Medicare works for almost all seniors. There are some areas that need to be addressed so all seniors get the coverage and benefits they need in their retirement years. Some of the changes are already being implemented by CMS and the Medicare Advantage companies offering MAPD plans throughout the US.
One such benefit that is required by law in almost all states is that prior to any surgery you are required to have a recent chest X-ray, an EKG and blood work. This is done to make sure you are able and healthy enough to have that surgery. Simply put; Medicare doesn’t pay for it. (Am referring to Original Medicare with or without a supplement. I recently had minor surgery and needed those tests before the surgery. It cost me over a $100 to get those tests done. (If it mandatory to have those tests prior to surgery, why doesn’t Medicare pay for it? (Some MAPD plans do pay for these services but vary by state and plan).
Many seniors cannot afford that but need the surgery so must pay even if they can’t afford it. The same situation is when you go to the emergency room and the doctors agree they don’t need to admit you but want you to stay in observation status for a day or so to observe you and make sure you are ok. Original Medicare doesn’t pay for that, so the bill is on you. The hospital doesn’t tell you that and you find out later you owe thousands. I tell my Medicare clients with supplements or just Original Medicare to tell the doctors to admit me or I’m going home. That usually gets their attention and they will probably admit you. (Most MAPD plans pay for observation status or charge a small copay for that service).
The other issue is being told you need a specific medication and it’s either not on your drug formulary or it’s a tier 4 or 5. The chances are the cost is prohibitive and you simply can’t afford it. Well, there are several things you can do such as ask the Doctor for an alternative that is on the formulary. If there is no substitute, you can have your Doctor as an exception.
This blogger was taking a generic medication for years and suddenly on a new drug plan, it went from a preferred generic to a brand. I simply called the insurance company and asked to speak to the pharmacist and after explaining and proving what I was asking, the insurance company made the drug a preferred generic. That doesn’t always work but you must try.
As a last resort, call the pharmaceutical company and see if they have a plan to reduce the cost to people who need it? Sometimes that works and other times it doesn’t, but you must try or go without the needed medication.
The other issue is that the drug you need is available but must be administered in the Doctor’s office. That is what is called a Part B drug. When that happens, if you are on an MAPD plan the cost will be 20% until you reach the max out of pocket for the plan. If you have certain Medicare Supplements, then the cost is taken care of between Medicare and the supplement.
While Medicare is usually a good alternative to regular group health plans, sometimes they are not and that needs to be investigated before deciding to go onto Medicare. Essentially, you compare the group insurance cost for the monthly premiums; the deductible and max out of pocket to the cost of Medicare. That Medicare cost includes the cost of Part B, Part D (if a standalone drug plan) then either the Medicare Supplement monthly premium and/or standalone drug monthly premium. Most MAPD plans have a zero premium so look at the maximum out of pocket.
The basic rule is who pays first? If the employer has more than 20 employees; you can delay Medicare Part B until you retire because your employer plan pays first, and you are only required to have Part A. However, if the employer has less than 20 employees you must take Parts A & B because Medicare pays first, and your employer would then pay second or last.
Those are the basic rules governing group insurance so be careful when deciding because if you make a mistake you could end up being fined for life. Talk to a Medicare insurance broker who can explain to you all your options, so you choose wisely and avoid unnecessary expenses.
Len Barend, Broker.
The Barend Agency Inc.