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Health 411: How to shop for best 'Medigap' coverage

Also: When does doctor's behavior cross the line?

September 19, 2011|By Lisa Zamosky, Special to the Los Angeles Times

I'm an 84-year-old man on Social Security with original Medicare and Mutual of Omaha gap insurance. My insurance premium was raised from $262 to $363 a month, a 39% jump. After all my monthly expenses, I have just $240 left. What can I do in the event of another increase in my premiums?

If you've had your current Medicare supplement plan for years, it's not surprising that you've seen your costs steadily rise, says Steve Zaleznick, senior Medicare advisor at PlanPrescriber, a Maynard, Mass.-based online provider of Medicare education and plan comparison tools. "If you got it at age 65, by the time you hit 84 it's going to have a noticeable impact on your budget," he says.

That's why experts say it's so important for all Medicare beneficiaries to continually evaluate their supplemental coverage to see whether another plan may meet their needs at a lower cost.

So-called Medigap plans are private insurance plans that work with original Medicare. "Medigap wraps itself around Medicare and covers some or all of the out-of-pocket cost-sharing," says Hilary Sohmer Dalin, director of benefits access policy at the National Council on Aging, a nonprofit advocacy organization in Washington, D.C.

All insurers offering Medigap have the same standardized packages, though the price can vary greatly, so it's worth shopping around. But beware: Although insurers cannot deny you Medigap coverage within the first six months of your turning 65, after that — with only a few exceptions — they can take your health into consideration when deciding whether to extend coverage.

That's not the case with Medicare Advantage plans, another option for filling in gaps in coverage. If you apply for a Medicare Advantage plan during annual open enrollment periods, you're guaranteed coverage.

These plans are administered by private insurance companies that typically provide all of your benefits under one roof, usually Medicare parts A (hospital care), B (outpatient care) and D (prescription drug coverage). Many also offer extras that Medicare typically does not cover, such as dental and vision benefits and help paying for a gym membership.

Unlike Medigap, Medicare Advantage plan benefits differ dramatically from one plan and insurer to another, so you need to review carefully what each offers.

There are other differences between these two types of plans as well. With original Medicare and a Medigap plan, you can see any doctor who accepts Medicare; with Medicare Advantage, you'll probably be limited to a network of participating physicians.

In terms of cost, Medigap plans tend to cover more out-of-pocket expenses — including co-pays and co-insurance — than Medicare Advantage plans do. The trade-off is that their premiums tend to be higher.

Finding the best Medicare supplement and drug benefit plan can be tricky: You need to simultaneously consider which benefit package will meet your medical needs while fitting within your budget. Sohmer Dalin and Zaleznick strongly advise people to get help navigating through the maze during open enrollment, which this year runs from Oct. 15 through Dec. 7.

You can compare plans and their costs side-by-side at the Medicare Plan Finder (go to Medicare.gov and look for Medicare Plan Finder under the Resource Locator heading on the home page) or by going to PlanPrescriber.com. PlanPrescriber also has licensed agents able to guide you at no charge, at (800) 404-6968.

Free personalized assistance is also available through your State Health Insurance Counseling and Assistance Programs (SHIP), which you can find by visiting the Medicare.gov Medicare Helpful Contacts page (click on the Help & Support tab on the home page, then select Useful Phone Numbers) or by calling (800) MEDICARE.

Sohmer Dalin also suggests you look into Medicare Savings Programs (MSPs), which help low-income seniors cover the cost of Medicare Part B premiums for outpatient care and may also help with co-pays, co-insurance and deductibles. And Medicare Extra Help offers assistance paying the premium for Part D, the Medicare drug benefit program. Both programs have income and asset limits.

To find out if you qualify, you can do a self-screening online at benefitscheckup.org, a service of the National Council on Aging. A SHIP counselor can also help with this process.

To apply for a Medicare Savings Program, contact your local Department of Social Services. Click on the Medicare Basics tab at Medicare.gov, then select Help with Medical and Drug Costs followed by the Medicare Savings Program menu item to find contact information in your area.

I had a family doctor for eight years with whom I became very friendly. He invited me to parties at his home, and we would meet for dinner and shop together. He once asked to borrow $5,000 to leave his wife. I didn't lend him the money. He later reconciled with his wife, and she forced him to terminate his relationship with me as a friend and doctor.

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