• the Coverage Corner

Medicare Diabetes Prevention Program: An Overview

Healthcare spending in the United States is approximately $3.3 trillion or $10,348 per person annually — and continues to grow. Each year, Medicare spends more than $104 billion treating patients with diabetes.

According to the American Diabetes Association, an estimated 25 percent of Medicare-eligible seniors have diabetes, and the prevalence of prediabetes is especially high in this age group. The Centers for Medicare & Medicaid Services (CMS) estimates that it spent approximately $1,500 more on Part D prescription drugs, $3,100 more for hospital and facility services and $2,700 more in physician and other clinical services for those with diabetes than those without it.

The good news for this population is that the most common type of diabetes, Type 2, often can be prevented or at least delayed through lifestyle and health changes.

Diabetes Prevention for Enrollees

Based on this conclusion, the Medicare Diabetes Prevention Program (MDPP) is designed to impede the onset of Type 2 diabetes for Medicare customers who:

  • Are enrolled in Medicare Part B
  • Have a body mass index (BMI) of at least 25 (at least 23 if self-identified as Asian)
  • Meet one of the following three blood test requirements within 12 months of the first core session:
    • A hemoglobin A1c test with a value between 5.7 and 6.4 percent
    • A fasting plasma glucose of 110-125 mg/dL
    • A 2-hour plasma glucose of 140-199 mg/dL (oral glucose tolerance test)
  • Have no previous diagnosis of type 1 or type 2 diabetes (other than gestational diabetes)
  • Do not have end-stage renal disease (ESRD).

The MDPP is available to eligible seniors and requires no referral or copayment. It is offered at more than 1,000 CDC-recognized organizations, including hospitals, community centers, YMCAs and more, in all 50 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands. However, the services that comprise it must be provided by Medicare-approved suppliers of the program.

Medicare Diabetes Prevention Program Curriculum

Updated in April of this year, the MDPP consists of a minimum of 16 intensive core sessions of a curriculum approved by the Centers for Disease Control and Prevention (CDC). Held over a six-month period, these sessions enable participants to receive group-based coaching and training focused on utilizing physical activity, dietary changes, behavior modification, stress management and weight loss strategies. They allow for group participation, accountability and direct interaction between coaches—including nutritionists and dieticians—and participants.

Once they complete the first 16 sessions, participants are invited to attend monthly follow-up meetings to help them maintain the healthy behaviors they learned. Participants who meet the program goal of a 5 percent weight loss may attend an additional year of ongoing maintenance sessions.

If you’d like more information about Medicare, visit our website.

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Understanding Medicare Part D

If you are
Medicare-eligible , you may find that navigating Medicare can be tricky. Now that the Annual Enrollment period is here, you may have started researching your options and coverage under Medicare. Your first step when signing up for Medicare is to see what plans you qualify for based on your state and income.

When deciding on the right Medicare plan for you, it’s important to look for what you need and want from your healthcare, whether that’s a focus on preventative care, or a plan that ensures your current medication regimen is continued.

Prescription Coverage

If you require access to consistent prescription medication you’ll need a plan that covers prescriptions. That’s where Medicare Part D plans come in. Part D plans offer prescription drug coverage to help ease the out-of-pocket costs of prescription medication.

Individuals covered under Medicare Part A and/or Part B plans are eligible for Part D plans regardless of income. Each Part D plan covers different drugs, so it’s important that you are signing up for a plan that covers the medication you need.

Part D Plans

So what do Medicare Part D plans look like? Most plans will have a monthly premium that varies from plan to plan, an annual deductible (exceeding no more than $405 as of 2018) and a co pay. Co pays are generally determined based on what “tier” the particular prescriptions falls under.

Most plans have tiers broken into Tier 1: lowest copay for generics, Tier 2: medium copay for preferred, brand-name drugs, Tiers 3: higher copay for non-preferred, brand-name drugs and the Specialty Tier: highest copay for very high-cost drugs.

Often, the same medication will vary in price based on what Part D plan you sign up for. Be sure to compare the plans you qualify for closely to determine which plan would best suit your needs and budget. The Annual Enrollment Period for Medicare Part D plans is from Oct. 15 to Dec. 7, unless you qualify for a Special Enrollment Period (SEP).

Need some expert guidance when making your final decision on Medicare Part D? As a private exchange, GoMedicare allows you to compare thousands of health plans from top carriers in your area, and unlike other exchanges, our licensed insurance agents are standing by to guide you through the enrollment process.

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Medicare for Diabetics: An Overview

Chances are you know someone with diabetes. That’s not surprising, given that 30.3 million people—or 9.4 percent of the population of the United States—have diabetes, and this number is only growing.

Approximately 1.5 million Americans are diagnosed with diabetes every year, with American/Alaska Natives having the highest prevalence of diagnosed diabetes for both men and women. Just two years ago, the Centers for Medicare & Medicaid Services (CMS) estimated that it spent $42 billion more on Medicare beneficiaries with diabetes than it would have spent if those beneficiaries did not have the disease.

About one in four U.S. residents over 60 years of age—an estimated 12 million—have diabetes. The National Institute on Aging defines Type 1 diabetes, found mostly in children and young adults, as occurring when the body makes little or no insulin.

In Type 2 diabetes, the most common type of the disease that accounts for the majority of cases, the body makes insulin but does not use it the right way. If you don’t have diabetes but want to know your risk for it, the American Diabetes Association has a free Type 2 diabetes risk test on its website.

If you’re a diabetic age 65 or older, it’s important to know what medicines and supplies are covered. Many of these items are covered under Medicare Part B, while some prescription drugs, supplies and devices fall under Medicare Part D. We’ll provide an overview of what both Medicare Part B and Part D cover for beneficiaries with diabetes.

Diabetes Supplies and Services: Medicare Part B

The following supplies are covered for Medicare Part B beneficiaries with diabetes:

  • Insulin pumps and insulin used in pumps
  • Blood glucose self-testing equipment/supplies (for both those who do and do not use insulin)
    • Blood glucose monitors
    • Continuous blood glucose monitors (classified by Medicare as therapeutic CGMs) if certain criteria are met
    • Blood glucose test strips
    • Lancet devices and lancets
    • Glucose control solutions for checking the accuracy of testing equipment and test strips
    • Supply allowance for therapeutic continuous glucose monitor (CGM) and all supplies and accessories
    • Up to 300 test strips and 300 lancets every three months for those who use insulin
    • Up to 100 test strips and 100 lancets every three months for those who do not use insulin
  • Preventative care/diagnostics screenings for diabetes
    • Obesity screening and counseling
    • Glaucoma tests
  • Medical nutrition therapy (limited number of hours per year)
  • Diabetes self-management training (limited number of hours per year)
  • Annual Wellness Visit every 12 months
  • Therapeutic shoes and inserts (if certain criteria are met)

Medicare also offers a national mail-order program for its beneficiaries with diabetes to receive testing supplies, including blood glucose test strips, lancets and lancet devices, batteries and control solution. In order for Medicare recipients with diabetes to obtain these supplies, they must have a prescription from their physician.

Once Medicare beneficiaries with diabetes have met their Part B deductible, they’re responsible for a coinsurance amount of 20 percent of the Medicare-approved payment rate for such supplies and services. All diabetes supplies are reimbursed under Medicare Part B at the same rate, and many Medicare beneficiaries who have diabetes own additional coverage to help them pay the amount of their coinsurance.

Diabetes Supplies and Services: Medicare Part D

In addition to covering insulin not used in an insulin pump, Medicare Part D (the prescription drug program available to all Medicare beneficiaries) is responsible for diabetes devices not covered under Medicare Part B.

It covers diabetes supplies, anti-diabetic drugs and supplies used to administer insulin, such as syringes, needles, alcohol swabs, gauze and inhaled insulin devices. Many of the anti-diabetic prescription drugs covered by Medicare Part D are sulfonylureas (Glipizide, Glyburide), biguanides (metformin), thiazolidinediones (Starlix®, Prandin®) and alpha glucosidase inhibitors (Precose®).

For information on Medicare eligibility or enrollment, visit GoMedicare.com.

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Self-Funded Health Plans: 10 Terms to Know

Curious about self-funded health plans but confused by all the jargon? GoHealth is here to help with 10 terms you need to know before jumping into the world of self-funded healthcare:

1. Self-Funded

Let’s start with the basics: What is a self-funded health plan? According to Health Care Administrators Association, a self-funded (or self-insured) plan is one by which your employer assumes financial risk, paying for claims out-of-pocket rather than at a predetermined premium.

2. Fully-Insured

Alternatively, a fully-insured health plan, as defined by the Business Benefits Group, puts the financial risk on an insurance company, requiring your employer to pay a large fee upfront to cover costs from employee claims.

3. Fixed Cost

For either plan, your employer pays a fixed cost—an amount that must be paid, regardless of actual expenses. Medcost explains that fully-insured plans are 100 percent fixed cost while self-funded plans are only 18-21 percent fixed cost, potentially saving your employer money.

4. Variable Cost

Additional savings may be acquired if your employer uses soft dollars or a variable cost, setting aside dedicated funds to cover estimated employee claims. If left unspent during the plan year, this amount carries over for future medical expenses.

5. Stop-Loss Insurance

As another precaution, some employers use stop-loss (or excess-loss) insurance to limit the financial risk that comes with self-funded plans. The Health Care Administrators Association describes it as coverage that “provides protection against catastrophic or unpredictable losses.”

6. Claims Corridor

The claims corridor, as defined by OptimaHealth, refers to the area of risk above the expected claims—the amount your employer anticipates to pay based upon your plan’s characteristics. This area acts as a type of cushion for your employer when dealing with unexpected claims.

7. Employee Retirement Income Security Act of 1974 (ERISA)

All self-funded health plans are regulated by the Employee Retirement Income Security Act of 1974 (ERISA). Medcost admits that if self-funded, your employer avoids certain fees (such as the Federally Facilitated Exchange User Fee, the Risk Adjustment Fee and the Health Insurance Provider Fee) and even some state premium taxes.

8. Summary Plan Description (SPD)

A plan’s complete terms and conditions can be located in the summary plan description (SPD). This report is specifically written for your employer and outlines all the coverage and exclusions associated with your plan.

9. Third Party Administrator (TPA)

According to OptimaHealth, employers usually contract with a third party administrator (TPA)—also known as a benefits administrator or administrative services organization (ASO)—to handle paperwork along with payments and other services.

10. Healthcare Reimbursement Arrangement (HRA)

Some employers offer variations of self-funded health plans that are only partially self-insured and include a healthcare reimbursement arrangement. (HRA). This account reimburses employees for medical expenses paid out-of-pocket.

Self-funded health plans can be confusing to understand, especially if you’re starting with a new company that uses self-funded plans. That’s why GoHealth offers many resources to help you navigate this challenging landscape.

Still have questions about self-funded health plans and their terms? Call (888) 332-7557 or visit our website for more information.

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Key Changes for Open Enrollment 2019

Have you looked into the Open Enrollment Period (OEP) for 2019 yet? Not only did registration begin Nov. 1, but the Dec. 15 deadline is looming!

Don’t panic, we have you covered so that you can lock in your policy before then. Here are some important things to note about Open Enrollment 2019 before you make your decision:

No Fines

The good news is you won’t be fined for not having health insurance in 2019. In previous years under the Affordable Care Act, if you went without coverage and didn’t fall under health-coverage exemptions, you might’ve incurred a fee (also known as the “Share Responsibility Payment” or “mandate”)—for as much as $695 per adult and $347.50 for each child under 18. Going forward in 2019, there will be no such tax penalties.


If you do not make the Dec. 15 deadline, re-enrollment in your current health insurance plan may be done for you automatically. However, don’t assume this, because some instances do not allow for auto-enrollment. Also, ensure you’ve provided current income and household information during registration in order to receive any applicable savings. Otherwise, you may get whatever you had for 2018’s insurance package.

Extended Deadlines

While the national time frame is shorter for 2019, some states have set their own periods with extended deadlines. See if your state is among the list here.

Short-Term Plans

Short-term healthcare plans have been extended. It’s one of the biggest changes made to the Affordable Care Act. Unlike the past, short-term plans will last an entire year. Plus, you can re-enroll in this option for a maximum of three years.

Catastrophic Plans

If you’re applying for a Catastrophic plan, you don’t need an exemption to enroll if you’re under 30. For those who are 30 or older and want this type of plan, you must be eligible for a hardship exemption. Access the hardship-exemption form here.

Small Businesses

If you’re running a small business but are struggling to obtain and/or provide group health insurance, you might be relieved to learn the U.S. Department of Labor broadened their criteria via Associated Health Plans. Because of a presidential executive order, small businesses and independent contractors can unite via location or profession to receive coverage as if they were one, large company. This will give smaller entities the same purchasing benefits as bigger companies.

If you want to shop and compare in order to get the best deals, GoHealth provides excellent information on health plans from first-tier carriers in your area.

To get help with Open Enrollment, call GoHealth at (866) 909-0798 and a licensed insurance agent will assist you.

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Open Enrollment 2019: Key Dates to Know [Infographic]

Open Enrollment 2019 is here! Before you shop for health insurance coverage, make note of these key Open Enrollment dates to know so you don’t miss a deadline. Then, when you’re ready to shop for coverage, call GoHealth at 866-931-9240 to get help from our licensed insurance agents.

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The Deadlines for 2019 Open Enrollment by State

It’s that time of year again! The Open Enrollment Period for the 2019 Health Insurance Marketplace is here. The Health Insurance Marketplace is for those who do not have insurance through an employer, Medicaid, Medicare, or the Children’s Health Insurance Program (CHIP).

Open Enrollment is the annual period established under the Affordable Care Act (often referred to as the ACA or Obamacare) in which you can enroll in a new health insurance plan through the Health Insurance Marketplace. Open Enrollment for 2019 runs from Nov. 1, 2018 through Dec. 15, 2018 in most states. Plans sold during the Open Enrollment period will go into effect Jan. 1, 2019.

If you miss the Open Enrollment period for 2019, you will not be able to apply again until the following year, unless you qualify for a Special Enrollment Period (SEP). SEPs are granted to those who have experienced a major life change such as a move, birth of a child, or marriage. If you do not qualify for a SEP, be sure to get enrolled before the Open Enrollment deadline. While Open Enrollment in most states closes Dec. 15, some states have extended deadlines.

The states with extended enrollment deadlines for 2019 are:

California – Enrollment opens Oct. 15, 2018 and runs through Jan. 15, 2019
Colorado – Enrollment opens Nov. 1, 2018 and runs through Jan. 15, 2019
D.C. – Enrollment opens Nov. 1, 2018 and runs through Jan. 31, 2019
Massachusetts – Enrollment opens Nov. 1, 2018 and runs through Jan. 23, 2019
Minnesota – Enrollment opens Nov. 1, 2018 and runs through Jan. 13, 2019
New York – Enrollment opens Nov. 1, 2018 and runs through Jan. 31, 2019
Rhode Island – Enrollment opens Nov. 1, 2018 and runs through Dec. 31, 2018

It’s important to note that in states with extended Open Enrollment periods, coverage may start later than Jan. 1, and even as late as March 1.

You may ask why some states have extended deadlines. When the ACA was first introduced in 2014, the enrollment period lasted a total of six months. Later, for 2015, 2016, and 2017 coverage, the deadline was cut down to three months. Starting this past year the enrollment period was cut down to just one month.

The states listed above with extended deadlines have fought for longer enrollment periods to ensure accessibility and coverage for more people. Several states such as California and Colorado have passed legislation to permanently extend the Open Enrollment periods in their states, while other states have extended the deadlines just for this year (for now).

Now that you know the scoop on Open Enrollment dates in your state, it’s time to find the insurance plan that is right for you. The enrollment and purchasing process can appear daunting, but it doesn’t have to be.

GoHealth allows you to compare thousands of health plans from top carriers in your area, and unlike other exchanges, our expert licensed insurance agents are standing by to guide you through the enrollment process.

To get help with Open Enrollment, call GoHealth at (866) 909-0798 and a licensed insurance agent will assist you.

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Have You Considered Medicare Part B?

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Some things aren’t mandatory, but they’re certainly a good idea. For instance, you don’t have to turn your car off while getting gas, but it might be a little dangerous to leave it running. No one’s going to arrest you if you deviate from a recipe when baking a bundt cake, but then you run the risk of a collapsed treat.

Though some people have the belief that enrolling in Medicare Part B is mandatory when they turn 65, that’s actually not the case. However, delaying enrollment or failing to enroll may result in considerably higher medical bills and even a penalty. The latest numbers show that approximately 52.1 million people in the United States are beneficiaries of Medicare Part B. Let’s look at the advantages of enrolling in Medicare Part B.

Decreased Medical Costs

Defined by Medicare as outpatient coverage, Part B encompasses payment at 80 percent—once the premium is met—for expenses including doctor appointments, laboratory tests, physical therapy, imaging services, medical equipment, mental health services, preventive care, and more.

Although Part A pays for hospital room and board, it doesn’t cover some services that occur within the hospital. By having a Medicare Part B plan, you’re able to save on these out-of-pocket costs. Even if you’re currently in good health, you may need these more advanced healthcare services as you age.

Those with low incomes who are hesitant to do so because of the cost are recommended to enroll in Part B to avoid the penalty for not doing so. They may also qualify for Medicaid, in which case the premium isn’t as high.

Penalty Avoidance

The standard premium this year for enrolling in Medicare Part B is $134 per month, for those who filed a single tax return with $85,000 or less in income or those who filed jointly with $170,000 or less in combined income. If you’re ineligible for the standard premium, the Social Security Administration will notify you. According to the law, those 65 and over who aren’t covered by employer insurance or through a spouse and don’t enroll in Part B or delay doing so for more than a year are assessed a monetary penalty. This penalty is 10 percent of the premium for every year of non-enrollment.

Eligibility for Expanded Coverage

If you’re eligible to enroll in Medicare Part B and fail to do so but want a Medicare Advantage and Medicare Supplement plan, you’re out of luck. Being enrolled in Medicare Part A and Part B is a prerequisite for both registering and applying for these other plans.

As these advantages show, enrolling in Medicare Part B once you turn 65 may be beneficial for you unless you have other health insurance coverage in place.

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The Difference Between Medicare Advantage and Medicare Supplement Plans

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Have you ever gone to the grocery store to buy a product and been confused by how many brands were available for that one item? It makes what should be a simple decision confusing. Likewise, products with similar names can sometimes be hard to differentiate.

If you’re not sure of the differences between Medicare Advantage and Medicare Supplement plans, you’re not alone. The healthcare industry can be confusing with its multitude of complex terms and acronyms.

In fact, it’s fairly common for people to think they need a Medicare Advantage plan and a Medicare Supplement plan. That’s not true, though. You select one or the other. But don’t worry, we’ve broken down each Medicare plan option and explained the differences between the two, so you can make an informed choice. First, a little history.

Former president Harry Truman received the first Medicare card on July 30, 1965, the day it was signed into law by the president at the time, Lyndon Johnson. Medicare coverage took effect in 1966 with a budget of approximately $10 billion and about 19 million enrollees. Medicare Supplement plans were created in the 1980s under a piece of legislation called the Baucus Amendment. They were designed to provide Medicare recipients with coverage for gaps in the Medicare product. Fast forward 50 years later, when there are currently an estimated 57 million Medicare enrollees in the United States, and approximately 16 percent of the population is covered by Medicare.

Medicare Advantage

Medicare Advantage plans are offered by private insurance companies and must cover the same benefits as Medicare Part A and Part B, which are sometimes referred to as “Original Medicare.”

Medicare Part A and Part B are federally-run Medicare coverage programs that cover Medicare basics, like medical and hospital services. It is separated into two different parts: Part A and Part B. You must have both to move forward with additional Medicare coverage options.

The four types of Medicare Advantage plans include Preferred Provider Organizations (PPO), Private Fee-for-Service Plans (PFFS), Medicare Health Maintenance Organizations (HMO) and Medicare Special Needs Plans (SNP).

These types of plans often are comprised of benefits and services not covered by Medicare Part A and Part B, including deductibles and copayments, and may incorporate prescription drug coverage. In that case, they are called Medicare Advantage with Prescription Drug (MAPD) plans. They also may offer benefits and services such as dental, vision, or hearing care.

Some Medicare Advantage plans require enrollees to visit physicians, hospitals, and other healthcare providers that are part of the plan’s network and may necessitate a referral before seeing a specialist. Such plans have an annual out-of-pocket limit. Those eligible for Medicare Advantage plans can enroll in one of the following time periods:

  • During your Initial Enrollment Period when you first become eligible for Medicare.
  • During the Annual Enrollment Period from October 15 to December 7.
  • If you have Part A coverage and you get Part B for the first time during the General Enrollment Period.
  • During a Special Enrollment Period, in certain situations; for example, if you lose your current Medicare plan coverage.

For those who live in rural areas, there is one caveat to note about Medicare Advantage plans. You may have problems finding a plan that works with the healthcare services located in your area.

Medicare Supplement Plans

Sometimes called Medigap plans, Medicare Supplement plans also are offered by private health insurance companies. Medicare Supplement plans can provide you with additional Medicare coverage to fill in gaps from Medicare Part A and Part B. These supplemental plans help cover out-of-pocket expenses, including copays, coinsurance, and deductibles. Regulated by both state governments and the federal government, Medicare Supplement plans pay a portion of the bill not paid by Medicare.

The Open Enrollment Period for Medicare Supplement plans is generally the six months that starts on the first day of the month in which you are at least 65 years old and enrolled in Medicare Part B. The premiums for this type of plan differ based on the plan and company from which it is purchased. Those with chronic conditions often choose a Medicare Supplement Plan, even though it may be twice the cost of its Medicare Advantage counterpart.

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Medicare in 2019: Changes You Should Know

medicare in 2019

Whether it’s your first time enrolling in Medicare or you’re already familiar with the program, all enrollees need to learn about its impending changes coming in 2019. The 53-year-old program—signed into law in 1965 under the Social Security Administration—will undergo a massive transformation affecting its 60 million members.

Although enrollees may feel concerned by the word “changes,” they should find relief in knowing these changes are for their own benefit. Those looking to enroll in Medicare to take advantage of these improvements may do so during Medicare Annual Enrollment, which takes place from Oct. 15, 2018 through Dec. 7, 2018.

From revamped digital resources to increased flexibility and benefits, here’s what you need to know about the improvements coming to Medicare in 2019:

Expanded Benefits for Medicare in 2019

According to Medicare Rights Center, Medicare Advantage plans will be able to expand their coverage to include supplemental health benefits previously not covered by Medicare. These expansions include benefits for social determinants of health, such as nutritional care.

AARP notes that some Medicare Advantage plans will now offer the option to cover home-delivered meals, transportation to doctor appointments, in-home safety features (such as handles or ramps) and provide the option to pay for in-home help (such as health aides for eating and dressing).

Increased Telemedicine

According to AARP, Medicare is broadening telehealth availability. Enrollees undergoing treatments for end-stage renal disease or strokes will now be able to confer with a nurse or doctor via the internet or telephone.

Say Goodbye to a Therapy Cap

Also according to AARP, those who benefit from Original Medicare will no longer have to pay full price for outpatient physical therapy, speech therapy, or occupational therapy. Although this was the case in the past, Congress has officially repealed the therapy cap so that enrollees can have more access to these health services.

Closing the Donut Hole

Are you familiar with the term? “Donut hole” refers to the coverage gap created when enrollees with high prescription costs are required to pay more for their medicine after a certain price threshold is met.

The Affordable Care Act (ACA) was originally supposed to close the donut hole in 2020; however, Congress recently decided to accelerate this process to 2019. Note that this change will only apply to brand-name drugs, at least for the time being. Generic drugs will see the same change, but not until the original deadline of 2020.

New Medicare Cards

Newer and safer Medicare cards are officially being issued. Due to the fraudulent risks associated with the previous cards, Congress authorized a change back in 2015. Rather than using your Social Security number as your ID number, these new cards utilize an 11-character Medicare identifier unique to the service.

Although these new cards intend to reduce the chances of identity theft, enrollees must continue exerting caution. As reported by The New York Times, criminals constantly find new ways to scam people, such as calling to ask for a fee (even though the card is free) or requesting personal information for mailing a new card (even though this process is done automatically). Medicare will never call you uninvited for such requests. If you receive a suspicious call, report it by calling 1-800-MEDICARE (1-800-633-4227).

These changes are just a few of the improvements coming to Medicare in 2019. Stay up-to-date with everything you need to know with GoMedicare.

Still have questions about Medicare coverage and how it affects you? Visit our website for more information. 


This information is for educational purposes only. Medicare has neither reviewed nor endorsed this information.

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