Medicare Advantage (MA) plans are developed by private insurance companies and have a yearly contract with CMS to take over from MediCare and provide:
● All the treatment and procedures covered by Part A & Part B
● Treatment and services through the plan's network of providers.
● A full annual physical plus additional benefits such as dental, vision, hearing, and fitness programs. Some 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.
MA plan's focus on improving members treatment outcomes by monitoring and coordinating all their medical services and prescriptions.
A new focus for 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 or not follow recommendations after surgery.
For example: MAPD companies found many people's health was declining because they didn't make their appointments. To correct this some plans added no cost transportation to needed medical visits as a benefit. Playing for transportation is cheaper than having to pay additional expensive treatment. Thus, considering SDoH factors results in better health.
● The quality of care is usually higher and the outcome following treatment is often better!
Why is that? When all medical treatment and medications is coordinated the results are better!
● Then too, a recent 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 like MAPDs because:
-> they receive a full annual physical, not just Medicare's annual wellness check, and the extra benefits.
-> the monthly cost is usually 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. Plus MA companies (usually) have a monthly cost based on the benefits in the selected plan. For example, plans with lower co-pays and treatment cost sharing and a lower Maximum Out of Pocket have a higher monthly cost.
● When any treatment is needed select MDs or other providers in the companies network. Show them 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 other medical treatment:
● Some services have cost sharing or a specific fee.
● When in a hospital you pay a per day fee for the first four or five days.
All your co-pays and other medical treatment costs are limited each calendar year by the plan's Maximum Out of Pocket (MOP) provision.
Note: MediCare sets a limit for the medical MOP. (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 the 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 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 will 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:
● Talk about whether you will soon be 65 and plan to sign up or will soon be leaving an employer plan, and:
-> your interests
● 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 which will 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. Only individuals with MedicAid & MediCare can sign up during the year
-> many benefits mentioned are not for everyone but only available to individuals who are dual eligible.
-> one is for a MediGap plan (a Medicare Supplement) not approved in CT!
● Face to face meetings are safe again — we can talk on the phone about your situation then meet first to review options and again if you decide to sign up. Then too, most enrollment forms can also be completed on line.
● Companies develop benefits for a specific MAPD plan.
● The planned benefits are then submitted to MediCare for approval. The proposal 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 period of seven months when turning 65 to apply for a MA plan! — People usually select a MAPD, which is a MA with prescriptions. The ICEP it's 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. They can:
-> Select a new MA or MAPD either with their current or another company.
-> Return to original Medicare, select a Medicare Supplement, and a stand alone Prescription Drug Plan.
● In addition, a person who signed up for MediCare when 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.
A SEP is also available to a person in a Medicare Supplement who changed to a MA/MAPD but 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 such as to 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.