Author Archives: Diane Reilly

Why I Switched From Medicare Advantage

posted November 2023 by Diane Reilly

I am a Medicare SME — subject matter expert. At the risk of sounding like a braggart, I have over 20 years of professional health insurance experience. Educating people about Medicare is what I do.

When I turned 65 almost three years ago, I assumed my decision about the Medicare insurance products I would choose would be more of a sprint than a marathon — but it wasn’t. Like a doctor facing a devastating diagnosis, or a lawyer in the middle of a divorce, when decision-making becomes a personal choice, it gets complicated!

The most important choice I had to make was deciding between Original Medicare (Part A, Part B as my primary insurance, Part D for a prescription drug plan) and a Medicare Advantage plan, in which I would receive Medicare benefits via a private insurer.

Here are few of the factors that played into my decision:

Risk Assessment and Tolerance

I turned 65 during the pandemic. At first, it seemed my risk of contracting a serious illness had become a very real threat. However, lifestyle changes during this period left me feeling healthier than ever before! For example, I now had time to walk five miles a day and cook healthier meals. And, because I limited my exposure to the outside world, I never even got a cold! I lost weight, my blood pressure and blood sugars dropped dramatically, and I found myself asking the following questions:

Should I save on monthly premiums by choosing a Medicare Advantage plan — one with a zero-dollar copay? The extra benefits — dental care, fitness reimbursement, eye exams and eyewear, hearing exams and hearing aids — were certainly enticing and might keep me healthier.

Was I prepared to limit my use of medical providers due to network restrictions?

Was I willing to deal with the administrative burdens of the managed care insurance world? As a former insurance company employee, I was all too familiar with network restrictions; prior authorization requests and denials; abbreviated hospital, skilled nursing, and rehab stays; medical decisions made by insurance company algorithms; and appeals necessitated by disagreements over clinical issues.

Was I being overly optimistic about the future state of my health? I have always been healthy, but many members of my immediate family have complex medical histories.

Financial Considerations

I was laid off during the pandemic. Without access to employer group insurance through my own employment or that of a spouse, I had no choice but to enroll in Medicare. Now I had a whole new set of questions to ponder!

If I enrolled in Medicare and got another job right away with employer group health insurance, should I disenroll from Medicare?

If I did not find another job, what could I afford to pay for my health insurance? Medicare premiums are a fixed expense and with a Medicare Supplement plan, I would not face the uncertainty of copays and coinsuranceas I would on a Medicare Advantage plan. Outside of fluctuations with prescription drugs costs, my health care expenses would be fixed and predictable. Keeping Medicare as my primary insurance with a comprehensive supplement plan and a Part D drug plan would cost more upfront but mitigate my potential financial risk.

If I had a catastrophic medical event while on a Medicare Advantage Plan, was I prepared to pay thousands of dollars to meet the out-of-pocket maximum dollar amount?

Access to Medical Care

During the pandemic, I limited my travel and had been mostly satisfied with the care received from local providers. But…

What if I were no longer satisfied with my current medical providers? A PPO Medicare Advantage plan would certainly increase the chances I could find a network provider, but was I willing to incur the extra cost if I could not find someone in the network to meet my needs?

With a second home in another state, would a Medicare Advantage plan allow me access to local doctors and hospitals if I were far away from my primary residence?

What if I, like my mother, I was diagnosed with an aggressive cancer? Would my plan allow me the freedom to seek the highest quality of care?

Emotions and Outside Influences

I was determined not to let fear dictate my path. However, other voices tried to influence my decision:

Misleading advertisements that did not disclose the full cost of Medicare Advantage plan choices

Well-meaning friends and others who shared horror stories or pressured me to follow their lead

Initially, I Chose Medicare Advantage…

I countered any doubts by remembering the following:

Medicare Advantage plans have a “trial right period.” During my first year, if I found my Medicare Advantage plan to be unsatisfactory, I had the right to disenroll and return to original Medicare, buy a Medicare supplement, and part D drug plan.

My decision was not forever. Every year during Medicare Open Enrollment season, Medicare beneficiaries can make plan changes. Massachusetts, along with Maine, New York, and Connecticut, is a “guaranteed issue” state. Residents are permitted to switch back and forth between Medicare Advantage plans and Original Medicare plans without paying a higher premium due to preexisting health conditions. In the other states, if you do not enroll in a Medicare supplement plan within six months of becoming eligible for Part B, and want to enroll later, an application is reviewed by underwriters. Depending on an individual’s health history, enrollment may be denied or an extra premium required.

But Then I Switched to Original Medicare…

During my third year, I switched. My reasons were numerous, but here are just a few:

When a screening mammogram revealed a suspicious lesion, I underwent another diagnostic mammogram, an ultrasound, a surgical biopsy, a breast MRI and, eventually, a lumpectomy. Each of these procedures had copays and they were starting to add up.

Under an Advantage plan, it was my responsibility to ensure that all the medical professionals rendering my care were within my network. Prior to undergoing anesthesia, I was required to wear a halter monitor for a few days. I did not know that the company used to interpret the results was not in my Advantage plan network. I ended up paying out of pocket for that service. I appealed the claim denial. It took me 18 months of frustrating phone calls and letters before I prevailed and received reimbursement.

I was fortunate that my lesion was discovered and excised early and I need no further treatment. But what if there is a next time?

I have now experienced an entire year with Medicare as the primary payer of my medical services, with a supplement plan picking up the balance. I have enjoyed the freedom of being able to see any provider who accepts Medicare, and the freedom from copays and unpredictable medical expenses.

I will admit to a brief cringe when I pay my premium each month and I miss some of the extra perks of my Medicare Advantage plan. But I am far less worried about accessing quality medical care — my decision makes financial and emotional sense.

Overall, my first-hand experience with both Medicare options has led me away from recommending Medicare Advantage plans to others — at least most of the time. Your circumstances may be different. As always, the best decisions are made with complete information and a rational weighing of the options.

Medicare Part D: Still Very Complicated

posted March 2023 by Diane Reilly

If you read the newspaper or listen to the news, it won’t take long before you encounter some reference to Medicare and lately, to Medicare Part D. Politicians, insurance companies, pharmacies, drug manufacturers, and most importantly, healthcare consumers, all have an important stake in prescription drugs.

Unfortunately, and to borrow a movie title, “It’s Complicated.” Even if you were to read every current publication on the topic, chances are you would still have questions. So, let’s see if we can simplify things down to the essentials…

What You Really Need to Know About Medicare Part D

Not until The Medicare Modernization Act of 2003 (implemented in 2006), was Medicare mandated to implement a prescription drug program that included plans being administered by private insurance companies.
Eligible plans are driven by your zip code. Typically, there are 20–25 different drug plans from which to choose.
Prescription drug plans (PDP) place drugs into different levels called “tiers.” The tier determines how much a drug will cost you.
In 2023, the estimated national average prescription drug plan premium is $32.74. The standard Part D annual deductible is $505.
Enrolling in a Part D drug plan is not mandatory. However, if you do not enroll in a Part D drug plan according to the regulations, you will be assessed a penalty for every month you were without Part D should you enroll later.
Enrollments into Part D plans are only accepted during designated Medicare enrollment periods.

How Medicare Part D Prescription Drug Plans Work in 2023

Part D drug plans are structured into four phases or stages. During each phase, Medicare, the prescription drug plan, and the consumer, each contribute different amounts toward the retail cost of the drug.

Because of this cost-sharing approach, a consumer may pay a different amount from month to month for the exact same drug! The four phases are as follows:

#1. The Deductible Phase

This phase begins with your first prescription of the plan year. If the deductible applies to the prescriptions you are purchasing, you will stay in this phase until your out-of-pocket costs hit the deductible threshold.

Not all drugs count towards the deductible and some people never leave this stage.

With plans allowed to have up to a $505 deductible, this phase often shocks consumers at the beginning of the plan year.

#2. The Initial Coverage Phase

During this stage, your plan pays for a portion of your prescriptions and you pay the remainder — determined by the Tier classification of your drug. You will remain in this phase until you and your plan have accumulated $4,660 in retail drug costs and you enter the Coverage Gap phase.

This phase makes good sense to consumers and eases their concerns.

#3. The Coverage Gap (aka “The Donut Hole”)

Here, your plan limits the amount they pay towards the cost of your prescriptions; you will pay approximately 25% of the retail cost of your drugs.

You will remain in the coverage gap until you and the plan have paid a total of $7,400 toward the cost of your drugs.

This phase confuses consumers because the cost of their prescriptions can go up exponentially.

#4. Catastrophic Coverage

During this phase, your plan and Medicare will pay 95% of the cost of your drugs.

This phase can be helpful to some, however, with the retail cost of some prescription drugs as high as $20,000/month, even the remaining 5% can still be significant ($1,000/month).

Recent Changes

The Inflation Reduction Act, passed in August of 2022, has already had a significant impact on the Medicare Part D benefit:

For insulin, the out-of-pocket cost sharing under Part D drug plans is now limited to $35 per month.
Cost sharing for adult vaccines covered by Medicare has been eliminated.
Drug companies will be required to issue rebates to Medicare for Part B drugs if the cost of these drugs rises faster than the inflation rate.

Anticipated Changes

Beginning in 2025, out-of-pocket prescription drug cost sharing will be capped for all Medicare beneficiaries at $2000 a year. This will be a huge development for those who take very expensive chemotherapeutic or biologic medications.
Beginning in 2025, beneficiaries will have the option of “smoothing” their Medicare Part D drug costs, allowing for monthly installments spread over the year.
Beginning in 2026, the federal government will be required to negotiate prices directly with drug manufacturers. So excited about this development!!!

Things to Do

Conduct a detailed analysis before enrolling. Consider your eligibility, the specific drugs you take, the dosage, how often you take them, and your preferred pharmacy.
Create a Medicare account and access a tool called the Plan Finder. (Healthassist will be offering webinar training on how to effectively use this tool prior to the next open enrollment season.)
Compare pharmacies. Larger chain pharmacies with significantly more buying power typically offer much lower costs.
Review the monthly explanation of benefits (EOB) you receive from your drug plan. It will show you the retail cost of your drugs, what Medicare contributed, what your drug plan paid and your out-of-pocket costs. This information will aid you in anticipating potential cost changes.
Investigate “Extra Help.” These government-sponsored programs can reduce prescription drug costs. Eligibility is based on income.
Use drug manufacturer coupons. Ask your prescribing physician about such programs. They may be able to assist you with accessing the program and completing required paperwork regarding your clinical status.
Investigate companies like Good Rx and SingleCare Rx. These companies distribute coupons and provide information on retail costs at varying pharmacies. Analyze first!! If you buy certain prescriptions without using your Part D drug plan, these purchases do not count towards the out-of-pocket costs tracked by Medicare and can affect your movement from one Part D drug plan phase to another.

Final Thoughts

There is much to learn about the reform provisions to the Medicare Part D Prescription Drug Program. Sorting fact from fiction, understanding changes to the program, and assessing the financial and practical impact to you as the Medicare consumer will not be easy.

But, an investment of time and effort will help you to get the most from it. Be sure to use trusted and reliable sources to gather information and stay abreast of the changes. It remains “complicated.”

Portals, Passwords, and Patience: Essential Elements for Understanding Your Health Plan

posted January 2023 by Diane Reilly

For many of us, the start of a new year brings a host of resolutions and a long to-do list for improving our physical health. One item that should be on that list is to fully appreciate, understand, and utilize our respective health insurance plans.

Patient Portals / Insurance Portals

Healthcare consumers have become accustomed to using healthcare system portals to make and cancel appointments, request prescription refills, view test results, and even pay bills.

However, health insurance portals are often underutilized. That’s unfortunate because these can provide a wealth of information, including assistance with healthcare accessibility, a detailed understanding of the terms and conditions of a policy, clarification of benefits, and more, all of which can potentially save thousands of dollars in healthcare costs.

To access your health insurance portal, simply visit the insurance carrier’s website and register for an account. While this will add one more portal and associated password to what I am sure is already a long list (!), I can assure you it is worthwhile.

The Benefits of Insurance Portals

Above all, using your portal will save you money. Most of us are in plans in which we have coverage and/or pay less if we use a certain network of providers and if we are prescribed prescription drugs that are in the plan’s formulary (list of drugs covered). We may also pay less if we use a free-standing facility rather than a hospital for lab work, X-rays, diagnostic imaging, outpatient surgery, etc. Your portal contains all of this information.

More specifically, your portal can help in…

Finding a provider. Most insurers have defined networks of providers. To determine if a provider is considered in or out of network, or to find a new provider, use the “Provider Look Up Tool.”

Understanding your prescription drug benefits. Health insurers are required to publish a drug formulary. This helps you know whether a particular drug is covered, how it is classified, and whether there are quantity limits or requirements for prior authorization.

Accessing plan documents. You may have received a Plan Summary or a Guide to Using your Health Plan and a booklet entitled “Evidence of Coverage” (EOC) in the mail along with your ID card when you first joined your plan. These documents are accessible on the portal; it is the place to begin your search for answers when you have a question about how your health plan works in a specific situation. The EOC is the contract you have with your insurer and will be found here, too.

Tracking your deductible. Most health insurance policies have an annual deductible — the amount you must pay out of pocket before your insurer begins to make contributions to your healthcare costs. Tracking this on the portal provides an accounting of what you have already paid out of pocket as well as the cost of upcoming services.

Clarifying Bills. If you receive a bill and don’t understand why, or if it seems incorrect, don’t just pay it! Do some research first. You can see how the claim was processed, helping you to calculate what your out-of-pocket cost should be. If you do need to call for an explanation, you will have good information in hand with which to begin a dialogue.

Making premium payments. Paying your premium online is fast and easy, saving you the time and money it takes to write a check.

Downloading forms for reimbursement or getting a new ID card. If you are seeking reimbursement from your insurer for services received out of network or out of the country, or for fitness and other benefits, all necessary forms are on the portal. You may also use the portal to request a duplicate copy of your ID card.

Obtaining healthcare information. Many portals provide both information and incentives for managing chronic conditions, such as asthma, diabetes, and heart disease. Phone numbers for 24/7 nurse call lines and what to do in an emergency are often published there as well.

Tips on Calling Your Insurer

If you do not have internet access or are not computer-savvy, you always have the option of calling the customer service line (the phone number is on the back of your ID card). When you call, remember to do the following:

Be prepared to wait. It may require both patience and tenacity to speak with a representative.

Have your information ready. Your health plan ID, member or group number, your date of birth and, occasionally, other identifying information such as your home address or Social Security number.

Know with whom you interacted. Obtain the first and last name of the representative. Make note of the time and date of the call as well. This may be useful later on if there are disagreements regarding the information you received.

Request a “call reference number.” In the event of a misunderstanding or dispute, the call reference number will provide quick access to a recording of the call, helping to expedite resolution.

Help a friend. If you are calling on behalf of a friend or family member, be prepared to have them join the call or submit a form designating you as an “authorized representative.” Health plans must follow strict privacy rules and cannot speak with anyone other than the member or their authorized representative.

Final Thoughts

Although we wish health insurance was simple, it is not. You need to invest some time and effort if you are going to get the most from it. Using an insurance portal for your plan can save you both time and money as the new year begins!