Category Archives: Health Insurance

2026 Medicare Advantage Plans are Changing

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Making Sense of Medicare

Advantage Plans are losing their luster. Regular Medicare chugs along.

For-profit private insurance companies offer Medicare Advantage plans that take the place of regular Medicare. 2026 Advantage plans are cutting back on provider choice and special benefits.

On October 16th the Wall Street Journal ran a major feature (behind its pay wall) entitled “Watch for Big Changes to Medicare Coverage.” Unfortunately, the title is misleading. Big changes are coming for Medicare Advantage Plans. There are small yearly increases for regular Medicare for Part B premiums. The deductibles for Parts A and B also increase.

Understanding the Medicare Alphabet.

  • Traditional Medicare includes Part A – hospitalization – and Part B – outpatient care such as doctor visits.
  • Part C cove . You need to enroll in Medicare Parts A and B to enroll in a Part C Advantage plan.
  • Prescription plans are Part D. You have to purchase prescription coverage unless you are in a group or other type of plan that includes coverage for prescriptions. You need to have a prescription plan whether you are in regular Medicare or an Advantage plan. Many Advantage plans include Part D coverage, but not all. Prescription plans are open to Medicare members who have Part A or Part B or both. Don’t be late or skip enrolling in prescription Part D plan. You will get penalties that you can never get rid of. So don’t skip enrollment in a Part D plan!

 

Jumbled colored prescription tablets

Medicare Part D Prescription Coverage – Photo by Aleksandar Pasaric – Pexels

What to know about Advantage plans and upcoming changes

Advantage plans sound great but there are some serious drawbacks that you should be aware of. sounds great. Many Advantage plans use managed care organizations that contract with hospitals and medical groups.  The HMO (health maintenance organizations) or EPO (exclusive provider) plans only contract with certain hospitals and doctors.You  may need to find new providers if your current providers do not contract with the plan. With PPO (preferred provider organization) plans, you can still choose services from non-network providers. But you will pay a larger share of the cost.

Many hospitals and physician groups are leaving Advantage plans this year. Be sure to read your Annual Notice of Change (ANOC) to find out all the details. Check that your providers are still in-network for your plan.

According to the Wall Street Journal here are some of the Advantage Part C changes :

  • Copayments and other costs are going up. The cost of Advantage plans and their deductibles are probably going up. Look at Annual Notice of Change for details.
  • Insurance companies are eliminating or modifying Advantage plans. These changes will affect approximately 1.2 million people.
  • Preferred Provider Organizations (PPOs) allow members more physician choice. Some insurance companies are limiting choice by shifting to HMO plans.These plans restrict your choice of providers and require approvals for specialty care. HMOs can restrict the number of procedures you may have and how long you can stay in the hospital.
  • Advantage plans are also trimming some of the extra benefits that have made them so attractive in the past – sports equipment, healthy food, and home repairs among others.
  • Insurers are cutting commissions for brokers and agents on certain plans to help drive customers to plans which the insurers prefer.

 

Kathleen Brewer de Pozos has over 30 years experience in health care management consulting and health insurance.

How regular Medicare works and why you need a supplement

If you want more freedom in your choice of providers, sign up for regular Medicare. It gives you access to any hospital and provider that accepts Medicare.

Regular Medicare is an 80/20 plan – comparable to the Gold Tier Affordable Care Act plans.  Insurers pay 80% of the agreed upon price. You pay the other 20%.

Regular health insurance pays providers less compensation for their services than they charge people without insurance. The Federal Government sets the Medicare payment rates for providers. Providers who accept “Medicare assignment” agree to accept what Medicare pays as payment in full. Providers can charge an additional 15% for their services since Medicare pays less than group or individual insurance. This is known as “accepting Medicare.” Beneficiaries pay the additional 15% themselves.

If you choose regular Medicare, you should purchase a supplement or Medigap policy. It cover most of the deductibles, copays, and other costs that Medicare does not pay for.Supplements may also offer additional benefits such as gym memberships and discounts on hearing aids and glasses.

There are no substantial changes for regular Medicare Parts A and B in 2026. However, there are changes for Part D prescription coverage, which will cover in a separate post.

Randolfo R. Pozos, California Insurance License #0A37551

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They’re at it again! – Efforts to Repeal Obamacare

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There’s a new attempt to un-do the Affordable Care Act (ACA) going on in D.C. It’s disguised as an attempt to reform the law, but make no mistake, this proposed change will take us backward in time.
This time proponents say it should be up to the states to decide which health benefits should be offered. They want to allow insurers to charge older plan members (that’s people somewhere around age 50) 5-7 times more than they charge younger members. They suggest High Risk pools for folks with pre-existing conditions. (Did you know that  a pre-existing condition could be something as seemingly simple as eczema?)
 

What’s the matter with letting states decide such matters?

The problem with all these ideas is that once again care will not be available to people who need it. It’s a move right back to where we were before the ACA was passed.
 
What benefits are likely to get dumped? Maternity care and mental health benefits are right up there on the list. Both can be very expensive. Both need to have a large pool of premium-payers in order for insurance companies to offer them. When they are optional benefits, insurers only offer them on their most expensive policies (we saw that before the ACA in California). Far too many people who need such care cannot afford to purchase the policies that offer coverage for it.
 
Not intending enter the controversy over abortion or to say anything about the pros and cons of abortion accessibility, I must note that when maternity care is not affordable, more women find their options for continuing a pregnancy limited. The abortion rate is more likely to go up.
 
We know that lack of mental health care raises the risk of homelessness, violence, and the use of emergency room care for conditions that could have been prevented with stable housing, food, and employment. Cutting out that benefit would again take us backward in time.
 
We’ve also tried High Risk pools in the past. The ones we had pre-ACA were limited in the number of people who could be covered, had annual limits on the amount of care they would pay, and were much more expensive than regular policies. A return to that will not help reduce the cost of care or access to care for people with pre-existing conditions.
 
Much of what the GOP is now proposing is simply a return to what we had before the ACA was passed. It’s being presented as a way to fix Obamacare. Don’t be fooled. It won’t fix the problems with the ACA / Obamacare. It will take out basic protections and ultimately make health insurance more expensive. It will also result in much larger numbers of uninsured people.

 

Contact your representatives in Congress.

Let them know that the Affordable Care Act does not need to be reversed or repealed. It needs to be fixed, but not by going back to the way things were before March 2010 when the ACA was passed. And don’t take your eyes off what’s going on in D.C. They think we might not notice what’s happening if they just change a few things here or there and call it returning control to state and local governments.

 

A Benefit in the National Interest

Health care and health insurance are topics of national interest, governed at the national level for the vast majority of Americans through Medicare, the VA, Medicaid, and employer-based insurance programs. Let’s not let anyone take protection away from the small number of other of Americans who have so recently received the benefits of comprehensive coverage. Good health and access to care are truly fundamental to making America a great place to live, work, and raise our families.
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Higher Deductibles and Co-pays? Look at Aflac

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Aflac for Peace of Mind

Help with deductibles and co-pays

Increasing costs are causing many employers to raise deductible and co-pays on insurance offerings. Take a look at supplemental benefits. Aflac offers hospital and accident policies that pay you directly for all of those costs not covered by your insurance, including deductibles and co-pays.

 

Smaller employers are often raising deductibles to $1,000 or more. People who don’t qualify for subsidies at Covered California — the Affordable Care Act exchange — can get help from supplemental insurance policies from Aflac. There are group and individual plans with policies for short term disability, dental, life, and cancer.

For more information ask Randy Pozos: Randolfo_Pozos@us.aflac.com. Call or text: 831-588-3423

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Policy Renewal Time Approaches

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Mark-your-calendar-clip-artAvoid Hassles and Heartburn – Start Early to Renew or Change Individual Health Insurance Plans

1.       Update your contact information. Covered California, “the Exchange,” will be sending out policy renewal and change information in October. If you have moved or changed other contact information let your agent know before September 30. You can also do it yourself directly online through Covered California. Be sure to let your insurance company know of any changes as well.

2.       Renew your Permission to Verify Income. You can’t get a subsidy from Covered California if the State cannot verify your income. Permission has to be renewed periodically. Check with your agent to be sure your permission is up to date or go directly to Covered California and do it yourself.

3.       Do you want to keep your doctor? Know your provider options. Different insurance plans contract with different doctors. Plans outside of Covered California may have the same provider networks as those on the Exchange. However, some of the older plans and group plans may have different networks. Be sure to check with your doctor’s office to confirm that they take Covered California insurance plans.

4.       Check with your agent about individual plans that are not subsidized as part of Covered California if your subsidy is going to be small or if your income is above the subsidy range. But be careful. Some of the plans outside Covered California can have less expensive premiums up front but be more expensive faster when care is needed than the standard plans on the Exchange.

For questions or help anywhere in California call Kathy Pozos at 831-713-6438 or email KathyPozos2000@gmail.com

On Covered California, look for Kathleen Brewer de Pozos as agent. (The only agent at Covered California with that last name!)

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Renewal Time Is Here

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calendar3-240x240We’ve now entered Renewal season for existing health insurance policies. Open enrollment for people new to Covered CA doesn’t start until November 1, but those with existing policies can make any necessary changes and renew their policies now.

Has anything changed in your life or income? A new member of the family? A child who is no longer a dependent? Have you moved? Did you get a raise? Did your income go down? Did you get a new job or lose a job? If there have been changes we’ll need to open a Change Report and enter the new information into the system that way. If there will be changes for next year, but things haven’t changed for this year, we report that by beginning the renewal process directly.

Once all information has been entered, you can select your policy for next year. Some of the carriers have new types of policies and premiums will be quite different. However, for those who have subsidized policies, the out-of-pocket share does not seem to be going to go up too much. That share is still based primarily on  household income.

There is one new carrier in our Central Coast market area, United Healthcare. Many Dignity doctors are on their network provider list. They don’t seem to have a contract with PAMF at this time. Other independent providers are also in their PPO network.

If you want to get a sense of what your premium might be before making any changes, I’ve found the Shop and Compare tool at www.Coveredca.com works with Chrome or Internet Explorer better than with Firefox. I haven’t tried it with Safari.

This year Pozos Insurance Services also offers Aflac supplemental policies that can enhance your protection by providing benefits to fill some of the gaps in traditional health insurance policies. Accident, disability, hospitalization, cancer, dental, and vision supplemental policies are available to groups and individuals. We also offer life insurance.

As always, if you have questions or need help with selecting or managing your policy or Covered California account, or if you’d like to know more about life insurance or Aflac options, please contact us. We’re happy to help you with these important decisions about protection for you and your family.

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Anthem’s Personal Info Protection Instructions

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I received this email just now from my Anthem Regional Sales Manager. It has the most recent information you need regarding how to protect your personal information in the wake of the cyber-attack announced this week.

The following is cut and pasted directly from the email:

California residents who have may have been impacted by the cyber-attack against Anthem Blue Cross should be aware of scam email campaigns targeting current and former Anthem members.  These scams, designed to capture personal information (known as “phishing”) are designed to appear as if they are from Anthem and the emails include a “click here” link for credit monitoring.  These emails are NOT from Anthem. 

 DO NOT click on any links in email.

 •             DO NOT reply to the email or reach out to the senders in any way.

•             DO NOT supply any information on the website that may open, if you If you have clicked on a link in email.

•             DO NOT open any attachments that arrive with email.

 Anthem is not calling members regarding the cyber-attack and is not asking for credit card information or social security numbers over the phone.

 This outreach is from scam artists who are trying to trick consumers into sharing personal data. There is no indication that the scam email campaigns are being conducted by those that committed the cyber-attack, or that the information accessed in the attack is being used by the scammers.

 Anthem will contact current and former members via mail delivered by the U.S. Postal Service about the cyber-attack with specific information on how to enroll in credit monitoring. Affected members will receive free credit monitoring and ID protection services.

 For more guidance on recognizing scam email, please visit the FTC Website: http://www.consumer.ftc.gov/articles/0003-phishing.

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Blue Shield / Sutter Health Agreement Reached

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Blue Shield announced today that the company has reached an agreement on a two year extension of its contract with Sutter Health, including the Palo Alto Medical Foundation (PAMF). This agreement, whose terms are not  public, protects both carrier and clients according to Blue Shield.

Sutter Health and the Palo Alto Medical Foundation are major players in the Northern California health care scene. In some  counties, including Santa Cruz, Blue Shield will be the only carrier whose network of providers for individual policies includes Sutter and PAMF, in contrast with 2014 in which these providers contracted with both Health Net and Blue Shield. Patients who had already moved from their Health Net policies to Blue Shield effective January 1, 2015 in order to keep their providers were facing the possibility of having to find new doctors anyway. News of the agreement will be welcomed.

The lack of a contract between Blue Shield and Sutter Health/PAMF affected both individual and group members of the plan.

Open Enrollment for individual and family health insurance continues through February 15, 2015. Contact us today for a free consultation and help enrolling in a plan to meet your needs.

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Using Your New Health Insurance

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StethoscopeCongratulations! You’ve completed the daunting task of researching options for health insurance, finding help to enroll in a plan, confirming which plan will work best for you and/or your family, and completing the application. Once your first premium payment has been made, you move into what may be a brave new world of having and using health insurance. Even if you have always had health insurance, today’s policies differ in important ways from the ones available only two years ago.

Covered California has a new web page specifically for people who have purchased an insurance policy through California’s state exchange/marketplace. I found it instructive, with a video and useful links.

Now it’s time to take advantage of the opportunity to get your preventive care visit and any lab tests or immunizations needed to help keep you healthy. Flu shots are considered to be preventive services, for example. So are vaccinations for illnesses such as whooping cough (pertussis) and shingles. Mammograms, PSA tests, and many other diagnostic exams are also included as preventive care.

If you have questions about whether a service is covered, you can call your health plan directly or speak with your agent. Before you see your doctor, make sure he or she is a contracted provider with your health plan’s network. When your doctor refers you to a specialist, double check that the specialist is also in-network. If the provider is not in the network, it’s possible that your plan will not pay for your care. Insurance plans have “provider finders” on their websites if you need to find a doctor who is in your plan’s network.

In the event you need urgent care rather than emergency care and your doctor’s office is closed, it’s better to go to an urgent care center that is in your network than the hospital emergency room. (Emergency care is for conditions that are life-threatening.) With Bronze and Silver plans, emergency room visits are subject to the deductible. This means that you will have to meet your medical deductible first before the visit will be priced at only the copayment set for your plan. Some of the Enhanced Silver plans have this deductible waived, but regular Silver and Silver 73 plans require payment of the deductible for emergency room visits. Urgent care visits will cost less.

I hope that you will not need any serious medical care in this coming year, but if for some reason you do need care, your purchase of a health insurance policy now has set the stage for a more positive outcome.

To your health!

 

 

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Health Insurance from Costco?

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Costco is offering health insurance to members and the question arises whether the policies offered and the pricing are better than what is available through Covered California or directly from the insurance companies. A bit of research resulted in the following:

Costco is working with a brokerage firm out of Nevada that has agents licensed in California. It offers plans from Blue Shield, Anthem, Health Net, and Assurant Health Plans. The Blue Shield, Anthem, and Health Net plans offer the possibility of subsidy, because they are the ones offered by Covered California, our state Affordable Care Act (ACA) marketplace. Assurant does not offer plans on the marketplace, so no subsidies are available.

The only plans offered are the Bronze, Silver, Gold and Platinum, with many variants of each to match the marketplace and non-marketplace options offered by these carriers. I checked the prices and they are essentially the same. Some are $1-3 per month less expensive. Some are a dollar or two more expensive on the Costco side.

The Minimum Coverage plan is not offered through Costco, at least not for anyone over age 29. It is not subsidized anyway, so clients would be dealing with essentially the same price for coverage as through the other carriers offering policies in this area. Minimum Coverage plans are available to persons over age 29 when the cost of insurance is above 9.5% of their adjusted gross income – a level deemed unaffordable. For 2014, they had to be purchased directly from the carriers, with a copy of the Federal Hardship Exemption application attached to the carrier’s application. The Assurant plans were all more expensive than the plans offered by the other carriers for the same benefits.

Given Costco’s reputation for discounted sales, this is one of the areas where they actually don’t offer any real pricing benefit and the products are identical to those that any licensed insurance agent in California can offer.

Remember, a local agent can provide a level of service that someone from out of state may not offer, if only the knowledge of which medical groups contract with which carriers. There is no additional cost for purchasing a policy through an agent, so don’t hesitate to call and take advantage of our training and experience. We look forward to hearing from you!

 

 

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Funding Sources for American Health Care

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Health Care Funding by Source

Employer-sponsored Health Insurance

According to the U.S. Census Bureau, funding for health insurance in the United States has three major sources. The largest and perhaps least recognized source is employer-sponsored health insurance. According to Census Bureau estimates, in 2012 a majority of Americans (55%) got health insurance as a benefit from their employers. Though generally not seen as a subsidized form of insurance coverage, this insurance is funded using premium dollars that are deductible from the employer’s taxable income. The money paid by the employers for employee health insurance is not counted as taxable income paid to employees. Therefore, both employer and employee benefit from income tax provisions that support including health insurance as an employee benefit. Nevertheless, as a result of the rising cost of health care, a greater share of the out-of-pocket cost of health care has been shifted to employees and benefits have been restricted as employers have faced premium increases out-pacing inflation.

Government Funded Health Insurance

The federal government is the second major source of funding for health care. Federal funded care includes the Veterans Administration, Tri-Care, The Indian Health Service (Department of the Interior), Medicare, and Medicaid. Medicare is funded through a combination of payroll taxes on W-2 income and insurance premiums paid by beneficiaries. Medicaid is funded by a combination of state and federal taxes. The others are all paid from taxes collected and funds appropriated to specific government departments and agencies. An estimated 21.5% of Americans have government funded health care.

Individually Purchased Health Insurance

The final source of funding for health care is the individual insurance market. Approximately 6.8% of Americans buy their insurance directly from insurance companies. Prices on the individual market are generally higher than group policies because the risk pools are smaller. Additionally, individuals traditionally were charged more for having certain health conditions or based on gender. Insurers were allowed to charge women more for the same policy than men, for example.

Uninsured Individuals

An estimated 16.6% are uninsured. Those who are undocumented are not allowed to enroll in insurance policies, but the majority are American citizens by birth. These uninsured citizens include those who have a pre-existing health condition that led to their exclusion from insurance, those who are low income but don’t qualify for Medicaid because they are able-bodied and don’t have children under the age of 18, and those for whom insurance is simply too expensive because of their age, gender, or health condition.

The primary focus of the Affordable Care Act is to help the uninsured and underinsured get affordable coverage. Small business owners and employees will find help getting insurance, as will individuals who must purchase their own insurance. The law requires that all insurers offer 10 Essential Health Benefits in their policies as a way of ensuring that risk pools for higher cost conditions are large enough to make the coverage accessible to all who need it. The Affordable Care Act does not change Medicare benefits except that preventive services are now more affordable and the “donut hole” in the prescription benefits plans is being closed.

Graphics courtesy of Advanced Knowledge Resources, Inc.

 

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