So, What Questions Should You Ask Your Medicare Insurance Agent?
What Is Medicare Advantage?
Sometimes there is confusion about Medicare Part C or Medicare Advantage insurance plans in Omaha, Nebraska. I have heard doctors’ offices call it “Medicare replacement plans” or “it is not Medicare.” So when asking what questions to ask your Medicare insurance agent, the definition of Medicare Advantage should be top of the list.
The key is in the name–Medicare Part C, like Medicare Part A and Part B. The Official Medicare.gov website says:”Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. They are sometimes called “Part C” or “MA Plans,” which are offered by Medicare-approved private companies that must follow the rules set by Medicare.”
Medicare mandates what the private insurance companies cover and even how they cover patients’ needs. The monitoring is incredible. This is definitely a question you should ask your Medicare insurance agent.
When I moved into my neighborhood, I got to know my next-door neighbor. He was a partner in a large public accounting firm in Omaha. When he saw my license plate–it says “Medigap”–he asked me to guess who his most prominent client was.
CMS (Center for Medicare and Medicare Services) administers Medicare. CMS is an enormous bureaucracy, but they do not have the capability to monitor something as complex and large as many insurance companies, so they hire auditors. My neighbor’s biggest client is Medicare.
His firm and many other accounting firms audit the financial and billing records of the insurance companies offering Medicare Advantage because Medicare is not directly administering the insurance programs like they administer Medicare Part A and Part B. Small world.
Even though private insurance companies design and administer the Medicare Advantage plans. “Medicare Advantage Plans must cover all of the services that Original Medicare covers,” as it says on Medicare.gov. Confused? These are questions you should ask your Medicare Insurance agent.
What Other Questions Should You Ask Your Medicare Insurance Agent?
Why Medicare Advantage?
In the early 1970s, Congress was trying to figure out how to keep the costs down for Medicare. They imagined involving private insurance companies and creating an atmosphere of competition. Over the decades, the program developed into what is now Medicare Part C or Medicare Advantage.
The number of Medicare beneficiaries on Medicare Advantage is over 40% and growing each year as the plan strengthens. The plans improve health outcomes from beneficiaries, more benefits, and lower costs to Medicare.
How Does Medicare Advantage Work?
How Medicare Advantage works is a question that you should ask your Medicare insurance agent. CMS, in effect, hired a private insurance company to develop a Medicare plan. The plan gives the same coverage as Medicare Part A and Part B. CMS pays the insurance companies an amount based upon the number of clients, ages, services, and outcomes. The formulas to determine payment have become increasingly complex as CMS and the insurance companies try to devise a system that motivates healthcare workers, institutions, and insurance companies to curtail costs and improve health outcomes.
You Should Ask Your Medicare Insurance Agent How To Compare Medicare Advantage To Medigap
Each type of Medicare plan is structured the same from place to place. The plans, however, vary in costs. High population centers like cities will have very rich plans compared to isolated rural areas.
They are not like Medigap plans that work with Medicare Part A and Part B, which are universally the same from one part of the US to the next. The population has absolutely no effect on Part A and Part B. The Medigap plans maybe even less in rural areas because older populations tend to move to higher population areas around doctors and hospitals. Thus Medigap claims in rural areas are fewer and smaller.
You cannot compare Medicare Advantage to Medigap in any way that is fair. They have two separate and distinct delivery systems for health care. Those who do attempt comparisons are usually building straw men to know down to serve their purposes.
One of the Most Important Questions to Ask Your Medicare Insurance Agent:
The first metric I like to consider is the maximum out-of-pocket. The maximum out-of-pocket (MOOP) is how much you potentially could spend out of your pocket while on that particular health plan in one year. During your working years, your employer’s health plan had a MOOP.
Many people confuse MOOP with a deductible. A deductible is the amount of money you pay before the plan begins to cover medical costs. For example, you have a $2,000 deductible. You go to the emergency room, and the bill is $20,000. You pay the first $2,000 upfront.
Then, you pay a coinsurance of 20% on the next $18,000, which would be $3,600 ($18,000 x 20% = $3,600).
This is how the maximum out-of-pocket (MOOP) works. The $2,000 deductible + $3,600 coinsurance = $5,600. If the MOOP is $6,000, you would pay $5,600. If the MOOP was $5,000, you would pay $5,000. This information is crucial, and it should definitely be part of the questions that you ask of your Medicare insurance agent.
I see the maximum out-of-pocket as the most important number because that is your potential maximum risk, which is why it’s so important to ask questions of your Medicare insurance agent about it. While it is highly unlikely that you will arrive at the maximum each year or any given year, there is some probability. Because of that chance, you should be prepared to cover that expense because you are contractually obliged.
If you have two years back-to-back of expense–imagine chemo and radiation for cancer over a year’s time–you could conceivably have two consecutive years together when you reach your MOOP both years. While the probability of hitting that maximum is very low, the possibility is always there.
You can either cover that risk by purchasing a Medigap policy instead of a Medicare Advantage plan and pay the monthly premium or save that amount each month until you have reserves equal to or greater than your MOOP.
When looking at Medicare Advantage plans in Omaha, Nebraska, the first number I look at is your maximum risk–the maximum out-of-pocket (MOOP).
What Other Questions Should You Ask Your Medicare Insurance Agent?
Medicare Part C Many Times Include Prescription Drug Coverage
Most Medicare Advantage also includes the Part D prescription drug plan, especially Medicare Advantage Plans in Omaha, Nebraska. I would run your medications through the Medicare.gov plan finder before going any further in plan selection. Many times I thought I had the best plan picked out, and then I come to find certain medications for that person or not covered. Or the cost of the medications is significantly higher than on other plans. Check the medications before doing anything else.
While you can ask for drug exceptions from a plan, I would absolutely not go into a new plan with that expectation. Ask your Medicare insurance agent to make sure all of the medications are covered and covered at a reasonable rate compared to the other plans in the area.
They Tell You What Doctor to Go See
Many times I will hear someone say, ‘Medicare Advantage plans tell you what doctors to see.’ When I hear that, I know that person only sells Medigap policies. Here’s a prime example of when you need a Medicare insurance agent to ask questions from.
Networks are important. The Medicare Advantage insurance plans in Omaha Nebraska are embedded in the three hospital network systems here.
You, of course, want to go to the medical professionals with whom you already have relationships. All three networks work with the principal insurance companies offering Medicare Advantage in the area. Those doctors, hospitals, and clinics are in-network. Even the few independent firms in the area also have relationships with the plans.
In other areas, the plans may not be as connected. You need to verify your doctors and hospitals before considering a plan.
What Are The Copays?
A question you need to ask your Medicare insurance agent is: what are the copays? Once you have determined the amount of MOOP you are comfortable assuming, verified your prescriptions and doctors, you look at the copays. Everyone has their own way of evaluating prices. Compare the various copays among plans, doctors, x-rays, MRI’s etc. Narrow down the number of plans. There is no perfect plan. There are always trade-offs.
Extra Benefits in Medicare Advantage Insurance Plans in Omaha, Nebraska
Many people focus on the extra benefits that Medicare Advantage offers, like dental and vision. Those are real benefits and should be weighed. However, dental expenses are usually not life-threatening nor do they run into the tens of thousands like health insurance or prescription drugs. This is a crucial place to ask questions of your Medicare insurance agent.
A particular plan may have a nice dental benefit of $1,500, but if the MOOP on that plan is $7,000 versus another plan with no dental at a $2,800 MOOP, I would favor the plan with the small MOOP. You can always purchase a separate standalone dental plan.
Many people do not realize that Medicare Advantage plans do not have underwriting like Medigap plans. During your Annual Election Period (AEP) October 15th–December 7th, you may change from one plan to the other without answering any health questions. The plan cannot refuse you. You may also change during the course of the year if you have a special reason for changing.
You Can Change During Annual Election Period (AEP) October 15th-December 7th
The Annual Election Period is the time when you may change your Medicare Advantage Plan. You don’t need a reason, but you could have one. You are not happy with the service. Another plan appears with richer benefits or lower MOOP and copays. You plan on doing extensive dental work and you want a plan with more dental for that year. There can be multiple reasons or no reasons for changing. You may change.
Ask Your Medicare Insurance Agent: Does Your Plan Have A National Network?
A concern people have with Medicare Advantage plans is with the network. The network concerns extend quite often beyond the local area. People are concerned about travel, outside of the service area, going to specialists not located in the service area.
Many of the major insurance carriers, including in the Omaha Metro area, have national networks. That is, you can go to doctors and hospitals outside of the local service area and still be in-network and pay in-network prices because the doctors and hospitals participate in the insurance company’s national network. This includes HMO (Health Maintenance Organization) plans. PPO (Preferred Provider Organizations) plans cover doctors and hospitals by design out of the local area. You may pay more, but you will have access. For emergencies, you are covered anywhere on Medicare Advantage plans. For some people, especially those who may travel, this is a concern.
Medicare is incredible health insurance. It comes in various forms to fit your needs and how you wish to be serviced. Medicare Advantage Insurance Plans in Omaha, Nebraska are a powerful way to receive your Medicare. Understanding the trust about Medicare Advantage and sorting through the exaggerations and distortions is important to make sure your needs are authentically served.