the differences when she visits community centers, high-end assisted living facilities and subsidized senior apartment complexes. "They all want to know the impact of Affordable Care Act on Medicare," she said. "They want to know, 'Should we sign up?' "

To clear up confusion in Montgomery County, Md., officials held meetings at six centers for the elderly. "They want to know if they are better off in the exchange than in Medicare," said Leta Blank, director of the Montgomery County State Health Insurance Assistance Program. "Everyone is looking for a less expensive way to get health care."

Finding the right drug or Medicare Advantage plan can be overwhelming even under the best of circumstances. Dozens of plans offer different benefits and cover different drugs from different pharmacies at different prices. And you are supposed to review new plan offerings every year.

So in a year in which the insurance market is being turned upside down, here are some shopping tips for people with Medicare and caregivers.

Are the exchange plans worth looking into if you're enrolled in Medicare?

No, with a few exceptions (more about that later). The state insurance exchanges are intended for people without health insurance, those who might qualify for financial assistance (subsidies or tax credits), owners of small businesses, and people who buy their own insurance. The authors of the Affordable Care Act did not anticipate that anyone with Medicare would be interested in exchange coverage. Medicare beneficiaries already get a pretty good deal, said Joe Baker, president of the Medicare Rights Center, in New York City.

The vast majority of Medicare's 52 million beneficiaries pay no premium for Part A, which covers hospitalization and other care. Premiums for Part B, for doctor visits and other outpatient services, cover only 25 percent of the program's annual cost. When the so-called doughnut hole, or gap in drug coverage, is finally closed for Part D, Medicare beneficiaries will pay only 25 percent of the average bill for prescriptions.

Do the exchanges sell Medigap plans?

Alfredo Cuellar, a retired overseas development specialist in Washington, has Medicare and a supplemental, or Medigap, policy that fills in the gaps that Medicare doesn't cover, including co-payments and some deductibles. His Medigap premium is going up 20 percent next year, so he wants to look for a cheaper policy on the exchanges.

He won't find one, said Mila Kofman, executive director of the District of Columbia Health Exchange Authority. Exchanges don't sell Medigap policies. They sell comprehensive insurance that covers medical and drug costs, along with other "essential health benefits" required under the Affordable Care Act.

"It's never going to be less expensive than what a person gets under Medicare Part A and Part B," said Ms. Kofman, the former insurance commissioner of Maine.

Does Medicare coverage meet the Affordable Care Act's requirement that most adults have health insurance in 2014?

Yes and no. People enrolled in premium-free Part A or a Medicare Advantage plan meet the requirement. But the relatively small number of Medicare beneficiaries who do not qualify for Part A — and have Part B only — do not meet the requirement, according to the Internal Revenue Service. In order to receive premium-free Part A coverage, you must have worked at least 40 quarters. Recent immigrants or someone who is not eligible under another person's work history (like a spouse's) will not be covered under Part A. Part B coverage alone does not meet the criteria for health insurance.

Can Medicare beneficiaries buy a plan on the exchange?

No, said Leslie Fried, policy and programs director at the National Council on Aging in Washington. It is illegal for someone who knows you have Medicare to sell you duplicate coverage. The ban applies to the vast majority of people who have full Medicare coverage, as well to those who have only Part A or only Part B.

But there are some exceptions: plans on the exchange can be sold to disabled people who are eligible for Medicare but have to wait two years for coverage to kick in. Exchange plans can be sold to the very small number of people who currently pay Part A premiums; however, an exchange plan probably will ultimately cost more. And should they decide later to rejoin Medicare, these people may be subject to late enrollment penalties.

To further complicate matters, there is nothing in most insurance applications on the exchanges to prevent someone with Medicare from buying coverage. And there is nothing in the paper application, not even a warning urging Medicare beneficiaries to think twice.

"I am very worried that, without the right information, people will drop Medicare and sign up," Ms. Kofman said. The District of Columbia will be changing its eligibly screening system to prevent people with Medicare from buying coverage on the exchange, but the fix will take a while to put in place.

Medicare beneficiaries who fill out New York's online exchange application will see a special message saying they will not be eligible for premium tax credits, although other financial assistance may be available. That doesn't mean you will be sold a policy. Once the application is received, it will most likely be rejected.

Do people with Medicare need to re-enroll or get new Medicare cards?

No, but some scammers have been telling the elderly that the Affordable Care Act requires them to do so. In Ohio, the state attorney general has received dozens of complaints about attempts at identity theft related to the A.C.A. and aimed at Medicare beneficiaries, said Kate Hanson, a spokeswoman for the office.

So should seniors just ignore the exchanges?

No, Ms. Fried said. "They are a great excuse to call your grandchildren," she said. "Tell them to get health insurance if they don't have it."

For more information about the exchanges, visit healthcare.gov or call 1-800-318-2596. For help with Medicare, visit medicare.gov, or call 1-800-Medicare (800-633-4227) or the Medicare Rights Center (800-333-4114).

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