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Question from Mike:
My wife has a Supplement with your company, but my question is about me. I have an employer sponsored retiree Advantage Plan. I’ve had several surgeries and procedures over the past several years which have been fully covered, so no complaints. The annual MOOP is pretty good too, $3,000. The only issue I have is that I must get prior approval for most everything and once it took entirely too long which delayed the scheduling of a necessary surgery and caused me serious anxiety. My question is can I leave my retiree PPO plan and switch to a Supplement without going through Medical Underwriting?
Yes. You can Mike. But let me first explain what Medical Underwriting is before I get into the details of your situation. Medical Underwriting is a tool that Supplement companies use to decide who they want to issue a policy to. It consists of a series of medical questions and a review of what is known as a Medical Information Bureau (MIB) to see if the applicant has been treated or taken medications for certain medical conditions. Those who have ever in their lives been diagnosed with Atrial Fibrillation, Lymphoma, Auto Immune disorders, Diabetes with complications, among a few others are not eligible for a Supplement. There are other questions asked, such as have you been treated, diagnosed, or taken medications for specific conditions within the last two to five years. As long as it had been longer since someone had a treatment or been discharged from care for those conditions: cancer, stroke, heart attack, bypass surgery, etc., for example, they will generally pass underwriting and get a Supplement. Many people don’t understand that a surgery, heart attack, or cancer that occurred over two to five years ago will not keep them from getting a Supplement or moving to a less expensive Plan G or N. Don’t assume. Give us a call to find out what your options are. In addition, no physical is necessary in the underwriting process.
Underwriting for Supplements is waived only in a few circumstances. The most common is when one turns 65 or goes on Medicare Part B for the first time. This is known as the Initial Election Period. It starts three months prior to the Medicare Part B effective date and lasts six months after. Medicare regulations state that all Supplement companies must accept everyone who is new to Part B regardless of their current or previous health into any letter plan they offer. The second situation is the one Mike is referring to. Anyone who is losing their employer or retiree sponsored health or Medicare coverage, either voluntarily like Mike is considering, or involuntary, gets what are known as Guarantee Issue rights which work similarly to the Initial Election Period when all companies must accept that person into a plan. However, they can limit plan choices to F or G, which are generally more expensive. Lasty and this is very important. Those who initially chose a Medicare Advantage Plan when turning 65 have 12 months to change their mind and get a Supplement without going through underwriting. Those who are still within this 12 month “trial period” as it’s called and have a condition that would keep them from enrolling in a Supplement ever again should really consider using this opportunity during the Annual Election Period that runs until December 7th.
The reason Mike is considering opting out of his Advantage Plan is he didn’t like the experience of having his care delayed. CT Scans, MRIs, surgical procedures, and several others require insurance company approval, “prior authorization,” before they can be performed and covered. It doesn’t happen often, but it also isn’t totally out of the ordinary to have an Advantage Plan company deny a scan or procedure or require physical or injection therapy before services are authorized.
Imagine the stress if your doctor discovered something abnormal and was concerned it could possibly be cancerous and having to wait two weeks for a scan of the area to be approved? These types of waits and delays are the biggest difference between Advantage Plans and Supplements. Those on Supplements have no wait because Medicare allows a treating physician to determine what is medically necessary. If those on a Supplement have a doctor order an MRI or CT scan, they can get them the same day. If the imaging revealed surgery was necessary, that could be performed immediately as well. After surgery, physical therapy can begin right away without authorization.
I like to use the example of a torn meniscus to compare how that would play out for someone on a Supplement versus an Advantage Plan. Both saw the same doctor the same day with the same complaints and symptoms. The person on a Supplement had their MRI that day, their surgery within the same week, and were almost done with their physical therapy before the person on the Advantage Plan had surgery because there was a two week wait to get the approval for the MRI, another two weeks to get the approval for the surgery, then the wait for the date it was scheduled. And that’s if everything goes well.
Not needing to worry about getting care authorized by an insurance company, waiting for it to happen, or any needing to jump through hoops is by far the number one reason many of our clients are willing to pay more money in monthly premiums and forgo the extra benefits such as dental, vision, OTC allowances, and other generous ancillary benefits Advantage Plans offer and choose Supplements.
And often retiree Advantage Plans are expensive, more than what a Supplement costs. Retiree HMOs and PPOs also may not come with as many, or any, of the ancillary benefits that the plans the general public pay less for have. If you are paying in the $150 range for a retiree HMO or PPO, I recommend giving us a call to have it reviewed to see if a Supplement or even another Advantage Plan might be a better value.
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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 email@example.com. And keep the great column questions coming! Also, I am now licensed in over 20 states and able to help people choose and enroll in Advantage, Supplement, and Part D plans throughout the country.
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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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