New Medicare rules on MOOP | New Medicare rules on the “Maximum Out-of-Pocket” in Advantage HMO/PPO and PFFS plans
By Dan Insdorf
The good news is that Medicare now requires that all Medicare Advantage plans must now have an annual “Out-of-Pocket” maximum and that all Medicare covered services must be applied to meet that limit. Traditional Medicare does not have a cap on “out-of-pocket” expenses for the year. The bad news is that the limit can be as high as $10,000.
Although Medicare suggested a $3400 limit in a 2010 “Call Letter”, many HMO/PPO/PFFS plans have much higher maximums. The annual “Out-of-Pocket” maximum is the amount a covered member must pay in co-pays and co-insurance before the plan pays 100%. The 2012 “Medicare and You” handbook now lists all the Advantage plans’ “out-of-pocket” maximums and chemotherapy co-insurance amounts.
While most Medicare Advantage plans do not have a monthly premium and some even pay the member all or part of the Medicare Part “B” premium, they can, in such serious cases as cancer treatment, cost the member 2X to 3X the cost a Medicare supplement.
Nearly all Medicare HMO/PPO/PFFS plans have a 20% co-insurance for Part “B” drugs (not to be confused with part “D’ prescription drugs). Part “B” drugs include expensive injectible drugs and infusion IV such as chemotherapy. A quality cancer insurance policy is a good adjunct to an Advantage plan. Look for one that pays “upon diagnosis’. Most are only available to age 69.
Example: A member is diagnosed with lung or breast cancer and is given chemotherapy treatments. The actual bill is $50,000.00 and the member’s Advantage plan co-insurance is 20%. The member will be responsible for $10,000 or the “Out-of-Pocket” limit whichever is lower.
Medicare claims can be very expensive and financially marginal Advantage plans should be avoided. Since most advantage plans are not insurance companies, they do not have an “AM BEST” rating. You can find financial information on these plans by going to www.floir.com. Click “industry reports” than “managed care summary reports”.
Contrary to popular belief, you can change plans after the Dec. 07 deadline. Special Enrollment Periods include persons that have a chronic illness such as diabetes, get extra help from Social Security for prescription drugs, qualify for various Medicaid programs and “exceptional circumstances”. Not all Advantage companies offer these plans.
Assume the worst and choose a plan that will serve your needs during a critical illness. Don’t think that you will get something for nothing. There is no free lunch.
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Daniel Insdorf |
| Mt. Dora Florida |
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Message from Daniel Insdorf | New Medicare rules on the “Maximum Out-of-Pocket” in Advantage HMO/PPO and PFFS plans
By Dan Insdorf
The good news is that Medicare now requires that all Medicare Advantage plans must now have an annual “Out-of-Pocket” maximum and that all Medicare covered services must be applied to meet that limit. Traditional Medicare does not have a cap on “out-of-pocket” expenses for the year. The bad news is that the limit can be as high as $10,000.
Although Medicare suggested a $3400 limit in a 2010 “Call Letter”, many HMO/PPO/PFFS plans have much higher maximums. The annual “Out-of-Pocket” maximum is the amount a covered member must pay in co-pays and co-insurance before the plan pays 100%. The 2012 “Medicare and You” handbook now lists all the Advantage plans’ “out-of-pocket” maximums and chemotherapy co-insurance amounts.
While most Medicare Advantage plans do not have a monthly premium and some even pay the member all or part of the Medicare Part “B” premium, they can, in such serious cases as cancer treatment, cost the member 2X to 3X the cost a Medicare supplement.
Nearly all Medicare HMO/PPO/PFFS plans have a 20% co-insurance for Part “B” drugs (not to be confused with part “D’ prescription drugs). Part “B” drugs include expensive injectible drugs and infusion IV such as chemotherapy. A quality cancer insurance policy is a good adjunct to an Advantage plan. Look for one that pays “upon diagnosis’. Most are only available to age 69.
Example: A member is diagnosed with lung or breast cancer and is given chemotherapy treatments. The actual bill is $50,000.00 and the member’s Advantage plan co-insurance is 20%. The member will be responsible for $10,000 or the “Out-of-Pocket” limit whichever is lower.
Medicare claims can be very expensive and financially marginal Advantage plans should be avoided. Since most advantage plans are not insurance companies, they do not have an “AM BEST” rating. You can find financial information on these plans by going to www.floir.com. Click “industry reports” than “managed care summary reports”.
Contrary to popular belief, you can change plans after the Dec. 07 deadline. Special Enrollment Periods include persons that have a chronic illness such as diabetes, get extra help from Social Security for prescription drugs, qualify for various Medicaid programs and “exceptional circumstances”. Not all Advantage companies offer these plans.
Assume the worst and choose a plan that will serve your needs during a critical illness. Don’t think that you will get something for nothing. There is no free lunch.
|
Daniel Insdorf |
| Lake County Florida |
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