When it comes to choosing medicare advantage plans in ct, residents have a variety of options and plans to pick from. Connecticut residents can choose from plans typically when they turn 65, first become eligible for medicare, become disabled with a qualifying disability and are on medicare or during an annual enrollment period. Right now the annual enrollment period for Connecticut is Oct 15 to Dec 7 2017. This is actually the enrollment period for the rest of the country as well. During the course of this article I would like to discuss the following:
To begin there are 4 parts to Medicare. The first is part A which covers your hospital expenses, next you have a part B which typically covers your doctors and outpatient services, after that you have part C, which I will address in a minute, and lastly you have part D, which covers
your prescription drugs. Now what part C does, is to wrap parts A, B, and most of the time D into one convenient medical plan known as Part C or a medicare advantage plan. Part C and medicare advantage plans are one in the same, some people refer to them as one or the other, but they both are the same. These plans are offered through private insurance companies that are authorized to offer through CMS, which stands for Center for Medicare and Medicaid Services. You must work providers that are in network with each plan!
Beneficiaries eligibility- seniors must be enrolled in Medicare part A and part B in order to enroll in one of these plans. I must stress that you always have your original Medicare and must continue to pay your part B premium in order to have one of these plans. Here is where things get a little confusing however. When you enroll in one of these plans you typically have co-pays instead of larger deductibles like you do in original Medicare. So what happens -is that you now follow the rules and co-pays set fourth by the Medicare Advantage Plan vs Original Medicare. Again this can be confusing to some folks, so we will look at a few examples of how these plans work. As always make sure that your prescribing physician in plan network with these plans. More on that later.
Let’s take a typical example. Let’s say January 1st you have to go see the doctor because of a cold, flu or you are just plain not feeling well. If you had original Medicare only, then you would have to meet the part B deductible which is $183 dollars for plan year 2018 (sometimes this changes from year to year.) In any event you would pay that once a year deductible, then you would be responsible to pay the 20 percent that Medicare does not cover. This could add up to a couple hundred dollars for a simple office visit.
Now let’s take that same example, only this time you are enrolled in a medicare advantage plan in ct. If you go to see the doctor you would not have a part B deductible or a 20 percent co-insurance. Instead you might have a $15 or $20 dollar co-pay to see your primary care physician. Let’s say instead of seeing your primary care physician, you instead see your specialist. Well these co-pays are typically a little higher more like $35 to maybe $50 dollars per office visit. Some plans vary depending on what they charge for a co-pay however most medicare advantage plans in Connecticut for 2018 are in this range. So you see in this type of plan you will pay much less per office visit then you would if you just had straight Medicare and not a medicare advantage plan or part C plan in Ct. What I must stress however is that you do not lose any benefits by enrolling in one of these plans. They must by law cover everything that original Medicare covers and then some. All medicare advantage plans must cover doctors, hospitals, blood work, skilled nursing, x-rays, durable medicare equipment, lab tests, mris, and most cover prescription drugs. As mentioned before anything that original Medicare covers for diagnoses, so must medicare advantage plans (that is including preventive care) at no additional charge.
Let’s take a look at how a hospitalization co-pay might be covered. In our original example we talked about how part B had a deductible of $183 dollars once a year. Well, guess what, so does part A. The first day that you step foot in the hospital you are responsible for roughly a
$1300 dollar deductible per benefit period. Now in that same example, lets say you have a medicare advantage plan in Connecticut. These plans typically charge a per day co-pay vs a deductible. So for example most charge anywhere from 300 a day to around $400 a day for days 1-4. So for instance, you could potentially pay less per day for the hospital or perhaps a little bit more depending on if you are in the hospital all 4 days then if you were just on original Medicare. This is one of the potential pros or cons we talked about earlier. Most people are discharged after 3 days and then shipped over to a inpatient skilled nursing facility. So to be clear if you were there one day and only had straight Medicare, then you would pay $1300 dollars. On a medicare advantage plan you might pay a per day co-pay of let’t say $300 dollars. So day 1 its only $300, day 2 another $300, if you are there for another 2 days then another $600. After that most plans cap what you pay and the plan picks up the rest. So if you were there one day then you paid much less than original Medicare would charge. If you were there 2 days or even 3 you would still come out ahead. If you were there 4 days then you pay a little bit more on a medicare advantage plan in ct vs original Medicare. Hopefully I made this clear.
Now let’s take a look at basic blood work, x-rays, and lab tests. Most of these would be considered a part B expense under original Medicare. Again these would be charged the 20% billing that you are responsible for under Medicare. Whereas with a part C or medicare advantage plan you would be charged a co-pay. Most of these co-pays range anywhere from $10 dollars or maybe even $20 dollars. Again this is much less than what you would potentially pay on original Medicare for medically necessary treatment. So this is again one of the pros of enrolling in a plan like this. Also just want to mention that ambulatory benefits are also covered for a co-pay. Another point to mention with these modernization Medicare Advantage plans is that hospice is covered at no additional charge. All CMS approved plans have this in their provisions and Medicaid patients should not be paying a co-pay anyway.
As I mentioned earlier in this article most of these plans include part d prescription drug coverage. These plans are called MAPD plans.
Typically if you stick with original Medicare only then you have to purchase a part D prescription drug plan on your own. These plans range anywhere from $14 dollars and month, all the way up to $80 dollars a month or more. The thing that many fail to realize, is that if don’t enroll in a Medicare prescription drug plan, when you first become eligible,then you could receive a penalty which is assessed by Medicare. This is something that you want to avoid, because it will add extra premiums to your drug plan which you want to avoid at all costs. Again these plans cover generic drugs, brand name drugs and specialty drugs. Each plan has its own formulary and you must see where your drug falls into each category or tier. Most plans operate off of 5 tiers for these part D plans. For example a generic drug, may only cost $3 dollars co-pay at your local pharmacy and would be considered a tier 1 drug. Non preferred generics may fall into a tier 2 which is a higher co-pay which could range from $6-12 dollars. Brand name drugs usually fall into a tier three and can range from $30 to $45 dollar co-pay. Tiers 4 and 5 are usually reserved for a non preferred drug and specialty drugs. This is where you have to pay a percentage of the prescription drugs. Again most of the medicare advantage companies operate off of very similar formularies, however there is always slight deviations among the plans. Remember folks some of these plans are Medicaid compatible, however you must check with your agent to make sure that proper plans are reimbursement proof by insurers. You want to make sure if you fall into the Donut hole you have the proper plan in place for your healthcare situation. If you are chronically ill you don not want your expenditures on prescription payments to outweigh your discretionary income. Retirees must watch their incomes on healthcare! In other words make sure that all your prescriptions are covered no matter what plan that a beneficiary may go with.
These plans vary in cost by insurance company in ct to insurance company. There are really about 5 or 6 major companies that can offer these medicare advantage plans in Connecticut. Guess what- some plans cost $0 premium per month. Yes you read that right folks. Some plans are no premium per month. Most people ask me in astonishment at meetings- “how can these plans be free are these phony plans?” They are not actually free folks. First off you have to remember that tax payers have paid into the medicare and social security all their lives, so really this is a plan that has been paid for years in advance of retirement some people refer to Medicare as entitlement. The bipartisan government pays a subsidy to insurance companies for each person that enrolls in these type of plans and is estimated the costs are in the trillion of dollars. The insurance company is responsible to manage this pool of money to pay claims for each person that enrolls in this type of plan from year to year. Insurance companies have been pretty good at managing claims and working with their networks of doctors and hospitals over the years. These types of plans have been shown to save tax payers and the government millions of dollars, so it all seems to come out in the wash so to speak. Now with the $0 premium plans there is a higher cost sharing among the insurance company and the enrollee. So some people like to take a look at the premium plans. For example some companies offer a $29 dollar a month plan. Some offer a $66 dollar a month plan and some offer a $100 dollar a month plan or even higher. Usually the more premium you pay, the less your co-pays will be for certain services and doctors. It all really depends on how much you utilize doctors, would really depend upon what type of plan you should enroll in. Again you really need to sit down and evaluate what plan and company may be best for your particular situation.
Well first off medicare advantage plans in ct as well as across the country are network based. Meaning that you have to make sure that your doctor or hospital is within these networks. This is unlike medicare supplement plans in ct which there are no networks, you are free to see any doctor or facility in the country that accepts Medicare. Many of these part c plans are either HMO based, POS, PPO, or RPPO types. What do all these mean? Essentially with an HMO based type medicare plan you must see only doctors or facilities that are within a plans network. Usually these are within the state that the resident resides in. While many urban areas have a majority of doctors or hospitals within the state, some rural areas may not. So it is vital that you check with your insurance agent in the state or provider directory to make sure that the plan has your doctor. Now with PPO and RPPO, type plans it is possible to see doctors that may be outside of the plan’s network. However there is usually a larger co pay or cost sharing involved. This is good if you have a specialist that you may see once or twice per year and don’t mind paying a higher cost to see this doctor. If however you are seeing this doctor frequently it may be better to look at an alternative plan. The same holds true if you are seeing a doctor across state lines. Connecticut is a very small state and borders some major hospitals and doctors in Massachusetts, New York and Rhode Island. This is where an RPPO type plan may benefit you. Again make sure that the doctor will accept the out of network plan and that you are ok with paying a higher cost sharing to see this doctor. You can always check into medicare supplement plans in ct. As a reminder these are not supplemental plans, but health plans that you are enrolling in! As always give us a call if you want to learn more about both options or if you just want to hear about medicare advantage plans in ct. One thing to keep in mind is that once you pass your 100 days of combined care in a skilled nursing facility/hospitalization, these plans typically are not designed to pay for custodial care. In other words if you go home you are limited on which benefits these plans will pay for long term care. This is where long term care insurance comes into play and is a different topic altogether. Unfortunately these plans would be unsustainable if they had to pay for long term care facilities as well.