Ask the Medicare Specialist
QUESTION:
What is most important to consider when choosing an Advantage Plan? Which plans and companies are the best?
This is Part V of my “Medicare Reset” series designed to prepare those on Medicare for the Annual Election Period ( AEP) that runs October 15th to December 7th.
ANSWER:
My experience with Medicare Advantage Plans is they’re always evolving as health care regulations, trends, and markets change. I believe this year’s AEP could be one of the most confusing ever for those on HMO’s or PPO’s due to two significant developments for the 2021 benefit year.
In the past ten years the first things I’ve always looked at and considered to be most important when deciding what Advantage Plans to recommend for the following year were premiums, co- pays for a four to six- day or longer hospitalization, and Maximum Out of Pocket ( MOOP) limits. In 2021, there will be another vital piece of the puzzle, companies that are participating in the Center for Medicare and Medicaid’s new “Part D Senior Savings Model.”
According to the American Diabetes Association website, “This model ... is designed to help 3.3 million Americans affordably access insulin by capping the cost of a 30- day supply for most insulins to a maximum of $ 35. For enrollees who choose a model participating plan, their insulin prescription will not be subject to a deductible or any coverage gap ( Doughnut Hole) cost increases. ( Whether it’s January or December, their monthly out- of- pocket cost for insulin will be $ 35 or less.)”
In addition to insulin, those who are using expensive brand name Type 2 diabetes drugs such as Trulicity, Jardiance, Ozempic, and Tradjenta can enroll in a plan where these medications will be priced like a Tier 2 generic and have a surprisingly low co- pay. This is huge for those who take insulin or other brand name diabetes meds and means those who enroll in participating plans will not pay higher prices in the Doughnut Hole, now being referred to as the “Coverage Gap,” when co- pays can reach $ 175/ month. The savings in 2021 for those who take these drugs could range from $ 1,000 to $ 3,000.
But only for those that choose the right plan( s). As if deciding on an Advantage Plan weren’t already confusing enough, the Part D Savings Model is voluntary with only one of the three most widely held Advantage Plans in our region participating. In addition, there is only one specific plan from that company which is also covering expensive Type 2 brand name diabetic drugs at the equivalent of a generic co- pay. And like insulin, they won’t be subject to higher costs in the Doughnut Hole/ Coverage GAP. Those who choose the company, but not this particular plan, will pay more for their Type 2 brand name diabetes meds in the Doughnut Hole as soon as April or May. We will be advising the majority of those who use expensive diabetic medications, including insulin, to risk taking a plan with a higher MOOP for the guaranteed savings that these plans provide.
For those who aren’t taking diabetic drugs, the Part D Savings Model will have no bearing on my recommendation for the benefit year 2021. I estimate that The Health Insurance Store will advise the following to 90% of those who seek our advice and opinions on what Advantage Plan to choose: It should be an HMO or PPO that has a MOOP less than the maximum allowed by CMS, a per- stay hospital co- pay under $ 400, and a premium less $ 50/ month.
In the past I’ve actually advised people not to fall in love with dental and what I called the “sizzle” of it and other ancillary benefits when making a decision. That was when so called “dental” equated to free or discounted teeth cleanings and a single set of bite wing X- rays. However, in today’s market, true comprehensive dental is provided by multiple companies and plans. So, I’ve added a new criterion when choosing an Advantage Plan, the inclusion of at least $ 2,000 in comprehensive dental that covers fillings, crowns, root canals, extractions, and dentures.
As far as who are the best companies and plans? Although I’m not allowed to name them in the columns, the answer is whomever and whichever offers the best value based on the combination of premiums, co- pays, and lower MOOP limits. And in the case of 2021, for many diabetics, the plans from the one company that is participating in the Part D Senior Savings Model and offering lower costs for both insulin and other brand name Type 2 diabetes drugs, regardless of the MOOP.
The best plans and companies can be different each year as benefits change, sometimes for the better and sometimes for the worse. Companies can make little or none, while others, changes I consider more dramatic, as is the case for 2021. I clearly remember a period from 2008 to 2011 where I advised many of my clients to move to a different company four years in a row.
I would like to remind everyone that Advantage Plans have several Federal regulations they must follow. Some of the most important are: All companies and plans, regardless of premium, must cover the same categories of benefits. They all must cover the same medical services as Medicare and as good or better than Medicare. They cannot have any pre- existing condition clauses, must accept everyone who has Medicare Part A and B regardless of current or past health issues, and must pay claims the first day the policy goes into effect.
Therefore, there’s no need to be fearful of moving to a new plan or company. It’s a mistake far too many seniors make, and insurance companies count on.
I suggest calling one of our offices and speaking to myself or another of our licensed and experienced agents who can tell you in just a couple of minutes if you have a plan that’s going to see significant changes or meets our most important criteria for the benefit year 2021. If you are on insulin or any other expensive Type 2 diabetic medications, it is vital you enroll in the right plan. The Health Insurance Store can ensure you do.