Ask the Medicare Specialist

Question from Keith: Dear Mr. Zolbrod, I'm not currently a client of the Health Insurance Store. I was diagnosed with A-Fib in late October of this year. I turn 75 in mid-2025 and am wondering if that diagnosis disqualifies me from getting Medicare Supplement insurance. Also, what would a typical Plan N supplement and Part D drug policy cost for someone in my age bracket? I'm now in a PPO Advantage plan that has worked very well for me. Due to testing back logs, I'm told that the more detailed tests I will need prior to my A-Fib treatments can't be done until early February 2025. It's likely that I should have sent this e-mail much sooner than now. However, if I can still pass underwriting with this A-Fib, is it too late to decide in 2025 whether or not I should stay in the Medicare Advantage environment.

Answer: Anyone who currently has an Advantage Plan, and can pass medical underwriting, can still make a change back to Original Medicare and a Supplement from January 1st until March 31st of 2025. For a 75-year-old male, Supplement Plan N costs between $98 and $123. A female the same age would be $88 to $110. Those who are younger than 75 would pay less and those over 75, more. Almost all of our clients on Part D prescription plans are paying under $15/month with the majority on no cost plans.

Unfortunately, in Keith's case, he will not be able to pass underwriting due to the A-Fib diagnosis.

However, I think Keith's question provides some learning opportunities. 1) Those who don't use The Health Insurance Store when first going on Medicare Part B, will likely never be given the Supplement option because most agents only sell Advantage Plans due to commissions on HMOs and PPOs being much higher, especially for those who are new to Medicare. During one's Initial Enrollment Period, the three months prior to getting Part B, the month it starts, and the three months following, it's essential to understand both options along with the pros and cons of each. Keith mentioned deciding if he should stay in the Advantage Plan market. If he, or you, don't understand the differences between them and Supplements, there's no way to make an intelligent decision on which choice is best for one's personal situation. 2) You can't wait until you get sick to enroll in a Supplement. Those going on Medicare Part B for the first time generally have the three months prior to their Part B effective date, and six months after, to enroll in a Supplement without their current or previous health being considered. During this time, all Supplement companies must accept anyone who has Medicare Part A and B who applies, must make all letter plans available, and offer the preferred premium rates. After this period expires, the same companies can discriminate on who they accept based on pre-existing conditions. As I stated, Keith will not pass underwriting and may never be able to get a Supplement due to his recent diagnosis. 3) If Keith had a Supplement or was able to pass underwriting to get one, he would be able to go to virtually any doctor or hospital in the country. If a concern of his is getting his tests done a sooner, a Supplement might have made that possible.

Let me address Keith's statement that his Advantage Plan "has worked well for me." They always have for those who are relatively healthy, especially here in Western PA, because premiums on well-chosen plans are extremely reasonable, co-pays for primary care doctors and specialists are usually no or low-cost, and outpatient surgeries and inpatient hospitalizations on the most popular plans in historically, and in 2025, have co-pays of just $175 to $400. That's not the case for most Advantage Plans sold outside of Pennsylvania, however. Co-pays for stays of six days or longer can be as expensive as $2,000 to $4,000. I'm really encouraging people on Advantage Plans in other states to move to Supplements because HMOs and PPOs don't offer nearly the value they do here. When Advantage Plans don't work so well for people is if chemo, other infusion, or injection therapy is needed and when insulin for a pump is necessary. Those have a cost of 20% of the billable amount to the insurance company and usually result in meeting one's MOOP, which in 2025 average around $6,000 on the most popular plans in PA and more in other states. In addition to the possibility of expensive bills, Skilled Nursing Stays can possibly be cut short by the insurance company, and MRIs, CT scans, or surgeries can be delayed due to the need for prior authorization or possibly being told physical or injection therapy needs to be done before those services can be performed. This is getting a lot of press right now. Supplements eliminate out-of-pocket costs for nearly all Medicare covered services as well as the need for authorizations for care, which can be had immediately upon a physician's order.

A couple pieces of advice for Keith and others on Advantage Plan HMOs and PPOs. First, Keith chose a plan that is out of network with one of the two largest health systems in Western PA. Having access to both might have also helped him get his tests done sooner. However, Keith is with the Advantage Plan company that I feel offers hands down the best member services. What Keith should do is call and ask them to find a network provider who can get him in for his tests sooner. The representatives can usually set up an appointment during that call. It's a great service that I've personally used on many occasions, most recently to get into an orthopedist. I had to drive a bit farther but was able to get an appointment withing 48 hours of my request! Lastly, Keith can become a client of ours by filling out a form to request The Health Insurance Store become his "Agent of Record." If you originally got your Advantage Plan from another agent and would like us to be your representative and help if you ever have any questions or issues, like Keith is currently dealing with, among others, reach out to us.

If you have any questions regarding this column as well as any other Medicare topic or would like to make an appointment for a no-cost consultation, call one of our offices or email me personally. [email protected].