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Maximum Out of Pocket on Medicare Advantage: Explained

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Table of Contents

Introduction

What is Medicare Advantage?

Medicare Advantage (Part C) is an “all in one” alternative to Original Medicare. It's like that swiss army knife you've always admired – it combines hospital insurance, medical services, and often includes prescription drug coverage. But like every tool, it has its nuances.

Why is MOOP Important?

Think of MOOP as a safety net. It's a feature that makes sure you don't end up in a free fall when it comes to healthcare costs. Ever wonder how high your medical bills could potentially go? MOOP sets that limit.

Understanding Maximum Out of Pocket (MOOP)

Defining MOOP

MOOP stands for Maximum Out-of-Pocket. Picture it as a spending cap, like the ceiling of a room, beyond which your Medicare Advantage plan begins to cover 100% of your costs.

How MOOP Works

Imagine you're filling a bucket with water (your medical expenses). Once it's full to the brim, you don't need to add any more. Similarly, once you reach your MOOP limit, you won't pay any more for covered services.

Differences Between MOOP and Traditional Deductibles

It's easy to confuse MOOP with traditional deductibles. Think of MOOP as the entire depth of a swimming pool, while the deductible is just the shallow end. Deductibles are the initial costs you pay, whereas MOOP is the absolute maximum for the year.

The Benefits of MOOP

Financial Protection

MOOP acts as a buffer. It's like having an umbrella during a rainstorm; even if it pours, you're shielded from the brunt of it.

Predictability

Knowing there's a cap on your medical expenses offers peace of mind. It's akin to knowing there's a safety net while tightrope walking; you're secure, no matter what.

Encouraging Preventive Care

Because of MOOP, people are less likely to skip important medical appointments. It's like owning a car with a warranty; you're more likely to get regular check-ups, ensuring everything runs smoothly.

Limitations and Considerations

Coverage Gaps

Like any system, Medicare Advantage with MOOP isn't flawless. It's essential to understand what's covered and what's not. It's like knowing the zones of an umbrella; some areas shield you from rain, while others might let a few droplets through.

Network Restrictions

While Medicare Advantage offers a plethora of benefits, it may come with certain network restrictions. Think of it as a VIP event; it's fantastic, but you might need specific credentials to get the most out of it.

FAQs

  1. What costs count towards MOOP? Most out-of-pocket costs related to covered services count towards MOOP. This includes deductibles, coinsurance, and co-pays.
  2. Do premiums count towards MOOP? No, monthly premiums don't count towards your MOOP.
  3. Is there a standard MOOP for all Medicare Advantage plans? No, MOOP limits can vary between plans, but there's a maximum limit set by Medicare each year.
  4. Can MOOP change year to year? Yes, the MOOP can be adjusted annually by Medicare.
  5. What happens if I switch Medicare Advantage plans halfway through the year? Your out-of-pocket expenses will reset, and you will need to meet the MOOP for your new plan.

Conclusion

Navigating the intricacies of Medicare Advantage and understanding MOOP can seem like unraveling a complex puzzle. But with the right guidance and insights, you can ensure you're adequately covered and financially protected. Remember, knowledge is power – and in this case, it's the key to sound health and peace of mind. Our office helps with all types of Medicare plans. Click here if you'd like our help.

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50 Cent Monthly Premium for Part D Drug Plan?

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Outline:

1. Introduction

  • 1.1 Brief on Part D drug plan 2024
  • 1.2 Christopher Westfall's introduction and role

2. The 50-Cent Medicare Part D Premium for 2024

  • 2.1 Initial reactions and questions
  • 2.2 The reality of the low-priced premiums

3. The Need for Regular Medicare Part D Reviews

  • 3.1 Changes in Part D plans
  • 3.2 Importance of being proactive

4. A Close Look at 2024 Premiums

  • 4.1 Plan Finder tool details
  • 4.2 Comparisons across various zip codes

5. Why the Plans are so Cheap

  • 5.1 Introduction to StartPartD.com
  • 5.2 The upselling strategy by drug plan companies

6. The Medicare Advantage Plan

  • 6.1 Definition and implications
  • 6.2 Other terminologies used
  • 6.3 Making an educated choice

7. The Financial Aspects of Medicare Advantage Plan

  • 7.1 The backend costs
  • 7.2 Potential expenses for patients

8. Solutions for Medicare Advantage Plan Holders

  • 8.1 Hospital Indemnity Plans
  • 8.2 Cancer plans

9. Importance of Cancer Insurance

  • 9.1 Challenges with Medicare Advantage and cancer treatment
  • 9.2 Benefits of cancer insurance for Medicare supplements

10. Closing Thoughts on 2024 Drug Plans

  • 10.1 Authenticity of the plans
  • 10.2 Recommendations for choosing a plan

Is it really true?

The buzz around the Part D drug plan for 2024 has been quite significant, especially with the shockingly low monthly premium offers.

Hi, I'm Christopher Westfall. I've been helping individuals navigate the maze of Medicare all over the country. Though specific benefit information is restricted, I'm here to shed some light on what's publicly available.

The 50-Cent Medicare Part D Premium for 2024

Recent news from Street reveals that these unbelievable premiums are, in fact, a reality for 2024. It's caused quite a stir among agents and clients alike. Many are left pondering, “Is this for real?”

The Need for Regular Medicare Part D Reviews

Every year, seniors find themselves navigating changes in Medicare Part D plans. With substantial changes on the horizon, it's crucial not to overlook the details.

A Close Look at 2024 Premiums

Taking a sneak peek into 2024, I've discovered some jaw-dropping prices. Using tools like Medicare.gov or StartPartD.com, you can review these prices across various regions.

Why the Plans are so Cheap

Venturing to my site, StartPartD.com, will give you a clear idea. The attractive pricing might be a bait for upselling attempts. Don't fall for the traps.

The Medicare Advantage Plan

Many are not familiar with the intricacies of Medicare Advantage Plans. These plans can remove you from original Medicare roles and come with their own set of benefits and drawbacks.

The Financial Aspects of Medicare Advantage Plan

While the upfront costs might seem negligible, there are other costs to consider. Always be prepared for unexpected expenses.

Solutions for Medicare Advantage Plan Holders

There are various solutions, like the Hospital Indemnity Plans, to cover potential expenses. Being informed can save you from financial surprises.

Importance of Cancer Insurance

Cancer treatment can be expensive, especially with Medicare Advantage. Consider investing in a dedicated cancer insurance plan.

Closing Thoughts on 2024 Drug Plans

Yes, the 2024 plans with low premiums are legit. Always be cautious and well-informed when making your choices.

FAQs:

1. Are the 50 cent and zero monthly premium drug plans for 2024 legitimate?

  • Yes, these plans are indeed legitimate for 2024.

2. Why are the 2024 drug plans so cheap?

  • While the exact reasons vary, some companies may offer low premiums to later upsell or promote other services.

3. What is the Medicare Advantage Plan, and how does it differ from original Medicare?

  • Medicare Advantage Plans provide Medicare benefits through private companies. They often come with added services but might also have restrictions compared to original Medicare.

4. How can I best prepare for unexpected expenses with a Medicare Advantage Plan?

  • Consider supplemental plans like Hospital Indemnity Plans or dedicated cancer insurance to cover potential high costs.

5. When is the best time to review and choose a Part D drug plan?

  • You can review and enroll in drug plans between October 15th and December 7th each year. Always compare based on total out-of-pocket costs for the year, not just monthly premiums.

We help with Medicare 1-800-729-9590

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Presidential Candidates: on Medicare

Medicare News, Medicare Supplement, Podcasts /

Presidential Candidate Questions on Medicare

 

1. “Can you explain your stance on the current state of Medicare in the United States? What would you say are its most significant strengths and weaknesses?”

2. “Many Americans are worried about the sustainability of Medicare. As a Presidential candidate, what steps do you propose to ensure Medicare's long-term viability?”

3. “How will your administration address the high cost of prescription drugs, which has a significant impact on Medicare beneficiaries?”

4. “What are your plans to improve access to Medicare for the most vulnerable populations, such as the elderly, the disabled, and those in rural areas?”

5. “Medicare Advantage plans are growing in popularity, but there is debate about their cost-effectiveness and the quality of care they provide. What is your stance on Medicare Advantage, and how will it influence your policy-making?”

6. “Should there be a cap on out-of-pocket expenses for those using Medicare? If so, what do you think would be a reasonable limit?”

7. “Some argue that expanding Medicare to include vision, dental, and hearing care is necessary. What is your position on expanding Medicare's coverage?”

8. “There have been proposals for ‘Medicare for All' as a solution to America's healthcare issues. What is your position on this idea, and how do you believe it would impact the overall healthcare system?”

9. “Medicare fraud is a significant issue, costing taxpayers billions of dollars each year. What measures will your administration take to tackle this problem and improve program integrity?”

10. “Do you believe that the age of eligibility for Medicare should be lowered, or should there be alternatives to cover those who are younger and uninsured?”

These questions are of major importance to the more than 54 million actual voting seniors on Medicare.


Christopher Westfall
1-800-729-9590
[email protected]

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Disadvantages of Medicare Advantage

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Medicare Advantage Disadvantages: Understanding the Downsides of Medicare Advantage Plans

Introduction

Medicare Advantage plans, also known as Medicare Part C, offer an alternative way to receive Medicare benefits. While these plans come with several advantages, it's important to be aware of their potential disadvantages. In this article, we will explore the Medicare Advantage disadvantages, shedding light on the drawbacks associated with these plans.

Medicare Advantage Disadvantages

Medicare Advantage plans, despite their benefits, may have some downsides that beneficiaries should consider before enrolling. Let's take a closer look at the disadvantages of Medicare Advantage plans:

1. Limited Network of Providers

Medicare Advantage plans typically have a network of preferred providers. This means that you may need to seek healthcare services from doctors, hospitals, and specialists within the plan's network. Going out-of-network may result in higher out-of-pocket costs or may not be covered at all.

2. Lack of Nationwide Coverage

Unlike Original Medicare, which provides coverage nationwide, Medicare Advantage plans often have limited geographic coverage. If you frequently travel or spend time in different states, it's important to check whether your plan will cover you outside its designated service area.

3. Potential for Higher Out-of-Pocket Costs

Medicare Advantage plans often require beneficiaries to pay certain cost-sharing amounts, such as copayments and coinsurance, for services rendered. These out-of-pocket costs can add up, particularly if you require frequent medical care or specialized treatments.

4. Prior Authorization Requirements

Some Medicare Advantage plans may require prior authorization for certain medical procedures, treatments, or medications. This means that you would need approval from the plan before receiving the service, which can introduce delays and additional administrative steps.

5. Limited Prescription Drug Formularies

Many Medicare Advantage plans include prescription drug coverage, known as Medicare Part D. However, these plans may have limited formularies that only cover specific medications. If you take medications that are not included in your plan's formulary, you may need to pay the full cost out-of-pocket.

6. Potential Disruption of Doctor-Patient Relationships

When you enroll in a Medicare Advantage plan, you may need to change doctors if your current healthcare providers are not part of the plan's network. This can be particularly challenging if you have established a trusting relationship with your doctors and specialists over the years.

7. Difficulty Comparing Plans

Medicare Advantage plans can vary significantly in terms of coverage, costs, and benefits. Comparing these plans can be complex and time-consuming, especially considering the frequent changes in plan offerings from year to year.

8. Risk of Plan Discontinuation

Medicare Advantage plans are offered by private insurance companies, and these companies can choose to discontinue or modify their plans from year to year. If your plan is discontinued, you would need to find a new plan during the next Medicare Annual Enrollment Period.

9. Extra Costs for Non-Essential Services

While Original Medicare covers medically necessary services, Medicare Advantage plans may offer additional benefits such as dental, vision, or hearing coverage. However, these added benefits may come with additional costs, either through higher premiums or increased out-of-pocket expenses.

10. Potential for Coverage Limitations

Medicare Advantage plans may have limitations on certain services or treatments. For example, they may impose restrictions on the number of physical therapy sessions covered or limit the frequency of certain diagnostic tests.

11. Difficulty Accessing Specialists

Specialist care may be more challenging to access under a Medicare Advantage plan. Some plans require referrals from primary care physicians to see a specialist, which can introduce delays and additional administrative steps.

12. Risk of Plan Non-Renewal

Similar to discontinuation, Medicare Advantage plans can also choose not to renew their contracts with Medicare. If your plan is not renewed, you would need to find an alternative plan during the next Medicare Annual Enrollment Period.

13. Inflexible Enrollment Periods

Medicare Advantage plans have specific enrollment periods, such as the Initial Enrollment Period and the Annual Enrollment Period. Missing these enrollment windows may limit your options or result in a gap in coverage.

14. Potential for Disenrollment Restrictions

Once enrolled in a Medicare Advantage plan, beneficiaries may face limitations on changing plans or returning to Original Medicare. It's important to carefully consider your healthcare needs and plan options before making a decision.

15. Limited Coverage for Certain Medical Facilities

Not all healthcare facilities, such as specialized hospitals or renowned medical centers, may be part of a Medicare Advantage plan's network. This can restrict your choices when seeking care from specific facilities.

16. Complexity of Plan Rules and Regulations

Medicare Advantage plans often have their own set of rules and regulations that beneficiaries must navigate. Understanding these complexities can be challenging, particularly for individuals who are not familiar with health insurance terminology and processes.

17. Potential Loss of Access to Medigap Plans

If you choose to enroll in a Medicare Advantage plan, you will not be able to purchase a Medigap policy. Medigap plans help cover out-of-pocket costs associated with Original Medicare, providing additional financial protection.

18. Lack of Standardization Across Plans

Medicare Advantage plans can differ significantly from one another in terms of coverage, cost-sharing, and network providers. This lack of standardization can make it harder to compare and select the best plan for your specific needs.

19. Limited Flexibility for Snowbirds

If you are someone who spends part of the year in a different state, a Medicare Advantage plan may not provide the flexibility you need. Some plans may only cover emergency care outside their service area, which may not be suitable for individuals with seasonal residency.

20. Potential for Plan Changes Throughout the Year

Unlike Original Medicare, which remains relatively stable, Medicare Advantage plans can modify their coverage, network, and costs during the year. These changes can impact your access to services and the affordability of your healthcare.

21. Difficulty in Dispute Resolution

If you have a disagreement or dispute with your Medicare Advantage plan, resolving the issue can be challenging. Navigating the appeals process and communicating with the insurance company may require time and effort.

22. Limited Coverage During Travel Abroad

Medicare Advantage plans usually do not provide coverage for healthcare services received outside the United States. If you frequently travel internationally or reside abroad, it's important to explore other options for healthcare coverage during your time outside the country.

23. Risk of Plan Marketing Misinformation

Medicare Advantage plans may be marketed heavily, and the information provided by insurance companies may not always be entirely accurate or clear. It's crucial to conduct thorough research and verify the details of a plan before making a decision.

24. Potential for Higher Administrative Burden

Medicare Advantage plans often require beneficiaries to navigate various administrative tasks, such as obtaining prior authorizations, coordinating care between providers, and understanding plan-specific guidelines. This increased administrative burden can be overwhelming for some individuals.

25. Impact on Low-Income Individuals

While Medicare Advantage plans are required to provide at least the same level of coverage as Original Medicare, certain low-income individuals may have better access to financial assistance through programs like Medicaid if they stick with Original Medicare.

FAQs about Medicare Advantage Disadvantages

Q1: Are Medicare Advantage plans better than Original Medicare?

A1: Whether Medicare Advantage plans are better than Original Medicare depends on your individual needs and preferences. While Medicare Advantage plans offer additional benefits and may have lower premiums, they also come with potential disadvantages.

Q2: Can I switch from a Medicare Advantage plan to Original Medicare?

A2: Yes, you can switch from a Medicare Advantage plan to Original Medicare during the Medicare Annual Enrollment Period (October 15 – December 7) or the Medicare Advantage Open Enrollment Period (January 1 – March 31).

Q3: Can I have both a Medicare Advantage plan and a Medigap policy?

A3: No, it's not possible to have both a Medicare Advantage plan and a Medigap policy. Medigap policies only work with Original Medicare.

Q4: Can Medicare Advantage plans deny coverage for pre-existing conditions?

A4: No, Medicare Advantage plans cannot deny coverage based on pre-existing conditions. However, they can impose waiting periods for certain treatments or services.

Q5: Are all Medicare Advantage plans the same?

A5: No, Medicare Advantage plans vary in terms of coverage, costs, network providers, and additional benefits. It's important to review and compare different plans to find the one that suits your needs.

Q6: Can I join a Medicare Advantage plan if I have end-stage renal disease (ESRD)?

A6: In most cases, individuals with end-stage renal disease (ESRD) are not eligible to enroll in a Medicare Advantage plan. However, there are certain exceptions and special circumstances.

Conclusion

While Medicare Advantage plans offer several advantages, it's essential to be aware of their potential disadvantages. From limited provider networks to higher out-of-pocket costs, understanding these drawbacks can help you make an informed decision about your healthcare coverage. Remember to carefully review and compare different plans before enrolling to ensure they align with your specific needs and preferences.e

We help compare all plan types here at the Senior Savings Network.
We can be reached at 1-800-729-9590.

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STOP Medicare Advantage! NYC Lawsuit Filed

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New York City Retirees Fight Against Medicare Coverage Changes

An important development regarding retirees' access to health insurance is the class-action lawsuit that has been brought against the City of New York. The complaint, which was filed on May 31, 2023, contests the City's intention to convert almost a quarter million retirees who are aged and disabled from their current Medicare coverage to “Medicare Advantage,” a less comprehensive form of coverage.
[source]

In contrast to the government-run Medicare program that has protected City retirees for more than 50 years, the new insurance policy, known as the Aetna Medicare Advantage plan, is a private, for-profit venture. The lawsuit asserts that the new policy exposes retirees to debilitating healthcare expenditures, has a small network of medical providers, and does not cover a wide range of medical services unless certified “medically necessary” by Aetna.[source]

The action also asks for a preliminary injunction to prevent the City's plan from being executed and to stop the forced move to Medicare Advantage immediately. They include causing risky denials of and delays in medical care, requiring senior adults on limited incomes to forgo medical care and other requirements, and prohibiting retirees from visiting their preferred doctors and staying in their continuing care homes.[source]

The lawsuit alleges that the City has promised every active and retired City worker since the 1960s that they would be entitled to City-funded healthcare through a combination of Medicare and Medicare “supplemental” insurance, which covers healthcare expenses that Medicare does not. The retirees argue that they reasonably relied on this promise and insist that the City must continue to honor it. The lawsuit alleges eleven other ways that the City’s new healthcare policy violates the rights of retirees, including violations of the New York State Constitution, the Retiree Health Insurance Moratorium Act, the New York State and New York City Human Rights Laws, the City Administrative Procedure Act, and the Donnelly Act.[source]

The legal filings include hundreds of affidavits from retirees, experts, and former high-ranking City officials supporting the allegations in the complaint.[source] Jake Gardener, a partner at Walden Macht & Haran LLP and counsel to the retirees, criticized the City’s new healthcare policy, saying, “The City’s new healthcare policy imperils the health of hundreds of thousands of senior citizens and disabled first responders and flagrantly violates their rights. To deprive them of those benefits now“`html
, in their old age, is an unconscionable bait-and-switch.”[source]

Marianne Pizzitola, President of the New York City Organization of Public Service Retirees, expressed her disappointment, stating, “As a former EMT who became sick working at Ground Zero, I feel disgusted and betrayed by the Mayor and union leaders, who chose to enrich themselves at the expense of elderly and disabled retirees. Retired municipal workers devoted themselves to this city for little pay. We were guaranteed certain healthcare benefits in return. To deny us that after a lifetime of service is outrageous and immoral.”[source]

The class-action lawsuit, a hybrid of a class action and Article 78 proceeding, was filed in the New York State Supreme Court. The retiree plaintiffs are being represented by Walden Macht & Haran LLP, with assistance from co-counsel at Pollock Cohen LLP.[source] As the case proceeds, the implications for the future of healthcare coverage for retirees in New York City remain to be seen.

The Senior Savings Network is a broker specializing in Medicare benefits throughout the United States. We are continuing to monitor this situation and provide help for alternative solutions for those who need it.  The Senior Savings Network can be reached at 1-800-729-9590.

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Medicare & You 2024 Guidebook

Medicare and You Book

Medicare, medicare advantage, Medicare Supplement, Part D /

The 2024 Medicare & You Guidebook is available and you can download it here.

When downloading the digital version, it will open in your Acrobat document reader, or in your browser. A tip for finding what you want, instantly, is to hit the Control and F button at the same time on your keyboard. This will bring up the FIND feature in your reader. 

Then, type in a word or phrase you are looking for. The reader should show you how many instances of that word or phrase exist in the entire book and you can click the down arrow to move from the first to the second, and so on.

This is how we zero in on things such as the Special Election Periods, Trial Right scenarios, Guarantee Issue Periods, and more. 

The 2024 Medicare & You book is slightly less controversial than those in the past.

 CMS (Center for Medicare and Medicaid Services) has been leaning more and more toward promoting Medicare Advantage plans and this bias has started to come through in their Medicare guide book.

In 2018, the non-profit Medicare Rights Center, in a joint letter with the Center for Medicare Advocacy and Justice in Aging, wrote a letter to the Administrator of CMS urging corrections in the proposed guidebook for 2019. 

They stated, “First, in several places, the Handbook suggests that Medicare Advantage is the less expensive alternative for beneficiaries. This is an overstatement. There are many variables determining whether enrollment in a Medicare Advantage plan may be more or less expensive for any particular Medicare beneficiary…. The repeated suggestion that Medicare Advantage can save beneficiaries money does not fairly represent these realities.”

The letter went on to point out that various descriptions throughout the book give the false impression that the benefits of Original Medicare are the same as the benefits in Medicare Advantage.

When the guidebook was first read by many of our clients, they found it to be confusing, contradictory, and inaccurate to their experience with Medicare. This again points to the benefit of using an independent Medicare professional who can interpret the realities of Medicare and how it works in the real world. This only comes from experience.

We are here to help and our service is always free.
1-800-729-9590

Medicare & You 2024 Guidebook

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Medicare Surprise: Drug Plan Prices Change Mid-Year

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Medicare Surprise: Drug Plan Prices Touted During Open Enrollment Can Rise Within a Month

Susan Jaffe

Something strange happened between the time Linda Griffith signed up for a new Medicare prescription drug plan during last fall’s enrollment period and when she tried to fill her first prescription in January.

She picked a Humana drug plan for its low prices, with help from her longtime insurance agent and Medicare’s Plan Finder, an online pricing tool for comparing a dizzying array of options. But instead of the $70.09 she expected to pay for her dextroamphetamine, used to treat attention-deficit/hyperactivity disorder, her pharmacist told her she owed $275.90.

“I didn’t pick it up because I thought something was wrong,” said Griffith, 73, a retired construction company accountant who lives in the Northern California town of Weaverville.

“To me, when you purchase a plan, you have an implied contract,” she said. “I say I will pay the premium on time for this plan. And they’re going to make sure I get the drug for a certain amount.”

But it often doesn’t work that way. As early as three weeks after Medicare’s drug plan enrollment period ends on Dec. 7, insurance plans can change what they charge members for drugs — and they can do it repeatedly. Griffith’s prescription out-of-pocket cost has varied each month, and through March, she has already paid $433 more than she expected to.

A recent analysis by AARP, which is lobbying Congress to pass legislation to control drug prices, compared drugmakers’ list prices between the end of December 2021 — shortly after the Dec. 7 sign-up deadline — and the end of January 2022, just a month after new Medicare drug plans began. Researchers found that the list prices for the 75 brand-name drugs most frequently prescribed to Medicare beneficiaries had risen as much as 8%.

Medicare officials acknowledge that manufacturers’ prices and the out-of-pocket costs charged by an insurer can fluctuate. “Your plan may raise the copayment or coinsurance you pay for a particular drug when the manufacturer raises their price, or when a plan starts to offer a generic form of a drug,” the Medicare website warns.

But no matter how high the prices go, most plan members can’t switch to cheaper plans after Jan. 1, said Fred Riccardi, president of the Medicare Rights Center, which helps seniors access Medicare benefits.

Drug manufacturers usually change the list price for drugs in January and occasionally again in July, “but they can increase prices more often,” said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University and a member of the Medicare Payment Advisory Commission. That’s true for any health insurance policy, not just Medicare drug plans.

Like a car’s sticker price, a drug’s list price is the starting point for negotiating discounts — in this case, between insurers or their pharmacy benefit managers and drug manufacturers. If the list price goes up, the amount the plan member pays may go up, too, she said.

The discounts that insurers or their pharmacy benefit managers receive “don’t typically translate into lower prices at the pharmacy counter,” she said. “Instead, these savings are used to reduce premiums or slow premium growth for all beneficiaries.”

Medicare’s prescription drug benefit, which began in 2006, was supposed to take the surprise out of filling a prescription. But even when seniors have insurance coverage for drugs, advocates said, many still can’t afford them.

“We hear consistently from people who just have absolute sticker shock when they see not only the full cost of the drug, but their cost sharing,” said Riccardi.

The potential for surprises is growing. More insurers have eliminated copayments — a set dollar amount for a prescription — and instead charge members a percentage of the drug price, or coinsurance, Chiquita Brooks-LaSure, the top official at the Centers for Medicare & Medicaid Services, said in a recent interview with KHN. The drug benefit is designed to give insurers the “flexibility” to make such changes. “And that is one of the reasons why we’re asking Congress to give us authority to negotiate drug prices,” she said.

CMS also is looking at ways to make drugs more affordable without waiting for Congress to act. “We are always trying to consider where it makes sense to be able to allow people to change plans,” said Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, who joined Brooks-LaSure during the interview.

On April 22, CMS unveiled a proposal to streamline access to the Medicare Savings Program, which helps 10 million low-income enrollees pay Medicare premiums and reduce cost sharing. Enrollees also receive drug coverage with reduced premiums and out-of-pocket costs.

The subsidies make a difference. Low-income beneficiaries who have separate drug coverage plans and receive subsidies are nearly twice as likely to take their medications as those without financial assistance, according to a study Dusetzina co-authored for Health Affairs in April.

When CMS approves plans to be sold to beneficiaries, the only part of drug pricing it approves is the cost-sharing amount — or tier — applied to each drug. Some plans have as many as six drug tiers.

In addition to the drug tier, what patients pay can also depend on the pharmacy, their deductible, their copayment or coinsurance — and whether they opt to abandon their insurance and pay cash.

After Linda Griffith left the pharmacy without her medication, she spent a week making phone calls to her drug plan, pharmacy, Social Security, and Medicare but still couldn’t find out why the cost was so high. “I finally just had to give in and pay it because I need the meds — I can’t function without them,” she said.

But she didn’t give up. She appealed to her insurance company for a tier reduction, which was denied. The plan denied two more requests for price adjustments, despite assistance from Pam Smith, program manager for five California counties served by the Health Insurance Counseling and Advocacy Program. They are now appealing directly to CMS.

“It’s important to us to work with our members who have questions about any out-of-pocket costs that are higher than the member would expect,” said Lisa Dimond, a Humana spokesperson. She could not comment about Griffith’s situation because of privacy rules.

However, Griffith said she received a call from a Humana executive who said the company had received an inquiry from the media. After they discussed the problem, Griffith said, the woman told her, “The [Medicare] Plan Finder is an outside source and therefore not reliable information,” but assured Griffith that she would find out where the Plan Finder information had come from.

She won’t have to look far: CMS requires insurers to update their prices every two weeks.

“I want my money back, and I want to be charged the amount I agreed to pay for the drug,” said Griffith. “I think this needs to be fixed because other people are going to be cheated.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Why People Leave Medicare Advantage Plans

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Why are so many people leaving Medicare Advantage Plans?
 Studies show several reasons for the trend.

  1. Location

An article in Modern Healthcare found that people living in rural areas are more likely to leave Medicare Advantage and go back to Original Medicare. This is partially attributed to the lack of available in-network doctors, specialists, facilities, etc. 

  1. Cost

Along with being in a rural area, those with costly services are also more likely to disenroll from Medicare Advantage. One study warns that if Private Insurers start charging out-of-pocket costs for lifesaving COVID-19 care, people on Medicare Advantage could face hospital bills of $1000  or more. 

In this video, we discuss several studies that address why enrollees are choosing to leave Medicare Advantage. We also cover time frames and how to switch your Medicare Advantage plan or get back on to Original Medicare. There isn’t one plan best suited for everyone but we can help get you the knowledge needed to decide what plan best suits YOUR needs.

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Diabetes and Medicare Advantage

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Differences between Original Medicare vs. Medicare Advantage

If I have diabetes, should I choose Original Medicare or Medicare Advantage?

The answer to this question depends on how important individualized care is to you.

Medicare Advantage plans are typically bundled, all-in-one plans that are made as a ‘one size fits all’, with a prescription drug plan included.

However, Original Medicare is set up for you to choose a supplement plan along with a prescription drug plan tailored to your individual needs.

The American Journal of Managed Care published a study pertaining to the difference in treatment of diabetes between Original Medicare and Medicare Advantage.

In the study, they concluded that in order to achieve savings, Medicare Advantage enrollees are more likely to be treated with cheaper medications, such as Metformin and Sulfonylureas, rather than receive costly, newer medications, compared to Original Medicare. This means Original Medicare affords you the opportunity to have the drugs that might best suit you.

In this video, we review the study and explain some of the differences between Original Medicare and Medicare Advantage. We also discuss why this decision is so important if you or someone you know has diabetes and are searching for the best plan.

If you would like help finding the best Medicare plan for you, please reach out. Our help is 100% FREE to you.

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How to Leave a Medicare Advantage Plan

Medicare, medicare advantage, Medicare Supplement /

In the first quarter of every year, seniors often discover that the plan they signed up for during the Annual Enrollment Period does not suit them.
Their doctors may have already left the network. Hospitals they thought participated might have dropped out already.

Still, some seniors have now had the time to review the Summary of Benefits and looked closely at how chemotherapy is covered by Medicare Advantage.

This is often quite a shock, when, not only must they use only network providers (in the case of the HMO), but the plans typically only pay 80% of the cancer treatment costs.

That's the “Advantage” they've been sold for the often-zero premium.

Regardless of the reason, Medicare says that the first quarter is the opportunity to go back to original Medicare or change to a more-appropriate Medicare Advantage plan.

Steps to Cancel a Medicare Advantage Plan

From January 1 to March 31, Medicare now calls this the “Open Enrollment Period.”

A more appropriate name would be the “Disenrollment Period“. Those without a plan cannot obtain one, so it is not open by any stretch.

If you wish to go from Medicare Advantage to a Medicare Supplement, here are the steps:

  1. Apply for a Medicare Supplement
  2. Wait for the Underwriting Approval from the Supplement company
  3. When approved, make an application for a Part D plan.
  4. When the Part D plan starts, it automatically cancels the Advantage plan

This process ensures that you do not prematurely cancel the only insurance you may be able to qualify for. By using an independent Medicare broker, like the Senior Savings Network, you can find out what Medicare Supplement companies will likely approve your application and guarantee that you will not be paying too much for the same coverage that is offered by all of the Medicare Supplement companies.

Careful: Do Not Act in Haste!

Far too often, we get calls from seniors telling us that they became angry with the details of their Medicare Advantage plan and have already called their company and told them to cancel it. This is the wrong move.

In a worst-case scenario, that Advantage plan MAY be the only insurance you can have and, having something is better than nothing at all. So let an independent professional advise you on which plans are available in the market and which ones are most likely to approve you.

We would be happy to help with this process.


You can contact us securely here or by calling us at 1-800-729-9590.

1-800-729-9590

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