The bad news: Medicare, along with all of its parts, is a bit complicated and confusing, like most things involving health insurance.
The good news: You know when you’re turning 65. So you know how many months or years you have to educate yourself about your options and the add-ons you can buy to cover the costs Medicare won’t. And there are numerous free resources to guide you, including help from local insurance brokers, who don’t charge commissions or fees, and from the state government and entities, such as AARP.
“It can be overwhelming,” Shalonda Cuyler-Cave, a licensed broker with Advanced Insurance Solutions in Aurora. “When you’re doing senior plans, you have to go through A to Z.”
Some quick facts first: When people turn 65, they’re eligible for Medicare, a national health insurance program for senior citizens. (Medicare isn’t to be confused with Medicaid, which is health insurance for low-income folks.) You generally don’t have to pay anything additional for what is called Medicare Part A: most people pay into it during their working years, or their spouse’s working years.
Medicare Part A covers hospitalization (about 80 percent of the first 60 days) and some home health and hospice care costs. Medicare Part B pays for some doctor bills and expenses like outpatient visits, lab test and X-rays, physical therapy and ambulances. For Part B, the standard monthly premium is $134, although it can be higher or lower depending on income and Social Security benefits.
Part C is a private insurance option that you can buy to pay more of your expenses or co-pays not covered by A and B. Part C also can cover expenses such as eyeglasses, dental visits, hearing aids and prescriptions, depending on the plan you choose. Part C advantage and supplement plans in Greater Cleveland may carry no additional monthly premium or cost a couple hundred dollars per month, depending on the coverage you choose. Some of those won’t include Part D prescription coverage, which typically costs an additional $20 to $80 a month.
There are two kinds of Part C plans:
There are “advantage” plans, which have lower monthly premiums but generally have a more limited choice of providers and come with co-pays and deductibles. Advantage plans generally include prescription coverage and work like managed care plans: You have to get your care from providers in a network.
Then there are “supplement” plans, which carry higher monthly premiums, but pay more expenses and provide more flexibility for care, particularly outside of your home state. That could be particularly important for retirees who spend the winter months outside Ohio or who otherwise plan on traveling to other states. Supplement plans do not include prescription coverage, so you have to buy Part D coverage, too. (Technically, supplements aren’t Part C, but Part C colloquially covers the private insurance options that complement Parts A and B.)
So with an advantage plan, you pay less up front but more when you use it. With a supplement plan, you pay more up front but less when you use it.
While you can buy supplement, advantage and Part D plans on your own, many experts recommend going through a broker because there are so many moving parts, so many laws and so many nuances.
Parma insurance broker George Halle said soon-to-be seniors typically will ask their friends or neighbors what they did about buying Medicare add-ons. But that can end badly.
“What is good for one individual may not be good for them,” said Halle, who’s with HealthMarkets Insurance in Parma. “It’s very important for them to understand all of their options . . . We get a real understanding of what their life is like.”
If you make the wrong choice, you could end up in an insurance plan that doesn’t include your preferred doctors or hospital, or doesn’t provide coverage outside of Ohio, or has high prices for your prescriptions.
Or, if you make the wrong choice, you could end being unable to switch to a different plan later without getting a physical or being denied coverage for pre-existing conditions.
Halle said many people don’t realize that insurance brokers’ services for senior plans are free. Brokers get paid by the insurance companies. Their time and expertise costs nothing extra. So if you buy a plan on your own, or go through a broker, you’ll pay the same.
That’s true, but consumers should realize that agents are licensed to sell certain products and may not be able to sell the one that’s best for you, said Chris Reeg, program director for the Ohio Senior Insurance Information Program. She encourages consumers to get objective information and answers to questions through OSHIIP, which is a state program that offers its services for no cost. (800-686-1578 or http://www.insurance.ohio.gov/consumer/pages/consumertab2.aspx)
You don’t have to choose a Part C supplemental or advantage plan. You can just go with A and B, and then purchase a Part D plan for prescriptions. But that could leave you with high medical bills. Supplement and advantage plans pay for much or all of what Medicare A and B do not. There are other options besides just an advantage plan or supplement, Halle said. For example, a person can purchase an advantage plan plus a hospital indemnity plan to cover gaps.
If you are going through a broker, “make sure the broker is local,” said Cave, the Aurora agent. Local brokers know the local network. Period. Someone on the other end of an 800 number in another state may not appreciate that many people in Northeast Ohio have strong ties to University Hospitals or the Cleveland Clinic, and that there is a difference. Cave said she has come across people in the past who signed up for the wrong plan through an out-of-town broker and kept going to their same doctors or hospital without realizing they were racking up exorbitant bills.
AARP advises that if you’re shopping for Part D prescription plans, or Part C supplement/ advantage plans, which are run by private insurers and not the government, then you should not rely only on what the insurance company tells you about its costs and coverages. A broker or state senior insurance hotline can validate or correct what you’re told.
Even if you decide to work with a broker, it’s helpful to do some homework on your own. The www.medicare.gov web site provides ratings for insurance plans in your area (on a scale of 1 to 5, based on quality of care and customer service), and also helps you determine which prescriptions are covered and at what cost.
The two most important decisions hinge on whether to go with a supplemental plan or advantage plan, and what kinds of costs you may be looking at for prescriptions. The issues seniors need to think about most, Reeg said, are cost and choice.
“At 65, it’s the only time you’re guaranteed a supplement plan” without getting a physical or going through underwriting, Cave said. If anyone has a pre-existing condition such as cancer or heart problems, and thinks she may want a supplement plan later, “age 65 would be the time to get it,” she said.
And besides important issues such as premiums, deductibles, co-pays and out-of-pocket maximums, you also want to look at whether a particular plan covers things that are important to you: Does it cover dental or vision or hearing aids? Does it include a gym membership? What about physical therapy or chiropractic care or a skilled nursing facility?
Seniors can change plans every year during fall open enrollment.
Reeg of the state said 60 percent of Medicare recipients who buy add-ons choose supplement plans, which cost more but cover more and offer more choices for hospitals and doctors. It’s also a hedge, because there’s no guarantee they can get a reasonably priced supplement plan later. Meanwhile, 40 percent choose advantage plans.
Halle agreed most of his clients choose supplements. “As you get older,” he said, “you’re not going to get healthier.”
QUESTIONS TO ASK:
AARP recommends making a checklist of questions to ask regarding every Medicare insurance plan you’re considering. Make a table or spreadsheet of the information to make it easier. Here are some good ones to start with:
1. How much will I have to pay for premiums, deductibles, doctor visits and hospital stays?
2. Will I have to choose hospital and health care providers from a network?
3. Will my existing doctors accept the coverage? If not, are there doctors near me who will?
4. Will I need referrals to visit specialists?
5. Will the plan cover me if I get sick while traveling in another state?
6. What will my prescription drugs cost?
7. Are my drugs on the plan’s drug list?
8. Does the plan include the pharmacies I use now?
9. Can I get my prescriptions through the mail?
10. Does the plan have a good quality rating on that 1-5 scale? (You probably don’t want anything with less than 4 stars.)
WHEN TO SIGN UP:
When do people need to sign up for Medicare? There’s a seven-month window when people generally should sign up for Medicare A, not the supplemental policies we’re talking about. The seven-month window includes the three months before the month of one’s birthday, the month of the birthday, and three months after the birth month.
But note, if you wait until after your birth month, coverage won’t begin for several months. When you sign up for Medicare A, you can also enroll in Medicare B. You don’t have to at that time if you’re still employed, enrolled in a qualified group plan, or your spouse’s group plan. If you don’t sign up for Medicare B within eight months after coverage ends with the group plan, you could face a higher premium forever of up to 10 percent a year for every year you delayed enrollment.
Written By: By Teresa Dixon Murray, The Plain Dealer
Orignal Date: Junr 3 2018