IT’S “THAT” TIME OF YEAR AGAIN. No, not halloween nor Thanksgiving. It’s Medicare Advantage plan decision time.
Like any annual (or in come cases, semi-annual) contracts, Medicare plans need to be compared.
This concerns only Medicare ADVANTAGE plans. Extra cost Medicare “Supplement” plans are noted only in passing.
ANYONE WHO THINKS THEIR monthly $104 (plus or minus) payment to Medicare pays for Advantage (or Supplement) plans is mistaken. The government pays the private insurers — and pays them handsomely — for each Medicare customer the insurance companies sign up, ergo in some “senior-heavy” areas, competition for customers is fierce. It’s a toss up who pays for more tv advertising: car dealers introducing the new model year or insurance companies trolling for customers.
Evidence of Coverage
All Medicare Advantage and Supplement plans must be certified by Medicare. Most insurers put their Medicare-approved plans on-line. Once approved, the plan benefits cannot be easily changed. (Providers — physicians, medical facilities, pharmacies — may change and certain prescription drugs may be changed, but the basic benefits are “cast into concrete.”)
- Medicare.gov’s Advantage1 information is the best place to start to find plans by ZIP code and insurers2.
Since I do this exercise annually for myself and some friends, I create a spreadsheet. My spreadsheet starts off with things critical to me:
Primary Care Provider/Physician (PCP): Is my PCP listed?
- If not, am I willing to change? Plans normally make their list if providers (ibid.) available on-line.
Specialists: Do I have any specialists I need to continue seeing? Is the specialist on the provider’s list?
- If not, am I willing to change?
Medications: Are all my medications listed and how much is my co-pay. Prescriptions are “tier” based; the higher the “tier,” the higher the co-pay.
- All of my medications are Tier 1 or Tier 2 ($0 co-pay) for all but one plan I reviewed; that plan has the same medication listed as Tier 3 with a $47-a-month co-pay.
Finally, I try to see if the plan’s PCPs are capitated. “Capitated” means that while the plan may list hundreds of specialists, a plan PCP may refer only to a limited number of these specialists.
- I had a capitated plan — once. Never again. If I want to see Specialist “A” who is on the plan Provider’s List, I don’t want to be told my PCP cannot refer me because that specialist is not on my PCP’s list. (I kept the PCP and changed plans.)
The Evidence of Coverage (EOC) lists the co-pays by tier. In order to find out (a) if a drug is supported and (b) what tier the insurer has assigned the drug (Tier 1, 2, 3, 4, or 5) you need the plan’s Formulary — drug list — this also should be on-line.
EOC standard format
MOST EOCs follow a standard format. For 2018, I found only one that fails to follow the standard Medicare EOC format. Because the one offering failed to follow the standard format, I eliminated it from consideration.
Since most plan EOCs follow the standard alphabetical format — albeit some with very minor variations — it is relatively easy to compare benefits. Medicare requires that many benefits have $0 co-pay and $0 deductibles.
Two areas potential customers need to address are hospital costs and outpatient surgery costs.
My first Advantage plan (AvMed) had $0 co-pay for the first 5 in-patient days, and then $40/day for Days 6 through 20, than back to $0 co-pay for the remaining days. The sales person told me that most hospitalizations were for 5 days or less; three operations later, the sales person’s statement has proved to be 100% correct. The same concern applies to mental health care.
For some reason, most plans charge a higher co-pay for outpatient surgery at a hospital and substantially less at a stand-alone day surgery facility.
All plans discourage trips to hospital emergency rooms (ERs). In lieu of running to the ER, plans promote use of urgent care clinics. Some plans have a $0 co-pay for visits to clinics while requiring an $80 (or more) co-pay for ER visits.
On the other hand, if the ER visit ends up with an admission to the hospital, the ER co-pay is waived, so any “life-threatening” issues still should be taken to the ER.
Ambulance co-pays also vary widely by plan.
Some plans offer an Over-the-Counter (OTC) medicine benefit. For 2017, one plan offered to pay up to $45-a-month for OTC products. The same plan for 2018 is offering $25 for three months , the suggestion is that Medicare Advantage and Supplement plans are “bleeding money” and looking for ways to reduce costs.
Insurance, even Medicare Advantage and Supplement plans, is a profit centered business, ergo the number of local and national (e.g., Aetna, Blue Cross, Humana, United Healthcare) insurers are aggressively seeking new members (customers).
A quick comment on referrals. Most Advantage plans now require PCPs to refer patients to specialists. In my opinion, this is a good thing. The PCP is the patient’s primary medical contact. It is for the patient’s benefit that the PCP knows what a specialist ordered — especially medications — so assure that there are no contra-indications. (Actually, when it comes to drug interactions, the pharmacist is the best source of information.)
Advantage or Supplement plan
Many — most — Advantage plans are zero EXTRA cost — they are not “free” or “no cost” since the customer still must pay the monthly Medicare fee. All Medicare Supplement plans have a “supplemental” fee.
(Supplement plans also are called “Medigap” plans.)
Some plans, such as UnitedHealthcare’s AARP Supplemental plans, require membership in the related organization (e.g. AARP).
According to Mediare.gov3, Every Medigap policy must follow federal and state laws designed to protect you, and it must be clearly identified as "Medicare Supplement Insurance." Insurance companies can sell you only a "standardized" policy identified in most states by letters.
All policies offer the same basic benefits but some offer additional benefits, so you can choose which one meets your needs..
Each insurance company decides which Medigap policies it wants to sell, although state laws might affect which ones they offer. Insurance companies that sell Medigap policies:
- Don't have to offer every Medigap plan
- Must offer Medigap Plan A if they offer any Medigap policy
- Must also offer Plan C or Plan F if they offer any plan
The Medicare.gov site has an internal link to a list of Supplement plans by ZIP code and by cost, along with a list of companies offering each plan type.4
CAUTIONARY NOTE: The most reliable sources for Medicare Advantage and Supplement plans is Medicare.gov. Some commercial (not “.gov”) sites fail to include all available plans since not all insurers are willing to pay to be listed. Medicare.gov lists ALL plans available in a particular ZIP code.
1. Advantage: http://tinyurl.com/opgeeqz
2. Available plans: http://tinyurl.com/2c6o5fh
3. Supplement: http://tinyurl.com/h5vfups
4. Compare plans: http://tinyurl.com/y8ooewmj
PLAGIARISM is the act of appropriating the literary composition of another, or parts or passages of his writings, or the ideas or language of the same, and passing them off as the product of one’s own mind.