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Evelyn Saguaro had a gall bladder issue that needed surgery, but her Medicare coverage wouldn’t pay for the procedure. But once she realized that she already had visited a California Health Insurance Agent to deal with what she called “her delicate matter,” she felt enormously relieved.

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Sixty-seven-year-old Evelyn Saguaro had the same problem her late mother had once been afflicted with. Besides her real gall bladder, she’d been born with a vestigial secondary one in which three cactus-like gallstones, each about the size of a quarter, had formed. Late in life, the vestigial gall bladder’s gallstones were starting to act up. Sharp pains would erupt beneath her breastbone immediately after she ate even a tiny serving of anything, and the acute pain made her sick to her stomach. When her doctor ordered tests to identify where the symptoms were originating from, he told Evelyn that her Medicare Plan only covered her original gall bladder, and since the stones had formed in the vestigial one, any procedure to remove them in “her unique case” would not be reimbursed. Her primary care physician kidded with her. “I suggest you refrain from eating,” he said. “Are you serious?” she asked. “No, a better idea might be to seek out a California Health Insurance agent.”

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That’s when she realized that she had done just that, two years previously. Was her Medigaps supplemental still in force? She headed on a beeline to the Visalia office where she’d purchased the Medigap coverage. Was the office still there? It was. The same agent, Glenda, was at her familiar desk. During their previous conversation which she’d somehow forgotten, Glenda had shared with her that she too had a “vestigial gall bladder,” with its associated symptomology not yet evident. Glenda had even belonged to an online organization, a regular support group called VGB Sufferers International.”

“Glenda, I’m so glad to see you,” Evelyn began. “Is my Medigaps policy still in effect?”

“Why wouldn’t it be, dear? Let me check.”

Evelyn waited expectantly. Suddenly her gallstone pain returned with a vengeance. “Is it? She asked, almost gasping.

“Of course it is, my dear Mrs. Saguaro.” A month later, Evelyn’s surgery was successful and her cacti-shaped stones were displayed on her mantle, and on the VGB Sufferers website as a digital photo – for all to see.

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Filling in the Medicare gaps can be tricky business for seniors, but it can be done with a little help from your California Health Insurance Agent.

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Esther Sirica, 68, was planning to have a surgery performed on her left foot’s hammertoe. She had joined a swim club for seniors and wanted to show off her feet. “I’d always wanted to be a foot model when I was younger,” she explained, “in my day; a well-turned ankle was just the beginning.”

But she wasn’t independently wealthy, and there were gaps in her Medicare coverage that she didn’t understand. “When I asked my primary care physician about the surgery, he said that I wouldn’t be covered. “It’s elective surgery on a pre-existing condition,” he asserted. But Esther wasn’t convinced. “Men used to find my feet lovely,” she told her physician, “except for THAT one.” She was pointing to her hammertoe, not the photo of President-elect Obama on the nearest wall.

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Esther quietly demurred amid the usual pleasantries, and begged her leave. A moment later she was off to find a second opinion. Her second opinion, an elderly physician who at least comprehended the surgery’s potential significance to the woman if not its urgency, did recommend the surgery, and perfunctorily checked out Esther’s Medicare coverage. “The surgery will cost $1,750,” he informed her.

“That’s not so much,” she said, assuming it was entirely covered except for her co-pays.

 “But Medicare will approve only about half of that, $825.00,” he added.

“Oh,” she said, with sadness suddenly re-encroaching upon her entire being, including the deformed toe.

Fortunately, Esther’s next visit was to her California health insurance agent, a valuable source for information on Medicare Supplement coverage for the past year or two. The nice young agent there had mentioned something called Medicare Supplement Insurance policies as a way to plug the disturbing Medigaps.

A month later, Esther was in the pool with the seniors, literally a new woman. A gentleman swimmer named Tony was looking at her foot when he noticed it. “Didn’t you used to have a hammertoe?” he remarked.

Esther Sirica flashed a big smile, her dentures clicking.

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It’s that time of year again.

Annual Election Period (AEP)
The Annual Coordinated Election Period runs from November 15 through December 31 each year. Medicare beneficiaries can change Medicare Advantage plans or change their Part “D” prescription drug plan during this time frame. During this time frame a Medicare beneficiary can also choose to return to original Medicare, or enroll in a Medicare Advantage plan for the first time. Enrollment changes take effect on January 1.

Open Enrollment Period (OEP)
The Open Enrollment Period extends from January 1 through March 31. During this time Medicare beneficiaries have one opportunity to enroll in, disenroll from, or change a Medicare Advantage plan. The change in Medicare Advantage enrollment or disenrollment becomes effective the month after the change is made.

Only Medicare beneficiaries who are eligible to enroll in a Medicare Advantage plan may make a change during the Open Enrollment Period. A beneficiary who has both Medicare Part A and Medicare Part B and wants to change must live in the area served by the Medicare Advantage plan.
During the open enrollment period beneficiaries may not add or drop Part D drug coverage. Medicare beneficiaries who already have drug coverage can only change to another plan that provides drug coverage. Medicare beneficiaries who do not have drug coverage may not change to an option that provides drug coverage.

Permissible changes during the Open Enrollment Period include:

-MA-PD to Original Medicare and a PDP
-MA-PD to a different MA-PD
-MA-only plan to original Medicare
-Original Medicare and a PDP to an MA-PD
-MA-only plan to a different MA-only plan
-Original Medicare to a MA-only plan

Beneficiaries who want to use the Open Enrollment Period to return to Original Medicare from an MA-PD must do so by enrolling in a PDP. Enrollment in a PDP during either the Annual Coordinated Election Period or the Open Enrollment Period terminates enrollment in a Medicare Advantage plan. Because beneficiaries are generally limited to changing their prescription drug coverage during the Annual Coordinated Election Period, MA-PD enrollees who want to return to Original Medicare during the Open Enrollment Period have a Part D Special Enrollment Period that allows them to make one enrollment into a PDP.

An overview of the different plan types.

Local HMOs and PPOs contract with network providers to deliver Medicare benefits. In 2008, 68% of all HMO and local PPO plans also offered Part D drug benefits. These local HMO and PPO plans account for 64% and 7% of total MA enrollment respectively.
Private Fee-for-Service plans (PFFS) are designed to allow open access to providers. PFFS plans are not required to establish provider networks, report quality measures, or have Medicare review and negotiate bids. The Medicare Improvements for Patients and Providers Act requires Private Fee-for-Service plans to comply with new quality reporting requirements and, beginning in 2011, to form provider networks in certain counties. From July 2006 to July 2008, PFFS enrollment nearly tripled from 765,000 enrollees to 2.3 million (22% of total MA enrollment).
Regional PPOs were established under the MMA to provide rural beneficiaries greater access to MA plans, with a $10 billion “stabilization fund” to encourage entry of regional PPOs. This fund was virtually eliminated under the MIPPA. In 2008, regional PPOs are available in all but five of the 26 MA regions but account for only 3% of all MA enrollees.
Medical savings account plans (MSAs) combine a high deductible health plan with an MSA into which Medicare makes annual deposits on behalf of enrollees. Beneficiaries draw from these funds to pay for qualified health care expenses until they meet a deductible (ranging from $2,500 to $5,100 in 2008), at which point the plan pays for all Medicare-covered services. In 2008, MSA plans have only 3,529 MA enrollees.

Special Needs Plans (SNPs), mainly HMOs, are restricted to beneficiaries who are dually eligible for Medicare and Medicaid, live in long-term care institutions, or have certain severe and disabling conditions. The number of SNPs increased from 125 in 2005 to 769 in 2008, with 1.2 million enrollees as of July 2008, mainly dual eligibles. The MIPPA reauthorized SNPs through 2010, but prohibits the entry of new SNPs until then.
Other plan types, including cost, HCPP, PACE contracts, demonstrations and pilots, account for 4% of MA enrollment.

For more Information on how to enroll in a California Medicare Advantage Plan call Matt Lockard at 1-866-861-0477.