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Advantage Plans The Health Insurance Store

However, they need to be chosen wisely. There are now approximately 50 HMO and PPO plans available in the Western PA market. It’s my professional opinion only a handful are worth considering. If you currently have Medicare and want to ensure you’re on what I consider to be one of the most competitive Advantage Plans for 2020, we can give you our thoughts in a matter of minutes with a simple phone call. 

 

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Ask the Medicare Specialist

 

Question: I’m going to be turning 65 in May. What do I need to do to enroll in Medicare? 

 

Answer:

 If you’re already collecting Social Security, you don’t need to do anything. You will be automatically enrolled and receive your Medicare card about 100 days prior to the month you turn 65. If you’re not yet collecting, you need to enroll in Medicare via Social Security. That can be done online at socialsecurity.gov or at your local office. You can apply for Medicare 90 days prior to the first day of the month you turn 65. I suggest starting that process as soon as possible to avoid delays in getting your card. Once it arrives, you can then choose a plan. 

 There are a couple of important scenarios people turning 65 need to be aware of. If you or your spouse are working and have the option of getting health insurance through an employer, you can opt out of Part B if that makes more sense financially. You’ll want to evaluate that, taking into consideration the cost of Medicare Part B, $144.60 per month in 2020, and the premiums for a Supplement or Advantage plan compared to what is being deducted from your paycheck for insurance. Many people don’t know what they’re paying for employer coverage. That’s a mistake. If you aren’t sure, ask your HR rep or whoever handles company benefits. It is also common for it to make sense for the employee to remain on the plan at work, but the spouse to come off. That’s because many employers are willing to cover more of the premium for the employee and less for the spouse. 

 There are more parts of the equation other than just cost. The size of your deductible and potential exposure to out of pocket medical bills also factor in. Medicare Supplements and Advantage Plans generally have little or no deductible. Another consideration when deciding to opt out of an employer plan and go with Medicare is what prescriptions you’re taking. 

Those who take expensive brand name drugs are almost always best to stay on employer insurance due to the “Doughnut Hole.” One of our agents will be happy to help determine if remaining on your plan at work or going on Medicare is the better option. Please be advised that you absolutely should not drop Part B if you get health insurance from the company you retired from. Only those who are still working can do so and avoid what is known as the “Part B Late Enrollment Penalty.” We have met far too many retired teachers and Federal employees who made that mistake. 

 If you remain on an employer plan past 65 and opt out of Part B, when you do retire or decide that Medicare’s a better value, a document titled “Request for Employment Information,” will be required by Social Security. This form needs to be filled out by your employer in order to in enroll in Part B without penalty. We can provide a copy when needed.

I can’t stress this enough. When going on Medicare for the first time, it’s vital you get all options explained thoroughly. Not all Medicare plans are Supplements! I estimate 95% of people I meet for the first time have no idea Medicare Advantage Plan HMO’s and PPO’s aren’t secondary to Medicare. Advantage Plans are not designed to pick up the portion of the bill Medicare doesn’t pay (generally 20%). People on Advantage Plans have co pays for practically every medical service. If you have an Advantage Plan you will pay for doctor visits, blood tests, X-Rays, MRI’s, CT Scans, ambulance services, Emergency Room visits, etc. Other more expensive services like hospitalizations, Chemotherapy, Radiation, and Skilled Nursing stays can have out of pocket costs in the thousands of dollars. 

Advantage Plans are quite popular and can make sense for those looking to save money on monthly premiums. However, they need to be chosen wisely. There are now approximately 50 HMO and PPO plans available in the Western PA market. It’s my professional opinion only a handful are worth considering. If you currently have Medicare and want to ensure you’re on what I consider to be one of the most competitive Advantage Plans for 2020, we can give you our thoughts in a matter of minutes with a simple phone call. 

Advantage Plans have networks of doctors. And while most plans provide access to all Western Pennsylvania hospitals, there are plans that don’t. We have had many clients who got a rare disease or form of Cancer who needed to use out of State hospitals such as the Cleveland Clinic, UCLA, MD Anderson Cancer Center. That isn’t possible with most Advantage plans. 

Supplement on the other hand, give you access to virtually all doctors and every hospital in the entire country, not just Western PA. There are no additional costs to use out of area medical providers. 

Very few people realize when you initially go on Medicare that’s generally the only time in you life when Supplement companies accept you regardless of your current or previous health conditions. Federal regulations state they cannot deny your acceptance. However, seven months after you get Medicare Part B, those companies can deny your acceptance based on pre-existing conditions. 

 If you haven’t compared Advantage plans from multiple companies, or to Supplements the risk of receiving large medical bills and paying more premium than necessary are often the results.

 

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Connellsville: 724-603-3403

 

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Ask the Medicare Specialist

by Arron Zolbrod

Question:

Question from Mary Ann: I’m on a Part D plan that only costs $15. Should I get a more

expensive plan in case I get put on expensive medications?

 

Answer: 

No. All you need to do is make sure you have the most cost-effective plan for 2020 based on the drugs you’re currently taking.

I often get this and similar questions such as, “what do I do if I need a medication that my plan doesn’t cover?”

There are protections for that as well as others when it comes to Part D plans, whether provided by an Advantage Plan HMO or PPO or what is known as Stand-Alone Part D, a separate policy those on Supplements need to purchase.

In the case of a drug not being on your plan’s formulary, there are two protections. Number one, all Part D plans must provide you with a 30- day “transitional supply,” even if the drug you’ve been prescribed isn’t on formulary. Most people don’t realize that. You would need to call your plan to get an override for the pharmacy. When we help our clients with this, we also get a list of alternative drugs the plan covers. You see, another regulation is Part D plans must cover at least two medications for every medical condition. What the transitional supply allows you to do is get with your doctor to see if he or she feels the alternatives are a viable, preferably one that’s available in generic. If the doctor doesn’t feel an alternative is safe due to a medical reason such as an allergy or it’s been taken previously without success, then an “Exception to the Formulary” can be applied for. Your physicianfills out a form that states why the medications on the plan’s formulary can’t be taken.

ANSWER:
If it’s a legitimate medical reason, the exception will

almost certainly be approved

There’s one other appeal or request you can make to a Part D plan. It’s called a “Tier Exception.” Often plans price generics as though they were brand name drugs, making them a Tier 3 or 4. If there isn’t another generic available for you to take that’s a Tier 1 or 2, this exception is often granted. Tier 4 drugs can be extremely expensive, from $100 to $250 for a 30-day supply. Getting them moved to a Tier 3 can result in significant savings.

One more important fact people need to understand. You cannot avoid the Doughnut Hole by paying a higher premium! In 2020 you can only receive $4,020 of drugs. This is based on the retail cost and has nothing to do with your co- pays. The average brand name drug now has a retail of $500 for a 30-day supply, regardless of the plan’s premium. This means the Doughnut Hole will be reached by August if that was the only drug you were taking, sooner if there are others. Even if a co-pay for a brand name drug were $25 less in the month’s prior to falling in the Doughnut Hole, you would pay the same after. You don’t need to spend an extra $600 to $1,000 more in premium to save $200 in co-pays.

Once again, paying more doesn’t necessarily get you more when to comes to Medicare Part D, Supplements, or Advantage Plans. For instance, the highest priced Advantage Plan HMO’s and PPO’s next year will be close to $300/month. People on these

expensive plans who receive Chemo, have a lengthy stay in a Skilled Nursing Facility, or get expensive drugs infused or injected as an outpatient will most likely pay the same amount of bills as those who have plans that costs $250-$300 less.

I had a client call me just today, who was paying $60 more per month for Medicare Supplement Plan N with another company and $40 more for a Part D Plan than she needed to. That’s $1,200/ year!

There’s still time for us to evaluate your plan before Annual Election Period ends on December 7th. In a five- minute phone call or a quick email, myself or another agent can let you know if you can save money or get a plan that offers a better overall value in terms of premiums and benefits.

And once you become a client, our staff is always available to advocate on your behalf regarding Part D or any other issue related to your policy.

Feel free to email me at This email address is being protected from spambots. You need JavaScript enabled to view it. with questions. And don’t forget to go online and listen to my live radio show on WMBS Uniontown 590am the first and third Monday of every month from 1:15 to 3. You can also catch the replay of all the shows on our website.

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No-cost, unbiased Medicare plan review and consultation with local, licensed agents 

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412-349-8818

Pittsburgh

724-603-3403

Laurel Highlands

www.getyourbestplan.com

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Fill out the form online at our website https://getyourbestplan.com/medicare-info/medicare-quote.html. One of our professional agents will get back to you quickly. It’s easy and we’re here to help. 

 

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Erie County Area

1105 West 12th Street, Suite – A
Erie, PA 16501
Phone: 814-920-5275
Fax: 814-920-5276

Fayette/Westmoreland County Area

121 North Pittsburgh Street
Connellsville, PA. 15425
Phone: 724-603-3403
Fax: 724-603-3402

Pittsburgh Area

21 Yost Blvd., Forest Hills, PA 15221
Mailing Address: 128 Forest Hills Plaza, Pittsburgh, PA 15221
Phone: 412-349-8818
Fax: 878-302-3149

Albuquerque/Santa Fe, New Mexico Area

821 Coors Blvd. NW
Albuquerque, NM 87121
Phone: 505-200-0069
Fax: 505-200-0073

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