BY MARGARET STEDT
Agents play a key role in helping the new Medicare Beneficiary in deciding what type of coverage and then the plan thatbest fits their needs. Many of the Medicare Beneficiaries are confused and frustrated as Medicare Coverage is brand new to them with different names, coverages and plan types than what they experienced on either group insurance plans or individual plans (On or Off Exchange).
When meeting with the Medicare beneficiary you should start by asking what their questions and concerns are. Ask what type of coverage they are on now and how it is working for them.
Who are their doctors and do they have relationships with specialists in several Medical Groups? Are they comfortable with the idea of a referral process? Do they travel both inside and out of the country? Is prescription drug coverage important to them and have there been any challenges? These questions will help you inexplaining the options and to determine which plans to consider.
Many times, the beneficiary insists that they want a PPO plan like their current coverage. This needs to be addressed carefully as you explain the difference between a MedicareSupplement Plan and the various types of Medicare Advantage Plans. Never say a Medicare Supplement Plan is a type of PPO plan. In the senior products arena, a PPO is a type of Medicare Advantage Plan.
Agents need to be able to explain the difference between the MedicareSupplement Plans (Med Supps) and the Medicare Advantage (MAPD) Plans.
I begin by using Section 1 of the CMS booklet “2021 Choosing a MediGap Plan “(CMS Product No. 02110) that is typically provided with the Medicare Supplement Sales Kit. I find the charton page 7 helpful for the beneficiary to take notes on.
The first step is to explain about Part A and B of Medicare by reviewing the different parts of Medicare. Note that there is no maximum out-of-pocket for the copayments, deductible and coinsurance amounts of Medicare.
Agents should review the monthly cost for Part B and IRMAA and note that it typically changes each year. The IRMAA (Income Monthly Adjusted Income Amount) for Part B and D may be found on the www.medicare.gov website.
Many times, the beneficiary insists that they want a PPO plan like their current coverage. This needs to be addressed carefully as you explain the difference between a MedicareSupplement Plan and the various types of Medicare Advantage Plans. Never say a Medicare Supplement Plan is a type of PPO plan. In the senior products arena, a PPO is a type of Medicare Advantage Plan.
Agents need to be able to explain the difference between the Medicare Supplement Plans (Med Supps) and the Medicare Advantage (MAPD) Plans.
The next step is to review the two main ways to get Medicare coverage
- by remaining on Original Medicare and enrolling in a Medicare Supplement (MediGap) Plan
- enrolling in a Medicare Advantage Plan (also known as a Part C of Medicare.
I use the chart provided on page 7 of the CMS MediGap Booklet to review the differences in the plans. Once the client understands Medicare Part A and B then it is time to review the difference between Med Supps and MAPD plans.
REVIEWING THE MEDICARE SUPPLEMENT PLANS
These plans are designed tocover the out-of-pocket costs such as coinsurance and copays of Medicare Parts A and B. The Original Medicare Part A and B is the primary coverage (pays first) and the Med Supp is secondary. The plans will only pay if itis a Medicare approved service and Medicare pays first.
There is a monthly premium for the plans. The rates for the most of the plans in California are based on the covered person’s age andresidence zip code or county. The rates will change from year to year based on age and a rating action by the company. If they move to another state, they may keep their plan but will pay the rates for the highest premium rate area.
Medicare Supplement Plans are subject to underwriting and pre-existing clauses apply unless the beneficiary meets a Guaranteed Issue (GI) situation. Agents should review the underwriting guidelines for each company they are representing. While the GI situations follow the CMSand state requirements, there are variations between the companies in the plans that can be offered andsome the situations such as voluntary or involuntary termination from a group insurance. Also, if and what plans can be offered to the age 65 Medicare Beneficiary.
In California we have the advantage of the California Birthday Rule that allows the covered person to change to an equal or lower plan (e.g., G to another company’s G or Innovative G or G to an N). The Guaranteed Issueperiod is on and 60 days following their birthday.
The main benefit to a Medicare Advantage plan is these plans include both Parts A and B and cover most,if not all the deductibles and out of pocket costs associated with Original Medicare. Many Medicare Advantage plans also include Part D coverage (prescription drugs), at no additional premium. Members will still be responsible to pay Part B premiums.
As the plans are designed to cover the copayments and coinsurance amounts of Medicare, they do NOT cover additional services suchas dental, Part D prescription drugs, hearing (hearing aids, exams and screenings), transportation, routine eye care and most glasses andcontacts and most health care outside the United States. However, in California some companies are now offering the Innovative Plans (one company calls theirs Extra) that offer vision and hearing benefits.
The advantages of a Medicare Supplement are:
- Choice of any doctor who accepts Medicare anywhere in the U.S.
This means if the beneficiary wants to see a Johns Hopkins doctor on the East Coast or a doctor at UCLA, they have that option. Of course, they areresponsible for all transportation, but at least they have the option. - Med Supp’s are portable, meaning if the covered person moves, the policy moves with them without anyunderwriting.
- The policy is guaranteed. This means the company cannot cancel the policy for anything other than non-payment. So regardless of the use, the covered person can rest assured that they will always have coverage.
- A MediGap Plan may reduce out-of-pocket costs. Medical costs are fixed and do not vary month to month.
The main disadvantages to Medicare Supplement plans are the premium costs that typically increase each year and no additional benefits. Some companies may offer ancillary benefits such as gym membership, over the counter items, chiropractic and acupuncture and limited overseas travel (depending on the plan). Remember the plans are designed to cover the copays and coinsurances of Medicare. (Plan C & F cover the Part B deductible.) The Medicare beneficiary must enroll in astand-alone prescription drug plan for coverage for their Part D prescriptions drugs.
In addition, there is an issue regarding skilled nursing coverage. If the Med Supp covered person was not admitted to the hospital as they were on observation status and did not meet the three-day hospital stay requirement prior to being admitted into skilled nursing, Medicare will not pay, so the Med Supp will not as well.
If a covered person disagrees with a decision by Medicare for a denialof coverage, there is an appeals and grievance process to request that Medicare revisits the decision.
Part C of Medicare are MedicareAdvantage plans. Medicare Advantage plans are approved by Medicare and administered by private insurance companies, taking the place of Medicare. This does not mean the member loses Medicare, as they can revert back to Original Medicare under Medicare guidelines, it just means the health plan will pay out Part A and Part B benefits instead of Medicare.
The main benefit to a Medicare Advantage plan is these plans include both Parts A and B and cover most,if not all the deductibles and out of pocket costs associated with Original Medicare. Many Medicare Advantage plans also include Part D coverage (prescription drugs), at no additional premium. Members will still be responsible to pay Part Bpremiums.
There are several types of Medicare Advantage plans such as Health Maintenance Organization (HMO) Plans, Preferred Provider (PPO) and Special Needs Plans. The plan offerings vary by company and by county. Note the benefits can be no less thanthose offered by Original Medicare. Depending on the company’s plan there may be a monthly premium. There are plans in some areas also offering a giveback of some or all of the Part B premium.
Medicare Advantage plans may also include additional benefits not offered by Original Medicare, such as, dental, vision and transportation to doctor visits! And many are covering the stay in a skilled nursing facility althoughthe individual was on observation status and did not meet the 3-day prior hospitalization Medicare requirement.
The main disadvantage to Medicare Advantage plans is members typically must use an established network for medical care unless it is an emergency or urgent care. Networks may limit which doctors a member may visit. For most services a referral is required from the Primary Care physician toa specialist or for treatment. (Types of services waiving the referral requirement vary by plan.)
Lastly, a beneficiary must be in an enrollment period to be eligible to join a Medicare Advantage plan in addition to the other eligibility requirements.
Youas the agent need to understand the differences and plans and present them clearly for the beneficiary’s understanding.
With any HMO plan, members can change to a primary care physician by contacting the plan and requesting the change. Usually if made before the 15th of the month, they can begin seeing their new primary doctor the first of the next month.
Disenrollment is also simple. If the member changes their mind prior to the plan’s effective date they can cancel the application andenroll in a new plan. If they disenroll after the plan’s effective date, one needs to submit a request in writing. The agent should discuss theoptions and consequences of the disenrollment as there are rules as to new plan eligibility and Part D.
If a member disagrees with a decision of their health plan, say on a drug exception or a denial of coverage for a C-pap machine for instance there is an appeals and grievance process to make the health plan revisit the decision.
Once you have determined which type of coverage the Medicare Beneficiary would like to consideryou then can go into the plan details, the prescription drug coverages and other benefits. Remember to always secure a Scope of Appointment prior to discussing the Medicare Advantage or Stand-Alone Part D plans.
Medicare Supplements and the Medicare Advantage Plans offer great coverage options to the Medicare beneficiary. One is not better than the other. It is a matter of which type and which plan best fits their needs both medically and financially. Youas the agent need to understand the differences and plans and present them clearly for the beneficiary’s understanding. And, it is important to note that you will be reviewing the plans with your client yearly to continue to determine the plans that best fit their needs!
MAGGIE STEDT isan independent agent that has specialized in the Medicare market for the past 21 years. She is currently president of California AssociationHealth Underwriters (CAHU) and is a past president of her local OrangeCounty Health Underwriters Association (OCAHU) chapter.
Reach her at maggiestedt@gmail.com.
FAQs
A Medigap policy is different from a Medicare Advantage Plan (Part C). A Medicare Advantage Plan is another way to get your Medicare coverage besides Original Medicare. A Medigap policy is a supplement to Original Medicare coverage.
Why are they pushing Medicare Advantage plans? ›
Many Medicare Advantage plans offer additional benefits , such as money toward dental or vision care, which isn't covered by original Medicare. About 1 in 4 people say extra benefits pushed them to choose Medicare Advantage, according to a survey by the Commonwealth Fund, a health care think tank.
Why is Medicare Supplement better than Advantage Plan? ›
A Medicare Supplement plan makes your out-of-pocket costs more predictable and easier to budget. “From a cost-sharing perspective, many people like it because you don't need to worry about how much is owed every time you go to the doctor or are hospitalized,” said Jacobson.
Which is cheaper Medicare Supplement or Medicare Advantage? ›
Medicare Supplement typically has a higher monthly premium compared to Medicare Advantage. Specifically, Medicare Advantage plans could cost between $0 and $100 a month, while Supplement coverage may vary between $50 and $1,000 per month.
Can I switch from a Medicare Supplement plan to an Advantage plan? ›
Not only you can switch from Medigap to Medicare Advantage (MA), but depending on your situation, this may be a smart move for Medicare-eligible seniors. Medigap is typically more expensive than Medicare Advantage, so if you start with Medigap but cannot afford it's monthly premiums, MA can save you money each month.
What percent of seniors choose Medicare Advantage? ›
Forty-five percent of Medicare beneficiaries are enrolled in Medicare Advantage plans in 2022, a share that is projected to rise to more than 50 percent by 2025.
Do most people choose a Medicare Advantage plan? ›
In 2022, 48% of Medicare beneficiaries were enrolled in Medicare Advantage plans instead of original Medicare, and experts predict that number will be higher in 2023.
Does getting a Medicare Advantage plan make you lose original Medicare? ›
If you join a Medicare Advantage Plan you'll still have Medicare, but you'll get most of your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare. You must use the card from your Medicare Advantage Plan to get your Medicare- covered services.
Why is Medicare Advantage more popular? ›
Higher Quality and Better Outcomes. Medicare Advantage provides beneficiaries with personalized, higher-quality care that leads to better outcomes. Research shows: Hospital readmission rates are 13% to 20% lower in Medicare Advantage than in Medicare Fee-For-Service.
What is the downside to Medigap plans? ›
Because Medigap plans are sold by private insurance companies, they can charge different monthly premiums. While plans are standardized in regard to coverage and benefits, they are not standardized in regards to cost. Cost can even increase over time based on inflation, your age and other factors.
In 2022, nearly half of (48%) eligible Medicare beneficiaries – 28.4 million people out of 58.6 million Medicare beneficiaries overall – are enrolled in Medicare Advantage plans. Medicare Advantage enrollment as a share of the eligible Medicare population has more than doubled from 2007 to 2022 (19% to 48%).
Who is the largest Medicare Advantage provider? ›
UnitedHealthcare is the largest provider of Medicare Advantage plans and offers plans in nearly nine out of every 10 U.S. counties. UnitedHealthcare also partners with AARP, insuring the Medicare products that carry the AARP name.
What is Congress doing with Medicare Advantage? ›
The Administration proposed a 1% increase in payments to Medicare Advantage for 2024 and finalized an 8.5% increase in payments to Medicare Advantage for 2023 – resulting in increased payments to insurance companies offering Medicare Advantage by nearly 10% over the last payment notice and the current proposed payment ...
Is there a penalty to switch from Medicare Advantage to Original Medicare? ›
If you move away from your Medicare Advantage plan's service area, you can re-enroll in Original Medicare without penalty. This works even if other Medicare Advantage plans are available at your new address.
What state has the cheapest Medicare Supplement plans? ›
The average Medicare Supplement plan costs in every state
The average monthly premium for Medigap policies was lowest in Wisconsin, Hawaii, and Iowa at around $102 monthly. On the other hand, New York had the highest average monthly premium for Medigap plans, which was $304.72 per month.
Will Medicare Part B premiums increase in 2023? ›
The Part B basic premium in calendar year 2023 is scheduled to be $164.90 per month, or about 25 percent of expected Part B costs per enrollee age 65 or older. Premiums can be higher or lower than the basic premium for enrollees who receive Part B benefits through the Medicare Advantage program.
How many times can you switch from Medicare Advantage to Medicare? ›
No, you can't switch Medicare Advantage plans whenever you want. But you do have options if you're unhappy with your plan. You can jump to another plan or drop your Medicare Advantage plan and change to original Medicare during certain times each year.
Can I switch from Medicare Supplement to Medicare Advantage without underwriting? ›
Switch Medigap plans at any time: If you already have a Medigap plan, you can switch your coverage at any time without going through medical underwriting.
How do I go back to traditional Medicare? ›
If you're already in a Medicare Advantage plan and you want to switch to traditional Medicare, you should contact your current plan to cancel your enrollment and call 1-800-MEDICARE (1-800-633-4227). Note there are specific enrollment periods each year to do this.
When can a client go from Medicare Advantage to Medicare Supplement without passing underwriting? ›
The only time you may switch from a Medicare Advantage to Medigap without underwriting is if you have a Special Enrollment Period that grants you guaranteed issue rights. This means that you will be able to enroll in the plan of your choice with no health questions. Thus, you cannot be denied coverage for any reason.
In 2023, the Part B standard premium is $164.90 per month, down from $170.10 per month in 2022. If you have a higher income, you may pay more . The Part B deductible dropped to $226 in 2023, down from $233 in 2022.
Does Medicare Advantage pay 100 percent? ›
Medicare Advantage Plan (Part C):
Deductibles, coinsurance, and copayments vary based on which plan you join. Plans also have a yearly limit on what you pay out-of-pocket. Once you pay the plan's limit, the plan pays 100% for covered health services for the rest of the year.
What percentage of people have Medicare Supplement plans? ›
About 23% of Medicare's 65.1 million beneficiaries are enrolled in a Medigap plan. While these supplemental insurance policies either partially or fully cover cost-sharing associated with basic Medicare (Part A hospital coverage and Part B outpatient care), the monthly premiums can be pricey.
What percentage of people take Medicare Advantage? ›
As of January 2023, 48 percent of all Medicare beneficiaries are enrolled in Medicare Advantage, translating to 30.7 million people. Medicare Advantage enrollment growth continued at a rapid pace, adding 2.7 million beneficiaries in 2023.
What percent of Medicare patients are on Advantage plans? ›
More than 28 million Medicare beneficiaries – 48 percent of all eligible beneficiaries – are enrolled in Medicare Advantage plans, which are mostly HMOs and PPOs offered by private insurers.
How do you qualify to get $144 back from Medicare? ›
To qualify for the giveback, you must:
- Be enrolled in Medicare Parts A and B.
- Pay your own premiums (if a state or local program is covering your premiums, you're not eligible).
- Live in a service area of a plan that offers a Part B giveback.
Call 1-800-MEDICARE (1-800-633-4227) to talk with a customer support representative about your Medicare questions and concerns—or visit the Medicare.gov website to start a live chat. TTY users should call 1-877-486-2048. The Medicare Support Hotline is available 24/7, except for some federal holidays.
Can you switch back from Medicare Advantage? ›
If you joined a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without a drug plan) within the first 3 months you have Medicare Part A & Part B.
Why are people leaving Advantage plans? ›
Beneficiaries may choose to leave their plan if they are dissatisfied with providers covered, if their medical needs change, or if out-of-pocket costs are too high.
How do I choose between Medigap and Advantage plan? ›
How do I choose between Medicare Advantage and Medigap? Consider your priorities, like budget, choice, travel, and health conditions. While Medicare Advantage can be more affordable for people with long term health issues, Medigap gives you flexibility and choice by expanding your network.
Medigap provides a larger network but is often pricier than many Medicare Advantage plan premiums. If you are in relatively good health and are not concerned with hereditary health conditions that could develop, then switching to a Medicare Advantage plan could significantly lower your monthly healthcare expenses.
Why do people choose Medigap? ›
Why Do I Need Medigap? Medigap policy supplements your Original Medicare coverage, covering more expenses. Medigap provides more choice and covers a larger network of health care providers than other options. If you travel or need coverage that Original Medicare doesn't provide, Medigap might be a good option for you.
Is AARP Medicare Advantage the same as UnitedHealthcare? ›
AARP Medicare Supplement plans are insured by UnitedHealthcare Insurance Company and endorsed by AARP.
Which is the cheapest health insurance for senior citizens? ›
Best overall: Medicare
For those age 65 and older or who have a qualifying disability, the Medicare program will be the cheapest health insurance with the best benefits. When you were working, you paid into the Medicare program via a Medicare tax on income.
Who pays the premium for Medicare Advantage plans? ›
If you have Original Medicare, the government pays for Medicare benefits when you get them. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Medicare pays these companies to cover your Medicare benefits.
What states have 5 star Medicare Advantage plans? ›
States where 5-star Medicare Advantage plans are available:
- Alabama.
- Arkansas.
- California.
- Colorado.
- Florida.
- Georgia.
- Hawaii.
- Idaho.
While the possibility of reducing Medicare spending emerged recently in the context of the debt limit debate – and some members of Congress continue to talk about changes to the program — President Biden and now House Speaker McCarthy have both declared that Medicare will not be part of those negotiations.
Can you be denied a Medicare Supplement plan? ›
You can be denied a Medicare supplement plan in some circ*mstances. If you try to buy a Medigap policy during your Medigap open enrollment period, then you should not be able to be denied. But you can be rejected if you delay enrollment and apply at any point later in your life, due to a preexisting health condition.
Can you change Medicare Advantage plans every year? ›
Typically, you can only enroll in a different Medicare Advantage Plan or switch between Original Medicare and Medicare Advantage during specific times each year. Make sure to enroll in a timely manner to avoid gaps in coverage when using these enrollment periods.
Is Original Medicare different from Medicare Advantage? ›
Original Medicare covers inpatient hospital and skilled nursing services – Part A - and doctor visits, outpatient services and some preventative care – Part B. Medicare Advantage plans cover all the above (Part A and Part B), and most plans also cover prescription drugs (Part D).
Medicare Advantage Plans must cover all of the services that Original Medicare covers except hospice care. Original Medicare covers hospice care even if you're in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, you're always covered for emergency and urgent care.
Is it necessary to have a Medicare Supplement? ›
Medicare supplement plans are optional but could save you big $$$ on doctor bills. Your cost-sharing under Part B is similar. You are responsible for paying your Part B deductible, which is $226 in 2023. Then Part B Medicare only pay 80% of approved services.
Can you go back to original Medicare from an Advantage plan? ›
Yes, you can elect to switch to traditional Medicare from your Medicare Advantage plan during the Medicare Open Enrollment period, which runs from October 15 to December 7 each year. Your coverage under traditional Medicare will begin January 1 of the following year.
Why do people choose Medicare Advantage over Medicare? ›
Medicare Advantage may appear cheaper, because many plans charge low or no monthly premiums. Unlike traditional Medicare, Advantage plans also cap out-of-pocket expenses.
Why do so many older adults choose Medicare Advantage? ›
Many Medicare Advantage plans offer additional benefits, such as money toward dental or vision care, which isn't covered by Original Medicare. About 1 in 4 people say extra benefits pushed them to choose Medicare Advantage, according to a survey by the Commonwealth Fund, a health care think tank.
Can I be turned down for a Medicare Supplement? ›
You can be denied a Medicare supplement plan in some circ*mstances. If you try to buy a Medigap policy during your Medigap open enrollment period, then you should not be able to be denied. But you can be rejected if you delay enrollment and apply at any point later in your life, due to a preexisting health condition.
Why would someone not have Medicare A? ›
You won't pay a Part A premium if you: Qualify to get (or are already getting) retirement or disability benefits from Social Security (or the Railroad Retirement Board). Get Medicare earlier than 65.
Can I go back to Medicare if I don t like Medicare Advantage plans? ›
If you joined a Medicare Advantage Plan during your Initial Enrollment Period, you can change to another Medicare Advantage Plan (with or without drug coverage) or go back to Original Medicare (with or without a drug plan) within the first 3 months you have Medicare Part A & Part B.
MAGGIE STEDT isan independent agent that has specialized in the Medicare market for the past 21 years. She is currently president of California AssociationHealth Underwriters (CAHU) and is a past president of her local OrangeCounty Health Underwriters Association (OCAHU) chapter. 