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TRENTON – As the 2016 Medicare open enrollment period continues, New Jersey Department of Banking and Insurance Acting Commissioner Richard J. Badolato today provided tips and guidelines to senior citizens as they renew or make changes to their health plans. 

“It is very important that seniors review their overall plans, coverage, deductibles, and coinsurance each year during open enrollment period, so that they have coverage that best fits their health care needs, lifestyle and income levels,” said Acting Commissioner Badolato.

The Acting Commissioner highlighted key terms for consumers to understand as they review their coverage during the annual open enrollment period, which runs from October 15 to December 7:  
• Original Medicare: The traditional healthcare program for senior citizens administered by the federal government, which can include Part A, which covers inpatient care, and Part B, which covers outpatient care. Part D plans, which includes coverage for drugs, must be purchased separately. There is no Part A premium for consumers with at least ten years U.S. work history. Most consumers must pay a monthly premium for Part B.
• Medicare Advantage: Medicare plans sold by private insurance companies that provide healthcare benefits for senior citizens.
• Medigap: Supplemental coverage that pays a portion of original Medicare out-of-pocket costs.
• Deductible: What you must pay before Medicare starts paying for care.
• Copayment/Coinsurance: The amount an enrollee must pay for each service.
• Formulary: List of covered prescription drugs each plan provides.
• Medicare Advantage Prescription Drug Plan (MA-PD): A private insurance company plan that provides both health and drug coverage.
Acting Commissioner Badolato explained that it is important for consumers to understand the differences between Original Medicare and Medicare Advantage plans. 
Under Original Medicare:
• Consumers pay a deductible and/or coinsurance when receiving health care, which is typically 20 percent of the Medicare-approved cost for outpatient care;
• Consumers may go to any doctor or hospital in the country that accepts Medicare;
• No referrals or prior authorizations are needed for services;
• Consumers may buy a Medigap plan for supplemental coverage
Under Medicare Advantage Plans:
• Plans must cover the same Part A and Part B benefits as Original Medicare and may cover extra benefits such as vision and dental care;
• Private carriers generally offer common plan types such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Private-Fee-for-Service (PFFS) plans;
• While containing similar Medicare coverage features, private plans come with different costs and restrictions;
• Consumers typically pay a deductible and/or co-pay for services (generally a fixed co-pay, such as $15 per office visit);
• Insureds still pay Medicare premiums and may pay an extra premium;
• Beneficiaries typically use doctors and hospitals in the plan’s network;
• Consumers may have to select a primary care doctor, get referrals to see specialists, and may be required to get prior authorization for certain procedures;
• Consumer cannot  buy Medigap supplemental insurance to pay for a portion of out-of-pocket health care costs;
• Plans must have out-of-pocket maximums after which consumers pay nothing for the rest of the year; and
Finally, the Acting Commissioner provided tips for those shopping for Medicare Part D plans:
• Covered medications may change from plan-to-plan and from one year to the next.  Consumers should check the formulary to make sure their prescriptions are covered;
• Premium prices may change. Consumers should shop around to make sure they have the plan that best fits their needs;
• Cost-sharing changes should also be verified as co-payments and coinsurance associated with drugs also vary;
• Most plans charge a standard deductible, but some plans may lower the deductible and may be doing so while raising premiums. Consumers should review deductible and corresponding premium changes carefully; and
• A majority of prescription drug plans offer lower cost-sharing requirements if filling prescriptions at selected preferred network pharmacies. Consumers should review their pharmacy to make certain it is part of a preferred network.

Consumers should make sure that the plan they chose is approved by Medicare at or by calling (800) MEDICARE, (800) 633-4227.

Free help for people with questions or problems related to their Medicare Insurance is available online at:

Or by calling the State Health Insurance Assistance Program (SHIP) at: 1-800-792-8820.

A list of local SHIP offices is available at:   

For health insurance inquiries or complaints, consumers can call either (609) 292-7272 or the Department Consumer Hotline (800) 446-7467, or file a complaint online at

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