Pick the Right Medicare Before You Need It

By SAM URETSKY

It has been said that the elderly is the only minority that people actually want to join. There was a time when the image of the senior citizen was of someone sitting around waiting to get worse. More recently it seems as if it’s a competition to see how many pathologic conditions you can have at one time – and given the number of specialty practices, the calendar of the average octogenarian is as filled with appointments as that of at least a junior member of congress.

Old joke:

Doctor: I’m sorry Mrs. Schwartz, but we can’t make an old person young again.’

Mrs. Schwartz: I don’t want to get younger, I just want to get older

It’s not that your memory begins to fail as you age, it’s that just getting the right health care insurance is slightly more confusing than advanced calculus. On Oct.15, the Wall Street Journal had a valuable article “The Big Mistakes People Make in Medicare—and How to Avoid Them.” It told the story of a 66 year old man who was enrolled in a Medicare Advantage Plan – the kind of plan that you see advertised on television, that offers coverage for lots of things that Medicare should cover, but doesn’t. These plans promise dental care, extra money for groceries, and even increases in you Social Security check.

The challenge is that, while these plans carry the label Medicare, which is a federal program, they’re run by private insurance companies which make all the rules. These are the plans that have limits on in-network and out of network physicians, and hospitals, and limit your choice of practitioners. In many cases the insurers will set limits on how much they’ll pay for specific procedures, and too often the limits may be too low to be useful. You may need a referral from your primary care MD in order to see a specialist – which, in some cases, may delay the start of treatment. Still, they may be a good choice for people who are relatively young and healthy.

But, “After he was diagnosed with prostate cancer last May, he discovered the specialists he wanted to see weren’t in his UnitedHealthcare HMO’s limited network. He faced delays getting tests and treatment.” In order to eliminate the rules and delays he tried to switch to traditional Medicare – no help with groceries or dental work, but no networks either. But traditional Medicare may require co-pays and deductibles, so he also applied for a Medigap policy. These are simple enough: after a specified out of pocket expense, a Medigap policy will help with the payments. But – he was turned down for a Medicap policy. He didn’t realize that he could be rejected. “Medicare beneficiaries generally don’t know that they have a right to get Medigap policies only at certain times, and if they don’t jump then, they might not be able to purchase them later.” Generally, the best time to get a Medigap policy is within the first six months of traditional Medicare enrollment.

Medicare Advantage Plans are fine as long as you’re healthy, but they can put unwanted restrictions on the practitioners and/or hospitals that provide care. Traditional Medicare offers more freedom, but the bills can grow rapidly with any costly condition and there are no limits. Medigap policies are standardized A to N but eligibility can take into account the age and condition of the patient. Because the plans are standardized, any insurer offering plan A (for example) will follow the same rules, although the prices may differ from different companies.

The Medicare Rights Center, a non-profit advocacy group, recommends that people choosing a Medicare Advantage plan double check everything, since practitioners may switch the plans that they join, and so may medical centers. People spend a lot of time and effort deciding what colleges to apply to, or what cars to buy, but picking a health insurance plan properly may take more time, and be a more important decision than any other.

Sam Uretsky is a writer and pharmacist living in Louisville, Ky. Email sam.uretsky@gmail.com

From The Progressive Populist, December 1, 2023

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