It was a heartbreaking reunion … sitting with a couple at the kitchen table with tears streaming down their faces. He was very ill, was losing weight rapidly due to digestive problems, and his constant migraines were so painful that ending his life seemed like the only option to live without pain. To say they were afraid would be an understatement. Doctors associated with your current Medicare Advantage Plan (Medicare Part C) were unable to diagnose the problem. They only prescribed more medication, which exacerbated his problems. In addition to his medical conundrum, the Plan denied medical tests, which could ultimately have diagnosed his problem. It was October 2011 and, through tears, they painfully asked, “What are our options?”

In this case, we together decided that it was best for him to switch to a Medicare supplement plan (MediGap), which would allow him to go to any doctor or facility that accepts Medicare, along with a “Stand-alone Part D Prescription Drug Plan.” “It was important that he be able to seek the best of the best, anywhere in the country. We chose a “Supplemental Plan F” with a provider that would allow him to switch between a lower and higher cost plan WITHOUT demonstrating insurability (if in the future he decides to keep the Supplemental Plan after his current medical problem is resolved).

Could you have avoided this problem in the first place? Possibly. Here are a couple of errors that I have seen, along with the solutions, to help you choose the right option for YOU:

ERROR # 1: Who are you working with?

* Work with a “captive insurance agent” (direct employment with the carrier, many times they are compensated by W2, commissions and / or bonuses) or work with an “independent career agent” (1099 contractor with the carrier and with tracks) . The last term confuses me a lot. They are classified as independent, however, if they write an application with another carrier because it was suitable for the beneficiary, their contract may be terminated. What incentive does the agent have not to be biased if he loses his main source?

** Another mistake is working with an agent who is not certified to market all types of Medicare health plans. Only certain add-on plans ‘MediGap’ without certification can be marketed.

*** Go directly to the insurance company. If something goes wrong, it will help to have an advocate on your side, especially one who can see and who lives / works in your community.

SOLUTION # 1:

* Choose an independent insurance agent who represents more than one insurance company. Why? Because independent agents will know the pros and cons of ALL plans and will be able to pass this information on so you can make an EDUCATED decision. They receive compensation from insurance companies, but they have no loyalty to any particular company. Also be on the lookout for carriers forcing their ‘independent agents’ to sign an exclusive agreement. I have seen this happen with ‘dual eligibility plans’ (Medicaid / Medicare plans). Again, how can the agent be “non-biased” if he is contractually bound to market only one Plan?

** Choose a “certified” Medicare insurance agent who can market Part C, Part D, and MediGap plans. They have additional training and supervision.

*** When you go directly to the carrier, you are eliminating a valuable person who will fix problems if any arise, while giving you additional peace of mind throughout the entire process.

ERROR # 2: Choose a Medicare Advantage plan that requires you to get approval from the insurance company before undergoing a procedure / test.

SOLUTION # 2: When comparing plans, see the “Summary of Benefits.” All operators must publish them and they must be the same and easy to compare.

ERROR # 3: Not paying attention to the ‘maximum out-of-pocket’ limit (MOOP). All Medicare Advantage plans have a MOOP, and many agents review it as they help you choose your plan. However, if a catastrophic medical problem arises (cancer, organ transplant, prolonged stay in a skilled nursing facility, etc.), it is very likely that you will reach your MOOP, so you need to make sure it is as low as possible. The reason: Chemotherapy and anti-rejection drugs are considered Part ‘B’ outpatient drugs, not Part ‘D’ prescription drugs, and many plans only pay for 80% of Part B drugs. Therefore , I would be hooked by 20% and they are very expensive.

SOLUTION # 3: Compare, compare, compare and choose a plan with a lower MOOP.

ERROR # 4: Choose a plan just because drug copays are slightly lower. Many smaller insurance companies will read it in their Plan with very low copays on their drug formulary, but they have a smaller network of doctors / facilities to choose from. The problem is, should a medical problem arise, you may be locked into the smaller network of doctors / facilities until Medicare’s Annual Open Enrollment.

SOLUTION # 4: If you are having trouble paying your prescription drug copayments and your income / assets are low enough, you may be eligible for Extra Help through Social Security. A good insurance agent will bring this up and guide you, or go to https://secure.ssa.gov/i1020/start. When getting help with your medication, you can choose the best plan based on other options (your network size, authorization rules, physician / facility convenience, optional additional benefits, etc.)

ERROR # 5: Choose a plan because you want a PPO plan and not an HMO.

SOLUTION # 5: Many people have the misconception that with a PPO plan they can go to any doctor / facility they choose. In reality, PPO plans still have a network of doctors / facilities that you must stay at to get the lowest costs. The biggest difference between a PPO and an HMO is that with a PPO, you don’t have to get a “referral” to see a specialist. With an HMO, you must get a referral. In order to choose ANY doctor / facility in the country that accepts Medicare, you must consider a Medicare supplement plan (MediGap).

I have seen most of the mistakes and solutions when it comes to choosing Medicare Advantage health plans. Outside of California, there are additional varieties of plans and there may be additional challenges.

What happened to my client, you ask? As I keep in constant contact with my clients, in June I was overjoyed to hear him exclaim the great news. Using the same test that his previous Medicare Advantage Plan denied, two doctors from a major Los Angeles medical group identified the problem. He was slowly leaking cerebrospinal fluid and was dangerously close to none remaining. With a quick outpatient procedure, they basically lasered the area of ​​the leak, replaced his cerebrospinal fluid, and he is healthier, happier, and better than ever. Since you are fine now, we will review your coverage during Medicare Annual Open Enrollment (October 15 – December 7, 2012) and decide whether to keep you on the Supplement or switch you to a Medicare Advantage Part C Plan.

As an insurance agent for many years, I have stories like this and many more. With compassion, our profession helps navigate the best options, explains the pros / cons based on the individual needs of our clients, and offers peace of mind. Plans change every year and your health / financial status can change too, so it’s a good habit to do a comparison every year. Finally, choose a good, local and independent insurance agent, be polite and stay well informed.