Medicare Advantage (MA) plans, developed by private companies, take over management of all medical treatment/service from MediCare and provide individuals:
● All the medical procedures & services covered by Part A & Part B
● All treatment/services through the plan's network of providers.
● Additional benefits such as a full annual physical plus dental, vision, hearing, and fitness programs. Some benefits are included and others can be added for at an additional cost.
● Prescription coverage, which is included in most MA plans, and then the MA plan is called a MAPD.
Note: (MA) plans are MediCare's Part C.
MA companies have a yearly contract with CMS, and focus on improving members treatment outcomes. This is accomplished by monitoring and coordinating all their medical services and prescriptions.
A new effort for many MAPDs is on Social Determinates of Health. (SDoH). These are the things in a person's life and surroundings which cause them to not get recommended treatment. Such as not going to follow up visits after surgery.
For example: MAPD companies found people's health declined when they didn't go to appointments. To correct this some plans added, as a no cost benefit, transportation to needed medical visits. Paying for transportation is cheaper than paying for additional expensive treatment. Thus, considering SDoH factors results in better health.
● The outcome following treatment is often better and quality of care is usually higher!
Why? When all the medical treatment a person received and their medications are monitored and coordinated the results are better!
● A study by the Better Medicare Alliance 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 full annual physical and have extra benefits, such as dental.
Note: Basic Medicare only provides an annual wellness check.
-> the monthly cost is usually significantly lower than a MediGap plan with a stand alone Part D plan. This is a Big Plus for many.
● Continue to pay your monthly Part B cost.
● Pay the MA companies monthly cost, if any. For example, plans with lower co-pays and treatment cost sharing and a lower Maximum Out of Pocket will have a monthly cost.
● When treatment or a service is needed use the MDs and other providers in the companies network.
● Show the provider you selected your MA plan's ID card not your MediCare card. They bill your MA company for your treatment not the MediCare system.
When going to a network MD for medical treatment:
● Visits for a preventive exam or test have no cost.
● Visits to a MD about a condition/situation have a co-pay.
● Seeing a Specialist will have a higher co-pay than for your primary care MD.
● Reveiving medical treatment such as a diagnostic test will usually have cost sharing such as 2t0% or a specific fee.
● Admitted to a hospital for a complex situation, there is a per-day fee which usually is for the first four or five days.
If a complex condition were to develop your ongoing medical related costs are limited during the year by the plan's Maximum Out of Pocket (MOP) provision.
Note: MediCare sets the medical MOP limit for each year. (up to $8,300 in 2023) Plans with no monthly cost plans often use the maximum MOP.
When going to the Pharmacy for medication:
● Medication costs are not included in a MAPD plan's medical cost MOP.
When the Prescription Drug Plan program was created all companies were to provide coverage based on four stages:
● First — the Deductible. Many plans only apply it on medications in higher Tiers.
● The second stage — Initial Coverage where you pay co-pays or cost sharing.
● The thrid stage — Coverage Gap [ was called donut hole] Coverage has been improved and now you pay 25% cost sharing for Brands and Genercs
● The fourth part — the catastrophic stage when you usually pay 5%. Currently, there is not a MOP for medication related costs.
Note: The co-pays and cost sharing used will vary based on the Tier level the PDP company place the medication in. Beginning in 2024 improvements will be made.
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 simplify how Medicare Advantage Plans in New London County Connecticut work.
● Select, if an enrollment period is available, the best MAPD for your situation and to provide peace of mind.
Note: In thinking about selecting a MAPD be alert for deceptive TV ads:
- > some say, which is not so, anyone on Medicare can get certain benefits.
Note: Only individuals whose income qualified them for MedicAid can sign up anytime during the year.
- > many benefits mentioned are not for everyone but only available to individuals who have MedicAid in addition to MediCare (dual eligible).
- > one retirement-focused ad mentions their MediGap plan (a Medicare Supplement) however it is not approved in CT!
Medicare regulations now require any call discussing enrollling in a Medicare Advantage or Prescription Drug Plan to be recorded. This does not apply for face-to-face meetings — we can talk on the phone about your situation then meet to review plan options. If interested in a plan and decide to sign up we can meet again.
- > Most enrollment forms can also be completed online but responding to confusing questions is easier when meeting in person.
● Companies develop benefits for a specific MAPD plan then submit it to MediCare for approval. The request also indicates the States and Counties where they want to offer the 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 your County.
MediCare pays the MA company a fixed monthly payment 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 MA plan! — People usually select a MAPD, which is a MA plan with prescriptions.
Note: The ICEP is at the same time as the IEP to sign up for MediCare.
During the ICEP a person can apply in month 3, 2, or 1 before eligible for MediCare, 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, Jan 1st to March 31st. It was developed so an individual in a 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 Medicare Supplement, and a stand alone Prescription Drug Plan.
● A person who signed up for MediCare when first eligible and enrolled in a MA or MAPD can also use the MA OEP to make a change during the first three months on the plan.
Priority Three — Special Election Period (SEP)
● The SEP is a time an individual, who has certain life events, can change their MAPD. Situations such as when:
-> moving to a different state.
-> learning, based on income level, they qualify for Extra Help with prescription costs.
In addition there are various situational SEPs. One for example is for to a person who was enrolled in a Medicare Supplement, then changed to a MA/MAPD,and then during the first 12 months became dissatisfied. 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 for individuals to 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 select 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 flexibility to meet their medical situation! They can make changes:
-> when entering,
-> while in,
-> when leaving.
Why do <—> election periods <—> have a priority?
If a persons situation results in being eligible for two election periods at the same time the rules for when their plan is effective date are based on the period with the highest priority.
An example: A person who moves would qualify for a SEP but if the move happens during their seven month ICEP their plans effective date would be based enrollment rules for the ICEP, which is Priority One.
Content on MedicarePlansSECT.com is © 2018 to 2023 by John C Parker, RHU, LTCP - All Rights Reserved.
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