As Annual Enrollment for Medicare Advantage and Prescription Drug plans approaches, it is time for Medicare beneficiaries to take stock of their current plans to determine if a change would benefit them.  Plan members should be receiving their Annual Notice of Changes in the mail to see what modifications (if any) are being made for 2023. But with the influx of new Medicare Advantage plans with myriad benefits, how do you choose the right one for you? Below is a checklist of items you want to consider when trying to make a decision if you are new to Medicare or just considering making a plan change.

1.  Do you want a PPO or HMO plan?  While most Medicare Advantage Plans are HMO’s, there has been an increase in the number of PPO’s being offered.  HMO’s require you to go to network providers or you won’t be covered.  PPO’s give you the option to go out of network, but you will pay more (in copays or coinsurance) if you do.  PPO’s normally have a higher premium because they give you this choice, but it might be worth it if you want to have the benefit of seeing out-of-network doctors.  Medicare Advantage Plan PPO’s should not be confused with Medicare Supplemental plans.  Supplemental plans have no networks but do require you to go to doctors who take Medicare.

2.  If you have a doctor or specialist you want to see, make sure they are in network for the plan you are considering.  Don’t assume that every doctor in a practice is contracted with the plan.  You can call the plan directly or look up the doctor online on the plan’s website to verify if they are in network.  Remember, however, that a doctor may discontinue his contract with the plan at any time, which means you would have to find a new physician if this were to happen.

3.  Do you have specific health issues you want addressed?  Some plans are designated as CSNP’s or Chronic Special Needs Plans.  These plans structure benefits to address certain illnesses like diabetes, certain heart conditions or end-stage renal disease.

4.  Are you on MediCal as well as Medicare?  There are DSNP’s or Dual-eligible Special Needs Plans that coordinate benefits with Medicare and MediCal to make it easier to access doctors and benefits.  They may include extra benefits like vision, hearing, dental, transportation and telehealth services. 

5.  If you take certain medications, make sure they are in the formulary of the plan.  Each plan has a unique formulary, or list of medications that they cover.  Be sure and check this list to ascertain your meds will be covered.  Some plans are part of the Senior Savings Model in which they cap the price of insulin at around $35. While you and your doctor can appeal to the plan to cover a medication that is not in the formulary, there is no guarantee that they will cover it.

6.  If you are new to Medicare, you may choose an Advantage Plan and find that this type of plan is not right for you.  If you cancel the plan within the first twelve months (from the effective date), you will have guaranteed issue rights to switch to a Supplemental plan, which means you can get a Supplemental plan without going through underwriting or answering medical questions.  If you wait longer than the twelve-month period, you would be subject to underwriting and could be turned down for a Supplemental plan.

Medicare is a complicated topic, so if you are confused, an experienced broker can help answer your questions and address your concerns. A local broker will be familiar with the plans available in your area, the physician networks contracted with the plans, and can help narrow down your choices based on your specific needs.

The No Surprises Act went into effect January 2022 as part of the Consolidated Appropriations Act of 2021.  The purpose of the Act is to address surprise or balance billing that health plans charge when you use out-of-network providers.  It prohibits insurers from charging higher rates or denying claims for care obtained from out-of-network providers for emergency services, and in some cases, certain services provided by out-of-network clinicians at in-network facilities.  It stipulates that the health plan must cover these services as if they were in-network.

The Act also requires insurers to send beneficiaries an Advanced Explanation of Benefits (AEOB) for upcoming procedures or services as a “good faith estimate” of the costs that you will incur.  Provided information in these AEOB’s should cover whether each provider or facility is in-network or out-of-network, the contracted rate of the service, how to obtain only in-network providers, all expected charges, any cost-sharing amounts and whether prior authorization (or other stipulations) apply.

Many plans may try and get around these requirements by having you sign a Surprise Billing Protection Form.  Think carefully before signing this form as it may limit your consumer protection rights.  It essentially says that you are willing to pay out-of-network rates for any services administered by out-of-network providers. The form must be given to you at least 72 hours before you receive care, and a good faith estimate should be included on the form. Providers prohibited from giving you this form include emergency room doctors, anesthesiologists, assisting surgeons and radiologists.

The American Rescue Plan Act (ARPC) extended the Special Enrollment Period to allow consumers to sign up for healthcare on the federal marketplaces until August 15, 2021.  This gives additional time for those seeking health insurance to take advantage of the new rules expanding coverage for millions who have suffered financial hardship due to the COVID-19 pandemic. 

Here are few things to consider when signing up.

If you have more than one SEP (marriage, adoption, birth) use the SEP that will give you retroactive coverage to the date of the qualifying event.  The SEP for the COVID-19 pandemic is not retroactive and would start the month following the month in which you apply for coverage.

You can change plans during the SEP after thirty days of coverage if you have another qualifying event.  However, be aware that if you had a birthday in the interim, you might be rated higher on the new policy (your premium may be higher).

Individual states may also offer the SEP to off-exchange plans. 

Cobra recipients may use the SEP to access a marketplace plan.  The American Rescue Plan Act is currently subsidizing Cobra premiums 100%, but this will expire (unless extended) on September 30, 2021. The ARPC also allows you to obtain Cobra coverage if you previously declined it.

     Medicare can be very confusing for those newly eligible, and often I see the same issues coming up for those who are trying to navigate the Medicare maze.  Here are few points to try and help clarify the process.

     Many confuse the Parts of Medicare with the various Supplemental Plans available to them to fill the gaps in Medicare.  The reason is that some of the Supplemental Plans have the same letter name as parts of Medicare.  You have Parts A, B, and C with Medicare, but these are also names of Supplemental Plans that go with Medicare.  Basically, Medicare has Part A – Hospital Coverage, Part B – Medical or Doctors’ Coverage, Part C – Medicare Advantage Plans, and Part D – Prescription Drug Coverage.  You also have Plans A, B and C which are Supplemental Plans that cover the gaps in Medicare.
     A Medicare Advantage Plan is not the same as a Medicare Supplemental Plan. When you sign up for a Medicare Advantage Plan, you are signing up for Part C with Medicare, even though these plans are administered through private insurance companies.  The insurance companies handle all costs associated with your care, but are subsidized by the Medicare program.  These plans are usually HMO’s that require referrals to see specialists, and you must use Network providers in your service area to be covered.  Supplemental Plans are PPO’s with no Network restrictions.  However, you must use providers that take Medicare.
     Cobra is not considered creditable coverage for Medicare.  If you lose your job and are Medicare-eligible, if you go on Cobra, it is not considered creditable coverage, which means you could be charged a penalty on your Medicare Part B and Part D premiums once you do sign up for Medicare. 
     If your employer has 20 or more employees, you can remain on your employee group plan (as well as your dependents) if you are actively working, even though you are eligible for Medicare.  The prominent word here is actively working, which means you cannot be on Cobra or laid-off from work. 
     Higher earners pay more for their Medicare Part B premium and their Medicare Part D premium.  If you make over $88,000 (as a single person) or over $176,000 (as a couple), you will pay more for your Part B and Part D premiums.  It is called IRMMA (Income-Related Monthly Adjusted Amount), and it increases in increments based on income level.

As the Biden Administration works with FEMA to open 100 COVID vaccination sites across the United States, there is still much confusion over who is eligible to get the vaccine and where they go to schedule an appointment. The two federal sites in California that have already opened are located at Oakland-Alameda Colosseum in the Bay area and California State University in Los Angeles.

To find out if you are eligible to receive a vaccination, you can visit the California state site at Riverside County’s COVID website is Orange County’s site is and the San Diego County site is

As well as these county sites, appointments can be made at certain Albertsons, Rite Aid, Ralphs and Pavilions pharmacies. Blue Shield and Kaiser Permanente have been contracted with the state to help manage the vaccine rollout. Those who are eligible currently, according to state guidelines, are those in phase 1A (healthcare workers and long-term care residents) and 1B (those 65 and older, agricultural and food workers, educators and emergency service personnel). The next phase, which includes those 16 to 64 with high-risk underlying conditions is scheduled to open on March 15.

A Medi-Medi plan, also often referred to as a dual-special-needs plan or “look alike” plan, is a type of Medicare Advantage plan for people who qualify for both Medicare and Medicaid or Medi-Cal in California. Medicare is the primary payer on these types of plans with Medi-Cal being the secondary payer. You must go to doctors who accept both Medicare and Medi-Cal, and your share of cost is determined by your asset level. In California, to qualify in 2020 as a single person, your asset level is at $2,000 or below ($3,000 or below for couples). There are many things that are not included in your asset level like your primary residence, household items, pre-paid burial expenses and your car.

The advantages of having a Medi-Medi plan are that they coordinate your care with a provider network and often include extra benefits such as vision, dental and transportation services. You do, however, have to use the doctors and specialists in the plan’s network to be covered (except in cases of emergency). These plans are provided by private insurance companies, and the benefits and costs can vary from company to company. Prescription drugs are included in the plan with copays at no more than $1.30 for generic drugs and no more than $8.95 for brand drugs. If you pay no share of cost, your copays would be $0 for your medications.

You will automatically be enrolled in Medi-Cal if you qualify and sign up for Supplemental Security Income (SSI) through Social Security. You may qualify, as well, if you don’t get SSI, but you must contact your Medi-Cal county office to see if you meet eligibility requirements. If you are considering a Medi-Medi plan, be sure and check that your current doctors are in the plan’s network (if you wish to remain with them), and that your medications are in the plan’s formulary. You can also apply for one of these plans if you become newly eligible for assistance or during the Annual Enrollment Period from October 15 to December 7.

Balance Billing is a common problem when you go to out-of-network doctors not covered or partially covered by your health insurance. The consumer is charged for these costs in bills that could come weeks or months after the initial visit or procedure.

There are steps you can take, however, to mitigate these surprise medical bills.  First, be sure to check your Explanation of Benefits (EOB) which usually comes with the bill.  Check the dates to make sure the service you are being billed for is accurate and which services were actually performed by out-of-network providers.  Be prepared.  Get an itemized copy of your bill and know what the “usual” charge is for the procedure.  Sites like FAIR Health can help you determine what costs are common for medical procedures in your area.  Call the provider and ask to speak to someone in billing who can assist you with the bill.  You can also write to your insurer and request that they cover a portion or all of the balance billing.

Ultimately, one of the best ways to avoid balance billing is to make sure you go to network providers.  Call your insurer in advance, if possible, to make certain all your care is being handled by in-network doctors, from the surgeon to the anesthesiologist.  Make sure all lab work and tests needed in preparation for the surgery is covered as well.  

If you failed to meet the January 31 open enrollment deadline to enroll in a health insurance plan for 2020, you might still be able to get coverage this year. Covered California is allowing those who didn’t know about the new mandate to have coverage to sign up by April 30. Not knowing about the new law is considered a qualifying event. You will have to mark a box on the application saying you did not know that there would be a penalty assessed if you do not have health insurance coverage in 2020.

Enrollment increased for the first time in three years, according to statistics from the state-run marketplace, most likely due to the new tax to be implemented on those going without insurance. “I encourage everyone who does not have qualifying health insurance to take advantage of the special enrollment period,” State Controller Betty Yee said in a press release. “I like signing tax refund checks, not assessing penalties.”

While the federal government under the Trump Administration has been slashing its advertising budget for the federal marketplace, California has done just the opposite, spending nearly $121 million on advertising. The state has also increased the length of open enrollment, giving residents longer to sign up than in other states. These factors resulted in an increase in enrollment in California by 1.6% compared to a decline in the federal marketplace of 0.5%.