It was a heartbreaking meeting… sitting with a couple at their kitchen table as tears streamed down both of their faces. He was very ill, rapidly losing weight from digestive problems, and his constant migraine headaches were so painful, ending his life seemed to be the only option to live pain-free. To say they were afraid would be an understatement. Physicians associated with his current Medicare Advantage Plan (Medicare Part C) could not diagnose the problem. They only prescribed more drugs, which exacerbated his issues. On top of his medical puzzle, the Plan denied medical tests, which might have ultimately diagnosed his problem. It was October 2011, and through their tears, they painfully asked, “What are our options?”
In this case, together we decided it was in his best interest to switch to a Medicare Supplement (MediGap) Plan, which would allow him to go to any physician or facility that accepted Medicare, along with a ” Stand alone Part D Prescription Drug Plan.” It was important that he be able to seek the best of the best, anywhere in the country. We chose an “F Supplement Plan” with a carrier that would allow him to switch between a lower and higher cost plan WITHOUT proving insurability (if in the future, he decided to maintain the Supplement Plan after his current medical puzzle was solved).
Could he have avoided this problem in the first place? Possibly. Here are a couple of mistakes I have seen, along with the solutions, to help you choose the right option for YOU:
MISTAKE #1: Who are you working with?
* Working with a “captive insurance agent” (direct employment with the carrier, many times they are compensated by W2, commissions and/or bonuses) or working with an ‘independent career agent’ (1099 contractor with the carrier and provided with leads). The latter term is very confusing to me. They are classified as independent, yet if they write an application with another carrier because it was right for the beneficiary, their contract may be terminated. What incentive does the agent have to be non-partial, if they will lose their lead source?
** Another mistake is working with an agent that is not certified to market all types of Medicare health plans. They can only market ‘some’ MediGap’ supplement plans with no certification.
*** Going directly to the insurance carrier. If something goes sideways, it will come in handy to have an advocate on your side especially one you can see and lives/works in your community.
* Choose an independent insurance agent that represents more than one insurance carrier. Why? Because independent agents will know the pros and cons of ALL the Plans and be able to relay this info so you can make an EDUCATED choice. They receive compensation from the insurance carriers but do not have allegiance towards any particular company. Also be on the look out for carriers that force 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-partial’ if they are contractually obligated to only market one Plan?
** Choose a ‘Certified’ Medicare insurance agent that is able to market Part C, Part D and MediGap Plans. They have additional training and oversight.
*** When you go to directly to the carrier, you are eliminating a valuable person who will troubleshoot problems if any should arise, while providing you additional peace of mind throughout the process.
MISTAKE #2: Choosing a Medicare Advantage Plan that requires you to obtain the insurance company’s approval before having a procedure/test.
SOLUTION #2: When comparing Plans, turn to the ‘Summary of Benefits’. All carriers must publish these and they must be alike 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 glaze over it while helping you choose your Plan. However, should a catastrophic medical issue arise (cancer, organ transplant, long stay in a skilled nursing facility, etc.), there is a good chance you will hit your MOOP so you want to make sure it’s the lowest possible. The reason: chemotherapy and anti-rejection drugs are considered Part ‘B’ out-patient drugs, not Part ‘D’ prescription drugs and many Plans only pay 80% of Part B drugs. Therefore, you would be on the hook for 20% and they are very expensive.
SOLUTION #3: Compare, compare, compare and choose a Plan with a lower MOOP.
MISTAKE #4: Choosing a Plan just because the drug co-pays are slightly lower. Many smaller insurance companies will lure you to their Plan with very low co-pays on their drug formulary but have a smaller network of doctors/facilities in which to choose. The problem is, should a medical issue arise, you may be locked into the smaller network of physicians/facilities until Medicare’s Annual Open Enrollment.
SOLUTION #4: If you’re having trouble paying for prescription drug co-pays and your income/assets are low enough, you may be eligible for Extra Help through social security. A good insurance agent will bring this up and guide you, or go to https://secure.ssa.gov/i1020/start. By obtaining help with your medication, you can choose the best Plan based on other options (the size of their network, authorization rules, physician/facility convenience, 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 actuality, PPO Plans still have a network of doctors/facilities you must stay in to obtain the lower costs. The biggest difference between a PPO and HMO is with a PPO, you will not have to obtain a ‘referral’ to see a specialist. With an HMO, you must obtain a referral. To be able to choose ANY physician/facility in the country that accepts Medicare, you should consider a Medicare Supplement (MediGap) Plan.
I have seen most mistakes and solutions when it comes to choosing Medicare Advantage Health Plans. Outside of California, there are additional varieties of Plans, and 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. With the same test that was denied by his previous Medicare Advantage Plan, two physicians from a major Los Angeles medical group pinpointed the problem. He was slowly leaking spinal fluid and was dangerously close to having none remaining. With a quick out-patient procedure, they basically laser-glued the leaking area, replaced his spinal fluid and he is healthier, happier and better than ever! Since he is now well, we’ll be reviewing his coverage during Medicare’s Annual Open Enrollment (October 15 – December 7, 2012) and deciding whether to keep him on the Supplement or switch him 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 to navigate the best options, explain the pros/cons based on our clients’ individual needs and offer peace of mind. Plans change every year and your health/financial status may change also, therefore it is a good habit to make a comparison each year. In closing, choose a good, local, independent insurance agent, be educated and stay well-informed!