Medicare Advantage (MA) plans, developed by private insurance companies, have a yearly contract with CMS to take over management of all treatment/service from MediCare and provide:
● All the procedures covered by Part A & Part B
● A person's 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 is included in most MA plans and are then called a MAPD.
Note: (MA) plans are MediCare's Part C.
The focus of a MA plan is to improve members treatment outcomes by monitoring and coordinating all their medical services and prescriptions.
A new effort for many MAPDs is on Social Determinates of Health. (SDoH). The things in a person's life and surroundings which cause them to not get recommended treatment such as after surgery.
For example: MAPD companies found people's health declined because they didn't go to their appointments. To correct this some plans added, as a benefit, no cost transportation to needed medical visits. Paying for transportation is cheaper than paying for additional expensive treatment. Thus, considering SDoH factors results in better health.
● Quality of care is usually higher and the outcome following treatment is often better!
Why is that? When all medical treatment and medications are coordinated the results are better!
● In addition, 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 like them because:
-> they receive a full annual physical, not just Medicare's annual wellness check, and the extra benefits.
-> 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 their monthly Part B cost.
● Pay any MA company monthly cost. For example, plans with lower co-pays and treatment cost sharing and a lower Maximum Out of Pocket will have a higher monthly cost.
● Select MDs or other providers in the companies network when treatment is needed. Show providers the 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:
● Office visits such as a PCP have a co-pay. Preventive visits have no cost.
● Seeing a Specialist means a higher co-pay than a primary care MD.
When going for more specialized medical treatment:
● Some services have cost sharing or a specific fee.
● Hospitals have a per day fee for the first four or five days.
All your co-pays and other medical treatment costs during each calendar year are limited by the plan's Maximum Out of Pocket (MOP) provision.
Note: MediCare sets the medical MOP limit for each year. (up to $7,550 in 2022) Plans with no monthly cost plans often use the maximum MOP.
When going to the Pharmacy for a medication:
● Medication costs are not included in a MAPD plan's medical cost MOP. They have their own MOP just like a stand alone Prescription Drug Plan.
● Benefits in the prescription part of your plan vary based on four stages:
-> First is the Deductible. Many plans only apply it on medications in higher Tiers.
-> The next stages are the — Initial Coverage where you pay co-pays or cost sharing — Coverage gap [was called donut hole] where you pay cost sharing — Catastrophic .
-> The co-pays and cost sharing used vary based on the Tier level the Plan placed a medication in.
John C Parker's Google Voice # — (860) 451-9793 today.
In talking we can:
● Review your situation and interests:
- > Will you soon be 65 and want to sign up?
- > Are you planning to leave an employer plan!?
● Simplify how the Medicare Advantage Plans in New London County Connecticut work.
● Select, if an enrollment period is available, the best MAPD for your situation so it provides 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 who also have MedicAid can sign up anytime during the year.
- > many benefits mentioned are not for everyone but only available to individuals who are dual eligible.
- > one ad is for a MediGap plan (a Medicare Supplement) not approved in CT!
● Medicare regulations now require any call discussing Medicare benefits to be recorded but face-to-face meetings are safe again — 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 on line but the questions are less confusing when meeting in person.
● Companies develop benefits for a specific MAPD plan.
● The planned benefits are then submitted to MediCare for approval and also indicate 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. The ICEP is at the same time as the IEP to sign up for MediCare.
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.
The MAPD works this way. 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.
There are also various situational SEPs. One for example is for to a person who was enrolled in a Medicare Supplement, the changed to a MA/MAPD,and then 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 to make a change to their MA or PDP.
● It happens each fall, currently from October 15th to December 7th.
● New coverage using 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 resulted in being eligible for two election periods at the same time the effective date rules for the period with the highest priority would be followed.
An example: A person who moves could have a SEP but if the move happens during their seven month [ICEP] their effective date will be based on the ICEP' enrollment rules, which is Priority One.