BY DONYA CURRIE

One of the biggest questions looming in Lydia O’Neil’s mind as she neared 65 was whether she could afford to retire.

“I didn’t know what Medicare would cover and what my co-pay would be,” said O’Neil, 68, of Fredericksburg.

Many people have those same questions as they approach their 65th birthday, and with good reason. Medicare, the government health program for the elderly and disabled, has complex rules and a myriad of options. Penalties ensue if a person does not enroll when eligible. And there are different enrollment periods for medical and drug coverage.

“It is confusing, and you don’t want to do anything wrong,” said Karl Karch, 66, of Fredericksburg, who found himself navigating an online Medicare “maze” in the months before he turned 65.

“If you don’t dot the i’s and cross the t’s, you’re fearful you could do something to jeopardize your benefits for the rest of your life,” Karch said. “There’s that added stress that goes with it.”

“People start to get information right around the time they turn 65, but sometimes they get confusing information from their employers,” said Fred Riccardi, director of programs and outreach for the Medicare Rights Center, which runs a national help line to assist in sifting through enrollment and coverage questions. “There’s just some misinformation out there. Also, one thing I’ve realized, too, is some people aren’t aware of the costs associated with health insurance in general. Not only do you have to pay your Part B premium, you also have to think about your drug coverage and your co-insurance.”

Medicare Part B covers medical care such as doctor visits, and carries a premium of about $100 a month for most people. Part A covers hospitalization and carries no premium because it’s paid for out of the yearly taxes deducted from a person’s paycheck throughout his or her working life.

Part D is prescription drug coverage, an option that can be especially confusing because it is administered through private health insurance plans, which can vary widely in what they cover. Monthly Part D premiums range from about $15 to nearly $120.

A person’s 65th birthday also brings the need for decisions about Medigap insurance, also known as co-insurance or Medicare supplemental insurance, which picks up the tab for services not covered by Medicare such as deductibles and co-pays.

And yet another question is whether to opt for a Medicare Advantage plan; those are provided by private insurance companies and cover both prescription drugs and medical care. As with other private insurance, a plan can change from year to year.

Add in a difficult economy that’s forcing some people to work well after age 65 and some to delay receiving retirement benefits, and you have the potential for mass confusion, said Terri Lewis, regional communications director for the Social Security Administration. What she wants to make clear is there is no one-size-fits-all when it comes to enrolling in Medicare.

“Every situation is so individual,” Lewis said. “We just want to be sure that people don’t forget that Medicare eligibility begins at 65.”

Both Lewis and Riccardi said people should begin the enrollment process, whether they opt for only Part A or all parts of Medicare, three months before their 65th birthday.

SOURCES OF CONFUSION

One source of confusion: The full Social Security retirement age is 66, but people can choose to begin receiving benefits as early as age 62 or as late as age 70. The Medicare eligibility age remains at 65.

Enrollment in Parts A and B is automatic for those already receiving Social Security benefits. Everyone who wants Medicare prescription drug coverage must actively enroll (unless they qualify for both Medicare and Medicaid).

People can enroll online, via phone or by visiting the local Social Security Administration office, which for the Fredericksburg area is on Southpoint Parkway in Spotsylvania County.

“Another thing that might be important for people to understand is [if] you do enroll for Medicare with Social Security, when it comes to questions about their coverage, that’s where we have to defer to their health care provider,” Lewis said.

In other words, call 800/MED-ICARE or visit medicare.gov, which are both run by the Centers for Medicare & Medicaid Services.

For recent retirees, Medicare enrollment can be especially confusing, Riccardi said. Many questions come in to the help line from people who have neglected to enroll in Part B because they had employee or retiree insurance coverage or COBRA, which allows a former employee to continue coverage for a set time period. Not enrolling at the right time can mean penalties tacked on to Medicare premium payments, and also a dangerous gap in coverage.

“We see that all the time; people don’t take Part B because they have retiree coverage or COBRA,” Riccardi said. “That’s a major pitfall, and it’s pretty heartbreaking depending on the story that you get.”

O’Neil, who retired from the Central Rappahannock Regional Library three years ago, sought help from local elder-care advocate Valerie Hopson–Bell in choosing her Medicare coverage. She has Parts A and B as well as a supplemental policy through Anthem, the same company that provided her health insurance while she was working. She has changed Part D plans each year to find the one that best fits her needs.

“I think that maybe some people don’t completely understand that every year you have to shop a new Medicare D plan,” O’Neil said. “They change drastically from year to year, and what was good for you in 2011 might not be good at all in 2012, and you really need to research these plans and what they’re offering each year and determine which one’s the best for you.”

Karch chose Medicare Parts A and B, a low-cost Part D prescription drug plan and supplemental insurance through the insurance company he had previously used for his overall health coverage.

“So far, I’ve had the need to use Medicare, and once you’re enrolled and you’re paying your premium, things are pretty good if you have a provider who’s still going to accept Medicare,” Karch said. “I’ve had some needs where I didn’t even have a co-pay. It’s an excellent insurance once you figure out how to enroll properly.”

WHAT YOU NEED TO KNOW

How can you enroll?

  • Visit socialsecurity.gov.
  • Call 800/772-1213.
  • Go to the local Social Security Administration office, 4954 Southpoint Parkway, Fredericksburg, Va. 22407. The hours are Monday–Friday, 9 a.m.–3:30 p.m.

Why should you enroll? A person who does not enroll in Medicare when first eligible faces financial penalties for life. Those penalties vary, but for Part B, for example, under current premium rates, waiting a year tacks on 10 percent, or about $10 a month, to the cost of the premium.

When should you enroll? Be prepared to enroll three months prior to your 65th birthday. If you do not enroll at age 65, you can file online during the general enrollment period, Jan. 1–March 31, but coverage usually won’t begin until July 1. You could qualify for a special enrollment period if you are currently covered by an employer or union health plan through your or your spouse’s job.

How can you get help enrolling?

  • Free individual insurance counseling is available through the Virginia Insurance Counseling and Assistance Program. In the Fredericksburg area, VICAP is based at the Rappahannock Area Agency on Aging, 540/371-3375.
  • Medicare Rights Center national help line: 800/333-4114 (Monday through Friday, 9 a.m.–5 p.m.)
  • AARP Medicare Starter Kit: aarp.org/health/medicare-insurance/ info-04-2011/medicare-starter-guide.html
  • ElderCare Connections of Fredericksburg: 540/419-4387 or eldercareconnections.net

SIDEBAR: DREADED DOUGHNUT HOLE TO DISAPPEAR

The federal health care reform law brought some good news for people on Medicare.

Preventive services such as a yearly wellness visit, mammogram, bone mass measurement, and cholesterol and diabetes screening are now fully covered without a Part B deductible or co-payment. The same goes for yearly flu and pneumonia shots and immunization against hepatitis B.

Because nothing associated with Medicare is simple, there are exceptions. For some preventive services, the actual services are free but a person might have a co-payment for the office visit. Also, those enrolled in Medicare Advantage plans might be responsible for a co-payment for preventive services.

The law also seeks to eliminate, over time, the dreaded prescription drug coverage “doughnut hole.” The gap in coverage for people with Medicare Part D has meant that once someone’s plan has paid a certain amount for prescriptions, that person then has to pay all drug costs up to a certain limit each calendar year. For some, that has meant hundreds or even thousands of dollars in drug bills.

Under the Affordable Care Act, the hole closes gradually between now and the year 2020. This year those in the doughnut hole get a 50 percent discount on covered brand-name prescriptions and a 14 percent discount for generic drugs. The discounts rise to 55 percent for brand-name drugs and 35 percent for generics by 2015, and 25 percent for both in 2020.

The change is good news to Lydia O’Neil, 68, of Fredericksburg, who struggled to make ends meet in 2011 because of so many prescription drug charges while she was in the doughnut hole.

“I was just robbing Peter to pay Paul to pay for my prescriptions,” O’Neil said.

Learn more about the Medicare-related changes in the health reform law at www.healthcare.gov/news/factsheets/2011/08/seniors.html.

Donya Currie is a freelance writer in Stafford County who regularly contributes to Healthy Living and other health-related publications, including the AARP Bulletin. You can write to her at healthyliving@freelancestar.com.