Medicare is Complicated! Thankfully, There’s Help
Kristan Dael
50plus Magazine
When it’s time to enroll or make changes in Medicare, meeting with an agent is a great first step. Free, highly trained counselors are available everywhere through state programs and private agencies. As your needs are unique, meeting a counselor yourself is the best way to ensure your coverage is tailored to your situation.
To illustrate the value of expert help, 50plus speaks with local agents each year to share their knowledge. This issue, we chat with Becky Foster, volunteer Medicare counselor with SHIBA (Senior Health Insurance Benefits Assistance) in Jackson County.
Becky has volunteered with SHIBA for three years, after previously volunteering with a like program in California. Having worked professionally in medical technology and life sciences, helping strategize how to make new technology more accessible to consumers, volunteering as a Medicare counselor was a natural next step. One question has long guided her professional and volunteer endeavors:
“How do we do better in making health coverage better for people?”
One way is conversations like this.
Q When meeting a person or couple, what helps you get a picture of a client’s needs?
A “The first questions are basic: Are you working now, receiving benefits from an employer? Or not working? Different rules apply to each. Also important to know is how much flexibility in choosing doctors they desire. I also share changes for the coming year.
There are some personal and subjective questions, including finances, and comfort with risk. That’s what insurance is all about, risk. For example, do we take the lower deductible knowing we’ll have higher premiums? Or do we opt for the lowest premiums and hope the house doesn’t burn down — or in this case, a health issue arises.
I try to be very clear that what works for a friend may not work for them based on financial situation or health needs. It’s common to hear, ‘My friend has this coverage and they really like it.’ That’s great, but if the client is healthier or sicker, or has different prescription needs, that friend’s coverage may be a great fit for them, but not for you.
I tell people there’s no right or wrong; it’s just what’s best for you. Sure, it’s worth asking around for people’s experiences, but keep in mind that someone else’s great coverage may not be best for you.
People should focus on their priorities. If they have longstanding relationships with their doctors, it’s important their plan provides access to those doctors. Same with prescription medications. It’s a great idea — and I ask this of my clients — to bring to their appointment a list of their doctors, dentists, physical therapists, and any other health practitioners, as well as any medications. This helps evaluate available plans to make sure we don’t lose access to coverage for important medications or providers.
Q: Is there an ideal time of year to meet with a counselor?
A: Open Enrollment is October 15 through December 7. For those already on Medicare, those who can’t for whatever reason stay on their current plan, or those who’d like to review their plan, this is the time to schedule a meeting. Counselors are typically available within the OEP window, but it doesn’t hurt to call a couple weeks ahead — though I’ve never had to turn anyone away.
Those enrolling in Medicare for the first time would want to meet with a counselor three months before their 65th birthday month. This gives ample opportunity to enroll, discuss options, and have everything in order for the plan to go into effect on the first day of their 65th birthday month, or on their retirement date if they were insured through an employer.
You don’t want to miss these important deadlines. If you do, you may lose or have limited coverage and/or incur fees and penalties.
Q What are common pain points for people you see?
A Things are different since the pandemic. People qualified for payment assistance through state financial assistance programs during the pandemic who wouldn’t normally qualify or would’ve fallen off the rolls. The past 18 months have been a period called “Unwinding” — states are now allowed to kick people off of payment assistance programs. What’s challenging is that some people are still financially strapped.
Another pain point this year is changes to Medicare Part D (prescription drug coverage). The changes are largely good — such as capping annual out of pocket costs at $2,000 (vs the previous $8,000 cap). And it’s good that plans have responded, but some are cutting other benefits, and some companies are simply pulling out of the market.
In Jackson County, for example, of two companies that offered eight plans between them, one now offers three plans, the other offers one.
Benefits and people’s needs change, as do prescription med plans. These are some of the most challenging issues when helping to ensure people are getting the best possible coverage.
Q Do you feel an annual plan review is important?
A Not everyone needs a review every year, but it is important that they at least understand their coverage and any pending changes. An Annual Notice of Changes goes out just before the Open Enrollment Period. If any changes might be beneficial, or if you have any major changes yourself — financial, health wise, or a concern that a prescription won’t continue to be covered — it’s a good idea to do a review. Also, if you’d just like to do a checkup, it can be good just to talk through your coverage to know everything is to your liking.
Q How can the public best stay abreast of Medicare news or changes?
A News articles can be good, but be skeptical. Make sure you understand what’s being said. Some reports that may sound bad (or amazing) can be misleading. Likewise, a report from, say, an organization with a national reach may discuss a benefit or change that does not exist in your area. Like ads for “zero premiums!” — they may exist somewhere, but possibly not where you live. Don’t trust ads or mailers. If you hear or see an offer you’d like to check out, ask an expert.
I personally do presentations at senior centers and senior living communities throughout the year. These can be valuable as you have an opportunity to hear directly from a local expert, and can ask questions.
Q What are the hallmarks of a good Medicare counselor?
A Compassion and patience. The best plan: sign up to meet with a counselor — all SHIBA-certified counselors have the same training. If you’re not comfortable with the counselor you meet, schedule another time to come in. I always hope people are happy to see me.
Q Is meeting with a SHIBA counselor “one and done?”
A It can be, but if there’s a decision that requires calls or research, we may need to meet a second time to finish up. Often that needn’t be in person; I want to minimize inconvenience for people, and often wrapping things up can be done with a phone call. I do give people my phone number in case they have questions after our meeting.
Q Top 3 things everyone should know about Medicare?
A #1: Medicare is not actually free. While few are surprised by that when they reach the age of eligibility, some are taken aback by the cost. Especially people who had a really generous health plan through an employer. For people transitioning from expensive or slim Marketplace plans, Medicare can be a great change.
#2: Deadlines and timelines. Know the timelines to get enrolled based on your situation. There are different deadlines for those working and have coverage through an employer and those no longer working. Again, missing these deadlines can result in becoming uninsured and/or incurring late enrollment penalties. While penalties may not be huge, they are levied against your policy for life.
#3 Get your Rx coverage. I’ve had clients who signed up for Medicare and didn’t initially get Rx coverage. Many people at 65 don’t need meds. But whether you do or not at the time of enrollment, eventually most people do. Getting this coverage upon enrollment is important. As mentioned above, late enrollment penalties get tagged onto your premiums for life.
More than once, I’ve had clients say they don’t need prescription coverage. I’ll say, ‘Sure you don’t want it?’ They say, “I don’t need it.’
People can feel it’s unfair to have to pay for coverage before it’s needed. But here’s a great analogy: you pay for home and auto insurance for when you do need it, right? Most can appreciate that.
Q Do you have stories you share or like to remember?
A It’s rewarding when I hear, ‘Thanks so much — you made this so much clearer.’ I feel good about being able to provide a little clarity.
SHIBA is part of the Oregon Department of Human Services, Office of Aging and People with Disabilities. To schedule an appointment, call 800 722 4134 or visit SHIBA.Oregon.gov.