It was a heartbreaking reunion… sitting with a couple at the kitchen table with tears streaming down their faces. He was very sick, losing weight rapidly due to digestive problems, and his constant migraines were so painful that ending his life seemed like the only option to live without pain. To say that they were afraid would be an understatement. Doctors associated with your current Medicare Advantage Plan (Medicare Part C) were unable to diagnose the problem. They only prescribed more medication, which exacerbated his problems. In addition to his medical investigation, the Plan denied medical tests, which could have finally diagnosed his problem. It was October 2011, and through tears they painfully asked, “What are our options?”
In this case, together we decided that it was in his best interest to switch to a Medicare Supplement (MediGap) plan, which would allow him to go to any doctor or facility that accepted Medicare, along with a “stand-alone Part D Prescription Drug Plan.” . .” It was important that you be able to shop for the best of the best, anywhere in the country. We chose a “Supplement Plan F” with an insurer that would allow you to switch between a lower and higher cost plan WITHOUT testing insurability (if in the future , you decide to keep the Supplemental Plan after your current medical problem is resolved).
Could I have prevented this problem in the first place? Possibly. Here are a couple of errors I’ve seen, along with solutions, to help you choose the right option for YOU:
MISTAKE #1: Who are you working with?
* Work with a “captive insurance agent” (direct employment with the carrier, many times are compensated by W2, commissions and/or bonuses) or work with an “independent career agent” (1099 contractor with the carrier and provided of tracks) . This last term is very confusing to me. They are classified as independent, but if they write an application with another company because it was a good fit for the beneficiary, their contract can be terminated. What incentive does the agent have to be impartial, if he will lose his main source?
** Another mistake is working with an agent who is not certified to market all types of Medicare health plans. They can only market “some” MediGap supplement plans without certification.
*** Go directly to the insurance company. If something goes wrong, it helps to have an advocate on your side, especially one you can see who lives or works in your community.
SOLUTION #1:
* Choose an independent insurance agent who represents more than one insurance company. Because? Because independent agents will know the ins and outs of ALL plans and will be able to pass this information along so you can make an EDUCATED decision. They receive compensation from insurance companies, but have no loyalty to any particular company. Also watch out for carriers forcing their ‘independent agents’ to sign an exclusive agreement. I have seen this happen with ‘Dual Eligible Plans’ (Medicaid/Medicare Plans). Again, how can the agent be ‘non-biased’ if they are contractually bound to market only one Plan?
** Choose a “certified” Medicare insurance agent who can market Part C, Part D and MediGap plans. They have additional training and supervision.
*** When you go directly to the carrier, you are removing a valuable person who will fix problems if any arise, while giving you additional peace of mind throughout the process.
MISTAKE #2: Choosing a Medicare Advantage plan that requires you to get approval from the insurance company before having a procedure/test.
SOLUTION #2: When comparing plans, please refer to the ‘Summary of Benefits’. All operators must publish them and they must be similar and easy to compare.
MISTAKE #3: Not paying attention to the “maximum out-of-pocket” (MOOP) limit. All Medicare Advantage plans have a MOOP and many agents overlook it when helping you choose your plan. However, should a catastrophic medical problem arise (cancer, organ transplant, extended stay in a skilled nursing facility, etc.), there is a good chance that you will reach your MOOP, so you want to make sure it is as low as possible. possible. The reason: Chemotherapy and anti-rejection drugs are considered Part ‘B’ outpatient drugs, not Part ‘D’ prescription drugs, and many Plans only pay for 80% of Part B drugs. So you’d be on the hook for 20% and are very expensive.
SOLUTION #3: Compare, compare, compare and choose a Plan with a lower MOOP.
MISTAKE #4: Choosing a plan just because drug copays are slightly lower. Many smaller insurance companies will lure you into their Plan with very low copays on their drug formulary, but have a smaller network of doctors/facility to choose from. The problem is, should a medical problem arise, you may be locked into the smaller network of doctors/facility until Medicare’s annual open enrollment.
SOLUTION #4: If you are having trouble paying your prescription drug copays and your income/assets are low enough, you may be eligible for Extra Help through Social Security. A good insurance agent will mention this and walk you through, or visit https://secure.ssa.gov/i1020/start. When getting help with your medication, you can choose the best Plan based on other options (the size of your network, authorization rules, convenience of the doctor/facility, additional optional benefits, etc.)
MISTAKE #5: Choosing a plan because you want a PPO plan and not an HMO.
SOLUTION #5: Many people are under the misconception that with a PPO plan they can go to any doctor/facility they choose. In reality, PPO Plans still have a network of doctors/facility that you should stay with to get the lowest costs. The biggest difference between a PPO and an HMO is that with a PPO you won’t have to get a ‘referral’ to see a specialist. With an HMO, you must get a referral. In order to choose ANY doctor/facility in the country that accepts Medicare, you should consider a Medicare Supplement Plan (MediGap).
I have seen most of the mistakes and solutions when it comes to choosing Medicare Advantage health plans. Outside of California, there are additional varieties of Plans and there may be additional challenges.
What happened to my client, you ask? Since I keep in constant contact with my clients, in June I was overjoyed to hear him exclaim the great news. Using the same test that was denied to him by his previous Medicare Advantage Plan, two doctors from a major Los Angeles medical group identified the problem. He was losing spinal fluid slowly and was dangerously close to having none left. With a quick outpatient procedure, they basically laser taped the area of the leak, replaced his spinal fluid, and he is healthier, happier, and better than ever. Since you are doing well now, we will review your coverage during Medicare’s Annual Open Enrollment (October 15 – December 7, 2012) and decide whether to keep you in the Supplement or switch to a Part C Medicare Advantage Plan.
As an insurance agent for many years, I have stories like this and many more. With compassion, our profession helps navigate the best options, explains the pros and cons based on our clients’ individual needs, and offers peace of mind. Plans change every year and your health/financial status can change too, so it’s a good habit to compare each year. In closing, choose a good local independent insurance agent, educate yourself and stay well informed.