Tag Archives: CMS

Why You Should Contact HICAP for Help Choosing a Medicare Prescription Drug Plan

Choosing a Medicare Prescription Drug Plan (PDP), which is also known as Part D, can feel overwhelming. With dozens of plans available, each with different premiums, deductibles, copays, and pharmacy networks, it’s easy to make a costly mistake.

As a Medicare Supplement (Medigap) insurance agent, I often get questions from clients who also want help selecting a Part D plan. While I’d love to help, I recently learned that helping someone choose or enroll in a Part D plan without proper certification could put my insurance license at risk. However, there’s a better option that is free, unbiased, and comprehensive through the Health Insurance Counseling and Advocacy Program (HICAP).

Many Insurance Agents Have Stopped Selling Prescription Drug Plans

If you’ve noticed that fewer independent agents are offering Medicare Prescription Drug (Part D) plans, you’re not imagining things. Over the past couple of years, the Centers for Medicare & Medicaid Services (CMS) has introduced an increasing number of onerous regulations that have made it extremely difficult for many agents to continue offering these plans, especially independent agents who value personal service and client relationships.

For example, CMS recently began requiring insurance agents to record every marketing, sales, and enrollment call related to Medicare Prescription Drug Plans (Part D). This means any discussion involving benefits, costs, or plan comparisons must be recorded, both inbound and outbound, and those recordings must be securely stored for 10 years. Agents don’t like this and many Medicare beneficiaries don’t want their conversations recorded.

While these rules were intended to protect consumers from misleading marketing, the burden of compliance has become overwhelming for many professionals in the field. For more detailed information, please click here to check out my other blog called “Why Many Insurance Agents Have Stopped Selling Prescription Drug and Advantage Plans,” and click here to to check out another related blog called “Why You May Be Better Off Choosing Your Own Medicare Prescription Drug Plan (Part D).”

Why an Insurance Agent Might Not Be Enough

Many insurance agents are only certified to sell PDP’s from certain insurance carriers, which means:

  • They may not have access to every plan available in your area.
  • Their guidance could be influenced by commissions or appointments, even unintentionally.
  • You may not get a complete picture of your options, which can lead to higher costs or gaps in coverage.

That’s where HICAP comes in.

What is HICAP and How It Helps

The Health Insurance Counseling and Advocacy Program (HICAP) is a free, state-run program in California that provides free, confidential one-on-one counseling, education, and assistance to individuals and their families on Medicare, Long-Term Care insurance, other health insurance related issues, and planning ahead for Long-Term Care needs.

HICAP also provides legal assistance or legal referrals in dealing with Medicare or Long-Term Care insurance related issues. HICAP counselors are trained in Medi-Cal and Medicare and can help you understand the complex insurance options to find the best fit for you.

HICAP counselors:

  • Can show all available Part D plans in your area.
  • Provide completely unbiased guidance, with no sales pressure.
  • Help you compare costs, deductibles, co-pays, and pharmacy networks.
  • Walk you through the Medicare Plan Finder tool or help you understand your plan options.

What HICAP Services Are Available?

HICAP can help you with the following:

  • Have questions on prescription drug coverage, co-pays, or eligibility rules?
  • Wondering how to sign up for Medicare now that you are almost 65?
  • Confused about all the different parts to Medicare, do you need A, B, C, D?
  • Need help filing an appeal or challenging a denial?
  • Considering long-term care insurance?
  • Need a speaker for a community education event?

How a HICAP Session Works

Whether over the phone or in person, the process is simple:

  • Prepare your information: Have a list of all your prescriptions, your preferred pharmacy, and your zip code.
  • Enter your own prescriptions: You input your medication information into Medicare.gov.
  • Guided support: The HICAP counselor explains your options, interprets plan details, and answers questions.
  • Compare plans: They help you see which plan offers the best coverage for your needs.
  • Enrollment: You complete the enrollment yourself online or by calling the plan.

Who Can Get These Services?

Counseling is provided to the following individuals:

  • Persons 65 years of age or older and are eligible for Medicare
  • Persons younger than age 65 years of age with a disability and are eligible for Medicare
  • Persons soon to be eligible for Medicare

Why HICAP is the Best Choice

HICAP counselors provide a full picture of your options, which an insurance agent cannot always do. Their guidance is independent, comprehensive, and free. This ensures you make an informed decision about your prescription coverage without missing important details or paying more than necessary.

Check Out My Video — How to Sign Up for a PDP on the Medicare Website

This past year, I created a step-by-step YouTube video that shows you how to use the Medicare Plan Finder tool. Nothing has changed since last year. Instead of contacting a HICAP counselor, you should be able to watch the video and be able to select a PDP and enroll on your own. It’s really very easy! Please click here to watch the video. It’s only 14 minutes long.

Next Steps

If you’re ready to compare Medicare Prescription Drug Plans for 2026:

  • Click here to watch my Youtube video that explains how to to use the Medicare Plan Finder tool to select a PDP and enroll on your own.
  • Call HICAP at 1-800-434-0222 or click here to find a local office in California.
  • In other states besides California, you can get help at your local State Health Insurance Assistance Program (SHIP). Their phone number is 1-877-839-2675 or click here to find a local office outside of California.

And if you have questions about Medicare Supplement (Medigap) plans, I’m here to help guide you through your options.

Conclusion

Choosing a Part D plan doesn’t have to be stressful. By using HICAP’s free, unbiased services, you can get all the information you need to make the best decision for your health and budget, while staying in control of the process.

About the Author

As an independent Medicare Supplement insurance specialist, I work with most of the major insurance carriers throughout California, Nevada, Arizona, and several other states. I shop around for my clients every year during their 60-day annual open enrollment period under the California Birthday Rule to help them save money on their Medicare Supplement premiums. Many of my clients have saved hundreds, even thousands of dollars on the same exact plan and coverage! Please click here to see what my clients have to say about my services.

There is no charge for my services as I’m compensated by the insurance carriers, not my clients. My goal is to help you find the lowest premiums and provide the best personal service possible, year after year. Unlike many agents, I won’t do a magic act and disappear after you sign up! 🙂

If you enjoyed this blog and found it helpful, please leave your comments, questions, or feedback below and feel free to share this article with your friends!

Thank you!

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

Why Many Insurance Agents Have Stopped Selling Prescription Drug and Advantage Plans

If you’ve noticed that fewer independent agents are offering Medicare Advantage (Part C) or Medicare Prescription Drug (Part D) plans, you’re not imagining things. Over the past couple of years, the Centers for Medicare & Medicaid Services (CMS) has introduced an increasing number of onerous regulations that have made it extremely difficult for many agents to continue offering these plans, especially independent agents who value personal service and client relationships.

While these rules were intended to protect consumers from misleading marketing, the burden of compliance has become overwhelming for many professionals in the field. Here’s a closer look at what’s changed and why it’s causing so many agents to step back.

The Call Recording Requirement

Perhaps the biggest change came when CMS began requiring agents and brokers to record every marketing, sales, and enrollment call related to Medicare Advantage plans (Part C) and Medicare Prescription Drug Plans (Part D). This means any discussion involving benefits, costs, or plan comparisons must be recorded, both inbound and outbound, and those recordings must be securely stored for 10 years.

That might sound simple, but for independent agents, it’s a major operational and financial challenge. Recording, encrypting, and storing every call securely requires specialized technology, data security systems, and compliance audits. If even one recording goes missing, an agent could face serious penalties. For small agencies and independent brokers, this rule alone has made it nearly impossible to operate efficiently.

Please click here for more specific details regarding marketing policies and FAQs for selling Medicare prescription drug and Medicare Advantage plans.

Increased Compliance and Oversight

CMS now classifies many independent agents and marketing organizations as Third-Party Marketing Organizations (TPMOs). Under these rules, agents must read lengthy government disclaimers at the start of every call or meeting, document every contact, and ensure all marketing materials are CMS-approved before use.

This includes websites, flyers, emails, and even social media posts that mention Medicare Advantage or Medicare Prescription Drug plans. Every piece of material must be filed through a formal process for review, which can take weeks. This makes it difficult for agents to respond quickly to client questions or market changes during the short Annual Election Period (AEP), which goes from October 15th through December 7th each year.

More Work, Less Reward

Despite the added workload and responsibility, commissions have not increased to reflect these changes. Agents still receive modest compensation for enrolling people in Medicare Prescription Drug plans and Medicare Advantage plans. So now, agents face hours of compliance documentation, call recording, and potential liability without a corresponding increase in pay. For many, it simply isn’t worth the time, risk, or stress. For more details, please click here to read my other blog called “Why You May Be Better Off Choosing Your Own Medicare Prescription Drug Plan (Part D)”

The Risk of Liability

Another issue driving agents away is the potential legal exposure. With every recorded call and piece of marketing material subject to audit, a single accidental error, like forgetting to read a required disclaimer, can lead to fines or the loss of certification.

Most agents take pride in helping clients find the best coverage possible, but with these new rules, even honest mistakes can be costly. It’s a high-stress environment for people who genuinely care about their clients.

A Shift Back to Personalized Service

Because of all this, many experienced agents are now focusing primarily on Medicare Supplement (Medigap) plans. These plans are not part of the CMS marketing system that governs Medicare Advantage and Prescription Drug plans, which means agents can provide clients with more individualized service and guidance without jumping through as many regulatory hoops.

With Medigap plans, clients get lifelong coverage that works seamlessly with Original Medicare, and agents can continue to provide the personalized advice and service that has always been the heart of this profession.

What This Means for You

If you are a Medicare beneficiary, you might notice fewer agents offering to review your Medicare Prescription Drug plans or Medicare Advantage plans this year. It’s not because they don’t care… it’s because the rules have made it nearly impossible to do so efficiently or profitably while still providing the level of service clients deserve.

The good news is that you can still review and compare these plans directly on the Medicare.gov website. The site allows you to enter your prescriptions, preferred pharmacies, and ZIP code to find the most cost-effective options in your area.

IMPORTANT: Medicare Prescription Drug plans and Medicare Advantage plans are annual contracts and they can change from year to year. What’s good this year may not be so good next year and it’s important to shop around every year!

Shopping for and signing up for a prescription drug plan isn’t difficult. I made a short video this past year that explains how to choose and sign up for a prescription drug plan. If you’d like to watch the video, please click here.

Final Thoughts

The Medicare program is complex and constantly changing. Most agents truly want to help people understand their options, but the ever-growing CMS compliance burden has pushed many out of this side of the business.

Although I’m an independent insurance agent focusing primarily on Medicare Supplement insurance, if you’re looking for unbiased help reviewing your options, please don’t hesitate to reach out. Even though I don’t sell Medicare Prescription Drug plans or Medicare Advantage plans, I’m happy to help you understand how they work and guide you toward resources that can help you make the best decision for your needs.

In my next post, I’ll explain why many Medicare beneficiaries are actually better off by NOT using an insurance agent to help them select their Medicare Prescription Drug plan and how they can easily and safely select a drug plan on their own using the Medicare.gov website.

About the Author

As an independent Medicare Supplement insurance specialist, I work with all the major carriers throughout California, Nevada, and several other states. I shop around for my clients every year during their 60-day annual open enrollment period under the California Birthday Rule to help them save money on their Medicare Supplement premiums. Many of my clients have saved hundreds—even thousands—of dollars on the same exact plan and coverage! Please click here to see what my clients have to say about my services.

There is no charge for my services; I’m compensated by the insurance carriers, not my clients. My goal is to help you find the lowest premiums and provide the best personal service possible, year after year. Unlike many agents, I won’t disappear after you sign up!

If you enjoyed this blog and found it helpful, please leave your comments, questions, or feedback below and feel free to share this article with your friends!

Thank you!

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

New CMS Marketing Rule Harms Medicare Beneficiaries

The Centers for Medicare & Medicaid Services (CMS) recently released their 2023 final rule, which includes two requirements that will have a significant impact on independent agents and brokers who sell Medicare Advantage (MA) and Prescription Drug Plans (PDP’s). In my opinion, this new CMS requirement will adversely affect Medicare beneficiaries because many independent insurance agents and brokers will no longer market or sell MA or PDP’s because of these onerous rules. Consequently, many Medicare beneficiaries will be left on their own to shop for these plans.

Although these new marketing guideline changes are for calendar year 2023, they begin on October 1st, 2022, just before the start of the 2023 Annual Election Period (AEP) for Medicare Advantage and prescription drug plans.

NOTE: The AEP begins on October 15th each year and ends on December 7th. Unless you are in a Special Enrollment Period (SEP), this is the only time of year you can switch to or from an MA or a PDP. With Medicare Supplements, you can change your plan any time of the year.

This new CMS ruling is in response to misleading TV commercials by Third Party Marketing Organizations (TPMO’s) and numerous consumer complaints to CMS. Under these new guidelines, the definition of TPMO’s has been expanded to include agents and brokers. The new definition of TPMO is too broad and will negatively impact many entities that are acting responsibly such as individual agents and brokers who will now be subject to new call recording requirements (see next section). It has been argued that consumer dissatisfaction is not usually with their insurance agent but with TPMO call centers that solicit beneficiaries to switch plans that do not necessarily meet their needs.

Do you recall those TV commercials and pitches from celebrities and pitchmen like Joe Namath, William Shatner, Jimmie Walker, etc.? They promise things from free meal delivery to money deposited in your Social Security account. A few MA plans may offer meal delivery for certain qualified individuals, but only one or two plans in your county may offer those benefits, but most don’t. And while the dental and vision coverage of MA plans may sound great, many plans only include routine visits, not more expensive items like dental implants, eyeglasses, etc.

There are a couple of things you need to consider before you race to your phone to “Call Now.” First, Joe Namath, while he may be a perfectly upstanding gentleman, is no Medicare expert. He is a paid endorser. In fact, I doubt he even understands what a Medicare Advantage plan is. Even if he is on a Medicare Advantage plan, I doubt he is concerned with the potential out of pocket costs involved. I believe his $25 million net worth may place him a little out of touch with the average American budget. Second, be aware that he is speaking on behalf of the Medicare Coverage Hotline, not Medicare. And if you were to pause the commercial on the last slide, you would see that The Medicare Coverage Hotline is a for-profit lead generation campaign. This means that they are simply trying to get you to call their 800 number so they can sell you as a lead to an insurance agent.

http://www.SeniorMark.com

New Call Recording Requirement

Agents and brokers must now record all sales calls with potential clients in their entirety including the enrollment process. These recordings must be retained in a HIPAA-compliant manner for 10 years! This applies to all new and existing clients.

What is considered a sales call? Anything that falls under the “chain of enrollment,” which is defined as the events from the point when a Medicare beneficiary becomes aware of an MA or PDP to the end of the enrollment process. This means when an agent is calling leads, scheduling appointments, collecting drug and provider lists and conducting education meetings and phone enrollments. All of these calls would fall under this category and must be recorded!

NOTE: Medicare Supplements are not included in the new call recording rules. However, if an agent is selling a Medicare Supplement and a PDP, the call must be recorded.

Zoom meetings must also be recorded. Only in-person, face-to-face marketing and sales appointments are excluded, however any follow-up calls related to sales and completing the enrollment process must be recorded. Sales calls conducted on cell phones must also be recorded.

Phone Recording Problems for Agents and Medicare Beneficiaries

This new phone recording requirement will add an additional burden to insurance agents attempting to assist Medicare beneficiaries when selecting suitable health and drug plans. According to the The National Association of Health Underwriters (NAHU), who are advocating against these new CMS changes, “The cost of setting up a HIPAA-compliant audio recording system with adequate and protected storage capabilities far exceeds the abilities of many of these licensed and certified agents who are now facing a decision as to whether to participate in this fall’s AEP.”

There is also a concern from Medicare beneficiaries who do not wish to have their enrollment recorded. An enrollment conversation can last hours, during which beneficiaries may disclose several private details about their health, financials and personal life. Many seniors are not comfortable with the requirement that these conversations be recorded and stored for up to 10 years, regardless of the protections that may be put in place for the recordings.

NAHU

New Disclaimer Requirement

When discussing MA or PDP’s, insurance agents must use the following disclaimer:

“We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all your options.”

Agents must include the new disclaimer in the following places:

  • Verbally stated during the first minute of a sales phone call
  • Electronically conveyed when communicating with a potential client via email, online chat, or other electronic form of communication
  • Prominently displayed on the agent’s website
  • On all marketing materials, in print (12-point font) and television advertisements

Contact Congress Today to Delay this New CMS Marketing Rule

Please click here to contact your member of Congress to request that CMS implement a delay of six to 12 months, during which CMS will work with stakeholders to develop marketing regulations that will protect Medicare beneficiaries while allowing them access to their trusted independent agent or broker.

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.

Hey Seniors… If You Like Your Medicare Advantage Plans, You Can Keep Them, Period…Maybe Not!

obama-if-i-like-your-plan-you-can-keep-itSound familiar? Part of the Affordable Care Act (ACA), also known as Obamacare, aims to reduce federal payments to the Medicare Advantage (MA) plans over time, and these savings would help pay for some parts of the ACA. In other words, Obamacare is slashing Medicare and MA benefits, which will adversely affect seniors in order to pay for other new programs created under the law that aren’t even for seniors!

According to Robert E. Moffit, Ph.D., “The money is cut from hospital services, Medicare Advantage, skilled nursing services, hospice services, and other Medicare services. To be clear, the cuts do not target individual institutions or medical organizations suspected of waste, fraud, or abuse.” Moffit goes on to say that “The $716 billion in “savings” from Medicare are taken out of the program to pay for new spending in Obamacare. The cuts do not strengthen the Medicare program, nor do they extend the life of the Part A trust fund.” Consequently, the $716 billion that is being cut from Medicare will not enhance Medicare Advantage benefits, and there is speculation that these drastic cuts will also adversely affect traditional Medicare and Medicare Supplements as well!

One way it’s expected to do this is by requiring Medicare Advantage plans to have a “medical loss ratio” of at least 85 percent. This means the companies offering the plans would have to spend at least 85 percent of the money they get on actual medical care. In other words, insurance companies can use no more than 15 percent for administrative costs and profits. As soon as these changes were announced with the ACA’s passage in 2010, there were fears and rumors that this was the beginning of the end for Medicare Advantage plans.

Medicare Advantage PlanThe Centers for Medicare and Medicaid Services (CMS) recently proposed a 1.9% cut in Medicare Advantage payments next year. If these cuts are implemented, many fear that millions of seniors who currently rely on the Medicare Advantage program will lose the plans, benefits, doctors, and financial protection they currently have. Seniors and people with disabilities who are enrolled in Medicare Advantage plans would face premium increases and benefit reductions of $35-$75 per month, or $420-$900 per year. According to Oliver Wyman of America’s Health Insurance Plans (AHIP), these types of cuts could result in a “high degree of disruption in the MA market,” including the “potential for plan exits, reductions in service areas, reduced benefits, provider network changes, and MA plan disenrollment.”

In all fairness to the supporters of the Medicare Advantage plan cuts, Medicare Advantage plans were paid on average more per beneficiary than what Medicare paid for beneficiaries enrolled in traditional Medicare plans. One of the goals of the ACA is to equalize the federal spending over time, so the government pays the same amount whether a beneficiary enrolls in Medicare Advantage or traditional Medicare. Cuts to Medicare Advantage plans are part of the $716 billion in Medicare spending reductions the health law calls for over the next decade.

As an independent insurance agent, I work primarily with Medicare Supplement (Medigap) insurance plans, which is health insurance for people who are 65 and over. The alternative to Medicare Supplements is Medicare Advantage (MA) plans. Personally, I’m not a big fan or advocate of MA plans because they are much more restrictive than “original” Medicare Supplements. By that I mean you are restricted to the doctors and hospitals in the plan’s network. With Medigap plans, you can go to any doctor or hospital in the country that accepts Medicare, and if you develop a serious illness, you have much greater freedom and options, and you are not limited or confined to a specific network of doctors or a geographic area.

Health Care Reform2Medicare Supplements do not include prescription drug coverage. For that, you would have to purchase a separate prescription drug plan (PDP) called “Part D.” (“Part A” is hospital insurance, “Part B” is medical insurance, and Medicare Advantage plans are referred to as “Part C.”) MA plans usually cost less than Medicare Supplements and many MA plans include prescription drug coverage. Some of the MA plans also provide additional benefits such as dental, vision, and wellness, which are not covered by Medicare. For these reasons, enrollment in Medicare Advantage plans rose in 2014 by 8.9 percent to 15.9 million enrollees, which is up from 14.6 million in 2013. Obviously, these plans are still very popular.

As mentioned before, I am not too excited about MA plans because of the network and geographic restriction. If money isn’t an issue, I would recommend a Medicare Supplement plan over an MA plan. However, for many retirees, MONEY IS AN ISSUE as many seniors live on fixed incomes, and every dollar counts.

Because of the cuts, reduction of benefits, and increased costs to seniors, there is no question that millions of seniors who rely on the Medicare Advantage program will lose the plans, benefits, doctors and financial protection they currently have. And just like the ACA, this could cause another major disruption in the health insurance market and a lot of confusion for seniors and their family, which they really don’t need at this stage of their life.

Unless the proposed cuts to Medicare and MA plans are significantly reduced or eliminated, I think there is a good chance that many seniors will not be able to keep their MA plan, even if they like it, PERIOD!

What do you think?