Medicare Recipients Have Much to Consider, Even Outside Election Periods
Many people didn’t make a change to their Medicare Plan during Annual Election Period that ended this past December. And that could be an issue for seniors who want to keep their doctors and have access to all Pittsburgh area hospitals after July 1st.
If you didn’t already know, there was a ruling last summer that affected literally tens of thousands of Western Pennsylvanians who will no longer be “in network” with the area’s largest healthcare provider. These folks were told by their insurance carrier that they could still use out of network providers and pay the same, or very similar, co-pays but unfortunately, it won’t be that simple.
“In a court of law, a judge would probably find that to be true, but logistically and realistically for most people, it may not be possible,” says Aaron Zolbrod, President and Founder of The Health Insurance Store, an agency in Forest Hills that has over 8,000 active Medicare clients. He goes on to explain that it’s likely those who voluntarily choose to use “out of network” providers will have to pay their bill up front, and in full, for services prior to an appointment being scheduled. “We’re not talking about the co-pay up front,” explains Zolbrod. “The entire cost of the service based on Medicare’s reimbursement rate will have to be paid. If you wanted to visit your cardiologist for an appointment and he she was is no longer in network, your copay may only be $25 to $50, but if the estimated cost of that visit was $260, that would have to be paid prior to seeing the doctor. If you needed a more expensive procedure like a catheterization for example, you might have to pay $4,000 or more before that service would be rendered. After the procedure is complete, you will then have to file a paper claim to your HMO or PPO and wait to get reimbursed.”
Even if having unfettered access to all local hospital isn’t a concern, everyone on Medicare should be looking at and evaluating their plan benefits prior to the next Election Period in October, according to Zolbrod. “So many seniors who have Advantage Plans pay much higher premiums and/or expose themselves to thousands of dollars more in bills compared to other available plans on the market. We never advise clients to choose an HMO or PPO that has a premium over $100. We also don’t recommend plans that have hospital co-pays on a ‘per day’ basis because a 5-day or longer stay usually results in charges of $1,000 or more in almost every plan that doesn’t have a fixed cost hospital co-pay.”
He also states that many seniors don’t pay enough attention to what is known as the annual Maximum Out of Pocket, aka MOOP, which represents the most money one can be billed for medical services in a calendar year. With many plans that can be $6,700 and as much as $10,000 when utilizing out of network hospitals. Services that could result in reaching the MOOP rather quickly include multiple hospitalizations, Chemotherapy, Radiation, Skilled Nursing, drugs that are infused or injected in an outpatient setting such as Remicade, and others. Several plans are available that have a MOOP thousands less than $6,700.
The good news is many Pennsylvanians can still change plans using what is known as a Special Election Period or SEP. Those who qualify for one can make a change at any time during the year. “If you are concerned about losing access to local doctors and hospitals, that you’re possibly paying too much premium, or have high co pays, give us a quick call and we can determine if you are eligible for an SEP,” says Zolbrod.
Those who don’t qualify can still do research and homework throughout the year. Information on how different companies compare when it comes to premiums, costs for the same medical services, and networks is always available.
“We never charge for consultations over the phone or in one of our offices,” says Zolbrod. “And sitting down before Annual Election Period when the stress of a deadline isn’t looming is a great idea. If nothing else, you really need to learn more about how your current plan works and how to make it work better for you.”
Mr. Zolbrod and the other licensed agents at The Heath Insurance Store can be reached at 412-349-8818 or on their website at www.getyourbestplan.com. Zolbrod also invites those with questions or comments to email him directly at aaron@getyourbestplan.com.