It was a heartbreaking encounter… sitting with a couple at their kitchen table with tears streaming down both cheeks. He was very ill, was losing weight rapidly due to digestive problems and his constant migraine headaches were so painful that ending his life seemed the only option to live pain free. To say they were scared would be an understatement. Doctors associated with his current Medicare Advantage Plan (Medicare Part C) were unable to diagnose the problem. They only prescribed more drugs, which exacerbated his problems. On top of his medical puzzle, the Plan declined medical tests, which could ultimately diagnose his problem. It was October 2011 and through their tears they painfully asked, “What are our options?”
In this case, we decided together that it was in his best interest to move 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 for him to find the best of the best anywhere in the country. We chose an “F supplement plan” with a carrier that allowed him to switch between a cheaper and more expensive plan WITHOUT proof of insurability (if he was in the future would decide to keep the supplement plan after his current medical puzzle was solved).
Could he have avoided this problem in the first place? Possible. Here are a few errors I’ve seen along with the solutions to help you choose the right option for YOU:
ERROR #1: Who do you work with?
* Work with a “captive insurance agent” (direct employment with the carrier, often compensated by W2, commissions and/or bonuses) or work with an “independent career agent” (1099 contractor with the carrier and provided with leads). That last term is very confusing to me. They are classified as independent, but if they apply to another carrier because it was good for the beneficiary, their contract may be terminated. What incentive does the agent have to be non-partisan if they lose their lead resource?
** 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 without certification.
*** Directly to the insurance company. If things go wrong, it’s helpful to have an attorney by your side, especially someone you can see and live/work in your community.
SOLUTION #1:
* Choose an independent insurance agent who represents more than one insurance company. Why? Because independent agents know the pros and cons of ALL plans and can pass this information on so you can make an EDUCATION choice. They receive compensation from the insurance companies, but are not loyal to any particular company. Also watch out for carriers forcing their ‘independent agents’ to sign an exclusive agreement. I’ve seen this happen with Dual Eligible Plans (Medicaid/Medicare Plans). Again, how can the agent be “non-partisan” 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 extra training and supervision.
*** When you go directly to the carrier, you eliminate a valuable person who will handle any issues, while giving you added peace of mind throughout the process.
ERROR #2: Choosing a Medicare Advantage Plan that requires the insurance company’s approval before having any procedure/test.
SOLUTION #2: When comparing plans, look at the ‘Benefit Summary’. All carriers must publish these and they must be similar and comparable.
ERROR #3: Pay no attention to the ‘maximum out of pocket’ (MOOP) limit. All Medicare Advantage plans have a MOOP, and many agents glaze over as they help you choose your plan. However, should a catastrophic medical problem arise (cancer, organ transplant, long stay in a skilled nursing facility, etc.), the chances of reaching your MOOP are high, so you want to make sure it is as low as possible. The reason: Chemotherapy and anti-rejection drugs are considered Part “B” outpatient drugs, not Part “D” prescription drugs, and many plans pay only 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.
ERROR #4: Choosing a plan just because the drug co-pays are a little lower. Many smaller insurance companies will lure you into their Plan with very low co-pays on their drug formulary, but have a smaller network of doctors/facilities from which to choose. The problem is that if a medical issue arises, you may be stuck with the smaller network of doctors/facilities until Medicare’s annual open enrollment.
SOLUTION #4: If you have difficulty paying a personal contribution for prescription medicines 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 show you the way, or go to it https://secure.ssa.gov/i1020/start. Getting help with your medication will help you choose the best plan based on other options (the size of their network, authorization rules, convenience for physician/facility, additional optional benefits, etc.)
ERROR #5: Choosing a plan because you want a PPO plan and not an HMO.
SOLUTION #5: Many people have the misconception that they can go to any doctor / institution they want with a PPO plan. In reality, PPO plans still have a network of doctors/institutions where you have to stay to get the lower cost. The main difference between a PPO and HMO is that with a PPO you don’t have to request a ‘referral’ to see a specialist. With an HMO, you must get a referral. To be able to choose ANY doctor/clinic in the country that accepts Medicare, you must consider a Medicare Supplement (MediGap) Plan.
I’ve seen the most mistakes and solutions when it comes to choosing Medicare Advantage Health Plans. Outside of California, there are additional variants of plans and may have additional challenges.
What happened to my client, you ask? As I am in constant contact with my clients, I was overjoyed in June when I heard him proclaim the great news. Using the same test that was denied by his previous Medicare Advantage Plan, two doctors from a major Los Angeles medical group exposed the issue. He was slowly leaking spinal fluid and was dangerously close to having nothing left. With a quick outpatient procedure, they basically laser glued the leaking area, replaced his spinal fluid and he is healthier, happier and better than ever! Since he is doing well now, we will review his coverage during Medicare’s annual open enrollment (Oct. 15 – Dec. 7, 2012) and decide 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 find the best options, explain the pros and cons based on our clients’ individual needs, and provide peace of mind. Plans change every year and your health/financial status can change too, so it’s good practice to make a comparison every year. Finally, choose a good, local, independent insurance agent, get well educated and stay well informed!
Mistakes to avoid while choosing the best
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