Question from Heather:
My husband signed up for traditional Medicare and a Supplement plan through your office with help from Bonnie, who was wonderful. I also obtained private insurance because I’m not yet 65 and took an early retirement. I feel like we made very good decisions in terms of our medical insurance policies.
The problem is my husband has faced about $15,000 worth of dental issues in the past year and we’ve just found out that he’s looking at between $6,000 and $16,000 in additional work. The first costs were related to extractions and implants. This round is related to decayed teeth that may not be savable even with root canals and crowns.
I am fully behind Bonnie’s recommendation to have gone with traditional Medicare and a Supplement because my husband is diabetic. But I must admit that I’m yearning for some of the coverage that we would’ve gotten had he’d gone with a Medicare Advantage Plan. Are there any options for us?
I’m sorry to hear about your husband’s extreme dental expenses. Unfortunately, I really don’t have any solutions and the benefits of Advantage Plans would not have made a significant dent in what you’ve paid out. Let me explain.
In the 15 years I’ve been in the health and Medicare insurance field, I’ve only seen one single dental plan that didn’t put an annual limit on what the insurance company would pay out in claims. That was 10 years ago, and was on a plan provided to union workers. I don’t believe implants were covered either.
The extra (ancillary) benefits Advantage Plans offer can be very valuable. However, 95% of those available in Western PA DO NOT cover implants. Only two plans that we recommend, and just one with Part D prescription coverage, do. The annual limit on benefits with that plan is $2,200, not even enough to cover one implant. Although an Advantage Plan could have helped pay $2,200 for an implant or 50% of root canals and crowns, up to $3,000 in a calendar year, the rest would still have been your responsibility. And considering that HMOs and PPOs may have exposed your husband to additional out-of-pocket costs for medical services, some of that savings could have been minimized.
There are no dental policies individuals can buy which pay more than $2,500 for dental services annually, let alone come even close to covering what Heather’s husband has spent and will be spending soon. Most plans that are available for sale to those on Medicare Supplements or who buy ACA health insurance plans on the Marketplace don’t cover Major Services such as crowns, root canals, and dentures. Those that do almost always have a two-year waiting period and I’m not aware of any that would pay for implants.
Even if individual dental plans were available with similar benefits to those provided by employers, which in my opinion are the only coverage worth having, the following are what the benefits would look like: 100% coverage for two teeth cleanings and one set of bite wing X-rays annually as well a panoramic X-ray every 5 years. These are known as Preventative Services. 80% coverage for fillings, simple extractions, and periodontal, which are known as Basic Services. 50% coverage for root canals, crowns, extractions of impacted teeth, partials, and dentures. These are known as Major Services. The average maximum claims that the dental insurance company will pay in a year is $1,500 to $2,000. Individual plans that have these kinds of benefits generally have monthly premiums of around $45/month which comes to $540 annually. Those who have their preventative services performed as well as two cavities filled per year, would still come out on the short end of the deal by more than $150. Unless someone is getting at least one crown or root canal annually, buying dental coverage is a losing proposition. This is why we don’t sell dental plans. There’s no value in them. We will never sell any kind of insurance or policy that doesn’t pay for itself or serve the purpose of protecting one’s health, assets, or family.
Purchasing additional insurance to pay for $150 worth of eyeglasses and one no cost routine eye exam, the standard coverage of a vision plan, is also unnecessary. Expensive medical conditions of the eyes such as glaucoma, cataract, and macular degeneration are covered medical benefits in Medicare, Supplemental, Advantage Plan, ACA, and employer health insurance, not vision plans.
Medicare Advantage Plan HMOs and PPOs supply as much as $3,000 worth of Preventative, Basic, and Major dental services each year, up to $400 for glasses and a no cost eye exam annually, as much $3,000 for hearing aids per year, over the counter allowances, and more. All the Advantage Plans we recommend only cost between $0 and $40 per month and come with this range of ancillary benefits. The value of that combination should absolutely be considered when making a choice between Supplements and Advantage Plans but should not be the only deciding factor. Heather’s husband is a diabetic. If he had the insulin dependent variety and enrolled in an Advantage Plan, he would have never been able to get a Supplement six to 12 months after his original Part B effective date. Diabetes is one of several conditions that eliminate the possibility of going from Advantage Plan to Supplement in the future. Had he had an insulin pump and enrolled in Advantage Plan, he would have been forced to pay 20% of the cost of insulin because used in a pump, insulin is considered Durable Medical Equipment and covered at only 80% by virtually all HMOs and PPOs. The $35 cap on a 30-day supply of insulin unfortunately doesn’t apply in this case. Conversely, insulin used in a pump is covered at 100% by the combination of Medicare and a Supplement.
These considerations and unending intricacies in the different types of Medicare plans, including Part D, are why it’s important to meet with one of the experienced and licensed agents at The Health Insurance Store. We understand all the pros and cons, where the “trap doors” are, and how to avoid or minimize them. Consultations in office, over the phone, or via a Zoom style internet meeting are provided at no cost, and our agents and staff are always available to service clients if there are erroneous bills, claim denials, or any other issues or questions. In addition, when it comes to the costs for expensive name brand medications, our Prescription Drug Case Worker, Tony Diroma, has extensive knowledge of how to find financial relief.
Make An Appointment
If you would like to make an appointment for a no cost consultation to go over Medicare options, individual ACA marketplace plans, you’re an employer and would like a second opinion on your group policy, or are interested in life insurance, give us a call or email me personally at firstname.lastname@example.org. And keep the great column questions coming!
Introducing New Facebook Group
We’re introducing a new Facebook group, “Ask the Medicare Specialist” where we will be posting exclusive content including our “Feel-Good Fridays” where we discuss a problem a client had that a member of our staff as well as a “Truths, Tips, and Tricks” series where we point out specific regulations, common areas of confusion and provide solutions on how to understand and navigate them while avoiding excessive costs. On Feel Good Friday we discuss recent problems a client had and how we resolved them. Visit our website and click on the banner to become a member.
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.
Erie County Area
1105 West 12th Street, Suite – A
Erie, PA 16501
Fayette/Westmoreland County Area
121 North Pittsburgh Street
Connellsville, PA. 15425
21 Yost Blvd., Forest Hills, PA 15221
Mailing Address: 128 Forest Hills Plaza, Pittsburgh, PA 15221
Albuquerque/Santa Fe, New Mexico Area
821 Coors Blvd. NW
Albuquerque, NM 87121
Serving These Areas
We proudly serve the health insurance and Medicare needs of the following Pennsylvania areas: Connellsville, Uniontown, Greensburg, Mt. Pleasant, Scottdale, Irwin, N. Huntingdon, Murrysville, Monroeville, Plum, Lower Burrell, New Kensington, Pittsburgh, Plum, Oakmont, Penn Hills, Forest Hills, Wilkinsburg, East Liberty, Lawrenceville, Bloomfield, Natrona Heights, Leechburg, Washington, Morgantown WV, Latrobe, Monnessen, Jeanette, Erie, Edinboro, Northeast, Girard, Fairview, Union City, Harborcreek, Corey, Meadville, Waterford, Ligonier, Kittaning, Somerset, Waynesburg, Fayette County, Westmoreland County, Armstrong County, Butler County, Somerset County, Erie County, Crawford County, Venango County, Allegheny Valley, Pennsylvania
We proudly serve the following New Mexico areas: Albuquerque, Rio Rancho, Sante Fe, Bernalillo, Belen, Los Lunas, Espanola, Moriarty, Corales, Tijeras, Cedar Crest, Edgewood, Soccoro, Sandoval County, Sante Fe County, Bernalillo County, Rio Arriba County, Valencia County, Soccoro County, New Mexico
Not affiliated with the U. S. government or federal Medicare program.
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.