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News From The Health Insurance Store

Question: From Judy in Monroeville: I’m paying over $200/month for my Medicare Advantage Plan. I’ve read where you advised everyone not to pay more than $100/month for an HMO or PPO. I don’t see how paying less for a plan would be better for me. Would I lose coverage for some medical services? I’m really afraid of that.

Answer: No. You won’t. In fact, if you choose the right plan, you may be able to lower co-pays for services like hospitalizations, MRI’s, Ambulance services, etc., and likely reduce your annual Maximum Out of Pocket, aka MOOP. The MOOP represents the amount of bills you could possibly receive in a calendar year. More than likely you have a MOOP of $6,700. If you needed Chemotherapy, other drugs administered in an outpatient setting like Remicade, have a lengthy stay in a Skilled Nursing Facility, or multiple hospital stays, among other more costly services, it wouldn’t be hard to meet that $6,700.

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Question: I’m a retired Federal Employee and have a Blue Cross Blue Shield plan and Medicare. Am I losing access to UPMC doctors and hospitals next year?

Answer: You will continue to have network access to UPMC doctors and hospitals as long as you have both Medicare Parts A and B. Those who have A only, will not have network access to UPMC.

I’ve been having ongoing discussions with a very informed representative of UPMC who assured me of this. As or more importantly, he also gave me an update on what the process will be for those who may still have Highmark Medicare Advantage HMO’s and PPO’s after June 30th of next year and wish to use UPMC health systems. I’m her to tell you, it’s going to be extremely inconvenient if you remain on your Highmark Medicare Advantage HMO or PPO.

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Question: From John in Moon: I already have a Supplement and I’m very happy with it. Is there anything I need to do during Medicare Annual Election?

Answer: Yes John. You will want to investigate a couple of things during Annual Election Period (AEP), which starts October 15th, and runs through December 7th. Frist let me briefly remind everyone that not all Medicare plans are Supplements. In fact, I estimate that at least 50% of seniors in our market have Medicare Advantage Plan HMO’s or PPO’s that are NOT secondary to Medicare. These plans are NOT designed to pick up the portion of the bill Medicare doesn’t pay, like the 20% for outpatient services. Very few people understand that.

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Question: From Joyce in the North Hills: Since my HMO will no longer provide access to UPMC hospitals and doctors next year, I am considering moving to a Supplement. But I don't want to lose Silver Sneakers or my dental and vision benefits. Can you comment on my concerns?

Answer: Absolutely Joyce. First, I want to remind everyone Advantage Plan HMO's and PPO's like Joyce has are NOT Supplements and are NOT designed to pick up the portion of the bill Medicare doesn't pay. Instead of paying 80%, when you have an Advantage Plan, Medicare instead pays the company you choose approximately $800 per month to become your one and only insurer. In return they provide your medical benefits and pays claims. You, the insured, are then responsible for a deductible (very few plans have one), coinsurance (a percentage of the bill you are responsible for, commonly 20%), and/or a co-pay for virtually every service you receive. Here's some examples of what your medical bills could be: $5 for a PCP visit. $40 for an X-Ray. $200 for an MRI, $300 to $2,000 for an inpatient hospitalization, up to $6,700 for Chemo or a lengthy Skilled Nursing stay.

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Question: Question from Don in Latrobe: I don't fully understand deductibles and what all is included in the Maximum Out of Pocket expense. Would you please explain?

Answer: You are not alone Don. If it were easy to understand, I wouldn't be in business. Let me clarify as it applies to Medicare plans, and explain what co-insurance and co-pays are
as well.

The deductible is the amount of money you must pay for certain medical services before the insurance company will pay any portion of the bill. Let me give you an example.

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