By D. Kenton Henry editor, agent
26 April 2022
There is good news in the SE Texas Medicare Advantage Market! It announces a new Medicare insurance plan which provides what is likely the greatest access to medical providers to date. It allows a member may go to any provider that sees Medicare patients. This equates access to that of the Medicare Supplement (Medigap) plans I typically encourage my clients to enroll in. And the out-of-pocket expenses are $0! There is not even the Part B annual out-patient deductible of $233 which applies to the most popular Medigap Plan G!
Additionally, it provides the convenience of Medicare Advantage Part D Drug (MAPD) plans because it includes Part D Prescription Drug coverage. This means one need not pay an additional premium for a standalone drug plan to accompany their medical coverage because your medical and drug coverage is included under the cover of one policy.
*(The details of this plan are described by the insurance company in the Feature Article below.)
FOR WHOM IS THIS PLAN BEST SUITED?
In my opinion, it is best suited for the older Medicare recipient for whom their Medigap and Part D drug plan premium now exceeds $215.40 – the monthly premium for this Medicare Advantage Plan. Someone who has just turned age 65 will find their Medigap premium combined with a low-cost Part D drug plan competitive for quite some time. However, as they get older, the total cost can greatly exceed the premium for this Advantage plan. Additionally, unless they have Medigap Plan F, they remain responsible for the annual Part B deductible noted above.
As we age, many of us acquire moderate to significant pre-existing medical conditions. In Texas, and most states, when their Medigap premium becomes burdensome, Texans cannot enroll in a new, and lower cost, Medigap plan and be guaranteed approval. They must go through underwriting and risk being declined due to their health history. With Medicare Advantage plans this cannot happen as approval is guaranteed during the eligible enrollment periods.
WHAT ARE THE DISADVANTAGES OF THIS MAPD PLAN?
First, as implied above, if someone is a relatively younger Medicare recipient – with little in the way of brand name drug usage – their combined premium for medical and drug coverage can be considerably lower than the premium for this MAPD plan.
Furthermore, because this plan combines one’s drug plan with their medical plan – one is tied, or captive to, its Part D drug coverage. Coverage which may not be the best drug coverage available to them in the Part D market.
Lastly, Medicare Supplement Plans (Medigap) are created by and standardized by the Centers for Medicaid and Medicare Services (CMS). They can only be changed by legislation. If legislation would result in a change in their benefits, the insured member would most likely be “grandfathered” or, otherwise, allowed to keep their existing coverage.
With this new “Flex PPO” plan from a major health insurance company, the company could decide to eliminate it in any new calendar year. CMS is not going to mandate an equivalent benefit Advantage Plan. And if none is available – the member is likely to find themselves with an alternative offering less access to providers and with out-of-pocket expenses. Or a member could move to a new area where equivalent coverage is not available.
These are all considerations that must be made before transitioning from Medigap – or another Medicare Advantage plan to this Advantage Plan. Regardless, unless one is just qualifying for Medicare due to age or disability – or losing access to another Medicare Advantage Plan – they will not be allowed to enroll in this new plan until this year’s Annual Election Period October 15th – December 7th.
When that time comes, do not hesitate to contact me for assistance in determining if this option is in your best interest and assistance in enrolling.
D. Kenton Henry
TEXT my cell 24/7 @ 713-907-7984
FEATURE ARTICLE 1
**(Due to compliance concerns the company will not be identified at this time. You may contact me for that information as well as all details of the plan. The following is their notice to agents and brokers.)
We want to remind you of our new Medicare Advantage Flex (PPO)SM plan that’s currently available for Medicare age-ins or those eligible for Special Enrollment.
Features include: $0 Copay/coinsurance, $0 deductible, no out-of-pocket costs – and it’s open access. Members can visit any provider nationwide who accepts Medicare. And it includes prescription drug coverage!
NOTICE DATED 04.25.2022 FROM:
Important Information Regarding Your Provider Plan Coverage Thank you for enrolling in the Medicare Advantage Flex (PPO)SM plan.
With this plan you can:
• See any provider accepting Medicare whether inside or outside the plan service area.
• See any health care provider, at no additional cost, when traveling nationwide.
• Access care from any provider who accepts Medicare assignment and bills Blue Cross and Blue Shield.
• Find providers by going to http://www.medicare.gov/care-compare. A few things to keep in mind:
• You are not required to obtain authorization for out-of-network services, however, services must meet medical necessity criteria to be covered.
• We also offer a traveler benefit for members leaving the service area for six months or less. If you plan to travel and be away from home for up to six months, contact customer service. SAVE THIS Below is a provider notification card for you to keep and present when seeking care from a provider. This will ensure your medical claims are processed in a proper and timely manner. If you have any questions, please call the number on the back of your member ID card.
• Write your name and member ID number on the front of the provider notification card
• Carefully remove and fold card
• Keep this card with your member ID card
• Take both cards to all health care provider appointments Thank you for being a Medicare Advantage Flex (PPO) plan member. Carefully punch out and fold this card
• As a provider, you do not need to be a Medicare Advantage Flex (PPO)SM contracting provider to see and treat this member.
• Members can see any provider who accepts payment from Medicare.
• If you are a provider with any of our MA networks, authorization requirements apply.
• The member’s coverage level is the same whether or not a provider is in the network for the Medicare Advantage Flex (PPO).
• At a minimum, eligible claims will be reimbursed at the Medicare Allowed Amount.