Ask the Medicare Specialist

This weeks new material will be featured in this Sunday 4/4 Edition of the Post-Gazette.

QUESTION:

From John: As a retired teacher, I’m on the HOP Medical plan. However, I see in your columns all of these different letter Supplements and have no idea which of these is most comparable to HOP. A) Is HOP different, or is it just one of the lettered plans without using the letter? I’m 71 and healthy and my wife is 69. She just had major cancer surgery and will start treatments next month. My thoughts on a Supplement are I want it to pay for most of our treatments and do not mind paying a bit more monthly for a plan to ensure that is the case. B) Is there a plan other than HOP I should consider? My wife starts chemo this week in Pittsburgh and we’ve have had lots of doctor meetings. Last week I got a call or from the hospital billing department about visits to oncologists and surgeons at the hospital. The representative said to check with my insurance as they bill chemo as a hospital visit and many insurance companies do not pay what the hospital demands. C) Has this been a problem for many in the past for those who have Medicare and HOP? D) Will HOP pay this or am I stuck paying their extra charge in a hospital setting for a regular visit to see them?

ANSWER:

This is another great question. Please keep them coming as they’re so important, not only for those asking the question, but the entire senior community. This one in particular has implications for both those on HOP as well as all Medicare beneficiaries. A) The HOP Medical plan is a Supplement as it’s secondary to Medicare and designed to pay almost all of what Medicare doesn’t: the $1,484 Part A hospital deductible, days 21-100 in a Skilled Nursing Facility, and the 20% for outpatient services (Part B). However, it’s not one that is regulated the same as Medigap policies A through N and why it’s not labeled with any letter. That being said, it most resembles plan N, my favorite and the one I recommend to approximately 95% of clients who choose to go the Supplement route. Both N and HOP have minimal co-pays, although unlike N, the HOP Medical plan does not have a Part B deductible. N has a $20 co pay for a PCP or Specialist visit and a $50 co-pay at the Emergency Room. HOP Medical has co-pays of $10 at a PCP, $20 for a specialist, $40 for an Emergency Room visit, $25 for an MRI or a CT scan, and 10% (up to $100 per item) for durable medical equipment. That’s it. And just like Plan N, every other Medicare covered service is paid for at 100%. This ensures that your wife will get no bills for chemo treatments. Please be advised that not all HOP plans are Supplements. They do offer Advantage Plan HMO’s and PPO’s. Although we often help clients who aren’t eligible for HOP enroll in Advantage Plans, we have never advised a HOP recipient to enroll in a one. That’s because they’re more expensive than the HOP Medical plan while limiting one’s access to doctors and hospitals. Those on HOP Medical can use any doctor or hospital in the country that accepts Medicare Assignment without paying any additional costs, not the case with HMO’s and PPO’s. I’m honestly not sure why HOP even offers Advantage Plans to public school retirees. B) Anyone eligible for HOP who gets the $100 premium assistance, which most teachers do, should absolutely never consider any plan other than HOP Medical. The price is fantastic and rarely increases like Supplements such as G, F, or N. The coverage is excellent, with all Medicare approved services paid at 100% other than the small co-pays I listed. It provides access not only to Pittsburgh’s best health care systems, but other world class hospitals such as the Mayo Clinic, Cleveland Clinic, Johns Hopkins, MD Anderson Cancer Center, etc. What we do often recommend is for the spouse of a HOP recipient to buy a Federally regulated Supplement because it’s about half the price of HOP Medical for those who don’t get the $100 discount. We also recommend both the HOP recipient and spouse buy a Medicare Part D prescription plan outside of HOP. As good of a value as HOP Medical is, the HOP prescription options are bad. The Basic plan is $69/ month compared to the $15 median premium our clients pay. Co-pays for both generics and brand name drugs are significantly higher on HOP plans as well. Any HOP recipient who would like us to analyze their Part D plan and make a recommendation this coming AEP can call or email me and request to be put in our database. They will then receive our annual recommendation letter in September like all our other Supplement clients. We provide this service at no charge. C) I have no idea why a representative would have mentioned this unless he or she thought you had an Advantage Plan HMO or PPO. I’m also wondering if there was a communication breakdown of some kind. Medicare is primary for those on the HOP Medical Plan as well as all other Supplements. That means any provider who accepts Medicare Assignment, which all full-service hospitals do including UPMC, is legally bound to accept what Medicare and the Supplement reimburse as payment in full. It would be illegal for a Medicare provider to bill any additional charges. I’ve never heard of this happening as a standard practice although that doesn’t mean there may not be a billing error from time to time. D) You don’t have to worry about HOP not paying for any Medicare covered service, which any related to Cancer will be with the exception of oral chemotherapy. It simply can’t happen to those with on the HOP Medical plan in addition to Medicare. In fact, HOP actually pays in place of Medicare in the rare occasion when certain Medicare covered services are exhausted such as physical therapy or days 101 or more in a Skilled Nursing Facility. They provide $1,000,000 in lifetime benefit, which would be virtually impossible to reach. Please call one of our office locations or email me personally if you have questions regarding this or any other Medicare/health insurance related topic or to request an appointment for a no cost consultation. I’d like to remind everyone that I do a live call-in talk show called Medicare A to Z every 1st and 3rd Monday of the month on WMBS Uniontown, 590AM and 101.1FM, from 1 to 3 PM. You can listen in on their website, wmbs590.com.