Medicare Advantage HMO plan with prescription coverage doesn’t cover it

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Medicare Advantage HMO is not enough when it comes to prescription coverage.

By Harry Thal

This past week, I received a phone call from a client who is very upset over the possibilities of a very negative prognosis of her husband’s medical condition.

He is not quite 66 years of age and has been on a Medicare Advantage HMO plan with prescription coverage (MA-PD). This plan was selected as it had good coverage and had a monthly premium of $0. What it did not have was the top oncologists in the county. His Primary Care Physician (PCP) was on the plan, and the plan covered his “current” medications with a very low co-pay at the pharmacy.

Recent medical tests indicate there most likely is a problem that will require surgery, followed by radiation and possibly chemo-therapy. All covered by the HMO, but not with the doctors they want to use. The $0 monthly premium is now looking like not a wise decision.

What the wife wants for her husband is a Medicare Supplement (MS) Plan. These plans allow you to select ANY Doctor, ANY Hospital and ANY medical provider that accepts Medicare. The supplement will pay the Medicare deductibles and co-pays. Yes, it will cost about $150 per month and will require a second policy for the pharmacy.

Unfortunately, Medicare Supplement policies are not available to just anyone. Anybody can enroll in a plan when they are first eligible for Medicare Part B.

There is a six-month window where no medical questions are asked. The “Guaranteed Issue” window then slams shut.

The window can reopen for people with a MA plan under special circumstances. If the MA person moves out of the area their plan covers, it opens a 60-day window to enroll in another MA plan or a Medicare Supplement with no medical questions.

Another possibility is during the Annual Enrollment Period (AEP) which runs each year from Oct. 15 to Dec. 7 with new plans taking effect Jan. 1. During the AEP, people can change to another Medicare Advantage plan offered in their area or a PDP plan.

California has a special law that often works when applied by a Medicare Specialist (and with some luck). If the MA plan has a cost increase of 15% or greater, then the member can apply for a supplement. If the MA company has a Medicare Supplement than it is a guaranteed issue. If that company does not have a Medicare Supplement plan, then the applicant may choose any company doing business in the state.

I have seen some previews of the MA-PD plans for 2021. It looks like benefits will be either the same or enhanced. I hope to find a few nuggets to be able to help people get out of the HMO and into a supplement if so desired.

It is amazing how people make decisions that will affect the remainder of their life based on their “current” health. Few people die of “good health,” and our culture tends to go to extravagant means to sustain life, regardless of cost.

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