Episode Transcript
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Speaker 1 (00:01):
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial
solutions with host licensed insurance agents Jennifer Lee, you are
guided through the ins and outs of Medicare, whether you
(00:22):
are nearing retirement, navigating your options, or just curious about
what's available. Everything you need to know is covered. Tune
in for knowledgeable insights, tips and answers to your Medicare
questions so you can take charge of your health and
your future. And Now Medicare three sixty.
Speaker 2 (00:45):
Welcome to today's Medicare three sixty show. I'm your host,
Jennifer Lee. We are going right at it to the
Medicare New Handbook for twenty twenty five, Page sixty six,
Section four on Medicare Advantage plans and other options. How
do I find out if my plan covers a service,
(01:07):
drug or supply? You or your provider could get a
decision either spoken or in writing from your plan in
advance to find out if covers a service, drug, or supply.
You could also find out how much you'll have to pay.
This is called an organization determination. Sometimes you have to
(01:29):
do this as prior authorization for your plan to cover
the service, drug, or supply. Go to page one on one. You,
your representative or your doctor can request this organization determination.
The requested organization determination can be either oral or written
based on your health needs. You and your representative or
(01:53):
your doctor can ask for a fast decision or your
on your organization determined determination quest. If your plan denies coverage,
the plan must tell you in writing, and you have
the right to appeal. Go to pages of ninety seven
to one hundred. If a plan provider refers you for
a coverage service or to a provider outside the network,
(02:16):
but doesn't get an organization determination in advance, this is
called plan direct care. Most cases, you won't have to
pay more than the plan's usual cost sharing. Check whether
your plan for more information about this protection. I would
say on this making sure you get the proper approvals
(02:38):
and authorizations is key. Sometimes when a client changes their plan,
reauthorizations approvals have to be submitted again, so keep that
in mind. You just might not be able to see
that specialists and think it's paid for, but there needs
(02:58):
to be authorization and approvals I've had this in instances
where this has happened, And depending on the insurance company
and the medical provider, if they're willing to put the
approval or authorization and send it in and get it approved,
(03:19):
it's a way for you to get reimbursed for that,
so that may help. This is a little bit different
in regards to like the prescription drugs or authorization. Actually
it's a little bit similar what I've been noticing lately.
Are there are prescription drugs like such as a GLP
(03:40):
like the Ozambique or the Manjaro that the insurance carrier
does request and approval from the doctor approving that this
person should take this medication. And so with that sometimes
a client will get a denial letter or think it's
(04:02):
a denial, and it's not necessarily the case. The drug
is covered on the formulay. However, there are approvals from
the doctor, so the insurance company could send that request
to the doctor and the doctor just sends an approval back,
or being proactive, the doctor could send it to the
insurance company as well. But of course every situation in
(04:25):
case is different, so please make sure to look at
your own designated plan. So let's go to type some
Medicare advantage plans Health Maintenance Organization HMO plan. Right, some
people hate this plan, some people love it, So let's
(04:47):
dive deep on it. Can I get my healthcare from
any doctor or other healthcare provider or hospital. No, you
generally must get your care and service doctors, other healthcare
providers or hospital in the plan network, except for emergency care,
out of area, urgent care, or temporary out of area dialysis,
(05:11):
which is covered whether it's provided in the plans network
or outside the plan's network. However, some HMO plans, known
as HMO Point of service HMO pos plans offer an
out of network benefit for some or all covered benefits
for a higher co payment or co insurance. Do you
(05:34):
get this question asked a lot if I'm going out
of state or not in my area, what's covered? Usually
for these HMO plans, when you're seeing a specialist or
primary doctor that's further from not on your ID card,
or further from where you live, you cannot do that.
(05:57):
Get approvals and authorizations, but it could get denied. But
of course, if you have an emergency and you need
to go to the hospital or you need to go
to urgent care out of the area. You definitely have
that coverage. Either you know, you show them your ID
(06:18):
card health id card and they will get that bill
to your provider or your insurance company, or you have
to pay it upfront and then you could get that
reimbursed by in your insurance company. So keep that in mind.
That's the biggest thing with the HMOs. Another thing to
cover is some plans do say HMO POS, so my
(06:43):
clients are like, oh, point of sale, I'm able to
go outside of my network. That may not necessarily true.
The key thing is the benefits right covered benefits. So
sometimes these Medicare insurance plans have that PO, but that
POS is.
Speaker 3 (07:01):
Only take for example, use for dental.
Speaker 2 (07:05):
The HMO is you know, you have to have the
one primary doctor general practitioner, and they refer you out
to the medical group.
Speaker 3 (07:14):
And then like.
Speaker 2 (07:15):
The POS could be some type of benefits like the
dental is a big one. Some Medicare plans Medicare Advantage
plans do allow you to go out of the network
for the dental, say Cairo Acupuncture proedietary, you name it,
So please do not get confused on that as well.
(07:37):
And then another big thing is urgent care if urgent
care is within your area. Sometimes a medical group that
you are with wants you or requires you to go
to an urgent care that's part of their medical group, right,
so keep that in mind. Sometimes it won't be covered
(07:58):
if it's a medical group, urgent care a place that
just doesn't cover that group.
Speaker 3 (08:06):
If that makes sense, Okay, let us move on.
Speaker 2 (08:11):
Do these plan cover prescription drugs? In most cases?
Speaker 3 (08:16):
Yes.
Speaker 2 (08:17):
If you're planning to enroll in an HMO and you
want Medicare drug coverage Part D, you must join an
HMO plan that offers Medicare drug coverage.
Speaker 3 (08:26):
If you join an HMO.
Speaker 2 (08:28):
Plan without drug coverage, you can't join a separate Medicare
drug plan.
Speaker 3 (08:34):
So let's talk about that.
Speaker 2 (08:39):
Most of the Medicare Advantage plans do have the drug
plan embedded. That's why it's called MPD or Medicare Advantage
Prescription Drug right, So that's MapD, so the drug coverage
is on there. However, there are Medicare advantaged plans that
(09:02):
don't include the prescription drugs, so those plans are just
called MA Medicare Advantage. So it's like, why do they
even have those plans? There's very reasons. Some people don't
need a drug plan, and it's because they have coverage elsewhere.
Speaker 3 (09:20):
I highly recommend not.
Speaker 2 (09:24):
Actually not having a drug plan on it if only
a few things apply. Right that you have credible drug
coverage somewhere else, be it VA or Trycare or a
group health plan, okay, but if you don't have that, please, please,
please get a drug plan. I've had a instance where
a client it's like, oh, I'm all set. Someone called
(09:49):
me over the phone and we went over options. I
don't take drugs, so I specifically told her I don't
need a prescription drug plan. So what did this agent
that was in order to take her do give her
a plan that didn't have a drug plan, which when
I compared it first, the maximum out of pockets were
(10:10):
way higher, the benefits were way lower, and she didn't
have a drug plan. Be it that she didn't need drugs,
but she did tell me she was going to go
to surgery, so who knows, maybe the doctor or the
hospital would needed to prescribe her drugs after the fact.
And then be it that for every single month that
(10:30):
you're not on a drug plan and should be on
it because you don't have credible drug coverage, you will
be penalized one percent, okay, so be it one year,
so that's twelve percent, two year, twenty four and even
five years at sixty percent okay. So might not be
if you could do the calculations that big, right, But
(10:55):
it's just the fact that.
Speaker 3 (10:58):
You needed to get one and you didn't, right.
Speaker 2 (11:01):
And most medicare advantage plans that do have a drug plan,
there's really no bigger costs to getting it. So please
take a look and make sure. I know my clients
always ask me, oh, do I have a drug plan? Yes,
I mean from my clients, they do have a drug plan. Obviously,
I wouldn't put someone in that predicament that they would
(11:22):
be penalized for something that I offered them or not
offered them. So be wary of those agents that are
just order takers and have no idea what they're doing.
I can't believe it does happen. I've seen it happen.
But more to that, Oh yeah, I actually had another
(11:43):
story on that.
Speaker 3 (11:45):
Just recently. I had a client.
Speaker 2 (11:49):
She had mentioned to me that, sorry, Jennifer, I accidentally
clicked on some Facebook ads and someone called me and
I I thought they were Medicare at first, but turns
out there another agent. She really wanted some over the
counter benefits on her plan, and so she says, you
(12:12):
know what, I was able to get more over the
counter benefits. So sorry, you know, I changed my plan.
And when you change your plan, I no longer become
our agent, right, I can't really service it. I can't
look at it and help her. So I totally understand.
Sometimes people are guilted or sold a plan, and it's
(12:36):
very hard for a person to say no over the phone.
So I said, you know, I totally understand, but let
me see what plan you have, just to make sure
that I'm doing my due diligence and seeing what's going on.
She told me the type of plan she had. Compared it.
Right off the bat, I'm like, oh no, this might
(12:59):
not be a good plan for her. So, right off
the bat, when I compared this person put her on
a plan without a drug plan, a prescription drug plan.
Speaker 3 (13:11):
Okay.
Speaker 2 (13:12):
So in set of an MPD which she had, they
put her on an Okay, she's getting one hundred and
twenty four dollars back given back to her part by premiums.
This plan was going to give her one hundred dollars,
albeit that she was going to get like fifty one
(13:32):
hundred and fifty dollars per porter over the counter. But
what good is that going to do with? First, your
drugs aren't going to be covered because there's no drug plan.
You'll be penalized one percent for every single month that
you didn't have a drug plan and had to You
essentially lost twenty four dollars a month. So what is that.
(13:55):
That's three hundred dollars. So all in all, it's it
wasn't right. The nice thing about it is she did
reach out to me right just to give me the
heads up and the respect that some agents do really
want because they know if clients want to leave. And
(14:16):
because it was an effective July first effective date, we
were able to cancel that plan that she was going
to go into.
Speaker 3 (14:25):
So be wary.
Speaker 2 (14:27):
You know, not all agents are going to be the same.
I would hope most agents do what's right, give sound
advice and recommendations to their client, versus just trying to.
Speaker 3 (14:40):
Make us out.
Speaker 2 (14:41):
And here at Premiere three to sixty, we are not
about that. We're always going to do what's right for
the client, what's in their best interest and just provide
the facts. Right, It's all about facts. What can a
plan provide a client piece of mind, coverage, the benefits
they want, and nothing else they don't need, right, because
(15:03):
some plans really are not as stable as others. Right.
But going off my tangent, sometimes you are Let's just
say you don't get something for nothing, right, So if
you're getting a lot of money back, you're really not
going to get like tons of benefits. And if say
(15:25):
the company is just more stable, they're not going to
give you tons of benefits.
Speaker 3 (15:29):
Right.
Speaker 2 (15:30):
Let's just say an insurance company wants to grow their
book of business, then they're going to entice you for
better benefits. So just taking all that in consideration for me,
because I know how to navigate through the ups, the downs,
the changes on these plans, I'm just confident in whatever
(15:52):
type of benefits you want or stability of the company
is forefront and we do talk about that. So we
could go over your options, right because ultimately it is
the person's choice on what plan they want to go to.
As a great agent, they're just giving you the options.
(16:14):
And the biggest thing too is you know, after the fact, right,
are are your agent? Going to be there for you
after they enrolled you in a plan. Right, Some agents
are like, set it, forget it. I'm never going to
talk to this client again, never going to go over
their benefits unless they call me. Like, what type of
(16:35):
approach do you want an agent to have? Be it
more proactive, reactive? You know, never talk to you again
and so forth.
Speaker 3 (16:43):
But I mean, for the most part, I think.
Speaker 2 (16:45):
People definitely want a relationship trust, just mutual understanding of
the client's needs as they progress in their you know,
senior journey and so forth.
Speaker 3 (16:59):
I did go over.
Speaker 2 (17:00):
A tangent on that, but I just I really wanted
to hone in on that it might not be you,
but it can be a loved one, a mother, father, aunt, uncle,
that just sometimes gets persuaded over the phone or even
(17:21):
in person. So those are near dear to my heart.
I really appreciate the client reaching out to me to
let me know, because if she did not, then I
would have known to till the end of the year
when I would called her for her review. And then
just surprising, sometimes it does happen. Sometimes clients think that
(17:45):
I am their agent, but they were called and reached
out to the insurance company, or maybe someone pretending to
be for an insurance company and move their plants like that.
It's just the bad stuff in our businesses that give
agents a bad name and wish more regulation and compliance
(18:06):
are on that.
Speaker 3 (18:09):
While Medicare is trying.
Speaker 2 (18:11):
To put more compliance, sometimes it's not.
Speaker 3 (18:17):
It's probably not with bad intention, but.
Speaker 2 (18:21):
Just knowing the industry and how it works and how we.
Speaker 3 (18:26):
Could just take the badges away.
Speaker 2 (18:29):
That is just another topic and I'm just going off
on a tangent here. So do I need to choose
a primary care doctor?
Speaker 3 (18:38):
Yes?
Speaker 2 (18:39):
So on your Medicare ID card, not the original one,
the one from the insurance company, it's going to have
your doctor on there in your medical group, so that
is your primary doctor. Of course, sometimes that doctor will
allow you to see someone in their own medical group
if they're busy or however they run their practice.
Speaker 3 (18:58):
But that's your.
Speaker 2 (18:59):
Doctor and your medical group, and that's the one you
have to see to get a referral? Do I have
to get a referral to use a specialist?
Speaker 3 (19:08):
In most cases?
Speaker 2 (19:09):
Yes, search and services like yearly mammogramscreenings don't require a referral. Okay,
So we are at page sixty seven what else do
I need to know about this type of plan if
you don't get non emergency healthcare outside the plans. If
(19:29):
you don't, I mean, if you get non emergency healthcare
side the plans network without authorization, you may have to
pay the full cost. It's important to follow the plan's
rules like getting prior approval for a search and service
when needed. Visit medicare dot gov or check with the
other plan for more information. So do you want to
(19:53):
dive on this a little bit more so? I would
say HMOs or health marketing organizations. You know, it could
definitely work for the consumer, the client, the senior right.
Sometimes there's a stigma on it, but sometimes for being
(20:13):
managed care, meaning you have one primary doctor that refers
you to specialists and they all sync up because they're
all in the same medical group. If you do choose
a great medical group, then it should sink they should
be talking to once to each other in regards to
your care. And that's why sometimes people are all like, I
(20:36):
don't know who to go to. You know, so you
have your doctor to refer you out. That's totally different
than the PPO option, but we'll discuss that later with
the HMO.
Speaker 3 (20:53):
That's why most people like it.
Speaker 2 (20:55):
They're okay with getting that approval or authorization and going
through their primary doctor. But of course if you're just
totally not into that, don't Depending on the medical group.
Some of the medical groups give you a referral really fast,
and I would say it just depends on their systems,
(21:18):
their staff, A lot of factors go to place. So
I do recommend that you do choose a good medical group.
So if there are an escalationist shoes, you could be
able to contact, like me, your Medicare agent or the
insurance company or your doctor for that case. What else
(21:44):
I want to talk about when it comes to chemos
So depending on the.
Speaker 3 (21:50):
Area that you're in.
Speaker 2 (21:53):
Or county, right, because these Medicare advantage plans are based
on county, I would say that it will make a
difference if HMO would be a good option for you,
because I would say medical groups that the doctors are
(22:13):
in as well as the hospitals do count for your
level of care.
Speaker 3 (22:20):
Right.
Speaker 2 (22:21):
The nice thing about these plans, you definitely could change
your doctor or your medical group. The only bad thing
is like if you are in an area that don't
have a lot of doctors, don't have a lot of
medical groups to pick from, right, But if you are
in a competitive area trying to get your business, there
(22:43):
is so many medical groups to pick from, and it's
a great thing because if you're not happy with one,
you could definitely.
Speaker 3 (22:53):
Transfer to a.
Speaker 2 (22:54):
Different doctor and medical group, and we're able to help
you out with that as well. So some of my
clients they are leering on the HMO model, but they're
quite healthy, they don't really have doctors or specialists, and
they're looking at the benefits and it just really is
(23:17):
different from say an original Medicare or a non HMO plan,
so they do.
Speaker 3 (23:23):
Give it a try.
Speaker 2 (23:24):
Haven't had a lot of complaints on this. Of course,
sometimes there's an approval or authorization needed, but that is
something we definitely help with and help contact the doctor,
the medical group, the insurance company, get you what you
want in a timely, fashionable manner. Those are things I
(23:46):
would say a great Medicare agency agent could do for you.
Speaker 3 (23:50):
Is actually just help you.
Speaker 2 (23:52):
Of course, you know, we're not healthcare professionals, but on
the insurance side with Thing Earth two and we do
have connections and contacts with different medical groups, doctors and
insurance companies to escalate your issues and so forth. So
(24:14):
I do want to end it with there. We are
still on Section four Medicare advantage plans and other options.
Speaker 3 (24:22):
I'm happy to.
Speaker 2 (24:22):
Discuss HMOs with you or PPOs or any other plan
until next week. We will sign off. I'm your host,
Jennifer Lee with Medicare three sixty. You have a wonderful
day and we will talk soon. You take care, Bye bye.
Speaker 1 (24:43):
Thank you for joining the program Medicare three sixty. Hope
you found today's episode insightful and empowering. Remember understanding your
Medicare options is key to making the right choices for
your health and financial well being. If you have questions
or topics you would like covered in future episodes of
Medicare three sixty, don't hesitate to reach out and speak
(25:06):
with our licensed insurance agent. Until next time, Stay informed
and take charge of your health care journey. This has
been Medicare three sixty, your trusted source for all things Medicare.
Take care,
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial
solutions with host licensed insurance agents Jennifer Lee, you are
guided through the ins and outs of Medicare, whether you
(00:22):
are nearing retirement, navigating your options, or just curious about
what's available. Everything you need to know is covered. Tune
in for knowledgeable insights, tips and answers to your Medicare
questions so you can take charge of your health and
your future. And Now Medicare three sixty.
Speaker 2 (00:45):
Welcome to today's Medicare three sixty show. I'm your host,
Jennifer Lee. We are going right at it to the
Medicare New Handbook for twenty twenty five, Page sixty six,
Section four on Medicare Advantage plans and other options. How
do I find out if my plan covers a service,
(01:07):
drug or supply? You or your provider could get a
decision either spoken or in writing from your plan in
advance to find out if covers a service, drug, or supply.
You could also find out how much you'll have to pay.
This is called an organization determination. Sometimes you have to
(01:29):
do this as prior authorization for your plan to cover
the service, drug, or supply. Go to page one on one. You,
your representative or your doctor can request this organization determination.
The requested organization determination can be either oral or written
based on your health needs. You and your representative or
(01:53):
your doctor can ask for a fast decision or your
on your organization determined determination quest. If your plan denies coverage,
the plan must tell you in writing, and you have
the right to appeal. Go to pages of ninety seven
to one hundred. If a plan provider refers you for
a coverage service or to a provider outside the network,
(02:16):
but doesn't get an organization determination in advance, this is
called plan direct care. Most cases, you won't have to
pay more than the plan's usual cost sharing. Check whether
your plan for more information about this protection. I would
say on this making sure you get the proper approvals
(02:38):
and authorizations is key. Sometimes when a client changes their plan,
reauthorizations approvals have to be submitted again, so keep that
in mind. You just might not be able to see
that specialists and think it's paid for, but there needs
(02:58):
to be authorization and approvals I've had this in instances
where this has happened, And depending on the insurance company
and the medical provider, if they're willing to put the
approval or authorization and send it in and get it approved,
(03:19):
it's a way for you to get reimbursed for that,
so that may help. This is a little bit different
in regards to like the prescription drugs or authorization. Actually
it's a little bit similar what I've been noticing lately.
Are there are prescription drugs like such as a GLP
(03:40):
like the Ozambique or the Manjaro that the insurance carrier
does request and approval from the doctor approving that this
person should take this medication. And so with that sometimes
a client will get a denial letter or think it's
(04:02):
a denial, and it's not necessarily the case. The drug
is covered on the formulay. However, there are approvals from
the doctor, so the insurance company could send that request
to the doctor and the doctor just sends an approval back,
or being proactive, the doctor could send it to the
insurance company as well. But of course every situation in
(04:25):
case is different, so please make sure to look at
your own designated plan. So let's go to type some
Medicare advantage plans Health Maintenance Organization HMO plan. Right, some
people hate this plan, some people love it, So let's
(04:47):
dive deep on it. Can I get my healthcare from
any doctor or other healthcare provider or hospital. No, you
generally must get your care and service doctors, other healthcare
providers or hospital in the plan network, except for emergency care,
out of area, urgent care, or temporary out of area dialysis,
(05:11):
which is covered whether it's provided in the plans network
or outside the plan's network. However, some HMO plans, known
as HMO Point of service HMO pos plans offer an
out of network benefit for some or all covered benefits
for a higher co payment or co insurance. Do you
(05:34):
get this question asked a lot if I'm going out
of state or not in my area, what's covered? Usually
for these HMO plans, when you're seeing a specialist or
primary doctor that's further from not on your ID card,
or further from where you live, you cannot do that.
(05:57):
Get approvals and authorizations, but it could get denied. But
of course, if you have an emergency and you need
to go to the hospital or you need to go
to urgent care out of the area. You definitely have
that coverage. Either you know, you show them your ID
(06:18):
card health id card and they will get that bill
to your provider or your insurance company, or you have
to pay it upfront and then you could get that
reimbursed by in your insurance company. So keep that in mind.
That's the biggest thing with the HMOs. Another thing to
cover is some plans do say HMO POS, so my
(06:43):
clients are like, oh, point of sale, I'm able to
go outside of my network. That may not necessarily true.
The key thing is the benefits right covered benefits. So
sometimes these Medicare insurance plans have that PO, but that
POS is.
Speaker 3 (07:01):
Only take for example, use for dental.
Speaker 2 (07:05):
The HMO is you know, you have to have the
one primary doctor general practitioner, and they refer you out
to the medical group.
Speaker 3 (07:14):
And then like.
Speaker 2 (07:15):
The POS could be some type of benefits like the
dental is a big one. Some Medicare plans Medicare Advantage
plans do allow you to go out of the network
for the dental, say Cairo Acupuncture proedietary, you name it,
So please do not get confused on that as well.
(07:37):
And then another big thing is urgent care if urgent
care is within your area. Sometimes a medical group that
you are with wants you or requires you to go
to an urgent care that's part of their medical group, right,
so keep that in mind. Sometimes it won't be covered
(07:58):
if it's a medical group, urgent care a place that
just doesn't cover that group.
Speaker 3 (08:06):
If that makes sense, Okay, let us move on.
Speaker 2 (08:11):
Do these plan cover prescription drugs? In most cases?
Speaker 3 (08:16):
Yes.
Speaker 2 (08:17):
If you're planning to enroll in an HMO and you
want Medicare drug coverage Part D, you must join an
HMO plan that offers Medicare drug coverage.
Speaker 3 (08:26):
If you join an HMO.
Speaker 2 (08:28):
Plan without drug coverage, you can't join a separate Medicare
drug plan.
Speaker 3 (08:34):
So let's talk about that.
Speaker 2 (08:39):
Most of the Medicare Advantage plans do have the drug
plan embedded. That's why it's called MPD or Medicare Advantage
Prescription Drug right, So that's MapD, so the drug coverage
is on there. However, there are Medicare advantaged plans that
(09:02):
don't include the prescription drugs, so those plans are just
called MA Medicare Advantage. So it's like, why do they
even have those plans? There's very reasons. Some people don't
need a drug plan, and it's because they have coverage elsewhere.
Speaker 3 (09:20):
I highly recommend not.
Speaker 2 (09:24):
Actually not having a drug plan on it if only
a few things apply. Right that you have credible drug
coverage somewhere else, be it VA or Trycare or a
group health plan, okay, but if you don't have that, please, please,
please get a drug plan. I've had a instance where
a client it's like, oh, I'm all set. Someone called
(09:49):
me over the phone and we went over options. I
don't take drugs, so I specifically told her I don't
need a prescription drug plan. So what did this agent
that was in order to take her do give her
a plan that didn't have a drug plan, which when
I compared it first, the maximum out of pockets were
(10:10):
way higher, the benefits were way lower, and she didn't
have a drug plan. Be it that she didn't need drugs,
but she did tell me she was going to go
to surgery, so who knows, maybe the doctor or the
hospital would needed to prescribe her drugs after the fact.
And then be it that for every single month that
(10:30):
you're not on a drug plan and should be on
it because you don't have credible drug coverage, you will
be penalized one percent, okay, so be it one year,
so that's twelve percent, two year, twenty four and even
five years at sixty percent okay. So might not be
if you could do the calculations that big, right, But
(10:55):
it's just the fact that.
Speaker 3 (10:58):
You needed to get one and you didn't, right.
Speaker 2 (11:01):
And most medicare advantage plans that do have a drug plan,
there's really no bigger costs to getting it. So please
take a look and make sure. I know my clients
always ask me, oh, do I have a drug plan? Yes,
I mean from my clients, they do have a drug plan. Obviously,
I wouldn't put someone in that predicament that they would
(11:22):
be penalized for something that I offered them or not
offered them. So be wary of those agents that are
just order takers and have no idea what they're doing.
I can't believe it does happen. I've seen it happen.
But more to that, Oh yeah, I actually had another
(11:43):
story on that.
Speaker 3 (11:45):
Just recently. I had a client.
Speaker 2 (11:49):
She had mentioned to me that, sorry, Jennifer, I accidentally
clicked on some Facebook ads and someone called me and
I I thought they were Medicare at first, but turns
out there another agent. She really wanted some over the
counter benefits on her plan, and so she says, you
(12:12):
know what, I was able to get more over the
counter benefits. So sorry, you know, I changed my plan.
And when you change your plan, I no longer become
our agent, right, I can't really service it. I can't
look at it and help her. So I totally understand.
Sometimes people are guilted or sold a plan, and it's
(12:36):
very hard for a person to say no over the phone.
So I said, you know, I totally understand, but let
me see what plan you have, just to make sure
that I'm doing my due diligence and seeing what's going on.
She told me the type of plan she had. Compared it.
Right off the bat, I'm like, oh no, this might
(12:59):
not be a good plan for her. So, right off
the bat, when I compared this person put her on
a plan without a drug plan, a prescription drug plan.
Speaker 3 (13:11):
Okay.
Speaker 2 (13:12):
So in set of an MPD which she had, they
put her on an Okay, she's getting one hundred and
twenty four dollars back given back to her part by premiums.
This plan was going to give her one hundred dollars,
albeit that she was going to get like fifty one
(13:32):
hundred and fifty dollars per porter over the counter. But
what good is that going to do with? First, your
drugs aren't going to be covered because there's no drug plan.
You'll be penalized one percent for every single month that
you didn't have a drug plan and had to You
essentially lost twenty four dollars a month. So what is that.
(13:55):
That's three hundred dollars. So all in all, it's it
wasn't right. The nice thing about it is she did
reach out to me right just to give me the
heads up and the respect that some agents do really
want because they know if clients want to leave. And
(14:16):
because it was an effective July first effective date, we
were able to cancel that plan that she was going
to go into.
Speaker 3 (14:25):
So be wary.
Speaker 2 (14:27):
You know, not all agents are going to be the same.
I would hope most agents do what's right, give sound
advice and recommendations to their client, versus just trying to.
Speaker 3 (14:40):
Make us out.
Speaker 2 (14:41):
And here at Premiere three to sixty, we are not
about that. We're always going to do what's right for
the client, what's in their best interest and just provide
the facts. Right, It's all about facts. What can a
plan provide a client piece of mind, coverage, the benefits
they want, and nothing else they don't need, right, because
(15:03):
some plans really are not as stable as others. Right.
But going off my tangent, sometimes you are Let's just
say you don't get something for nothing, right, So if
you're getting a lot of money back, you're really not
going to get like tons of benefits. And if say
(15:25):
the company is just more stable, they're not going to
give you tons of benefits.
Speaker 3 (15:29):
Right.
Speaker 2 (15:30):
Let's just say an insurance company wants to grow their
book of business, then they're going to entice you for
better benefits. So just taking all that in consideration for me,
because I know how to navigate through the ups, the downs,
the changes on these plans, I'm just confident in whatever
(15:52):
type of benefits you want or stability of the company
is forefront and we do talk about that. So we
could go over your options, right because ultimately it is
the person's choice on what plan they want to go to.
As a great agent, they're just giving you the options.
(16:14):
And the biggest thing too is you know, after the fact, right,
are are your agent? Going to be there for you
after they enrolled you in a plan. Right, Some agents
are like, set it, forget it. I'm never going to
talk to this client again, never going to go over
their benefits unless they call me. Like, what type of
(16:35):
approach do you want an agent to have? Be it
more proactive, reactive? You know, never talk to you again
and so forth.
Speaker 3 (16:43):
But I mean, for the most part, I think.
Speaker 2 (16:45):
People definitely want a relationship trust, just mutual understanding of
the client's needs as they progress in their you know,
senior journey and so forth.
Speaker 3 (16:59):
I did go over.
Speaker 2 (17:00):
A tangent on that, but I just I really wanted
to hone in on that it might not be you,
but it can be a loved one, a mother, father, aunt, uncle,
that just sometimes gets persuaded over the phone or even
(17:21):
in person. So those are near dear to my heart.
I really appreciate the client reaching out to me to
let me know, because if she did not, then I
would have known to till the end of the year
when I would called her for her review. And then
just surprising, sometimes it does happen. Sometimes clients think that
(17:45):
I am their agent, but they were called and reached
out to the insurance company, or maybe someone pretending to
be for an insurance company and move their plants like that.
It's just the bad stuff in our businesses that give
agents a bad name and wish more regulation and compliance
(18:06):
are on that.
Speaker 3 (18:09):
While Medicare is trying.
Speaker 2 (18:11):
To put more compliance, sometimes it's not.
Speaker 3 (18:17):
It's probably not with bad intention, but.
Speaker 2 (18:21):
Just knowing the industry and how it works and how we.
Speaker 3 (18:26):
Could just take the badges away.
Speaker 2 (18:29):
That is just another topic and I'm just going off
on a tangent here. So do I need to choose
a primary care doctor?
Speaker 3 (18:38):
Yes?
Speaker 2 (18:39):
So on your Medicare ID card, not the original one,
the one from the insurance company, it's going to have
your doctor on there in your medical group, so that
is your primary doctor. Of course, sometimes that doctor will
allow you to see someone in their own medical group
if they're busy or however they run their practice.
Speaker 3 (18:58):
But that's your.
Speaker 2 (18:59):
Doctor and your medical group, and that's the one you
have to see to get a referral? Do I have
to get a referral to use a specialist?
Speaker 3 (19:08):
In most cases?
Speaker 2 (19:09):
Yes, search and services like yearly mammogramscreenings don't require a referral. Okay,
So we are at page sixty seven what else do
I need to know about this type of plan if
you don't get non emergency healthcare outside the plans. If
(19:29):
you don't, I mean, if you get non emergency healthcare
side the plans network without authorization, you may have to
pay the full cost. It's important to follow the plan's
rules like getting prior approval for a search and service
when needed. Visit medicare dot gov or check with the
other plan for more information. So do you want to
(19:53):
dive on this a little bit more so? I would
say HMOs or health marketing organizations. You know, it could
definitely work for the consumer, the client, the senior right.
Sometimes there's a stigma on it, but sometimes for being
(20:13):
managed care, meaning you have one primary doctor that refers
you to specialists and they all sync up because they're
all in the same medical group. If you do choose
a great medical group, then it should sink they should
be talking to once to each other in regards to
your care. And that's why sometimes people are all like, I
(20:36):
don't know who to go to. You know, so you
have your doctor to refer you out. That's totally different
than the PPO option, but we'll discuss that later with
the HMO.
Speaker 3 (20:53):
That's why most people like it.
Speaker 2 (20:55):
They're okay with getting that approval or authorization and going
through their primary doctor. But of course if you're just
totally not into that, don't Depending on the medical group.
Some of the medical groups give you a referral really fast,
and I would say it just depends on their systems,
(21:18):
their staff, A lot of factors go to place. So
I do recommend that you do choose a good medical group.
So if there are an escalationist shoes, you could be
able to contact, like me, your Medicare agent or the
insurance company or your doctor for that case. What else
(21:44):
I want to talk about when it comes to chemos
So depending on the.
Speaker 3 (21:50):
Area that you're in.
Speaker 2 (21:53):
Or county, right, because these Medicare advantage plans are based
on county, I would say that it will make a
difference if HMO would be a good option for you,
because I would say medical groups that the doctors are
(22:13):
in as well as the hospitals do count for your
level of care.
Speaker 3 (22:20):
Right.
Speaker 2 (22:21):
The nice thing about these plans, you definitely could change
your doctor or your medical group. The only bad thing
is like if you are in an area that don't
have a lot of doctors, don't have a lot of
medical groups to pick from, right, But if you are
in a competitive area trying to get your business, there
(22:43):
is so many medical groups to pick from, and it's
a great thing because if you're not happy with one,
you could definitely.
Speaker 3 (22:53):
Transfer to a.
Speaker 2 (22:54):
Different doctor and medical group, and we're able to help
you out with that as well. So some of my
clients they are leering on the HMO model, but they're
quite healthy, they don't really have doctors or specialists, and
they're looking at the benefits and it just really is
(23:17):
different from say an original Medicare or a non HMO plan,
so they do.
Speaker 3 (23:23):
Give it a try.
Speaker 2 (23:24):
Haven't had a lot of complaints on this. Of course,
sometimes there's an approval or authorization needed, but that is
something we definitely help with and help contact the doctor,
the medical group, the insurance company, get you what you
want in a timely, fashionable manner. Those are things I
(23:46):
would say a great Medicare agency agent could do for you.
Speaker 3 (23:50):
Is actually just help you.
Speaker 2 (23:52):
Of course, you know, we're not healthcare professionals, but on
the insurance side with Thing Earth two and we do
have connections and contacts with different medical groups, doctors and
insurance companies to escalate your issues and so forth. So
(24:14):
I do want to end it with there. We are
still on Section four Medicare advantage plans and other options.
Speaker 3 (24:22):
I'm happy to.
Speaker 2 (24:22):
Discuss HMOs with you or PPOs or any other plan
until next week. We will sign off. I'm your host,
Jennifer Lee with Medicare three sixty. You have a wonderful
day and we will talk soon. You take care, Bye bye.
Speaker 1 (24:43):
Thank you for joining the program Medicare three sixty. Hope
you found today's episode insightful and empowering. Remember understanding your
Medicare options is key to making the right choices for
your health and financial well being. If you have questions
or topics you would like covered in future episodes of
Medicare three sixty, don't hesitate to reach out and speak
(25:06):
with our licensed insurance agent. Until next time, Stay informed
and take charge of your health care journey. This has
been Medicare three sixty, your trusted source for all things Medicare.
Take care,
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