Ask The Medicare Specialist

QUESTION:

Lydia: I follow your column as it’s informative and I love that you seem genuinely concerned for folks. I’m 75 and my husband, Don, is 66. We are signed up for Medicare Part A only because although my husband owns his own business, he stayed with the union, and they provide health insurance for both of us. One issue is they changed from UPMC to Highmark and of course we had to find other doctors. Now he’s considering retiring to tap into pension, S.S. and retirement from the union, but he will still own the business. The retiree coverage appears to be an Advantage Plan PPO. My husband has Crohn’s disease and is getting Entyvio infusions every month. He also takes many medications including Trelegy, which I know is expensive. From following your column, I think a Supplement will give us better coverage. Am I correct? Please help.

ANSWER:

This is the perfect example of why I say there is no “one size fits all” approach when it comes to choosing a Medicare plan. There are many things Lydia and her husband need to consider. Only an agent or agency with lots of experience and who does indeed genuinely care about people, and not just a commission, can ensure the right choice is made. Here is a list of questions that need to be asked before I could possibly make a recommendation in this case. 1) Do you need help enrolling in Part B? This is a somewhat complicated process. There’s a form that needs to be signed by the employer who is currently providing the insurance and it needs to be delivered to Social Security in a timely manner 2) Is Dan considered an employee of the union despite having his own business? This is important because to qualify for enrollment in Medicare Part B on demand and without a late enrollment penalty, that must be the case. 3) Which union is supplying the benefits? 4)What’s the premium? 5) What is the deductible, which some union Medicare plans have, and Maximum Out of Pocket (MOOP)? If the union Advantage Plan has 20% coinsurance for infusion therapy and the MOOP is $4,000 to $8,350 like virtually every other HMO or PPO in Western PA, that’s a huge deal and probably almost a certainty it would be best to opt out of union coverage and go with a Supplement. However, it’s quite possible it may be $0 and the MOOP much lower than plans the general public has access to. 6) If you opt out of the union plan, can you ever get back in? In most cases that answer is no. Opting out when first eligible means opting out for life. 7) What is the prescription coverage and is there a Donut Hole? If not, paying more for the union coverage than a Supplement might make more sense for Don, who has many health issues. 8) How important is it that you have access to both UPMC and AHN doctors and hospitals as well as other world class providers like Cleveland Clinic, Mayo Clinic, MD Anderson Cancer Center, and others?

I also want to make Lydia and Don aware if they start with the union Medicare Advantage Plan, they can opt out during any Annual Election Period and move to a Supplement without going through medical underwriting. Normally, those who choose an Advantage Plan must have their current and previous medical history reviewed by the Supplement company they apply with. Those who have or have had certain cancers, A-Fib, Crohn’s like Don has, Rheumatoid arthritis, an autoimmune disorder, heart disease, insulin dependent diabetes, among other diagnosis will be denied acceptance. However, when one loses employer or retiree coverage either voluntarily or involuntarily, they qualify for what is known as Guaranteed Issue. All Supplement companies must accept any applicant who has this right regardless of pre-existing conditions.

Too many other agents aren’t interested in putting in the time and effort it takes to help someone like Dan, who has so many variables, especially when there isn’t a commission in it for them. It’s quite possible, even probable unfortunately, that another agent outside of The Health Insurance Store would suggest opting out of the union coverage and into another Advantage Plan that would have a higher out of pocket costs, which in Dan’s case would be his MOOP that he would meet every year as long as he’s receiving infusion therapy. We meet and talk to people literally every day who have been given bad advice due to agent incompetence, lack of knowledge and training in the industry, or because they lack ethics. Sadly, making the wrong decision can cost someone tens of thousands of dollars and may not be reversable. This will never happen to those that choose The Health Insurance Store to help them with their Medicare and health insurance choices.

I have an appointment in a little over a month with Dan and Lydia. If I had to guess, my advice is going to be that they choose union coverage. If my hunch is correct, this option has a much lower MOOP than other HMOs or PPOs that most people have access to. It may also have enhanced drug coverage. If I do make that recommendation, there won’t be any commission for myself or the agency. We don’t charge for consultations so there will be zero compensation. And that’s okay. I estimate that 25% of the people we talk to are better off choosing an option they have because they’re retired teachers or union members, military veterans, or have access to insurance that’s a better overall value than what’s available on the open market.

Annual Election Period is right around the corner and starts on October 15th. If you want to make an appointment to go over your current plan and compare benefits and costs side by side with others, contact us. If you have questions regarding this topic or any others, you can call and ask to speak to an agent or email me personally at aaron@getyourbestplan.com.

Don’t forget to join our new Facebook group, Ask the Medicare Specialist where we offer exclusive content as well as the columns. Go to our website and click the banner at the top of the page to become a member.