Simplify Enrollment, Minimize Treatment Disruptions with the CareMetx Medicare Resource Guide


Today, nearly 64 million Americans rely on Medicare and Medicare Advantage plans for their healthcare coverage. What this means is that every year, these 64 million people participate in open enrollment—a time when they can join, switch, or adjust their plans. In preparation for this, stakeholders across the healthcare landscape spend increasing amounts of time and resources every year to help this mass of people navigate what can often be a complex process. 

Each part of Medicare is funded differently:

Part A—The Hospital Insurance Trust Fund via payroll taxes
Part B—General revenues and the premiums paid by Medicare beneficiaries
Part C (Medicare Advantage)—General revenues and beneficiary premiums
Part D (Prescription drug coverage)—General revenues, premiums, and state payments

Individuals eligible for Medicare include:

  • Those 65 years old or older who have been legal permanent residents of the US for at least five continuous years
  • Those who are under 65 and have amyotrophic lateral sclerosis (ALS) or end-stage renal disease (ERSD), or
  • Those who aren’t yet 65, but have been entitled to Social Security Disability benefits for at least 24 months

Medicare Annual Open Enrollment 

Coverage and costs can vary widely across Medicare plans, particularly between the Advantage plans and Part D prescription drug plans. Plans can change from one year to another, which sometimes leads to unexpected costs and disruptions in care for beneficiaries who do not review their options each year. Provider network changes can lead to beneficiaries losing access to their preferred providers, while changes in the list of covered drugs and cost-sharing requirements can result in higher out-of-pocket drug costs. 

Additionally, beneficiaries’ healthcare needs can change, making it even more important for them to have up-to-date information on their coverage options. Even without changes to their plans or changes in their health status, beneficiaries may be able to find alternatives that better meet their individual needs in the new enrollment period. Thus, the Centers for Medicare & Medicaid Services (CMS) advises that beneficiaries review Medicare plans every year.

With the large number of Medicare private plans offered each year in addition to traditional Medicare, beneficiaries can reassess their coverage each year during the Medicare open enrollment period. The complexity of the process however, is almost legendary, leading many beneficiaries to forego this review. In 2019, 71% of all Medicare beneficiaries reported that they did not compare their plan to other Medicare plans that were available during the 2018 open enrollment period.

Additionally, last year, Congress passed some important changes to Medicare in its end-of-year spending bill that were intended to improve coverage for hundreds of thousands of eligible adults, further complicating the process. Aside from the administrative challenges involved, the financial implications these changes can have on things like out-of-pocket costs have the potential to negatively impact adherence to care. Keep in mind that once out-of-pocket costs for a treatment reach $500 or more, the abandonment rate for treatment rises to 41%.

Consequently, anything that can help patients ascertain the available coverage options, easily determine benefit levels and simplify enrollment can be worth its weight in gold.

How CareMetx’s Medicare Resource Guide Simplifies 

For Medicare Part D and Medicare Advantage patients exploring coverage options, the CareMetx Medicare Resource Guide is a self-service tool that can determine coverage and benefits in real time, with a more differentiated connectivity and level of detail than nearly all other available solutions can provide. How much detail? Well, the Guide provides information on features as granular as transportation and meal benefits. 

The CareMetx Medicare Resource Guide not only gives patients a clearly defined view of out-of-pocket costs, but also provides them with the ability to compare how that out-of-pocket responsibility would be impacted if they decided to renew or switch plans. This way, they can understand payer formulary changes in advance and quantify any financial implications. Additionally, the Resource Guide provides the contact information for each payer’s customer support services. These have been included specifically to help Medicare beneficiaries select the most optimal plan design based on known prescriptions.

Relief for Low Income Beneficiaries

Too often, patients who are struggling to pay for healthcare are unaware that they qualify for government-sponsored assistance programs. These patients often make a first attempt to secure coverage through their insurance provider; if that fails, they typically reach out to their drug manufacturer in search of patient assistance programs or manufacturer-sponsored financial aid. If these don’t pan out, often they abandon the process (and critical treatment), completely unaware that they qualify for government assistance. 

To create awareness of these supplemental government programs, the CareMetx Medicare Resource Guide provides an easy-to-use low income subsidy calculator that quantifies the likelihood of a patient qualifying for additional government assistance. If the patient is likely to qualify, the Medicare Resource Guide links them directly to the Social Security enrollment platform, where the patient can submit their application.

Every year prior to open enrollment, this much-needed resource guide is updated to reflect formulary changes and thus how beneficiaries’ financial responsibilities will be impacted in the upcoming year. For patients, this proactive look into the new year can equip them to make the best choices for their coverage—before open enrollment is even underway. 

The CareMetx Medicare Resource Guide facilitates an easier coverage exploration and annual enrollment journey for beneficiaries. This minimizes treatment disruptions, reduces unexpected affordability obstacles and bolsters patient adherence—which is of incalculable value to patients and providers alike. Companies interested in giving patients on their brands access to this much-needed guide can book a demonstration by reaching out to their CareMetx account representatives.

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