Nolan Alexander (Host): Jefferson Healthcare and Kristin Manwaring Insurance are working together to help educate people in East Jefferson County about their insurance options. Today we're talking with Jefferson Healthcare's patient access manager, Damon McCutchen. And Kristin Manwaring, President of Kristin Manwaring insurance.

Welcome to To Your Health from Jefferson Healthcare. I'm Nolan Alexander. Well, first things first, Damon and Kristin, how are you both today?

Kristin Manwaring: Great, Nolan, thank you. Thank you for inviting us into this podcast today. We're looking forward to sharing some information with our community.

Damon McCutcheon, CHT-A: Agreed. Doing well and very much looking forward to this opportunity.

Host: Well, this is a timely podcast. Open enrollment season is coming right along. Let's establish what is it and what can patients do during this time?

Kristin Manwaring: Yeah, so Nolan, the open enrollment period, really at this time of year, I call it overlapping enrollment period. So I'm going to focus probably most of our content today to talking about the annual open enrollment period, which is specific to Medicare beneficiaries. It's the time period every year from October 15th to December 7th, where Medicare beneficiaries have an opportunity to review their Medicare Part D prescription drug plans or Medicare Advantage, which is also referred to as Medicare Part C.

It's an important time of year. Generally speaking, Medicare beneficiaries are locked into their coverage for the year ahead whether they make a change or not, it will determine that coverage for the year ahead.

Some of the things that Medicare beneficiaries can do during this time period is, they can change from original Medicare to a Medicare Advantage Plan. They can change a Medicare Advantage plan to another Medicare Advantage plan. They can change their standalone Medicare Part D prescription drug plan, or if they're on a Medicare Advantage plan, they can consider going back to original Medicare during this time period.

Host: So Damon, needless to say, this seems like a very important time for patients to establish what their plan is for the upcoming year.

Damon McCutcheon, CHT-A: Absolutely. This is really imperative for patients to understand where they are going to be seeking the bulk of their services, and making sure that whatever plan, whether it be a traditional Medicare, Medicare Advantage or a even a private insurance plan, is considered in-network with that organization, that healthcare area, whether it be Jefferson Healthcare or whether it be another healthcare organization. And that's something that we work closely with Kristin and her team on to make sure that, that knowledge is really shared with our community.

Host: There are several notifications and communications people receive during open enrollment. Can you talk to us about these?

Kristin Manwaring: Yeah, I would say the most important communication that Medicare beneficiaries need to be looking for from their insurance carrier directly, is what's referred to as an annual notice of change. We have a lot of acronyms in our industry, so if you hear the term ANOC, that stands for annual notice of change, and that's a really important communication if you're on a Medicare Part D prescription drug plan or a Medicare Advantage, Medicare Part C plan. You will, in most cases, I'll talk about the exception in a minute, but, you will receive your annual notice of change and there's a chart within the first few pages of that ANOC that outlines what your current coverage is today in 2025. It'll highlight your plan name, what the premium is, if there's a deductible associated, cost shares like copays, co-insurance, comments on pharmacy formulary. Formulary is a list of covered drugs and when we get into Medicare Advantage plans, that then lends to provider networks. So this is a really important document. The next column next to that 2025 is 2026. What does the plan look like as you look at renewing in 2026?

Sometimes the plan name can change if you're being mapped from one plan to another within a carrier's offerings. Or if the plan name is remaining the same, it will reflect that as well. So if you do nothing, then the benefits and the plan that is outlined in the 2026 column will be the benefits that you have effective January one.

So if there's anything within that document that creates concern or, maybe requires review in order to feel confident about benefits moving into the year ahead, this annual enrollment period is the time to review those and make changes. There is an exception before I move there, and ANOC is going to be received either, in your mailbox or you may receive it electronically.

So this all is determined by the way that a Medicare beneficiary elects to receive their communications from their carrier. And so it may be in the mailbox. It may be that you need to log in and access that information at the carrier's website. So keep that in mind. One exception to an ANOC, if there is a plan discontinuation. A plan discontinuation means that the plan is no longer going to be available in 2026 and the carrier is not allowed to map you to one of their other plans. Therefore, there's what's called a plan discontinuation. You would not receive an annual notice of change in that case. You would actually receive a discontinuation letter from your carrier, and that letter is really important to outlining not what's happening with your plan, but the fact that you haveand enrollment window that last until December seventh.

A discontinued plan offers an extended enrollment window. So it's important to understand, the time period that you have to take action within and to please hold onto those letters. After December 7th, carriers will require, in many cases, that those letters be provided with the application in order for those applications to go through underwriting.

So review your annual notice of change. Really important. And take action from there. Call your carrier. Call a broker. Ask the questions that are necessary for you to make well-informed decisions.

Host: So even if things are ho-hum and we're fine with the plan that we're on, we really need to pay attention to what's coming in the mail or checking our email in the event there is an ANOC or a discontinuation.

Kristin Manwaring: So true, Nolan. Because the name of the plan and the premium of the plan that you pay on a monthly basis is just one aspect of plan details. There's the deductible that runs on a calendar year. There's the copays and co-insurance, that can change within a plan. So even if the name of the plan is the same, and let's say even the premium is the same, look under the hood. Make sure you understand deductibles, copays, co-insurance. Understand if your pharmacy is still going to be part of that plan's network in the year ahead and make sure that your medications are still covered in the drug formulary. And again, a drug formulary is a list of covered drugs, and those lists are going to be different from carrier to carrier as well as plan to plan.

The other thing that we see happening, at the change of the calendar year within a plan is there can be what we call tier creeping. There are tiers of medications within a drug plan. The lower the drug tier, tier one, tier two is typically your lower cost medications. If you get into tiers three, four, and five, those are generally your higher cost out-of-pocket medications.

And tier creeping means that maybe your medication is considered a tier two drug today. And maybe it's still covered in the drug formulary next year, but now it's considered a tier three, which would change the amount that you would have to pay outta your pocket to pick up that medication. So there's a lot of details to review, and we think it's important with Medicare Part D and Medicare Part C to do annual reviews.

Host: Those are so many important details, and you're both partnering to take efforts to educate the community. Right. Let's shift gears a little bit there. Jefferson Healthcare and KMI are offering a host of learning opportunities that are open to the public. What are the details there?

Kristin Manwaring: Yeah, so this has been, um, I'm going to say a dream of mine for years to roll out to a, to the community, an education series. And, we are really fortunate to be able to roll this educational series out in partnership with Jefferson Healthcare. We both have a common interest in Jefferson Healthcare, having their patients be well-informed and understand the insurance that pays for their healthcare.

We have an interest in our clients and well beyond our client base just the general community at large, and our community is beyond Jefferson County. At KMI, we are licensed in the state of Washington. And so there can be variables, depending on where you live in the state, that to be taken into consideration.

Provider networks is one of them. So, at the heart and the heartbeat I will say of KMI is education first. We want to share our knowledge. We want our clients, our communities, to feel empowered, um, in understanding the options they have. We love seeing those aha moments when somebody walks out our door and says you basically made that so easy to understand. You demystified something so complex and now we feel like we understand it at least a little bit better to make the next step in making a decision about financing our healthcare into the year ahead, because that's really what insurance is, is assisting with financing your healthcare.

Damon McCutcheon, CHT-A: If I can just say, as we've seen with Kristin's kind of high overview responses, medical insurance is very, very complex, and can be very complicated even for those of us in the industry. I've had the opportunity to sit through bits and pieces of Kristin Manwaring's teams presentations, and amazing the amount of information that they're able to pack into a very small timeframe and really make it digestible for the average lay person.

It's imperative to have a general understanding of what you are purchasing for your healthcare needs in future years. And I, just can't stress enough how beneficial, this has been for our community.

Host: In one of those educational seminars that's coming up is Medicare 101, and you touched on that a little bit, Kristin, to start out this podcast. Can you talk a little bit more in depth about the different types of Medicare? What makes them different? For those of us who may not already be in the know.

Kristin Manwaring: Yeah, Nolan, so original Medicare has two parts, part A and part B. Part A is generally our hospital or inpatient type coverage. And part B is our outpatient physician coverage. Both A and B are administered by the federal government and, uh, administered specifically through the Social Security Administration.

There's two additional parts to Medicare, Medicare Part C, which is, uh, a set aside for Medicare Advantage plans, and then Medicare Part D, which is a set aside for prescription drug plans and both Medicare Part C and Part D as well as Medicare supplement, Medigap plans are offered through private insurance companies, so there's really two fundamental ways to elect your Medicare benefits as a Medicare beneficiary. You can either do that under what we call original Medicare, oftentimes referred to as traditional Medicare. And we can layer a secondary coverage in with that, a Medicare supplement plan. And then we would need a third type of coverage, which is a standalone prescription drug plan, to cover those prescription drugs.

So that is one way that we can access our benefits through Medicare. Original Medicare allows you to use or see any provider that is part of Medicare. And by being part of Medicare, it means that the provider or the healthcare system has a contract with Medicare, which means that they agree to bill Medicare on your behalf.

And so your network is really broad under original Medicare and a Medicare supplement acts as your secondary coverage. And again, you can use any provider that's part of Medicare. So when we move over to the second way that you can access your Medicare benefits, it's under a Medicare Advantage plan, Medicare Part C.

And what happens is these are plans that are managed by private insurance companies. The government is paying the private insurance company to manage the benefits of Medicare, so a Medicare Advantage plan is going to include all of the benefits that you see under original Medicare A and B. Cost sharing can and will be different, but the benefits are still there.

Medicare Advantage plans oftentimes include the prescription drug benefit. And then oftentimes they will include some extra benefits. It might be dental or vision type benefits that we see in those plans. Really important to understand within these plans is there is a provider network, so we begin to narrow the scope of who we can access and who we can see under a Medicare Advantage plan versus original Medicare.

So in order for a provider to be considered part of the plan, they need to be contracted directly with that private insurance company. And if they're not, under HMO plans as an example, it means that you have no access to that provider because HMO plans do not offer out of network benefits. PPO plans do offer some out-of-network benefits, but the caution there is,

you are allowed on paper to go to an out-of-network provider, but only if that out-of-network provider is willing to see you as a patient, on an out-of-network basis with that Medicare Advantage plan. So providers on a case by case basis can elect to see you or not if they're not contracted. So either an HMO plan or a PPO plan can really begin to narrow who you have the flexibility and access to see for your medical needs.

Host: Shifting gears once again. At this time of year, people are contacted by insurance broker solicitors. What do they need to know when they're contacted by someone like this?

Kristin Manwaring: Yeah, so there's a lot of compliance and regulation in our world. So I think, just to put this in plain terms, part of CMS compliance, CMS is the Center for Medicare and Medicaid Services. They do not allow outbound calls, if you will, or cold calls to Medicare beneficiaries. Medicare beneficiaries need to initiate either through a business reply card that they send back to an insurance carrier, or through making a phone call directly to a broker or to an insurance carrier. But we're not allowed to solicit Medicare beneficiaries. So things I would offer for guidance is if you are receiving a call, ask for the broker's name. Ask what agency they work for. Ask for their NPN number. Ask for a callback number. If that caller is legitimate, they're going to happily share that information with you. I would also advise against beginning to give information like your Medicare ID number or information that really lends to the possibility of an application.

So we've heard over the last year more than we've ever heard that Medicare beneficiaries got enrolled into Medicare Advantage plans, and then after the first of the year tried accessing their benefits and were advised that Jefferson Healthcare was out of network with a particular insurance carrier.

That is something that should be communicated clear and well during an enrollment process and really prior to an enrollment process, before a Medicare beneficiary jumps into an application to make a change, to really understand, where they can run into some hurdles using their care. So utilizing, um, there could be call centers.

Again, I'm, these are things that we heard out of Florida or California or just brokers outside of our area that don't have the guardrails around our local healthcare system. We're working closely with insurance carriers. We're working really closely with Jefferson Healthcare to understand where they do have contracts and that way, if a carrier has information not represented accurately on their website, we have the ability to say, we see that same information, but in our partnership with Jefferson Healthcare, we understand that that information is not accurate. So we want you to understand that if you enroll in this plan and you intend to use a particular provider, you need to do your own due diligence in making sure that the information you see on a carrier's website is accurate.

Make sure those providers that you want to see, um, are going to give you that access to the care that you desire.

Host: Well, Kristin, it sounds like your biggest takeaways are the importance of preparing for this, as you just said, doing your due diligence, but also don't try to go through open enrollment alone. Can you tell us a little bit more about the resources available in our communities?

Kristin Manwaring: Yeah, never go about it alone. There's too many pitfalls. So I'm going to go back to one of the things that you can do, um, during the annual enrollment period is you can consider going from original Medicare and you might have a Medicare supplement plan, and you're considering going to a Medicare Advantage plan, and maybe you're intending to just try it out because the premium seems to fit the budget better. So you want to try it out. And I think there's some unintended consequences that most people don't realize that a year later or beyond while during the open or annual enrollment period, we certainly can go back from Medicare Advantage back to original Medicare, but we might have to go through health underwriting to gain access back to a Medicare supplement plan, and our health could decline coverage. So there are some unintended pitfalls that I believe it's very important, whether it is talking to one of the brokers at KMI or whether you're working with another trusted broker, please work with somebody to evaluate what your options are. And I would also say if a broker is presenting you with one option, I would say that there is a bit of a red flag there for you in not really looking at the broader marketplace for you and truly making sure that you are getting access and knowledge, not just for one plan, but for all the plans so that you can feel confident in what you're selecting for the year ahead.

So we definitely believe in, in doing reviews, and we put a lot of time in at this time of year, and I want to go back, Nolan to one thing that, um, you asked around our education series is we are spending time, on either virtual or in-person educational events. Um, because we again, believe so deeply in educating our community, so it's well worth our time to step away and speak to individuals in the community and really meet them where they're at and find out as they walk in the door, what is it that you want to learn today and take away today so that I can adapt a presentation and make sure that we have value added to our community.

Host: Well, Damon, based on everything that Kristin has said today, I think I need to attend one of these educational seminars because there's so much more information than I ever knew going into open enrollment.

Damon McCutcheon, CHT-A: Absolutely. I did hear Kristin mention the importance of really understanding your plan and ensuring that you're doing the diligence to make sure that your plan is accepted and provides coverage where you're primarily seeking your care, that your primary care provider is documented correctly, that you are able to go to the healthcare organization or organizations of your choice. That is one of the most common complications that we see in healthcare in general is patients not understanding where they are able to go in or out of network, and what their plans offer. And, so taking advantage of an educational resource and such a knowledgeable, team such as Kristin's team, is just imperative for really making sure that you're setting yourself up for success with your healthcare needs in the future.

Host: Well, Damon McCutchen and Kristin Manwaring, thank you so much for your time and insight today.

Kristin Manwaring: Thank you, Nolan. Our pleasure.

Damon McCutcheon, CHT-A: Thanks so much for having us.

Host: For more information, visit jeffersonhealthcare.org. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. This has been To Your Health. Thanks for listening today.