Ask The Medicare Specialist

QUESTION:

Question from Shannon: I’m very much considering moving from my Supplement to an Advantage Plan like many of my friends have done. Premiums are less (almost $200 per month for me), they come with drug coverage that has no deductible which I pay every year, and supply lots of ancillary benefits, as you call them, that I don’t get. What’s your opinion?

ANSWER:

You’re certainly not alone in thinking about or actually pulling the trigger, especially if your Supplement premiums are over $200/month. Helping people choose and transition to Advantage Plans is a daily occurrence at The Health Insurance Store. However, I recommend you make an appointment to discuss the pros and cons with us first. It’s absolutely not right for everyone and there are several factors that need to be considered, including how much you might pay for medical services with an HMO or PPO. There’s also a good chance we can cut your current Supplement premiums by as much as 50% by moving you to a new letter plan and/or company which can be done year-round.

2023 marked the first time more people on Medicare had Advantage Plans than Supplements. Some of what led to this is the affect inflation has had on those living on fixed incomes. Add the increases in Part B (now $175/month) and Supplement premiums to the rising costs of groceries, fuel, and utilities and the fact is there are seniors on fixed incomes who simply can no longer afford a Supplement.

Another reason many are moving from Supplements or choosing Advantage Plans when they first go on Medicare is how attractive and generous the ancillary benefits are on select HMOs and PPOs: As much as $3,000 in comprehensive dental for everything from cleanings to dentures. Up to $400/year for glasses and a no cost eye exam, $2,500 for hearing aids, $400/year or more in Over the Counter (OTC) allowances, debit cards to pay for copays and groceries, and a free gym membership. It’s hard to believe just how much dollar value these benefits provide, especially considering almost none of them were offered prior to 2018.

Those who have been considering this move may want to make it now because I’m expecting many of these benefits to be less generous or even disappear starting in 2025. If you need some expensive dental work, get it in 2024. Load up your closet with those OTC products, get hearing aids if needed. Use every perk while you can. If you’re not getting most or all of them, reach out to us. Even though we’re not in the Annual Election Period, there is still a limited time to enroll in another plan.

But please, please, please don’t just move from a Supplement to the HMO or PPO your friend or family member is on. It’s so important to have a conversation with us prior to making the decision to disenroll from a Supplement. The number one reason is it can be permanent. Other than the three months prior and six months following one’s initial enrollment in Part B, with very few exceptions, Supplement companies are allowed to discriminate on who they accept into their plans. There is quite an extensive list of conditions and medications that automatically disqualify a Medicare beneficiary from acquiring a Supplement.

And for those who don’t know, coverage is vastly different between the two plans. Instead of having no bills for almost all medical claims with Supplements, Advantage Plan copays range from $10- $40 for an X-ray, to $200- $250 for CT scans, MRIs, and outpatient surgeries, from as little as $200 to as much as $1,800 for a six day or longer hospitalization, to thousands for Chemo, Radiation, a lengthy Skilled Nursing stay, as well as other infused or injected drugs.

How claims are approved and processed is also different. There are no prior authorizations necessary for virtually any medical service with Supplements. The patient and his or her doctor determine what is medically necessary and the best course of testing or treatment. Advantage Plans require approval for CT scans, MRI’s, outpatient surgeries, home health care, and more before those services can be delivered and claims paid. Dealing with that can be a hassle and is probably the biggest complaint we get about Advantage Plans.

Access to medical providers also works differently. There are no networks with Supplements, meaning practically every doctor and all non-VA hospitals can be used at no additional cost. This isn’t the case with Advantage Plans. Most have very good networks in Pennsylvania. However, HMOs provide very little access to care outside of the state apart from West Virginia and the Cleveland Clinic. And just because you choose a PPO doesn’t mean claims will be paid by your Advantage Plan company at an out of network provider the same as if you were in network. It’s not as simple as just making an appointment like you do near home.

I don’t want anyone to think I’m discouraging enrollment in an HMO or PPO. It’s an excellent option as long as there is an understanding of both the rewards and the risks they pose. Too many agents don’t explain it properly or at all.

If you would like to make an appointment for a no cost consultation or have a question regarding information in this column or any other related to Medicare, give the office a call or email me personally at aaron@ getyourbestplan.com.

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