Should you change your loved one's Medicare plan from Medicare Advantage (MAPD) to Medigap (Also known as Medicare Supplement Plans)
Do you have a family member who is in either Assisted Living or Memory Care? Have you been told that your loved one would be better off with a different type of Medicare Plan?
If your loved one is currently on a Medicare Advantage Plan, likely an HMO, it is possible that either the Mobile doctor doesn’t accept that plan, or perhaps your loved one needs 14 home health visits but the HMO has only approved four visits. You may be considering switching their Medicare Advantage Plan to a Medigap plan. Medigap Plans are also called Medicare Supplement plans.
Let’s talk about some of the issues about making the change from MAPD to Medigap
1. First, you may or may not be able to make this change right now. If it is not currently the Annual Election Period, you most likely will not be able to change your loved one's plan from MAPD to Medigap. The Annual Enrollment Period or AEP is October 15th through December 7th of every year. Don’t worry; I’ll also cover what to do during AEP.
2. If it’s not the AEP, you won’t be able to make the change unless your loved one has a Special Election Period or SEP.
3. A SEP might be that your loved one moved out of the coverage area and has or will be losing the HMO. Generally, you’ll have about 2 months from the date of the official move to get a new plan. And in this type of SEP, your loved one will also be able to get certain Medigap Plans regardless of health issues. This is not true of all SEPs.
4. Another SEP might be a stay in a Skilled Nursing Facility. This will allow your loved one to leave the MAPD but will not provide a guarantee of getting a Medigap (Medicare Supplement) plan. In fact, the skilled nursing stay will likely disqualify your loved one from getting a Medigap plan.
5. Your loved one also has a quarterly SEP if he or she is on Medicaid, known as Medi-Cal in California. However, if your loved one has 100% share of the cost, meaning that Medicaid picks up the copays to see a doctor or any other provider, then it’s against the law for an insurance company or broker to sell you a Medigap Plan. You might, however, be able to get an MAPD PPO, which is different and more restrictive than a Medigap Plan. For example, an MAPD PPO can restrict the number of visits you get with a Home Health Company where original Medicare and a Medigap plan will not restrict you.
6. If you are making a change during the open enrollment period, and you live in California, then you have special rights that don’t exist in other states. If your Medicare Advantage Plan increases any of your copays or coinsurance amounts, then you may have the right to get certain Medigap plans in California. Because this type of change can be tricky, I highly recommend that you work with me or a member of my team to make these types of changes.
Just understand that there is a difference between a Special Election Period that allows you to drop or change your Medicare Advantage Plan, and a Guaranteed Issue period which allows you to obtain a Medigap Plan regardless of your health. They are not the same, and likely you’ll need both in order to make the changes you want.
Some other questions I get have to do with the change itself.
Let’s say that your loved one has been with the same HMO for many years. You are worried because all the medical records are at the current HMO. What will happen if you change plans? Will there be a problem?
In most cases, there won’t be an issue. Original Medicare and a Medigap plan will generally allow you to see any doctor or provider that accepts Medicare Part B. So if your current doctor accepts Medicare Part B then you’ll still be able to see that doctor under the new plan.
To fully understand the differences between Medigap and Medicare Advantage, please watch the video named Making Medicare Decisions, which can be found at MedicareQuick.com/MMD or part of my course site if you’ve signed up for that.
However, there is one MAPD plan that I’m aware of that doesn’t accept Part B. That is Kaiser. If your loved one is on Kaiser, then there's a big negative here that you need to understand. That is Kaiser doesn’t accept part B. They only accept their own Medicare Advantage Plan. They only accept their own membership program. The disadvantage is that you're going to have to get all new doctors. Now if you're in memory care, chances are that's not going to be a problem because your loved one is going to have a hard time getting to appointments with the doctors that he or she has been using for a long time.
But some people love Kaiser. If your loved one is still making their own decisions, I just want to make sure that you're aware that you would need to get new doctors. And it might be a problem.
You have a right to your medical records, so that won’t be an issue. There might be a small fee, but in most cases, it’s negligible if there is one. When my husband and I moved I was able to get my medical records and my husband was able to get his.
Another question I get is how much the new plan will cost.
Right now your loved one could be paying zero for the MAPD plan. In addition to that he or she is paying the Part B premium. No matter what, the Part B premium will still have to be paid. That money is not going to the MAPD plan, it’s going to Medicare.
How much will the Medigap plan cost in addition to that? It varies. The premium is based on zip code, age, and what plan you want. It’s something that we’ll have to run an actual quote for. Don’t worry, there are plans that likely fit your budget, but the less you pay in premiums, the more you’ll have to pay for doctor visits and other care.
I’ve also been asked whether you can keep your Medicare Advantage Plan, and just add the Medigap plan to it. Unfortunately, this isn’t allowed. The reason is that when you get a Medicare Advantage Plan you are actually replacing original Medicare with a privatized Medicare plan. And privatized Medicare Plans don’t work with Medigap. They don’t work together. It’s either/or.
The best thing to do is to watch the video called Making Medicare Decisions so you more fully understand the differences between the two types of plans.
Then schedule an appointment to talk with me or a member of my team. Just go to MedicareQuick.com/Schedule and find a time that works for you. You can schedule the appointment right then and there to make sure it doesn’t get taken. Then we can discuss your options with you.
It can seem like a confusing process to change your loved ones plan from MAPD to Medigap and we are here to help with any questions you may have. You don’t have to wait until you have a SEP to get your questions answered. In fact, you should do that right away to make sure you understand how the process works.