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What You Need to Know About Medicare Advantage Plans in The Coming Year

October 15th marks the beginning of the Annual Enrollment Period for Medicare. It is the time of year that everyone may change Medicare Advantage plans.

CMS (The Centers for Medicare and Medicaid Services) is implementing changes to Medicare over the next 3 years. 2024 will mark the first year of changes.

Because there will be a reduction in the funding from CMS, it is more important now than ever to shop your Medicare Advantage plans wisely.

The difficulty surrounding The Annual Enrollment Period is knowing which plan is best for you. Medicare Advantage is not a “one-size-fits-all” program. What may be best for one spouse might not be right for the other; which begs the question: How do I know which plan is best for me?

A good analogy would be shopping for a diamond. The experts will tell you to look for The “4 Cs” – Carat, Color, Clarity, and Cut.

When shopping for a Medicare Advantage plan I recommend you look for what I call The “4 Ps” – Physicians, Out-of-Pocket, Prescriptions, and Perks.

Physicians relates to the size of your Network, or the number of doctors & hospitals that are available to you. Always make sure that:

1) Your doctors are in your network.

2) Your preferred hospitals are in your network – is it possible you might need M.D. Anderson in the future? Since M.D. Anderson doesn’t accept most Medicare Advantage plans, that is something you need to confirm.

3) You know how many doctors in your area participate in the plan. You can establish this by asking “How many Primary Care Physicians are available to me in a 10, 20, 30, 50 0r even 100-mile radius?” -I recommend you ask for documentation of this.

An agent should be able to email the lists for your records. If they can’t send the documentation, I wouldn’t enroll in that plan.

4) If you have a condition that requires Specialists, you should confirm how many different Specialists are available to you.

Using diabetes as an example, you would want to find out how many Endocrinologists, Cardiologists, Neurologists, Infectious Disease/Wound Care, and Retina Specialists would be available to you. The last thing you want to find out after enrolling in a plan is that while your Primary Care doctor is in-network, there are no Specialists in-network that are available to you.

Don’t assume that there are Specialists in your network, or that you can get a referral out.

Out-of-Pocket refers to the maximum you would be responsible for the year. It’s the “financial worst-case scenario”. It’s important because it tells you what your financial risk is.

I’ve seen plans vary from $3,400 a year to $11,550 a year. That’s a big difference. To date I’ve never spoken with anyone who has known what their Maximum-out-of-Pocket is. You need to know this.

Prescriptions- people would be shocked if they knew the difference in the price between drug plans.

You need to know the cost of your prescriptions within a plan. Any agent or tele-agent should be able to do this.

You also need to make sure that your prescriptions have been priced accurately.

There are multiple versions of many drugs. Is your drug the Tartrate or the Succinate version? Is it Extended Release, a capsule, or a tablet?

Diabetic medications are especially tricky to price because there are so many versions and so many delivery systems.

You need to make sure your prescriptions are priced with the right dosage and frequency taken.

I also recommend you request a copy of the prices quoted. That way you will know how much to expect to pay throughout the year, and if the pricing is completely off when you go to the pharmacy, and it ends up that you were mis-quoted you will have documentation for a grievance.

Perks are the extra benefits that Medicare Advantage plans give out. These are the things you see advertised on TV. Examples of these are Dental, Vision, OTC Cards, Flex Cards, Transportation, etc.

Everyone knows that the bigger the diamond the higher the cost, which is why most very large diamonds that you see have internal flaws or are a less desirable color.

The same goes for Medicare Advantage Plans. The bigger and better the benefits, the smaller the network. Invariably.

The only way companies can give things away is to not pay for other things, and in this case it’s doctors and hospitals. You are literally trading your healthcare for those “benefits”.

In addition to the “4 Ps”, never rely on name recognition when choosing a plan. If you were shopping for a diamond, you would inspect it through a jeweler’s loop. The name of the jewelry store wouldn’t deter you.

That is good advice for Medicare Advantage plans as well. You should inspect them too. Do not assume that because the plan is attached to a highly recognizable name it is good.

It would probably shock you to know that virtually every health insurance company that enjoys incredible name recognition and has fantastic plans also has really terrible plans. There are multiple reasons for this, but you need to be aware of it. Don’t rely on name recognition alone.

In addition to all of these suggestions, look for carriers (insurance companies) that are stable. That’s important during times of change, like what we are about to see.

I know that shopping for Medicare Advantage plans can be overwhelming and a bit scary. It’s that way because no one knows what to look for in a plan, and the stakes are high.

With all of the different plans and options out there, knowing what to look for is key. Hopefully this information will give you a vantage point, keep your head from spinning, and help you when making your Medicare Advantage plan selection this year.

- From the November issue of Bentwater Life Magazine

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