Medicare Options

AHIP will give you all the basics of Medicare.  We are not going to regurgitate that info.  We will add to the basic information you learned.  Read the “Medicare and You” handbook annually.  It is a wealth of information about Medicare. Along with AHIP, it should be your Medicare Bible. Keep it with you when you are in an appointment.  You will refer to it often.

Medicare coverage options.

There are many different plan options within these combinations, but there are only a few ways to obtain your Medicare coverage.  The right combination depends on the client’s health, financial situation and what gives them “peace of mind”.  You might think you know what is best for someone, but until you review the options with them, you never know. This is why probing with questions before you start to fully understand their situation is critical.  Refer to the module probing for info

• Original Medicare + Part D Drug Plan
• Original Medicare + Supplement + Part D Drug Plan
• Medicare Advantage Drug Plan. 
• Original Medicare + Group health insurance.  

Someone can be Dual Eligible, which means they are on Medicare and Medicaid, but this eligibility depends on their income, assets and whether they apply for Medicaid with the state.  See our module on Medicaid for more information.

Medicare Supplement or Medigap Plans

Medicare supplements are also called Medigap plans because they supplement or fill in the gaps to original Medicare.  Medicare supplements were standardized in 1992.  The Medicare Improvements for Patients and Providers act of 2008 re-standardized Medicare supplement plans on June 1, 2010.  The standardization of the plans required all companies to offer the same coverage.  It ensured that plans could be easily compared and that the benefits would not change after someone had a policy.  The Medicare Access and CHIP Reauthorization Act of 2015 mandated that as of Jan 1, 2020, the Plan F and C are no longer available.  The Medicare supplement plans are no longer allowed to cover the Part B deductible.  If you were on Medicare as of Jan 1, 2020, you can still purchase a Plan F or Plan C.  If you are new to Medicare after Jan 1, 2020, you cannot purchase the Plan F or Plan C.

There are 10 different Medicare Supplement plans.  Plan A-D, F, G, K-N.  

Medigap Benefits	Medigap Plans
	A	B	C	D	F*	G*	K**	L**	M	N
Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Part B coinsurance or copayment	Yes	Yes	Yes	Yes	Yes	Yes	50%	75%	Yes	Yes***
Blood (first 3 pints)	Yes	Yes	Yes	Yes	Yes	Yes	50%	75%	Yes	Yes
Part A hospice care coinsurance or copayment	Yes	Yes	Yes	Yes	Yes	Yes	50%	75%	Yes	Yes
Skilled nursing facility care coinsurance	No	No	Yes	Yes	Yes	Yes	50%	75%	Yes	Yes
Part A deductible	No	Yes	Yes	Yes	Yes	Yes	50%	75%	50%	Yes
Part B deductible	No	No	Yes	No	Yes	No	No	No	No	No
Part B excess charge	No	No	No	No	Yes	Yes	No	No	No	No
Foreign travel emergency (maximum of $50,000 lifetime limit)	No	No	80%	80%	80%	80%	No	No	80%	80%
Out-of-pocket limit**	N/A	N/A	N/A	N/A	N/A	N/A	$6,220 in 2021	$3,110 in 2021	N/A	N/A

* Plans F and G also offer a high-deductible plan in some states. With this option, you must pay for Medicare-covered costs (coinsurance, copayments, and deductibles) up to the deductible amount of $2,370 in 2021 before your policy pays anything. (Plans C and F aren’t available to people who were newly eligible for Medicare on or after January 1, 2020.)

** For Plans K and L, after you meet your out-of-pocket yearly limit and your yearly Part B deductible, the Medigap plan pays 100% of covered services for the rest of the calendar year.

*** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in inpatient admission.

If you live in Massachusetts, Minnesota or Wisconsin the plans are standardized differently.  You will need to refer to the Medicare.gov website for specifics.  (https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies)

You must have Part A AND Part B of Medicare to get a Medicare Supplement. That is because the supplement pays AFTER Medicare.  If Medicare doesn’t pay, then the supplement will not pay.  The only exception to this is foreign travel emergency.  As long as a provider accepts Medicare, they must accept the Medicare supplement no matter what company it is.

Part B Deductible

The Part B deductible is what the client pays before coverage starts on plans after Jan 1, 2020.  The Plan F and Plan C covered that deductible.  The Part B deductible is how much the clients has to pay for Part B services.  The cost the client pays during this phase is Medicare’s cost.  For example, if the doctor wants to charge $195 for an office visit, Medicare may only allow $50.  Your client will pay the $50 until they have paid out of their pocket the Part B deductible.  It may take more than one doctor visit to meet the deductible.  They may meet in in one doctor visit.  This deductible is in three different areas:  

1. Outpatient services like doctor visits, outpatient surgery and services, physical therapy, diagnostic tests, and more. See the Medicare and You book for a list of all the services provided.
2. Receiving the first 3 pints of blood.
3. Durable Medical Equipment (DME) like crutches, walkers, wheelchairs, diabetic testing supplies, oxygen, CPAP machines and more.

Even though the deductible is in three different areas, it is only ONE time per year.  A client might meet it by going to the doctor or by getting their diabetic testing supplies, but it is only met once per year.  The year starts over every January.

Guarantee Issue (GI) Situations – Medicare Supplements

You must have Part A AND Part B to get a Medicare supplement.  When a client first goes on Medicare at age 65 and picks up Part B, they have 6 months from their 65th birthday or Part B effective date, to pick up a Medicare Supplement with no underwriting (health questions).  If the client was on Medicare due to a disability, when they turn 65, they have another Initial Election Period to pick up a Medicare supplement with no underwriting.   Refer to our module on Disability for more information on the initial choices someone under 65 on Medicare has available to them.

If the client is coming off of employer coverage and already has Part B, they have 63 days to pick up a Medicare supplement with no underwriting.  If they are picking up Part B when they leave employer coverage, they have the 6-month guarantee issue window to get a Medicare Supplement.  When coming off employer coverage, they only have 63 days to get a prescription drug plan as Part D only requires Part A.  Part D doesn’t require Part A AND Part B.  Refer to the GI section for Part D below.  Likewise, they only have 63 days to pick up a Medicare Advantage plan.  Refer to the GI section for Medicare Advantage below.

The Medicare guidelines state that if you were eligible for Medicare prior to Jan 1, 2020, then you are GI for the Plan F.  Companies interpret this differently.  Some companies will base your Part B effective date as to whether or not you would be eligible for the Plan G guarantee issue.  Make sure you know the rules for each company.  If you are not sure, then call agent services for guidance.  For example, United Healthcare will not give you a Plan G GI if your 65th birthday or Part A effective date is before Jan 1, 2020.  This is true even if your Part B effective date is AFTER Jan 1, 2020.  Anthem, Aetna, Medico and Mutual of Omaha on the other hand will base your Part B effective date as to whether you are eligible for a GI Plan G.

Medicare Supplement Strategy

When meeting with a client, it is good to have an idea of what plan you might recommend. The right plan for a client is based upon their health, finances and what gives them peace of mind.  Never discount the fact that a client may spend more for coverage, just to have peace of mind. The other factor that comes into play is the cost for the plan and what provides the best value for a client.  

Not all insurance companies offer all plans.  They must offer a Plan A at a minimum.  If they offer any plan in addition to the Plan A, they must offer the Plan C or Plan F or Plan G. Look at the different plans and compare the premium difference.  Sometimes, that will drive what is the best plan.  For example, if the Plan G has a cost of $110 and the Plan N has a cost of $117, then it is no-brainer. The Plan G is the way to go because it is better coverage.  If on the other hand, the Plan G has a cost of $100 and the Plan N has a cost of $99, that is an $11/month difference.  Take that difference and multiply it by 12.  That is a difference of $132/year.  The main difference between the Plan G and the Plan N is that after the part B deductible you pay $0 on the Plan G and a $20 copay for the doctor on a Plan N.  Divide the annual difference by $20.  In this example, 132/20 = 6.6. That means if your client goes to the doctor more than 6 times per year, the Plan G is a better value than the Plan N.  Ask your client how many times the go to the doctor in a year.  Keep in mind that as we get older, we usually don’t get healthier.  If you show them what the difference in premiums mean, they can make an informed decision. 

The Plan K and High deductible F/G is a different sort of animal.  We call it the Medicare Advantage plan on steroids.  Refer to our module on Advanced topics for more information on selling those plans. 

Medicare Supplement Company Choices

Since premiums for every plan vary by company, what plan would be best for one company may not be for another.  Premiums are based on claims history.  You want to stick with a company that has lots of policy holders in your state.  Premiums and rate increases are approved by the Department of Insurance for a state. The annual percentage increase for Plan G will be different for Plan N.  It will also differ between Company A and Company B.  A company that is new to the market and doesn’t have lots of policy holders, may offer a very attractive rate as they are trying to build their business and attract clients.  The lowest price for a plan is not always the way to go.  That is because of the new company doesn’t get a lot of policy holders quickly, then a few large claims from some clients may skew the whole annual increase.  Clients can change their Medicare supplement at any time, but must go through underwriting to change.  Their health may have changed such that they will not pass underwriting with another company and will be stuck with the plan they have.

Every company will have an annual increase.  It is important that you let the client know that their premiums will go up each year.  If you know when the increases are for the company you are recommending then you can prepare them ahead of time for when to expect it.  The reason there is an annual increase is twofold.  

1. The deductibles within Medicare increase each year.  The insurance company is on the hook for more, so the client is on the hook for more.
2. Premiums are based on claims history, so if the insurance company is paying out more, they need to recoup some of those costs.  

Remember to make sure the client knows that their premium will not go up more just because they had a lot of claims. It is the same percentage for everyone in the state that has that plan for the insurance company.

Some of the companies offer some extra items like a gym membership, dental discounts, vision discount, hearing discounts and more. Refer to the brochure for the Medicare supplement on the specifics of those extras.  They are subject to change, vary by company and vary by state.  

Refer to our lesson on Analysis of Medicare companies for more specific information on each of the companies.  

• UHC typically has their annual rate increase in June.  The way they price their policies, is if you are within 10 years of your Part B effective date or your 65th birthday, they give you an early enrollment discount.  You will lose 3% of that on your anniversary.  That means that if your anniversary is in September, you will get an increase in June and a second one in September.  UHC is community rated which means everyone of the same gender pays the same price.  Because of the early enrollment discount, it looks and smells like and age rated plan but it is not.  UHC offers a $2 discount for couples using the same bank account.  As of July 2017, the pricing on this plan is very attractive compared to where it was.  They have a very reasonable history of rate increases. Typically, the annual increase comes in June of each year. This is a community rated plan. That means that the premium does not go up because of their age. Clients will see their rate go up a couple of times a year. The reason is for a number of reasons:

1. Usually in June is the annual rate increase
2. There is a 36% early enrollment discount when you turn 65.  That decreases the older you get.  On your anniversary, you lose 3% of that discount each year.  This means that most clients will see 2 increases per year depending on their anniversary.  
3. There is a 6-month rate guarantee. 

 

What this means is that if someone has an effective date of Feb 1 and their rate is $140/month, they will stay at $140/month until August. On Aug 1st, the rate will go to whatever the annual increase was in June (for example $144/month) because the 6-month rate guarantee will expire. From Aug to Feb, they will pay $144/month.  On their anniversary in Feb, the 3% discount will come off and their rate will go to $148.32/month.  Then in June they’ll get the annual increase. It is not necessary to get to this level of information with the client. 

They do need to be a member of AARP to get the UHC Medicare Supplement. They do NOT need to be a member to get the UHC-AARP Drug plan. They do not need to renew it to keep their Medicare Supplement, but they might like the benefits they get. If they are not a member when you enroll them, you can sign them up for a membership. You will need to get a credit card number to do that. DO NOT get a check that you will have to mail. That will totally slow down the application approval process. The membership fee is $16 for one year and will cover someone else living in the household with them for free. The AARP membership is done via your MyAARPConnection web portal. Additionally, you get a free 3-year AARP membership as an agent regardless of your age.  You do have to sign up for it on the MyAARPConnection portal. 

If you have 2 people in the household who have UHC Medicare Supplements, you only need one AARP membership because of the +1 membership. The only exception to that is if they want their Medicare Supplements to come out of 2 different checking accounts. In that case, you will have to do 2 separate AARP memberships. Each person will need their own membership.  UHC will not allow 2 members to use different bank account with only one AARP Membership. UHC offers a $2 discount for bank draft.  There is no additional discount for annual payment. If they have 2 people on the AARP membership, they will only get one $2 monthly EFT discount.  The UHC premiums for both people are lumped together into one payment.  Since there is only 1 payment, there is only one $2 discount. 

UHC Medicare Supplements do not come with the Silver Sneakers, but they do come with Renew Active.  It is similar to Silver Sneakers. The networks of gyms are not exactly the same but very similar.  

UHC Medicare Supplements are unique in that they will allow a client to switch their plan to any other plan as of the first of the next month with no underwriting. For example, if they want to do the Plan G when they first get the policy because they go to the doctor frequently, they can do that. Then once they don’t have the need to go to the doctor as much, they can move down to the Plan N and pay less in premium and have the $20 copay when they go to the doctor. Likewise, if they did the Plan K and then knew they were going into the hospital, they could move up to the Plan N and not have to pay the hospital deductible.  The exception to this is that if later they want to go back up to the Plan G, they will have to go through underwriting.  The plan change is made as of the first of the next month. 

There is a CMS rule that if within the first year of having an MAPD for the first time, if the client doesn’t like it and they dropped a Medicare Supplement to get it, they can get a Medicare Supplement again with no underwriting. UHC is the only company who extends this to 2 years.   

UHC’s underwriting is also the most lenient of all the companies. There are a few knock out questions. If they answer yes to anything in number 6, they are not denied a plan but are charged the Level 2 rates.  They will take people with Parkinson’s and Alzheimer’s where most companies will not.  UHC will do a med pull when they do the underwriting.  You will receive an email if your client is rated to a Level 2. There is an appeal process that you and your client can follow.  They will receive a letter stating why they were rated at Level 2.  They can call the underwriting number in the letter to get more clarification.  You cannot call underwriting without them on the phone. Underwriting will not talk to you about it because of HIPPA. 

UHC does not offer Medicare Supplements to people under 65 on disability. 

Commissions are paid as a 9-month advance and then monthly after that.  The Plan F/G are commissioned higher than the Plan N.  Plan K commissions are ½ of the Plan N commission. Commission amount is determined by the first plan written. If you write someone on a Plan N or K and then they upgrade to the Plan F, you are only paid at the Plan N or K rate. Roughly, commissions are less than what you might get paid from Anthem or Medico. Look at the difference in premium and have the client do a Plan G if they are going to the doctor frequently, then they can switch down to the Plan N if they want.  This way you are locked into the higher commission amount.  Having said that, you ALWAYS do what is in the best interest of the client. 

There are no Agent of Record (AOR) changes with UHC. The original agent is always the agent of record even if the client switches plans. The only exception to this is if there is a 30-day gap in UHC Medicare Supplement coverage. For example, if the client does an MAPD for January and then during OEP (1/1 to 3/31) and then goes back to and UHC Medicare Supplement.  You would then be the agent on the new plan.  You might want to use this strategy to move them to one of the new plans that came out July 2017 to get them a lower rate and to get paid on it. See Allison or Madeline for more information on this strategy. We call it the “Two Step”.   Remember, even with this, they are not GI for the Plan G.

• Anthem typically has their annual rate increases in January. They are an attained age rated plan. That means that each year they get older up to age 78, they will get an increase because they are a year older.  They also receive the annual increase, so your client will see one bigger increase once a year vs 2 smaller ones with UHC.  Anthem will offer a $2/month discount if the policy is on a bank draft and a $4/month discount for paying annually.  They also offer a 5% couples discount if 2 people living in the same household have a Medicare supplement policy with Anthem. This is a strong company in the major metropolitan areas.  In Louisville, the select plan has all of the hospitals in their network.  Typically, the premium will be a handful of dollars less than the UHC plan.  You have to check both company’s premiums based on their age. If they are eligible for a couple’s discount, then the difference in premium will be more attractive than the UHC. It is an attained age rated plan. That means their premium will go up for each year they get older. They will also get an annual increase typically each January.  This means that compared to UHC, they will see one bigger increase each year vs UHC which will typically have 2 increases. See our UHC section below for why that is.  The age-related increase caps out at age 78. That means that after that age, they will only see the annual increase. 

A Select plan means there is a network of hospitals for a non-emergency, in-patient hospital stay.  All of the hospitals in Jefferson county, Oldham county, Shelby county and over the river in Indiana are in the network.  If your client is outside the Louisville area, you MUST ask the person which hospital they would go to in a non-emergency to ensure it is in the network. I always caution people that the network is subject to change. A number of years ago, Norton and Anthem got into a spitting match.  All of the Norton hospitals went out of network for those 6 months.  It just means if you were planning surgery, you had to use a different hospital. In an emergency you can go to any hospital.  Just make sure they know they would need to go in through the emergency room.   

If someone has a select plan, they can go anywhere in the US to see a doctor, receive treatment, get a second opinion or have outpatient surgery.  If they move outside of the Select plan’s area (outside KY), they are guaranteed issue for a Medicare Supplement in the state they move to.  I always tell people, if you are outside this area and someone tells you that you need to be admitted to the hospital, go in through the emergency room.  If at any time it is an emergency, tell them to go to the closest place they need to get help. 

There are a lot of people in Louisville that have the Anthem Select plan. It has a good history of reasonable rate increases.  For the most part you can’t go wrong with this plan as clients will talk to their friends and their friends probably have this plan. The Anthem plans also come with Silver Sneakers, which is a free gym membership to participating gyms.  They can join as many gyms as they want. Any Anthem supplement effective after June 2010 now has the Silver Sneakers. The prefix of their ID number is VNG.  All clients got a new card in December 2016 if they were eligible for the Silver Sneakers. 

You will NOT propose the Standard Anthem plans.  These don’t have the hospital network. The premiums on those are really high.  Instead, you would do the UHC plan.  If you have a snow bird (someone who lives somewhere else part of the year) or if they would go to Mayo Clinic for something, then do NOT do the Anthem Select plan. In this case you would do the UHC plan. 

Anthem will offer a limited selection of Medicare supplements to clients under 65.  Only if they are coming off of employer coverage.  It does not have to be involuntary like Medico.  You will receive no commission for these plans.  They will take a third-party check for payment.  This is typically seen for people on dialysis where the American Kidney Foundation is paying their Medicare Supplement premium. 

For Medicare supplements commissions are a flat 21% for years 1-6.  They are paid now with a 9-month advance. After that they are paid monthly. In year 7 that drops to 4%.  If you AOR an older plan, the commission percent may be different depending on the level the agent that wrote it was at and how old the policy is.  If you write a new policy for a client who already has a Medicare Supplement and you are not the agent on that plan, you are not automatically made the agent by submitting the Medicare Supplement new application.  You will need to get an AOR signed by the client when you write the new Med Sup.  

With Anthem, you can “poach your way to prosperity”. Anthem will allow you to do an Agent of Record (AOR) change.  When you have your client sign a letter stating that they would like you to be their agent, you will begin to get commissions on their plan. Clients can choose to have their supplement taken from their bank account.  A couple can have 2 separate accounts for their bank drafts. The husband can use his account and the wife can use hers.  UHC is different. See their section below for that information.  Anthem gives a client a 5% discount for 2 people in the household both having Anthem Medicare supplements.  They do not need to be husband and wife, but can be partners or siblings. They just need to have the same address.  Anthem provides a $2/month discount for bank draft and a $48/year ($4/month) discount for annual pay.  The year is always prorated to 12/31.  Anthem’s annual year always starts on Jan 1.  So if the policy effective date is 7/1, then they would only pay for 6 months and would get a $24 discount (6 times $4).  

Enrollments are done online through your agent portal via MProducer.  You can take the application and then enter it electronically later. All products can be done this way.  The only exception to the online enrollment is for clients under 65 for whom you are submitting a Medicare Supplement. Those applications MUST be faxed to Anthem.  

• Humana – Humana’s Medicare supplements are not their bread and butter. Their plan can be attractive for price and with a 12% couple’s discount can look attractive.  The history of rate increases is not good.  We do not recommend their Medicare supplements.
• Medico typically has their annual rate increase in October.  Attained age???  Until July 2017, Medico was a company that we liked. They started a new company in KY and are now putting Medicare Supplements out under the new company. This has resulted in some rate increases that we have not been too pleased with, but they are not so bad that we will still sell them.  Medico will give you a 7% household discount if you live with someone over the age of 18.  So, if they have a spouse or child or grandchild that lives with them, they will get a discount.  That person does NOT need to have a Medico med sup for the household discount. 

Medico does not have MAPD or PDP plans. They have a very good Hospital Indemnity plan that you can add to an MAPD.  The household discount on the Hospital Indemnity plan only applies if BOTH members of the household have a Medico Hospital Indemnity plan. 

Medico’s rates for people in their 70’s are VERY competitive compared to Anthem or UHC.  With the 7% household discount, they can be significantly lower. 

Medico does offer a High Deductible Plan F which might be an option for your client and they are one of the 2 companies that we like that offers HDF.   

Medico is the only company that will pay you on under 65 Medicare supplements.  You only get 4% but it is better than 0%.  Under 65 people are only GI for the Medicare supplement if they are INVOLUNTARILY losing employer coverage. That means through no fault of their own.  For example, termination of employment or exhaustion of COBRA benefits.  They will require a letter with the application or shortly after before they will approve the application.  Under 65 Medicare supplements cannot be submitted through My Enroller.  You must fax them in.  Medico will NOT accept third party checks for payment of Medicare Supplements.  In the case where the American Kidney Foundation is paying, the AKF will send the money to the client and the client will send the money to Medico. 

Enrollments are done electronically via the My Enroller Application. It does not require a signature pad by the client. You can take the application and then enter it electronically later. The My Enroller also serves as a quoting tool for their products.  It can be put on your desktop or accessed via their agent portal.  We have process documents on this as well. 

Commissions are pretty good with Medico.  You get 19% (KY) for years 1-6 and then 2% until year 10. Anthem and UHC will pay you beyond year 10.

• Mutual of Omaha – Mutual of Omaha, United of Omaha, Omaha Insurance Company, are all the same.  Typically, Mutual of Omaha (the parent company) every 3-4 years will introduce a new company (usually with Omaha in the name). When this happens, they close the book of business on the old company. That means they are not adding new clients to the old company. This is called “Blocking the Business”.  What we have seen happen is that the premiums on the old book of business start to increase greatly over time. Clients will see 2 rate increases per year to the tune of about $20/month. Premiums are based on claims history, so if you aren’t adding those new, younger, healthier clients to the pool, then as the pool of clients age and have more claims, the premiums go up more.  This is the Omaha company strategy.  They also have rates for new people that are lower than what your attained age rate is.  For example, a client who is 68 will pay more than a 68 year old just getting a policy.  

Because of this strategy with the company and what we have seen with our own clients, we encourage you to steer clear of the Omaha companies. Outside of Louisville, there are a number of agents who push these plans. The premiums are based on zip code and out in the country can be very affordable. Make sure your clients know how the Omaha companies work and encourage them to look at a more stable company.  

Their underwriting can be a little more lenient as they have multiple underwriting categories. The categories are based on the height/weight ratio, so if you have someone who is too short for their height (nice way of saying overweight), you might be able to get them a policy with Mutual of Omaha or whatever Omaha they are now.  Enrollments can be done via your agent portal. Commission percentages are around 18%.

• Cigna – Cigna is another company like Mutual of Omaha who comes out with different companies every few years. They are the only company who will give a person under 65 who is first getting Medicare a Medicare supplement with no underwriting. In this case, the American Retirement Life company under Cigna has the best rates.  They will not accept third party checks so if the person is on dialysis and AKF is paying, then AFK will need to pay the client and the client will need to send in a check.  If they don’t have a checking account and pay with a money order, the client must include a note saying they purchased the money order themselves.  Under 65 Medicare supplements pay $0 commission.  

Do not get contracted with Cigna just to sell their under 65 Medicare supplements.  If that is the only business you write with them, they will terminate your contract and it is many years before they will allow you to recontract.  Instead, you will send the client to the customer service line to get the supplement. 

• Aetna – They offer Medicare Supplements
• Newest Companies – There is always a new player coming into the market.  Currently, there is Trivent, Combined, Central States, etc.  Our feeling about these companies is that while they might have a lower rate (usually not by much), they don’t have a proven track record of reasonable rate increases since they are new. They also don’t have a robust book of policyholders, which means their income isn’t as solid as a well-established carrier.  We like to stay with companies that we know are continually adding new, healthy clients to their book of business. A client can change their Medicare Supplement at any time, but they have to go through underwriting. This may mean they are stuck with the company they have now if they can’t pass.  Our recommendation is that you do not run out and start offering the newest kid on the block until you have seen their history of rate increases.  Our job it to provide the client with the best long-term solution as we want to be there for them now and in the future.  Use the Gordon Marketing Medicare supplement tool to get the market analytics on these companies.  

When you get a call from a marketer, and you will touting the newest lowest Medicare supplement in the state, ask them how long the company has been offering it in KY and what their last rate increase was.  Have them send you the summary of benefits and check the rates against Anthem, UHC or Medico.  You should not need to get contracted to get this info.  If they pressure you to get contracted, disengage from the call as quickly as you can.  You can always check with us to get our feedback.

Part D Prescription Drug Plans (PDP)

Part D drug plans (PDP) provide for prescription drug coverage for Medicare.  These are one-year contracts with insurance companies. Finding the right PDP for a client takes a little practice.  You start by putting their medications into the Medicare.gov website.  You can go enter them on a carrier’s website, but that does not compare them to all the different companies.  

The best way to compare plans is via Medicare.gov. The only way to save their medications on that site is to have the client create an account on Medicare.gov and share the logon information with you.  We suggest having the client sign an authorization form giving you permission to access their account. There are ways to logon to the account that don’t allow you to see all their other information.  Inform the client that is how you will access their info.  We have a process document detailing how to enter their medications into the Medicare.gov site and how to pick a plan.  

Most plans have preferred pharmacies.  Using a preferred pharmacy will save the client money. Copays are lower and generic drugs costs might be waived at a preferred pharmacy.  Run the client’s plan using the pharmacy they prefer and then take the best plan and run it with a preferred pharmacy for that plan so you can show the client how much they can save.  Many clients are willing to change pharmacies to save money. 

The only time a client can change their PDP (unless it is a SEP) is during the annual enrollment period from Oct 15th to Dec 7th.  If they utilize the OEP (Jan 1st to Mar 31st) to drop an MAPD, they can then pick up a PDP.

Guarantee Issue Situations – PDP

When a client is first going on Medicare, they have 3 months before and 3 months after their Part A effective date to get a PDP.  It only takes Part A in order to get a PDP.  This is important to note because if there is no other SEP reason, a client cannot pick up a PDP later. For example, if they did not pick up Part B when they turned 65 and are enrolling in Part B during the OEP, when their Part B starts on July 1st, they will not be able to add a Part D drug plan.  They would need to pick it up during AEP as a PDP only takes Part A. 

If a client is coming off of employer coverage, they only have 63 days to pick up a PDP without a penalty.  If they miss that window, they will only be able to add a PDP during AEP.  They will also have a Late Enrollment Penalty (LEP).

PDP Coverage Limits Explained – Put the document here.

Late Enrollment Penalty – Put the document here

PDP strategy

Do we have in the process document?

PDP Company Choices – Add from script

Medicare Advantage Plans

A Medicare Advantage plan is where the government pays money to a private insurance company to take on all the risk of Medicare.  They are paid a fee per person, per month to provide Medicare. The client will NOT use their Medicare card, but instead will use a card from the insurance company.  They still have to pay the Part B premium as this goes to help fund the fee paid to the insurance companies. Most of the plans include prescription drug coverage in them.  If they do not, you cannot purchase a separate drug plan.  Medicare Advantage plans must cover the same benefits as original Medicare and can offer additional benefits.  These plans are county specific so the plans available in one county may not be available in a neighboring county.

Medicare Advantage plans come in a couple of different ways.  

• MAPD – Medicare Advantage Prescription Drug. This is most common type of plan.  These include not only the healthcare coverage, but prescription drug coverage as well. There can be multiple types of these kinds of plans. There is an alphabet soup of plans. See below for the differences between them.
• MA (Medicare Advantage) plans only.  These do not include drug coverage in them.  A client cannot purchase a separate drug plan to go with it. These are primarily oriented toward Veterans who get their medications through the VA but want some extra benefits and the ability to go outside the VA system.  The client might have other credible coverage through an employer that they want to use instead of a Part D plan. These can be either a PPO or an HMO.
• MSA – Medicare Savings Account. These work similarly to an HSA.  It is a high deductible plan where the company puts money into an MSA account.  It acts like an HSA.  The client can use the money to pay for items during the deductible.  The client cannot add money to the account, but the money stays in the account and rolls over from year to year.  It is the client’s money.  They pay all of Medicare’s cost until they reach the deductible, which can be $5000+ per year.  They can use the MSA account for any qualified health expense.  

Types of MAPD Plans

As mentioned above, MAPD can come in various types.  Most of them have networks.  They can be HMO, HMO-POS, PPO (LPPO and RPPO), PFFS, SNP plans.  

HMO – Health Maintenance Organization

Generally, unless it is an emergency, urgent care or out-of-area dialysis, the client must receive their care from doctors, other care providers or hospitals in the plan’s network.  In most cases they will cover drug coverage and have that built in.  The client will need to choose a primary care provider (PCP).  With some companies, you must get a referral from our PCP in order to see a specialist.  Some companies, referrals are recommended but not required.  You need to check with the carrier to know their policy on this.  PCPs can become “gatekeepers”.  If the client receives care outside the network, other than for emergency care, they will pay the full cost.  Often times with companies, the client must get prior approval for certain services.  It is necessary to check with the carrier.  

The out-of-pocket maximums and extra benefits are usually more generous with an HMO.  This is because the insurance company has different contracts with the doctors and are able to better control costs.  Usually because you need a referral to see a specialist, so the PCP is more involved and potentially reducing the number of specialists a client sees.

HMO-POS – Health Maintenance Organization – Point of Service

Basically, all the same information above, applies to the HMO-POS.   The exception is that for certain services the client can go out of network.  A higher fee will apply if the provider is not in the network.  It is not for all services. The client needs to check with the insurance company for what is allowed.  

PPO – Preferred Provider Organization

There can be LPPO – Local PPO or RPPO – Regional PPO plans.  They have a network of doctors, specialists, hospitals and other care providers, but you can also use out-of-network providers.  You will pay more (sometimes a lot more) for using out-of-network providers.  You are always covered for emergency and urgent care as being in network. You don’t necessarily need to choose a PCP and referrals are usually not required to see a specialist. Most of the plans have drug coverage built into it.  You cannot purchase a PDP if your plan does not have it built in. The plan may include some extra benefits that you would not get with original Medicare.  

Local PPO plans typically have a network of doctors that is in the region the plan is offered in.  A Regional PPO plan is typically good in the entire state and the network includes doctors across the whole state.  In general, the RPPO plans do not offer as many extra benefits as the LPPO plans.  You need to check the summary of benefits for the plan to determine the exact benefits.

PFFS – Private Fee For Service

With a PFFS plan, you can see any provider that takes Medicare and agrees to accept the plan’s payment terms and agrees to treat you.  If the PFFS plan has a network, you can see any of the network’s providers who have agreed to always treat plan members.  If the provider is not in the network, they can choose to treat a person or not, except in an emergency. This choice to treat can be on a case-by-case basis. They may choose to see you one time and then not after that.  They may choose to see your neighbor and not you.  Not all PFFS plans include drug coverage.  With this type of plan, if it does NOT include drug coverage, then a client CAN purchase a stand-alone drug plan. You will not need to choose a PCP and do not need referrals to see a specialist.  The plan decides how much you will pay for a service.  Some PFFS plans will allow “balance billing”.  This means that providers can charge you up to 15% over what the plan pays for a covered service.  You would pay the difference between what the provider charges and the plan’s reimbursement.

SNP – Special Needs Plan

Agents pronounce these “SNIP” plans.  These sorts of plans provide benefits and services to people with specific diseases, health care needs or limited incomes. They may tailor their benefits, drug formularies and provider choices to meet the specific needs of the group.  Most SNP plans are HMOs so they will not cover out of network providers.  They must all provide drug coverage in them.  In most cases you will need to choose a PCP and need referrals to see specialist.  There are 3 types of SNP plans.

• D-SNP – Dual Eligible Special Needs Plans. You must be eligible for both Medicare AND full Medicaid.  See our module on Medicaid for more information on this.  The extra benefits provided by these plans are generally very generous compared to the other Medicare Advantage plans.  You must verify before submitting an application that they are eligible for a D-SNP plan. Some companies require a special code to be able to enter the application.  Verification of their eligibility can be done on various carrier websites or via the agent support number.
• C-SNP – Chronic Condition Special Needs Plan.  These plans cater to people with specific severe or disabling chronic conditions such as diabetes, heart failure, dementia or End-Stage Renal Disease (ESRD). A client will need to get certification from a doctor that they have the condition for which the C-SNP provides coverage.  You can enroll anytime during the year.  But can only make one selection.  MORE
• I-SNP – Institutional Special Needs Plan. For people who live in certain institutions (like a nursing home) these plans may be available.  They may be specific to that particular institution but can provide county wide services if they have at least one long-term care facility that can accept enrollment and is accessible to the county residents.

Guarantee Issue Situations – MAPD

You must have Part A AND Part B to get an MAPD.  That is because it takes the place of Part A and Part B.  When a client first goes on Medicare at age 65 and picks up Part B, they have 3 months before and 3 months after their birth month to enroll into an MAPD.  Once the plan is active, they can no longer change the plan until the annual enrollment period.  Until the plan is active, they can change their plan choice.  There are no health questions for enrolling into an MAPD.

If the client is coming off of employer coverage and already has Part B, they have 63 days to pick up an MAPD with no underwriting.  If they are picking up Part B when they leave employer coverage, they have the 3-month window to get an MAPD.  

The AEP – annual enrollment period (Oct 15th to Dec 7th) is a time when a client can change their Medicare Advantage plan. They can enroll in as many as they want. The last one processed is the one that will take effect on Jan 1st.  

The OEP – open enrollment period (Jan 1st to Mar 31st) is a time when a client can make ONE change to their Medicare Advantage plan.  If the plan has not gone active, they can make a change.  Once the plan is active, there are no other changes unless there is a SEP or until AEP. 

Trial Rights.  GI if MAPD leaves service area. 

MAPD Strategy

Selecting the right MAPD for a client take a little finesse.  Start by putting their medications into Medicare.gov.  Ensure you put the right zip code and pick the correct county as MAPD are county specific.  See which plans are the lowest for their medications and cover all their medications.  Note that there are some medications that no plan will cover. Ensure your client knows this when presenting the plan.  Find them a Good RX coupon for the medication. Then look up their doctors in the network for the plans you are considering.  You must look up the doctors on the carrier’s website.  DO NOT call the doctor’s office to ask if they are in network. The people in the office are not reliable.  Look up EVERY doctor the client lists on their paperwork. Always as, do you see any other doctors or are there doctors you would want to see.  You may find that not all the doctors are in the network for the plan you want.  If the client is not willing to change their doctor, then move on to the next best plan.  It is uncommon, but you might not be able to find a plan where all their medications are covered and all the doctors are in the network.  

If you find 2 or 3 plans where the medications are about the same and all the doctors are in the network, then start to look at the copays between the different plans.  You may find a plan where the copays for most procedures are lower than another plan.  You don’t want to be presenting 3 different plans to a client.  You do the shopping for them and make a recommendation as to what plan you think is best.  Be prepared to backup or defend your plan.  

MAPD Company Choices

Networks, formularies, copays and extra benefits can vary greatly by company.  Always refer to the summary of benefits for any specific information.  You are not permitted to create your own comparisons between plans and benefits.  Everything must come from approved sources.  You can print off the information from the Medicare.gov website or put the summary of benefits side-by-side to assist your client in comparing plans.  Imagine creates a side-by-side spreadsheet of the benefits of each company. This is for agent use only and CANNOT be shared with client.  Refer to the MAPD comparison in the reference material. Refer to the lesson on Company Analysis to get our thoughts about the different companies.  This part is not finished.

• Anthem – Anthem’s MAPD plans have been very consistent over the years. As of 2021, they offer an HMO, 2 PPOs, 1 RPPO, D-SNP and a no RX Medicare Advantage plan. See our MAPD comparison document for the details of all these plans. Anthem has a D-SNP (Dual Special Needs Plan) if someone has Medicare and Medicaid. You should call agent support or use the D-SNP tool in MProducer to verify that they have the right level of Medicaid.  Anthem will take some levels of Medicaid that other companies will not.  To enter the application, you must have the D-SNP code.  they do have a relationship with an agent, you do not want to sever that.  Perhaps over time if you help them with their drug coverage, they will value you more and sign the AOR. As of 3/1/21, MAPD and PDP can no longer be AOR-ed without a plan change. You would need to write the client on a new policy in order to be the agent of record.  Enrollments are done online through your agent portal via MProducer.  You can take the application and then enter it electronically later. All products can be done this way.  If you are doing an MAPD or PDP, you MUST upload the Scope of Sales Appointment Form.  
• United Healthcare – They offer HMO, PPO, D-SNP and a no RX Medicare Advantage plans. Their MAPD plans also offer the insulin savings.  As of 2021, they have only been in the MAPD arena in KY for a few years. They are still working on developing their network of doctors.  They are also not in every county in KY. Enrollments can be done electronically via the LEAN application. You must have a signature pad or email them for an electronic signature to do the enrollment. You must also be connected to the internet to do the enrollment. If you don’t do it via LEAN, you will need to fax the application to UHC.  HRA
• Humana – Historically their Medicare Advantage plans have been pretty good.  They tend to have a LOT of difference Medicare advantage plans which can make it really confusing.  Refer to our MAPD comparison document for the differences between them.  They have 2 different HMO plans. The networks are very different for each one.  The Community HMO only has Jencare and some Norton doctors in the network.  The only hospitals in the network are Norton.  The Gold Plus HMO has a much better network.  It is really pretty good.  Their Community and Gold Plus plans offer the insulin savings plan. Humana’s PPO plan is good and the network is good. You really need to understand the differences between all the PPO plans as the differences can be subtle.  Humana has multiple Special Needs Plans (SNP). They have a dual for people with Medicare and Medicaid, one for people with chronic diseases (Heart and Diabetes). Within the D-SNP, there are is the Community Network and the Gold Network like the HMO above.  The Chronic SNP (C-SNP) only uses the Community Network. The C-SNP requires that the doctor fill out a form confirming they have a Heart of Diabetes problem or the plan will be cancelled.  Make sure this is done in the right time frame. Enrollments are done via faxing the application or doing an electronic enrollment on the enrollment hub. With enrollment hub you can either take their signature with a signature pad or mouse/finger signature or email them a link where they can click on it and electronically sign it.  NOTE: If you are doing that and the client wants to logon to your computer to get to their email, you will get a violation. Humana tracks the IP addresses.  You cannot have the client’s signature come from your machine.  It has to be done on a separate computer. HRA
• Wellcare – The network is pretty good.  It has gotten better over the years as they also have Medicaid plans.  They have a number of different HMO plans and a PPO plan.  They also have a DSNP plan.  The copays on their MAPD plans are very reasonable especially when it comes to the diagnostic tests.  The complaint we have about Wellcare is that their customer service doesn’t always speak English very well.  The customer support is in the Philippines.  You can ask to be transferred to a US based agent.  Enrollments are done via the Ascend application.  We have a process document on that walking you through the process. If you are doing a D-SNP, you will need to do an additional Special Populations (SPOP) call to get a code.  If you don’t do the SPOP call, the SNP plan will not show up as an option when you enroll.    Immediately after the enrollment you can do a HRA (Health Risk Assessment).  Purchased by Centene
• Aetna – Yes, they have them. We need more info here.