Term Insurance Agency-Calif. Insurance License #0563687
Phone: 877-itsterm (877-487-8376)
"Insurance Designed To Last A Lifetime"
MEDICARE ADVANTAGE
Medicare Advantage (MA) plans, sometimes called Part C, do not replace Medicare, but pay instead of Medicare. Enrolling in a MA or MAPD (Medicare Advantage with Part D included) is very much like assigning your Medicare benefits to an insurance company.
HOW THEY WORK
An insurance company contracts with the Centers for Medicare and Medicaid Services (CMS) to administer Parts A, B, and Part D Rx coverage of Medicare in specific geographical service areas. An Advantage plan may deliver services as an HMO (Health Maintenance Organization model), PPO (Preferred Provider Organization), Private Fee for Service (PFFS), Special Needs Plan, or MSA (Medical Saving Account). The plans I represent are HMO, or HMO/PPO with Part D included (MAPD or MAPD/PPO). Although MA HMO plans without Part D are available, it is best to include Part D with your Medicare Advantage plan (MAPD). MAPD plans with a PPO option are offered only in certain zip codes at additional premiums. MAPD monthly premiums range from -0- to over $100- depending on the service area zip code and if a PPO option is available and selected. The Part D Rx part included in a MAPD plan is a fixed benefit with usually only one formulary (list of covered drugs) available.
CHOICES
If a Medicare Advantage plan with Part D Rx included is at -0- premium, why enroll in a Medicare supplement Medigap alphabet plan (A, G, N, etc.)?
1. To protect your insurability. On the hierarchy of plans, Plan G would rank higher in benefits compared to Plan A, and all would be considered richer than a Medicare Advantage HMO plan. But it is not an accurate comparison, because if you drop an MA (Medicare Advantage) plan, you return to Original Medicare. With a Medicare supplement Medigap policy, you never leave original Medicare. You must prove your insurability if you want to apply for a Medigap alphabet plan, unless you have a special enrollment period (SEP). For instance, an insurance company leaves Medicare, drops the plan, or you move out of the plan’s service area, or when you are in your Initial Enrollment Period (IEP).
2. Drug Formulary. With a Medigap alphabet plan, your prescription drug Part D coverage will be in a separate stand-alone policy. You have the option to select the Part D plan which meets your medication needs within your budget. Medicare Advantage plans with Part D included contain a formulary which may or may not meet your needs.
3. Government regulations. MAPD plan’s benefits and premiums increase because the MA is paying instead of Medicare. You can return to Original Medicare (Parts A and B), but you lose your Medicare Advantage benefits as a form or supplemental coverage. With a Medigap plan, you can move to another alphabet plan of equal or lesser value in order to reduce premiums, if necessary. Or, enroll in a Medicare Advantage plan during the Annual Enrollment Period (AEP). In other words, you have options.
4. Most MA plans are HMOs. Beginning in 2013, Medical Loss Ratio (MLR) rules and frozen benefit levels were imposed to control health care costs. Political and economic forces will pressure the government to constrain future benefit/cost ratios because Congress controls Medicare Advantage plans administered by insurance companies. Medigap plans are regulated by the states and supplement parts A and B of Medicare. So, as Social Security Medicare benefits change, a Medigap plan will adjust to meet the gaps in coverage.
5. Echelon tier health care. As more people enroll in Medicare and the uninsured population meet the mandate to get health insurance in 2014, the health care delivery system, (doctors, hospitals, labs, clinics, etc.), will be confronted with greater demand for their services without a commensurate increase in providers. Medigap policyholders will rank higher in the echelon of benefit tiers, because their plans pay providers more for their services-especially Plan F members. Already, some doctors are demanding concierge service fees as a source for additional income to their practice. Medicare Advantage plans are HMOs, and do not have the same financial leverage to pay healthcare providers if the government reduces the monthly fees paid to insurance companies for plan administration.
SO, WHY ENROLL IN A MEDICARE ADVANTAGE PLAN?
1. -0- dollar premium, or at least lower premiums. A Medigap plan G monthly premium could be $150- or more at age 65, and will increase with age. Part D Rx monthly premiums range from about $15- to over $100-, depending on formulary and coverage selected (see Part D discussion). As you age, Medigap premiums and Part D Rx premiums will increase. Medicare Advantage plans with Part D included (MAPD) premiums start at -0- and go up to the over $100- range depending on your zip code and if the PPO option is selected.
2. If your doctors, specialists, and hospitals, are listed as providers, and your medications are covered in the formulary on the MAPD or MAPD/PPO plan, Medicare Advantage total premium costs are going to be much less compared to the costs for a Medigap policy combined with the costs for a Part D Rx plan. The MAPD premium could be from -0- to the $100+ range. You would continue to pay the Part B premium with a Medigap or Medicare Advantage plan.
3. You have a voice. While it is true political and economic forces will coalesce to control Medicare Advantage plan costs, the same forces will apply to all of Medicare and U.S. healthcare inflation. You have a voice and a vote in the political system which regulates CMS (Centers for Medicare and Medicaid Services) making healthcare funding decisions. You have more power over a Medicare Advantage plan’s administration and services because it pays instead of Medicare. A Medigap plan can only respond to what Medicare pays because it is a private supplemental contract regulated by the states.
Medicare Advantage Shopping Tips
All insurance companies must follow the rules and regulations of the Medicare program and CMS. Medigap plans are based on Medicare Parts A, B and Part D Rx benefits, if Part D is included in their Medicare Advantage plan, making it a MAPD. MAPD plans are a type of Medigap policy in which Medicare pays first. That is, Medicare must approve a claim before the insurance company or plan administrator pays.
So, what are the differences between MAPD plans and what factors should be compared to find the best plan to meet your needs?
Consider the following: HMO or PPO, monthly premium, provider network, drug formulary, maximum out-of-pocket limit, co-pays for primary care and specialist providers, hospital, labs, clinics and imaging center locations, star rating, insurance company financial rating, your previous medical insurance carrier experience, dental, vision and hearing benefits, ancillary add-on benefits such as; OTC (over the counter) medicine and devices cost reimbursement, medical emergency alert device, telehealth coverage, fitness gym membership, transportation costs, meal delivery, acupuncture, and chiropractic services, for instance.
SNP, PFFS, COST and PACE programs are additional Medicare Advantage plan options.
Remember, the Annual Enrollment Period to enroll in or change MAPD and Part D Rx plans begins October 15, 2024 for a January 01, effective date.
Use the following links to get more information:
Medicare plan comparison tool:
https://www.medicare.gov/plan-
https://aging.ca.gov/Programs_
https://www.dmhc.ca.gov/
https://seniors.insurance.ca.
Copyright All Rights Reserved Robert M. Coleman 2024
Medicare Supplement Plan Shopping Tips
Even though you may not be eligible for Medicare yet, the information presented may be helpful for you to share with your parents, grandparents, etc.
Remember: Medicare Advantage, also known as Part C of Medicare, and MAPD (Medicare Advantage with Part D Rx coverage) plans are a type of Medigap insurance to cover some of the Medicare coinsurance, copays, and deductibles along with medications. MAPD plans use HMO networks of providers, have maximum out-of-pocket limits and offer extra benefits like dental, vision and free gym membership. Prior authorizations and referrals may be required. Some insurance companies offer a PPO provider network option. Monthly premiums are often lower than traditional Medicare Supplement alphabet plans. In California, Many MAPD plans have -0- dollar premiums.
Consider the following comparison factors: Benefits, deductibles, coinsurance amounts, exclusions, Part B excess charges, SNF care amount and foreign travel.
Summary:
How much can your budget afford? Generally, in California, MAPD plans will have lower monthly premiums than Medicare Supplement alphabet plans.
With some exceptions, underwriting would be required to switch from a MAPD plan to a traditional Medicare Supplement alphabet plan.
Medicare Supplement alphabet plans allow the choice to see any doctor that accepts Medicare anywhere in the U.S. No prior authorizations or referrals required.
If there is a possibility you may move outside your MAPD plan’s service area, it could be difficult to find HMO providers in your new location. Especially, if you move out of state.
Generally, in California, urban areas offer a good choice of HMO provider networks compared to rural areas. Population density and healthcare provider selection is an important factor in choosing a Medigap plan.
MAPD plans have a single formulary list of covered prescription drugs. Stand alone Part D Rx plans which accompany Medicare Supplement alphabet plans offer a variety of formularies, underwriting is not required and the PDP (Part D Rx Plan) can be with a different company than your Medicare Supplement alphabet plan.
In California, the “birthday rule” can be used to switch to another Medicare Supplement alphabet plan of equal or lesser value at your birthday. The AEP (Annual Enrollment Period October 15th-December 7th) allows the switch to another MAPD or Part D Rx plan. The switch to a MAPD plan from a Medicare Supplement alphabet plan can be made without underwriting during the AEP. With a few exceptions, underwriting would be required to switch from a MAPD plan to a Medicare Supplement alphabet plan during the AEP.
Compare star ratings assigned to plans by CMS (Center for Medicare and Medicaid Services).
Conclusion
A Medicare beneficiary has many choices in the selection of a Medigap insurance plan to help fill the gaps in basic Medicare coverage. Age, location, health status, income budget, lifestyle, retirement benefits and medical provider selection availability are important factors to consider in reaching a decision.
Visit www.medicare.gov and www.terminsuranceagency.com for more information. Contact me for additional assistance.
I represent Aetna, Anthem Blue Cross, Blue Shield of California, Humana and United Healthcare Medicare Advantage plans, along with Silverscript (CVS/Caremark) and AARP United Healthcare Part D Rx plans.
Click here to get help in selecting a Medicare Advantage, Medigap, or Part D Rx plan to help meet your financial healthcare security needs.
Rates quoted are estimates. Premiums and effective dates are determined by the insurance company and the Centers for Medicare and Medicaid Services (CMS).
Remember to include dental as an additional feature provided by the insurance company of your choice. Or, click here for a dental quote.
We and the licensed agents that may call you are not connected with or endorsed by the U.S. Government or the federal Medicare program. Medicare has neither reviewed nor endorsed the information contained on this website. This is not a complete listing of plans available in your service area."We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area which are plans offered by six companies. Please contact Medicare.gov, 1–800–MEDICARE, or your local State Health Insurance Program to get information on all of your options.” For a complete listing please contact 1-800-MEDICARE or consult www.medicare.gov (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov
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