Ask the Medicare Specialist
QUESTION:
I’ve looked over at least 15 Advantage Plan HMO’s and PPO’s for 2020. I can’t believe how co-pays for the same services can be so different. Not just from company to company, but even plan to plan within the same company. Why do they do that? How can they do that?
ANSWER:
Welcome to the Medicare maze. Without the right guide, it’s easy to get lost, take a wrong turn, or get stuck.
And it isn’t just with Advantage Plan HMO’s or PPO’s. Supplements and Part D present their own challenges for those who try to navigate Medicare on their own, deal directly with a single company, or end up working with an inexperienced or unscrupulous agent.
You want to hear crazy? Paying more premium often doesn’t translate into lower co-pays or out of pocket costs. For example, the highest priced Advantage Plans in our area are going to be around $300/month in 2020. Companies offering plans that expensive, also have them as low as $0. People paying in the $300 range could actually be billed more for Chemo, Radiation, or Skilled Nursing than those paying $0. Costs for Durable Medical Equipment, Diabetic Supplies, the Emergency Room, and Urgent Care are often the same on both the high and low costs plans. And co-pays for other services like X-Rays, CT Scans, and others that are more common may only be $5 to $40 less than plans that cost up to $3,600 more per year. And get this. The ancillary benefits like Dental and Over the Counter allowances can also be better on the lower priced plans!
Not all similarly priced plans are created equal either. Almost every company offers a $0 premium plan. Some have a MOOP that is literally $3,400 higher than others, and there can be as much as a $1,400 difference in hospital co-pays from one $0 premium plan to another.
Just when you think you have everything figured out and changed plans to one that has a lower premium, MOOP, and hospital co-pays, something else can happen. Benefits can change year to year. So, you might have made the right choice in plan for 2020, but in 2021 or 2022, co-pays for a 5-day hospital stay could go from $250 to $1,250. The MOOP could increase from $3,400 to $6,700. One year there’s great dental coverage and the next it’s gone. I’ve seen it happen and it will almost certainly occur in the future.
Speaking of dental, virtually all Advantage Plan companies are going to advertise it, but benefits can be very different. Most plans provide cleanings and X-rays only, while others offer true “comprehensive” benefits that include coverage for fillings, crowns, root canals, extractions, dentures, and even implants. One way to avoid this merry go round is enrolling in a Supplement. They are regulated so benefits can never change. Those who buy Supplement Plan G, one of the two we advise our clients to choose from, have only one bill for the entire year, the annual Medicare Part B deductible, which is currently $185. Once that’s satisfied, there are no others – not for a doctor visit, a surgery, hospitalization, blood test, Chemo, diabetic supplies, etc. If they live to be 95, that would still be the case. Premiums will certainly go up, but there’s still just that single bill, the Medicare Part B deductible and nothing else.
Supplements can be curious as well, however. They’re all created equal in the fact they cover the same services and provide access to practically every doctor and hospital in the country. But again, prices can vary quite dramatically. It isn’t uncommon for me to meet someone who’s paying $1,200 to $2,000 per year more for the same letter plan and coverage. Those on Supplements also must buy a “stand alone” Part D prescription plan. These companies are notorious for introducing plans with low premiums and co-pays. But after two or three years, they do one or all of the following: raise premiums, increase co-pays, stop covering certain drugs, and/or change drug tiers. It’s almost cyclical. Every year or two there’s a new company that comes in the market like gangbusters. They “fill up their bucket,” so to speak, with new members. Once its full, they change benefits and not for the better. I’ve been in the Medicare business almost as long as Part D and Advantage Plans have been around. This type of business model is hardly a new concept.
How can this happen? Medicare allows it. The question really should be why? I honestly can’t answer that.
What myself and The Health Insurance Store have been doing since 2007 is help people enroll in the best possible plan for their individual needs and circumstances. Just as importantly, we advise every single client each Annual Election Period, ensuring they get the best value in Advantage Plan, Supplement, or Part D for the following year. In addition, any problems that may arise such as questionable bills, claim denials, prescription issues, etc., our dedicated support staff will solve.
If you would like to make an appointment for a no cost consultation, give us a call. We’re now offering virtual appointments for those who can’t make it to one of our office locations. If you have the internet and a computer or iPad, you can get the same information and thorough evaluation as if you were sitting across the desk from an agent.