TONI KING: Turning 65 with cancer; is Medicare Advantage right for me?

Hi Toni:

I am turning 65 this August and have no idea what I should do because I have lung cancer. Currently I am on a COBRA policy from my old employer with all of my medical bills now being paid because I have met my deductible.

I receive all of my care from MD Anderson and am currently taking chemotherapy with my radiation treatments to start in July.

Do I enroll in Original Medicare with a Medicare supplement and get Part D, go with a Medicare Advantage plan or stay with my current COBRA plan until it ends in about 15 months. If you could help me sort this out I would greatly appreciate your help. Jonathon from Spring, TX

Hello Jon:

Recently, I had a phone call from a frantic daughter, who was trying to help her father who had been diagnosed with pancreatic cancer and he had chosen a Medicare Advantage HMO when he turned 65. Now her father has to wait until Medicare’s annual enrollment in the fall to make a change back to Original Medicare because MD Anderson is not in that Medicare Advantage plan’s HMO network.

Feb. 15 of every year begins lock-in for Medicare Advantage plans and one has to wait until Oct. 15-Dec. 7 to make any changes back to Original Medicare for the following year.

I have good news for you, Jon … because you are turning 65 in August, there is a special enrollment time called Medicare Supplement /Medigap open enrollment.

As I have said before, this is the best time for someone to purchase a Medicare Supplement because the open enrollment period lasts for a 6 month period beginning the first day of the month in which you are 65 or you are older and have just enrolled in Part B for the first time.

During this open enrollment period, you may enroll in a Medicare Supplement and not have to answer any health questions to be accepted by any Medicare Supplement plan.

If you decide not to keep your COBRA plan, you do not have to worry about your medical care being taking care of with the Medicare Supplement, but after the 6 month window, you will have to submit to a complete underwritten application for a Medicare Supplement.

You may not qualify for a certain policy or it may cost more, if there are other health issues including the cancer after this 6 month window.

I have been advised by many healthcare professionals that some of the newest healthcare and cancer procedures are not readily approved by Medicare Advantage plans, but these procedures are generally approved with “Original or Traditional Medicare.” They have to fight everyday to get the care many desperately need when they have a Medicare Advantage plan. Talk to your medical professional who knows your health situation when making your Medicare plan choice, even if you are someone with a serious health condition, such as heart problems, Alzheimer, MS, end stage renal disease and the list could go on and on … always talk to those that know your health situation.

Medicare Advantage plans are a good option when someone is relatively healthy.

Upcoming workshop

May’s Confused about Medicare and Social Security Workshop is set for 2 p.m. Thursday, May 19, in Sugar Land at Two Sugar Creek Center, 77 Sugar Creek Center Blvd, 5th floor Conference Room, Sugar Land, TX 77478. Seating is limited. Please RSVP 832-519-8664.

Toni King, author of the new Medicare Survival Guide®, which is a simple guide that puts Medicare in “people” terms, is on sale at www.tonisays.com Email questions or to schedule a “Confused about Medicare and Social Workshop” for your organization or company lunch and learn to www.tonisays.com/ask-toni or call 832/519-TONI (8664).

Delegates Address Patient Satisfaction as Quality Metric, Other Issues

Triche went on to explain that patient satisfaction surveys can lead to physician burnout when physicians who know they have been practicing sound, evidence-based medicine receive low satisfaction scores.

Leanne Swiderski, M.D., a new physician delegate from Saint Clair Shores, Mich., and another co-author of the resolution, said these surveys have become a driver in how physicians are reimbursed.

“It seems there is a perception that (the surveys) add to providing quality care, but we know very clearly that they are associated with increased costs, increased prescription use — opioids and antibiotics — and, probably most frightening to me, increased mortality for patients,” she said.

Wael Mourad, M.D., an IMG delegate from Kansas City, Mo., also supported the resolution, noting that although patient satisfaction surveys may bring value to patient care, scores should not be used for punitive measures against physicians.

“I think we all can agree that withholding pay is a punitive measure. Physicians should not be punished for measures they have no control over,” he said.

Educating a Diverse Physician Workforce

Another substitute resolution adopted during the business session called for the AAFP to support pipeline programs and encourage providing support services for underrepresented minority students beginning as early as elementary school and continuing through college, medical school and residency.

The resolution also directed the Academy to support the AMA in recommending that medical school admissions be based on a holistic evaluation of applicants, taking into account the diversity of preparation and talents these students bring to medical school and residency.

Finally, the measure asked the AAFP to support the AMA in its efforts to improve the diversity of the physician workforce, including advocating that the National Resident Matching Program track and disseminate demographic information on race and ethnicity that is collected from Electronic Residency Application Service applications.

Ada Stewart, M.D., a minority delegate from Columbia, S.C., and co-author of this resolution, said the resolution is intended to support a measure that is scheduled to be introduced during the annual meeting of the AMA House of Delegates in June.

“We realize it is important for us to have a diverse (physician) workforce to provide care to our diverse populations,” she said. “We would like the Academy to support the AMA’s Minority Affairs consortium to address this issue.”

3 Ways to Maximize Your Medicare

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Medicare is a big deal for most Americans because healthcare is so costly. Per Fidelity Investments, a 65-year-old couple retiring today is estimated to face, on average, lifetime healthcare costs in retirement of $245,000. Any help that Medicare offers can make a big difference. Here are three ways to maximize your Medicare.

Don’t enroll late

First off, be sure to enroll on time. Signing up late can result in more expensive premiums for the rest of your life. (Specifically, your Part B premiums, which cover medical services but not hospital services, can rise by 10% for each year that you were eligible for Medicare but didn’t enroll.)

You’re eligible for Medicare at age 65 and can sign up anytime within the three months leading up to your 65th birthday, during the month of your birthday, or within the three months that follow. If you fail to enroll during these seven months, you can always enroll during the “general enrollment period,” which is from Jan. 1 through March 31 of each year. (If you’re still working and have employer-provided healthcare coverage at age 65, or are serving as a volunteer abroad, you can delay enrolling in Medicare without penalty.)

Most people will automatically be enrolled if they’re already receiving Social Security benefits during their enrollment period. That’s a good safety net, but don’t assume that you’re taken care of. Make sure you’re enrolled on time.

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Be sure to consider your prescription drug costs when comparing options. Image source: Pixabay.

Choose the best plan for yourself

There isn’t a one-size-fits-all Medicare plan. Instead, there’s a bunch of options you can choose from, which can be distilled into two main choices: “original” Medicare and a Medicare Advantage plan. Let’s review each.

Original Medicare, the form of the coverage familiar to most people, consists of Part A, Part B, and very often Part D. Part A covers inpatient hospital care (such as surgery), as well as care provided by skilled nursing facilities, hospice, and some home health-care providers. It also covers some lab test and doctor visits. Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services. More specifically, it covers “medically necessary” services needed to diagnose or treat you, as well as preventive and early detection services such as certain vaccines and screenings. It also covers durable medical equipment (such as blood sugar monitors and home oxygen equipment), mental-healthcare, and limited prescription drugs. Part D offers prescription-drug coverage. There are also Medigap plans available to supplement coverage.

Medicare Advantage plans are newer and are sometimes referred to as Part C. They are plans offered by private organizations (such as health insurance companies) that are regulated by the federal government. A Medicare Advantage plan must offer at least as much coverage as Medicare (i.e., Part A and Part B benefits, respectively covering hospital and medical services), but it will often sport more than that, such as vision care, dental care, and/or prescription drug coverage, in order to attract customers. The extras it offers can be in the form of lower copayments for services, or broader coverage. These plans are sometimes great choices, as they may cost less and provide more coverage.

When it’s time for you to choose coverage, read up on all these options available to you where you live. (Different Medicare Advantage plans, for example, are offered in different regions by different insurance companies.) Don’t just compare premiums, either, because Medicare Advantage plans may offer different co-payments, deductibles, and so on. Compare total expected out-of-pocket costs. Another key consideration is travel, because Medicare Advantage plans are typically rooted in your local area. If you plan to travel a lot, original Medicare plans may be preferable as they’re honored by providers nationwide.

Once you decide, know that you can change your mind and choose a different plan next year. In fact, it’s a good idea to review all your options and their costs each year.

Image source: Pixabay

Use your Medicare plan wisely

Finally, a key way to maximize your Medicare is to make the most of what it offers. It entitles you to a free wellness visit with your doctor once a year, so be sure to schedule that. Many important screenings are also free for enrollees. These include mammograms and Pap tests, along with screenings for heart disease, colorectal cancer, prostate cancer, depression, glaucoma, hepatitis C, alcohol misuse, HIV, STDs, diabetes, and osteoporosis. Take advantage of all the preventive care you can, as it can keep you living longer and paying less for healthcare, too.

Below are a bunch of other Medicare benefits that you may not know about but might want to. Most are provided free of charge or have the patient paying 20% of the Medicare-approved cost (with a deductible applying):

  • Abdominal aortic aneurysm screening: If you’re deemed to be at risk and your doctor orders this screening.
  • Ambulance services: These are covered in many cases when deemed necessary.
  • Artificial limbs and eyes: These are covered when ordered by a doctor.
  • Breast prostheses: Both external breast prostheses (including a post-surgical bra) and surgically implanted breast prostheses are covered after a mastectomy.
  • Chiropractic services: If manipulation of the spine by a chiropractor or other qualified provider is deemed medically necessary to correct a subluxation, it’s covered.
  • Continuous Positive Airway Pressure (CPAP) therapy: If you’re diagnosed with obstructive sleep apnea, Medicare will cover some of the costs of a CPAP machine and its supplies.
  • Durable medical equipment (DME): These include blood sugar monitors and diabetic testing strips, suction pumps, walkers, wheelchairs, crutches, home oxygen equipment, commode chairs, nebulizers, infusion pumps, and hospital beds, among other items.
  • Hepatitis B shots: If you’re at high or medium risk of hepatitis B, shots are covered.
  • Home health services: These include intermittent skilled nursing care, physical therapy, speech-language therapy, and occupational therapy.
  • Hospice care: If you’re deemed to have a life expectancy of no more than six months, you can qualify for free hospice care.
  • Laboratory tests: Medically necessary clinical diagnostic laboratory tests ordered by your doctor or practitioner are covered, usually free of charge.
  • Mental healthcare: Both inpatient and outpatient mental healthcare services are covered, to some degree.
  • Obesity screening and counseling: This is available free for those who qualify by having a body mass index (BMI) of 30 or more.
  • Physical therapy/occupational therapy/speech-language pathology services: These are covered, with yearly limits applying to services from most outpatient providers.
  • Second opinions: If you are having non-emergency surgery, Medicare will sometimes cover the cost of getting a second opinion from a different doctor and, on occasion, even a third opinion if the first two differ.
  • Smoking cessation counseling: This is covered both for those who have and have not yet been diagnosed with a tobacco-related illness.
  • Telehealth: This is where patients consult and interact with healthcare providers remotely and electronically, and it’s a growing practice. Medicare covers some telehealth services when the patient is at a health-service facility.
  • Transplants: Medicare covers doctor services for certain organ transplants.

If you sign up for Medicare on time, choose the plan(s) that suit you best, and then make the most of the coverage you have, you’ll be doing a great job of maximizing your Medicare.

The article 3 Ways to Maximize Your Medicare originally appeared on Fool.com.

Longtime Fool specialistSelena Maranjian, whom you can follow on Twitter, owns no shares of any company mentioned in this article.Try any of our Foolish newsletter services free for 30 days. We Fools may not all hold the same opinions, but we all believe that considering a diverse range of insights makes us better investors. The Motley Fool has a disclosure policy.

TONI KING: 65 with cancer; is Medicare Advantage right for me?

Hi Toni:

I am turning 65 this August and have no idea what I should do because I have lung cancer. Currently I am on a COBRA policy from my old employer with all of my medical bills now being paid because I have met my deductible.

I receive all of my care from MD Anderson and am currently taking chemotherapy with my radiation treatments to start in July.

Do I enroll in Original Medicare with a Medicare supplement and get Part D, go with a Medicare Advantage plan or stay with my current COBRA plan until it ends in about 15 months. If you could help me sort this out I would greatly appreciate your help. Jonathon from Spring, TX

Hello Jon:

Recently, I had a phone call from a frantic daughter, who was trying to help her father who had been diagnosed with pancreatic cancer and he had chosen a Medicare Advantage HMO when he turned 65. Now her father has to wait until Medicare’s annual enrollment in the fall to make a change back to Original Medicare because MD Anderson is not in that Medicare Advantage plan’s HMO network.

Feb. 15 of every year begins lock-in for Medicare Advantage plans and one has to wait until Oct. 15-Dec. 7 to make any changes back to Original Medicare for the following year.

I have good news for you, Jon … because you are turning 65 in August, there is a special enrollment time called Medicare Supplement /Medigap open enrollment.

As I have said before, this is the best time for someone to purchase a Medicare Supplement because the open enrollment period lasts for a 6 month period beginning the first day of the month in which you are 65 or you are older and have just enrolled in Part B for the first time.

During this open enrollment period, you may enroll in a Medicare Supplement and not have to answer any health questions to be accepted by any Medicare Supplement plan.

If you decide not to keep your COBRA plan, you do not have to worry about your medical care being taking care of with the Medicare Supplement, but after the 6 month window, you will have to submit to a complete underwritten application for a Medicare Supplement.

You may not qualify for a certain policy or it may cost more, if there are other health issues including the cancer after this 6 month window.

I have been advised by many healthcare professionals that some of the newest healthcare and cancer procedures are not readily approved by Medicare Advantage plans, but these procedures are generally approved with “Original or Traditional Medicare.” They have to fight everyday to get the care many desperately need when they have a Medicare Advantage plan. Talk to your medical professional who knows your health situation when making your Medicare plan choice, even if you are someone with a serious health condition, such as heart problems, Alzheimer, MS, end stage renal disease and the list could go on and on … always talk to those that know your health situation.

Medicare Advantage plans are a good option when someone is relatively healthy.

Upcoming workshop

May’s Confused about Medicare and Social Security Workshop is set for 2 p.m. Thursday, May 19, in Sugar Land at Two Sugar Creek Center, 77 Sugar Creek Center Blvd, 5th floor Conference Room, Sugar Land, TX 77478. Seating is limited. Please RSVP 832-519-8664.

Toni King, author of the new Medicare Survival Guide®, which is a simple guide that puts Medicare in “people” terms, is on sale at www.tonisays.com Email questions or to schedule a “Confused about Medicare and Social Workshop” for your organization or company lunch and learn to www.tonisays.com/ask-toni or call 832/519-TONI (8664).

Medigap insurer’s discounts to hospitals and premium credits to patients approved by OIG

In advisory opinion (15-03) earlier this month, the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) found that a Medigap insurer’s arrangement allowing discounts on deductibles at certain preferred hospitals  – with a portion of the resulting savings going to the insurer’s policyholders  – would not result in penalties under the Anti-Kickback Statute (AKS) or Civil Monetary Penalties (CMP) Law prohibition on inducements to beneficiaries, because the likelihood of fraud and abuse under the proposal is minimal.

The requestor was an offeror of Medigap insurance, a supplemental insurance policy sold by private companies to pay some costs that Medicare does not cover. For its Medigap plans, the insurer proposed an arrangement with certain network hospitals through a preferred provider organization (PPO) where the PPO hospitals would provide discounts of up to 100 percent of the Part A inpatient deductibles, for which the requestor would otherwise be liable. Policyholders who were admitted for an inpatient stay at a network hospital would receive a $100 premium credit from the requestor towards the policyholder’s next renewal premium. If the policyholder was admitted to a non-network hospital, the requestor would pay the full deductible.

OIG stated that the AKS safe harbor for (1) waivers of beneficiary coinsurance and deductible amounts and (2) for reduced premium amounts offered by health plans would not protect the requestor’s proposal. First, the safe harbor for waivers of beneficiary coinsurance and deductible amounts “specifically excludes such waivers when they are part of an agreement with an insurer.” Second, the safe harbor for reduced premium amounts offered by health plans “requires health plans to offer the same reduced cost-sharing or premium amounts to all enrollees.” But under the requestor’s plan, the discounts would be available only to policyholders who opted for network hospitals.

Nevertheless, OIG found the risk of fraud and abuse under the AKS to be minimal, for several reasons:

  1. Neither the discounts nor the premium credits would increase or affect per-service Medicare payments, as Part A payments are fixed and not affected by cost-sharing;
  2. The arrangement would not likely increase utilization, as the discounts effectively would be invisible to the policyholders since they “would apply only to the portion of the individual’s cost-sharing obligations that the individual’s supplemental insurance otherwise would cover”;
  3. The arrangement would not unfairly affect competition among hospitals, since the PPO’s hospital network would be open to any accredited, Medicare-certified hospital that meets the requirements of applicable state laws and that contractually agrees with the PPO to discount all or a portion of the Part A deductible for policyholders;
  4. The arrangement was not likely to affect professional judgment, as the providers for the policyholders would not receive remuneration, and policyholders could go to any hospital without additional expense; and
  5. The requestor made clear to policyholders that they have the ability to go to any hospital without additional liabilities or penalties, thereby operating transparently.

OIG also said that the premium credits implicated the CMP prohibition on inducements to beneficiaries, because the credits are offered to induce policyholders to select certain network hospitals. OIG, however, found that the exception to the definition of remuneration for differentials in coinsurance and deductible amounts as part of a benefit plan design, in section 1128A(a)(i)(6)(C) of the Social Security Act, instructive for its analysis.  While the premium credits do not technically fit the exception, OIG viewed the premium credits as having “substantially the same purpose and effect” as differentials in coinsurance and deductibles, thus presenting a low risk of fraud or abuse.

OIG’s advisory opinion is consistent with similar opinions (e.g., 14-02, 14-04, 14-07, 14-10) issued in the past year approving discounts to Medigap insurers by preferred hospitals and credits to Medigap policyholders who use preferred hospitals.

Medicare: 3 Tips to Get the Right Medigap Coverage

Medicare Disease
Medicare covers a lot, but it doesn’t pay for everything. Image: Medicare.

Tens of millions of Americans benefit from Medicare after they turn 65, but one potentially surprising fact about Medicare is that the program doesn’t cover all of your healthcare expenses. With substantial copayments and other charges left uncovered, many Medicare participants turn to Medicare supplemental insurance, also known as Medigap coverage, to help get the full protection they need. Most people have numerous options for choosing Medigap policies, so it’s important to know how to select the right one for you. Let’s take a look at three of the most important things you need to know to find the right Medigap coverage for your particular situation.

1. Different categories of Medigap plans offer different types of coverage.
Throughout most of the nation, Medigap policies are standardized into 10 separate types of plans. Each plan is identified by a letter of the alphabet, and each one covers different expenses that standard Medicare doesn’t cover.

For instance, Plan A policies cover the required coinsurance and hospital-cost payments under Medicare Part A, as well as hospice care. They also cover copayments and coinsurance for medical visits under Part B. However, they don’t cover the expense of skilled nursing facilities or the deductibles for Part A or Part B. By contrast, Plan F policies cover all the expenses Plan A policies take care of as well as the ones listed above that Plan A policies don’t pay for. You can see the full list here at the Medicare website, showing each of the plan categories and what they do and don’t cover.

Keep in mind that more comprehensive coverage will cost more. The most popular plan choices are Plans C and F, which are on the more comprehensive end of the spectrum. Regardless of which plan you like best, it’s essential to make sure you compare the same category of policy when you compare premiums across different health-insurance companies, or else the figures you get will be misleading.

2. Insurance companies can choose from three ways of pricing their policies.
It surprises many people that different health-insurance providers charge widely disparate premiums for what is essentially the same Medigap coverage. The reason often has to do with the method an insurer uses to set prices for Medigap policies.

Medicare allows insurers to price Medigap policies using one of three methods. The community-rated method charges the same premium to everyone in a particular location regardless of their age. Issue-age-rated policies charge you an amount based on the age at which you first get coverage, which tends to benefit those who get their Medigap coverage when they’re relatively young and penalizes those who are late to join. Both of these policies don’t change their policy pricing as you get older, but the attained-age-rated policy does, resetting premiums each year. This results in lower premiums early in retirement, but they’ll steadily rise because of age even if loss experience remains the same.

3. Make sure you coordinate prescription drug coverage with your Medigap policy.
Many retirees like having coverage for prescription drug costs under Medicare Part D. Many Medigap policies also include prescription drug coverage, so to avoid double-paying for identical coverage, you have to coordinate what your Medigap policy covers with what any other available insurance will pay for.

Usually, handling Medicare Part D is as simple as talking with your Medigap insurer and saying whether you need a Medigap policy with or without drug coverage. Keep in mind, though, that if you decide to go beyond your Medigap insurer to get separate Part D coverage, the Medigap drug coverage will get removed from your policy, and you won’t be able to get it back.

To make a smart comparison, you’ll need to find out how much your Medigap insurer charges both with and without drug coverage, and then look at what you’d pay for separate Medicare Part D drug coverage of your own. Then, you can figure out which combination best fits your particular healthcare needs in retirement.

As important as Medicare is in helping people cope with the financial implications of healthcare costs in retirement, a Medigap policy can be essential to protect your assets to the greatest extent possible. Finding the right Medigap coverage is a great way to make sure you’ll be able to afford all the healthcare you need in your golden years.

How one Seattle couple secured a $60K Social Security bonus — and you can too
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Research the differences between Medigap plans

My neighbor just turned 65 and was able to purchase a Medigap plan that costs $160/month. I am 62 and just received Medicare under Social Security disability. I called my neighbor’s Medigap plan and was quoted a price of $350/month for the same plan. I was told that because of my disability, I had to pay more. Isn’t this discrimination?

Most people become eligible for Medicare when they turn age 65. People younger than age 65 may become eligible for Medicare if they develop end-stage renal disease (kidney failure). Other people younger than 65 become eligible for Medicare after it is determined they are disabled under Social Security’s disability rules.

Original Medicare does not cost a person more simply because they are disabled. However, Medicare supplements (a.k.a. Medigap) may charge a person, younger than 65, a higher premium. While this does not seem fair, it is legal.

The federal law does not dictate that Medigap plans sell their products to people younger than 65. Maryland enacted laws protecting disabled people with Medicare; the state requires certain Medigap plans be offered to Medicare-eligible people younger than 65. Specifically, Medigap Plan A and Medigap Plan C are offered to people younger than age 65.

The book “Choosing a Medigap” is available online at www.medicare.gov/Pubs/pdf/02110.pdf and provides details about Medigap coverage.

Savvy Senior: Mobile safety products that can help seniors on the go

Savvy Senior: Mobile safety products that can help seniors on the go

Dear Savvy Senior, Do you know of any medical alert SOS buttons for seniors that work away from the home? I would like to get one for my 80-year-old mother, but would like to find one that’s not limited to the house. — Shopping Son

Dear Shopping, There are actually a number of medical alert products…

Dear Savvy Senior, Do you know of any medical alert SOS buttons for seniors that work away from the home? I would like to get one for my 80-year-old mother, but would like to find one that’s not limited to the house. — Shopping Son

Dear Shopping, There are actually a number of medical alert products…

(Jim Miller)

Under state law, there is a limited period of time that Medigap companies are required to issue a policy for people younger than age 65. During the first six months a person (under 65) is enrolled into Medicare Part B (medical insurance), the person is allowed to enroll in either a Medigap Plan A or Medigap Plan C.

Medigap Plan A is a basic plan that covers the 20 percent of outpatient costs that Medicare does not cover. Medigap Plan A policies have to keep their rates comparable; Maryland law states: “a (Medigap) carrier may not charge individuals who are under the age of 65 years, but are eligible for Medicare due to a disability, a rate higher than the average of the premiums paid by all policyholders age 65 and older in the state who are covered under that plan A policy form.”

Covering the Bases: Enrolling in Medicare and paying the premiums

Covering the Bases: Enrolling in Medicare and paying the premiums

I am turning 65 this year, and I plan on enrolling into Medicare. When and how do I enroll? How do I pay my monthly Part B premiums since I don’t plan on drawing a Social Security check until I am 66?

To enroll into Medicare, you need to contact the Social Security Administration. The easiest way…

I am turning 65 this year, and I plan on enrolling into Medicare. When and how do I enroll? How do I pay my monthly Part B premiums since I don’t plan on drawing a Social Security check until I am 66?

To enroll into Medicare, you need to contact the Social Security Administration. The easiest way…

(Amy Rubino)

The more comprehensive Medigap option is Medigap Plan C. Medigap Plan C covers deductibles, copayments and foreign travel emergency. However, a Medigap carrier may charge a person who is younger than age 65 a higher premium for a Medigap Plan C than it does for a person 65 and older.

Interestingly, when you turn 65, you are no longer viewed as “disabled” under the Medigap rules. At age 65, you would be able to purchase a comprehensive Medigap plan without the higher disability rates applying.

Instead of a Medigap plan, you have the option of enrolling into a Medicare Advantage Plan. This option may help to lower your out-of-pocket costs.

Medicare Advantage Plans are private companies that have contracted with Medicare to offer Medicare benefits. Medicare Advantage Plans may also have added benefits such as vision, dental and hearing services. Medicare Advantage Plans may also include a Part D drug benefit.

If you are considering a Medicare Advantage Plan, request a summary of benefits to better understand the coverage. These plans may limit which doctors and hospitals you must use. There will be copayment requirements for most services.

As a disabled individual, there may be other options available to you. You may contact a SHIP counselor at 410-222-4464, ext. 3080, to see if you qualify for any subsidies to help offset the cost of your Medicare.

Amy Rubino is director of the Senior Health Insurance Assistance Program and the Senior Medicare Patrol for the Anne Arundel County Department of Aging and Disabilities. You may contact either program at 410-222-4464 or ship_program@aacounty.org.

Medicare 2015: Is a Medigap supplement right for you?

Next week, The Oregonian/Oregonlive publishes its annual guide to open enrollment for Medicare Advantage plans. From Oct. 15 to Dec. 7, some 320,000 Oregonians can switch plans without worrying about being rejected based on their medical history.

But for readers approaching age 65 and new to Medicare, it’s important to know that Medicare Advantage isn’t your only option. Depending on your health, where you live and whether your current plan still wants you, it might not be your best option.

For years, Medicare Advantage has dominated the market in Oregon, particularly around Portland, where roughly 60 percent of Medicare beneficiaries enroll in one.

But since 2014, the number of Medigap enrollees in Oregon has jumped by 14 percent, from 129,000 to more than 147,000, according to Oregon Insurance Division records. The spike coincides with Medicare Advantage price increases in some of the more rural counties and the emergence of a new, lower-cost plan in Oregon from Stonebridge Life Insurance Co., state insurance officials said.

Medigap might be especially attractive in 2016 to 5,000 Oregonians whose Medicare Advantage plans are ceasing their coverage. That includes more than 3,000 people in Hood, Clatsop, Tillamook and Lincoln counties, where Cambia Health Solutions is withdrawing its Regence Blue Cross Blue Shield Medicare Advantage plans.

A spokesperson for Cambia said Regence would have had to significantly increase premiums and raise other costs to continue offering its plans in those areas.

“Unfortunately, rising costs have made Medicare Advantage plans financially unsustainable in some areas,” said Cambia spokesman Jared Ishkanian.

Medicare 101

Before we go any further, let’s review some of the basics about Medicare insurance.

Original Medicare covers hospitalizations (Part A) and medical visits (Part B), mostly for seniors age 65 and over. But its coverage is limited. You pay a deductible ($1,260 in 2015) for hospitalizations,, for instance, and 20 percent of the cost of seeing a doctor. Long stays in a hospital or nursing home can lead to high out-of-pocket costs.

Medigap, also known as Medicare Supplement Insurance, fills in some or all of those coverage gaps. There are 10 types of Medigap plans, ranging from letters A through N. Each offers a different level of coverage.

Most Medigap enrollees choose Type F, which covers all out-of-pocket costs. That means their only medical cost, aside from prescription drugs, is their monthly premium.

Medicare Advantage plans, by contrast, can provide somewhat broader coverage than basic Medicare with Medigap supplements. Some Medicare Advantage plans, for instance, cover prescription drugs, dental and eyecare, usually within a prescribed network of providers. Premiums can be lower, too.

But Medicare Advantage plans impose additional costs, too  — deductibles, coinsurance and copays — when members seek care. Those costs can add up quickly if you have a lot of health issues.

“The advantage plan is good if you’re healthy but it breaks down if you aren’t,” said Richard Reynolds, a volunteer with Oregon Senior Health Insurance Benefit Assistance (SHIBA) program in Newport.  

So which is right for you? Consider these advantages and disadvantages:

Medigap Pros

They’re standardized. Coverage varies by plan type (see the chart below), but within each type, the benefits are the same. Insurers can’t offer extras or curb coverage. This makes comparing rates a lot easier. Even so, premiums differ quite a bit.

They’re portable. You need not stick to a health maintenance organization or physician network to find care as you would with most Medicare Advantage plans.

John Melvin, diagnosed with prostate cancer,  sought a targeted radiation treatment that wasn’t available in Portland, his wife said. He ended up traveling to Swedish Medical Center in Seattle. Medicare and his Medigap Type F plan have paid all of his bills totalling more than $50,000, she said.

“We haven’t paid a penny – just as advertised,” Susan Melvin said.  “On an Advantage Plan we would have had to pay the premium plus probably the max out of pocket.” And it’s not clear any Medicare Advantage plan would have allowed him to go to Seattle to seek treatment, she said.

For retirees who travel a lot, Medigap might be more suitable. Six types of Medigap plans provide up to 80% coverage for emergency care outside the country.

There may be fewer billing disputes. Providers submit claims to Medicare for reimbursement. Then the Medigap policy pays the rest. As long as Medicare covers the care, you shouldn’t have to haggle with the insurance company to cover the claim.

“The insurance company isn’t making any decisions,” said Reynolds. “Claims to go Medicare and they determine what’s allowable.

Plan F covers all gaps. One monthly premium takes care of all copays, coinsurance and deductibles. Policyholders know their medical and hospital costs up front, though prescription drug costs will be extra.

By contrast, medical bills under some Advantage plans could reach $6,700 a year, possibly more, on top of premiums.

Birthday rule. Each year, Oregon allows Medigap policyholders to switch carriers within 30 days of their birthday. They can only switch to the same type of Medigap plan or a type with fewer benefits (from Type F to Type C, for instance).

This special open-enrollment period gives consumers an out if premiums continue to increase or they want a less expensive plan.  Without the rule, insurers could inquire about a senior’s health history and use it to deny coverage.

Lyn Weber switched on her birthday in May from Omaha Insurance Co. Plan F to USAA Life Insurance Co. Plan F. The move saved more than $300 a year in premiums, her husband said.

“No brain surgery required,” Walt Weber said of the switch. “There’s no discernable difference in service. All bills are being paid and handled the same.”

Medigap Cons

They don’t cover prescriptions. If you want drug insurance, you’ll have to buy a stand-alone Part D drug plan. This can increase your monthly costs next year in Oregon by between $18 and $154 a month. Such plans might have their own deductibles, and seniors with large drug bills will pay even more in the Part D coverage gap. Many Medicare Advantage plans, by contrast, include prescription drug coverage as part of one monthly premium.

And if you wait to get a Part D plan after you’re first eligible for Medicare, you’ll pay a monthly penalty that increases for each month you delay. More on that online at bit.ly/PartDpenalty

They don’t cover eyeglasses, hearings aids or dental care. Some Medicare Advantage plans do, for an additional premium.

Premiums are generally higher and increase with age. Last year, for instance, more than 40 insurers offered Type F plans for between $128 and $267 a month for a 70-year-old, according to Oregon SHIBA. That’s without any drug coverage.

In 2016, Medicare Advantage premiums in Oregon will range from $0 to $242 a month. Some of those cover prescription drugs and other care. But remember, Medicare Advantage plans also impose additional costs in the form of co-pays, co-insurance and deductibles.

Some doctors won’t see you. Several large doctors’ practices in the Portland and Salem areas — including The Portland Clinic and Cascade Physicians — have stopped taking new Medicare patients with Medigap plans, requiring Advantage plans instead. This could make finding a primary care provider more time consuming, experts say.

Volunteers in Oregon’s rural counties, where fewer Medicare Advantage plans are available,  do not see this trend, however. “For the most part, people are able to access the physicians that they need,” said Cheryl Webb, a SHIBA volunteer in Baker City.

Guaranteed acceptance is limited. If you buy a Medigap policy within 6 months of starting basic Medicare Part B, an insurer must accept you, regardless of your medical history. But if you wait, insurers can deny coverage based on your health.

There are exceptions. There’s the birthday rule mentioned above. If your current Medicare Advantage or Medigap plan drops coverage, you get guaranteed acceptance into another plan. That’s also true if you move out of your Advantage plan’s coverage area or if you enrolled in an Advantage plan and want out in less than 12 months.

Bottom line

What’s right for the Melvins and Webers might not be best for Mr. Weed or you. If you’re new to Medicare, review your options with an Oregon SHIBA volunteer or a health insurance broker who sells a variety of plans. Read last year’s Oregon Guide to Medicare Insurance Plans from SHIBA. And search for Medigap policies and prices at Medicare’s online search engine:  bit.ly/MedigapFinder.

— Brent Hunsberger is an Investment Adviser Representative and CERTIFIED FINANCIAL PLANNER™certificant in Portland. For important disclosures and information about Brent, visit ORne.ws/aboutbrent. Reach him by email or leave a message about his columns at 503-683-3098.

 

‘Medigap’ insurance covers what Medicare doesn’t

If you’re about to turn 65, you may be shopping soon for a health plan that covers the costs that traditional Medicare doesn’t.

As welcome as Medicare’s health care coverage is, it does have its gaps. The traditional fee-for-service program generally pays 80 percent of the medical bills. Which means the remaining 20 percent becomes the responsibility of beneficiaries.

To protect themselves, many people buy supplemental coverage from private insurers. The “Medigap” insurance, as it’s called, helps fill the gaps that deductibles, copayments and coinsurance leave. It makes out-of-pocket costs more manageable.

Not everyone should consider a Medigap policy. You don’t need to supplement your Medicare coverage if you’re on Medicaid or signed up for a private Medicare Advantage plan or enrolled in a group health plan through an employer or former employer.

But about one in four Medicare beneficiaries does purchase a Medigap policy.

The best time to buy one is within six months of turning 65 and enrolling in Medicare’s Part B medical insurance. During that period, insurers can’t refuse to sell you a policy, or charge you more than other people, because of a health problem.

If you try to buy after those six months, there’s no guarantee an insurer will cover you.

To help you understand what you’re buying, the government standardized Medigap benefits years ago and labeled each kind of plan with a letter, from A to N. Today, there are 10 kinds of plans. All insurers selling a particular kind of plan must offer the same package of benefits.

Visit www.medicare.gov and click on “Supplements and Other Insurance” to find out more about each of the 10 available kinds of plans.

All 10 standardized plans cover these basic benefits: the coinsurance for extended hospital stays, the coinsurance for doctor visits and outpatient services, the coinsurance for hospice care, and the cost of the first three pints of any blood you might need.

Beyond that, different Medigap plans cover additional out-of-pocket expenses, such as the hospital deductible, the outpatient deductible, the coinsurance for skilled nursing care, and the cost of medical emergencies while traveling outside the country.

You’ll pay the insurer a monthly premium for your Medigap policy in addition to the monthly premium you’ll pay Medicare for Part B. Although insurers must offer the same benefits within each kind of plan, their premiums can vary widely. So shop around.

It’s also wise to find out how often an insurer has raised premiums. It’s not just the initial price, but what happens year to year. An insurance broker will have that information.

One note of caution: Medigap insurance doesn’t plug all the holes. It’s not a way to pay for long-term custodial care, dental care, eyeglasses or hearing aids. Also, new Medigap policyholders need to buy separate drug coverage under Medicare’s Part D if they want it.

Still, the combination of traditional Medicare coverage and a Medigap plan makes good sense for beneficiaries who prefer a broad choice of doctors, hospitals and other health care providers but still want to limit their out-of-pocket expenses.

If you’re interested in supplemental insurance, here are four steps to follow:

First, decide which benefits you want and which standardized Medigap plan best meets your needs. Visit www.medicare.gov or call 1-800-633-4227 and request a free copy of the Medicare publication “Choosing a Medigap Policy.”

Next, find out which insurers sell Medigap policies in your area. Visit www.medicare.gov for a comparison of supplemental plans. Or call the Texas Health Information Counseling and Advocacy Program at 1-800-252-9240 or the Texas Department of Insurance at 1-800-252-3439.

Then, do some research on the insurers that interest you. Besides comparing premiums, check the companies’ customer service. The State Department of Insurance will have a record of consumer complaints against particular insurers.

Finally, pick the policy that best fits your needs. Contact the insurance company directly, or work with an insurance broker or agent. Once your application has been accepted, you can keep your insurance as long as you pay the premiums.

Bob Moos is Southwest public affairs officer for U.S. Centers for Medicare and Medicaid Services.