Ask The Medicare Specialist

Question from Connie: Thank you so much for answering my question in your last column. I'm relieved you think Advantage Plans can be the right choice for those of us on Medicare. I have a follow-up question. How do I know if I'm with the best company and plan?

Answer: Connie didn't originally get her plan from The Health Insurance Store. If she had, it would be a certainty that she's on one of the best plans available in Western Pennsylvania. As I wrote last week, those who don't use our services aren't assured they're getting the best options presented because too many agents make recommendations based on what pays them the most commission and nothing else.

Eight companies sell Advantage Plans in Western Pennsylvania, and between them, there are over 100 total offerings to choose from! Among those, it's my professional opinion that only around 10 are worthy of consideration. The rest are either non-competitive as far as premiums, their overall benefit packages and higher co-pays, or don't have a good network of doctors and hospitals.

When we sit down with a new client, what we do first is go over how Original Medicare Parts A and B work as stand-alone insurance, vital information needed to make an educated decision. Then we explain in detail the differences, pros and cons, risk and rewards of both Advantage Plans and Supplements in a way that's easy to understand. We listen to the client's needs and wants, answer questions, and help them determine if they prefer an Advantage Plan or Supplement.

If a client has decided Medicare Advantage is the right fit, then we get into looking at viable plan options. As brokers, The Health Insurance Store is contracted and appointed with every competitive Advantage Plan company on the market. As I wrote earlier, there are only about 10 HMOs and PPOs for the calendar year 2025 that we feel should be considered and almost all of them meet the following criteria: 1) Have a premium under $30/month. 2) Have a Maximum Out of Pocket (MOOP) that is thousands less than the highest allowable of $9,350. 3) Have a per stay inpatient hospital co-pay, a flat amount under $500, regardless of how long the stay versus a per day co-pay that can end up costing as much as $2,500. 4) Provide a generous ancillary benefit package, valuable extras that neither Original Medicare nor Supplements provide. The real value of these goods and services can be worth as much as $3,000 or more annually.

It's amazing how many people are still on plans that aren't competitive, with premiums ranging from $70 to almost $300 per month that have similar or even higher co-pays compared to lower cost plans, while providing much less ancillary benefits. I estimate that as many as 100,000 Western PA seniors who have an Advantage Plan are overpaying or not on one that we recommend to our own clients.

Let me use my father as an example of how expensive it can be having a non-competitive plan. In 2024, he unfortunately had five inpatient hospital stays due to reoccurring C. Diff Colitis. Each was four days or longer. Had he been enrolled in one of the Advantage Plans we recommend most often, his total combined bills for all five hospitalizations would have been $1,100 to $1,750. Had he been on a plan we never recommend, his bills would have been between $5,000 and $7,000!

Please remember that my columns are written and published to provide general knowledge and education and not meant as a substitute for a one-on-one consultation with myself or another of our well trained, experienced and licensed agents. Choosing an Advantage Plan is tricky with only 10% of plans being competitive. After enrolling, the confusion doesn't stop either. Insurance companies can deny claims or delay care by mandating that physical or injection therapy be done prior to CT scans, MRIs, or outpatient surgeries being approved and performed. It's extremely common to receive an erroneous bill or be given bad information from a medical provider. There can be all sorts of issues with prescription drug coverage. And plans can change benefits from year to year, sometimes dramatically. We've had years where popular plans nearly doubled their MOOP, or hospital copays increased by almost 500%. Last year some of the most popular plans went from a $0 deductible on Tier 3 and higher drugs to $590 while costs for brand name drugs increased from $47 for a 30-day supply to over $200.

This is why prior to the Medicare's Annual Enrollment Period (AEP) that starts October 15th, we send a letter to every Advantage Plan client, making them aware of any significant changes to their plan and providing a recommendation to either remain where they are or consider moving to another plan or company for the following year.

In addition, our clients have access to advocacy services and assistance with any issue remotely related to their policies. We will make phone calls to get questionable bills straightened out, help with denied claims, find solutions when prescriptions aren't covered, apply for government or private programs that can ease financial burdens of unexpected out of pocket expenses, and more.

If you're not currently a client, you can be put in our database and receive our recommendation letter this Fall. And for those who are on one of the three most popular Advantage Plan companies and originally used another agent to enroll, you can become a client with and receive all our great services by allowing us to become your "Agent of Record." Give us a call or email me ([email protected]) with that request or with any other questions.