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Question: Claire’s youngest sister, Nicole, lives in another state and is considering moving to live near Paul and Christine to help take care of Claire

11 Sep 2023,1:25 PM


Medicare, Medicare Advantage, Medigap, and Other Options

Using the Weeks 1-7 APA Template, and limited to three pages of text, respond to the following: Claire’s youngest sister, Nicole, lives in another state and is considering moving to live near Paul and Christine to help take care of Claire. Nicole is a widow aged 67 and on a Medicare Advantage plan that is only available in the state where Nicole currently lives. Nicole is visiting the Kelly family and called you to find out what her options would with Medicare if she moved to be near the Kellys. Nicole is in good health. The past twelve months she only saw her primary care provider for an annual physical and to get vaccinations to prevent pneumonia and the flu. She did have to stop jogging because of arthritis in both knees but has been going to a gym at least three times a week for exercise classes offered for people having the Silver Sneaker pass. Nicole does not have any long-term care insurance. Jessica, one of Nicole’s friends, recently had a stroke and required skilled nursing care. The friend had traditional Medicare and a Medigap Plan F. Nicole was impressed that Jessica did not have any out-of-pocket cost for the hospitalization or during the 100 days of skilled nursing care. The Medicare Advantage plan that Nicole currently has would have included daily co-payments up to the $4,000 out-of-pocket maximum. Nicole knows that she can no longer purchase the Medigap Plan F but is interested in comparing a Medigap Plan with Medicare Advantage plans available where the Kellys live. Although Nicole is not taking any prescriptions, she likes having the prescription benefit that her current Medicare Advantage plan includes. She knows that most of her friends are on one or more prescriptions and Nicole wants to have prescription coverage. Nicole has over $280,000 in savings and investments. Nicole receives $989 monthly survivor benefit from her husband’s pension plan and her current Social Security benefit is $1,757 after deduction of the Medicare Part B premium.


What Medicare option, or options would you recommend Nicole consider?

Would the option(s) be subject to underwriting or pre-existing condition limitations?

Would Nicole be able to get the coverage immediately, or would she have to wait until the annual open enrollment?



For Nicole's situation, considering her desire to move near the Kelly family and her Medicare-related concerns, there are a few options to explore:

  1. Medigap Plan with Traditional Medicare:

    • One option Nicole can consider is enrolling in Original Medicare (Part A and Part B) and purchasing a Medigap (Medicare Supplement) plan. Since she's impressed with the coverage her friend Jessica had with Medigap Plan F, she could explore other available Medigap plans in her new state.
    • Medigap plans are standardized and offer comprehensive coverage, which can help cover Medicare deductibles, coinsurance, and copayments. However, Medigap plans do not typically include prescription drug coverage. To address this, she can also enroll in a standalone Medicare Part D prescription drug plan (PDP) for her prescription needs.
  2. Medicare Advantage Plan in Her New State:

    • Nicole can explore Medicare Advantage plans available in the state where the Kellys live. These plans offer a bundled approach, including hospitalization, medical, and often prescription drug coverage. Since Nicole values prescription coverage, she can compare the prescription drug formularies of different Medicare Advantage plans to ensure her medications are covered.
    • Keep in mind that Medicare Advantage plans may have network restrictions and cost-sharing requirements, which could include copayments, coinsurance, and annual out-of-pocket maximums.

Regarding underwriting or pre-existing condition limitations:

  • If Nicole chooses to enroll in a Medigap plan, it's crucial to understand that there may be underwriting requirements. These requirements can vary by state, but during the initial open enrollment period (the first six months after enrolling in Medicare Part B), she may have guaranteed issue rights, which means that insurers cannot deny her coverage or charge higher premiums due to pre-existing conditions. However, if she applies for a Medigap plan outside of this period, she may be subject to underwriting, and coverage could be more limited or expensive.

  • For Medicare Advantage plans, there are generally no medical underwriting or pre-existing condition limitations. Nicole should be able to enroll in a Medicare Advantage plan without concern for her arthritis or any other pre-existing conditions.

As for the timing of enrollment:

  • Nicole can enroll in Medicare Advantage or make changes during the annual open enrollment period, which typically runs from October 15th to December 7th each year. Any changes made during this period will take effect on January 1st of the following year.

  • If Nicole chooses Original Medicare with a Medigap plan and a standalone Medicare Part D plan, she can enroll during her initial enrollment period when she first becomes eligible for Medicare or during the annual open enrollment period mentioned above.

In summary, Nicole's recommended options would depend on her specific preferences and healthcare needs. She can consider either a Medigap plan with Original Medicare or a Medicare Advantage plan in her new state, and the choice between these options would involve evaluating her budget, prescription drug needs, and preferred healthcare providers. Nicole should also be aware of enrollment timing and potential underwriting considerations if she opts for a Medigap plan. Consulting with a licensed Medicare insurance agent or counselor can provide her with personalized guidance in making this decision.

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