Am I on the Right Plan?

“Am I on the right plan” is the question we get all the time, and we hope to answer you every year.  We see lots of commercials with Joe Nameth and other celebrities touting great benefits that direct you to a call center. The people that answer these calls have one goal:  Sell you something.   We like to think it’s better that you have a relationship with a reputable agent whose goal is to make certain that you are on the appropriate plan and will be there after the sale to assist with any challenges.  When we first helped you enroll in your Medicare coverage, we discussed the two main types of insurance that help pay for the costs that Medicare doesn’t cover:

  • Original Medicare with two types of additional coverage: A Medicare Supplement plan and a separate Part D Prescription Drug Plan for help with Rx costs.
  • Medicare Advantage plans that replace your Original Medicare with combined medical and drug coverage, lots of extra benefits Medicare doesn’t cover, as well as a specific provider network.

 

Which type of plan is right for you depends on:  What doctors and other providers you want to see, what prescriptions you are taking, what your budget is, whether you’ll be traveling or residing outside of your home state, and what extra benefits do you desire. Our job is to help figure that out.

The TV and print ads you see mentioning all the extra benefits “you are entitled to” are for Medicare Advantage HMO plans.  If you are interested, I can help you explore these plans offered by AARP/United Healthcare, Aetna, Anthem, Blue Shield of California, Clever Care, Health Net/WellCare, Humana, and SCAN.  Call me and we can discuss your options.

In Los Angeles County (and often in Ventura, Riverside, San Bernardino, and Orange), most Medicare Advantage HMO plans have a zero-monthly premium (your Part B premium continues).  The plans include Part D drug coverage and offer lots of extra benefits that Medicare doesn’t cover.  These extra benefits can include Vision, Dental, Hearing, gym membership, Over-the-Counter allowance, free rides to doctor appointments, routine acupuncture and chiropractic, podiatry, as well as free Personal Emergency Response devices.  Some offer free Fitbit, Brain Fitness programs, Home Health assistance and free Meals after hospital stays.  And more…

Improved Networks: Blue Shield and AARP/UHC are offering Medicare Advantage HMO plans now that have in-network access to UCLA or Cedars – the Hospitals and a specific Medical Group of Doctors.

Most of the Medicare Advantage HMO plans have zero copays for doctor/specialist visits, hospitalization, labs, and radiology.  There are copays for ambulance, skilled nursing (after 20 days), chemotherapy, physical and radiation therapy, and other medical services.  But these plans also cap your out of-pocket costs (except for Part D drug costs) at less than $1000/year.

Several Medicare Advantage plans offer a Part B Premium Reduction “Give Back” benefit up to $125/mo.  That’s up to $1500/year back to you in the way of credits to your Part B premium.  Sometimes, these “Part B Give Back” plans have higher copays and out-of-pocket maximums, but they can help those with tight budgets who don’t qualify for Medi-Cal or Low-Income Subsidy/Extra Help.  We have been leery of these plans, but this year there appears to be a new plan from SCAN that could be a game changer.

These plans offer exceptional value, but they’re not for everyone. 

Most Medicare Advantage plans are HMO Managed Care with specific provider networks (including the hospitals) and require referrals for all services except seeing your Primary Care doctor.  There are also one or two Advantage PPO plans (depending on the county where you reside).  The PPO plans have monthly premiums, different out-of-pocket maximums for in- and out-of-network services, and you pay a significantly higher share of cost when seeing non-network providers.  We have yet to find the value in these plans for most of our clients.

Medicare Advantage plans will work great if ALL your providers are in the plan’s network and ALL in the same Medical Group. These plans work best with people who like the HMO model, their doctor and their medical group and are OK seeing their primary doctor to get a referral.

Medicare Supplement plans (Also known as Medigap):  We are contracted with the major carriers including Anthem, Blue Shield of California, and AARP/UnitedHealthcare. There are presently 12 Medicare supplement plans available nationwide.  Each plan has a letter that indicates benefits are standard to that plan.  The most popular plan we are enrolling clients in now is plan G.  Most of these plans include a free gym membership.

The primary advantage to Supplemental plans is the network.  You have access to any provider anywhere in the United States that is “contracted with Medicare”.  You can go directly to a specialist.  You can go to UCLA, Cedars, City of Hope, USC Norris Cancer Center to name a few.  You have a tremendous choice of hospitals, doctors as well as skilled nursing care and other facilities.  When clients get very sick and want treatment alternatives, I see some benefit to being on a supplemental plan.

The disadvantage of these plans is that they charge a monthly premium and don’t include Part D drug coverage.  Premiums on a Plan G in Los Angeles range from $113 to $282/mo. depending on age.  Rates will increase annually.  Stand alone Part D plans range from $7.50/mo. to $160.20/mo. with the average being around $17.

“What if I want to change plans?”

That’s what the Annual Election Period is for – being able to enroll in or change Medicare plans.

The Annual Election Period runs from Oct.15-Dec.7 for a January 1 effective date.   During this time period you are allowed to make many plan changes on a Guaranteed Acceptance basis.  Call us – We’re happy to help you shop and compare these options:

  • You can change your “standalone” Part D drug plan. There are 25 drug plans available in California for 2022.  We use the Medicare.gov website along with your specific list of Rx to compare plans.
  • You can change your current Medicare Advantage plan to one with more extra benefits or a different provider network. We first need to discover which plans have your doctors in-network.
  • You can drop your Medicare Supplement plan and Part D drug plan and enroll in a Medicare Advantage plan that covers Part D.
  • You can drop your Medicare Advantage plan to return to Original Medicare with a wider access to Medicare providers. You can enroll in a Part D drug plan.  If you also want to enroll in a Medicare Supplement plan you will usually have to answer health questions and qualify medically.  There are certain “Guarantee Acceptance” rules that may fit your specific situation.  Contact us to explore this.

There are additional Special Enrollment Periods that also allow plan changes, such as: moving out of California, moving to a different county within California, becoming eligible for Medi-Cal or a Low-Income Subsidy/Extra Help.  Also, moving into an assisted living facility.  We are now licensed in 18 other states.

If you currently have a Medicare Supplement Plan in California, you can change to any similar or lesser Medicare supplement plan on a guaranteed basis within 60 days of your birthday (several other states have similar provisions, but MOST DO NOT).  We shop all our clients every year in states that offer the guaranteed provision.

Final Note:  If you or someone you know is struggling to pay medical bills or RX costs be sure to explore eligibility for Medi-cal, Low-Income Subsidy or Extra help!