This week’s question from Shannon
After reading your last few columns, I’m very much considering moving from my Supplement to an Advantage Plan like many of my friends have. Premiums are less (almost $200 per month for me), they come with drug coverage that has no deductible which I pay every year, and supply lots of ancillary benefits, as you call them, that I don’t get. What’s your opinion?
Answer
You’re Not Alone
You’re certainly not alone in thinking about or actually pulling the trigger, especially if your Supplement premiums are over $200/month. We speak to and help people choose and transition to Advantage Plans literally every day. However, I recommend you make an appointment to discuss the pros and cons with us first. It’s absolutely not right for everyone and there are several factors that need to be considered.
I attribute quite a bit of this trend to the effect inflation is having on those living on fixed incomes. It’s crazy how expensive groceries, fuel, and utilities have become. Add in the $170/month Part B now costs, annual premium increases, especially on Plans C, G, and F, and the fact is many people simply can’t afford a Supplement.
The other reason many are choosing Advantage Plans when they first go on Medicare or moving from Supplements is how attractive and generous the ancillary benefits are on select HMOs and PPOs: as much as $3,000 in comprehensive dental for everything from cleanings to dentures. Up to $400/year for glasses and a no cost eye exam. Up to $2,500 per year for hearing aids. $400/year for co-pays. A free gym membership, and more. It’s hard to believe just how much dollar value these benefits provide, especially considering almost none of them were offered prior to 2018. When premium savings are taken in to account, it’s the reason, for the first time ever, people enrolled in Advantage Plans now outnumber those on Supplements.
But please, please, please, don’t just move from a Supplement to the HMO or PPO your friend or family member is on. It’s so important to have a conversation with us prior to making the decision to disenroll from a Supplement. The number one reason is it can be permanent. Other than the three months prior and six months following one’s initial enrollment in Part B, with very few exceptions, Supplement companies are allowed to discriminate on who they accept into their plans. There is quite an extensive list of conditions and medications that automatically disqualify a Medicare beneficiary from acquiring a Supplement.
Coverage Differences
And for those who don’t know, coverage is vastly different between the two plans. Instead of having no bills for almost all medical claims with Supplements, Advantage plan co-pays generally range from $25-40 for an X-ray, to $200-350 for CT scans, MRIs, and outpatient surgeries, from as little as $250 to as much as $1,800 (on an unwisely chosen plan) for a six day or longer hospitalization, to thousands for Chemo, Radiation, a lengthy skilled nursing stay, as well as other infused or injected drugs.
How claims are approved and processed is also very different. There are no prior authorizations necessary for virtually any medical service with Supplements. The patient and his or her doctor determine what is medically necessary and the best course of testing or treatment. Advantage Plans require approval for CT scans, MRI’s, outpatient surgeries, home health care, and more before those services will be rendered and claims paid. Dealing with that can be a hassle and is probably the biggest complaint we get about Advantage Plans and other commercial health insurance provided by an employer or the ACA. Access to medical providers also works differently. There are no networks with Supplements, meaning practically every doctor and all non-VA hospitals can be used at no additional cost. This isn’t the case with Advantage Plans. Most have very good networks in Pennsylvania. However, HMOs don’t provide very much access to care outside of the state apart from West Virginia and the Cleveland Clinic. And just because you choose a PPO doesn’t mean claims will be paid by your Advantage Plan company at an out of network provider the same as if you were in network. Not even close. With most PPO plans you don’t just have the right to make an appointment at any doctor or hospital of your choice, show up, and get treated.
Let the Experts Help
I don’t want anyone to think I’m discouraging enrollment in an HMO or PPO. It’s an excellent option for many who understand and are okay with the couple of risks they pose. Agents of The Health Insurance Store are appointed to provide plans from every competitive Advantage plan company on the market and we have over 4,000 active clients who we helped apply and continue to service. In the event any of them have a claim denied, are told they need physical therapy before they can have a surgery or advanced imaging, need a medication that isn’t on formulary, have gotten erroneous or expensive bills, we advocate and start contacting insurance companies, medical providers, billing departments, or pharmacies to get issues resolved. We also have experience finding programs and foundations that can help relieve the burden of expensive out of pocket costs.
Although Annual Election Period doesn’t start until October 15th, now is a good time to learn about all the differences between Supplements and Advantage Plans and most importantly, make sure you’re a good candidate to move from one to the other. If it does make sense, we then will ensure the right company and plan is chosen based on individual needs. To schedule a no cost consultation, give us a call, go to our website, or email me personally at Aaron@GetYourBestPlan.com.
Thank you!
If you have any questions or concerns regarding this column topic, or would like to make an appointment for a no-cost consultation, please feel free to give us a call – we would be happy to help. I’d like to remind everyone that I do a live call-in talk show called Medicare A to Z every 1st and 3rd Monday of the month on WMBS Uniontown, 590AM and 101.1FM, from 1 to 3 PM. You can listen in on their website, wmbs590.com.
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