If you are turning 65 in the next four months, you are getting lots of mail from Medicare Advantage plans and Medicare supplement companies. Not all of this mail is junk, but some pieces have some questionable information in them.

Anne is turning 65 in June. She showed me some of the materials she has received in the mail. She asked me if she needed to respond to one particular card that said,

“Updates to the Medicare program could affect you. Many seniors may be faced with health care and prescription drug cost increases this year. Now more than ever, it’s important for you to understand how this update can impact your situation.”

Then the mailing offers “FREE Information” if you “return the card below“.

The free information is a government publication titled “Choosing a Medigap Plan”. In small print at the bottom of the card it says an agent will be contacting you “regarding this solicitation of insurance...”.

If you send in the card to get the free information, you are giving permission for someone to contact you, even if you are on the federal “Do Not Call List”.  You will get a call.

Or you might get a knock at your door.

Roger is turning 65 soon. It just so happens that Roger is an insurance agent working in the Medicare market. He showed me a letter he got from an independent insurance agent and said he had not responded to it. Yesterday he got a knock at his door.  It was the insurance agent who had sent him the letter!  Roger asked the agent what she was doing at his door, and she said she was following up on the letter she had sent him. Wow!

Apparently it is okay for insurance agents to do “door knocking” if they are selling Medicare supplements. But that agent should not talk about Medicare Advantage or Part D if she is allowed in the house.  Going to someone’s house uninvited is totally against Medicare rules when it comes to Medicare Advantage and Part D.

Roger is an independent insurance broker who follows all the Medicare rules. He would never show up at someone’s door uninvited, and he was shocked to have this agent turn up at his door. He wasn’t sure what he should do about it. Should he complain to Medicare?  When he told his story to a group of brokers, who also follow all the Medicare rules, none of us knew if he had grounds for a complaint.

For folks who are turning 65, Medicare choices are confusing enough on their own. When you throw in misleading mailings and unethical insurance agents, it makes for an even more complicated situation.  By the way, the insurance agents I know are ethical, and they would never show up at someone’s house uninvited.

To see a short video presentation on your Medicare choices, click here.

Most Medicare Advantage plans have set co-pays for services like doctor visits and outpatient surgery.  This plan design should make it simple for people to understand the bills they receive from doctors, hospitals, and outpatient surgery facilities.

Yesterday I got a call from Shirley, who is enrolled in a Medicare Advantage plan. She had surgery on her foot at an outpatient surgery facility.  She paid the $150 co-pay as required by her Advantage plan – and that’s a good deal.

A month after her surgery, Shirley got a bill saying she owed $75 for anesthesia and $100.78 for a doctor’s assistant.  Whaaat?

When I enroll someone in a Medicare Advantage plan, I tell them to call me if they have any problems, like an unusual bill they receive from a provider, or a problem getting prior authorization for a test.

Thank goodness Shirley remembered my advice – because she should not be getting those bills. It sounds like the Shirley was being “balance billed” – and that should not happen to people who are enrolled in Medicare Advantage plans.

I asked Shirley if she had spoken to her Medicare Advantage plan’s Member Services, and she said she had.  The person she spoke with said she probably owed those bills.  Whaaaat?

I called Shirley’s plan and I was instructed to tell Shirley to call Member Services again and hope she gets somebody who knows what they’re talking about.

Shirley made the second call and talked a another (more experienced?) representative who told her she should not have to pay those bills. Shirley was told her plan would talk to the billing department for the two different doctor groups who were balance billing her.  Her Advantage plan would get this problem fixed.

I asked Shirley if the Member Services rep said he would get back to her, but Shirley said this did not happen. Hopefully all this does get resolved – and quickly. You see, hospitals, doctors, and medical groups do not wait around to get paid.  They very quickly turn over unpaid bills to collection agencies, and collection agencies quickly send negative reports to credit rating companies. Here is one such story.

Shirley is pretty sharp, and she has kept the Summary of Benefits and the Evidence of Coverage for her Medicare Advantage plan. She referred to the Evidence of Coverage (100+ pages) when she spoke to the billing department for the doctor group, but they were not swayed. They said she owed the money.

I told Shirley it was up to her Medicare Advantage plan to fix this problem because they have a contract with the surgical facility that says they will pay a certain amount for each medical service. I would assume the contract says they should not balance bill the patient.

Important lesson #1:  People need to know how their Medicare Advantage plan works, so they don’t end up paying bills they don’t owe.

Important lesson #2:  If you don’t get the answer you think you should get from your Advantage plan’s Member Services, try calling again. It is possible you spoke to an inexperienced employee who gave you the wrong answer.  You could also ask to talk to a supervisor if you are pretty sure that rep is wrong.

How does a person pick a Medicare Advantage plan?  Is the hospital network the most important factor?  Is having the biggest network of doctors important?  Is the plan with the lowest co-pays for doctor visits and hospital stays the top choice?  Are drug co-pays for expensive brand drugs the deciding factor?

The answer to all the questions above is “yes”….. depending on the person making the decision.

HOSPITALS:

Some people want to go to University Medical Center (UMC in Tucson) if they need complicated surgery – but only two Medicare Advantage plans in Tucson are contracted with UMC. So this would narrow down a person’s choices for a Medicare Advantage plan pretty quickly.

DOCTOR NETWORK:

Some people have four or five doctors and they want to keep seeing them when they get on Medicare. If they want an Advantage plan, their insurance agent will need to make sure all their doctors are contracted with the plan he recommends.  In Tucson there are two or three Advantage plans that have very large networks that might include all five of a person’s doctors.  So this will narrow down a persons Medicare Advantage plan options.

LOWER CO-PAYS:

If a person is turning 65 and hasn’t been to a doctor in a long time, she might be more open to a small-network Advantage plan. Small-network plans will have lower co-pays for doctor visits, hospital stays, outpatient surgery, and skilled nursing facility charges.

If cost is the most important factor for someone turning 65 and considering Medicare Advantage, they will choose an Advantage plan that has a small network.

DRUGS:

Drug co-pays can vary from Advantage plan to Advantage plan. One brand drug might have a $45 co-pay on one plan, and that same drug might have a $95 co-pay on another plan.  Even co-pays for generics can be very different from plan to plan. One Advantage plan charges $15 for Hydrocodone while another plan charges $40 for the same generic drug.

Insulin is another drug with very different co-pays from plan to plan. One plan has no charge for insulin, except for the new insulin pens that are easier for people to use. These insulin pens have a $35 co-pay, but the lancets have no co-pay.  Most Advantage plans charge a $45 co-pay for all insulin, and one plan charges $35 for the insulin pen lancets in addition to the $45 pen co-pay.

*************

I can’t name names here because I am an insurance broker and I cannot be seen as promoting one Advantage plan over another.  Actually, there isn’t one plan I would say is “the best” - which is something Medicare strictly forbids agents from saying.  Some plans have big networks. Some plans have a smaller network and lower co-pays.

I have talked to people who are diabetic and suggested they enroll in the plan that has no charge for insulin. But a number of people would not consider this plan even if they could save a lot of money on their medical and drug bills. Their decision came down to keeping their three or four doctors, or their concern about being in a Medicare Advantage plan with a small network of hospitals and doctors.

Picking a Medicare Advantage plan is easy for a healthy person. For folks with a long list of doctors and drugs, selecting a Medicare Advantage plan can be quite complicated.