Medicare Advantage (MA) plans take over the management of an individual's medical treatments/services and pay providers from the original Medicare "system."
MA plans are developed by private companies to provide Medicare beneficiaries with:
● All medical procedures & services covered by Part A & Part B.
● All treatment/services through the plan's network of providers.
● Additional coverage not available in original Medicare, such as a complete annual physical.
● Some plans include additional coverage called Supplemental benefits; in others, they can be added at an additional cost.
● Prescription coverage is included in most MA plans. The plan is then called a MAPD.
Note: (MA) plans are MediCare's Part C, and the company has a yearly contract with CMS.
The focus or mission of MA companies is to improve members' treatment outcomes by monitoring and coordinating all their medical services and prescriptions.
Note: Recent studies have shown "enrollees are much healthier than enrollees who stick with 'Original Medicare,' with or without Medicare supplement insurance."
Social Determinates of Health (SDoH) is a new effort for many MAPDs to improve member outcomes. SDoH involves the plan monitoring events and happenings in a person's life and surroundings.
For example, health will decline by not going to follow-up appointments after being hospitalized. To correct this, some MA plans provide transportation to needed medical visits as a no-cost benefit. Paying for a vehicle is cheaper than paying for additional expensive treatment. Thus, considering SDoH factors results in better health.
● The outcome after receiving treatment is often better — plus the quality of the care received is usually higher!
Why? All the treatment an individual receives is coordinated and monitored, which means better results. Monitoring medications adds to this!
● A Better Medicare Alliance study found — "individuals in private MA plans had:
- > one-third fewer ER visits
- > 23% fewer stays in a hospital than those in traditional fee-for-service MediCare."
● People enrolled in MAPDs report they like their plan because:
-> They can receive a complete annual physical (not in basic Medicare) and other supplemental benefits.
-> "75% of regular Medicare Advantage members used at least one supplemental benefit a year, and 48% used at least two supplemental benefits."
-> The monthly cost is usually significantly lower than a MediGap plan with a stand-alone Part D plan. Lower cost is a Big Plus for many.
● Continue to pay your monthly Part B cost.
● Pay the MA companies monthly cost, if any.
● Use the MDs and other providers in the companies network when treatment or a service is needed.
● Show any of the providers you use your MA plan's ID card not your MediCare card. They bill your MA company for your treatment not the MediCare system.
● Have a Maximum Out of Pocket for medical expense and plans with a monthly cost will have lower co-pays and treatment cost sharing.
● Have an additional Maximum Out of Pocket for prescriptions expenses.
When going to an MD for medical treatment:
● Visits for a preventive exam or test have no cost.
● Visits to an MD about a condition/situation will have a co-pay.
● The co-pays to see a Specialist will be higher than your primary care MD.
When receiving more complex medical treatment such as:
● A diagnostic test. There will usually be cost-sharing, such as 20% or a specific fee.
● Being in a hospital in an admitted status for a complex situation. Plans have a per-day fee. Which usually applies to the first four or five days.
If a complex condition develops with ongoing treatments/services, the plan's Maximum out-of-pocket (MOP) provision will limit your ongoing medical-related costs during the year.
Note: MediCare limits the medical MOP each year. (up to $8,300 in 2023) Plans with no monthly cost often have an MOP close to the maximum.
When going to the Pharmacy for medication:
● Costs for medications are not included in the MAPD plan's medical cost MOP. There is a separate MOP.
When the Prescription Drug Plan (PDP) program was created in 2004, all companies were to develop plans with four coverage stages :
● First — the Deductible. Many plans only apply it to medications in higher Tiers.
● The second stage — Initial Coverage, where you pay co-pays or cost sharing.
● The third stage — Coverage Gap [was initially called the donut hole] Over recent years, it has been improved, and now you pay 25% cost sharing for Brands and Generics
● Fourth — the Catastrophic stage. In 2023, an individual usually pays 5%, and there is no MOP for medication-related costs. Beginning in 2024, improvements will be made to eliminate this 5% cost-sharing.
Note: The co-pays and cost-sharing the PDP company uses will vary based on the Tier level in which they placed the medication.
John C Parker's Google Voice # — (860) 451-9793 today if you:
+ Will soon be 65
+ Are planning to leave an employer plan and want to sign up.
We can meet and:
● Review your situation and interests:
● Take time to help you better understand MediCare and simplify how Medicare Advantage Plans work in New London County, Connecticut.
● Select, when an enrollment period is available, a MAPD that fits your situation and will provide peace of mind.
In thinking about and considering a MAPD, be alert for deceptive TV ads:
- > Some say, which is not so, that anyone on Medicare can get certain benefits.
Note: Only individuals whose income qualified them for MedicAid, in addition to MediCare, and thus are dual eligible:
- > can sign up anytime during the year.
- > can qualify for many of the benefits mentioned
In addition, one retirement-focused ad mentions their MediGap plan (a Medicare Supplement); however, it is not approved in CT!
Working with a professional Medicare Health Plan Professional
MediCare federal regulations now require any phone discussion about enrolling in a Medicare Advantage or Prescription Drug Plan to be recorded.
However, when meeting face-to-face, which is more effective, a recording is not required:
- > we can talk on the phone about your situation
- > then meet to review plan benefits and options
- > if you are interested in a plan, we can meet again to sign up.
BTW - Most enrollment forms can be completed online, but understanding - what a question on the application means is more straightforward when meeting in person.
Individuals gain a lot from meeting with a Medicare Insurance professional to enroll.
● Companies develop benefits for an MAPD plan and submit the specifics to the MediCare system for approval. The request also states the Counties where the company wants to offer this plan.
● When approved, the company signs a one-year contract.
● Marketing the plan to individuals can begin Oct. 1st for a Jan 1st effective date.
● Individuals can enroll from Oct 15th to Dec 7th in a plan approved for the County where they reside.
MediCare pays the MA company a fixed monthly payment to manage treatment, pay providers, etc., for each person who signs up for their MAPD.
Priority One — Initial Coverage Election Period (ICEP)
● The ICEP is a one-time, seven-month period at age 65 to apply for a Medicare Advantage plan! — People usually select a MAPD, an MA plan with prescriptions.
Note: The ICEP is at the same time as the IEP to sign up for MediCare's Parts A & B for the first time.
Using the ICEP, a person can apply in either month 3, 2, or 1 before eligible, during their eligible month, and in month 1, 2, or 3 after 65.
Priority Two — Medicare Advantage Open Enrollment Period (MA OEP)
● The MA OEP is a special once-a-year time from Jan 1st to March 31st. It was developed so an individual in an MA or MAPD who is dissatisfied with some part of their plan can make a change.
How the MA OEP works. An individual can:
-> Select a new MA or MAPD with their current or another company.
-> Return to original Medicare, select a stand-alone Prescription Drug Plan (PDP), and a Medicare Supplement plan.
● A person who signed up for MediCare when first eligible and enrolled in a MA or MAPD can also make a change during the first three months enrolled in the plan using the MA OEP.
Priority Three — Special Election Period (SEP)
● The SEP is a time for individuals who have certain life events such as:
-> moving to a different state.
-> learning they qualify for Extra Help with prescription costs.
When they can change their MAPD.
In addition, there are various situational SEPs. One example is a person enrolled in a Medicare Supplement who changed to an MA/MAPD and became dissatisfied during the first 12 months. They can then:
-> Return to Medicare, apply for a Medicare Supp and a PDP.
Priority Four — Annual Election Period (AEP)
● The AEP is the most common time when individuals can change their MA or PDP.
● It happens each fall, currently from October 15th to December 7th.
● New coverage selected during the AEP is effective January 1st.
Individuals can make changes during the AEP, such as selecting a:
● different plan from their current Medicare Advantage company.
● plan with a different Medicare Advantage company;
Priority Five — Open Enrollment Period for Institutionalized (OEPI)
● The OEPI is for individuals in a long-term care facility
● Gives them the flexibility to meet their medical situation! They can make changes:
-> when entering,
-> while in,
-> within the first two months after leaving.
If a person's life situation results in being eligible for two election periods, the rules say the plan they selected will be effective based on the highest priority election period.
For example, A person who is moving would qualify for a SEP, but if the move happens during their seven-month ICEP, the effective date for the coverage they select will be based on the ICEP enrollment rules, which is Priority One.
● He is appointed and certified by the eight Medicare Advantage (MA) companies offering plans during 2024 in New London County, the only area where he helps individuals. They have 31 regular MA plans, not special needs plans, for John to offer beneficiaries.
● He is also appointed and certified by six of the eight Prescription Drug Plan (PDP) companies with plans available in New London County and CT.
Note: The other two PDP companies do not make their plans available to Medicare beneficiaries through MediCare insurance professionals.
However, using Medicare.gov, John can share insights with clients about plans from these two companies. He can not, however, process an enrollment for plans from these two PDP companies!
● They can also find help with plan choices in New London County by contacting:
+ Medicare.gov and
+ CT's State Health Insurance Program (SHIP).
< - - > However, this help will not be from a licensed or certified professional.
Note: CMS regulations state information created about Medicare Plans, such as the content on this website that does not mention a company name, plan benefit details, or plan costs, is considered Communication material, not marketing material.