Ask the Medi­care Spe­cial­ist

Pittsburgh Post-Gazette - - News - by: Aaron Zol­brod


I get so con­fused about drug costs and med­i­cal bills I re­ceive. I’m not a client of yours but can you still help me?


You’re not alone. If Medi­care was sim­ple, The Health In­sur­ance Store wouldn’t be in busi­ness. There are Parts A, B, C, and D, HMO’s PPO’s, POS’s, Sup­ple­ments, and on and on and on. Good grief. Right?

Plus, se­niors get over­whelm­ing stacks of ad­ver­tise­ments and lit­er­a­ture in the mail when they turn 65. It all starts get­ting de­liv­ered again ev­ery Septem­ber be­fore that the An­nual Elec­tion Pe­riod (AEP) be­gins and doesn’t stop com­ing un­til De­cem­ber. Some of the ads can be very mis­lead­ing too.

Then there are all the cor­re­spon­dences from the com­pany you have your plan with. Ev­ery time there’s a claim sub­mit­ted on your be­half, they are re­quired to send what is called an Ex­pla­na­tion of Ben­e­fits (EOB). It states what the provider billed, what Medi­care paid, what your plan paid, and what you might be on the hook for. Al­most no one can un­der­stand them. I’ve been in the busi­ness since 2008 and at times they don’t make sense to me. For many se­niors they of­ten cause stress and anx­i­ety. And to an­swer your ques­tion. Yes, we’ll help any­way we can. If you’re pay­ing a lot of money for pre­scrip­tions, if you go into the Dough­nut Hole, have bills you don’t un­der­stand or think might be in er­ror, have a claim de­nied, or just have ques­tions about your cur­rent plan and ben­e­fits, we don’t mind tak­ing a look and do­ing our best to an­swer those ques­tions and solve prob­lems. We are very fa­mil­iar with pro­grams for se­niors, as well as some tricks that can help save money and limit con­fu­sion. Mov­ing from an Ad­van­tage Plan to a Sup­ple­ment is one way to re­duce uncer­tainty be­cause there are vir­tu­ally no med­i­cal bills in­volved. Our clients who have Sup­ple­ments are in­structed that after they pay their small de­ductible of $185, they should never get an­other bill. If one is re­ceived, they know to just pick up the phone and dial us so we can get it straight­ened out. For those who get er­ro­neous bills, more of­ten than not, a sim­ple call to a provider or billing depart­ment is all that’s needed. On other oc­ca­sions a re­fer­ral to a foun­da­tion or non-profit can be ex­tremely help­ful.

There are well known pro­grams like PACE and PACENET, as well as oth­ers that have been kept some­what of a se­cret we’ve come across over the years while as­sist­ing clients.

On the topic of PACENET, I want to re­mind ev­ery­one that the in­come lim­its were re­cently in­creased. A sin­gle per­son mak­ing less than $29,108, and a mar­ried cou­ple earn­ing less than $38,716 now qual­ify. It’s a fan­tas­tic pro­gram that’s paid for with PA lot­tery pro­ceeds. It can save se­niors thou­sands of dol­lars an­nu­ally in drug costs. Any of our agents can help see if you qual­ify and even make the ap­pli­ca­tion.

Many peo­ple don’t re­al­ize the only de­ter­min­ing fac­tor is the dol­lar fig­ures from your prior year’s tax re­turn. As­sets such as check­ing or sav­ings ac­counts, stocks, bonds, other in­vest­ments, prop­erty, etc., are not con­sid­ered when your ap­pli­ca­tion is be­ing re­viewed.

Also, don’t as­sume be­cause you were de­nied in the past, you won’t qual­ify to­day. We’ve helped over 1,000 peo­ple en­roll in PACENET, many who were told they didn’t qual­ify in prior years.

PACENET pro­vides an­other ben­e­fit in ad­di­tion to pre­scrip­tion sav­ings. It gives those who are cur­rently en­rolled, or new to the pro­gram, what is known as a Spe­cial Elec­tion Pe­riod (SEP). SEP’s al­low you to en­roll in a Medi­care Ad­van­tage Plan, Part D, or a Sup­ple­ment all year round, not just dur­ing AEP. There are sev­eral sit­u­a­tions in which peo­ple can uti­lize an SEP to change plans. We can help de­ter­mine if you qual­ify for one and ad­vise you if we feel the plan you have of­fers the best value or mov­ing to an­other might make more sense.

As I’ve writ­ten in so many col­umns, mis­takes those on Medi­care com­monly make are over­pay­ing pre­mi­ums out of fear of chang­ing plans and ex­pos­ing them­selves to thou­sands of dol­lars in un­nec­es­sary out of pocket med­i­cal bills. But the er­ror made most of­ten is not un­der­stand­ing the dif­fer­ences be­tween Medi­care Ad­van­tage Plan HMO’s and PPO’s vs Sup­ple­ments.

Even if you don’t qual­ify for an SEP to change plans now, you’re wel­come to come and sit down with my­self or an­other li­censed agent to get an ed­u­ca­tion, re­view your plan, or get some ad­vice any time dur­ing the year. We never charge for con­sul­ta­tions in our of­fice or over the phone.

If you have any ques­tions, please feel free to call one of our of­fices. You can also email me di­rectly at [email protected]­ourbest­

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