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 to be the only option to live pain-free. To say 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 him more medications, which exacerbated his problems. In addition to his medical challenge, the Plan denied him medical tests, which ultimately could have 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 best for him to switch to a Medicare Supplement plan (MediGap), 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 around for the best of the best, anywhere in the country. We chose a “Supplemental Plan F” with an insurer that would allow you to switch between a lower and higher cost plan WITHOUT demonstrating insurability (if you decided in the future maintain the Supplemental Plan after your current medical puzzle was resolved).
Could I have avoided this problem in the first place? Possibly. Here are a couple of mistakes 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 insurer, many times compensated by W2, commissions and/or bonuses) or work with an “independent career agent” (1099 contractor with the insurer and provided of contacts). This last term is very confusing to me. They are classified as independent, but if they write an application with another carrier because it was the right thing to do for the beneficiary, their contract can be terminated. What incentive does the agent have to be impartial if he loses his primary 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” supplemental MediGap plans without certification.
***Go directly to the insurance company. If something goes wrong, it will be helpful to have an advocate on your side, especially one you can see and who lives/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 pros and cons of ALL plans and will be able to convey this information so you can make an EDUCATE decision. They receive compensation from insurance companies, but have no loyalty to any particular company. Also be on the lookout for companies 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-biased” if he is contractually obligated 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 eliminating a valuable person who will fix problems if any arise, while giving you additional peace of mind throughout the process.
MISTAKE #2: Choose a Medicare Advantage plan that requires you to get approval from the insurance company before undergoing a procedure/test.
SOLUTION #2: When comparing plans, see the ‘Summary of Benefits’. These must be published by all carriers and must be similar and easy to compare.
MISTAKE #3: Not paying attention to the ‘maximum outlay’ (MOOP) limit. All Medicare Advantage plans have a MOOP, and many agents discuss it as they help you choose your plan. However, if a catastrophic medical issue arises (cancer, organ transplant, extended stay in a skilled nursing facility, etc.), there is a good chance you will reach your MOOP, so you want to make sure it is as low as possible. The reason: Chemotherapy and anti-rejection drugs are considered outpatient Part ‘B’ drugs, not prescription Part ‘D’ drugs, and many plans only pay for 80% of Part B drugs. So Therefore, you would be stuck with 20% and they are very expensive.
SOLUTION #3: Compare, compare, compare and choose a Plan with a lower MOOP.
MISTAKE #4: Choose a plan only because the drug copays are slightly lower. Many smaller insurance companies will attract you to their plan with very low copays on their drug formulary, but they have a smaller network of doctors/facilities to choose from. The problem is that if a medical problem arises, you may be locked into the smaller network of doctors/facilities until Medicare Annual Open Enrollment.
SOLUTION #4: If you are having trouble paying 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 mention this and guide you, or go to https://secure.ssa.gov/i1020/start. When getting help with your medications, you can choose the best Plan based on other options (your network size, authorization rules, doctor/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 have the misconception that with a PPO plan they can go to any doctor or facility they choose. In reality, PPO plans still have a network of doctors/facilities that you must stay with to get lower costs. The biggest difference between a PPO and an HMO is that with a PPO you will not have to get a “referral” to see a specialist. With an HMO, you must obtain a referral. In order to choose ANY doctor/facility in the country that accepts Medicare, you should consider a Medicare Supplement Plan (MediGap).
I’ve seen the most mistakes and solutions when it comes to choosing Medicare Advantage health plans. Outside of California, additional varieties of plans exist and may present additional challenges.
What happened to my client, you ask? Since I keep in constant contact with my clients, in June I was very happy to hear him exclaim the great news. Using the same test that his previous Medicare Advantage Plan denied him, two doctors at a major Los Angeles medical group identified the problem. He was slowly losing cerebrospinal fluid and was dangerously close to having none left. With a quick outpatient procedure, they basically lasered the area of the leak, replaced his cerebrospinal fluid, and he is healthier, happier, and better than ever! Since you are well now, we will review your coverage during Medicare’s Annual Open Enrollment (October 15 – December 7, 2012) and decide whether to keep you on the Supplement or switch you to a Medicare Advantage Part C Plan.
As an insurance agent for many years, I have stories like this and many more. Compassionately, our profession helps navigate the best options, explain the pros and cons based on our clients’ individual needs, and offer peace of mind. Plans change each year and your health/financial status may change too, so it’s a good habit to make a comparison each year. In closing, choose a good local and independent insurance agent, educate yourself and stay well informed.
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