insurance question

[sunandsea]

Not sure if anyone can answer this but I thought I would try. We currently have private insurance through my employment and medicare is my husband's secondary insurance. We have the option of dropping our private coverage for him and making medicare primary. We would also purchase supplemental plans for medical coverage and prescriptions. This would save us some money but I'm concerned that the coverage won't be as good.

I'm sure others have been in this position. Can anyone share their experience and advise? Our current situation is quite expensive (I'm home on leave and paying to continue benefits) but I will continue to do so if it is the better option.

Thanks for any advice, comments.

 

[lgelb]

Hi Sun,
That is a complex question, as you know, because it depends so much on the plans. You will want to look at:

What Medicare Advantage plans are available in your zip code for him [available at medicare.gov] and their ratings, reputation of the network in your area, whether your current docs and hospitals participate

What drug(s) he takes, and how they are treated (tiered) by these plans compared to now, what the copays are

What durable equipment like hospital bed, wheelchair, BiPAP, suction, CoughAssist, lift he has now/will need in future and whether your area is subject to competitive bidding for DME currently (though they are all heading there)
What you currently pay to "rent" any equipment, etc.

And of course plan design overall...what office visits, etc. cost, is there an annual cap on anything, what max out of pocket is, etc.

The one thing I will say is that I wouldn't switch to "traditional" Medicare, but would consider an Advantage plan as primary depending on all of the above.

 

[Diane H]

You probably need more than the remaining 6 days of this open enrollment period to compare the plans available.
Before deciding, call your company benefits plan to find out whether he can be put back on your plan if he is taken off it now. That probably doesn't apply to dependents, but you need to be certain in case the new coverage doesn't work out, changes over the year, or doesn't exist next year.
Go to medicare.gov and find the plans available in your area. It will include supplemental, advantage, drug plans, HMOs and more. Look for plans that have limits for what you have to pay out of pocket as your copays before you are free of copays for the rest of the year. Medicare alone does not have this critical financial disaster preventative!
Supplements are expensive, especially when not offered by an employer, but cover 80% to 100% of what is left after Medicare pays their 80%.
Advantage plans pay only the same as Medicare but have prescription coverage and that important limit on out of pocket copays. The rest of their added coverage are small things, but you don't have to deal with Medicare's complicated hospital coverage.
Advantage plans require getting care from doctors, hospitals, clinics, pharmacies and medical equipment (DME) from providers in their network.
Check the Star ratings! A plan may entice you by having a lower copay on some big items such as a DME copay of only 12% instead of the usual 20%, but if the plans Star rating is only 3.5 out of 5 when others are 4.5 you can probably expect more hassles and poorer accounting and service in general.

 

[lgelb]

I would not rely on any answer as to whether he could go back to using the private plan as primary, and would presume "no," for several reasons. The "qualifying event" definition that plans use does not generally include "I chose to send Medicare back to secondary carrier status." Qualifying events key on involuntary events.

In fact, at future company re-enrollments, you should be prepared for the possibility that they will force Medicare as primary.

Competitive bidding requirements represents a narrower network (and narrowing by the day) than that of most MA plans, and MA plans can be richer if only in the likelihood of speaking to a human with authority who has flexibility, than traditional FFS Medicare. There is also better coordination/less paperwork since you don't need a separate Part D plan.

Supplements are generally an expensive way to avoid coinsurance; look at exclusions and terms carefully.

 

[sunandsea]

Thank you, Laurie and Diane. I really appreciate the advice. I have spoken to a medicare specialist and another insurance rep and the plans offered almost sound too good to be true for the difference in cost from what we are currently paying. Which is why I'm hesitant. One factor pushing me forward on the change is learning that some supplemental plans can refuse to accept an individual (as a new member) after they have been on Medicare, Part B, for 3 years. My husband has been on Part B (secondary) since diagnosis of ALS when it was offered and we accepted. Knowing that we will need to go on Medicare as primary at some point (I won't be working forever or if something happens to me - both cases meaning he isn't covered under my group plan at work), I thought I would be proactive and make the change now when we can choose the supplemental plan we want.

I do know prescription coverage is key and he is on a couple of very costly drugs.

So much to consider. I was curious if anyone had changed coverages and had good or bad experiences as a result. I think we may keep what we have. I know we have been fortunate to have as much covered as we do. If only we could also get home care assistance. That is one area we are really struggling in, as so many do.

Many thanks again.

 

[KimT]

Just remember every state is different and there is a HUGE difference between GAP plans (medicare supplements) and Medicare Advantage Plans. In my area it is necessary to get a GAP plan in order to cover the 20% for durable medical equipment not paid by Medicare. If your state offers better Medicare Advantage Plans, look for one that pays for all or most DME. The medical equipment is, by far, the most expensive thing. If you get Medicare Advantage, check the drugs covered. If you get a GAP plan, you will need a Plan D to cover drugs. Again, compare.