Alert: Kaiser Medicare Advantage HMO Out of Pocket Maximum Raised to $6,700 in 2018

(Note: The below information concerns only those who are Medicare-Eligible.  It does not concern you if you are under-age 65, on an Individual & Family health plan, or on an Employer or Employee Group-sponsored or Government-sponsored health plan.  This information pertains only to California and may not apply to other states.)

It’s come to my attention that Kaiser Medicare Advantage HMO has raised its Annual Out of Pocket maximum to $6,700 starting on Jan. 1, 2018. This could be a financial burden for many seniors.

As an alternative, Medicare Supplement Plan F has $0 Out of Pocket costs for any Medicare-eligible medical expense (except for a separate Prescription Drug Plan), and allow access to any Medicare provider in the U.S.

For those turning 65 in Contra Costa, Anthem Blue Cross Medicare Supplement Plan F plan premiums can be as low as $115/month, after discounts. (This is compared to Kaiser Medicare Advantage’s monthly premium of $103/month, including Rx.)

If you have any questions, we’d be happy to consult with you on your options.

(The above is meant to be informational. This information has not been approved by CMS or any regulatory agency. This is not sales material and should not be relied upon to make purchase decisions. We recommend that you consult a knowledgeable insurance agent before making any decisions.)

Phil Lee
Lee Health Insurance Services 925-284-2000
Employee Benefits & Health Insurance

Reminder: Annual Open Enrollment Period

(This information concerns those who are on Individual & Family health plans, and Medicare health plans. It does not concern you if you are an Employer or Employee on a Group-sponsored or Government-sponsored health plan. This information pertains only to California and may or may not apply to other states.)

This is a reminder that we are in Open Enrollment season for several lines of health insurance plans.

(A) For Those Under Age 65 on Individual & Family Plans
Annual Open Enrollment period (AEP) this year runs from Nov. 1 through Jan. 31.
• You may enroll into or change Covered CA On-Exchange (with subsidy) as well as Off-Exchange (no subsidy) plans.
• Competitive Rate Comparison Proposals for On Exchange as well as Off Exchange plans are now available for Jan. 1, 2018. Please let us know if you would like one prepared for you.
• On Jan. 1, Anthem Blue Cross will be terminating their Individual plans in most counties in California except for some in rural Northern California.
• If you received a cancellation notice from Anthem Blue Cross, please contact us for a proposal to show you alternative plans from Blue Shield, Health Net, Kaiser, etc.
• If you received a large rate increase, ask us for a proposal showing alternatives.

(B) For Those Seniors Over Age 65 on Medicare
• For those on Supplement plans, there is NO Open Enrollment Period. Your supplement plans do not require renewal and continue uninterrupted until you cancel it.
• For those on Supplement Plan F, CMS (Center for Medicare Medicaid Services) will prohibit new sales after Jan. 2020. But those who are already on Plan F at that time will be grandfathered indefinitely.
• For those wishing to switch from a Medicare Advantage HMO plan to a Supplement Plan, there is no Open Enrollment and no Guarantee-Issue (GI) unless you have a Qualifying Event (QE), such as a move from out of state. You will wish to review the 13 Guarantee-Issue (GI) situations in CA that you may possibly qualify for. Even if you don’t qualify, there is no penalty for applying and going through the non-GI underwriting (approval) process. Chances are good that you may still qualify based on your health. The process for this type of transition is tricky and the timing very tight. If you think you may want to do this, start this process early to give yourself enough time to receive approval. We recommend that you seek professional assistance from an experienced agent knowledgeable in this area.

(The above is meant to be informational. This information has not been approved by CMS or any regulatory agency. This is not sales material and should not be relied upon to make purchase decisions. We recommend that you consult a knowledgeable insurance agent before making any decisions.)

Phil Lee
Lee Health Insurance Services 925-284-2000
[email protected]
Employee Benefits & Health Insurance

Medicare Annual Open Enrollment Period AEP 2016-2017

(This information concerns Medicare Health Plans. It does not concern you if you are either on an Employer-Sponsored Group Health Plan or an Individual & Family Health Plan. This information pertains only to California and may or may not apply to other states.)

Here are some common questions that we have been asked:

(A) When is the 2016-17 Medicare Annual Enrollment Period (AEP)?
For most people, Medicare AEP runs from Oct. 15th to Dec. 7th.
You may do the following during this time:
1. Enroll or change your Medicare Advantage plan (MA-PD).
2. Enroll or change your Medicare Rx (PDP) plan.
3. Enroll in a Medicare Supplement and a PDP plan (the supplement plan is not guarantee-issue unless you have a qualifying event).
Technically, AEP only applies to Medicare Advantage plan. These plans include Advantage MA-PD (Medicare Advantage-Prescription Drug, mostly HMO) plans as well as Advantage PDP (Prescription Drug Rx Plan) plans. These Advantage plans are regulated by CMS (the federal Center for Medicare & Medicaid Services, which is part of HHS, the federal Dept. of Health & Human Services). Medicare Supplement plans on the other hand, are regulated by the State’s Dept. of Insurance which does not have AEP’s and go by different rules.

(B) Can I Switch into a Medicare Supplement Plan from a Medicare Advantage HMO Plan during AEP?
Supplement plans may be purchased anytime, as long as you have Original Medicare Parts A & B. However, if you have an Advantage MA-PD plan currently, you must either have a qualifying event or get your Original Medicare Parts A & B back from your Advantage plan, before you can be allowed into a Supplement plan.
For those who have a Qualifying Event (QE), e.g. their Advantage plan is terminating or moving out of their area at year end, they have until Dec. 31st to enroll into a Medicare Supplement and PDP plan for a Jan. 1st effective date. I recommend that you enroll no later than Dec. 15 because of the holidays as well as the crushing workload of the insurance carriers.
For those without a QE, switching to a Supplement Plan is difficult and filled with pitfalls. This process should be started early in the Enrollment season (Oct. 15th), and handled very carefully with assistance from a knowledgeable Medicare insurance agent. It involves medical underwriting (approval based on health). There is no guarantee of approval by a Supplement carrier. And you must not enroll into a PDP plan before you have received approval from a Medicare Supplement carrier, otherwise your MA-PD plan may be cancelled, leaving you with no coverage except for A/B.

(C) Is Medicare Supplement Plan F going away?
CMS (Center for Medicare Medicaid Services) has announced this year that they will outlaw the sale of Medicare Supplement F, the most popular supplement plan, after 2020.
Those who will turn 65 after the year 2020 will unfortunately never be able to experience Plan F.
However, anyone who is already on an F plan at that time will be grandfathered and permitted to keep it indefinitely. (**Please see (E) below.)

(D) Are rates for frozen Supplement Plan F (after 2020) likely to skyrocket?
Some concerns were raised that the premium for F plans may skyrocket, after 2020, due to there being no future new entrants into the risk pool. Although this is a distinct possibility, it is unlikely to be a cause for alarm for the following reasons: (1) Unlike under age 65 plans, supplement plans are secondary payers (Medicare is the primary payer) and not subject to the brunt of the risk, (2) In the past when older supplement plans were frozen, such as the Anthem Classic J plan, there were no great increases in rates, (3) After the freezing of Plan F, other plans like G and N will still be available. Although these other plans are not as comprehensive as F, (4) The Birthday rule allows members to switch to like, or downgrade plans, guarantee-issue, every year, on their birthday month.
The practical implication is that seniors may keep plan F and take a wait and see attitude. If rates go out of line, then simply downgrade, guarantee-issue, on their next birthday.

(E) **Are there any instances where one can enroll into Supplement F after Jan. 2020?
This information has not been confirmed or published by CMS, but we were told by a couple of insurance carriers that CMS rules will allow someone to enroll into Plan F after Jan. 2020, if they were initially eligible for F before Jan. 2020.

(The above is purely informational. This information has not been approved by CMS. It is not to be used in sales. And should not be relied upon to make purchase decisions. We recommend that you consult a knowledgeable insurance agent before making any decisions.)

Phil Lee
Lee Health Insurance Services
[email protected]
Employee Benefits & Health Insurance

The Pitfalls of Leaving Original Medicare & Supplement Plan for Medicare Advantage HMO

(This information concerns Medicare Health Plans.  It does not concern you if you are either on an Employer-Sponsored Group Health Plan or on an Individual & Family Health Plan)

We frequently hear stories about seniors who made this change hastily because they attended a meeting, or an agent came to their home.  Frequently these agents would represent a limited number, usually just one, Medicare Advantage HMO plan.  They typically do not give prospects an adequate overview or understanding of the entire universe of plans in the marketplace because they have limited knowledge and products to offer.   They don’t fully explain the consequences of your making such a switch.

If you are contemplating such a change, you should not do so lightly.  You should only do this after much thought and research.  It’s not a matter of simply changing plans or changing carriers.  It’s nothing short of changing  from one world of plans, Original Medicare with Medicare Supplement, to another entirely different world of plans, Medicare Advantage.

These are the issues you must consider:

  1. This change may not be reversible in the future because Medicare Supplement plans are not guarantee-issue, except at age 65.  Supplement plans do not have an annual open enrollment period as Advantage plans do.   If you ever want to go back to Medicare Supplement from an Advantage plan, you will have to be medically underwritten and approved on your application before you will be enrolled.
  2. 90% of our clients choose Medicare Supplement F plans because of the freedom to choose their own providers anywhere in the country, and also because of the freedom from Copays, Coinsurance and Deductibles for all medical costs, excluding Rx.  However over the years, many non-clients have approached us for help to make the difficult transition from Medicare Advantage, such as Kaiser back to Original Medicare and Supplement.  This process is not easy, and is full of tricky timing and health approval issues.
  3. Medicare Advantage HMO plans like Kaiser Advantage or Scan Health require you to use only those doctors that are in their network.  You will not have the option to see any outside doctors such as from UCSF, Stanford, etc.  You will be required to obtain referrals and authorization for all specialists, procedures, etc.
  4. Advantage plans do not include Foreign Travel benefits.
  5. Kaiser Medicare Advantage does not cooperate with independent agents.  So we will not be able to service you on your Medicare plans at all.
  6. CMS (Center for Medicare & Medicaid Services) has ruled that Medicare Supplement F plans can no longer be offered to new enrollees after the year 2020. If you think you might want a Medicare Supplement F plan in the future, you must enroll before 2020.
  7. Medicare Trial Period and Medicare 24 Month Rule – Under very limited circumstances, Medicare beneficiaries who enroll in an Advantage plan at age 65 may have a 12 to 24 month Medicare Trial Period where they may switch back to Original Medicare, a Medicare Supplement plan and a Medicare PDP (Rx) plan, guarantee-issue.   But it must be done within 24 months from age 65 Medicare ICEP (Initial Coverage Enrollment Period).

Phil Lee

Lee Health Insurance Services

Medicare Introduces New Competitive Bidding Program

Medicare (CMS) just announced great success at saving hundreds of millions of dollars in a limited pilot bidding program for Durable Medical Equipment by reducing prices and curbing inappropriate uses.  Kathleen Sebelius, Secretary of the U.S.  Dept. of HHS, who is in charge of CMS credits this success to the Affordable Care Act, ACA, or Health Care Reform.

This raises the following questions:

·         Why did CMS not already have a competitive bidding process in place?  Don’t all Government programs (including the not so frugal Pentagon) routinely use competitive bidding to curb fraud, waste and abuse?

·         Why did CMS wait so long for ACA before implementing such an obvious cost-saving procedure?

·         What other Medicare benefits, other than oxygen tanks, are also experiencing rampant fraud, waste and abuse?

·        Would a private insurer, if they were operating such a program, have allowed such rampant abuse to occur unchecked for so long?

Medicare was originally designed to be an insurance program.  This is more evidence why this program is inflating the nation’s deficit.  It’s become an unfunded Government program with out-of-control spending at Pentagon prices.

More details and links to full story below:

NAHU Newswire April 19, 2012:

Medicare To Expand Bidding Program After Pilot Saved $202 Million In First Year.

USA Today (4/19, Kennedy) reports, “A new competitive bidding pilot program that replaces Medicare fee schedules for durable medical equipment – such as wheelchairs, oxygen tanks or diabetic test strips – has saved Medicare $202 million in its first year,” according to a report by the Centers for Medicare and Medicaid Services (CMS). “Beneficiaries also saw 42% in savings in their co-insurance payments for medical equipment.” The CMS report also projects that “the program, if expanded nationwide, could save seniors and people with disabilities $17.1 billion over the next 10 years.”

The New York Times (4/19, B1, Pear, Subscription Publication) reports that Secretary Sebelius “said the pilot program had reduced Medicare costs by 42 percent, or $202 million, by securing lower prices and curbing ‘inappropriate utilization’ of personal medical equipment.” She added that “the savings showed the value of the” Affordable Care Act. The story says, “the bulk of the savings came from oxygen equipment, power wheelchairs and mail-order test strips for people with diabetes.” CMS deputy administrator Jonathan D. Blum “said the switch to competitive bidding had not compromised beneficiaries’ access to the items they needed,” and that “Medicare had received few complaints from beneficiaries in the last year.”

The AP (4/19, Alonso-Zaldivar) reports, “The nine-city crackdown targeting waste and fraud has drawn a strong protest from the medical supply industry, which is warning of shortages for people receiving Medicare benefits and economic hardship for small suppliers. But the shift to competitive bidding has led to few complaints from those in Medicare.” It will be expanded “to a total of 100 cities next year, along with a national mail order program for diabetes supplies.” The story quotes Blum saying, “Costs are lower and there is no impact on the health status of our beneficiaries.”

CQ (4/19, Reichard, Subscription Publication) cites Blum saying that “contrary to the claims of critics, the program hasn’t led to disruptions in access to products … Nor has it led to adverse health effects requiring more hospital, doctor, or skilled nursing care.” In response, “Michael Reinemer, spokesman for the American Association for Homecare (AAH), said ‘we don’t find that credible,'” adding, “We documented four or five hundred complaints from patients or clinicians.”

The Hill (4/19, Pecquet) in its “Healthwatch” blog cites the CMS report and the AAH dissent.

How to reduce Medicare Prescription Drug Costs Using Mail Order

We assisted a client in reducing her out of pocket costs for Medicare prescription drugs simply by switching from buying 30 day supplies from her her local pharmacy to using Express Scripts, the mail order service used by Anthem Blue Cross. Her projected annual expense for copay, co-insurance, deductible and premium for the next 12 months will drop from $1,971 to $1,099.
After you switch to mail order, the reduction may even allow you to downgrade to a less expensive prescription drug plan, increasing your savings.

Use the Medicare Rx calculator to compare drug plans:

Compare health plan rates at:

© Philip W Lee,,


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Lee Health Insurance Services | Healthcare Insurance Agency, Individual Health Insurance, Family Health Plans, Group Medical Insurance, Small Business Health Insurance, Whole & Term Life Insurance, Dental Insurance, Health Care Reform Assistance, Covered California Insurance Exchange Plans, Medicare Supplement Insurance, Medicare Advantage, Medigap Plans, Anthem Blue Cross, Kaiser Permanente, Blue Shield of CA, Health Net, Cigna, Aetna, Contra Costa County CA, Pleasant Hill, Danville, Concord, Berkeley, Martinez, Albany, Oakland, San Ramon, Alameda, Santa Clara, Campbell, Milpitas, Cupertino, Sunnyvale, Saratoga, Fremont, Palo Alto, Newark | 935 Moraga Road, Suite 240, Lafayette CA 94549 (925) 284-2000 or Toll-Free, (800) 286-7445