Ask the Medicare Specialist

QUESTION:

Question from J: I’m turning 65 in February and currently receiving Social Security, so I was automatically enrolled in Medicare. Can you please recommend a few Advantage Plans with part D coverage, including one from company xxxxx, based on the following? I take two medications, Simvastatin and Lisinopril, and currently have no health concerns or problems. My doctor is with Northern Area Family Medicine.

ANSWER:

This seems like a simple question, but there’s much to dissect here.

J’s Medicare A and B began only 19 days from the time he initially contacted me. He’s already had an appointment and I got him enrolled in the plan he chooses prior to February 1st effective date he needed. However, I prefer to meet with clients 60 to 90 days before their Medicare starts in case we need to tie up some loose ends such as enrolling in Part A and or B, working with doctors regarding changing medications due to expense or coverage, among other common issues that can take a bit of time. J mentioned he was auto enrolled in Medicare since he’s already receiving Social Security. Those who collect prior to age 65 need to do nothing. There are no forms to sign or mail in, and no account that needs to be created online. A Medicare card with both Parts A and B will be in the mailbox about 100 days before those effective dates. In J’s case, that was mid-October. Those who aren’t collecting need to apply for both A and B, which is easy to do online at SSA.gov. However, those who remained on an employer provided health plan, have A but not B, need to start that process as soon as possible, up to 90 days prior to the desired effective date. With Social Security closed for faceto-face appointments, the time it takes to apply and get Part B processed has increased dramatically.

I did recommend Medicare Advantage Plan HMO’s and PPO’s to him. But before I did, I went over in detail how both they and Supplements work, as well as the pros and cons of each. I also made it clear Advantage Plans are not secondary to Medicare or designed to pay the portion of the bill(s) Medicare does not, a very common misconception. I also compared and contrasted the two types of plans on several levels.

J asked me to show him a plan from a particular company, which I cannot name due to regulations. Although I’m appointed to sell plans from the company he inquired about, it’s not one I normally advise someone to choose due to very high hospital co-pays, as much as $1,700 for a six-day or longer stay. I compared these plans side by side to others on the market, but he quickly understood they aren’t competitive. That’s why it’s important to use a broker, like the agents at The Health Insurance Store, who can provide plans from every competitive Advantage and Supplement company on the market. Had he worked with someone who sells Advantage Plans only or just this particular company’s offerings, he could have made the wrong choice, likely without being told about the Supplement option, something those with certain preexisting health conditions can’t afford to have happen. The part of the question that really stuck out to me was the statement he had no health concerns. He was more interested in Advantage Plans and chose a low-cost PPO’s because he rarely goes to the doctor and was willing to bet he won’t need Chemo or radiation therapy, Skilled Nursing, or other more costly medical services which can result in bills of a few thousand dollars. By choosing a less expensive Advantage Plan, he can maximize premiums savings vs a Supplement, the number one reason to choose an HMO or PPO in my opinion. If J stays relatively healthy, his premium savings over a five-year period can be as much as $5,000. That being said, I reminded him that cancer doesn’t discriminate. I have countless clients who were in great health at age 65 only to be diagnosed with a serious medical condition shortly after. Not only might there be thousands of dollars in out-of-pocket medical bills, but once enrolled in an Advantage Plan over a year, it may not be possible to move to a Supplement because those companies can discriminate on who they accept based on current or previous medical conditions. I also weighed these risks against the prospects of receiving valuable comprehensive dental coverage the HMO’s and PPO’s I recommended provide but aren’t available with Supplements.

As far as doctors, Supplements provide access to virtually every doctor and hospital in the country which means there are no networks to be concerned with. As far as Advantage Plans, two of the three most popular companies in our region provide network access to all hospitals in Western PA and almost every doctor. Network access to the Cleveland Clinic is also available with a couple companies. Lastly, J is taking two very inexpensive medications that will be $0 with almost every Advantage and Stand-Alone Part D plan. This is an area I don’t worry about what medication one could be prescribed later. Paying more for a plan rarely equates to less out of pocket costs or guarantees a future prescription will be covered. All Part D plans have several regulations to protect consumers in the event a specific medication was needed, even those not on formulary. There’s so much for someone who is new to Medicare to consider. In 13 years of helping clients, guiding and advising them as they get older, learning, and navigating through issues as they arise while dealing with what can be a very confusing heatlh care and insurance industry, I’ve come to know what information and future scenarios are most important to consider both short and long term when making one’s initial Medicare choice, which is extremely important and can impact someone for years to come.