As individuals retire or age into Medicare, their insurance situation can change dramatically. There are a multitude of options open to those with Medicare. The terms are different, the prices are different, the products offered are dramatically different each year.
The purpose of this column is to give those who are eligible for Medicare, or soon to be eligible for Medicare, some understanding of their insurance options and how it could impact their health and finances.
These questions and answers are meant as a guide to help you understand the complex questions you are now thinking about. Each individual's specific situation may create a different solution. You shouldn't necessarily do what your friends, family and neighbors do.
Q: I have recently been diagnosed with cancer. I think I am in shock, but am trying to keep an open mind. Should I be doing something with my insurance? How do I know if I am in the correct plan for my new health situation?
A: Wow, you have a lot on your mind right now. I am sorry to hear of these types of stressful news that people sometimes get.
There are many situations where your insurance decisions can have a significant impact on your finances. This is one of those situations. When we sit down to evaluate our insurance options, we make that decision based on what we know. What is happening right now, or what do we expect to happen? This type of new diagnosis adds a whole different variable to that decision-making process. This new information doesn't necessarily indicate you need to make a new or different decision, but it is good you are thinking ahead to some steps you may want to take.
This answer first off depends on the insurance that you currently have. Medicare and all the options available with that would cover most cancer treatment options. I can never say that it will be covered absolutely, but your doctor and treatment team will have a very good idea of what is covered and what isn't. The difference would most likely be if it is considered standard practice treatment or experimental treatment. Medicare often does not cover experimental treatments without some special permission. Sometimes experimental treatments are covered differently through research grants and studies.
The biggest difference with regards to your insurance is what your cost share would be with the different types of Medicare coverage. If you have just Medicare A and B, each hospital stay will cost $1,184 for the deductible; Part B coverage has a $147 deductible and then you would pay 20 percent of all approved costs after that. Medicare B would cover things like doctor appointments, testing - like CT scans, X-rays, bloodwork, etc., and outpatient services - like Chemotherapy, blood transfusions, radiation therapy and ambulance rides. The 20 percent of these types of services could be a significant amount of money.
Most individuals have more than just Medicare A & B. Many individuals have Medicare Advantage Plans. These are health plans that require Medicare A & B, but then the private insurance company covers your medical costs. With Medicare Advantage plans you usually have a co-pay for all services. Common plans to our region are: Senior Choice, Encompass 65, Senior Blue, Forever Blue, Blue Saver-MSA, Medicare Complete, Humana Readers Digest Healthy Living Plan, Independent Health Medicare Passport Basic, Today's Options or maybe Evercare. All of these plans require you to have A and B, but then the private insurance company processes and covers all costs of your health insurance claims.
In this situation your insurance has a different co-pay structure for your health care. You may pay $60 for each test, or $40 for each doctor appointment or 20 percent of chemotherapy. The percentage costs sometimes can be significant, if your chemotherapy is $2,700 per dose and you go once a week, that is a big 20 percent. If your radiation co-pay is $40 per time and you go once a day for six weeks, those co-pays add up.
In a situation like this one, I would suggest looking at the information that you received about your insurance plan. What are your deductibles, co-pays and cost shares? Think about what options for treatment you have and how that matches your cost shares? Then decide if you need to switch insurance products. I never say automatically switch insurance products. Evaluate the information you have and how it impacts you financially.
Also evaluate your choices for where you are treated. If the hospital and physicians you want to see participate in your insurance, you may not need to switch. If you and your family want to go to Sloan-Kettering Cancer Center, you need to be sure that they participate with your insurance products. Most HMO products available locally would not include that hospital as a participating network facility. That means your treatment there will not be covered. If you have Original Medicare and a Medicare Supplement, you would be fine using almost any hospital or treatment center in the country to pursue treatment of your new diagnosis.
If you find that after reviewing your current insurance you feel like you want to switch to something different, we need to evaluate that possibility. Those of you who currently have Medicare are told over and over that you can't switch insurance products anytime you want. You have the months of October, November and December to make your switch for the coming year. That is true. There are also Special Enrollment Periods (SEP) that we can use to switch plans if appropriate. There are 16 SEPs that are available to you. I am going to go over just one here.
If you have a Medicare Advantage Plan and feel your co-pays are going to be too much with cancer treatment, we could use the SEP of a Five-Star Prescription Drug plan. In 2013 we have one Five Star Plan and it is a Stand-Alone Drug plan. If you were to enroll into this plan to begin next month, you would automatically be disenrolled from your Medicare Advantage Plan. That means you have Original Medicare and the Five Star Prescription Drug plan. That is not enough. I would highly recommend getting into a Medicare Supplement Product also.
With this scenario you would have significantly higher monthly premiums probably, but your co-pays for your health and medical care could be as low as zero. The higher monthly premiums for the insurance amount to significantly less out of pocket each month when you don't have co-pays for your health care.
This is just one scenario where I would use an SEP to correct an insurance choice. I think that the next couple of weeks I will cover the other SEPs you could use to switch insurance products.
Good luck with your treatment plan and review the upcoming articles for other options open to you. If you don't want to wait, you know how to reach me. Call with further questions.
Janell Sluga is a geriatric care manager certified and works for Senior Life Matters, a program of Lutheran Senior Housing, and has worked in Chautauqua County with seniors for more than 18 years. She is HIICAP (Health Insurance Information, Counseling & Assistance Program) counselor-trained by Office for the Aging. She does not sell insurance or represent any insurance company. She is an unbiased source of insurance and education to help seniors choose the best option for them.