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Medicare Advantage Plans

Medicare Advantage Plans are managed health programs that serve as a substitute for both “Original Medicare” Part A and B benefits. There are a number of types of Advantage plans.  The majority are either HMO or PPO plans. Medicare Part A provides payments for in-patient hospital services and stays. Part B provides coveage for outpatient services.  Doctors visits, lab work, scans and x-rays all fall under part B.  Original Medicare claims are processed through the Centers for Medicare and Medicaid Services (CMS). Medicare Advantage plans are offered by commercial insurance companies. They receive compensation from the federal government, to provide all Part A and B benefits to enrollees, but do not pay claims through the CMS.

Most Medicare Advantage plans (sometimes referred to as “Part C”) include the Part D prescription drug benefits, and are known as a Medicare Advantage Prescription Drug plan (MAPD). The government makes seperate payments to the plans offering drug benefits with the advantage plan. Medicare pays the insurance company a set amount every month for members enrolled in the plans.

Medicare Advantage plans

must offer a benefit that is at least equal to Medicare’s and covers what Original Medicare covers. They do not have to cover every benefit in the same way. Plans that require higher out-of-pocket costs than Medicare for some benefits,  can balance it out by offering lower copayments for doctor visits or other benefits.  CMS limits how much the Medicare Advantage plans can vary from benefits under Original Medicare. Many plans offer benefits which are not covered by Original Medicare.  They do this as a value added benefit to entice more people to enroll in the plan.

All Medicare Advantage plans must have out of pockets maximums for medical services.

The limit for 2016 is $6,700 medical out of pocket.  This applies to in-network services only. Once the out of pocket maximum is obtained, the plan will pay all additional costs. This assumes the services received are in network.  Medicare advantage plan have networks. This means the enrollee must use in network doctors to be covered.  There are exceptions to this such as with a PPO plan.

Other ways to get care out of network would be for an emergency or urgent care situation. Enrolling in a PPO plan provides the ability to go out of network. PPO plans permit a subscriber to use any physician or hospital, but at a somewhat higher expense. Certain PPO plans can lead to much higher costs for going out of network.  The combined out of pocket max goes up to $10,000 on a PPO.  The total is for in and out of network usage.

People can enroll in a Medicare Advantage plan

when first eligilble for Medicare A and B.  They must enroll in A and B prior to enrolling in an advantage plan.  Under most situations, the member can change plans every January during AEP. There are exceptions to this rule however. Many states have multiple Advantage plans offered by various companies.  Some states have over 20 different plans to choose from.  Companies will also offer plans by county.  They may offer a plan in one county but not another within the same state. 

People with low medical utilization tend to migrate towards advantage plans.  If someone is going to the doctor a few times a year on average, they tend to look at the low Advantage premiums as a way to save money. Those with higher medical utilization will have a tendency to go with a Medicare supplement plan of some type.  Supplements tend to have higher premiums and less out of pocket costs which appeals to someone utilizing care more often.  Supplements are also attractive to those that do not want to abide by a network of doctors.  Others tend to go with a supplement to avoid the need for prior authorization which is required on advantage plans.

Trial Right–

Medicare Advantage trial rights are rules that allow someone to switch out of their advantage plan. There are two cases in which a trial right is created.

• Taking an advantage plan when first eligible for Medicare.  A trial right is created allowing the member to change back to Original Medicare any time in the first 12 months.  They can go to Original Medicare with a supplement and/or Rx plan the first of any month
• Taking an advantage plan for the first time. If someone is taking an Advantage plan for the first time. (Even if they have been on a supplement previously). They will have a trial right for the first year they are in the advantage plan. This would allow them to change to a supplement and/or drug plan

AEP- At this time you can change your plan (Advantage to supplement or supplement to advantage) every January 1st during AEP.  At this time someone can make any change they would like. Some states will underwrite a move to a supplement however.

MADP- During this period, a person may leave an advantage plan and go back to Original Medicare.   MADP runs from  January 1 through February 14th every year.  They can also enroll in a supplement and/or Rx plan if they would like.

SEP- A Special Election Period allows someone to make a change outside of AEP.  Certain circumstances will create a SEP.  Moving outside the plan service area, qualifying for extra help, lose of employer coverage.  These are all examples that would create a special election.

Additional Resources:

 Medicare Basics Video – Click here

 For Medicare Advantage Basics Video Click

Click for Medicare Supplement Basics Video

Medicare Information for state of Connecticut

Medicare Supplement Plans

Medicare Supplement Plans, also called “Medigap” insurance, provides extra coverage for Medicare beneficiaries. People in Original Medicare often take Medicare Supplement insurance to cover the gaps in Original Medicare. Medicare has two parts, Part A and Part B.  Both programs have gaps in coverage that a supplement may cover. (Depends on which on is purchased.)

Gaps In Coverage

Part A Gaps:

Medicare Part A (Hospital Insurance) covers inpatient hospital, inpatient skilled nursing facility, home health, and hospice services.  The following is a list of gaps in coverage:

• Hospital deductible per stay
• Hospital coinsurance (Medicare covers the first 60 days in full after the deductible has been met.  Days 61 to 90 have a copayment, and days 91 to 150 – the “lifetime reserve” –  a higher copay.
• No coverage after 150 days.
• Skilled nursing facility coinsurance payments (Medicare covers the first 100 days).
• No coverage after 100 days.
• Home health aide services that are provided on more than a part-time basis.
• Home health nursing and aide services.

See exact amounts for the current year here.

Part B Gaps

Medicare Part B (outpatient coverage) provides coverage for a number of outpatient and physician services.  It also pays for durable medical equipment, prosthetic devices, supplies and ambulance.  The following is a list of gaps Medicare does not cover.

• Part B deductible (annual deductible of $166).
• Part B 20% coinsurance payment (Medicare pays 80% of the allowable charges).
• Balance billing above the Medicare-approved charge (some physicians and providers charge more than the amount Medicare approves).  Billing above Medicare approved amounts not allowed in all states.  The amount they can bill above is limited as well.

Who Needs Medicare Supplement Plans?

There are a number of programs that help fill in the gaps of A and B.

• Government Programs such as QMB or Full Medicaid.
• Group Retirement Plans.
• Standardized Individual Medigap Policies. (Means the plans have the same core benefits.)

If you have Medicaid or are a QMB

Medicare beneficiaries with Medicaid (Title 19 or QMB) usually do not need Medigap insurance because Medicaid will cover their out of pocket costs. Chick here for a short video about Medicaid.  Not all doctors and facilities will take Medicare however.  People who do not qualify for Medicaid may still be eligible for the QMB program. QMB program benefits include:

• The payment of monthly Medicare premiums.
• All costs of Medicare annual deductibles.
• Payment of Medicare coinsurance.

Those not on Medicaid or QMB

People that are not on Medicaid or QMB may want to consider one of the many Medicare supplement plans available.  Currently, there are plans A,B,C,F, High F,G,K,L,M and N. Each plan covers different amounts of the gaps not covered by Original Medicare.  Plans are standardized which means benefits in a plan must be the same from company to company. Example: Plan F has the same benefits no matter who offers it.  A persons health is the biggest factor when choosing between all the options. Price point of a specific plan in an area is a consideration as well. Many people take a Medicare supplement because there is no network to follow.  As a result, the beneficiary may see any provider that accepts Original Medicare when using a Medicare supplement plan.

What is the best Medicare supplement plan option?

There is not a perfect plan for everyone.  Each individual situation is different and as a result, the right supplement for one person may be wrong for another.  In general plans F,N,G,K and High Deductible F have the best price points for the benefit.  This is very dependent on the state you reside in however.  In most states, the best deal for a supplement is the high deductible F supplement.  Most people do not understand how high F works however so they overlook it.   CLICK FOR MORE INFO ON HIGH DEDUCTIBLE F SUPPLEMENT  Note: call our office at 203-796-5403 or email Edward@croweandassociates.com if you want a quote over the phone or sent to you by email.

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When do you take a Medicare Advantage plan instead?

A Medicare Advantage Plan is not a supplement. Instead,they are very different types of plans.  A supplement is secondary to Medicare.  A Medicare Advantage plan replaces Medicare and acts as the primary insurance as a result.  There are a number of things to consider when choosing a supplement or Advantage plan.  What doctors will be used?  How often is care received? Does the beneficiary plan to travel? These are just a few things to consider when choosing.

Do they cover prescriptions?

Medicare Supplement Plans do not include Rx coverage.   A beneficiary can consider a stand alone drug plan for coverage because they can not buy a supplement with a drug plan.  Instead they would buy a part D plan from an insurance company. The part D plan can be from a different company than the supplement company.  Part D plans are offered by many companies. They have very different premiums and benefits from one company to the next.

What plans are popular? 

It depends on the state you live in but, in general, plans F, N and G are popular choices.  The high F plan can be the best choice if the cost is low. Some states have low cost High F plans and others do not.  Some states allow you to change from one supplement to another any time.  The change can be made without any type of health check.  Other states will check health if changing plans outside of a guaranteed issue period.

More info about Medicare Supplement plans.

Supplements will only cover services allowed by Medicare. If Medicare does not approve the care, the supplement will not cover it either.  An example is acupuncture which is not covered by Original Medicare. The supplement will not cover the charges either. Medicare supplement benefits do not change every January like they do with an Advantage plan.  The premium is subject to change but the benefits do not.  Medicare supplement plan F will no longer be available as of 2020. As a result, the plan G supplement will be the closest option to a plan F.  This is not a big issue because those in it already can keep it but no one can buy a new plan F as of 2020.

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Medicare Part B Coverage

Medicare Part B coverage is medical insurance.  Part B covers doctor visits.  It also covers well visits.  Coverage for medically necessary services and supplies is provided. This coverage includes any service or supply that you require for either diagnosis and or treatment of a medical condition. Part B also covers outpatient services.  Covered services include those provided by either a hospital, doctor’s office, clinic or other health care facility.

Medicare Part B also covers many preventive services to prevent illness or detect them at an early stage.  Together,  Parts A and Part B are known as Original Medicare.

Medicare Part B benefits

Medical services and supplies covered by Medicare Part B include (but may not be limited to):

• Doctor’s visits,
• Urgent care visits,
• Laboratory tests,
• X-rays,
• Emergency ambulance services,
• Mental health services, and
• Durable medical equipment.
• Preventive services, such as pap tests, flu shots, and screenings.
• Rehabilitative services, including physical therapy, occupational therapy, as well as speech-language pathology services.

Part B has a monthly premium associated with it.  The monthly premium is $104.90 in 2016.  If you get either Social Security, Railroad Retirement Board, or Office of Personnel Management benefits, your Part B premium will be automatically deducted from your benefit payment. If you don’t get these benefit payments, you’ll get a bill.   Note:   If you did no take Part B when you were first eligible, the cost of Part B will go up 10% for each full 12-month period that you  could have had Part B but didn’t sign up for it, except in special cases. You will have to pay this penalty as long as you have Part B.

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