Medicare is complicated. Helping your clients make the right Medicare health plan choice requires a thorough needs assessment while making sure they understand the rules and components of the coverage. Whether a client is new to Medicare or a beneficiary who is more familiar with Medicare, it's important to cover the following topics when reviewing and providing consultation on a Kaiser Permanent Medicare Advantage plan. This helps to ensure the plan meets the client's needs — and that there are no surprises once they are enrolled. Here are a few important reminders to cover when meeting with your clients along with some resources:
It's important to understand both the plan type your client is moving from and moving to. Is their current plan an HMO, PPO, or HMO‑POS? Is their plan a Commercial group or Individual & Family plan? Is the plan a Medicare Advantage Prescription drug plan (MAPD), Medicare Advantage (MA‑only with no Part D), or Original Medicare with a standalone Prescription Drug Plan (PDP)?
- Does the client understand what these plan types mean? If they are coming from a Medicare Advantage plan without Part D coverage and electing a plan that includes Part D, are they aware of potential Part D enrollment penalties?
- If the client is opting for an MA‑only plan, are they aware of potential Part D enrollment penalties if they enroll in a Part D plan in the future?
Note: Kaiser Foundation Health Plan of Washington offers only Medicare Advantage HMO plans including MAPD and MA‑only with no Part D options. Part D late enrollment penalties may not applicable if the beneficiary has other creditable coverage like VA benefits.
Are your client's current providers in‑network? Are they okay with switching providers? Do they understand referral requirements and what is covered out‑of‑network and out of the Medicare Advantage plan service area? Checking the network of doctors is important, even if your client is an existing Kaiser Permanente member. Many Kaiser Permanente non-Medicare health plans are HMOs with similar provider networks, but we also offer a variety of PPO plans to large and small employer groups with provider networks that can be quite different from the Medicare Advantage HMO network. For example, a provider may be "in‑network" in a PPO network but "out‑of‑network" in an HMO plan, including a Medicare Advantage HMO network.
Are your client's prescription drugs in the Kaiser Permanente Medicare Advantage formulary? Are they comfortable with the tier cost‑shares? Do they know what pharmacies they can use or about the cost‑savings for most tiers when they take advantage of mail‑order?
Mandatory and optional supplemental benefits
Does the plan meet your client's vision, hearing, alternative medicine, and dental needs? Have they reviewed the optional supplemental dental coverage, and do they understand the extra coverage that plan provides along with the extra cost?
In support of you — and ensuring your client's plan selection meets their needs — we've created the Plan Summary Worksheet (PDF) to walk through these (and other) important topics with them. This includes reviewing plan documents such as the Summary of Benefits, Evidence of Coverage, formulary, and provider directory.
Have questions or need additional resources?