Ask The Medicare Specialist

QUESTION:

Question from Shelley: I was reading one of your columns and your example about being diagnosed with cancer and the cost of the services that go along with those on Advantage Plans. Unfortunately, that’s exactly what has happened with my dad. He’s now getting chemo along with an infused drug, Keytruda, has a XYZ PPO plan, and has met his $6,500 MOOP (Maximum Out of Pocket), or so I thought. But my dad’s continuing to be charged 20% coinsurance on each Keytruda infusion, which is billed around $2,100 a treatment. Is it correct that there is no MOOP on that drug? That’s what I’m being told when I reached out to his insurance company. Any help is appreciated.

ANSWER:

I have a couple questions for Shelley myself. Who sold your dad this policy? Do you have their contact information? Did you try to call him or her for help? If Shelley’s father had come to us for advice in choosing a plan, there would be some certainties: He would have been told about the differences between Supplements and Advantage Plans which include both the risks and rewards. Had he chosen a Supplement and remained on it through his heath ordeals, he would have received no bills for chemotherapy, the Keytruda infusions, and had little or no out of pocket costs for any other Medicare covered services. If he couldn’t afford a Supplement at that time, didn’t qualify, or preferred an Advantage Plan, we would have made sure he chose an HMO or PPO where UPMC doctors and hospitals were in network, advising against the company he is currently with. And lastly, a member of our staff would have called his company and/or providers and found out exactly how much of his MOOP was met and if it had, what exactly was causing the discrepancy and made sure he didn’t pay a dime more than he was responsible for. Keytruda is subject to the MOOP and Shelley’s dad should not be charged once he’s been billed whatever that amount is. My first guess when I received this email was that the provider being used was out of network which turned out to be correct. PPOs are often sold untruthfully to Medicare beneficiaries as providing unfettered access with no strings attached to every doctor and hospital in the country. That’s not true. Any doctor or hospital who isn’t in network has the choice not to accept a PPO plan. If an out of network provider does agree to accept the plan, costs for the same services can be thousands more vs those provided in network, and the MOOP often can increase to more than $12,000!

I don’t know how old Shelley’s father is, but he’s an example that we just never know how long our good health will last. I realize people don’t want to think about getting sick, let alone discuss it. But understanding how one’s plan will work if it happens and what the costs will be is just one of the many things we feel must be mentioned and disclosed when people are going on Medicare for the first time, considering changing from one Advantage Plan to another, and especially moving from a Supplement to an Advantage Plan. I predict more people than ever are going to consider and do that this Annual Election Period (AEP) because of inflation and the significant cost increase on brand name medications for those on Supplements in 2024. As AEP approaches (it’s only two months away), I’m once again concerned about misleading advertising and sales tactics by companies and agents who don’t have Medicare beneficiaries’ best interests in mind. Those who are concerned more about their paycheck will go on and on about all the “free stuff” or ancillary benefits like dental, vision, hearing, gym memberships, and more that can truly be very valuable. They will boast that some generic drugs and PCP visits are $0. However, they often leave out the part where a diagnosis of Cancer or the need for other infused or injected drugs, insulin used in a pump, comes with a bill of 20% of the provider’s billable amount to the HMO or PPO. As Shelley mentioned, just one Keytruda treatment costs her father $2,100 until the MOOP is met. They probably don’t explain that prior authorizations (approvals) are needed before surgeries, MRIs, and other services can be performed which can delay those weeks or months. That said, let me be clear. This past year and during this upcoming year we have, and we will move more clients than ever from Supplements to Advantage Plans for the reasons I just mentioned and more. However, there are plenty of instances when it’s simply best for those on Supplements to stay put and we make that recommendation all the time. Too many other agents won’t. I really recommend that those who are contemplating a move to an Advantage Plan from a Supplement make an appointment to have an initial discussion about the pros and cons before AEP starts to allow time for that information to be digested and given the thought it deserves as one of the most important decisions you may ever make again.

Please remember that we have a new Facebook group that has the same title as the columns and provides exclusive content that can only be read by those who join. Go to our website and click the banner at the top of the page to become a member. I think you will really enjoy the weekly submissions, Feel Good Fridays as well asTruths, Tips, and Tricks.

If you have questions about this or any other Medicare, health, life insurance related topic or want to make an appointment for a no-cost consultation, call us. I also welcome you to email me personally at aaron@ getyourbestplan.com.

And now licensed in over 20 of the most populous states, if you or anyone else don’t live in Pennsylvania, we can also help you choose and enroll in a Medicare Supplement, Advantage, and/or Part D prescription plan.