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True Medicare Stories2021-08-14T00:19:31-07:00

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Bennett, a Veteran, Gets Part B Refund, Dental, Vision2022-03-10T00:51:57-07:00

At 72 years old, Bennett feels better than he has in years and sees the doctor only on rare occasions. He lives near a VA medical center and plans to get care there when needed in the future.

He is well suited for a Medicare Advantage Plan with a Part B reimbursement. There are several in his community, but the two plans with the highest reimbursement offer $100 and $95 back. This money will be credited to his social security check to take some of the sting out of that $170.10 monthly Part B payment (2022 price). Refund amounts offered on these plans vary widely by county and are not available in every county.

Both plans he considered have a $0 monthly premium, so there was no cost to Bennett to enroll. The plan reimbursing $100 does not include dental or vision care—both services that Bennett needs. The plan reimbursing $95 includes $1000 in dental coverage with $0 patient copays, plus $200 in vision coverage, so that’s the one Bennett chose.

Since Bennett has drug coverage through the VA, he could have chosen a Medicare Advantage plan without prescription drugs, but the Part B refund amounts for those plans in his county were just $30 and $50, so he opted to get a Medicare Advantage plan with prescription drug coverage in order to get the greater refund. He is unlikely to use the plan for healthcare services or prescriptions since he intends to use the VA for both.

Medicare Advantage plans with Part B refunds are heavily advertised so many people have questions about them, but they are not suitable for many people. They are open to anyone who has Part A and Part B and resides in the service area of the plan, but they were designed primarily for Veterans and others who intend to seek care outside of the Advantage plan. Copays for specialists, hospital stays, and all other services are much higher with the Part B refund plans than with other Advantage plans.

Veterans and those who have coverage other than the Medicare Advantage plan’s network and intend to get care outside the plan will appreciate the credit to their social security check. Those who receive frequent care through the plan will spend so much more on copays for services that their payments could exceed the Part B refund received. Still, it is worth seeing what’s available in your county and determining whether it is a good option for you.

People who receive help from their state’s Medicaid program for low income earners are not eligible for Part B premium refunds because they don’t usually pay the Part B  premium at all. The Medicare Advantage plans for those on both Medicare and Medicaid are waaaaay more generous than these plans with the Part B refund.

Yvette: No up front costs with Medicare Advantage2021-10-24T04:01:34-07:00

Yvette is 73 and has enjoyed the freedom of a Medicare Supplement plan for many years, but she no longer works and has been struggling to pay the premium. It started out reasonable, but with years of increases is now about $260 per month—an amount that Yvette finds a little uncomfortable. She does have some medical issues, but still thinks she’ll save money with Medicare Advantage.

Leaving a Medicare Supplement plan with no provider network was a worry to Yvette at first, but we were able to find a Medicare Advantage plan with all of her most important providers in network. The Advantage plan includes drug coverage, so she won’t need to pay separately for that, and it also includes dental, vision, and hearing benefits.

The monthly premium for her Medicare Advantage plan is $0 per month, and it has a $0 medical deductible and a $0 drug deductible. The Maximum Out-of-Pocket limit is $3,300 for Yvette’s plan, so if she ever spends this much on copays and coinsurance for Part A and Part B services during a calendar year, the insurance company will pay her remaining out-of-pocket costs for the rest of the year. (Maximum out-of-pocket amounts vary widely by county. The highest legal maximum in 2021 is $7,550 for an HMO and $11,300 for a PPO. Many counties have plans with lower out-of-pocket maximums than this.)

Considering her definite costs with the supplement were over $3300 per year, she feels good about switching to a plan that she’ll pay for as she uses. Getting the low max out-of-pocket limit is a comfort. If she has a terrible health year, then she’ll be spending no more than what she’d spend every year with her supplement. If she has a healthy year, then she will have low healthcare costs.

Medicare Advantage plans don’t allow the flexibility that Medicare Supplements do, but they make good financial sense for certain people in some geographic regions. Yvette understands that her new plan will not be as convenient or flexible, but her tighter budget necessitates the change.

Find out how much a medicare solution that meets your needs will cost YOU!

Lorilynn: Medicare Supplement Plan F Has Paid All Her Medical Bills2021-11-14T04:10:18-07:00

Lorilynn is 72 and has had a Medicare Supplement Plan F for about seven years. The price has increased a little each year and is now about $240 per month, so she decided to check into other options.

She has Parkinson’s, diabetes, heart disease, and is prone to falling. On a recent vacation, she fell and bumped her head and needed helicopter transport to a trauma center for brain surgery. She sees a physical therapist four times per week. She has had many other medical adventures in recent years and has never received a bill for any of it. Her Plan F pays for everything. In addition, she was able to spend a whole summer with her grandchildren 2,000 miles away and know she could seek medical care if needed. There are no provider networks with Medicare Supplements; enrollees can see any provider in America who accepts Medicare.

Because Lorilynn is not healthy enough to qualify for a different Medicare Supplement, I recommended that she keep her Plan F. Eventually, it may become too expensive for her and she can switch to Medicare Advantage. In her county, physical therapy copays are $40 on Medicare Advantage plans, so switching while she is getting physical therapy four times per week is not a smart move.

There are no date restrictions with MediGap plans (another name for Medicare Supplement). She can drop her supplement whenever she chooses. However, she can only add a Medicare Advantage plan in the Fall during Annual Election Period, for a January 1 start date. If she chooses to move to Medicare Advantage in the future, she will want to end her supplement on December 31 of the year before she starts her Advantage Plan on January 1.

Because Lorilynn started Medicare before 2020, she is eligible for a Medicare Supplement Plan F, which is being phased out and cannot be purchased by new-to-Medicare enrollees. Plans G and N are the most common Medicare Supplement plans for new enrollees.

Rodney: Turning 65, Medicare Supplement2021-11-14T04:23:03-07:00

Rodney is turning 65 and will continue to work in his business as much as he chooses. He doesn’t have any health insurance currently. After learning about  Medicare Advantage plans and Medicare Supplement plans, he much prefers Medicare Supplements so that he is not restricted to a network of providers. He wants to be able to go to any doctor he chooses without needing a referral or worrying about whether the provider is in network.

He is starting Medicare after January of 2020, which makes him ineligible for Plan F, so Plan G and Plan N are his top choices for Medicare Supplement plans. He has an open enrollment period around his 65th birthday so he won’t have to answer medical questions to apply. That’s good news for Rodney because he wouldn’t qualify medically for a MediGap plan since he had a heart attack recently.

Rodney will need to pay his Part B premium of $170.10 (2022 price), in addition to a Medicare Supplement Plan G monthly premium of about $150 for a 65-year-old male tobacco user in his state. He will also be subject to the $233 Part B deductible at the beginning of each calendar year, to be paid as he gets treatment during the year. These costs will be predictable, regardless of what happens with his health during the year. Whether he has a stroke or goes all year with just the sniffles, his healthcare costs will be the same: the monthly premium times twelve, plus the Part B deductible.

Because drug coverage is not included in Medicare Supplements, he will pay separately for a drug plan. Dental, vision, and hearing coverage is not included in Medicare Supplements either so he could choose to buy a separate plan for that.

Those who don’t want to pre-pay healthcare in advance might like how Medicare Advantage works better, with little-to-no upfront costs. Instead, costs are incurred as medical services are received during the year. This makes budgeting hard because you can’t predict what will happen during the year, but healthy people can often save money with a Medicare Advantage plan. (Those with critical illnesses who need frequent treatments will usually spend more with a Medicare Advantage plan.)

Carrie: Turning 65, Medicare and Medicaid2022-03-10T02:25:26-07:00

Carrie is turning 65 soon but doesn’t plan to retire until she is at least 66, maybe older. She currently has no health insurance. She is hesitant to sign up for Medicare because she can’t afford the Part B monthly premium of $170.10 (2022 price).

She is a Medicaid recipient in her state, and we determined that her current level of Medicaid does qualify her for special Full Benefit Dual Eligible Medicare Advantage plans that include very generous benefits with $0 copays for nearly everything. This also means that Medicaid will be paying her Part B premium. She will be able to start this healthcare coverage the month she turns 65, and it will be a real boon to Carrie because she is developing cataracts and will need surgery within the next year.

It is likely that Carrie will lose this level of Medicaid help when she returns to work (after the pandemic) and is no longer receiving unemployment. If that’s the case, she may no longer qualify for the special Dual Eligible Medicare Advantage Plan, and will need to enroll in a plan for the general population.

Harry and Frannie: Medicare Advantage PPO vs HMO2021-10-20T02:06:39-07:00

Harry and Frannie had been on the same Medicare Advantage PPO plan for many years. Frannie now has dementia so they don’t travel like they used to and live a simple life close to home. They have long-time doctors who they like well. Because they no longer need the flexibility of a PPO, we were able to switch them to a Medicare Advantage plan with an HMO while staying with their same insurance company. They can go to their same doctors, but now have lower copays across the board and also have a lower maximum out of pocket cost.

HMOs always cost less than PPOs, but PPOs always offer more flexibility. If you need the freedom to see out-of-network doctors, then a PPO is the solution. PPOs are often helpful to people living in rural communities, those who travel often, and those who want to be treated by out-of-network specialists for specific medical issues.

If you find all Medicare Advantage plans too restrictive, then a Medicare Supplement (MediGap) plan might work better for you. These allow you to see any provider in the United States who accepts Medicare, and don’t have the rules and regulations that Medicare Advantage plans have.

Geoff: Parts A and B only, Medicare Advantage2021-10-17T12:25:33-07:00

Geoff is now 79 years old and has dementia. He started Medicare Parts A and B when he was 65 and also continued working at least part time until he was 75.

When he lost his group health insurance, he had just original Medicare parts A and B, so he was covered at about 80% for hospital and doctor expenses plus some lab and diagnostic costs. Geoff and his wife learned how much his 20% could cost the year he was presented with a $6,000 hospital bill and a $2,000 ambulance bill.

He is now on a Medicare Advantage plan that costs $0 per month for the premium. He pays a co-pay each time he uses a medical service, but his financial risk each calendar year is capped at his plan’s maximum out-of-pocket amount. (This amount does not include the cost of prescriptions or money spent on dental, vision, and hearing services.)

The vast majority of people do not incur enough costs to reach their Maximum Out-of-Pocket (MOOP) costs each year, but Medicare Advantage plan members should always know their MOOP so they know their financial risk. The highest legal limit for MOOP in 2021 is $7,550 for HMOs and $11,300 for PPOs, but plans in many parts of the country have MOOPs that are lower than this.

The fastest way to reach the Maximum Out-of-Pocket limit on a Medicare Advantage plan is to get cancer. Most plans pass 20% of the costs of chemotherapy and radiation on to the patient. Cancer treatments often spread over more than one calendar year so some people reach their MOOP limit two years in a row. A cancer insurance plan pays cash to the patient upon a cancer diagnosis and can bring peace of mind to the policy holder.

June: Group insurance, Medicare Supplement vs. Medicare Advantage2021-11-03T02:06:21-07:00

June is 73 and still working part time for her county but expects to retire soon. She started Medicare parts A and B when she was 65 and has also had group health coverage through the county all these years. She will lose her group insurance when she retires, so she is exploring Medicare Advantage and Medicare Supplement plans.

The prices shared below are specific for the county where June lives, and factor in the costs of her specific prescriptions and medical needs. Your own scenario could look very different than this, but you can still learn from this analysis.

Since she has had creditable coverage  through her employer, she will not need to pay a late penalty for her Part D. She has a guaranteed issue window for a Medicare Supplement (meaning she won’t need to answer medical questions when applying), so we priced that option. She takes some expensive medications that would cost about $1163 per year MORE on a stand-alone Part D plan that she would need to buy with a MediGap plan than these same drugs would cost on a Medicare Advantage plan that includes prescription drugs. June is used to using in-network providers and no longer travels since her husband has Alzheimer’s. Thus, the flexibility that Medicare Supplements offer is not important enough to her to pay all the extra costs.

We weighed the DEFINITE costs of the Med Sup package against the POSSIBLE costs of the Medicare Advantage plan and June decided to go with Medicare Advantage to save money up front.

Medicare Supplement Costs for June

  • Plan G $116.77 per month = $1401.24 for 12 months
  • Drug Costs (premium + medications) = $2243 for 12 months
  • DVH Plan ($1500 benefit level) = $596.04 for 12 months
  • Total annual costs of $3,143.58 with Med Sup, not including Part B premium of $148.50 per month or the Part B deductible of $203 per year.

Medicare Advantage costs for June

  • Medicare Advantage with Prescription Drugs that includes DVH coverage: $1080 per year.
  • This includes the cost of her prescriptions but does not include co-pays that she’ll make when she visits a specialist and receives other treatment and testing.
  • The maximum out-of-pocket for her plan is $4,900, but she is not likely to reach this amount unless she gets cancer or has multiple stays in the hospital.

Some employers require employees over 65 years to enroll in Part B insurance in order to stay in the group plan; however, other employers consider Part B optional. In this case, June has been paying her Part B premiums unnecessarily for 8 years—well over $10,000 that she didn’t need to spend.

Each senior who has group insurance needs a thorough analysis to make a smart decision about group insurance vs. Medicare. Some employer groups offer choices and others do not. Some people will determine Medicare is a better value and others will come to the opposite conclusion. It really depends on the costs of group insurance and the costs of a Medicare solution in your community.

If you need help making a decision about group insurance, make an appointment so we can weigh all the costs and come up with a plan that’s best for your situation.

Jeremy: Group health insurance, delay Part B2021-10-17T12:31:50-07:00

Jeremy worked two full-time jobs for many years but chose to retire from his main job when he turned 65. He plans to continue at his second full-time job, where he is eligible for group health insurance, until he’s about 68. Because of this, Jeremy could have delayed his Part B start date but he didn’t know that and signed up for Part B to start the month he turned 65. (Some employers require employees to start Part B when they turn 65, but Jeremy’s employer doesn’t.)

He was signed up to start paying for group health insurance through his employer and to also start paying for Part B. Since his group health plan doesn’t require him to have Part B, this would be an unnecessary expense so he decided to delay his Part B enrollment until he lost group coverage. However, Medicare had planned to charge him a three-month penalty (about $445), so we decided to more closely compare his group coverage to Medicare to figure out which was best.

We did a three-way call with his human resources director to ask about costs through the group health insurance. The premium, copays, deductible, and maximum out-of-pocket costs of the group plan were higher than the Medicare plan, so Jeremy decided to drop the group coverage and just have Medicare.

We signed him up for a Medicare Advantage plan that includes prescription drug coverage plus dental, vision, and hearing coverage, for a $0 monthly premium. He occasionally sees a specialist and will pay a modest copay when he does.

Freddie: Parts A and B Only, no drug plan, late penalty, Extra Help, dental2021-10-19T23:19:11-07:00

Freddie was 72 years old with Medicare Parts A and B but no Medicare Advantage or Medicare Supplement plan and no Part D coverage for drugs. He can’t remember the last time he went to the doctor and he takes no prescriptions.

He needs some major dental work done, so we identified the Medicare Advantage and Prescription Drug plan in his county that offers the most generous dental benefits with $0 copays. (Some Medicare Advantage plans have a dental benefit that sounds generous but actually requires a hefty co-insurance, meaning that the patient pays a large percentage, and the insurance company pays the rest.)

Two-thirds of Medicare Advantage plans have no monthly premium and they are available in most counties. Members pay copays or coinsurance as they use medical services during the year. Those who don’t need medical services have protection without paying a premium for it, but the coverage is there in case it’s needed.

Since Freddie waited seven years past the time he was eligible for Part D to add prescription drug coverage, he has to pay a late enrollment penalty of about $30 per month. Medicare beneficiaries who go more than 63 days after the end of their Initial Enrollment Period without Part D or other creditable prescription drug coverage may owe a late penalty.

The penalty amount changes a little bit each year but is currently about 33 cents per month for every month late. It is owed as long as you have Part D (usually for life). Those with income low enough to qualify for either Medicare’s Extra Help program or for Medicaid will have the late fee waived.

Doug: Group health insurance, turning 652021-07-21T04:05:04-07:00

Doug was turning 65 and exploring his Medicare options. He retired a couple of years ago, has been getting social security checks, and was added to the group health insurance plan through his wife’s employer. Adding him to her plan costs several hundred dollars per month in additional premium.

We reviewed all the details about Medicare Advantage and Medicare supplement plans, and Doug decided Medicare Advantage is a better fit for him. Paying the $148.50 per month Part B premium (2021 price) and getting a Medicare Advantage and Prescription Drug plan that includes dental, vision, and hearing benefits will cost him substantially less than what his wife’s employer is charging, so he plans to drop her group health insurance and just have Medicare Advantage.

Juan: Parts A and B only, financial risk, no drug plan, late penalties2021-11-03T01:51:54-07:00

Juan, a 68-year-old retired engineer had Original Medicare parts A and B, but no Medicare Advantage or Medicare Supplement plan, and no Part D coverage for drugs.

He had come to the conclusion that he probably needed Part D for his prescriptions. However, he was emphatic about not wanting any additional coverage except Medicare Parts A, B, and D. He definitely wasn’t willing to pay for additional coverage so I knew a Medicare supplement was out.

I entered his medications into my software and priced some Part D plans, all of which had a modest monthly premium. Then I asked him why he would consider paying a premium for only Part D when he could instead have a Medicare Advantage with Prescription Drug plan for a $0 premium that also included benefits for dental, vision, hearing, and more.

He was completely confused as to how he could get substantially more benefits for a $0 monthly premium, and asked question after question of me. I explained that if he has a Medicare Advantage plan, that means the Medicare department of the government pays his insurance company a fixed rate per month and his insurance company is responsible for providing all his care under Part A and Part B. The insurance company can do this more cost effectively than the government can, so they throw in additional benefits for no extra charge in order to encourage customers to sign up with them.

Medicare Advantage plan participants have more restrictions than those on Original Medicare or a Medicare Supplement. With those restrictions come extra benefits like drug coverage, dental, vision, and hearing. Some Medicare Advantage plans now offer chiropractic or acupuncture care, transportation to and from medical appointments, over-the-counter benefits, and more.

Because Juan delayed his Part D coverage for three years after he was eligible, the government imposed a late enrollment penalty that he will need to pay for the rest of his life or as long as he has Part D. This is why it’s important to sign up for Part D when you are eligible if you are not covered under any employer’s group health insurance. Those who have other coverage at least as good as Medicare (called “creditable coverage”) have the option of delaying Part D until their other coverage ends.

Juan now has drug coverage as part of a Medicare Advantage plan that subsidizes the cost of his insulin, and his financial risk in a calendar year is limited to the Maximum Out of Pocket amount stated by his plan. This is much less risky than what he had before because Original Medicare parts A and B only pay about 80% of costs, leaving consumers exposed to that 20% risk, which has no cap or maximum. That 20% can become exorbitant if there is a serious health event.

Timothy: Overpaying for a mediocre Medicare Advantage plan, no annual review, bad agent2021-10-17T13:04:35-07:00

At 72 years old, Timothy had been on the same Medicare Advantage with Prescription Drug plan for 7 years. He was happy with the plan and very loyal to the insurance company because he felt they had treated him well over the years.

When I looked up his plan, I asked him why he had a plan with an $87 per month premium when there were comparable plans available for $0 per month. As I compared the features of two plans offered by the SAME insurance company side by side, I noticed that the $0 per month plan had lower co-pays across the board, a lower drug deductible, greater dental and vision benefits, and was a better plan in every way except one: the $87 per month plan allows members to visit a much larger of network of providers for a higher fee (both plans are PPOs).

I asked Timothy if that was still an important feature to him and he told me it wasn’t. He asked me why the insurance company hadn’t contacted him to tell him there was a plan that would save him money. I told him “It’s not the insurance company’s job to save you money. That’s your agent’s job. If your agent hasn’t been contacting you each Fall to review changes to your plan, changes to your health, and a discussion of new plans coming to your county, then you need a new agent.” Timothy now has a new agent!

Annual Medicare reviews are important, especially for Medicare Advantage Plans and Prescription Drug Plans. Your healthcare needs and priorities will change over time, your prescriptions will change, your plan costs and benefits will change, and your plan’s network of providers will change, and the drug formulary will change. That’s why it’s important to do a Medicare review each fall to see if there is something better for you coming up for the new year. Any changes made will be effective January 1.

Help is free!

I’m Laraine Sookhoo and I’m passionate about helping you understand your Medicare options so you can get the most out of your Medicare benefits. My help is free, so book an appointment to get started!

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