Each year, many people in California decide to leave their Medicare Advantage (Part C) plan and return to Original Medicare (Part A and Part B) with a Medicare Supplement (Medigap) plan. Often, this happens when premiums, copays, or out-of-pocket costs increase, or when clients find their favorite doctors or hospitals are no longer in their plan’s network.
If you’ve ever wondered how to switch from Medicare Advantage to Medigap, it’s important to understand how the process works, and the potential challenges if you have existing health conditions.
You Can Switch Back to Original Medicare — But You’re Not Automatically Guaranteed Medigap Approval
You can drop your Medicare Advantage plan and go back to Original Medicare during certain times of the year, such as the Annual Election Period (AEP), which goes from October 15th through December 7th every year or during the Medicare Advantage Open Enrollment Period, which goes from January 1st through March 31st.
However, many people are surprised to learn that once they return to Original Medicare, they must apply separately for a Medicare Supplement plan, and approval is not guaranteed. In most cases, insurance companies can review your health history, which is called “medical underwriting,” and deny coverage if you have serious or chronic health conditions. That’s why timing and knowing the rules can make all the difference.
Medicare Guaranteed Issue Rights: The Hidden Opportunities
Here’s the good news… even if you have health problems, there are special Guaranteed Issue (GI) rights or situations that often let you enroll in a Medigap plan without health questions or underwriting.
These rights apply in specific situations and many beneficiaries don’t realize they qualify. Some are tied to Medicare Advantage plan changes, others to state-specific protections. In California, there are several lesser-known GI opportunities that can help people switch to Medigap coverage, even when they’ve been told “no” before.
I work with clients every year who thought they couldn’t qualify due to health issues and I’ve helped them get accepted for Medicare Supplement coverage using legitimate Guaranteed Issue options that most agents aren’t aware of or don’t mention to their clients.
Why Work with a Specialist Who Knows the California Rules
The Medicare rules in California are unique. Between the California Birthday Rule and other state-specific guaranteed issue protections, there are several ways to save money and secure coverage without medical underwriting.
As an independent Medicare Supplement insurance specialist, I work with all the major insurance carriers throughout California, Nevada, and several other states. My goal is simple. I want to help you find the best Medicare Supplement plan with the lowest premium and the most reliable coverage, year after year.
Let’s See What You Qualify For
If you’re considering leaving your Medicare Advantage plan or want to see if you qualify for a Guaranteed Issue Medicare Supplement, don’t wait until it’s too late.
There is no cost for my help. I’m paid by the insurance carriers, not my clients. I can review your situation, identify any Guaranteed Issue opportunities, and help you apply for the coverage that fits your needs and budget.
Contact me today to learn your options and see how much you could save on your Medicare Supplement plan.
About the Author
As an independent Medicare Supplement insurance specialist, I work with all the major insurance carriers throughout California, Nevada, and several other states. I shop around for my clients every year during their 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 for the same exact plan and coverage! Please click here to read 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 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
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
If you’ve ever tried to compare Medicare Prescription Drug Plans (PDPs), also known as Medicare Part D, you know how confusing it can be. There are dozens of options, and each plan has its own list of covered drugs (called a formulary), preferred pharmacies, and cost structure. What looks like a small difference in co-pays or premiums can easily add up to hundreds of dollars over the course of a year.
Why Most Agents No Longer Sell Prescription Drug Plans
You might assume that a licensed insurance agent can help you find the best plan, and in the past, many could. However, today’s system makes that much more difficult. Because of how Medicare’s certification and contracting rules work, most independent agents are not certified with every drug plan available in your area. They can only recommend or enroll you in a limited number of specific plans they are contracted with and certified to sell.
If another company offers a plan with lower co-pays or better coverage for your medications, your agent may not even be allowed to discuss it with you. Why? Because they don’t get paid for selling plans they’re not certified or contracted to represent. Even if they know a different plan would save you money, compliance rules and commission structures prevent them from showing it to you.
The Hidden Time and Cost Burden on Agents
Before an agent can help anyone with a PDP or a Medicare Advantage (MA) plan, they must complete extensive training and certification every year. This starts with the AHIP certification exam, which takes many agents 10–20 hours of study time to complete. The AHIP exam covers topics such as Medicare compliance, plan rules, CMS marketing guidelines, etc.
But that’s only the beginning. Agents must also spend time studying and taking individual certification exams for EVERY insurance company whose plans they want to sell. Each carrier’s certification process is different. Some require several hours of training, testing, and annual renewal. Altogether, a well-rounded agent could easily spend 50+ hours each year just keeping up with certifications before they can even begin helping clients.
Then there are the CMS compliance rules, which now require all sales calls related to PDPs and MA plans to be recorded and stored securely for 10 years! The added administrative burden and potential liability make it even less practical for agents to offer these plans, especially since commissions for prescription plans are typically under $100 per year per client. Many agents have simply decided that it’s not worth the time and effort.
How You Can Shop and Enroll in a Drug Plan On Your Own
Fortunately, Medicare makes it easy for you to shop around on your own and sign up for a prescription drug plan at www.Medicare.gov by using the exact same tool that agents use.
This past year, I put together a short video that explains how to shop for and sign up for a Medicare prescription drug plan using the Medicare Plan Finder tool. It’s actually very easy, and there aren’t any significant changes since last year. Please click here to watch the video.
The Medicare Plan Finder is available 24/7 and it is updated every fall with the latest plan information. It allows you to make an informed decision without pressure or bias, and without worrying whether your agent is certified to sell a particular plan.
Review Your Coverage Each Fall
Even if you’re happy with your current PDP, it’s important to review your coverage each year during the Annual Election Period (AEP), which goes from October 15th through December 7th each year. PDPs are annual contracts, and drug prices, plan premiums, and pharmacy networks can change every year. What’s good this year may not be so good next year.
It only takes about 15 to 20 minutes to shop around and review your PDP options, and it could save you literally hundreds of dollars and ensure you have the right coverage for your specific prescriptions.
The Bottom Line
Most Medicare agents are honest, hardworking professionals who want to help their clients, but the system is stacked against them when it comes to prescription drug plans. Between certification costs, compliance rules, and low commissions, many agents have chosen to focus on Medicare Supplements, Medicare Advantage plans, or other types of insurance products instead.
By learning how to shop for your own prescription drug coverage at Medicare.gov, you can take control of your health care costs, stay informed, and make sure you’re always getting the best prescription drug plan every year.
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 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 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
The Annual Election Period (AEP) is from October 15th through December 7th each year. During this annual open enrollment period, you can sign up for or change your Medicare Advantage (MA) plan or your Prescription Drug Plan (PDP). Medicare Advantage and prescription drug plans are annual contracts, and they can change from year to year. Therefore, you should shop around and compare plans every year.
NOTE:If you have a Medicare Supplement, the AEP does not apply to you unless you want to enroll in or change your PDP.
If you have an MA plan and you want to change to a different MA plan, or if you want to leave your MA plan and switch back to Original Medicare, Part A (Hospital insurance) and Part B (Medical insurance), you would normally do so during the AEP. The new coverage will begin on January 1st of the following year. In most cases, you must stay enrolled in your MA plan for the calendar year beginning in January or on the date your coverage begins. However, in certain situations, you may be able to join, switch, or drop an MA plan during a Special Enrollment Period (SEP), such as if you move out of your plan’s service area, etc.
Pros and Cons – Medicare Supplements Versus Medicare Advantage Plans
When it comes to Medicare Advantage (MA) plans, I’m going to be totally honest and admit to you that I am biased because I don’t like them! Unless you can’t afford to pay the monthly premium for a Medicare Supplement (aka Medigap), I would NEVER recommend or advise someone to give up their Original Medicare rights (Part A and Part B) and sign up for an MA plan!
If you currently have an MA plan, or if you are thinking about signing up for one, I would strongly recommend that you read this article first so that you can make an “informed decision” about whether an MA plan is right for you and in your best interest.
There are pros and cons to each, but the benefits of having a Medicare Supplement plan far outweigh the benefits of having an MA plan. Please click here for a detailed comparison between Original Medicare and Medicare Advantage plans.
MA Plan Advantages
Here are some of the benefits of having an MA plan:
MA premiums can be very low, and some plans have no monthly premiums at all.
Some MA plans include Medicare prescription drug coverage (Part D).
Maximum out-of-pocket (OOP) costs are limited. Plans vary, but in 2025, the most you can pay for in-network OOP costs is $9,350 per calendar year. If you go out of network, you would normally pay all costs! (I wouldn’t really call this a benefit since $9,350 is a lot of money, and the most you would pay in OOP costs with a Plan G Medicare Supplement is the Medicare Part B deductible, which is currently $240 per calendar year in 2024! The Medicare Part B deductible for 2025 is projected to be $257. However, the Centers for Medicare & Medicaid Services (CMS) will not finalize the deductible until fall 2024.)
Some MA plans offer additional benefits such as vision, hearing, dental, and other health and wellness programs. (Some Medicare Supplement plans also offer additional benefits such as free gym memberships, vision, and hearing aid benefits.)
Medicare Supplement Plan Advantages
Here are some of the benefits of having a Medicare Supplement plan:
You have much more FREEDOM of choice with a Medicare Supplement than you do with an MA plan because you can go to ANY doctor, hospital, specialist, care facility, etc. in the United States as long as they accept Medicare, and most do, about 93%. (You can’t do that with an MA plan.)
You have much for financial stability with a Medicare Supplement than an MA plan because there are no unexpected expenses for deductibles, co-payments, hospitalizations, surgeries, chemotherapy, etc.
With a Plan G Medicare Supplement, other than your premiums, your maximum OOP cost in the 2025 calendar year will be no more than the Part B deductible, which is currently projected to be around $257. With an MA plan, your in-network maximum OOP “in-network” costs can be as high as $9,350! If you go out of network, your costs can be significantly higher.
NOTE:The Medicare Part B deductible is payable only one time per calendar year. If you’ve already met that deductible, you won’t have any other costs for Medicare-approved charges for the rest of the year.
You are not limited to a specific geographic region or a restrictive network of doctors, hospitals, specialists, care facilities, etc. like you are with an MA plan. Most MA plans are HMO’s and you will normally pay all costs if you go out of network.
With a Medicare Supplement, you can go directly to the specialist of your choice, ANYWHERE in the United States, as long as they accept Medicare. Most MA plans require you to go through a primary care doctor first and get permission to see a specialist within the local, geographic network.
Unlike MA plans, there are no HMO or PPO plans or networks with Medicare Supplements. You can go to any doctor or specialist in the US as long as they accept Medicare.
If you want to go to a renowned treatment center such as the MD Anderson Cancer Treatment Center in Texas, you can do so with any Medicare Supplement, as long as they accept Medicare. You can’t do that with most MA plans.
If you move to another part of the country, you can keep your Medicare Supplement, but you cannot keep your MA plan if you move out of your network.
There are only 10 “standardized” Medicare Supplement plans to choose from, (Plan A through Plan N). Since Medicare Supplements are standardized, the coverage and benefits for every Plan G, etc. is exactly the same with every insurance carrier, so it’s much easier to shop around and compare “apples with apples.” MA plans are not standardized, and the co-payments, deductibles, out of pocket costs, etc. vary between MA plans, and they change every year making them unnecessarily complicated and confusing.
A Medicare Supplement plan cannot be cancelled as long as you pay your premiums. MA plans are annual contracts, and they can be cancelled or benefits changed at the end of each calendar year.
There is no Annual Election Period (AEP) for Medicare Supplements, and you don’t have to shop around every year and make sure that your coverage, co-payments, co-insurance, deductibles, and benefits haven’t changed since the previous year. If there are any Medicare changes from one calendar year to the next, your Medicare Supplement will automatically pay the difference.
Medicare Supplements are “portable” meaning that you can keep them and take them with you if you travel to another state or if you move to another state, and your Medicare Supplement cannot be cancelled for leaving your “service area.” With most MA plans, if you travel outside of the MA plan’s service area for more than six months, you could be dis-enrolled from the plan.
With a Plan G Medicare Supplement, there are no co-payments when you go to the doctor. With most MA plans, you have to pay co-payments every time you see a doctor.
You can switch Medicare Supplement plans or Medicare insurance carriers any time of the year as long as you meet minimum health and underwriting requirements. With an MA plan, you can only join or leave an MA plan during the AEP or a SEP. Otherwise, you are locked into your MA plan for the entire calendar year.
NOTE:In California, there is a law called the California Birthday Rule. Under this law, if you have a Medicare Supplement, you can change it every year during the 60 days following your birthday to any other Medicare Supplement plan with “equal or fewer” benefits. For example, if you have Plan G, you can switch to Plan G with any other insurance carrier, regardless of your health. If you have Plan G, you can also switch to Plan N because Plan N has fewer benefits than Plan G, etc. Under the birthday rule, you just can’t switch from a plan with fewer benefits to greater benefits.
As you can see from the facts mentioned above, the benefits of having a Medicare Supplement far outweigh the benefits of having a Medicare Advantage plan.
Are Some Medicare Advantage Plans Really Free?
Because some MA plans have very low monthly premiums or no monthly premiums at all, some unscrupulous individuals promote them as “FREE” Medicare insurance plans, which is inaccurate, misleading, and, in my opinion, unethical. During the AEP, there are a lot of commercials for MA plans on TV. If you listen carefully, the one thing you’ll NEVER hear them mention is the maximum out-of-pocket costs for those plans. In 2025, in-network OOP costs can be as high as $9,350, and if you go out of network, you can pay significantly more!
Also, regardless of whether you have an MA plan or a Medicare Supplement plan, you still have to pay the monthly Medicare Part B premium, which is currently $174.70 per month for most people in 2024. The Medicare Part B premium in 2025 hasn’t been released yet, but it is estimated to be around $185.00 per month.
You Can Always Get a Medicare Advantage Plan But You Can’t Always Get a Medicare Supplement Plan
MA plans are adequate as long as you are healthy, but if your health should change and you develop a serious illness, you will wish that you had a Medicare Supplement instead of an MA plan because you will have much more freedom of choice and control over your health care with a Medicare Supplement!
Original Medicare (Part A and B) only cover about 80% of medical and hospital costs and Medicare Supplements pick up most of the remaining 20%. During the AEP, you can always switch from a Medicare Supplement to an MA plan, regardless of your health, and you can always switch from an MA plan back to Original Medicare (Part A and Part B), regardless of your health. However, if you switch back from an MA plan to Original Medicare during the AEP, there is no guarantee that you can get a Medicare Supplement as you must be in good health, answer health questions, and be medically underwritten to be approved. If you have any serious health issues, more than likely, you won’t be able to get a Medicare Supplement.
NOTE:There are some situations where you can switch from an MA plan to a Medicare Supplement as a “guaranteed issue” without answering any health questions or going through medical underwriting. If you are in this situation, please let me know.
Also, if you are in the first year of your MA plan, you are guaranteed the right to switch back to a Medicare Supplement during the first 12 months. This is called a trial right. The trial period gives you a year to try an MA plan and see if it’s right for you. If you decide it’s not, you are guaranteed the right to switch back to original Medicare (Parts A and B) and purchase a Medicare Supplement plan.
The Maximum Out of Pocket Cost for MA Plans Can Be Twice As Much As You Think
Depending on which MA plan you have, the most you would pay for in-network out-of-pocket (OOP) costs in 2025 is $9,350 per calendar year! If you go outside of your plan’s network, you will pay even more than that!
Now suppose that you get really sick and need expensive treatment in the second half of the year. You could end up paying up to $9,350 (or whatever your plan’s maximum OOP cost is) by the end of the calendar year, but your OOP maximum zeros out in January, and it starts all over again! You could potentially end up paying your OOP TWICE in a 12-month period!
Conclusion
If you have an MA plan, you give up your Original Medicare (Part A and Part B) rights and you compromise your freedom of choice to go to the best doctors, specialists, hospitals, care facilities, etc. throughout the United States. Unless you are impoverished and can’t afford to pay the monthly premium for a Medicare Supplement, I would never recommend an MA plan to a friend or family member as you are always better off with a Medicare Supplement.
I’m an independent insurance agent, not a captive agent, and I work with most of the major insurance carriers. I shop around for my clients, every year, and I will shop around for you too! If you have any questions or if you have an MA plan and would like for me to help you switch to a Medicare Supplement plan, please let me know! And if you have a Medicare Supplement, I’m happy to shop around for you to save you money on your premiums!
There’s no such thing as free Medicare insurance! As the old expression goes… “You get what you pay for!”
If you liked this blog and found it informative, please click the “Like” button, and please send me your questions, comments, or feedback! And please 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
If you are a California resident and you have a Medicare Supplement, aka a “Medigap” plan, I have good news for you! Under a law called the California Birthday Rule, you have 60 days of “open enrollment” following your birthday each year when you can change your Medigap plan, REGARDLESS OF YOUR HEALTH. During this period, there are no health questions to answer, no medical underwriting or waiting periods, and YOU CANNOT BE TURNED DOWN FOR COVERAGE! To qualify, the new plan must have “equal or fewer” benefits as your current policy.
For example, if you have Plan G, you can switch to Plan G with any other insurance carrier or you could switch to Plan N since Plan N has fewer benefits than Plan G. You just can’t switch from Plan N to Plan G, etc. under the birthday rule because Plan N has fewer benefits than Plan G.
NOTE:In California, most insurance carriers will let you apply during the 30 days before your birthday up to 60 days after your birthday, so in reality, you have a 90-day open enrollment period each year.
You can change your Medigap plan any time of the year, but if you do so around your birthday, it’s a lot easier because you don’t have to answer any health questions on the application and you can’t be turned down for coverage.
The Annual Election Period
There is another open enrollment period called the Annual Election Period (AEP) that goes from October 15th through December 7th every year. This open enrollment period has nothing to do with Medigap plans. It’s only for people with Medicare Advantage (MA) plans and/or Prescription Drug Plans (PDPs). If someone has an MA plan or a PDP, the AEP is the time to shop around and change those plans. The new coverage would begin on January 1st of the following year.
During the AEP, you can always switch from a Medigap plan to an MA plan, but there is no guarantee that you can switch from an MA plan to a Medigap plan. If someone has an MA plan, they are guaranteed the right to switch back to Original Medicare, which is Medicare Part A (Hospital insurance) and Part B (Medical insurance). However, they are not guaranteed the right to get a Medigap plan unless they are in a special enrollment period (SEP) that allows them to do so.
For example, if someone had an MA plan for the first time and they have had it for less than one year, they would be in a SEP, and they could still get a Medigap plan. Otherwise, they would have to answer health questions, be medically underwritten, and they could be turned down for certain types of health conditions.
NOTE:Medicare Part A and Part B cover approximately 80% of medical and hospital costs, so most people will get a Medigap plan to pick up most of the remaining 20% of the costs that are not covered by Medicare.
Most States Don’t Have a Birthday Rule
Most states don’t have a birthday rule, so the California Birthday Rule is definitely very beneficial for California residents because if your health should change, or if your rates go up significantly, or if you are not happy with your plan or insurance carrier, etc., you can always change to a different plan or insurance carrier, REGARDLESS OF YOUR HEALTH, every year around your birthday. In contrast, for those living in a state without a birthday rule, you could be stuck with your current Medigap plan, insurance carrier, high monthly premium, etc.
NOTE:Some states have recently added their own version of a birthday rule such as Idaho, Illinois, Louisiana, Maryland, Nevada, and Oregon. Besides the birthday rule, other states offer guaranteed issue protections for changing Medigap plans including Connecticut, Maine, Massachusetts, Missouri, New York, Rhode Island, and Washington. Each of these states have their own rules and requirements for changing Medigap plans, which are beyond the scope of this article.
When is the Best Time to Apply For New Coverage Under the California Birthday Rule?
In California, Medigap rates are based primarily on your age and zip code. Other factors that can affect the rate is if you use tobacco products and whether you live alone or with someone else in the household. Under the California Birthday Rule, most insurance carriers base their rates on your age after your birthday, but a couple carriers base their rates on your age on the date your application is submitted and signed. This one year age difference can make a big difference in the rate so for this reason, I normally recommend checking Medigap rates during the 30 days before your birthday each year.
Under the birthday rule, the new effective date is usually the 1st of the month following your birthday. For example, if your birthday is June 3rd, the new effective date would normally be July 1st, etc.
IMPORTANT:I shop around for my clients every year around their birthday to take advantage of the California Birthday Rule. If you aren’t a client of mine, and you would like for me to shop for you too, please let me know. As an independent agent, I work with all the major insurance carriers, and there’s no charge for my service!
10 Standardized Plans To Choose From
Nationwide, there are 10 standardized Medigap plans to choose from with lettered names, Plan A through Plan N. The term “standardized” means that the coverage and benefits for every Plan F, Plan G, Plan N, etc. are exactly the same no matter what carrier you are with. In other words, Plan G with Anthem Blue Cross is exactly the same as Plan G with Blue Shield of California, etc. Plan G is Plan G, Plan N is Plan N, Plan F is Plan F, etc.
As of January 1st, 2020, Medigap plans purchased by individuals who are turning 65 or who are new to Medicare can no longer cover the Part B deductible, which is currently $240 in 2024. (That amount can change from year to year.) Because of this, Plan C and Plan F aren’t available to people who are new to Medicare on or after January 1st, 2020.
NOTE:If you turned 65 before January 1st 2020 or you were eligible for Medicare before then, you can still get Plan F and Plan C. Those plans just aren’t available for those individuals who turned 65 after January 1st, 2020, etc.
Medigap Plans Are Standardized but Medigap Premiums Are Not Standardized
Although the coverage and benefits for all Medigap plans are standardized, the premiums for these plans are not standardized, and the rates vary significantly from one insurance carrier to another for the same identical plan and coverage.
For example, for a 72 year old female living in Encinitas, CA in the 92024 zip code, Plan G rates currently range from $178 to $280 per month for the same exact plan and coverage! That’s a difference of $102 per month or $1,224 per year! Since the monthly premiums vary significantly between insurance carriers, it’s important to shop around periodically.
The Application Process
Today, almost all Medigap insurance carriers in California use online applications that the agent completes. I work with clients throughout California and in several different states, so it’s not necessary to meet in person. The application process is simple, and it usually takes less than 15 minutes to complete.
In addition to the application, under the California Birthday Rule, most insurance carriers require some kind of proof that you currently have a Medigap plan. A copy of your Medicare Supplement card or a recent bill showing which plan you currently have (Plan G, etc.) is sufficient. Once the application has been submitted, the entire application process normally takes a couple of days to a week to complete since there is no medical underwriting. Underwritten applications usually take longer. After you are approved, you should contact your current Medigap insurance carrier to let them know that you will be canceling your old policy when your new policy begins.
CAUTION – Some Insurance Carriers Are Better Than Others!
In addition to finding an insurance carrier with competitive rates, you also have to be careful to choose a good insurance carrier because not all carriers are the same. Although the coverage and benefits for Medicare Supplement plans are standardized and the same, not all insurance carriers are the same; some are better than others!
For example, some insurance carriers will give you a 12-month rate lock and some don’t. Some have better financial ratings than others. Some will give you up to a 12% household discount if you live with someone else in your household, and some don’t. Some have much better customer service than others. Some have call centers in the US and some are overseas. Some provide free gym memberships and some don’t, etc. Price is important, but there are also other factors to consider when choosing a Medigap plan.
For More Information
As an independent insurance agent, I work with the major insurance carriers in California, Nevada, Arizona, and Washington state. I’m not limited to one particular insurance carrier. I shop around for my clients, every year, to find them the best rates, and I’m happy to shop for you too!
If you have any questions about the California Birthday Rule, etc. or if you would like a free, no-obligation Medicare Supplement quote, please don’t hesitate to let me know. There is no charge for my services as I am compensated by the insurance carriers, not my clients!
My contact information is below, and please click here to check out what my clients have to say about me. If you feel that the information in this blog would be helpful to a friend or family member, please feel free to pass it on and please feel free to add your comments below!
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.
The Annual Enrollment Period (AEP), which is from October 15th through December 7th each year, is almost here!
If you currently have a Medicare Advantage (MA) plan, you should switch back to Original Medicare and get a Medicare Supplement plan instead!
IMPORTANT:If you have a Medicare Supplement plan (aka “Medigap” because it picks up the “gap” in Medicare coverage) the AEP does not apply to you unless you want to enroll in or change your Prescription Drug Plan (PDP).
Why Medicare Supplement Plans Are Better
With Original Medicare (Part A and Part B) and a Medicare Supplement, you have much more freedom of choice and lower costs than you do with an MA plan!
NOTE:Medicare Part A is hospital insurance and Part B is medical insurance.
Which Plan Gives You the Most Freedom?
With an MA plan, you are locked into the plan’s network of doctors, specialists, hospitals, and care facilities. If you want to see a specialist, you often have to see your preferred care provider first, who acts as a gatekeeper, before you can see a specialist within your network. If you want to see a specialist or doctor that is outside of your network, good luck! That will cost you a lot more in out-of-pocket (OOP) costs.
With a Medicare Supplement plan, you can go to ANY doctor, specialist, hospital, or care facility in the US as long as they accept Medicare!
For example, the MD Anderson Cancer Treatment Center in Texas accepts Medicare and therefore, they accept ALL Medicare Supplement plans. They don’t, however, accept most MA plans!
Which Plan Has Lower Out-Of-Pocket Costs?
With an MA plan, your OOP costs can be as high as $6,700 per calendar year and even higher if you go to doctors and/or care facilities that are outside of your network! With a Plan F or Plan G Medicare Supplement (the two best Medigap plans), the most you would normally pay in OOP costs in a calendar year is either $0 with Plan F or $183 with
Plan G!
NOTE:The $183 is the Medicare Part B (Medical) deductible, which is $183 per calendar year in 2017. That amount can change from year to year, but historically, it has always been very stable.
Maximum Out-Of-Pocket Costs for MA Plans in San Diego
The following data was obtained from the Medicare.gov website and shows the current OOP costs for MA plans in the 92009 zip code in San Diego. These costs currently range from $3,300 to $6,700 per calendar year!
If you go out-of-network with your MA plan, your OOP costs will be even higher!
Current (in-network) Maximum OOP Costs for MA Plans in the 92009 Zip Code:
AARP MedicareComplete SecureHorizons Plan 4 (HMO) – $3,400
AARP MedicareComplete SecureHorizons Premier (HMO) – $4,300
AARP MedicareComplete SecureHorizons Value (HMO) – $5,300
Aetna Medicare Choice Plan (PPO) – $6,000
Aetna Medicare Select Plan (HMO) – $3,400
Anthem MediBlue Coordination Plus (HMO) – $6,700
Anthem MediBlue Plus (HMO) – $3,400
Blue Shield 65 Plus (HMO) – $3,400
Brand New Day Classic Care Drug Savings (HMO) – $3,400
Brand New Day Classic Choice for Medi-Medi (HMO) – $6,700
Care1st AdvantageOptimum Plan (HMO) – $3,400
Coordinated Choice Plan (HMO) – $6,700
Health Net Healthy Heart (HMO) – $3,400
Health Net Seniority Plus Sapphire (HMO) – $6,700
Health Net Seniority Plus Sapphire Premier (HMO) – $6,700
Humana Gold Plus H5619-016 (HMO) – $4,900
Humana Value Plus H5619-037 (HMO) – $6,700
Kaiser Permanente Senior Advantage San Diego (HMO) – $4,900
Scripps Classic offered by SCAN Health Plan (HMO) – $3,400
Scripps Plus offered by SCAN Health Plan (HMO) – $6,700
Scripps Signature offered by SCAN Health Plan (HMO) – $4,000
Sharp Direct Advantage Gold Card (HMO) – $3,400
Sharp Direct Advantage Platinum Card (HMO) – $3,300
Sharp SecureHorizons Plan by UnitedHealthcare (HMO) – $3,400
In contrast, in a calendar year, your maximum OOP costs are either $0 with a Plan F Medicare Supplement or $183 with a Plan G Medicare Supplement!
Is Your MA Plan’s Maximum OOP Costs Really No More Than $6,700 Per Year?
If you stay within your MA plan’s network, your maximum OOP costs are not supposed to be more than $6,700 per calendar year. However, if you go outside of the plan’s network, your OOP costs can be significantly higher than that!
Suppose that you get really sick and need expensive treatment such as Chemotherapy, etc. in the second half of the year. You could end up paying up to $6,700 (or whatever your plan’s maximum OOP cost is) by the end of the calendar year and guess what? Your OOP maximum zeros out in January, and it starts all over again!
If you are still receiving expensive medical care in the beginning of the year, you could potentially end up paying your maximum OOP cost two different times in a
12-month period! For example, if your maximum OOP cost is $6,700, your total OOP cost in a 12-month period, not a calendar year, could be more than $13,400!
Which Plan Has Lower Co-Payments?
If you have an MA plan, you will make a co-payment almost every time you go to the doctor, see a specialist, a physical therapist, etc. With most Medicare Supplement plans, there are no co-payments for doctor’s visits, etc.
How Difficult is it to Switch From an MA Plan to Original Medicare and a Medicare Supplement Plan?
That depends if you are in a Special Enrollment Period (SEP).
Special Enrollment Period
If you currently have an MA plan, and you are in a SEP, you can switch to Original Medicare and to any six of the 10 “standardized” Medicare Supplement plans any time of the year, REGARDLESS of your health.
The six “guaranteed issue” Medicare Supplement plans are plans A, B, C, F, K, and L. In other words, if you are in a SEP, you are guaranteed the right to get a Plan F Medicare Supplement, but not a Plan G supplement, etc.
NOTE:You could apply for Plan G, but you would be medically underwritten, and you could be turned down for certain medical conditions.
The 10 Standardized Medicare Supplement Plans
Nationwide, there are 10 “standardized” Medicare Supplement plans to choose from (Plans A through N). The term “standardized” means that the benefits and coverage for every Plan F, Plan G, etc. is exactly the same with every insurance carrier. Unlike MA plans, which are not standardized, it’s much easier to compare “apples with apples” with Medicare Supplement plans.
Medicare Supplement rates are not standardized. They vary significantly between insurance carriers. For that reason, it’s very important to shop around every year!
NOTE:In the preceding chart, notice that the only difference between Plan F and Plan G is the $183 per calendar year Part B deductible.
SEP Situations
Here are some SEP situations that would guarantee you the right to switch back to Original Medicare and a Medicare Supplement plan:
The plan is leaving the Medicare program or stops service in your area.
You move out of the plan’s service area.
You leave the plan because the company has not followed certain rules or has misled you.
You decide to switch to Original Medicare within the first year of joining an MA plan when first eligible for Medicare Part A at age 65.
If you are in one of these situations, you cannot be turned down for Medicare Supplement insurance coverage, regardless of your health!
If You Are Not In a Special Enrollment Period
If you are not in a SEP, you will have to wait until the AEP (between October 15th and December 7th) to switch back to Original Medicare (Part A and Part B) on January 1st of the following year.
Although you can switch back to Original Medicare, there is no guarantee that you will be able to get a Medicare Supplement plan because you will be medically underwritten, and you must be in relatively good health to qualify for a Medicare Supplement plan.
If You Have Serious Health Conditions, You May Not Be Able to Get a Medicare Supplement Plan!
If you are not in a SEP and you are coming off of an MA plan during the AEP, you would normally have to meet minimum underwriting requirements to qualify for a Medicare Supplement plan, and you could be turned down for coverage.
If you live in California and you have serious health issues, more than likely, I can still get you a Medicare Supplement without having to answer any medical questions on the application! Call me for more details!
The Pros and Cons of MA Plans and Medicare Supplement Plans
Is there really an advantage to having a Medicare Advantage plan? Let’s take a look at the pros and cons of each, and you can decide for yourself.
MA Plan Advantages
Here are some benefits of having an MA plan:
MA premiums can be very low, and some plans have no monthly premiums at all.
Some MA plans include Medicare prescription drug coverage (Part D).
Maximum OOP costs are “limited.” Plans vary, but in 2017, the most you can pay in OOP costs is $6,700 per calendar year. (I wouldn’t really call this a “benefit” since $6,700 is a lot of money! With a Plan F Medicare Supplement, you won’t pay any OOP costs!)
Some MA plans offer additional benefits such as vision, hearing, dental, and other health and wellness programs. (Note that some Medicare Supplement plans also offer additional benefits such as free gym memberships, vision, and hearing aid benefits.)
Medicare Supplement Plan Advantages
Here are some benefits of having a Medicare Supplement plan:
You have much more FREEDOM of choice with a Medicare Supplement than you do with an MA plan because you can go to ANY doctor, hospital, specialist, or care facility in the United States as long as they accept Medicare. (You can’t do that with an MA plan.)
You have much for financial stability with a Medicare Supplement than an MA plan because there are no unexpected spikes in costs and OOP expenses for co-payments, hospitalizations, surgeries, chemotherapy, etc.
With a Plan F or Plan G Medicare Supplement, other than your premiums, your maximum OOP costs in a calendar year will be either $0 (Plan F) or $183 (Plan G) per calendar year in 2017. With an MA plan, your maximum OOP costs can be as high as $6,700 per calendar year!
Chemotherapy is very expensive. With an MA plan, you have to pay the entire 20% Medicare Part B co-payment for chemotherapy, which can cost thousands of dollars. With a Plan F or Plan G Medicare Supplement, the most you will pay for Chemotherapy is either $0 (Plan F) or $183 (Plan G)!
You are not limited to a specific geographic region or a restrictive network of doctors, hospitals, specialists, care facilities, etc. like you are with an MA plan. With most MA plans, you must use their providers or you may pay more or all of the costs if you go out of their network.
With a Medicare Supplement, you can go directly to the specialist of your choice, ANYWHERE in the United States, as long as they accept Medicare. With most MA plans, you must go through your primary care doctor first (the “gatekeeper”) before you can see a specialist within your network.
There are no HMO or PPO plans or networks with Medicare Supplements. If you have an MA plan and you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network for non‑emergency or non-urgent care services, your services may not be covered, or your costs could be higher.
If you want to go to a renowned treatment center such as the MD Anderson Cancer Treatment Center in Texas, you can do so with any Medicare Supplement, as long as they accept Medicare. You can’t do that with most MA plans.
If you move to another part of the country, you can keep your Medicare Supplement, but you cannot keep your MA plan if you move out of your network.
There are only 10 “standardized” Medicare Supplement plans to choose from, (Plan A through Plan N). Since Medicare Supplements are standardized, the coverage and benefits for every Plan F, Plan G, etc. is exactly the same with every insurance carrier, so it’s much easier to shop around and compare “apples with apples.” MA plans are not standardized, and the co-payments, deductibles, out of pocket costs, etc. vary significantly between MA plans, and they change every year making them unnecessarily complicated and confusing.
Your Medicare Supplement plan cannot be cancelled as long as you pay your premiums. MA plans are annual contracts, and they can be cancelled or benefits changed at the end of each calendar year.
There are no provider networks with Medicare Supplements. With MA plans, providers can join or leave a plan’s provider network anytime during the year meaning that you could have to start shopping around for a new doctor while simultaneously undergoing Chemotherapy or other specialized medical treatments.
There is no AEP for Medicare Supplements, and you don’t have to shop around every year and make sure that your coverage, co-payments, co-insurance, deductibles, and benefits haven’t changed since the previous year. If there are any Medicare changes from one calendar year to the next, your Medicare Supplement will automatically pay the difference.
You can travel around the US for as long as you want (or even move to a different geographic location), and your Medicare Supplement cannot be cancelled for leaving your “service area.” With most MA plans, if you travel outside of the MA plan’s service area for more than six months, you could be disenrolled from the plan.
With most Medicare Supplements, there are no co-payments when you go to the doctor. With most MA plans, you have to pay co-payments when you go to the doctor.
With Medicare Supplements, pre-certification is not required for surgeries, etc. as long as the procedure is “medically necessary.” With most MA plans, pre-certification is required for surgeries or before getting expensive treatments.
You can switch Medicare Supplement plans or insurance carriers any time of the year as long as you meet minimum health and underwriting requirements. With an MA plan, you can only join or leave an MA plan during the AEP. Otherwise, you are locked into your plan for the entire calendar year, except for certain circumstances, such as moving out of your plan’s service area, etc.)
As you can see, you are much better off with a Medicare Supplement plan than you are with a Medicare Advantage plan!
Conclusion
If you currently have a Medicare Advantage (MA) plan, you have given up your Original Medicare rights that you have worked so hard for, and you are compromising your freedom to go to the best doctors, hospitals, specialists, neurosurgeons, care facilities, etc. in the United States.
I would strongly urge you to switch back to Original Medicare and get a Medicare Supplement plan during the upcoming AEP, between October 15th and December 7th)! Contact me TODAY for more information or a free quote!
As an independent insurance agent specializing in Medicare Supplements, I work with ALL of the major insurance carriers, not one particular company. I will shop around for you, every year, and save you money on your Medicare Supplement insurance!
If you live in California and you have a serious medical condition, more than likely, I can still get you a Medicare Supplement at a competitive price without answering any of the health questions on the application!
I hope that you have found this article to be helpful and informative. Please feel free to forward this article to anyone who may be interested.
Your comments and feedback are appreciated! If you have any questions, please contact me… I’m always happy to help!
Yes, you read the title correctly. When it comes to Medicare Supplement plans, which are also known as Medigap plans because they pay for the “gaps” in coverage that are not paid for by Medicare, some of my clients prefer to pay retail instead of wholesale! That’s right, “Why pay less when you can pay more?”
Most people that I meet are very happy to save a lot of money on their insurance premiums, but there are always some that really don’t seem to care. Or maybe they are skeptical because it just “seems too good to be true,” which I can totally understand.
A Tale of Two Cities, I Mean Two Clients…
I was working with two different clients yesterday, Client “A” and Client “B.”
Client “A”
Client “A” has Plan F with Blue Shield of CA, and his monthly premium is $279 per month. I shopped around for him and found several other insurance carriers that are offering Plan F at much lower rates. The lowest rate that I found for him is $179.33 per month. That is a savings of $99.67 per month or $1,196.04 per year for the same identical plan and coverage!
Many people who have Plan F have been switching to Plan G because both plans are identical except there is no deductible with Plan F, and there is a small $166 (Part B) deductible with Plan G. That is the only difference between the two plans!
However, Plan G is usually much more cost effective (cheaper) because the rates are lower. So even if you pay the $166 deductible, in most cases, you still end up spending much less money with Plan G than Plan F.
In addition to getting the current Plan F rates for Client “A,” I also provided him with the current Plan G rates for comparison. If he switched from Plan F to Plan G, he would have saved even more money! The best Plan G rate is $156.70 per month. That would be a gross savings of $122.30 per month or $1,467.60 per year! If he spent the $166 deductible, his net savings would still be $1,301.60 per year! In this particular case, Client “A” would have saved even more money by switching from Plan F to Plan G.
Inexplicably, Client “A” decided to keep his current plan for another year!
Client “B”
Client “B” also has Plan F with Blue Shield of CA, and her rate is $219 per month. I shopped around for her and, like Client “A,” I found several other insurance carriers that are also offering Plan F at much lower rates. The lowest rate that I found for Client “B” is $170.99 per month. That is a savings of $48.01 per month or $576.12 per year for the same identical Medicare Supplement plan and coverage!
Client “B” also had the option to switch from Plan F to Plan G, and again, she would have saved even more money on her premiums by doing so. Her current Plan F rate is $219 per month, and the best Plan G rate for her is $147.19 per month. That would be a gross savings of $71.23 per month or $854.76 per year! If she spent the entire $166 deductible, her net savings per year would still be $688.76 per year!
Just like Client “A,” Client “B” also decided to keep her current plan for another year!
Some Common Misconceptions
It’s very baffling to me when I can literally save someone hundreds and even thousands of dollars a year on their premiums for the same exact plan and coverage, and for whatever reason they are not interested in doing so.
If my auto and homeowner’s insurance agent told me he could save me $100 a month on my premiums, I would be thrilled to be able to save that much money. I guess that some people just aren’t as happy about saving money as I am!
Misconception #1 – By Switching Medigap Plans, I Won’t Be Able to Go to the Same Doctors
Some people are reluctant to change Medigap plans because they are afraid that they won’t be able to continue seeing the same doctors. This is a misconception because you can go to ANY doctor or hospital in the US with your Medicare Supplement as long as the doctor or hospital accepts Medicare. If your doctor accepts your current Medicare Supplement plan, then they have to accept ANY Medigap plan or insurance carrier that you have, PERIOD.
Misconception #2 – The Rates Are Too Good to Be True
If the new rates are significantly lower than the current plan, some people think it’s either too good to be true or a huge rate increase is soon to follow. This is also a misconception because most of the carriers that I work with lock in their rates for the first 12 months, so there wouldn’t be any unexpected rate increases.
Misconception #3 – My Coverage Will Not Be the Same
Another common misconception is that the coverage will not be the same, even if someone is switching from Plan F to Plan F or Plan G to Plan G, etc. There are 10 “standardized” plans to choose from, Plan A through Plan N. This means that the coverage for every standardized plan is exactly the same with every insurance carrier. So if someone has Plan F with Blue Shield and they want to switch to Plan F with Mutual of Omaha, etc., the coverage is exactly the same. Plan F is Plan F is Plan F…Period!
One of the other reasons people don’t want to switch their Medicare Supplement plan is because they fear change. “Everything has been going great so far. Even though the rates are cheaper and the coverage is the same, why take a chance by going with a different carrier?”
If you decide to switch carriers, the transition is seamless. Your coverage with the first insurance carrier will end at the end of the month, and the new coverage begins on the 1st of the following month. There are no forms or paperwork to fill out. When you go to the doctor after your new coverage begins, they will make a copy of your new Medicare Supplement card, and after that, everything will be the same as before.
The California Birthday Rule
In California, there is a law called the California Birthday Rule. If you have a Medicare Supplement, you are lucky to live in California for more reasons than just the beautiful weather and the great beaches!
This law guarantees you the right to switch insurance carriers, EVERY YEAR, within 30 days of your birthday (before or after) REGARDLESS OF YOUR HEALTH and without answering any health questions on the application! This is known as your annual open enrollment period. If another insurance carrier is offering the same plan that you currently have, or if they are offering another plan that has fewer benefits, you are guaranteed the right to switch carriers every year if you want to, and you cannot be turned down due to health reasons.
For example, if you have Plan F and another carrier is offering Plan F for a lower rate, you are guaranteed the right to switch to the other carrier every year around your birthday, without answering any health questions on the application. Likewise, you are guaranteed the right to switch to a plan with fewer benefits as well. So if you have Plan F, which has the most comprehensive coverage, you could switch to Plan G if you want to because Plan G has fewer benefits than Plan F.
NOTE:Under the California Birthday Rule, if you have Plan F, you can switch to any other plan, but if you have any other plan, you cannot use the California Birthday Rule to switch to Plan F because it has more benefits than any other plan.
You can actually switch insurance carriers or plans any time of the year, but if you do so at any time other than during the 30 days before or after your birthday, you will have to answer the health questions on the application, you will be medically underwritten, and you could be turned down for coverage due to medical reasons. If you have any serious health conditions, you should apply during the 30 days before your birthday!
In most other states, there isn’t a birthday rule. That means that once you sign up, if you later develop any serious health issues, you would have to meet minimum health and underwriting requirements if you wanted to change your Medicare Supplement plan or your insurance carrier. If your insurance rates increased significantly, you could be stuck paying very high premiums for many years! In California, that would never happen because you can always change your insurance every year around your birthday, regardless of your health!
Rates Vary Significantly Between Insurance Carriers For the Same Identical Plans and Coverage
In California, rates are based on “attained age,” which means that your rates are based on your current age, and they usually go up in price every year as you get older. As mentioned before, there are 10 “standardized” Medicare Supplement plans to choose from, Plan A through Plan N. When I say “standardized,” that means that the coverage for Plan F, Plan G, etc. is exactly the same no matter which insurance carrier that you are with.
Although the coverage is exactly the same with every insurance carrier, the rates (prices) vary significantly between insurance carriers!
For example, in the 92056 zip code the Plan F rates for a 72 year old man range in price from $164.06 to $278.86 per month! That is a difference of $1,377.60 per year for the same exact plan and coverage! In other words, some 72 year old individuals in the 92056 zip code are paying $164.06 per month for their Plan F coverage while others are paying $278.86 per month for their Plan F coverage!
Examples of How I Recently Saved Clients Money By Switching From Plan F to Plan F
Here are some examples of how I took advantage of the California Birthday Rule and saved my clients a lot of money on their annual premiums by switching them from Plan F with one carrier to Plan F with a different carrier:
$142.08
$257.64
$334.08
$338.64
$349.68
$432.84
$498.24
$501.78
$501.78
$516.96
$536.76
$879.84
$1,003.56
Examples of How I Recently Saved Clients Money By Switching From Plan F to Plan G
Here are some other examples of how I took advantage of the California Birthday Rule and saved my clients a lot in their annual premiums by switching them from Plan F with one carrier to Plan G with a different carrier:
$203.12
$278.96
$349.16
$425.48
$462.68
$600.00
Although it’s not the norm, the most I have ever saved one of my clients, a married couple, was over $5,300 per year just by switching from Plan G with one insurance carrier to Plan G with a different insurance carrier! As you can see, it’s really important to shop around and compare rates!
Sometimes I Feel Like “I Get No Respect!”
Once in a while, however, I feel like Rodney Dangerfield because “I get no respect!” Most of my clients are 65 or over and many are retired and on fixed incomes. The majority are very receptive to saving money on their insurance premiums, but once in a while, I have to practically beg people to let me save them hundreds and even thousands of dollars a year on their premiums, and quite honestly, that drives me crazy!
For whatever reasons, some people, like Client “A” and Client “B,” are apparently not so budget conscious. I was very excited and happy to tell them how much money I could save them, and their response was basically “Let me think about it!”
Think about it? Really? What is there to think about! It seems to me that it’s pretty much a no-brainer. I can hear them now. “Do I want to save $1,200 per year on my premiums for the same exact plan and coverage? Hmm, this is really a tough one. What am I going to do with an extra $100 a month? This might complicate my taxes! Eh, who needs this kind of stress and aggravation!”
I don’t want any of my clients to feel stressed or aggravated! If you’re one of those individuals that prefer to pay wholesale instead of retail, instead of the other way around, please don’t hesitate to contact me if you have any questions or if I can help in any way. If you’d like me to, I’m happy to do the shopping for you, EVERY YEAR, to save you money on your Medicare Supplement insurance!
NOTE:Although this article focuses primarily on Medigap plans in California, I am licensed and work with Medicare Supplement insurance plans outside of California as well. If you need premium rates for other states, I am happy to provide you with that information as well.
If you or someone that you know would like a free quote, please let me know. If you know anyone that might enjoy reading this blog, please feel free to forward it on! And please feel free to send me any of your questions, comments, and feedback!
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.
IMPORTANTIf 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.
Accessing 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:
2.) Under the blue tab at the top left-side of page that says Sign Up/Change Plans, click Find health & drug plans.
The Medicare Plan Finder page displays.
3.) In the General Search section, enter your zip code and click Find Plans. The Step 1 of 4 page displays.
NOTEIf a survey window displays, close it and continue.
4.) 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.
5.) Enter your prescriptions in the text box and choose the appropriate dosages for each. A window, similar to the following, displays.
6.) 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.
NOTEThe 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.
8.) Click My Drug List is Complete when your drug list is complete. The Step 3 of 4 window displays.
9.) Click Add Pharmacy to add up to two pharmacies, and then click Continue to Plan Results. The Step 4 of 4 window displays.
NOTEYou can click the drop-down menu at the top of the page to select from more pharmacies near your zip code.
10.) 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.
NOTEBy 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!
NOTEIn 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).
After you click the name of the plan, a window, similar to the following, displays.
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.
The previous window shows the estimated monthly totals for prescriptions at CVS Pharmacy.
The previous window shows the estimated monthly cost (premium and deductible) for prescriptions at CVS Pharmacy.
The previous window shows the estimated monthly cost (premium and deductible) for prescriptions at Costco Pharmacy.
The previous window shows the estimated monthly cost (premium and deductible) for prescriptions through a mail order pharmacy.
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).
After you click the name of the plan you are interested in, a window, similar to the following, displays.
2.) Call the toll-free number for non-members, and speak to a representative of the company.
IMPORTANTIf 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.
The 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)
If 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.
Eligibility for Guaranteed Issue In California
In California, you would qualify for a guaranteed issue Medicare Supplement for any of the following situations:
Has your employer-sponsored retiree plan that is supplementing Medicare involuntarily terminated?
Has your employer-sponsored retiree plan stopped providing Medicare supplement benefits or the Medicare Part B 20% coinsurance for services?
Have you lost eligibility for an employer-sponsored retiree plan due to divorce or death of a spouse or family member?
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?
Have you moved out of the area of your MA plan or Program for All-Inclusive Care for the Elderly (PACE) organization?
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?
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?
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?
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.
For 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!
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.
Today, there are 10 standardized Medicare Supplement plans (Plans A through N). The coverage for these plans is the same no matter which insurance company you have. For example, the coverage and benefits for Plan F is exactly the same at Aetna, Cigna, Blue Shield, Stonebridge, Blue Cross, etc., so it’s much easier to shop around and compare plans and prices today.
As you can see in the following chart, Plan F provides the most extensive Medicare Supplement coverage. (The plans with the empty boxes indicate coverage that is not included with that particular plan.)
Of the 10 standardized Medicare Supplement plans (aka “Medigap” plans), Plan F is considered to be the best plan because it provides the most comprehensive coverage. Plan F pays for all of the coinsurance, copayments, and deductibles not paid for by Medicare.
Plan F pays for the following benefits:
Medicare Part A Hospital Deductible (Currently $1,216 per benefit period) *
Medicare Part A Hospital Coinsurance
Medicare Part B Deductible (Currently $147 per year)
Medicare Part B Coinsurance
Medicare Part B Excess Charges
Hospice Care Coinsurance or Copayments
Skilled Nursing Facility Care Coinsurance
Charges for First Three Pints of Blood
Foreign Travel Emergencies
* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Therefore, there can be multiple Part A hospital deductibles in one calendar year.
Which is Better, Plan F or Plan G?
Plan F and Plan G include the following benefits:
Freedom to choose any doctor or hospital that accepts Medicare patients.
Benefits start immediately with no waiting period for pre-existing conditions.
There are no networks and no referral needed.
No cancellation for age, health or the number of claims you file.
Covers 100% of all Medicare allowable excess charges.
Coverage that expands automatically with any future changes in Medicare.
Virtually eliminates all claims paperwork for you.
30-day, no-risk free look guarantees your satisfaction or you get your money back.
Medicare Plan G Is Identical To Plan F Except For the Part B Deductible
Medicare Plan G provides the same identical coverage as Plan F except it does not cover the $147 Part B calendar year deductible (in bold above). That is the only difference between the two plans. They are exactly the same in every other way! Plan F and Plan G are the only two Medicare Supplement plans that pay 100% of any excess charges, so there would rarely be any unexpected out-of-pocket expenses. (Excess charges are additional expenses incurred outside of the Medicare-approved charge. For example, if you go to a doctor that charges more than the Medicare-approved amount.)
Why Would I Choose Medicare Plan G Over Plan F?
The decision to go with Plan G depends on whether the annual savings will exceed the $147 Part B deductible. For example, if your Plan G premiums are $30 per month less than the Plan F premiums, then you will save $360 per year in premiums ($30 x 12 = $360). If you are healthy, and you didn’t go to a doctor that year, you would have saved $360 on your premiums. If you had to pay the $147 Part B deductible, then you still would have saved $213 for the year in premiums ($360 – $147 = $213). On the other hand, if your annual premium savings would be just slightly more than, equal to, or less than $147 per year, then you are unquestionably better off with Plan F.
The Likelihood of Future Rate Increases is Less With Plan G Than With Plan F
Under federal law, Plan F falls under certain Guaranteed Issue (GI) requirements while Plan G doesn’t. For example, if someone has their health insurance with an employer plan or if they are on a Medicare Advantage plan and they loose their coverage, in most cases, they are guaranteed the right to switch to Plan F, regardless of their health and without medical underwriting.
Plan G is not a guaranteed issue plan. Consequently, the overall pool of people with Plan G are healthier than those on Plan F, and the quantity of submitted medical claims is lower with Plan G. Rate increases are often a result of too much GI business, so “F” plans have historically had greater and more frequent rate increases than “G” plans. That’s not a guarantee that “G” plans won’t have future rate increases, but if they do, the increases will more than likely be smaller.
Make the Switch!
The Only Potential Risk That I See With Plan G…
The only potential risk that I see for the future is that nobody knows for sure what the Part B deductible for Medicare will be in the future. Between 2011 and 2012, the Part B deductible actually went down from $162 per year to $140 per year. For the last few years, from 2013 through 2015, the Part B deductible has been stable and remained the same at $147 per year.
Here is the history of Medicare Part B deductibles:
2017 — $183
2016 — $166
2015 — $147
2014 — $147
2013 — $147
2012 — $140
2011 — $162
2010 — $155
2009 — $135
2008 — $135
2007 — $131
2006 — $124
2005 — $110
1991 through 2004 the Part B deductible was $100
1982 through 1990 the Part B deductible was $75
1973 through 1981 the Part B deductible was $60
1966 through 1972 the Part B deductible was $50
As you can see, the historical Part B deductible rates have been relatively stable over the years. For me, it wouldn’t be an issue if I could otherwise save $200 to $300 per year by having a Plan G Medicare Supplement. On the other hand, many of my clients can afford to pay for the best and most comprehensive plan, Plan F, and they don’t want the uncertainty of not knowing for sure what the future will bring. Saving $200 to $300 per year isn’t always a big enough motivator for many to warrant switching from Plan F to Plan G. Then again, many retirees are on tight budgets and fixed incomes, and if that is the case, I would unquestionably recommend that they switch from Plan F to Plan G if they can save money on their premiums.
The California Birthday Rule
With the California Birthday Rule, you are guaranteed the right to switch plans every year within 30 days after your birthday, regardless of your health and without underwriting, if another company is offering the same plan or a lesser plan for less money. In other words, if you have Plan F, you can switch to Plan F with a different company if their rates are lower, or you could switch from Plan F to Plan G with a different company since Plan G is considered to have less benefits (the $147 Part B deductible) than Plan F. Rates vary significantly from one company to the next for the same identical plan and coverage, so it’s important to shop around every year.
Please let me know if you have any questions or comments!
If you or someone that you know would like a Medicare Supplement quote, please let me know, or click here to visit my website. Or, you can compare Medicare Supplement prices on your own by clicking the “Get A Quote” button below.
Sound 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.
The 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.
Medicare 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!
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