If you have a Medicare Advantage plan you most likely have medical and Rx coverage together in your plan. I do not write about Medicare Advantage plans for I am not certified to market and sell them, however we do have people how specialize in Medicare Advantage (MA)  &  Medicare in general.

For people who want to check on your existing coverage or who are “aging in” to being eligible for Medicare coverage, there are tools that can be found on  the “Official” Medicare web site.

The main   “tool” or Medicare plan finder is the one that I think is very useful.

You can use the link to help find and compare plans for you and it is not from Insurance Company or on an agent’s web site.

For Medicare Health plans and Medicare Supplement plans the tool helps you find plans in your area.

The Part D plan tool is very useful I think and will explain. The Rx plan tool will ask you to list any prescription drugs you may take. This tool will help you make a list and will give you an ID to get back to  your list.  (very useful)

To use this at it’s best,  you will need to keep the ID   that the web site will  give to you and write  IT  down  and the date you did create the list.  These two pieces of information will act as your user name and password for this list.

The tool will ask you where you want to purchase your prescriptions and in most cases give you some good pricing information. The tool also illustrates the power of purchasing your prescriptions by mail and gives you some info to show the price advantage. I think mail order is great for maintenance medication prescriptions that will not change and you are certain you will need to take on a regular basis.

You are in control and can purchase where you want in all case and the tool will help show you what plans will work best for you.

I will advise that consumers use these tools to do some basic homework and then contact a licensed agent / broker to help you make a decision that works best for you.  If  you are in Texas,  do not have an agent and would like to talk to our office then please call or send us an email and If you are in the greater Houston, TX area please contact us to schedule an appointment in the office in Sugar Land, TX, just of Highway 59 at Highway 90.

Other useful Medicare.gov  links

A Quick look at Medicare  (CMS Product No. 11514 -Revised July 2011)

Medicare Prescription Drug Coverage (Part D)

DB- You have the option of

downloading the data used in the search and compare tools onto your computer.

If it is important “to you” to go to a particular doctor for something and can afford it or can justify the cost due to your concern for your health,  then I would go” out of network “ and  pay more. But you should be aware of this so you will not be surprised by the much greater cost to you.

As part of your selection process in choosing a health insurance plan you should check to see how large the in-network list is. The most important thing is to see if doctors and health facility’s you do or could use are on the in-network list.

Check on the hospitals that you could use that are in your area. And make a real note of which are in-network and which are out-of-network.  This could be of a real value to you.

Note in a real “emergency” you will not be penalized for where you are treated.
However.  if you are given the choice as to where you go this way you can go to a facility or doctor’s  office that is “in-network” and be treated in the most cost effective way.

It  is better late than never to note on this website that Miss Blair Piercy has left  Sugar Creek Financial Group as of the end of January 2011.

Blair had worked for Mr. Bob Roy part time for over four years while attending college at UH Downtown.  In December of 2010 she  graduated and got engaged to be married. Mike is a lucky man.

Blair moved forward in her life  to a full time position with Plains Exploration & Production Co.  in downtown Houston.  She will be missed at our Sugar Land office and I want to wish her well in all she does in life.

As of August 2011 Ms. Lynette Azar joined the office of Sugar Creek Financial Group.

Bob Roy and Casey Lowery want to welcome Lynette.  Lynette is a Texas licensed insurance  professional  and  brings a wealth of experience in the Houston Texas Health & Medicare Insurance market.

Improving our health is always a topic for Texans and all Americans. Even if you are in “good shape” you have things you want to improve. The old Diet and Exercise combo is one of the most popular new year resolutions that a lot of people work on.   Most people could stand to “lose a few pounds”,  through  more exercise and  examining  our eating habits to find ways to live by doing what’s  right for ”our body”.

I do not work for the HEB Grocery Store  but I have noticed some ad’s they ran on diet and exercise.  The  web site to find some good information is  Healthy at HEB.  HEB has stores in most parts of Texas and I think the web site offers some good general info on the whole topic of diet and exercise.  They are not by a long shot the only resource, but they are a resource that most Texans can relate to.

I have enjoyed some 30 minute monthly health webinars presented by Kelsey Seybold.  Please note that they are hosted live, usually on the first Wednesday of each month, but there is also an archive of past webinars available on their website.

The other “Resolution”  topic I will touch on is financial.

That is to review  your bank accounts, investments  including  stocks and mutual funds (IRAs,  401Ks and other qualified accounts) and taxable investments.

Look at your home situation whether you own or rent and see what is best for you.

The topic that is relevant to this web site is to look at the insurance you now have  and determine whether or not you  have the right “risk protection”.

Start with a look at your health insurance.   I believe all prudent people should have health protection, and like all insurance,  you must have the right coverage before you need it.

Then move on to to the broad topic,  your personal  risk protection (this would be life insurance, disability, Long Term Care Insurance (LTCi) and other forms of risk protection.)

If you do not work with an insurance professional and would like to look at the options you have and talk about other possible options then please contact me.

All the best for 2012 and I hope it is a good year for Texans and all Americans in this national election year.

This is scheduled to go into effect on January 1 2012 and, for the most part will impact Medicare .  ACOs  from what I can see look like  HMOs but will be different.  HMOs, however, can be ACOs.

The Houston area  Kelsey’s Seybold Doctor Group and their association with St. Luke’s Hospital is a form of ACO.

ACOs are the latest model for delivering  medical services by offering doctors and hospitals financial incentives to provide quality care to Medicare beneficiaries while keeping down costs.

I have fielded questions on this acronym and wanted to put up some information on this on the website. I have also provided the following two links to what I think are reliable news sites with an explanation of ACOs.

See

NPR  from 01/18/2011 on ACOs
And
Kaiser Health News from 10/21/2011 on ACOs

The recent big news on brand-named drugs vs. generic’s is the story on Lipitor.
Lipitor, which became available in 1997 and generated annual sales of $13 billion at its peak, and did 10.7 billion in sales in 2010 from a wsj report, reduces “bad” LDL cholesterol and the risk of heart attack and stroke. It loses U.S. patent protection on 11-30-2011.

As cholesterol fighter Lipitor goes generic, its maker Pfizer Inc. is hoping to hold onto perhaps thirty percent of the 3 million Americans who take the biggest-selling drug of all time.

In health insurance coverage whether individual or group, the Rx or prescription drug part of the coverage is an important part of the insurance protection.  Drugs can be very expensive and very necessary for medical treatment given by a person’s doctor.

Drug coverage that has a copay for prescription drugs is usually tiered. Generic,  brand-name , and non preferred brand or formulary are the most common three tiers.

The lowest co-pay is for generic drugs and today most major drug retailers even have a loyalty card to give people  decent access to low cost generic drugs. This is a big help for people without insurance.  These programs are, OK in my opinion, but are actually a tool of the retailer and give  effective access  for generic drugs ONLY.

Consumer Driven Health Plans (CDHP) are in most cased also Qualified High Deductible Health Plans (QHDP) that are eligible for Health Savings Accounts (HSA).

These plans do not have the separate (embedded) individual deductible per person like conventional PPO plans. In most cases these high deductible plans have an aggregate deductible. This means that the deductible for all persons covered on the plan must be met before any other benefit is paid by the insurance.

To spell it out,  these plans have no co pay amounts for doctor visits or filling prescriptions. The insured pays the full negotiated rate the insurance company has set and this amount is counted towards your deductible for the year.

That is to say a preferred provider organization or PPO plan has co-pays for going to the doctor and using the pharmacy etc. verses high deductible plans that do not have these immediate benefits.

Plans that only cover one person are not affected by “aggregate” family deductibles.

When considering Health Insurance plans that cover more than one person, make sure to  take a close look whether their health plan will require their family to meet the full family deductible before benefits are payable.

When given a choice, “embedded” deductibles provide better coverage for those covering dependents assuming all other benefits are the same.

An important distinction needs to be made concerning how deductibles are computed for qualified high-deductible health plans, including Health Savings Account (HSA) type coverage.

The family deductible is an aggregate or combined deductible.  Each person’s covered medical expenses go toward meeting the family deductible.  Each insured person’s covered medical expenses go toward meeting this amount.

Once the family deductible is met, most plans will cover 100% of all allowable expenses for the entire family. Therefore, any other covered expense you have done that year, will be paid for by the insurance company.

Compare this to a traditional copay plan where three of the insured persons EACH have their own deductible that must be met.  It is much more difficult to have each person meet their deductible than it is to meet an aggregate deductible.

When I present Consumer Driven Health Plans, I prefer to first show the so-called deductible and then, 100% plans which offer great coverage and are easier to understand.

Let me say again that most Qualified High Deductible Health Plans (QHDP) eligible for Health Savings Accounts (HSA) do not have the separate (embedded) individual deductible per person like conventional PPO plans.  This is an important detail when covering more than one person on these types of plans. High deductible plans are gaining in popularity and will continue to do so if pricing for this coverage makes more economic sense.

The following is a list of other terms that come into play when writing on this subject:

Consumer Driven Health Plan (CDHP)
Qualified High Deductible Health Plan (QHDP)
Health Savings Accounts (HSA)
Flexible Spending Account (FSA)
Health Reimbursement Account (HRA)

Therefore, any other covered expense you have done that year, will be paid for by the insurance company.  Compare this to a traditional copay plan where three of the insured persons EACH have their own deductible that must be met.  It is much more difficult to have each person meet their deductible than it is to meet an aggregate deductible.

Saving money is the first lesson most people started out learning as a child and it continues on through a person’s entire life.  That is to say the learning and I hope the saving for tomorrow, planned and the unexpected, should be a ongoing process.

The simple lesson of savings is to live below your means vs. above.

I did see a good tool that illustrates savings in the NYTimes.com.  In short this tool shows the power of compounding and that saving more early in a time period or a live will pay off.

Life insurance should be part of a long term savings and accumulation plan for a person and especially their family.  Insurance in general and life insurance in particular should be thought of and used when you have a risk or a thing you want to protect.

This could be a business – corporation – partners, or more important the people you love like children and spouses.

I like to work with people to help them protect the gains from the  hard work they have done and will do. And so try to  help them work smart. People and  situations are unique so there are not  standard answers that will  work for all people.

You  might consider the need to find  professional’s ( Stock Market investments – Banking – Insurance – Real Estate and etc) to work with. Then you have a person to talk with who can help you make a plan.  Then review the plan every so often  so if needed you can change “your plan”.

If you would like to talk to someone about personal insurance protection and  see if one of the people in our office could be right to work with,  then give a call or send a email so we can start a conversation and then, create a plan.

NPR radio:

Saving for retirement: how much do you need?

Plans may have both per individual and family deductibles.

Some plans may have separate deductibles for specific services. For example, a plan may have a prescription drug plan that has a deductible for all Rx except for generic drug prescriptions, or a hospitalization deductible per admission.

Deductibles may differ if services are received from an approved provider as opposed to a provider not on the approved list.

The most common type of deductible for basic medical expense and major medical contracts is the calendar-year deductible, which is the amount that must be paid by the insured in a calendar year before the insurance company pays anything. This scenario is for what is termed a 100% plan. After the insured has paid the deductible for the year, then the insurance company pays everything for the rest of year. This is basically the same as the aggregate deductible in commercial insurance policies.

In a plan with a deductible amount and co-insurance the covered person must pay the deductible amount then the covered party and the insurance company are in the “co-insurance” part where they share the cost. A typical plan has co-insurance 80% -20% for a fixed dollar amount. I have created an Excel spread sheet to help people see the numbers that make up deductible and co-insurance for a health insurance plan.

For more information on health insurance deductibles, copays, co-insurance and maximums, check out this video on YouTube.