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Medicare Options – Save $$ ??

After much studying and spreadsheeting 2026 Medicare Supplement go forward rates.....the "Big 3" - Anthem, Blue Shield, UnitedHealthCare/AARP, are staying close to each other in premiums.  Age 79 and above, UnitedHealthCare is the place to be in the "Big 3", as long as you enrolled in their plan within 9 years of your Part B effective date.

Cigna/HealthSpring has made a splash with their lower premiums.  Savings of $500.yr.- $900./yr. for a Plan G or N....below the "Big 3".  In your 80's the savings lessen.  Thankfully Plan G & Plan N are mandated to be the same, whichever insurer you choose.  

Cigna-HealthSpring also offers a High Deductible Plan G.  $2950./yr. deductible. Same Plan G benefits apply after deductible met.   Premiums approximately 64% lower than the Plan G premiums.                                        

So, how do you get savings?                                                                   

1. Call us to enroll in Cigna/HealthSpring.  Realize that the Cigna/HealthSpring reputation is not the same as the "Big 3".  That being said, a Medicare mentor of mine in the Northeast says they have made great strides.  We have also heard a case that your insurer does not have much involvement with the payment of claims.....much of this is between Medicare and the insurer, with little wiggle room.  We also don't know if this is a market grab, and rates will disproportionately increase.....of course your can change your plan at your Birthday if this were to happen.
   
   
2. Consider enrolling in a Medicare Advantage during open enrollment, 10/15 - 12/7.  Low or no premiums and co-pays.......network restrictions.  May be difficult to get back to supplement.
   
   
3. Call, text or, email after you've digested your options, and we'll talk it out together.
   
   
4. If you do decide you want to change your plan to a different supplement, we typically do this at your Birthday.  There is a 59 day window to change with no health questions or underwriting, guaranteed acceptance at lowest premium.  You can change your plan to equal or lesser coverage.  If you can pass underwriting, you can change anytime.  Passing underwriting is difficult.....not only are health conditions looked at, also any prescription currently treating current or past issues.  Ex.: AFIB and Eliquis.  We can talk this through together.

This is a lot....sorry.....we are trying our best to keep you in an informed position and offer you the best options.

Happy Spring!

UnitedHealthCare/AARP change to internal policy changes - Plan G to Plan F

Wanted to let you know that if you want to change to a Medicare Supplement Plan G or F in the future, you will have to pass the underwriting health exam questions.

Each year at your Birthday + 59 days, you are able to change to an equal or lesser plan, with no underwriting/health questions.

Why are we updating you with this info?  Previously, you were able to make plan changes within UnitedHealthCare, to any plan, at any time, with no underwriting/health questions.

As of 4/29/26, any plan change will require underwriting/health questions….underwriting can be rigorous.

When we initially sat down, I promised a change to this policy would be communicated to you asap.

This previous United HealthCare/AARP internal policy of changing to any plan, at any time, with no underwriting has been exclusive to UHC.  They are now aligning themselves with the other carriers to protect those already covered by Plan N.

If you want to change to Plan G or F, please contact us prior to 4/29/26.

Also, we have done much studying and spreadsheeting of all available plans in this health premium increase environment.

Our newsletter with options with be emailed no later than Wednesday 4/8/26.

If you do not receive our newsletter, please go to the updates tab on our website...

www.InsuringByDesign.com.

We have taken the time to put this together because of your belief in us to do the right things by you.  Please look at your options, and let us know if you would like to discuss changes.

Happy Spring to all of you!

Sorry for so many newsletters in such a short period of time.......many changes and updates coming at once.

Currently, if you want to participate in the GLP-1 craze using your Medicare Part D plan, you need to have a diagnosis of diabetes and/or heart disease.

Per the below update from Centers for Medicare/Medicaid (CMS), this is changing.  There will be Medicare Part D access to GLP 1's for weight loss.

This document outlines the CMS Medicare GLP-1 Bridge demonstration, providing early access to certain GLP-1 drugs for weight management ahead of the upcoming BALANCE Model in 2027.

Medicare GLP-1 Bridge Overview and Distinction from BALANCE Model

• The Medicare GLP-1 Bridge is a short-term, separate demonstration running from July to December 2026, offering eligible beneficiaries early access to specific GLP-1 drugs outside the standard Part D coverage and payment flow.
• The BALANCE Model, a broader initiative for comprehensive health and nutrition, will launch in Medicaid as early as May 2026 and in Medicare Part D in January 2027. The Bridge serves as a transitional step, with no direct impact on Part D sponsors' participation or risk.
• CMS will manage prior authorization, claims, and payments centrally via Humana, independent of Part D sponsors, who must apply to participate in BALANCE starting March 2026.

Eligibility and Access

• The Bridge is nationwide, available in all states and territories, with beneficiaries needing to be enrolled in a standalone PDP or Medicare Advantage plan offering prescription drug coverage.
• Eligible beneficiaries include those in certain Part D plans, SNPs, EGWPs, and LI NET, with exclusions for some private plans unless also enrolled in a PDP.
• Drugs available are Wegovy® (injection and tablets) and Zepbound®, used for weight reduction and maintenance.
• Providers can refer beneficiaries via prior authorization, which CMS will detail in Spring 2026. Providers do not need to be Medicare-enrolled but must not be on the Preclusion List.

Clinical and Authorization Criteria

• Beneficiaries must meet clinical criteria at therapy initiation, including age ≥18, BMI thresholds (≥35, ≥30 with certain diagnoses, or ≥27 with other conditions), and ongoing lifestyle modifications.
• Prior authorization requires attestations that the drug is prescribed for weight reduction, with criteria verified at therapy start, even if therapy began before the demonstration.

Operational and Payment Details

• A single central processor, Humana, will handle prior authorization, claims adjudication, and pharmacy payments, processing claims electronically via NCPDP standards.
• Pharmacies will submit claims using a specific BIN/PCN, and will be reimbursed at wholesale acquisition cost minus a $50 copay, plus dispensing fees and applicable taxes.
• The central processor will not coordinate benefits with other payers, and coupons or discounts cannot be applied to claims.
• Beneficiaries pay a $50 copay; the net price of drugs provided under the Bridge does not count toward their Part D out-of-pocket costs or coverage phases.

Transition and Future Participation

The Bridge is temporary; beneficiaries must enroll in a Part D plan participating in BALANCE in 2027 to maintain access.

CMS will provide guidance on transitioning beneficiaries and on Part D plan participation requirements.

Part D Sponsor and Pharmacy Interactions

• Part D sponsors should redirect prior authorization requests for Bridge-eligible drugs to the central processor.
• Pharmacies do not need to opt-in but will send claims to a designated BIN/PCN, with additional operational guidance forthcoming.
• CMS emphasizes that claims for drugs under the Bridge are primary and do not impact Part D coverage or cost-sharing, including low-income subsidies.

Legal and Policy Context

• The demonstration operates under Section 402(a)(1)(A) of the Social Security Amendments of 1967, authorizing CMS to test payment methods to improve efficiency.
• The program is independent of the Medicare Drug Price Negotiation Program, which applies to certain drugs starting in 2027; during the Bridge, no negotiated prices apply.

Additional Information and Contact

• CMS will release further operational details and guidance in Spring 2026.
• Contact information is provided for the demonstration team, the BALANCE team, and CMS Innovation Center updates.

This summary captures the demonstration's purpose, eligibility, operational procedures, and policy context, providing a clear overview of the Medicare GLP-1 Bridge initiative.

Ok, UnitedHealthCare supplement policyholders.....your rate increase for July has been announced early.  Blue Shield and Anthem policyholders, I hear the rate increases will be in July, however the new rates won't be announced for a month or two.

None of us like increases.  There are economic pressures driving these increases....the CA Dept. of Insurance does not seem to approve increases, unless justified to protect the consumer.

There are options:

  1.  We are looking at another insurer that has lowered their premiums in the California market.  I have not had confidence in their reputation until recently.  So....we are studying the age bands where the premiums might save you up to $40./mo.  You can change to this plan anytime,  if you can pass health underwriting....or change at your birthday with no health questions.  You will receive another newsletter from us, within 3 weeks, with details.

 2.  If you have a Plan G or F with UnitedHealthCare, Plan N might save you $.  This would be based on less than 1-2 office visits per month. There is a co-pay of up to $20. for office visits, with the Plan N.

 3.  We can look at Medicare Advantage plans during open enrollment - 10/15 - 12/7.  As you know,  Medicare Advantage plans are network driven, however typically have low co-pays, and low or no premiums.  They also include your Part D premium.  Full knowledge of the differences between Supplement and Part C Medicare Advantage plans, is paramount.  We are here to help.

  4.  If your plan is the one for you......no need to do anything.

Talk to you soon!

Wow, what a wild open enrollment.  The Part D and Medicare Advantage changes were the most we have seen in an open enrollment season....and we've been at this since dinosaurs roamed the earth!

The good news......for prescriptions covered in your Part D drug formulary, there will be a maximum out of pocket of $2,000.  This number can be lower.....a weird formula that CMS has not shared with brokers.  

Part D Formulary & Tier exceptions -  we are seeing doctors processing more of these for our clients, as there are so many new prescriptions hitting the market that the doctor is sold on you using, however it is not covered by your formulary.

There have been many changes to Part D and MAPD compliance.  Most of you created Medicare.gov accounts as we worked together to find your best value for 2025 Part D.  Once we worked out the kinks, this seemed to work well. I apologize to those caught in the middle of the struggle.

Our screen shares in October to demystify how to set up a Medicare.gov account and what we are looking for when searching for your best Part D values were so much fun.  We will schedule more next open enrollment.  

Again, please review your Part D or Medicare Advantage during open enrollment 10/15 - 12/7......costs and coverages change....you can be caught in an unpleasant position if you are not reviewing.  We are always here to help.

We thought it might help to share an experience.  Medicare supplement, mammogram, Medicare did not cover.  As we have discussed, this was once again a case of the service being mis-coded.  A call to Medicare - 1-800-633-4227 was immensely valuable.  The representative shared what the submitted code was, and what that code covered.  This was coded as what they call "diagnostic"....meaning there is a symptom or problem the test is looking to diagnose.  The situation did not need a "diagnosis", it was a preventative service, and should not be billed to the beneficiary.  The correct code was provided by the Medicare rep.  Calls back to the billing entity were not met with much co-operation.....until one person with common sense understood and referred the call to a supervisor who could resolve the charge.  Typically, your Medicare Supplement insurer will tell you that they pay the remaining balance due of a Medicare covered expense.  Most times a call to them does not help remedy your "non-Medicare covered" issue.  Remember with a supplement, after your $258.00/yr deductible, the only out of pocket for hospital or medical charges are for non-Medicare covered services.  Not likely you will get these, unless explicitly notified up front.  Example - the newest 3-d modeling of joints for joint replacement.  This is many times not covered by Medicare.

If you are one of the few that runs into these incorrect billings, we love helping you strategize how to remove the charge.

Genworth Long-Term Care coverage premium increases - the state of California is allowing some new options when looking to moderate rate increases.  So good! 

Those of you with hybrid plans will not see increases.  

And as we welcome in the New Year.....some things never change.....Kenzo the attention hog.

1. In browser go to www.Medicare.gov
2. Upper right, go to login
3. Go to create account
4. Follow prompts

1. After logged in, go to Open all Options
2. Update my saved drugs
3. Confirm pharmacy
4. Start
5. Check box you are not getting any extra help (bottom)
6. Hit Find plans now
7. Check Part D plan – not Medicare Advantage, or supplement
8. Typically as we roll into open enrollment, there will be a toggle to check 2024 or 2025 plans.  Please double check you are in the correct year.  When you get to the step where you are looking at listing of all plans, it will say 2024 or 2025.
9. Hit Find plans now
10. See drug costs
11. Confirm
12. Hit done

Open enrollment is rapidly approaching for your Part D and Medicare Advantage plans...Oct. 15 - Dec. 7 - Please call in for appointment to review your current coverage. These reviews can be very important for you, going forward. Soon we will have a way to set your own appointment, online, at your convenience. We will email you details soon.....or call/email to set appointments now.

Please call or text 559-960-9655 to set an appointment, or email me at Julie@InsuringByDesign.com