Cancer is one of the treatments likely to cause your Medicare Advantage client to hit her Out Of Pocket  (OOP) maximum for the year. Many will look at a $5,000 or $6,700 risk and think they have the savings to cover it. Other clients reason that they will save over $100 per month (on average on a Medicare Advantage plan over the Medicare Supplement plan they were on, and that savings will be waiting in the bank if they might get cancer in the future.

American men have a 50/50 chance of getting cancer, women have a one in three chance. Cancer is a big risk and that OOP max might actually be more than your clients anticipate.

Once you’ve had clients experience cancer claims on a MAPD, you learn that network can be a big obstacle. Many of the top cancer centers in the nation do not accept MAPD plans. Some accept a few carriers but as you know, network contracts change.

“My Client Knows To Stay In Network To Limit Her Risk”

Sure your client agreed that she’d would likely seek treatment at the hospitals in network and keep her total OOP risk to the policy limits, let’s say it is $5,000 this year. It’s easy to say that when your life isn’t threatened. My personal client got a rare form of skin cancer and the only place in the nation that was able to give her hope with an experimental treatment, was out of network.Since it was experimental, it was not covered at all. While experimental treatment would not have been approved by Original Medicare and a Medicare Supplement either, your client still tends to want to blame you.

Another of my Indiana clients had a Medicare Advantage plan. His type of cancer was best treated in Florida, out of network. Luckily, he had a United Healthcare PPO plan with an added benefit for those how travel out of network. UHC calls their plan “Passport.” Because he was out of network, it caused his total OOP to rise to $10,000, the CMS maximum amount. He was OK with that. But then I pointed out that with a MAPD plan, the OOP resets each January and he would still be in treatment. Therefore, his actual out of pocket costs would be $10,000 x 2 years or $20,000.

Don’t Forget That “Trial Rights” May Be An Option

If your MAPD client left a Medicare Supplement to enroll into a MAPD plan for the first time, he may be able to go back into a Medicare Supplement plan without underwriting.

Depending on your state, agents may not be paid at all for this type of Guaranteed Issue plan. You can’t blame the insurance company for trying to disincentivize agents from bringing clients sick with cancer to them. Many states require that commission be paid (Indiana and Colorado included). You could be paid 50% of standard commission or only $25 or $0, so check that carrier’s commission chart.

Many Agents Use Hospital Indemnity Plans To Cover This Risk

When your clients can qualify for a HIP plan, it becomes a great “supplement” to a Medicare Advantage plan. This will allow your clients the peace of mind to know they could afford to go out of network, if needed. A slightly higher monthly premium could pay them a larger lump sum if they needed to get experimental treatments not yet approved by Medicare. Or to go to the Mayo Clinic who may not accept their MAPD plan at the time. There are a lot of unknown variables in our line of work. And just as many types of insurance available to cover those risks. You may be like more agents in the senior market and didn’t offer Hospital Indemnity Plans during your hectic AEP. There is still time to go back to all your clients and present this option to them. If they decline coverage, at least you will rest easier knowing that you presented an option to them.

Medicare Advantage all boils down the network. Good agents must understand and be able to explain the network limitations, challenges, possible solutions (HIP) or strategies (trial rights or travel benefits) that each plans offers.



Sylvia Gordon and her sister, Rebecca, run Gordon Marketing, one of the nation’s largest Medicare FMO/NMA offices. They have a team of over 100 that train and support independent insurance agents in all 50 states. You can find Sylvia’s weekly posts on LinkedIn and the sisters' Youtube channel posts 2 training videos each week. Contact Sylvia at or 800-388-8342.