Getting the Maximum Benefit From Your Medicare Advantage Plan

Congress recently made significant changes to Medicare's Part D prescription drug benefit as part of the Inflation Reduction Act. While some changes aim to help seniors afford their medications, others may have unintended consequences.On the positive side, insulin costs are now capped at $35 per month for Medicare beneficiaries. This has already provided relief for many seniors with diabetes.Starting in 2025, out-of-pocket Part D drug costs will be capped at $2,000 annually. Seniors will also have the option to spread these costs throughout the year through the new Medicare Prescription Payment Plan. These changes can benefit seniors who rely on multiple brand-name medicines or have fixed incomes.However, awareness of the new payment plan is low. Medicare could do more to inform seniors about this option, which requires opting in. Seniors should consider contacting their Part D insurers during open enrollment if they would benefit from spreading out pharmacy costs.The law's drug price negotiation provision has led to some unintended effects on drug development. At least 36 research programs and 22 experimental drugs have been discontinued as a result.Part D premiums have also increased. This year, standalone Part D plans were set to cost 21% more on average compared to last year. Many seniors switched to lower-cost options as a result. The number of available plans has decreased by about 25% since 2020.Some insurers have moved certain medications to tiers requiring higher out-of-pocket costs, restricting access to previously covered drugs. New rules like step therapy requirements have also been implemented, potentially making it harder for patients to access drugs their doctors recommend.It's important for seniors to understand these changes and their potential impacts on drug access before Medicare's open enrollment period begins in October.  Contact Carleen Lachman, Independent Insurance Specialist at 724-571-4688 to learn more.  

Health insurance jargon can be the hardest to understand for consumers. Thats why you have a broker who goes to work for you and explains your policy options with clarity. However, not all brokers work ethically. You may not have an insurance broker who values you and may not elaborate on your policy limitations. The omission of these limits is illegal and should result in the termination of that broker. In contrast, the insured typically doesnt take legal action, and the broker makes his or her desired commission.This is not to say that all health insurance brokers operate in this zone of immorality. Just as with any profession, there are good and rotten eggs. Your moral compass and ability to judge a persons intention is a significant factor people can typically smell a sleazy salesperson. Below, are the most common limitations obscurely mentioned in health insurance policies. This information should adequately equip you for when you are asking questions of your broker.Heres a screenshot from the summary of the benefits of an insurance carriers product:*Note these limitations do not exist in all policies. Ask your broker.The list of benefits above is towards the end of the policy summary. Most people are interested in seven factors when it comes to their health insurance:Deductible/coinsurance/max out of pocket, doctor visits/specialists/urgent care, the network, prescription coverage, preventative/wellness coverage, emergency room fees, and ambulatory services. If your insurance broker goes over those seven things, this is how the policy would look and sound:Choice of $500-$10,000 deductible/max out of pocket (1 million in coverage)Choice of 70/30, 80/20, or 100/0 coinsuranceUnlimited $25 copay to doctor, specialist, and urgent carePHCS Network (PPO)$50 copay for annual wellness/preventative checkupER subject to deductible and coinsuranceAmbulatory services (above) $500 per transportMost people would agree that those seven things sound fantastic for health coverage. You have all your daily doctor needs taken care of and one million dollars in coverage, right? Wrong, let me show you a scary breakdown if you had an appendectomy while being covered by this policy.On average, the Fair Price for an Appendectomy lies somewhere between $7,000 and $25,000 (may vary due to zip code). If there are complications, it could be upwards of $35,000 or more. Heres a breakdown of the services and their estimated costs. You can always check on any surgery, and its price by visiting Healthcare Bluebook.Hospital Services for a 2-day admission, itll cost roughly $9,700.Physician Services the fee for procedure and routine postoperative care costs around $1,400.Anesthesia the price for an average surgery time of 1 hour and 15 minutes costs about $750.This cost adds up to the lower end of about $11,000 for an appendectomy. If you look above at the example policy, youll see that for the entire coverage term an appendectomy will be given a $2,500 coverage benefit. Even though your plan has a deductible, coinsurance, and max out of pocket; theres a specific limitation for appendicitis. With this knowledge, the insured will be left an $8,500 bill as an out of pocket expense! Keep in mind; these numbers are on the low end with no complications.Of course, its always better to have health insurance instead of going uninsured. With insurance, that remaining $8,500 for the appendectomy may negotiate to a lower bill. Policygenius.com does a great job explaining the functionality of network negotiated rates. Without insurance, you would be paying the almost full retail price for your medical surgery, which is a terrifying thought!

You can, but should you?Theres a dark stain over the insurance industry for consumers searching for quotes online. Families and individuals are aware they need to carry health and life protection but dread entering their information online, consequently experiencing the bombardment of phone calls that follow. Its so bad some people would instead go without coverage than speak with a broker over the phone. When in reality, all it takes is working smarter, not harder.Some people will advise you to buy your own auto, home, health, life, or any other insurance. They will tell you horror stories about the number of calls youll receive if you submit information online. They will present a convincing argument, and youll be tempted to accept their advice. I urge you to resist that temptation.Its no surprise that many people are turning to self quoting websites and applications. The appeal is undeniable. Theres nothing inherently wrong about this approach, and it does save the consumer the headache of having to speak to countless agents. However, should you buy insurance without speaking to a licensed broker? Its fine to quote yourself and see whats out there in terms of options, but then proceeding to purchase that insurance without educational guidance is extremely risky for the consumer. When you use past experiences, personal knowledge, and stories heard from friends to make an informed decision on your insurance; the result tends to be medical debt or bankruptcy.A licensed agent or broker has a fiduciary responsibility to you. They are mandated by state and federal law to undergo licensed certification. While you may not have had pleasant experiences in the past, having a broker perform a needs analysis to personalize the policy is a better alternative. Just like any other profession, some paid attention during class, and others did not. It isnt appropriate to blanket statement all insurance brokers as untrustworthy.Heres your solution to avoid entering your information online. Instead, reach out to family members and friends. Ask them whom they use for their insurance needs and their experience with their broker. If you cant find a family or friend who uses a local agent or broker; reach out to colleagues and people within your circle of influence for guidance. By doing so, you are acquiring a real person who is aware of your personal needs and whom others trust. Its an ideal win-win situation between a trusted broker and client. You leave feeling confident in your policy because you are informed, and youve supported a local small business owner and their family. It may not be the fastest solution, but should it?When the world is more efficient, were all happy. Quicker load times, faster test results, high-speed internet. The need for convenience and expedience permeates everything we do. Theres relief in knowing you can quote and compare prices without receiving dozens of calls.However, when you go to purchase your insurance slow down, consult a professional, ask questions, and then fill out your application with the knowledge youre protected and supported.