Tag Archives: ANOC

If You’re Losing Your Scripps Medicare Advantage Coverage… Don’t Panic!

Scripps Will No Longer Accept Medicare Advantage HMO Plans In 2024

Scripps recently began notifying about 32,000 Medicare beneficiaries that beginning on January 1st, 2024, the Scripps Clinic and Scripps Coastal medical groups will no longer accept Medicare Advantage (MA) HMO plans from carriers such as Anthem Blue Cross, Blue Shield of California, Health Net, UnitedHealthcare (UHc), etc. However, doctors from Scripps Clinic and Scripps Coastal will continue to accept Original Medicare Part A (Hospital insurance) and Part B (Medical insurance) as well as Medicare Supplement insurance, aka Medigap.

NOTE: Although Scripps will no longer accept MA HMO plans, I called and asked if they will accept MA PPO plans. I was told that individuals with MA PPO plans can still go to Scripps and see their doctors with those plans, BUT they will be billed as “out of network” instead of “in network” meaning that those individuals could have very high out-of-pocket costs if they continue going to Scripps with MA PPO plans.

If you have to pay out-of-network costs for your MA PPO plan, they are very expensive. In the 92024 zip code, there are 66 MA plans offered in 2024. Of those plans, 56 are HMO’s, and 10 are PPO’s, which are shown below. As you can see, the in-network and out-of-network costs are very expensive for all of the MA PPO plans.

In and Out of Network Costs for 2024 MA PPO Plans Offered In the 92024 (Encinitas) Zip Code:

AARP Medicare Advantage from UHC CA-0035 (PPO)
$9,550 In and Out-of-network
$4,500 In-network

Aetna Medicare Choice Plan (PPO)
$8,950 In and Out-of-network
$5,500 In-network

Aetna Medicare Core Plan (PPO)
$8,900 In and Out-of-network
$3,900 In-network

Aetna Medicare Eagle Plus Plan (PPO)
$9,500 In and Out-of-network
$6,700 In-network

Alignment Health AVA (PPO)
$8,950 In and Out-of-network
$3,900 In-network

Blue Shield Select (PPO)
$8,950 In and Out-of-network
$4,200 In-network

Humana USAA Honor (PPO)
$9,550 In and Out-of-network
$5,900 In-network

Humana USAA Honor with Rx (PPO)
$9,050 In and Out-of-network
$6,100 In-network

HumanaChoice H5525-076 (PPO)
$7,000 In and Out-of-network
$3,900 In-network

HumanaChoice H5525-077 (PPO)
$8,900 In and Out-of-network
$5,900 In-network

If you get seriously sick with one of these MA PPO plans, you can still end up with very high out-of-pocket costs, even if you stay in-network!

The Problem

More than half of the nation’s seniors have MA plans, but many hospitals and care facilities throughout the country are dropping MA plans altogether. Some of the most common reasons are because of excessive prior authorization denial rates and slow payments from insurers. Also, some MA insurers have faced allegations of billing fraud from the federal government, and they are being investigated by lawmakers over their high denial rates. Please click here to read “Kaiser Permanente Sued By Federal Government Over Alleged Medicare Fraud.”

According to Chris Van Gorder, president and CEO of Scripps Health, “It’s become a game of delay, deny and not pay. The health system is facing a loss of $75 million this year on the MA contracts, which will end Dec. 31 for patients covered by UnitedHealthcare, Anthem Blue Cross, Blue Shield of California, Centene’s Health Net and a few more smaller carriers. If other organizations are experiencing what we are, it’s going to be a short period of time before they start floundering or they get out of Medicare Advantage. I think we will see this trend continue and accelerate unless something changes.” For more information, please click here to read “Hospitals are dropping Medicare Advantage left and right” by Jakob Emerson.

Scripps Health released a statement explaining the reason for their decision. “Scripps has long served seniors and others in our community who are enrolled in Medicare and Medicare Advantage plans. Scripps and health systems across the country are facing unprecedented financial pressures. We are looking at all we do and, when necessary, making difficult decisions to ensure that we can continue to meet the needs of the community we serve. The revenue from Medicare Advantage plans is not sufficient to cover the cost of the patient care we provide.”

Understandably, many Scripps’ patients with MA plans are upset and panicking. If they keep their MA plans, they will no longer be able to keep the the same doctors and specialists they have been going to at Scripps, and they will have to go somewhere else and find new doctors. For those who are undergoing serious procedures such as cancer treatment, etc., this is not a viable option.

Scripps’ Patients Have Three Choices

If you are a Scripps patient with an MA plan, you have three choices for 2024:

  • You can keep your MA HMO plan (or switch to a different MA HMO plan), but if you do, you will not be able to go to Scripps Clinic or Scripps Coastal in 2024, and you must find new doctors.
  • You can keep your MA PPO plan (or switch from a MA HMO to a MA PPO plan, and continue going to Scripps and seeing your regular doctors, but you will incur very high out-of-pocket in-network and out-of-network costs.
  • The third and best option, in my opinion, is to switch back to Original Medicare (Part A and Part B) and get a Medicare Supplement plan.

With the third option, you can continue going to Scripps in 2024 and you can still go to the same doctors, specialists, etc. that you have been going to in the past. For those who are undergoing any serious medical procedures, such as cancer treatment, etc., you will continue in January 2024 with no changes or interruption in service or treatment.

When To Make These Changes

The time to make any of these changes is during the upcoming Annual Enrollment Period (AEP), which begins on October 15th and ends on December 7th every year.

If you want to keep your current MA plan, you don’t have to do anything (as long as it is still being offered in 2024). If you have an MA plan and want to switch to a different MA plan, you must do so during the AEP. You can also apply for or change your Prescription Drug Plan (PDP) or switch back to Original Medicare (Part A and Part B) during the AEP.

NOTE: If you have a Medicare Supplement, the AEP does NOT apply to you unless you want to enroll in or change your PDP. You can change your Medicare Supplement any time of the year.

The Solution

If you would like to continue seeing your doctors at Scripps in 2024, your only option is to drop your MA plan, switch back to Original Medicare, and get a Medicare Supplement. Normally, when you switch from an MA plan to a Medicare Supplement, you must answer health questions and go through medical underwriting. If you have a serious health condition such as cancer, etc., you will not be approved for coverage.

And Now For The Good News!

For all Scripps’ patients that have any kind of a Medicare Advantage plan (HMO or PPO), you can get a Medicare Supplement beginning on 1/1/24 to replace your MA plan REGARDLESS OF YOUR HEALTH! Because of this current situation with Scripps, you will be in a “Guaranteed Issue” situation meaning that you can get the best Medicare Supplement plan available, Plan G, without answering any health questions or being medically underwritten! As a Guaranteed Issue, YOU CANNOT BE TURNED DOWN FOR COVERAGE!

NOTE: With a Plan G Medicare Supplement, your only out-of-pocket cost for the entire calendar year is the Medicare Part B deductible, which will be $240 for all of 2024!

For example, with a Plan G Medicare Supplement, if you have multiple doctor visits, a couple of surgeries, and a hospital confinement in 2024, all you would pay is the $240 Part B deductible and that’s all! That’s a lot better and cheaper than the in-network and out-of-network maximums with MA plans!

Plus, with a Medicare Supplement, you can go to any doctor, specialist, care facility, hospital, etc. ANYWHERE in the US as long as they accept Medicare, and most do, about 93%. If you want to see a specialist, you can go directly to any specialist you want, anywhere in the country. With an MA plan, you must go to your primary care doctor first and get permission to see a specialist that’s in your local network, etc. You have much more freedom of choice with a Medicare Supplement than you do with an MA plan.

Other Guaranteed Issue Situations

There are other Guaranteed Issue situations that will qualify anyone with an MA plan to be able to bypass underwriting and get a Medicare Supplement as a guaranteed issue, REGARDLESS OF THEIR HEALTH. Regardless of your situation with Scripps, everyone with an MA plan should have received their Annual Notice of Change (ANOC) by now. The ANOC is a notice you receive from your Medicare Advantage or Prescription Drug Plan (PDP) every year in late September. The ANOC provides a summary of any changes in the plan’s costs and coverage that will take effect on January 1st of the following year.

If your MA plan did any of the following, you are in a guaranteed issue situation, which will allow you to get a Medicare Supplement, regardless of your health:

  • If your MA plan increased your premium or co-payments by 15% or more from this year to next year.
  • If your MA plan reduced any of your benefits next year from what they are this year.
  • If your MA plan terminated its relationship with your medical provider or the certification of the organization or plan has been terminated, such as Scripps.

Are Medicare Supplement Plans Expensive?

Many people are under the incorrect impression that Medicare Supplement plans are very expensive. I guess that’s kind of a relative question. In California, rates are based primarily on age and zip code, and rates normally go up as we get older.

Nationwide, there are 10 standardized Medicare Supplement plans to choose from, Plan A through Plan N. The term “standardized” means that coverage and benefits for every Plan G, Plan N, etc. are exactly the same, regardless of what insurance carrier you are with. In other words, Plan G is Plan G, Plan N is Plan N, etc. Although these plans and coverage are standardized (exactly the same), the rates are not standardized and prices vary significantly from one insurance carrier to another. For example, in the 92024 zip code (Encinitas), the Plan G rate for a 70 year old ranges from $158.29 per month with Cigna up to $262.04 per month with Humana!

As mentioned before, Plan G is the best Medicare Supplement plan offered today because your only out-of-pocket cost for the entire year is the Medicare Part B deductible, which will be $240 in 2024. As an independent agent, I work with all the major insurance carriers, and I shop around for my clients, every year, to find them the best rates as well as the best insurance carriers.

Do You Want to Change Your MA Plan to a Medicare Supplement Plan?

If you would like to switch from your MA plan to a Medicare Supplement in 2024, I can help you! Please call, text, or email me. My contact information is below. Please send me your birth date, zip code, and whether you live alone or if you have lived with someone else for longer than a year, and I can let you know what the best Medicare Supplement rates are for your age and zip code.

NOTE: Some carriers will give you a household discount (HHD), up to 12%, just for living with someone, even if they don’t have a plan. If this applies to you, please let me know their exact age.

If you’d like to apply for a Medicare Supplement, I can handle everything for you, and there is no charge for my service. If you have any questions or would like a no-obligation quote, please don’t hesitate to let me know.

Thank you!

Ron Lewis
CA agent #0B33674
NV agent #3822123

Ron@RonLewisInsurance.com
866.718.1600 (Toll-free)
760.525.5769 (Cell)
www.MedigapShopper.com

Major Medicare Supplement Rate Discrepancies Between Insurance Carriers!

Do you know that Medicare Supplement (MediGap) rates vary significantly between insurance carriers for the same identical plan and coverage? In the US, there are 10 “standardized” Medicare Supplement plans to choose from, plans A through N.

medigap

NOTE: The plans are labeled A, B, C, D, F, G, K, L, M and N to signify the plan differences. (Plans E, H, I and J are no longer available.)

The word “standardized” means that the coverage for Plan F, Plan G, etc. is exactly the same no matter what insurance carrier you have. For example, the coverage for Plan F is exactly the same with Mutual of Omaha, UnitedHealthcare, Blue Shield of CA, Aetna, Cigna, Anthem Blue Cross,  etc.

Although the coverage is exactly the same between insurance carriers for the standardized plans, the PREMIUMS ARE NOT THE SAME! In fact, most people are paying hundreds of dollars per year more for their insurance premiums than they should be!

For example, the Plan F premiums for a 70 year old living in the 92056 zip code in San Diego range in price from $153.98 per month to $264.19 per month. That’s a difference of $110.21 per month or $1,322.52 per year for the same identical plan and coverage! On the following rate sheet, you can see the different Plan F rates for 18 different insurance carriers in the 92056 zip code. Obviously, some carriers are more competitively priced than others!

Mary Jones Plan F Rates_Page_1

Mary Jones Plan F Rates_Page_2

As you can see, in the 92056 zip code, the Plan F rates for a 70 year old range in price from $153.98 per month to $264.19 per month! Again, that’s a difference of $110.21 per month or $1,322.52 per year for the same exact plan and coverage!

It’s Important to Shop Around Every Year!

The Medicare Supplement market is constantly changing, and so are the premiums. If you have a Medicare Supplement and you haven’t shopped around during the last year, there’s a good chance that you’re paying hundreds of dollars a year more for your insurance than you should be! Many people that I meet haven’t shopped around at all since they first signed up for Medicare! Many of these individuals haven’t heard from their insurance agent since then as well!

This past year, two of my clients (a husband and wife) had Plan G, and they were paying $809 per month for both of them, approximately $404.50 each! I shopped around for them and found them Plan G with a different carrier, Mutual of Omaha, and their total monthly premium is now $367.01 per month! That’s a savings of $441.99 per month or $5,303.88 per year! While this is not the norm, I can usually save most of my clients from $300 to $600 per year each on their Medicare Supplement insurance premiums and often more.

What is the Price Range for Plan F Medicare Supplement Rates?

In the following chart, I have taken the lowest and highest Plan F premiums for ages 65 through 90 in the 92056 zip code. As you can see, the monthly and annual differences are significant for every age group.

2 Lowest Plan F vs Highest Plan F

Is There An Open Enrollment Period for Medicare Supplement Plans?

No. Unlike Medicare Advantage (MA) plans, which have an annual open enrollment period from October 15th through December 7th every year, you can shop around and apply for Medicare Supplement plans all year long.

NOTE: There is a six month-open enrollment period for Medicare Supplements when you first sign up for Medicare Part B.

Do I Need to Be In Good Health to Get a New Medicare Supplement Plan?

Unless you are in a Special Enrollment Period (SEP), if you already have a Medicare Supplement, you need to be in relatively good health to apply for a new Medicare Supplement with a different carrier. However, if you have a Medicare Supplement and you apply during the 30 days before or after your birthday, you don’t have to answer any health questions on the application, and you cannot be turned down due to health reasons if you apply for the same plan or another plan with fewer benefits. For more details, please see the California Birthday Rule section below.

Heart

What Happens If I Am Not In Good Health? Can I Still Apply For a New Medicare Supplement Plan?

Yes, absolutely! Because of the California Birthday Rule, if you already have a Medicare Supplement and you have serious health issues, YOU CANNOT BE TURNED DOWN FOR COVERAGE if you apply during the 30 days before or after your birthday.

California Birthday Rule

In California, there is a law called the California Birthday Rule. This law guarantees you the right to apply for a new Medicare Supplement plan EVERY YEAR, as long as you apply during the 30 days following your birthday. This is also known as the annual 30-day open enrollment period.

NOTE: Although the California Birthday Rules specifies that you can apply, REGARDLESS OF YOUR HEALTH, during the 30 days following your birthday without being turned down for coverage, several insurance carriers will let you apply during the 30 days BEFORE or AFTER your birthday!

This is more advantageous for you because the premiums with these carriers are based on your current age when you apply, and your rates will be lower if you apply during the 30 days prior to your birthday. With these carriers, your new rates are also guaranteed and locked in for the first 12 months of your policy, so there won’t be any unexpected rate increases.

NOTE: Not all insurance carriers lock your rates for the first 12 months.

If you want to take advantage of the California Birthday Rule and apply during the 30 days before or after your birthday,  YOU CANNOT BE TURNED DOWN FOR COVERAGE as long as you apply for the same plan that you currently have OR if you apply for a different plan that has fewer benefits. For example, if you have Plan F (the most comprehensive plan) and you want to apply for Plan F with another carrier to save money on your premiums, or if you have Plan F and you want to apply with Plan G, etc.

NOTE: If you apply under the California Birthday Rule, there are no preexisting waiting periods for prior health conditions.

If you are in relatively good health, you can apply for a new Medicare Supplement plan any time of the year. If you have serious health issues, you should take advantage of the California Birthday Rule and apply for coverage during the 30 days before your birthday to save money on your premiums.

Consider Plan G to Save More Money On Your Premiums

Besides shopping around every year to make sure that you aren’t paying too much for your premiums, if you currently have Plan F, you should consider Plan G. Why? Because Plan G is identical to Plan F in EVERY way except you would pay a small $166 Part B (Medical) deductible one time per calendar year. That is the only difference between the two plans!

NOTE: I have an Obamacare Bronze plan, and my individual medical deductible is only $6,000 per year! I would gladly pay $166 per year for my medical deductible!

In other words, the most you would pay for any out-of-pocket expense with Plan G in any calendar year is $166. However, in most cases, you will save significantly more than $166 per year on your premiums, which usually makes Plan G a better value and more cost effective.

NOTE: The Part B (Medical) deductible is subject to change each year, but historically, it has remained stable.

To see the difference in coverage between Plan F and Plan G, please see the following chart:

Medigap Chart Plans F and G

As you can see, when you compare Plan F and Plan G, everything is exactly the same except for the $166 Part B deductible. Plan F has no deductible, and Plan G is basically Plan F with a small, $166 deductible.

Price Differences Between Plan F and Plan G

Although the two plans are almost identical in coverage, the rates for Plan G are usually significantly less than the Plan F rates. For a 70 year old in the 92056 zip code, the Plan F rates (above) range in price from $153.98 per month to $264.19 per month. The Plan G rates (below) range in price from $132.64 per month to $152.32 per month!

Plan F or Plan G

Plan G Rates Age 70

As you can see, the Plan G rates are significantly less than the Plan F rates for almost the same identical coverage.

Conclusion

The rates vary significantly from one insurance carrier to the next for the same identical plan and coverage. I recommend that you take advantage of the California Birthday Rule and shop around, every year, to make sure that you aren’t paying too much for your insurance. I would also suggest that you check out Plan G as another way to save a lot of money on your insurance premiums.

If you have any questions, or if you would like a free, no obligation quote, please don’t hesitate to let me know! I’m always happy to help!

Ron Lewis OHCC AD

Also, your feedback and comments are appreciated!

Thanks!

Ron Lewis
Ron@RonLewisInsurance.com
(760) 525-5769 – Cell
(866) 718-1600 – Toll-free

Save Money On Your Medicare Supplement by Comparing Rates Each Year

One of the most rewarding parts of my job is helping my clients save money on their Medicare Supplement (Medigap) insurance premiums. Most of the time, I can usually save individual clients at least $30 to $50 per month ($360 to $600 per year) on their premiums. Occasionally, I have saved them as much as $1,000 to $1,200 per year on their premiums!

medigap

I don’t mean to come across as bragging, because I’m not. However, I am very happy and excited because this past week I was able to save one of my clients (a husband and wife on a fixed income) over $5,300 per year on their Medicare Supplement premiums!  I was able to do this just by simply switching them to the same exact plan that they had, but with a different carrier!

They had Plan G with another company for quite a few years, and they were very happy with the company and their coverage. Their insurance rates were very low when they originally took out their plans, and the company always paid their claims promptly and without a problem, just as most Medicare Supplement insurance companies do. However, over time, their rates crept up, slowly but steadily. Until this past week when they called me, they didn’t realize that they were literally paying thousands of dollars more for their insurance than they should be!

Most people shop around every year or two and compare rates on their auto and homeowner’s insurance. Medicare Supplements are no different. If you have a Medicare Supplement plan, it is critically important that you shop around every year and compare rates between various companies because insurance rates vary significantly from one carrier to the next for the same identical plan and coverage. For example…

For a 72 year old female living in the 92056 zip code, the current Plan F rates range from $164.06 per month to $245.50 per month! That is a difference of $81.44 per month or $977.28 per year more for the same exact insurance coverage!

Attained Age

In California, Medicare Supplement insurance premiums are based on attained age. This means that as you get older, your rates usually continue to go up every year. Many companies start off at the “younger” ages (65 to 70) with very competitive rates, but over time, the rates continue to go up. Every company is different, and some companies raise their rates a lot more than others.

If you become complacent and don’t shop around every year to compare rates, you are probably paying hundreds or even thousands of dollars more per year on your insurance premiums than you should be!

California Birthday Rule

In California, there is a law called the California Birthday Rule. This law allows anyone with a Medicare Supplement to switch to another insurance carrier every year within 30 days of their birthday (before or after), REGARDLESS OF THEIR HEALTH and without medical underwriting, if another insurance carrier is offering the same plan, such as Plan F, at a lower rate. During the annual 30-day open enrollment period, you are also guaranteed the right to switch to a “lesser” plan, such as from Plan F to Plan G, etc.

CA Birthday Rule

If you have a Medicare Supplement plan, you are guaranteed the right to shop around every year within 30 days of your birthday to save money on your insurance premiums. During this period, you cannot be turned down for coverage, regardless of your health.

You Can Apply for Medicare Supplement Plans All Year Long

Unlike Medicare Advantage plans that have an Annual Enrollment Period (AEP) from October 15th to December 7th every year for a January 1st effective date, you can apply for Medicare Supplement plans all year long. The only difference is that if you apply using the California Birthday Rule within 30 days of your birthday, you do not have to answer any of the health questions on the application, and you cannot be turned down for coverage due to health conditions.

If you apply for a Medicare Supplement plan any time of the year other than during your annual 30-day open enrollment period, you will have to answer the health questions on the application, and if you have certain health conditions, you could be turned down for coverage. If you are in relatively good health, you should not have any problem qualifying for a Medicare Supplement plan.

Guaranteed Issue Situations In California

In California, there are certain circumstances when you would qualify for a Medicare Supplement due to a guaranteed issue situation.

CA Bear

If you can answer YES to any of the following questions, you may be eligible for guaranteed issue:

  1. Has your employer-sponsored retiree plan that is supplementing Medicare involuntarily terminated?
  2. Has your employer-sponsored retiree plan stopped providing Medicare supplement benefits or the Medicare Part B 20% coinsurance for services?
  3. Have you lost eligibility for an employer-sponsored retiree plan due to divorce or death of a spouse or family member?
  4. Has your Medicare Advantage plan increased your premium or co-payments by 15% or more, reduced your benefits, or terminated its relationship with your medical provider who was treating you?
  5. Have you moved out of the area of your MA plan or Program for All-Inclusive Care for the Elderly (PACE) organization?
  6. Has your MA plan, Medicare SELECT Plan, PACE provider or any other health plan under contract with Medicare: (a) committed fraud; (b) ended or lost its contract with Medicare; (c) misrepresented the plan you bought, or (d) failed to meet its contractual obligations to Medicare beneficiaries, as determined by the federal government?
  7. Did you join a MA plan or PACE organization when you first became eligible for Medicare at age 65, and you want to switch to a Medicare Supplement policy during your first 12 months in the MA plan or PACE organization?
  8. Have you switched from a Medicare Supplement policy to a MA plan, PACE organization, Medicare SELECT plan, or any other health care organization contracting with Medicare, for the first time since becoming eligible for Medicare within the past 12 months?
  9. Has your MA plan left your area, and if so, did your MA plan benefits end within the past 123 days?

NOTE: Many people with Medicare Advantage plans who have serious health issues can still qualify for a guaranteed issue Medicare Supplement plan. See item #4 above.

What Insurance Carriers Do I Work With?

As a licensed independent insurance agent, I work with ALL the major insurance carriers in California. Most importantly, I WORK FOR YOU, not a particular insurance company! I’m also licensed in Arizona, Colorado, Nevada, and Washington state. Here are some, but not all, of the Medicare Supplement insurance carriers that I work with:

  • Aetna
  • Anthem Blue Cross
  • Blue Shield of California
  • Cigna
  • Health Net
  • Humana
  • Individual Assurance Company (IAC)
  • Mutual of Omaha
  • Oxford
  • Stonebridge
  • Transamerica
  • UnitedHealthcare (AARP)
  • United of Omaha

Let Me Do the Shopping For You!

While it is unusual for me to be able to save most of my clients over $5,300 per year on their annual insurance premiums like I did this past week, it is not unusual for me to give someone a free, no obligation quote and save them anywhere from $300 to $500 per year on their Medicare Supplement premiums. That happens quite frequently.

As an independent insurance agent, I have access to insurance quote engines and other information that is not available to the public. You should take advantage of my knowledge and experience and let me do the shopping for you to save you money on your insurance premiums.

grocery-shopping-cartIf you have a Medicare Supplement plan, please contact me for a free, no obligation quote. More than likely, I will save you hundreds of dollars on your Medicare Supplement insurance premiums.

As one of my clients, I will contact you every year, about a month before your birthday, and I will let you know what the best rates are at that time. You always have the option to either keep your current plan, or you can take advantage of the California Birthday Rule and change carriers if another company is offering better rates.

Either way, I strive to build trust and relationships with my clients. I will not do a magic act and disappear after you have your new policy, 😉 and you will always have the peace of mind knowing that you are not paying hundreds or even thousands of dollars more than you should be for your Medicare Supplement insurance.

If you have any questions, or if you or anyone that you know would like a free Medicare Supplement quote, please contact me at (760) 652-6060 or toll-free at (866) 718-1600. You can also reach me by email at Ron@RonLewisInsurance.com. Your questions and feedback are always welcome!

How to Use the Medicare.gov Website to Purchase a Prescription Drug Plan

The Medicare open enrollment period just started, and it goes from October 15th through December 7th. During this period, you can choose a Prescription Drug Plan (PDP) that will begin on January 1st, 2016. Many people are confused because they don’t know how to shop around for a PDP. You don’t have to be an “expert” or a rocket scientist to purchase your own PDP. The purpose of this blog is to help you save money on your insurance premiums and find a PDP that is right for you.

IMPORTANT If you decide not to join a Medicare drug plan when you’re first eligible, and you don’t have other creditable prescription drug coverage, and you don’t get Extra Help, you’ll likely pay a late enrollment penalty if you join a plan later.

Medicare SimplifiedAccessing the Medicare.gov Website

If you have access to a computer and the Internet, shopping around for a PDP is really quite easy. If you’re ready to begin, follow these steps:

1.)  Navigate to the Medicare.gov website.

PDP1-0003x2.)  Under the blue tab at the top left-side of page that says Sign Up/Change Plans, click Find health & drug plans.

PDP1-0004xThe Medicare Plan Finder page displays.

PDP3-0001x3.)  In the General Search section, enter your zip code and click Find Plans. The Step 1 of 4 page displays.

NOTE If a survey window displays, close it and continue.

PDP1-0007x4.)  In the first section, select Original Medicare, and in the second section, select I don’t get any Extra Help. After that, click Continue to Plan Results. The Step 2 of 4 window displays.

NOTE You can choose other options that are more appropriate for your situation.

PDP1-0009x5.)  Enter your prescriptions in the text box and choose the appropriate dosages for each. A window, similar to the following, displays.

PDP1-0010x6.)  After you select the appropriate prescription dose, click Add drug and dosage.

NOTE: Continue adding your prescriptions until your prescription drug list is complete. You can add up to 25 prescriptions, and you can see your list in the lower part of the window. You can also choose “mail order pharmacy” to have your prescriptions mailed to you. In some instances, it is more cost effective to do that. If you select “mail order pharmacy,” information for both retail pharmacies and mail order options will display.

7.)  Write down the Drug List ID number AND the Password Date on a separate piece of paper.

NOTE The prescriptions, dosages, etc. that you entered are saved, and you can enter this number and the date later on to retrieve your prescription information instead of reentering it again.

Medigap PDP Window2x8.)  Click My Drug List is Complete when your drug list is complete. The Step 3 of 4 window displays.

PDP1-0014x9.)  Click Add Pharmacy to add up to two pharmacies, and then click Continue to Plan Results. The Step 4 of 4 window displays.

NOTE You can click the drop-down menu at the top of the page to select from more pharmacies near your zip code.

PDP3-0002x10.)  Click the check box next to Prescription Drug Plans (with Original Medicare), and then click Continue to Plan Results. The Your Plan Results window displays.

PDP1-0019NOTE By default, the prescription drug plans are sorted from the lowest to highest estimated annual retail drug cost. In the Plan Results window, click View All to see all the plans.

Understanding the Plan Results Window

After you access the Plan Results window, you are ready to evaluate and compare prescription drug plans and decide which plan is best for you.

There are different variables to take into consideration when choosing a PDP. Here are some of the more important ones:

  • Are drugs on the formulary?
  • Drug restrictions
  • Estimated annual drug costs
  • Annual drug deductible
  • Monthly premium
  • Overall star rating of the company

Are Drugs on the Formulary?

If a drug is not on the PDP formulary, that means that the plan does not offer coverage for that specific drug, and you should continue looking at other plans.

Drug Restrictions

If there are drug restrictions, the plan may have certain coverage restrictions (including quantity limits, prior authorization, etc.) on a prescription drug. Although your prescription may have limitations, these limits may not necessarily adversely affect you, and the plan may still meet your needs. For example, if you take 30 pills a month and the plan will cover a maximum of 60 per month, that would not impact you, and the plan is still worth considering.

Estimated Annual Costs

This is an estimate of the average amount you might expect to pay each year for your prescription drug coverage. This estimate includes the following costs:

  • Monthly premiums
  • Annual deductible
  • Drug copayments/coinsurance
  • Drug costs not covered by prescription drug insurance

If you entered your drugs into the Medicare Plan Finder, then this estimate includes the cost of those drugs.

IMPORTANT If your prescriptions are covered by the plan’s formulary and there are no major drug restrictions on the plan, this is the critical piece of information you need to determine which plan you select because it factors in all your premiums, deductibles, co-payments, and miscellaneous drug costs for the entire year. I don’t really factor in the various co-payments of each prescription; the estimated annual costs tell you approximately how much you will spend during the entire year.

Compare the estimated total annual pharmacy and mail order costs between the different plans to determine which plan offers you the best deal for the entire year!

PDP1-0019xNOTE In the previous example, the total retail annual costs for Humana are approximately $341 compared to $221 for the mail order costs. For Aetna, the total retail costs are approximately $347 compared to $387 for the mail order costs. Therefore, in this example, the most cost-effective option is to purchase the Humana PDP and use their mail order service.

If you selected “I don’t take any drugs,” then this amount includes only the cost of the monthly premiums that you would pay for the plan and it does not include any drug costs. If you selected “I don’t want to add drugs now,” then this estimate includes the average drug costs for people with Medicare and may differ depending on your age and health status.

Annual Drug Deductible

Some plans have no annual deductible and others have a maximum annual deductible up to $360 per year. Again, use the estimated annual costs to determine the value of the plan, not just the deductibles, the co-payments, etc.

Monthly Premium

The lowest monthly premium (and deductible) does not necessarily mean that you will be saving the most money. Again, compare the estimated annual drug cost to determine which plan is the most cost effective.

Overall Star Rating of the Company

For plans covering drug services, the overall score for quality of those services covers many different topics that fall into four categories:

  • Drug plan customer service: Includes how well the plan handles member appeals.
  • Member complaints and changes in the drug plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Member experience with plan’s drug services: Includes ratings of member satisfaction with the plan.
  • Drug safety and accuracy of drug pricing: Includes how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition.

If the plan has a low star rating, I would not recommend signing up for it.

Drilling Down a Little Deeper on the Medicare.gov Website

To get more information about a specific plan, click on the name of the plan, which is a hypertext link. In the following example, click Humana Walmart Rx Plan (PDP).

Medigap2-0002a

After you click the name of the plan, a window, similar to the following, displays.

Medigap2-0003a

The previous window shows the phone numbers, for members and non-members.

NOTE  If you have questions about the plan or wish to enroll, you would call the phone number for non-members. For more information, see “Signing Up for a PDP Plan” below.

Medigap2-0006a

The previous window shows the estimated monthly totals for prescriptions at CVS Pharmacy.

Medigap2-0007a

The previous window shows the estimated monthly cost (premium and deductible) for prescriptions at CVS Pharmacy.

Medigap2-0008a

The previous window shows the estimated monthly cost (premium and deductible) for prescriptions at Costco Pharmacy.

Medigap2-0009a

The previous window shows the estimated monthly cost (premium and deductible) for prescriptions through a mail order pharmacy.

Medigap2-0010a

The previous window shows drug coverage information, such as formulary status and Tier information, for the various prescriptions you entered on the Medicare.gov website.

Signing Up for a PDP Plan

After you have evaluated and compared several prescription drug plans, you are ready to sign up for a PDP on your own.

Follow these steps to sign up for a prescription drug plan:

1.)  From the Your Plan Details window, click on the hypertext name of the plan you are interested in. In the following example, click Humana Walmart Rx Plan (PDP).

Medigap2-0002a

After you click the name of the plan you are interested in, a window, similar to the following, displays.

Medigap2-0003a

2.) Call the toll-free number for non-members, and speak to a representative of the company.

IMPORTANT  If you have questions about the plan or wish to enroll, you would call the phone number for non-members. When you decide to enroll, call the plan and verify that your prescriptions are covered by the plan and that the estimated annual retail pharmacy or mail order drug costs are accurate. You want to make sure that you are interpreting and understanding the information correctly from the Medicare.gov website.

Conclusion

After you go to the Medicare.gov website and play around with it a little, you will find that signing up for a prescription drug plan is really quite easy.

NOTE  If you are having trouble signing up for a prescription drug plan or if you ever have Medicare questions or need help understanding information on the Medicare.gov website, call 1-800-MEDICARE. They are open 24 x 7, and most of the representatives are very helpful.

My primary specialty is Medicare Supplement insurance, but if you have any questions or comments, please feel free to contact me at RonLewisInsurance@yahoo.com.

Want to Change Your Medicare Advantage Plan to a Medicare Supplement Plan During AEP?

MEDICARE_MazeThe Annual Enrollment Period (AEP) for Medicare Advantage (MA) plans (Part C) is almost here! If you have an Advantage plan and you’d like to change to a traditional Medicare Supplement plan, you can apply during the upcoming AEP, which is from October 15th through December 7th, for an effective date of January 1st, 2016.

If you have an Advantage plan or a Prescription Drug Plan (PDP), this is the one time of year to make changes to your health and/or prescription drug plans for the following year. To make these changes, the plan has to receive your enrollment request (application) no later than December 7th. If you stay with the same plan that you had, any changes to coverage, benefits, or costs for the new year will also begin on January 1st.

What is the Annual Notice of Change (ANOC)

Medicare_AdvantageIf you have an Advantage plan, your plan will send you an “Annual Notice of Change” (ANOC) each fall. The ANOC includes any changes in coverage, costs, provider networks, or service areas that will be effective in January. These are usually mailed out in September by your Advantage plan. After you receive your notice, review any changes to decide whether the plan will continue to meet your needs during the following year. If you don’t receive this important notice, contact your Advantage plan and request that they send it to you.

IMPORTANT: If you have health conditions that may prevent you from meeting the underwriting requirements for a Medicare Supplement, the ANOC may qualify you for one of the “guaranteed issue” situations listed below.

Minimum Health Requirements for a Medicare Supplement

To apply for a Medicare Supplement during the AEP, you must complete a Medicare Supplement application, which includes a section with health questions. If you have serious health issues, there is a good chance that your application will be turned down. However, there are certain “guaranteed issue” situations that you may qualify for. This means that you will not have to answer any of the health questions on the application, and you cannot be turned down!

In the “Eligibility for Guaranteed Issue In California” section below, there are nine situations that would guarantee you the right to change your Advantage plan to a Medicare Supplement plan, REGARDLESS OF YOUR HEALTH, without answering any health questions on the application!

Carefully check the ANOC. If your Medicare Advantage plan has increased your premium or co-payments by 15% or more, reduced your benefits, or terminated its relationship with your medical provider who was treating you, YOU PROBABLY QUALIFY FOR A GUARANTEED ISSUE MEDICARE SUPPLEMENT PLAN!

Guaranteed Issue Rights

Guaranteed issue rights are rights you have in certain situations when insurance companies MUST offer you certain Medicare Supplement policies (plans A, B, C, F, K, or L). In these situations, an insurance company:

  • Must sell you a Medicare Supplement policy
  • Must cover all your pre-existing health conditions
  • Can’t charge you more for a Medicare Supplement policy because of past or present health problems

In most cases, you have a guaranteed issue right when you have other health coverage that changes in some way, such as when you lose the other health care coverage. In other cases, you have a “trial right” to try an Advantage plan and still buy a Medicare Supplement policy if you change your mind.

Medicare_Supplement

Eligibility for Guaranteed Issue In California

In California, you would qualify for a guaranteed issue Medicare Supplement for any of the following situations:

  1. Has your employer-sponsored retiree plan that is supplementing Medicare involuntarily terminated?
  2. Has your employer-sponsored retiree plan stopped providing Medicare supplement benefits or the Medicare Part B 20% coinsurance for services?
  3. Have you lost eligibility for an employer-sponsored retiree plan due to divorce or death of a spouse or family member?
  4. Has your Medicare Advantage plan increased your premium or co-payments by 15% or more, reduced your benefits, or terminated its relationship with your medical provider who was treating you?
  5. Have you moved out of the area of your MA plan or Program for All-Inclusive Care for the Elderly (PACE) organization?
  6. Has your MA plan, Medicare SELECT Plan, PACE provider or any other health plan under contract with Medicare: (a) committed fraud; (b) ended or lost its contract with Medicare; (c) misrepresented the plan you bought, or (d) failed to meet its contractual obligations to Medicare beneficiaries, as determined by the federal government?
  7. Did you join a MA plan or PACE organization when you first became eligible for Medicare at age 65, and you want to switch to a Medicare Supplement policy during your first 12 months in the MA plan or PACE organization?
  8. Have you switched from a Medicare Supplement policy to a MA plan, PACE organization, Medicare SELECT plan, or any other health care organization contracting with Medicare, for the first time since becoming eligible for Medicare within the past 12 months?
  9. Has your MA plan left your area, and if so, did your MA plan benefits end within the past 123 days?

Purchasing a Medicare Supplement Insurance Policy if You’ve Lost Your Health Care Coverage

If you believe that you have a guaranteed issue right to purchase a Medicare Supplement policy, make sure you keep the following items:

  • A copy of any letters, notices, emails, and/or claim denials that have your name on them as proof of your coverage being terminated.
  • The postmarked envelope these papers come in as proof of when it was mailed.
  • You may need to send a copy of some or all of these papers with your Medicare Supplement application to prove you have a guaranteed issue right.
  • If you have a Medicare Advantage Plan but you’re planning to return to Original Medicare, you can apply for a Medicare Supplement policy before your coverage ends. The Medicare Supplement insurer can sell it to you as long as you’re leaving the plan. Ask that the new policy take effect no later than when your Medicare Advantage enrollment ends, so you’ll have continuous coverage.

Which is Better, a Medicare Supplement or an Advantage Plan?

This topic is big enough to have its own blog! Personally, I strongly prefer Medicare Supplements over Advantage plans because you can go to ANY doctor or hospital in the US as long as they accept Medicare, and most of them do. With an Advantage plan, you are limited to their local networks of doctors and hospitals, and that is a major disadvantage. Also, a lot of people seem to think that Advantage plans cost less than Medicare Supplements, but if you are every hospitalized or develop a serious medical condition, you will be spending thousands of dollars on co-payments and deductibles with your Advantage plan.

Here are some pros and cons when comparing Medicare Supplements to Advantage plans.

Medigap Advantage Comparison ChartFor the reasons mentioned above, I would recommend Medicare Supplements over Advantage plans. If you are relatively healthy, an Advantage plan may be okay. But if you later develop serious health conditions, you’ll wish you had a Medicare Supplement because you should have the freedom to go to the best doctors, hospitals, specialists, and facilities ANYWHERE in the United States!

Peace of Mind Next Exit

If you (or someone you know) have an Advantage plan and you have any questions or would like to find out more about Medicare Supplement plans, please contact me at Ron@RonLewisInsurance.com. As an independent agent, I work with ALL the major insurance carriers in California, Washington, Nevada, and Arizona, and I’ll shop around for you to get you the best rates.