Medicare Advantage Issues you Should Know before Selecting a 2023 Plan.

Use It or Lose It Benefits

As we enter the end of the year, it’s important to check if your health insurance plan has benefits that you need, but have not used and will be erased on New Year’s eve.

This applies to Medicare Advantage (MA) plans as well as some employer and marketplace plans.

Some plan benefits that you may have, but could use or lose, before year-end include:

  • Prescription drugs and vaccines
  • Preventative dental care
  • Contact lens/eyewear allowances
  • Healthy living rewards
  • Over-the-counter medication/supplies
  • Telehealth consults
  • Rides to/from medical appointments

Prescription Medications

The cost of prescription medications can be your highest medical expense each year and its one of the most complicated and least disclosed aspect of your health insurance. There can be considerable differences among private Medicare Advantage plans in their cost, choice & access to the medications that your doctor prescribes. 

To help understand these differences, go to Medicare Plan Finder and enter your medications for Medicare Advantage plans in your area and the program will show the comparative: medical and drug premiums, deductibles, co-pays and co-insurance and optional benefits for all plans. Then, you can select a more detailed comparison of up to 3 plans that you are most interested in buying for 2023, before December 7th.

A couple things of other things that you can do before year-end are to check if your current plan offers discounts for using: 1.a preferred pharmacy 2. a discount for 90-day supplies of your maintenance meds (usually generics) from your plan’s preferred pharmacy. Some plans provide up to a 33% discount for a 3-month supply over the cost of buying medications monthly. In some cases, the cost of your medications from your pharmacy can be cheaper by not running it through your insurance plan, especially if your meds are subject to a high deductible and/or co-payment. So, check with your pharmacy.

If you take Tier 3-5 maintenance medications and have already met your yearly deductible, consider having your prescription refilled with a preferred pharmacy before year-end. If you wait until after the 1st of the year, you’re likely to have to pay another deductible early in the year.

Finally, if you are diabetic and use insulin, you should definitely check to see (using the Medicare Plan Finder) what your current or another MA plans for 2023 charges for the insulin that your doctor prescribes. Some plans may include the insulin that you use for $35 or less a month.

Vaccines 

Many FDA approved adult vaccines are covered in full with no co-pay or deductibles through your plan’s network of providers (PCP, pharmacy). These include flu, pneumonia, Hepatitis B, Covid-19 virus. However, not all plans include other important FDA approved vaccines that prevent illnesses such as shingles, tetanus, diphtheria and pertussis. Many insurers require an out-of-pocket deductible payment and a high-cost Tier 3 co-payment.

This means you can have insurance coverage for vaccines, but you may have to pay up to the full cost for specific vaccines.

Preventative Dental Care

In recent years, a number of MA plans have added preventative and some restorative dental care to their plans. While plans often emphasize two “free” cleanings, x-rays and exams a year. Some plans have also expanded their dental coverage to include other services such as filling, root canals, crowns etc. However, a common limitation to these dental benefits is that there is a maximum fee that the plan will pay participating providers for each service/procedure and often full payment coverage is limited to a low-negotiated fee agreed to by a small group of local dentists. If your dentist does not participate in the plan and accept their fee schedule, you will need to pay for the service out-of-pocket and then submit a claim to your insurance company and request reimbursement up to what they allow, not what you paid. Finally insurance companies commonly don’t provide you with their allowable fee schedule and they usually won’t pay for more than the plan’s negotiated rate with their in-network dentists. So, in most cases you won’t know if your dental work is covered until it is completed, paid and you submit a claim for reimbursements.

If you haven’t used up your dental allowance for the year, check with your dental office and either book an appointment before year-end and/or ask to go on an appointment cancellation list. This is another use it or lose it benefit.

Eyewear/Contact Lens Allowance

Most insurance plans have an eyewear/contact lens allowance. The amount of the allowance varies by insurer from $75 to $300/yr. and is usually tied to the premium that you pay. This benefit is another use it, claim it, or lose it. There is no rollover of the benefit to the next calendar year and you usually need a recent eye exam in order your eyewear or contact lens.

If you have a simple lens prescription, there are many options for ordering what you want/need online at reasonable prices for both contacts & eyewear. Examples can include regular & prescription sunglasses, reading glasses and stocking up on contact lenses.

Healthy Living Rewards

More plans are including incentives for healthy living because they attract healthier customers that use fewer medical services and cost the insurance company less to serve. Some plans offer rewards up to $200/yr. in debit cards for taking brief online classes, getting a flu shot, completing surveys, having an annual physical, mammogram, colorectal & PSA screenings, vision test, use of a gym etc.

As with many benefits, you need to earn the rewards, report them, claim them or lose them. There is no roll-over of unclaimed rewards to the following year.

Over-the-Counter Medications/Supplies

Some MA plans also include an allowance of up to $100 a year for over-the-counter medications and supplies. However, there are a number of procedures to complete along with restrictions and limitations that vary for each plan. For example, some plans advertise a $100/yr. benefit, but the fine print states that it is limited to $25 a quarter with no carry-over of the unused benefit from one quarter to another.

So, check with your insurer for the benefit details, limitations and procedures for claiming your rewards.

Emergency, Urgent Care and Ambulance Services

Health care systems continue to evolved and there are new services that are available, less costly and more accessible than your doctors office or a hospital emergency room. The first level of service is a call to your primary care provider (PCP) during office hours for a phone consult. The second option is to use a “Telemed Service” affiliated with your PCP for questions and concerns that you may have. Telemed services are often covered by your insurance plans with either a low or no fee. The next level of services is an Urgent Care Center. These centers. are designed to divert people from overwhelmed emergency departments. They can diagnose and treat a limited number of medical conditions. Hospital Emergency Departments and Ambulance Service providers are costly and designed to provide a rapid response to people facing life-and-death crises such as heart attacks, strokes, serious accidents & injuries etc. Ambulance service providers are responsible for assessing, stabilizing and transporting patients experiencing a medical crisis to an emergency department. Insurance companies won’t reimburse ambulance companies for providing transportation to individuals with less acute problems. However, recently some insurance plans have added coverage for a limited number medical rides to and from medical appointments. Check your policy or call your plan’s customer service representative listed on the back of your insurance card for more benefit information.

Major Differences among HMO, PPO and Medigap Plans

Unlike original Medicare where you can receive services from any health care provider that has a service and payment contract directly with Medicare, private Medicare Advantage (MA) insurance plans have the primary contract with Medicare and are paid on per capita basis (approx. $12,000/yr./person.) with higher Medicare rates based on the patients’ diagnoses & medical conditions.

HMO plans have well-established provider networks with service contracts and geographical boundaries. Services and use of specialists need to be coordinated and approved by your primary care provider. The patient cost for receiving out-of-network services can be substantially higher than in-network services with the exception of emergency services.

PPO plans also have service and payment contracts with providers that can include broader geographical areas and have less restrictions on prior approval to receive services from speciality providers. However it’s important to note that PPO service providers,who participate in Medicare, are not required to accept all medical insurance plans. This is a common problem for subscribers in small regional MA PPO plans who want to receive services in another state in the absence of a formal contract between the insurance plan and the service provider.

However, a recent development addressing this issue is that national Medicare Advantage insurers such as United Health Care, Humana and Blue Cross affiliates have developed reciprocal agreements among their plans that allow for the acceptance of patients from other affiliated plans at the in-network rates, thereby increasing access to services with lower out-of-pocket expenses. This expanded MA PPO plan coverage can provide a more comprehensive and less costly alternative (for some people) to the option of buying a free-standing Medigap plan and a Prescription Drug Plan along with the cost of your original Medicare.

Medigap plans are private insurance plans used to supplement the coverage of original Medicare including the subscriber responsibilities for deductibles, co-payments and co-insurance. Plans differ based on the comprehensiveness of their coverage, 12 different plan designs and cost of monthly premiums among the different states and regions. If you sign-up for a Medigap plan, you also need to sign-up for a freestanding Prescription Drug Plan (PDP), unless you have credible medication coverage from an retiree employer plan or the VA.

Individuals with high medical expenses, such as renal dialysis and chemotherapy, are good candidates to consider a Medigap plan. MA plans generally require a 20% co-insurance payments for dialysis & chemotherapy until you have paid up to $7,900 -$11,700 in a calendar year, not counting the cost of self-administered medications.

Opportunities to Change Your Medicare Plans

The period of October 15 to December 7th is the annual open enrollment period. If you already signed up for a MA plan, you can still change your plan until December 7th. If you missed this deadline, you can switch from one MA plan to a different MA plan or switch from a MA plan to original Medicare and add a PDP between January 1 and March 31st.

You can make changes yourself by using Medicare.gov, calling the respective plans or calling the State Health Insurance Assistance Program SHIP (877-839-2675)

If you have any comments, or suggestions, please share them with us.

Thanks

Jim Sorrentino

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