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Mistakes to Avoid When Deciding On The Best Medicare Advantage Plan

It was a heartbreaking meeting… sitting with a couple at their kitchen table as tears streamed down both of their faces. He was very ill, rapidly losing weight from digestive problems, and his constant migraine headaches were so painful, ending his life seemed to be the only option to live pain-free.

To say they were afraid would be an understatement. Physicians associated with his current Medicare Advantage Plan (Medicare Part C) could not diagnose the problem. They only prescribed more drugs, which exacerbated his issues. On top of his medical puzzle, the Plan denied medical tests, which might have ultimately diagnosed his problem. It was October 2011, and through their tears, they painfully asked, “What are our options?”

In this case, together we decided it was in his best interest to switch to a Medicare Supplement (MediGap) Plan, which would allow him to go to any physician or facility that accepted Medicare, along with a ” Stand alone Part D Prescription Drug Plan.” It was important that he be able to seek the best of the best, anywhere in the country. We chose an “F Supplement Plan” with a carrier that would allow him to switch between a lower and higher cost plan WITHOUT proving insurability (if in the future, he decided to maintain the Supplement Plan after his current medical puzzle was solved).

Could he have avoided this problem in the first place? Possibly. Here are a couple of mistakes I have seen, along with the solutions, to help you choose the right option for YOU:

MISTAKE #1: Who are you working with?

* Working with a “captive insurance agent” (direct employment with the carrier, many times they are compensated by W2, commissions and/or bonuses) or working with an ‘independent career agent’ (1099 contractor with the carrier and provided with leads). The latter term is very confusing to me. They are classified as independent, yet if they write an application with another carrier because it was right for the beneficiary, their contract may be terminated. What incentive does the agent have to be non-partial, if they will lose their lead source?

** Another mistake is working with an agent that is not certified to market all types of Medicare health plans. They can only market ‘some’ MediGap’ supplement plans with no certification.

*** Going directly to the insurance carrier. If something goes sideways, it will come in handy to have an advocate on your side especially one you can see and lives/works in your community.

SOLUTION #1:

* Choose an independent insurance agent that represents more than one insurance carrier. Why? Because independent agents will know the pros and cons of ALL the Plans and be able to relay this info so you can make an EDUCATED choice. They receive compensation from the insurance carriers but do not have allegiance towards any particular company. Also be on the look out for carriers that force their ‘independent agents’ to sign an exclusive agreement. I have seen this happen with ‘Dual Eligible Plans’ (Medicaid/Medicare Plans). Again, how can the agent be ‘non-partial’ if they are contractually obligated to only market one Plan?

** Choose a ‘Certified’ Medicare insurance agent that is able to market Part C, Part D and MediGap Plans. They have additional training and oversight.

*** When you go to directly to the carrier, you are eliminating a valuable person who will troubleshoot problems if any should arise, while providing you additional peace of mind throughout the process.

MISTAKE #2: Choosing a Medicare Advantage Plan that requires you to obtain the insurance company’s approval before having a procedure/test.

SOLUTION #2: When comparing Plans, turn to the ‘Summary of Benefits’. All carriers must publish these and they must be alike and easy to compare.

MISTAKE #3: Not paying attention to the ‘maximum out of pocket’ (MOOP) limit. All Medicare Advantage Plans have a MOOP and many agents glaze over it while helping you choose your Plan. However, should a catastrophic medical issue arise (cancer, organ transplant, long stay in a skilled nursing facility, etc.), there is a good chance you will hit your MOOP so you want to make sure it’s the lowest possible.

The reason: chemotherapy and anti-rejection drugs are considered Part ‘B’ out-patient drugs, not Part ‘D’ prescription drugs and many Plans only pay 80% of Part B drugs. Therefore, you would be on the hook for 20% and they are very expensive.

SOLUTION #3: Compare, compare, compare and choose a Plan with a lower MOOP.

MISTAKE #4: Choosing a Plan just because the drug co-pays are slightly lower. Many smaller insurance companies will lure you to their Plan with very low co-pays on their drug formulary but have a smaller network of doctors/facilities in which to choose. The problem is, should a medical issue arise, you may be locked into the smaller network of physicians/facilities until Medicare’s Annual Open Enrollment.

SOLUTION #4: If you’re having trouble paying for prescription drug co-pays and your income/assets are low enough, you may be eligible for Extra Help through social security. A good insurance agent will bring this up and guide you, or go to https://secure.ssa.gov/i1020/start. By obtaining help with your medication, you can choose the best Plan based on other options (the size of their network, authorization rules, physician/facility convenience, additional optional benefits, etc.)

MISTAKE #5: Choosing a Plan because you want a PPO Plan and not an HMO.

SOLUTION #5: Many people are under the misconception that with a PPO Plan, they can go to any doctor/facility they choose. In actuality, PPO Plans still have a network of doctors/facilities you must stay in to obtain the lower costs. The biggest difference between a PPO and HMO is with a PPO, you will not have to obtain a ‘referral’ to see a specialist. With an HMO, you must obtain a referral. To be able to choose ANY physician/facility in the country that accepts Medicare, you should consider a Medicare Supplement (MediGap) Plan.

I have seen most mistakes and solutions when it comes to choosing Medicare Advantage Health Plans. Outside of California, there are additional varieties of Plans, and may be additional challenges.

What happened to my client, you ask? Since I keep in constant contact with my clients, in June I was overjoyed to hear him exclaim the great news. With the same test that was denied by his previous Medicare Advantage Plan, two physicians from a major Los Angeles medical group pinpointed the problem. He was slowly leaking spinal fluid and was dangerously close to having none remaining.

With a quick out-patient procedure, they basically laser-glued the leaking area, replaced his spinal fluid and he is healthier, happier and better than ever! Since he is now well, we’ll be reviewing his coverage during Medicare’s Annual Open Enrollment (October 15 – December 7, 2012) and deciding whether to keep him on the Supplement or switch him to a Part C Medicare Advantage Plan.

As an insurance agent for many years, I have stories like this and many more. With compassion, our profession helps to navigate the best options, explain the pros/cons based on our clients’ individual needs and offer peace of mind. Plans change every year and your health/financial status may change also, therefore it is a good habit to make a comparison each year. In closing, choose a good, local, independent insurance agent, be educated and stay well-informed!

Medicare Advantage Plan

A Medicare Advantage Plan, also known as Medicare Part C, is a type of health insurance plan offered by private insurance companies as an alternative to Original Medicare (Medicare Part A and Part B). It combines the benefits of both hospital (Part A) and medical (Part B) coverage, often including additional benefits such as prescription drug coverage, vision, dental, and wellness programs.

Key points about Medicare Advantage Plans:

Private Insurance Companies: Medicare Advantage Plans are offered by private insurance companies that are approved by Medicare. These plans are required to provide at least the same coverage as Original Medicare, but many plans offer additional benefits beyond what Original Medicare covers.
Coverage and Benefits: In addition to hospital and medical coverage, many Medicare Advantage Plans include coverage for prescription drugs (Part D) and extra benefits like routine dental, vision, hearing, and wellness programs. These added benefits can vary widely between different plans.
Network Restrictions: Medicare Advantage Plans often have provider networks, which means you may need to use doctors and hospitals that are within the plan’s network to receive full coverage. Some plans also offer out-of-network coverage but may have higher costs associated with it.
Costs: While Medicare Advantage Plans can have lower premiums compared to purchasing separate Medicare Part A, Part B, and Part D plans, they may have different cost-sharing arrangements, such as copayments and deductibles. It’s important to review the plan’s details to understand the costs involved.
Enrollment and Disenrollment: To enroll in a Medicare Advantage Plan, you must first be enrolled in both Medicare Part A and Part B. Enrollment is typically done during specific enrollment periods, such as the Initial Enrollment Period, the Annual Enrollment Period, or during special circumstances. You can also switch or disenroll from a Medicare Advantage Plan during certain periods.
Rules and Regulations: Medicare Advantage Plans must follow Medicare guidelines, but they may have their own rules, networks, and coverage limitations. It’s essential to carefully review the plan’s Summary of Benefits and other materials to understand how the plan works.
Geographic Coverage: The availability of Medicare Advantage Plans can vary by location. Some areas may have multiple plan options, while others may have fewer choices.

It’s crucial to thoroughly research and compare different Medicare Advantage Plans based on your individual health needs, budget, and preferences before making a decision. Consulting with a licensed insurance agent, a Medicare counselor, or a knowledgeable healthcare professional can help you make an informed choice that suits your specific circumstances.

Medicare

Medicare is a federal health insurance program in the United States that provides coverage for individuals aged 65 and older, as well as certain younger people with disabilities or specific medical conditions. The program was established in 1965 under the Social Security Act and is administered by the Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services.

Medicare is designed to help people cover the costs of medical services, hospital stays, and other healthcare needs. It consists of several parts, each covering different aspects of healthcare:

Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care services. Most people do not have to pay a premium for Part A if they or their spouse have paid Medicare taxes while working.
Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, and some home health care services. Beneficiaries pay a monthly premium for Part B coverage.
Part C (Medicare Advantage): This is an alternative to Original Medicare (Parts A and B) and is offered by private insurance companies approved by Medicare. Medicare Advantage plans often include Part D (prescription drug coverage) and may offer additional benefits such as vision, dental, and fitness programs.
Part D (Prescription Drug Coverage): Provides prescription drug coverage through private insurance plans approved by Medicare. Beneficiaries can choose a standalone Part D plan to supplement Original Medicare or choose a Medicare Advantage plan that includes prescription drug coverage.
Medigap (Medicare Supplement Insurance): Medigap plans are private insurance policies that help cover certain out-of-pocket costs associated with Original Medicare, such as deductibles, copayments, and coinsurance.

It’s important to note that while Medicare covers a significant portion of healthcare expenses, it may not cover all costs, and beneficiaries may still have some out-of-pocket expenses. Additionally, eligibility requirements, coverage options, and costs can vary, so individuals are encouraged to carefully review their options and choose the plans that best meet their needs.

Since my knowledge cutoff date is in September 2021, there may have been changes or developments in the Medicare program since then. It’s always a good idea to refer to the official Medicare website or consult with a qualified healthcare professional for the most up-to-date information.

Insurance

Insurance is a way to protect against financial loss. It involves paying a premium to an insurance company in exchange for the promise of payment or reimbursement for certain losses or damages. Insurance can help individuals, businesses, and organizations manage risks and protect against unexpected events.

There are many different types of insurance available, including:

Health Insurance: This type of insurance helps cover the cost of medical expenses, such as doctor visits, hospital stays, and prescription drugs.
Life Insurance: Life insurance provides a lump-sum payment to the insured’s beneficiaries in the event of their death. It can help provide financial security for loved ones and cover expenses such as funeral costs and outstanding debts.
Auto Insurance: Auto insurance provides coverage for damage or injury caused by a car accident. It can also provide coverage for theft, vandalism, and other incidents.
Homeowners Insurance: This type of insurance helps protect homeowners against damage or loss to their property, as well as liability for injuries or damage caused to others on their property.
Renters Insurance: Renters insurance provides coverage for personal property and liability for renters.
Business Insurance: Business insurance provides coverage for various types of risks that businesses may face, such as liability, property damage, and employee injuries.

Insurance policies can vary widely in terms of coverage, exclusions, and premiums. It’s important to carefully review any insurance policy before purchasing it and to understand what is covered and what is not.

Insurance companies use various methods to assess risk and determine premiums, including actuarial science, statistical analysis, and underwriting. Factors such as age, health status, driving history, and location can all impact insurance premiums.

In conclusion, insurance is a way to protect against financial loss and manage risks. There are many different types of insurance available, including health insurance, life insurance, auto insurance, homeowners insurance, renters insurance, and business insurance.

It’s important to carefully review any insurance policy before purchasing it and to understand what is covered and what is not. Insurance companies use various methods to assess risk and determine premiums, and factors such as age, health status, driving history, and location can all impact insurance premiums.