Ask the Medicare Specialist

There's no question today. As the Medicare Annual Enrollment Period (AEP) has wrapped up and we move into 2025, I want to go over some items and areas of concern for me.

1) Too many seniors still have the wrong Advantage Plans. I thought this was much less prevalent than five or ten years ago, but it remains a prominent problem. This came to my attention as WVU Uniontown Hospital announced they had come to an impasse on a new contract for reimbursement with one of the largest providers of HMOs and PPOs in Western PA.

Those who wanted to continue to have network access to their local hospital and doctors were forced to enroll with a new company. I was surprised at how many people we met in this situation who were grossly overpaying, as much as $2,500 per year for plans with much higher hospital co-pays and/or far fewer and less valuable ancillary benefits, or "extras" as I often refer to them. Those who are 75 and older are much more likely to be enrolled in these "legacy" plans.

They signed up for them long ago but never changed even as premiums were dramatically increased or despite newer, less expensive plans that offered much better value being introduced by the same company. Fear of change and a failure to understand Medicare regulations are almost always the reason seniors stay on non-competitive plans.

I estimate close to 50% of those older than 75 are being taken advantage of. If you have friends or family in this age bracket, encourage them to reach out to us. Do it with them. There are still opportunities to change plans at the beginning of the new year.

2) As I've written about all AEP, those who have Supplement Plans C, F, or G are also overpaying without getting fair value in return.

I will be giving examples of just how much in a future column soon. But again, we're talking about thousands of dollars per year for plans with antiquated benefits and no real extra protections. Get out of these plans now and move to Supplement Plan N while you can!

I'm going to continue to repeat this over and over because I'm adamant that no one who can pass medical underwriting should be on the more expensive C, F, and G.

3) I'm very concerned that many people on Advantage Plans who are currently taking a Tier 3 medication, or end up being prescribed one later in the year, don't understand they're going to be forced to pay $600 or more the first time they have it filled due to the introduction of a large deductible on some of the most popular Western PA HMOs and PPOs in 2025.

Other plans will have a co-pay that is increasing from around $45 for a 30-day supply to 25% of the retail cost. For example, Eliquis will be around $150 per month and Ozempic or Trulicity $250.

4) Maybe my biggest concern is for those on Advantage Plans who don't live in Pennsylvania. Hospitals all over the country are cancelling contracts with Advantage Plan carriers, leaving fewer companies to choose from or people without access to their local hospitals and doctors. WVU Uniontown Hospital is an example of this occurrence. HMOs in other states, Florida for instance, force people to get referrals from their PCP to see specialists. This has resulted in doctors opting out of accepting HMO plans and left people with few, even zero good choices in plans. The lowest co-pays for hospitalizations on Advantage Plans outside of Pennsylvania are upwards of $2,000 for a five to eight day stay in most states.

I had clients down south who had to settle for a PPO plan with a $3,500 eight-day inpatient hospital co-pay so they could remain in network with their doctor and local hospital. I'm highly encouraging people outside of PA to enroll in Supplements while they can still pass underwriting. Those who are interested can still do that until March 31st.

5) Lastly, some good news. One of the three most popular Advantage Plan providers has extended the opportunity for people who aren't satisfied with the level of service they have gotten from the agent who originally signed them up for their Medicare HMO or PPO to become an official client of The Health Insurance Store by filling out a simple form to make that request.

This allows us to call the insurance company on your behalf if there are ever any issues with claim denials or delays, bills, prescription costs, or any other questions or concerns.

With a completed "Agent of Record Change Request," you then get all the same great benefits as clients who allowed us to help them enroll in an Advantage Plan or Supplement.

Lastly, please be advised that I'm negotiating to continue a column in another area newspaper. I'm hopeful an agreement can be reached. However, it's possible that it may not be successful, and I will need to make the decision to discontinue. The column will continue in The Daily Courier. The only other place the column can be accessed is on our Facebook group with the same title as the columns.

We also post four other great weekly series there. You can join by searching Ask the Medicare Specialist on Facebook or go by going to our website and clicking the blue banner at the top of the home page.

If you have any questions regarding this column or would like to make an appointment for a no cost consultation, give us a call or email me personally, [email protected].