Medicare Advantage Plans are contracted with the government to provide health services to Medicare beneficiaries, and these plans receive payments from the government to help cover the cost of care. They are also called Medicare Part C and do not require medical underwriting to get the plan. These plans are rated up to Five Stars that measure their effectiveness in addressing their members’ health concerns. Four and Five-Star rated plans indicate a high level of efficacy in evaluating and rectifying health issues.

The Centers for Medicare and Medicaid rate the plans using a list of measures, including issues like management of chronic disease, member experience, complaints, health maintenance, and customer service. The list of measures is updated annually by CMS so that improved methodology can be applied to more effectively gauge the success of individual plans. Plans that score high can get an additional quality bonus from the government.

Most Advantage Plans include prescription drug coverage or Medicare Part D in their coverage. Part D coverage is rated separately and may be different from the overall plan rating. Part D includes parameters that measure drug pricing and patient safety. A plan may have an overall rating of 5 Stars but a Part D rating of 4 Stars so the rating of the plan would be 4.5 Stars.

Use the rating system as a helpful guide when evaluating Medicare Advantage plans. Also, make sure the doctors you want to see are in network, and check the plan’s formulary to see that your prescription medications are covered.

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.

Most people know that the Medicare Annual Enrollment Period is October 15 through December 7.  The barrage of commercials featuring aged sports icons and actors not seen on television in decades starts in early October and doesn’t end until well after the holidays.  But there is another enrollment period called the Open Enrollment Period (OEP) from January 1 through March 31 in which you can still change your Advantage Plan if you are not happy with your previous choice.  This coincidentally coincides with the Medicare General Open Enrollment Period in which you can sign up for Medicare if you failed to do so during your Initial Enrollment Period (when you turn 65). 

During this OEP period, you can change to a different Medicare Advantage Plan or switch to Original Medicare (and enroll in a Part D drug plan).  If you want to add a Medicare Supplemental Plan, you might have to go through underwriting (answer medical questions) unless you were in your Advantage Plan for less than a year or have a Special Enrollment Period that applies (such as having moved out of the service area of your Advantage Plan).

Reasons you might not be happy with your original choice include:  Discovering your doctor or doctors are not in network for the plan  –  Finding that some of your medications are not in the formulary of the plan – Discovering the cost of your medications on the plan are higher than expected – Finding the network of available doctors and specialists too limited

Whatever the reason, you will be able to change your plan and not have to wait until October 15 when the Annual Enrollment Period begins again. If you make a plan selection in January, your new plan will start February 1. If you wait until March, your effective date would be April 1. Unlike the Annual Enrollment Period in which you can make several choices with your last application submitted being the plan you end up with, you will have only one opportunity to choose a plan during OEP.

Medicare recipients are facing more choices than ever before this Annual Enrollment Period (AEP) as carriers roll out plans with rich benefits, zero dollar premiums, and even reimbursements on Part B premiums.  So how should you narrow down the many options?  Here are some things to look for when contemplating a plan change.

  1. Look beyond the gimmicks.  A plan might have a lot of benefits, but if your doctor isn’t in the network, or if the network is so skinny you will have trouble finding providers, it might not be worth all the “extras”.
  2. Look at your ANOC, Annual Notice of Changes, to see if your plan is still the best one for you. If your premium or deductible is going up or your out-of-pocket maximum, you might consider a change.  Also, look at benefit changes.  Did your copays and coinsurance increase?  Are your medications still covered in the plan’s formulary? 
  3. Plans change networks frequently, so make sure your doctor is still in the plan’s network.  Also, look at any specialists you’ve been seeing to make sure they’re still in network as well.  Remember, if you go out of network, with most Advantage Plans, you will not be covered.
  4. Some plans have special features like low-cost insulin for people with diabetes.  These plans cap insulin costs at $35 or lower.  There are also plans now for those with End Stage Renal Disease that will help cover the cost of dialysis and plans for those with chronic medical conditions like heart disease.  If you have any of these conditions, these plans would be worth a look.
  5. There are also rich plans for those on Medicare and Medicaid.  These plans help coordinate care, give you extra benefits, like transportation to and from doctors’ appointments and meals after a hospital stay, and make it easier to find providers that accept both Medicare and Medicaid.
  6. Not all plans are available in all areas.  Plans are divided into service areas (usually a county) so they are specific to that region.  Make sure you are looking at plans in your area when comparing benefits, pricing, and provider networks.

If you have made the decision that you want to go with a Supplemental Plan to help cover the gaps in Medicare rather than an Advantage Plan, how do you narrow down your choices to get the plan that best fits your needs? Here is some information that might help.

There are ten basic supplemental plans you can choose from lettered A, B, C, D, F, G, K, L, M and N.   The ones that are going to give you the most coverage are F, G and C.  To get an F or C plan, you must have been eligible for Medicare before January 1, 2020.  Plan G has the same benefits as the F plan, except that you have to pay the Part B annual deductible of $203. Plan G also has the same benefits as the C plan, except you must pay for Part B excess charges (up to 15% more for doctors who are not on assignment with Medicare’s fee schedule).  All the supplemental plans are standardized, which means they have all the same basic medical benefits regardless of carrier.  Some F and G plans have extra benefits added, like vision and hearing, and some F and G plans have a high deductible version of the plan.  What differs among these plans is the premium.  Each company charges a different rate for each plan. Price is determined by the age you will be on the plan’s effective date and the location where you live. 

Another factor that influences cost is the type of plan you choose.  The plans with the most benefits are going to cost more than a plan with fewer benefits.  The F plan will be the most expensive with the most benefits, followed by the G and C plans, then D, A and B.  Lower cost plans like K and L have an out-of-pocket limit which you must meet before the plan pays 100% of costs.  Plan M pays only 50% of the Part A deductible, and the N plan has copayments for office and emergency room visits.   Some companies give first-year introductory discounts of up to $30 off your monthly premium, as well as household discounts of up to 5 to 7% for members of a family who have the same plan.

If you decide you can live without some of the benefits and pay out-of-pocket costs yourself, you may save on up-front premium costs if you decide to go with a lower-level supplemental plan.  All the plans are going to give you one of the most coveted benefits of all, however, which is the freedom to go to any doctor that takes Medicare with no referrals to see specialists, anywhere in the United States.  Most people choose a supplemental plan for that one reason, because they don’t have to worry about networks and referrals when selecting a provider for their healthcare.

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.

The Low Income Subsidy (LIS) federal program helps Medicare Part D beneficiaries pay for costs associated with their Part D prescription drug plan.  To be eligible to participate in the program, the insured must meet certain asset and income levels which can change yearly, and they must also have Medicare Parts A & B.  Part D plan premiums can be covered from 25 to 100 percent, depending on where the recipient falls on the Federal Poverty Level (FPL).   For 2021, yearly gross income limits in California are $19,560 for individuals and $26,370 for married couples. 

Full-benefit dual eligible, those who receive Supplemental Security Income, and those enrolled in a Medicare Savings Plan automatically qualify for the program.  Late enrollment penalties may also be reduced or eliminated once enrolled.  Consumers who become eligible for LIS have a Special Election Period to enroll which may be used once per quarter from January through September.

Debate about controlling drug pricing is on the legislative agenda as Democrats weigh whether to include it in the new infrastructure package.  The debate about allowing the government to negotiate drug prices, which was largely derailed by the pandemic, was brought back to life by one of Big Pharma’s most vocal critics, Senator Bernie Sanders.  Senator Sanders scheduled a hearing in the new Congress on drug pricing, which got the attention of Pharma industry lobbyists who oppose the measure.

Democrats are looking at H.R. 3, the bill introduced by Elijah E. Cummings that passed the house in late 2019 but never made it to the Senate.  The Lower Drug Cost Now Act, as the bill was called, would have allowed the Secretary of Health and Human Services to negotiate the price on expensive medications that don’t have generic alternatives.  It would also have capped out-of-pocket cost Part D beneficiaries would pay yearly for prescription medications at $2,000.00.  Further measures would have mandated rebates by drug manufacturers that raised prices more than the rate of inflation.

With the Democratic majority in both houses, there is a chance the bill, or one similar to it, could be passed despite the pharmaceutical industry’s opposition to what they see as price controls that would limit future research and development.

One of the largest relief packages in U.S. history, the American Rescue Plan Act of 2021, gives about $34 billion to aid Americans in buying health insurance.  The provisions in the bill do expire in two years, however, there may be a push by Democrats down the road to make them permanent.

Among the biggest winners in President Biden’s $1.9 trillion COVID relief package are those who buy health insurance on the federal marketplace exchanges, which in California is Covered California.  The bill includes a provision that caps what an insured would pay for premiums on the exchange to 8.5 percent of income.  It also provides for those who find themselves unemployed due the pandemic, allowing them to buy health insurance on the exchanges even though they are receiving unemployment benefits, which typically excludes them from getting subsidies. 

Another key aspect of the bill addresses those who are on COBRA, the program that allows workers to buy coverage offered by their former employer.  The bill would pay 100 percent of the COBRA premiums from April 1, 2021 to September 30, 2021.  The bill also includes incentives for states that did not expand Medicaid to do so, allowing more people to qualify for help from the federal aid program.

     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.