Medicare Advantage (MA) plans take over, from the original Medicare "system", the management of an individual's medical treatment/service and paying providers. MA plans are developed by private companies to provide individuals with:
● All medical procedures & services covered by Part A & Part B.
● All their treatment/services through the plan's network of providers.
● Benefits not available in original Medicare called Supplemental benefits. Services such as a complete annual physical. Some plans have certain benefits included and in others they can be added at an additional cost.
● Prescription coverage in most MA plans, and then the plan is called a MAPD.
Note: (MA) plans are MediCare's Part C and have a yearly contract with CMS.
The focus or mission of the 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 typical enrollees who stick with 'Original Medicare,' with or without Medicare supplement insurance."
A new effort for many MAPDs to improve outcomes is on Social Determinates of Health. (SDoH). They monitor things in a person's life and surroundings, which causes them not to 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 follow-up appointments after being in a hospital. To correct this, some MA plans added, as a no-cost benefit, transportation to needed medical visits. Paying for a vehicle is cheaper than paying for additional expensive treatment. Thus, considering SDoH factors results in better health.
● The outcome after a treatment is often better and the quality of care is usually higher!
Why? Coordinating and monitoring all the treatment a person receives means results are better. Monitoring medications adds to this!
● 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 (not available in basic Medicare) and other supplemental benefits.
-> A study found "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. For example, plans with lower co-pays and treatment cost sharing and a lower Maximum Out of Pocket usually have a monthly cost.
● 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.
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 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 only apply to the first four or five days.
If a complex condition develops with many treatments/services, the plan's Maximum Out of Pocket (MOP) provision will limit your ongoing medical-related costs during the year.
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:
● The costs for medications are not included in an MAPD plan's medical cost MOP.
When the Prescription Drug Plan (PDP) program was created, all companies were to create plans with coverage based on four 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 they placed the medication in.
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 understand MediCare better and simplify how Medicare Advantage Plans work in New London County, Connecticut.
● Select, when an enrollment period is available, a MAPD which fits your situation and will provide peace of mind.
In thinking about and considering an 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, in addition to MediCare, and thus are dual eligible:
- > can sign up anytime during the year.
- > can qualify for many of 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
Everyone on MediCare needs to understand federal regulations now require any discussion, over the phone, about enrolling in a Medicare Advantage or Prescription Drug Plan has to be recorded.
However, when meeting face-to-face, a recording is not required:
- > we can talk on the phone about your situation
- > 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 getting answers to the - what does this question on the application mean is easier when meeting in person.
Individuals gain a lot from meeting with a Medicare Insurance professional to enroll.
● Companies develop benefits for a specific MAPD plan then submit the plan coverage to the MediCare systwn 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 to manage the treatment and administration 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, which is a MA plan with prescriptions.
Note: The ICEP is at the same time as the IEP to sign up for MediCare's Part A & B.
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 from 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 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 use the MA OEP to make a change during the first three months they are enrolled in the plan.
Priority Three — Special Election Period (SEP)
● The SEP is a time for individuals, who hav certain life events, to 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 also situational SEPs. One for example is for to a person who was enrolled in a Medicare Supplement, then changed to a MA/MAPD and 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 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 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,
-> 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 election period with the highest priority.
Here is an example: A person who is moving qualifies for a SEP but if the time of the move happens when they are in their seven month ICEP the effective date when they sign up will be based enrollment rules for the ICEP, which is Priority One.
● He is appointed and certified by all seven companies offering Medicare Advantage plans in New London County, the only area where he helps individuals. He can thus offer the 30 regular, not the special needs plans, options they have available in 2023.
● He is also appointed and certified by six of nine Prescription Drug Plan companies with plans available in New London County. The other three do not offer their plans through MediCare insurance professionals. However, by using Medicare.gov. John can share insights with clients about the 24 plans available from all nine companies!
● Help with plan choices in New London County is also available by contacting:
+ Medicare.gov and
+ CT's State Health Insurance Program (SHIP).
< - - > However, they are not licensed or certified professionals.
The CMS marketing regulations for Medicare Advantage and Prescription Drug plans state websites that do not mention company names, benefit details, or costs, like this one, are considered Medicare Communications.