Time to sign up!

All Medicare recipients, and most people enrolled in health plans through their employers or the Affordable Care Act, have the opportunity to sign up and/or change plans during the annual Open Enrollment Period. For Medicare, this is Oct 15 through December 7, 2023.

While I am sure you have many things you would rather do than review your health insurance options, PLEASE set aside time for this critically important task.

Why is it important? Once you choose a plan, you are generally locked in for a year. If you find in March that you have a condition you want treated by “Dr. X,” but Dr. X is not in your health plan, you are out of luck. The fall open enrollment period is your chance to ensure that your needs are best met in 2024.

In the early days of Medicare, there was very little choice and life was much simpler. Now you have the major option of “classic” Medicare or Medicare Advantage (MA). In addition, if you opt for classic Medicare, there are options for the “fill-in” plans that cover Medicare’s deductibles.

This year, for the first time, over half of Medicare enrollees are in MA plans. These plans, run by commercial health insurance companies and heavily marketed, offer benefits not covered by traditional Medicare, such as payment towards hearing aids and eyeglasses, and even gym memberships. Their major downside is limited choice of doctors and hospitals. There have also been allegations that some plans have denied or delayed needed care. There is no free lunch, and plans that lure you in with lower out-of-pocket costs (and are run by profit-making companies) need to cut costs somewhere.

Suggestions:

1.Even if you are happy with your current MA plan, read the plan information carefully to see what has changed. Plans can and do change what they cover each year. Be sure you know what medications will be covered if your plan provides drug coverage, and what your medicines will cost you. Check if any doctors you are seeing will no longer be covered. Ditto a hospital you prefer to use.

2.Double check with your doctors’ offices to be sure what plans they will be accepting. MA information is often out of date with their list of participating doctors.

3.Be sure your plan and your health needs are a good fit. A plan that covers your fitness club membership may have been inviting when you felt healthy but may no longer be the best fit if you have a new serious illness and the best doctors and hospitals for this condition are “out of network.”

4.Take the time to look at alternatives. Since both plans and your health needs change, there may be a plan that is a better fit. Check the plan ratings on medicare.gov.

5.Ignore the hype and read the fine print. You will be barraged with advertising and sales pitches. Regard these with the same skepticism as you would any other advertising.

Finally, maintain good health habits. Do not smoke or drink; exercise and eat a health plant-focused diet. The healthier you are, the less you will need to worry about what services your plan covers



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RSV - should I get vaccinated?

Respiratory syncytial virus (RSV) has traditionally been thought of as a disease of infants. As many as 80,000 babies under 5 are hospitalized annually in the U.S. with RSV, mostly in the winter, and some 300 die. Until very recently there was little that could be done to prevent RSV.

A monoclonal antibody has recently been approved that was 80% effective at reducing hospitalizations in infants, but it costs $495/dose.

Also new are two RSV vaccines for adults that were shown quite effective, and this availability has focused attention on RSV in older adults.

The “usual” winter respiratory virus about which we have worried for years is influenza. There is quite a bit of variability in influenza from year to year, with estimates of 140,000 to 700,000 flu hospitalizations and 12,000 to 52,000 deaths annually over the past decade. Flu vaccine efficacy has been quite variable but vaccination is universally recommended.

For the past 3 years, Covid has pushed flu out of the headlines, and it is unfortunately still with us.

Estimates for RSV for the same 10-year period are that 60,000 to 160,000 older adults are hospitalized each winter with RSV and 6,000-10,000 die. A CDC analysis of a large sample of adults over 60 found that while RSV was much less common as a cause of hospitalization than flu or COVID, patients with RSV tended to be sicker.

The two recently approved vaccines both reduced the rate of RSV illness requiring medical attention by about 85%. The advisory committee recommended the vaccine for pregnant women to protect their newborns and for adults 60 and older.

Like all new vaccines, there are unanswered questions. There seemed to be a small but real increase in neurologic side effects (notably Guillain-Barré, a temporary paralysis) in vaccine recipients and possibly a small increase in atrial fibrillation. For the frail elderly, the benefits clearly outweigh the risks. For healthier seniors it is less clear.

Cost may be an issue. The vaccine costs $200-$300. It is covered under Part D of Medicare, not Part B like flu or Covid shots. Not all private insurances cover it.

If you are older with heart or lung disease, I would definitely recommend it. If your general health is excellent, the decision is a personal weighing of risks and benefits.

By the way – masks reduce the spread of all respiratory illnesses. And if you are sick and coughing, do everyone a favor and stay home until you are better!



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