What you need to know about Medicare according to an expert
by Kristan Dael
50plus Magazine
Some of the most important questions to ask about your Medicare coverage each year, according to longtime SHIBA (Senior Health Insurance Benefits Assistance) counselor Bob Earnest of Portland, include:
- Will your medications be covered next year?
- Will your doctor still accept your plan?
- Has the medication pricing changed?
Earnest recommends reviewing your plan each year during open enrollment Oct 15 to Dec 7 to determine if your plan will continue to work for you, your doctor and provider. He counsels as a volunteer with Multnomah County SHIBA, part of the Dept. of Human Services, Aging and People with Disabilities. SHIBA provides free, unbiased, confidential assistance with Medicare.
In addition to Medicare counseling, Earnest teaches a free monthly informational Medicare class (currently via Zoom) through Mt Hood Community College.
Another very important thing to know, Earnest says: “One size does not fit all.”
He tells those who attend his classes, “A husband and wife eligible for Medicare no longer have to have the same plan. One may have a Medigap supplement while the other has a Medicare Advantage plan.”
Because each person has unique needs, ensuring your medication coverage fits your needs and circumstances is key. Reviewing your plan annually is important as things do change; a review ensures your coverage will continue to meet your needs.
“That’s where a SHIBA counselor comes in. They don’t sell anything. They are simply there to show, ‘If you do this then you’ll have this outcome. Or, if you do that, then you’ll have this outcome.’”
SHIBA counseling is always free. Counselors do not represent any insurance company and compare plans objectively.
Another consideration: Zero-premium plans.
“A zero-premium plan might not be best for you given other factors,” Earnest explains. “There are many zero-premium plans, and they can be great options — with coverage for your doctor and hospital in network. The deciding factor, however, is often ‘MOOP’ or Maximum Out of Pocket. Some zero-premium plans will have a $7,550-$11,000 MOOP, where a plan with a $30 monthly premium could save you $3,000-$5,000 per year.” Sometimes, pay more, get more, Earnest says.
The most expensive plan might cnot be the best plan for you, either. “Some of the more expensive plans may have a better formulary for prescription meds,” says Earnest, “but might have lesser coverage or higher copays for some services.
Be sure to look at the big picture as you compare plans.”
If you have a hospital of choice, check plans you’re considering to make sure it is accepted.If you have an HMO (Health Maintenance Organization), be sure to check hospital affiliations.
For travelers
Those who travel out of state or country should look closely at this aspect of their coverage. Check with your Medicare Advantage plan for out of area emergency coverage within the US. “With Medigap, the coverage is usually valid in any state for any provider accepting Medicare. Some Medigap plans provide for emergency care outside the US with 80 percent coverage and a $50,000 lifetime limit,” says Earnest. Travelers themselves, when Earnest and his wife travel internationally they opt for travel insurance, which can provide up to $500,000+ in coverage for $500-$700 per person, depending on the destination and length of trip.
“I’m not concerned about baggage insurance,” Earnest says with a good-natured chuckle. “I’m concerned about getting my body home if needed!”
Rx is huge
Prescription meds are a primary concern for many. Earnest says the tool at Medicare.gov can help, showing the different tiers/pricing of coverage for various medications, including generic and brand-name.
“They’re getting information from friends or relatives who have great plans — for them — but may not be a great fit for you. Make sure your plan meets your needs.”
“For example, a friend’s plan covering their insulin might not be a good fit for you for heart medications. Consider your medication needs and make decisions on the best available coverage.
Got a retirement plan?
Anyone with a retirement plan — such as PERS or FEHB — should carefully compare the benefits of staying with their existing coverage or moving to a Medicare open market plan. “If you leave PERS,” says Earnest, “you leave for life.” So, know what you’re leaving, and what the new plan offers.
Those who served
Veterans should also carefully consider their options. You can only have one drug plan at a time. The exception is if you are an eligible Veteran in the VA health system, you can have VA drug coverage and a Part D drug plan. More on options for veterans next issue.
About Bob
Earnest began working as a Medicare counselor shortly after retiring at age 56 in 2004 following 30 years of working in social services with the State of Oregon.
“I retired on a Friday and on Tuesday walked to the grocery store. Suddenly I stopped and thought, ‘What happened.’ I was walking home with two bags — $30 worth of groceries — just days after being entrusted with a multimillion-dollar operating budget and managing 150 staff in four locations. Now I was entrusted with $30 worth of groceries,” he laughs.
“I came on as a SHIBA volunteer with 30 years’ experience,” he says. “My hat’s off to all the volunteers who learn this complicated system from scratch. I still learn something new every day.”
Earnest continues, “Many SHIBA volunteers are expert in specialized areas. Some of our volunteers are doctors, attorneys, nurses, teachers, billing specialists, mental health professionals and more. We can shoot things to each other to help figure out a best plan; it’s really a team.”
“Give SHIBA a try. We can really help.”
Resources
SHIBA offices throughout Oregon 800-722-4134
In the Community Education Section, click on “Welcome to Medicare” See course # HE4MC