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Enrolling in Medicare Advantage: Understanding the Star-Rating System
Facts About Medicare
94% of people eligible for Medicare are enrolled in a plan that is not optimal for their needs or budget.*
As we approach age 64, and for the rest of our lives, we are inundated with confusing Medicare plan promotions. Unbiased Medicare support is difficult to access.
Many people don’t research Medicare options because it’s too confusing to sort through the thousands of insurance combinations and have the confidence that you’ll choose the right plan.
Selecting the wrong plan option can lead to a patient not having optimal clinical coverage and can increase bad debt for hospitals.
Once enrolled, 87% of individuals using Medicare never go back and change their plans, even as their health conditions or financial situations change. *
Facts About Medicare Advantage
Medicare Advantage is like Original Medicare, except is is offered by private insurers. There are a variety of Medicare Advantage plans, and they all follow the rules set by Medicare. Other facts about Medicare Advantage:
Medicare Advantage is also known at Part C coverage.
Many plans include prescription drug coverage.
The open enrollment period for Medicare Advantage is January 1 - March 31.
We’ve just created a guide that will help you understand Medicare Advantage enrollment and its star ratings. Click here to download “Enrolling in Medicare Advantage: Your Guide to Understanding the Star-Rating System.”
Facts About Medicare Prescription Drug Plans
There are four main phases of Medicare prescription drug coverage, also known as Part D. These phases are in effect each year and include:
A deductible period. This is where you pay the full negotiated price of your prescription drugs up to a certain limit. This is your deductible, or what you must pay before your insurance plan begins coverage. Keep in mind that not every drug plan has a deductible. The most you can pay as a deductible in 2022 is $480. More good news: Not every tier of drugs has a deductible.
Initial coverage period. After you’ve met your deductible (whether it’s $0 or some amount up to $480), your insurance plan will now start paying its share for your drug coverage. You will also have a copayment. When your and your insurance provider’s payments reach $4,430, you move on to the next stage of coverage.
Coverage gap. Here you are responsible for 25% of the cost of your covered drugs (brand-name and generic alike). Keep in mind that you may pay more than you did for the same drugs during the initial coverage stage (because 25% of the cost of any one drug may be more than your copayment in the previous stage). This phase ends when you reach $7,050 in out-of-pocket costs for your drugs (not including your drug plan premiums). Keep in mind that what your insurance plan paid does not go toward this amount.
Catastrophic coverage. During this phase, you pay much lower copays for your covered drugs for the remainder of the year. You pay only the greater of the following: 5% of the cost of each of your drugs, or 3.95 for generics and $9.85 for brand-name drugs.
Facts About Medicare Special Needs Plans
Medicare Special Needs Plans are designed to support people with targeted care. To qualify for a Special Needs Plan, you must be any one of the following:
Dually eligible for Medicare and Medicaid.
An institutionalized person who lives in a nursing home or requires nursing at home.
Someone with a severe or disabling chronic condition. These conditions include cardiovascular disease, dementia, and diabetes.
A Medicare Special Needs Plan is a type of Medicare Advantage Plan. You will have access to a network of providers who specialize in your condition and/or situation. Special Needs Plan benefits include:
Complete Part A and Part B coverage for hospital and doctor’s office care
Prescription drug insurance
Full emergency and urgent care
Watch the recording of our online event “How Medicare Special Needs Plans Work.” You’ll learn about the costs of these plans and when you can join.
Facts About Medicare Supplemental Plans (Medigap)
Medicare Supplement insurance, also known as Medigap, is offered by private insurance companies to pay for healthcare services and supplies. After your Original Medicare plan pays for its share of the services you receive, then your Medigap plan will pay its share. Other important things to know:
Medigap is not the same as a Medicare Advantage plan.
You cannot be on a Medicare Advantage plan and purchase a Medigap policy.
Medigap plans do not cover prescription drugs (for that, you need Medicare Part D coverage or a Medicare Advantage plan, which usually covers prescribed medications.
You must pay a monthly premium for a Medigap plan.
A Medigap policy covers one person. If you and your spouse are covered by Medicare, you will each need separate Medigap policies if you each want supplemental insurance.
Four Kinds of Medicare Savings Programs
The four programs below each have different qualifications based on household income. The limits shown below are for 2022. For more information and directions on how to apply, please see the Medicare’s Medicare Saving Programs page.
Qualified Medicare Beneficiary (QMB) Program
Individual monthly income limit: $1,153
Married couple monthly income limit: $1,546
Specified Low-Income Medicare Beneficiary Program
Individual monthly income limit: $1,379
Married couple monthly income limit: $1,851
Qualifying Individual (QI) Program
Individual monthly income limit: $1,549
Married couple monthly income limit: $2,080
Qualified Disabled and Working Individuals (QDWI) Program
Individual monthly income limit: $4,615
Married couple monthly income limit: $6,189
Medicare Enrollment Checklist
As you prepare for Medicare enrollment, this checklist shares the information you’ll need to help ensure you select the Medicare plan option that best aligns with your clinical needs, your physician and hospital preferences, and your budget.
How Well Advised Helps You Find the Right Medicare Plan
Well Advised makes it easy to find the optimal Medicare plan.
The Well Advised solution is unbiased, confidential, and free for patients and hospitals.
Enrollees input their unique clinical needs and provider and financial preferences.
Unlike other solutions, Well Advised uses artificial intelligence (AI) to look at ALL plans from ALL insurance companies and match the optimal Medicare plan based on individual inputs.
While Well Advised will recommend the best plan, there is no obligation to enroll.
Well Advised will never spam anyone who provides their information. Personal information is confidential and will never be shared without authorized permission.
If the individual chooses, Well Advised can support the Medicare enrollment or re-enrollment process, providing all required paperwork for ease of process and signature.
Well Advised tracks the Medicare market and will alert the individual if a better option to meet their needs becomes available.
Well Advised assures the best clinical coverage while matching to a patient’s financial abilities.
*Plan Selection in Medicare Part D: Evidence from Administrative Data. 2012 by Florian Heiss, Adam Leive, Daniel McFadden and Joachim Winter.