Choosing the right MA/MAPD

Now that you've taken the time to listen to your client's needs and compared all options, you've both decided that a Medicare Advantage (MA/MAPD) plan is the way to go. So, what's next? It's time to put your active listening skills to use and choose the plan that will fit your client's needs and budget. In most cases, there are usually multiple plans available that appear almost identical at first glance.

Keep in mind that plan costs, benefits, service areas, and provider networks may all change from year to year, so it’s a good idea to review your client's coverage every year and make sure it’s still a good fit for their situation.

Using two different client types for practice, see how you can feel confident in your choice.

High Risk / High Utilization

Scenario #1

Your client stays close to home more often than not. They see their trusted PCP regularly (same provider for the last 10+ years, will NOT switch), who often will refer them to specialists for additional medical care due to existing health conditions. On average, they fill as many as 8 different prescriptions per month. They only receive partial LIS (extra help) and are not qualified for Medicaid assistance. They wear prescription glasses, and just received a new set of dentures last year. They don't workout or need a gym membership, but they could benefit from nutrition benefits in lieu of a fitness program (where available). Having to stick with a budget, they cannot go without over-the-counter benefits, even a little goes a long way. They gush about having caring children who often take them to any appointment as needed, so transportation isn't a must but would be nice to give the kids a break every once in a while.

For this client, priorities would be: 1). PCP - making sure there are plans available that the provider accepts due to no desire to switch. 2.) Confirm current prescriptions and dosage. *Important to note that some plans limit quantity. 3). If client gives medical conditions, check for any available C-SNPs. *Important to note Medicaid is NOT required for C-SNPs. 4). If no C-SNP available, filter by PCP, prescriptions, vision, OTC, transportation, and fitness. 5). Verify with client importance of low/$0 monthly plan premium w/benefits.

• Ex.: In YourMedicare (Sunfire/blaze) use or add client Johnathan Dozier. Zip: 28205; PCP - Melissa Jones; Medications: HYDROcodone-Acetaminophen Oral Tablet 10-325 MG, Simvastatin Oral Tablet 20 MG, Lisinopril Oral Tablet 10 MG, Levothyroxine Sodium Oral Tablet 75 MCG, amLODIPine Besylate Oral Tablet 10 MG, Omeprazole Oral Capsule Delayed Release 20 MG, metFORMIN HCl Oral Tablet 500 MG, hydroCHLOROthiazide Oral Tablet 25 MG (all 30-day supply/1 per day). At this point, options should be narrowed down to Cigna, preferably the $0/month or $29/month plans. Opt for the $0/m. due to budget, and all needs are met.

Cigna Preferred Medicare (HMO) should be the plan of choice.

Low Risk / Low Utilization

Scenario #2

Your client is a 'snowbird' and spends about 3 - 4 months away from home in the cooler months, but remains within the states close to family. Client is also a Veteran and uses Champ VA for all prescriptions and only seeks civilian care on rare occasions. They see a PCP a few times a year for regular check-ups and get Acupuncture a few times a year, but is currently an out-of-pocket expense. Their prescription refills are done through the VA for $0. Mainly they take 1 to 3 prescriptions per month, and are considered to be rather healthy. They maintain that by staying active and going to the gym (SilverSneakers member for 4 years now but pay out-of-pocket for that membership currently) several times a week with friends. They currently have no coverage for supplemental benefits such as vision, dental and hearing. They are not eligible for either Medicaid or LIS so savings on monthly premium is the only budgeting factor.

For this client, priorities would be: 1). MA-Only should be priority so as to not interfere with VA benefits. A PPO plan would allow for in/out-network flexibility. 2). Rx isn't necessary and may interfere with prescription costs. 3). Supplemental benefits should be included (dental, vision, hearing). 4). Fitness/SilverSneakers should be included. 5). Acupuncture should be included. *Important to note, acupuncture is not a standard service covered by all plans.

• Ex.: In YourMedicare (Sunfire/blaze) use or add client Janice Dozier. Zip: 77003; No PCP required; No medications; Priorities are: vision, dental, hearing, fitness (SilverSneakers), and acupuncture. Narrow options down to Humana and Aetna. Once comparing side by side, notice Humana does not cover Acupuncture and all supplemental benefits are covered for higher coverage limits.

Aetna Medicare Eagle plan (PPO) should be plan of choice.