Medicare Traps and Mistakes

You are turning 65. What are the Medicare traps and mistakes most retirees make in navigating the Medicare maze? One big-mistakewrong decision can cost you thousands of dollars. Your choice is much more complex than just deciding on original Medicare and a supplement plan or Advantage.

There are various ways to go down this journey and no doubt self education is part of the process. You can attend seminars, read the countless brochures and pamphlets that arrive daily before you turn 65 and talk with friends. Whatever you do, just make sure you avoid the Medicare traps that lie ahead.

No doubt the BIGGEST mistake in choosing a Medicare plan is failure to properly estimate the cost of health care.

Maybe my story will help.

I am a baby boomer, going on Medicare in September of this year. In spite of 40 years in the health insurance industry, transitioning to Medicare was more challenging than I expected. Looking at Medicare options reminds me of my first time in Home Depot.

 

Georgia Medigap plans & Prices

Georgia Medigap plans & Prices

Medicare traps and Home Depot

The first time I walked into Home Depot I was overwhelmed. I am not much of a handy man, but I do know which end of the hammer is useful.

hd hammerHome Depot must have had 100 hammers.

I needed someone to not only point me in the right direction, but explain why one hammer was better than another for the particular work I was doing.

Before Home Depot I owned 1 hammer. Now I have at least half a dozen, each designed for a particular job.

Medicare is the same way.

There are over 170 different GA Medicare plans to pick from. How do you find the right one?

Perhaps the biggest mistake people make in choosing a Medicare plan is underestimating the cost of health care.

Most people I talk to are in relatively good health and they assume they will remain that way for years to come.

I hope they do.

But we never know what lies around the next turn of the page on a calendar. Things can happen overnight.

 

Medicare Part D mistakes

One very common Medicare trap is failing to anticipate the cost of health care. More specifically, underestimating the cost of medications under Medicare Part D. drugs

If you have had a decent health insurance plan with Rx copay’s before Medicare you will probably be very disappointed in what you get with Medicare. Drugs that had a $20 copay under a group health plan may be $35 or more.

Diabetics using Novolog can expect to pay anywhere from $55 to $90 or even more for a 30 day supply. After you hit the donut hole your cost increases to $200 for a months supply.

AARP lists Part D goofs in their Top 10 Medicare Mistakes.

Mistake No. 5:
Not signing up for Part D because you don’t take any prescription drugs

Mistake No. 6:
Picking a Part D drug plan on the basis of its premium or its name or because your best friend chose it

If you are like most people, at some point while you are retired your largest expenditure will be for medication. Roughly 70 – 80% of your OOP health care costs will go toward medication.

 

Ken’s Medicare journey

About 4 years ago I met Ken and his wife over coffee at a McDonalds. Both were active and had enjoyed good health. Both were turning 65 and going in Medicare in a couple of months.

They were financially comfortable. Not wealthy but better off than many their age. They had been accustomed to high deductible health plans and wanted the same once they were on Medicare. The high deductible plan F (Hi F) appealed to them as a way to keep their monthly costs down.

They were business owners and, while the business was not going as well as it once did it still provided them with income to supplement their savings and Social Security.

At the time the Blue Cross Hi F plan was reasonably priced around $40 per month. Blue discontinued that plan about a year after they bought it because they lost too much money on it. Premiums for the Hi F have risen by double digits ever since. Aetna has one of the best rates now and is charging around $70/month for someone turning 65.

hospital bed emptyA few months after Ken enrolled in Hi F his health took a turn for the worse. Several weeks in the hospital and the doctors could not figure out what was wrong. He was weak, his heartbeat was erratic and they had difficulty stabilizing him.

He was eventually well enough to go home only to return to the hospital the next month, and in a new year.

Medicare Part A, the hospital inpatient portion, currently has a $1260 per admission deductible. When you have Hi F you pay the first $2180 in charges before the plan pays anything.

If your claims cross a calendar year you are looking at more than $4,000 in out of pocket costs.

That’s tough for anyone but to make matters worse, his illness meant he could no longer work. Their business continued to falter which put more financial pressure on them.

In addition to hospital and doctor charges, Ken began a new medication regiment. His drug costs went from less than $100 per month to over $600.

The biggest Medicare trap in my opinion is failing to anticipate your out of pocket health care costs.

In this situation, the worst thing he could have done would have been to have a Medicare Advantage plan where his OOP (out of pocket) costs would have more than tripled from $2,000 per year to $6,000.

Comparing Hi F to plan N is a much better value and in many cases about $30 more per month.

 

Confusing Medicare Advantage and Medigap

Along with buying the same plan your friends have, we often find that retirees think Medicare Advantage and Medicare supplement are the same thing. medicare disadvantage

They are not.

Medicare Advantage has a lot of moving parts, usually requires you to use a network provider to avoid penalties, makes it necessary to review (and probably) change your plan every 1 – 3 years, and will end up costing you a lot of money in OOP expenses when you need your plan the most.

Consumer Reports says confusing Medicare Advantage with original Medicare is one of the Seven Medicare Traps and Costly Blunders.

About one in four Medicare recipients opt for the newer Medicare Advantage plans. These are private plans (mostly HMOS) that take the place of original Medicare plus Medigap, and usually the Part D drug plan as well. While you’ll probably pay lower monthly premiums, bear in mind that you will not have Medigap to cover any deductibles and co-pays, which can vary from plan to plan. Thus, one of the downsides of an Advantage plan is potentially higher out-of-pocket costs if you get seriously ill.

Ken (in our story above) did have original Medicare and a Medicare supplement plan (Hi F) and still had over $4,000 out of pocket over 2 years. As bad as that was it could have been over $13,000 with an Advantage plan.

 

More Common Medicare mistakes

At one time your Social Security normal retirement age and beginning Medicare occurred at the same time, age 65. In 1983, long before Congress started raiding the “Trust Fund” to pay current obligations, they decided something had to be done to “save” Social Security.

medicare bad newsBeing politicians, their ingenious way was to DELAY future benefits for baby boomers and younger by changing the NRA (Normal Retirement Age) from 65 to 66 and even later.

Deciding when to start receiving Social Security is one thing, but don’t just assume that your Medicare should coincide with Social Security.

Bottom Line lists failure to sign up with Medicare at number one on their list of Medicare Traps

How much could a sign-up delay cost you? With Medicare Part B (that’s medical insurance), for each full 12-month period that you are late in signing up, a 10% penalty is tacked on to your premiums (basic premiums are $104.90 per month in 2015) for as long as you keep getting Part B. With Part D drug coverage, the penalty is 1% of the “national base beneficiary premium” ($33.15 per month in 2015) multiplied by the number of full uncovered months you were eligible but failed to sign up. The penalty applies if you are not enrolled for 63 days or more in a row when you don’t have creditable prescription drug coverage. (Creditable coverage means that your plan’s coverage is comparable to Part D plans.)

All of that could add up to perhaps $3,000 to $5,000 in penalties over the course of your retirement if you are one year late signing up…or climb to more than $10,000 if you are several years late.

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Free Colonscopy

Free colonoscopy! Courtesy of Obamacare, everyone is entitled to a free colonoscopy when it is age appropriate. You may also be eligible for a colonoscopy at no charge (to you) based on your medical or family history. Normally this procedure is $1200 – $1500 but the folks at Obamacare have said you can have it at no charge along with over 100 different preventive services.find medicare information

Free birth control was not part of the law but it just sounded so good they decided to shoehorn that in because it worked into the overall political pitch. Along with you can keep your plan and your doctor why not throw in free contraceptives?

Nothing has been more confusing in the law than the much touted “free” colonoscopy. I still get calls from clients when they open a bill from their doctor and are surprised to find they owe several hundred dollars for this free procedure.

In fact, I had a call just this morning and had to explain the difference in free and not exactly free because we were only kidding.

 

Georgia Medigap plans & Prices

Georgia Medigap plans & Prices

Free colonoscopy that really isn’t

For starters, let’s address the meaning of the word free.

FB Groucho Marx3Free doesn’t mean there is no cost, it simply means you don’t pay directly for this procedure. Think about that for a moment.

The doctor doesn’t work for free. The exam room, drugs, equipment and assistants aren’t free. Someone has to cover the cost. That someone is everyone else that has coverage through Medicare or a private insurance plan.

Providing these “free” services means the premiums you pay for your insurance are higher than they would have been if not for these “free” services.

In the case of the free colonoscopy it is only free until it isn’t.

 

Why a colonoscopy?

Depending on your age or medical history, a colonoscopy might be appropriate. Dr. Stephen Schimpff offers this explanation.

The concept and purpose of colonoscopy is to find a polyp and remove it before it turns into cancer. Colon cancers arise from polyps. Polyps are common but only a minority of polyps progress to cancer. But if removed they obviously cannot become colon cancer. Colon cancer is the third most common cancer in men and women in the USA with about 150,000 new cases per year, behind only lung, breast and prostate cancers. And it causes about 50,000 deaths per year. Prevention obviously makes sense. – Kevin MD

No one really wants to go through the procedure but most don’t want to get cancer either. If you are in a high risk category you probably should schedule your procedure sooner rather than later.

I have a close relative that has a significant family history when it comes to cancer. Her mother and father both died from cancer. All of her fathers siblings died from cancer and (if I remember correctly) so did two of her mother’s siblings.

So far she has been cancer free but has been conscientious in taking care of her overall health and making sure she has regular screenings.

 

When does a colonoscopy change from free to not free?

You are not the first one to ask and you won’t be the last. Even doctors can be confused about the free colonoscopy.

A check at healthfinder.gov stated that colonoscopy was covered by the ACA and that, “if your doctor finds polyps inside your colon during testing, these growths can be removed before they become cancer.”

I decided to call the doctor’s billing office to check. After the clerk talked to her supervisor she called back to say that I was correct that there was to be no deductible if it was a simple “screening” colonoscopy. But since the doctor had found and removed a polyp it became a therapeutic procedure. Medicare and Medigap (and apparently commercial insurers as well for those under 65) do not recognize this as a preventive screening procedure under the ACA guidelines. Hence I was on the hook for the remaining $65.52.

Now $65 for a colonoscopy isn’t bad at all, but when you were expecting free you deserve an explanation. When the government designed Obamacare it was obvious they had no idea how insurance works and were completely clueless with regard to the claim process.

ricky ricardoWith the free preventive screenings, the intent was good. Encourage people to get tested for as many things as possible and keep the entry fee for those screenings at a minimum. If something can be caught early it won’t be as costly to treat over the long haul.

Kind of like routine maintenance on your car. Change the oil on a regular basis, check the fluids and you can get a lot of miles out of your car and avoid expensive repair bills in the future.

It isn’t foolproof but certainly better than no preventive maintenance at all.

But when it comes to coding medical care there are different codes for preventive procedures vs. diagnostic.

Generally, once something out of the ordinary is discovered the coding changes from preventive to diagnostic and the procedure is no longer free.

Someone neglected to tell that to the Congress critters when they were writing the legislation.

I sometimes feel like I am Ricky Ricardo talking to Lucy. “Lucy, you got some splainin’ to do”.

 

 

Dr. Schimpff and his Medigap plan

The doctor makes several references to his high deductible Medigap plan. After all was done and billed his out of pocket cost for the procedure including doctor, facility fee and anesthesia was $250. Not bad for something that was billed out at $2634 but more than “free”.

I presume Dr. Schimpff  is referring to a Hi F plan where after Medicare does their part his share of the cost is to pay the remaining balance up to $2160. Once the deductible is satisfied the Medigap plan pays 100% of remaining approved Medicare A and B charges for the balance of the year.

dr houseIn some areas and at some ages the high deductible plan made sense at one time. Here in Georgia someone age 65 could buy a Hi F plan from Blue Cross for less than $40/month a few years ago.

Blue Cross no longer offers Hi F. I assume they lost too much money on the plan. Depending on your age, gender and zip, you can get Hi F for $58 per month. Still not bad, but not great either.

You still have to pay the first $2160 in charges before the plan pays so it probably is a good value as long as you are healthy.

But most clients would rather pay an extra $30 per month and get Medigap plan N with no deductible and a $20 office visit copay.

Plan N is also a good alternative to Advantage plans where you have doctor and hospital networks to contend with.  Most Advantage plans cap your OOP (out of pocket) expenses for approved, in-network claims at $5900 to $6700 while others have no cap.

Why have a plan if there is no upper limit on your OOP expenses?

If you live in Gilmer county there are 7 Medicare Advantage plans available to you but over 170 different Medigap plans and everyone of them, including Hi F, have less out of pocket than the Advantage plans.

Why pay upwards of $90 per month for an Advantage plan that has a network but does not limit your OOP expenses when for the same monthly premium you could have plan N?

Have you checked our plan N rates lately? Plan N is not for everyone but we have a lot of clients looking for great value and they pick plan N based on their needs and budget.

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What Does Medigap Plan N Cover?

What does Medigap plan N cover?

Medigap Plan N is a relatively new Medicare supplement plan that came into existence in 2010. It is now the 3rd most popular plan in Georgia behind plans F and G. happy couple

Medigap plan F is oversold for many reasons, not the least of which is the high premium and corresponding high commission. Many Medigap brokers take the easy way out and simply try to compete on price for plan F without ever explaining the value of plans G and N.

Simply stated, Medigap plan N covers 100% of your approved Medicare Part A hospital expenses in the same was as plans F and G. Approved Medicare Part B charges have cost sharing under plan N.

When you have the N plan you are responsible for office visit copay’s up to $20, ER copay’s up to $50 and any excess charges incurred when you use a provider that does not take Medicare assignment.

httpv://www.youtube.com/watch?v=2wZbLoBKceM

 

Does Medigap plan N include out of country coverage?

eiffel towerOnly Medicare supplement plans F and G include some coverage when you travel outside the United States.

For the most part, original Medicare does not cover out of country charges. Exceptions would be if you had a medical emergency while in a neighboring country like Canada or Mexico and it was not reasonable to travel to the U.S. for treatment.

Medigap plans C, D, F, G and N will pay 80% of emergency medical expenses after a $250 deductible. Refer to Medicare publication 11037 for more details.

Anytime you travel out of the country you should always consider purchasing a travel medical plan as offered by HCC.

hcc

 

 

What are Medicare excess charges?

Excess charges occur when a Medicare beneficiary uses a provider that does not accept Medicare assignment. Since 96% of providers DO accept assignment it is not an issue that will come up with any frequency.

If you do decide to use a provider that does not take assignment, be aware when you have Medigap plan N you are responsible for any balance billing by the provider once Medicare has approved your claim.medicare excess charges

Excess charges are capped by Medicare. The calculation works like this.

If the Medicare approved amount for a Part B expense is $100 (and you have satisfied your Part B annual deductible), Medicare will pay you 80% of 95% of the Medicare approved claim. The claim is initially reduced by 5% for a non-par provider which means the MAC (Medicare approved claim) is now $95. Medicare pays you 80% of $95 or $76.

Your Medigap plan N will pay you 20% of the 95% or $19.

Your doctor is allowed to bill you 15% in excess of the $95 MAC.

At this point you have received $76 from Medicare, $19 from your Medigap plan N carrier. The claim is capped at $109.25 which is referred to as the limiting charge.

In this case you will owe the doctor $14.25 out of your pocket.

Your doctor is required to submit your bill to Medicare and must wait until Medicare has adjudicated the claim and you have received payment from Medicare and your supplement carrier before they can bill you.

 

Why pick Medicare supplement plan N?

SenCitFor many people it is a cost effective alternative to most Medicare Advantage plans. Medicare Advantage plans have doctor and hospital networks that may be inconvenient for you, the patient. The cost sharing under Medicare Advantage plans can be significant, as much as $6700 in 2018 and that is just for IN network approved charges. Your out of network charges are in addition and may not be capped at all.

It is rare for a Medicare beneficiary with plan N to have out of pocket expenses that exceed $500 per year and with most people your out of pocket is considerably less.

Medigap plan N offers more value than plans F or G for most people but it is not for everyone. If you have a chronic condition that requires multiple doctor visits over the course of a year, plan N may not be the best plan for you.

I  turned 65 in September of 2015 and chose Medicare supplement plan N for myself. Next April when my wife goes on Medicare she will probably pick the same plan.

How much can you save with plan N?

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