Subscribe
Share
Share
Embed
Welcome to Healthcare Redefined: Advocating for Aging Adults and Their Families, where we empower families to navigate the complexities of aging and healthcare. Presented by Your Nurse Advocate Consulting, we share real stories, expert advice, and practical tools to help you and your loved ones confidently navigate aging with dignity.
We explore topics like creating collaborative care plans, demystifying Medicare, handling healthcare crises, and preparing for the future. Join us as we transform uncertainty into understanding.
Pam: [00:00:00] Well, before we dive in, if you're thinking "I'll deal with Medicare during enrollment", you're not alone. But we see families lose money and peace of mind every year because they wait too long or compare plans the wrong way. Today we are going to make it simple, practical, and doable, especially as we look ahead to the 2027 annual Medicare enrollment period.
Linda: [00:00:23] Well hello everyone. Welcome to Healthcare Redefined, advocating for aging adults and their families, the podcast where we tackle the real life challenges of caregiving, aging, and navigating the healthcare system. I'm Linda Kriticus.
Pam: [00:00:37] Hi, and I'm Pam Dunwald. Together, Linda and I have over 80 years of combined experience as registered nurses and also board certified patient advocates, and we're here to help you feel confident, informed, and supported every step of the way.
Linda: [00:00:52] So today we're going to talk about getting ready for the 2027 Medicare annual enrollment period. What may change, what you need to watch for, how to choose between Medicare options. So, Pam, I'm ready for you to introduce our guest.
Pam: [00:01:07] Okay. Well, we're joined today by Wendy. Wendy Schoonover, business owner of Integrity Insurance Group. And also Kevin McGuire, owner of Taylored Health Designs. So just a quick reminder, today's conversation is for educational purposes only. It's not legal, financial or medical advice. Your situation is always unique, so please talk with a qualified professional about your specific needs. You know, don't forget to check the show notes for resources that we're going to talk about during this episode, and Wendy and Kevin, welcome. We're really super glad that you're here. So I just want to take a minute. So Wendy, can you get us started? Wendy, can you give us a quick version of your story? You know, Air Force medic to insurance and then, you know, and Medicare and what you focus on now.
Wendy: [00:01:58] Absolutely, and I'm super glad to be here. Thanks for having me. I am an Air Force veteran. I was a medic when I was active duty. That is going way a lot further back in time than I'd like to admit. When I got out, I practiced in the home health arena and I was just, I guess a medical assistant for some time and then got recruited into the insurance field. I've been focused on Medicare specifically for, I guess I'm coming up on 13 years, but, you know, I've been in the insurance industry since I guess about 2002. So I've been around for a little bit.
Pam: [00:02:37] Well, awesome. Well, first of all, thank you for your service. We appreciate you.
Wendy: [00:02:41] Thank you.
Pam: [00:02:42] Kevin, it's your turn. So tell our listeners what you do, how your clinic and billing background help shape you as a Medicare advisor.
Kevin: [00:02:51] Yeah, absolutely. You know, it's kind of a funny little symmetry between me and Wendy there. I started more in healthcare generally as well. I wasn't a practitioner as much as she was. That makes sense. She's been very hands on with that. That's very cool. I worked with the software side of it. I was with an electronic health record that specialized in dialysis clinics. So dialysis and Medicare have always been very hand in hand. So that was my introduction to Medicare. About nine years after that, I got laid off. I got recruited to join some of my friends at National Insurance Carrier in their call center. I did that for a little under two years, and I started my own business back and forth six years ago. Six and a half years ago.
Pam: [00:03:31] You both have very impressive backgrounds. So tell me, what's one thing you both wish families understood before they ever pick a plan and take turns, however you want to answer this, but I need answers from both of you on this one.
Kevin: [00:03:48] Yeah, that's a great question.
Wendy: [00:03:52] Go ahead.
Pam: [00:03:53] Kevin. Go ahead. Yeah.
Wendy: [00:03:55] Yeah. For me, I think it's just having the mindset that it's important to even just have the conversation. I think the biggest mistake people make is just not really taking it that seriously, I guess. There's a period a few years ago where you could pretty much set somebody's plan when they turn 65 and forget about it. Plans are very stable. There weren't a lot of changes, but over the last few years in particular, there's been a lot of disruption in the industry. And doing that look is the most important thing. So having a plan for how you're going to get a thorough review I think is probably my biggest thing.
Pam: [00:04:32] Wendy, what about you?
Wendy: [00:04:34] Your timelines, when you need to enroll under what circumstances to avoid lifetime penalties would be probably my number one. And also do not take your friends or family's advice necessarily, unless your friend or family member is in the insurance industry in terms of what plan to choose. I talk to people on a regular basis that is like, well, my brother said, you know, I should do whatever. Like, well, your brother probably has different medications, different preferences, a different budget, different, you know, so and also there's a lot of misinformation on the internet, specifically Facebook. So just don't, just don't. If you question something, do your own thorough research or ask a trusted advisor, you know, to clarify what you've read online.
Kevin: [00:05:29] Yeah, I think you bring up a really good point. You know, I think a lot of the stuff that I run into kind of going along that vein is, you know, it's well meaning advice from trusted people. It's your friend or your relative or like a couple times recently I've had like even a healthcare professional be like, you know, check in with your insurance to make sure what your co-pay is to somebody that's on Medicaid. And like when you're that type of consumer, like as soon as you have a co-pay, like you're, you know, the bell's going crazy in your head. So I think, you know, like, it's important to appreciate that. And I think when you're getting that advice to acknowledge, you know, I appreciate where that's coming from, but then, you know, go behind their back and talk to a professional.
Wendy: [00:06:09] I always tell people like, do you want me prescribing your medication or diagnosing you? Probably not. So let them be healthcare professionals or administrative staff at the doctor's office, do what they do best and let us do what we do best.
Pam: [00:06:25] Great. Great point. Yeah. Great point. So I'd like to just step into like annual enrollment and what exactly that is. So Kevin, I'm going to ask you what you can define. Because I know there's two periods of time, one's open enrollment and one's annual enrollment. So can you please define annual enrollment and the time period that it is for people to enroll and in plain language. So what do you know, what's it for? What can you change if you can change those types of things?
Kevin: [00:06:57] Yeah, absolutely. So we are approaching Medicare's annual enrollment period. And that starts loosely on October 1st. That's when you're going to start seeing information about plans, about the upcoming year out and available for review. That's when we're allowed to start talking about those benefits. And then October 15th is the big day. That's the first day that you're able to start making those changes for January 1st. That period is running through December 7th. When people are talking about open enrollment. That's a separate type of situation for people who are on Medicare Advantage plans only. And you're allowed to take advantage of that from January 1st to the end of March. It's kind of like a period to reevaluate a decision that you made to either act or not act during the annual enrollment period.
Pam: [00:07:48] So does that mean, Kevin, with those advantage plans, could you switch during that time and maybe go back to Medicare and a supplement if you felt that you chose, you know, poorly?
Kevin: [00:07:59] Yeah, absolutely. You're allowed to go from your Medicare Advantage plan to another Medicare Advantage plan. If you decide that you would prefer to have original Medicare as your primary insurance, you can absolutely enroll into a part D plan to get rid of that Medicare Advantage.
Pam: [00:08:13] All right. Thanks. So what is the difference between the annual enrollment period and when someone turns 65, maybe. Wendy, can you speak to that a little bit?
Wendy: [00:08:24] Yeah. I thought you were going to ask in the open enrollment period. I was ready for that. So.
Pam: [00:08:29] Oh, you can answer that too. If you want.
Wendy: [00:08:32] I might trail off. You never know. So that during the annual enrollment period Kevin's absolutely correct. So essentially during that time frame, regardless of what plan type you were on, you can make unlimited changes, and the last change you make takes effect January 1st. So you can make a change on October 15th and sleep on it and come back on November 30th and say, no, just kidding. And you know that kind of thing. When you are turning 65, that is a can of worms. You've opened a little bit because it kind of depends. If you're turning 65 and you are completely retired and you don't have any other creditable coverage, you've got what's called your initial enrollment period that stretches from three months prior to the month you turn 65 all the way through three months after the month you turn 65 to make some decisions there. If you're not covered by when I say creditable coverage, basically, an active employment with 20 or more people enrolled in it would be considered a creditable plan that would allow you the opportunity to opt out of, say, Medicare Part B as an example, until you retire, if you want to do that, if that makes sense for you. That's also the time frame where, you know, if you are not already taking Social Security and you want Medicare to start, that's the time frame to actively enroll through Social Security.
Wendy: [00:09:58] Because if you're not taking Social Security, you're not going to automatically be enrolled into Medicare. So you have to actually go actively enroll. People who are already drawing Social Security would actually be automatically enrolled into Medicare Parts A and B, and would have to opt out of part B if they, you know, are on creditable coverage, either through active employment or maybe a spouse's active employment. But it also triggers when your part B starts, whether that's when you turn 65 or, you know, maybe when you retire at a later age, you also have what's called an open enrollment period that lasts for six months. And it's specific to a Medicare supplement plan. So Medicare supplements are the only kind of Medicare plan that would ever, under certain circumstances, look at a person's health history. But during that open enrollment period window, which is six months after your part B starts, there's no medical underwriting. So you can enroll and choose a better plan of your liking. And you can't be deemed unworthy because of medical history. And that's also the time frame to pick up either a standalone drug plan, if that's your choice or a Medicare Advantage plan with drug coverage included. That was kind of a lot. There's more to it, but I'm going to stop.
Pam: [00:11:15] But Wendy, that makes a really good point because in listening to both you and Kevin, really you have a large window. Individuals have a big window to be able to change that. I think what I'm hearing is, is it that it's them taking the action to get going is the challenge versus what if they don't like what they chose, so to speak? Is that correct?
Wendy: [00:11:44] Yeah, I, I would agree with that. Yeah. I mean, it's what happens, I think that this is just my perspective, right? We're working, we're young, we have employer coverage, right? We that we almost never use. So most people that I'm dealing with when either they're turning 65 or retiring don't really have, and not everybody, but a lot of people don't have a basic knowledge of how health insurance works because most people haven't used it really, you know, we're young and healthy, right?
Wendy: [00:12:15] So yeah. So then you get there and like Medicare's required to communicate when your timelines are and when you need to do things, but they're not required to make it clear and they're not required to remind you. Right. So there are a lot of, I tell people, like, if you think for a moment that you might want Medicare at 65, depending on whether or not. And this is bringing up another thing, but you're contributing to an HSA at work. I tell people, if you are on an HSA, you want at least 12 months of a running start before your 65th birthday month to evaluate your plan options. If you're not, you could wait probably till six months out or something. But those timelines are. I mean, the government doesn't care if you take the action you're supposed to take when you're supposed to take it. There are hundreds of millions of dollars of revenue that the government gets off of late enrollment penalties. And that is, again, that's like a huge, huge problem. I see people run into that regularly. Yeah.
Pam: [00:13:19] Kevin, do you have anything to add to that?
Kevin: [00:13:22] Yeah. No. In my experience, I definitely think that those late enrollment penalties have gotten a lot better over the years. I think it was kind of those first wave of retirees where part D came into action, where I think you saw a lot of those people. But yeah, absolutely. The other thing I'd say too, is just talking about not being proactive. I mean, frankly, like in some markets, like in Wisconsin, like it's very easy to change your plan any time of the year. So like when he's talking about how like through much of your life you are, you're very passive, you're very hands off with it. And like, I've compared it for that reason to kind of like being living at home and having your mom cook all your meals for all the years and all of a sudden your first, your first outing out to restaurants and all you can eat buffet. Like it's a little scary and a little overwhelming, but it's actually empowering too. I mean, you really have an opportunity to choose something for yourself and enrich your life at that time versus benefits of managing your job, trying to make it fit within, you know, the market that they're trying to attain.
Pam: [00:14:28] Gotcha. So what do you guys think is the biggest number one mistake you see during these annual enrollment periods every year, what is like a common theme that you see?
Wendy: [00:14:43] I went first last time, Kevin, I'm going to make you go first this time.
Kevin: [00:14:47] Yeah. You know, I think it's mostly again, it's you know, it's kind of been a theme throughout the episode. But the thing I wrote down is just deciding not to look. You know, we kind of touched on it again, it's, it's not actually like or like saying you're looking, but then just kind of taking the advice of somebody who's not actually licensed and looking at these plans. You know, it can be empowering because we have this opportunity now. But I understand why it's not exciting or enjoyable, but that's why people like Wendy and I are around like, I wish people thought more sometimes about the hours of certification work.
Linda: [00:15:27] Oh my God. Yeah.
Kevin: [00:15:29] It's beating our head every single year. Like, you know, use us. Don't be afraid to use somebody. You can ask, we're required to tell you how many plans we represent. And you can decide if that is, you know, some enough of a source for you, or at least that gives you a start and you can continue your search.
Pam: [00:15:50] Wendy, anything to add to that?
Wendy: [00:15:53] I mean, I think just at least in my experience, my advantage plan clients tend to be more on it when it comes to scheduling a review. Occasionally I'll have 1 or 2. This is just like whatever. I'll read the annual change. But I think a lot of times, like my Medicare supplement, folks that have a standalone drug plan, those are the ones that will just totally blow it off. And even if you don't want to make a plan, change every year, your deductibles change with part B, your standard deductible with your part D changes, your max out of pocket on covered drugs is going to change. So even if you're not making a change in terms of like, maybe the drug plan you're on, or even the Medicare Advantage plan that you are on is exactly the right one for you in 2027. Wouldn't it be neat if you didn't just wake up in January and go, wait a second, why was my deposit for Social Security less when you could just have a a 20 minute conversation with somebody so that we could go over those changes? Also, because it's not just about the coverage that you might experience, it's also about what the government is implementing in the upcoming calendar year. That's definitely going to affect you.
Kevin: [00:17:07] Yeah, no, you bring up a great point about the prescription drug only plans. That's been even when things have been calm in the Medicare Advantage market. Those are very volatile plans. The premium can be, you know, $10 one year and 60 the next. When you're not taking advantage of that and you're not actually looking out. I mean, that costs you a lot of money. The premium is a big part of what you spend on your. It's on your healthcare. It's one of the biggest fixed costs.
Linda: [00:17:35] I just have one comment to make. I have a couple clients that basically, you know, they're looking at this open enrollment period and they're saying, oh, well, we're going to go talk to our financial advisor and see what insurance plans he recommends. I said, why would you go to your financial advisor? Oh, well, they know how much, you know, we can spend with our insurance and that. And we know they know how much our drug costs, you know, what we can spend on our drug costs. So I just found it a little surprising that they were going to go talk to their financial advisor to go through insurance plans with them.
Pam: [00:18:11] Well, I guess, I mean, if you think about it, I, I, I guess if they want to go to their financial advisor and get recommendations on what they can spend or what, you know, a budget, I guess for I, I, I guess if they're looking at dollar amounts before they go meet with their advisor, but I agree. I mean, that could give them, you know, an idea that can give them some information to take with them to go see their Medicare advisor, but that can't take the place of that. I know. Alright.
[00:18:41] Well, I have something to add to that. There's a lot of those advisors who also carry the same licenses that we do. Like I actually know people who will do that also.But I will tell you, I also can handle a retirement rollover, but I don't because I want to be really, really good at one lane. And so when you're working with financial products, whether it's your insurance program or your investments or whatever, to me, I would want to make sure that Medicare wasn't just like this other thing that this person happens to do, right. I would want to make sure because next year the part D, I mean, subsidies are ending, premiums are going to change, you know? Kevin and I are over here. You know, to his point, you know, getting inundated with these ridiculous but necessary recertifications and a hip and that kind of thing. And, you know, we're just probably a little bit more on the ball. And the other thing that I would ask those clients is, okay, cool. I'm going to give you Wendy's phone number, and Wendy's going to tell you which stocks you should invest in, right? Like, I mean, you know, so it's just, and it's a preference thing, you know, and maybe it is to your point, Pam, maybe it's about like what they can spend, but even then, what you're able to spend on insurance, especially when it comes to Medicare is somewhat irrelevant because those companies are dictating what it is anyway.
Linda: [00:20:23] Yeah. And I think they're looking at more of a dollars and cents component than actually what is my health care needs, and what am I going to need to meet my healthcare needs this year?
Kevin: [00:20:32] Yeah, just tack on that real quick. I'm really sorry. Like I've, like, I find financial advisors to be great partners in this process. They do have those licenses, but they tend to favor certain types of products. And sometimes it can be enlightening for them and it can help them draw a better picture for you. So I've always found, like, I've had an example where like, literally I've met my clients for open enrollment in their office. These were ACA people, but I met them in their office with their financial advisor. And we talked about it. So, you know.
Wendy: [00:21:05] Sources to man.
Pam: [00:21:07] Yeah. Yeah. Awesome. Well, thank you so much for clarifying that. We're going to move on. We've got a lot to talk about. So I just want to try and move on to the next topic. So before we get into the changes, Linda's going to talk about looking into 2027 and the changes. But before we get into that, I just wanted to kind of break it down and just take a few minutes to cover the basics. So we've got original. So we're going to have a couple of questions based on the three options option an original or straight Medicare and a part D drug plan. You know what that covers what it doesn't cover. Then there's the option original Medicare and Medigap or a supplement and a part D, we'll get into what what those differences are. And also option C would be for someone to choose a Medicare Advantage plan or part C. So let's start with if if a listener was trying to decide between a supplement versus advantage, what are the questions you start with or what, what should they be thinking of thinking about when they're looking at these three options? Who would like to go first?
Kevin: [00:22:13] Yeah, I think it was me last time. Go ahead. Wendy.
Pam: [00:22:15] All right, Wendy, you're up.
Wendy: [00:22:17] All right. Well, so The. The first thing is your budget, I think. I think we fall on like this. I work with people that are dual eligible, meaning they have Medicare and Medicaid to very wealthy people. So that plays a factor in who you want. Managing your health care is a big deal because original Medicare and nothing or original Medicare and a Medicare supplement says that original Medicare is essentially they're administering your healthcare coverage. And a lot of people feel more comfortable with that. On a Medicare Advantage plan, a private insurance company is. But they are required to offer exactly what A and B an original Medicare would cover. And a lot of times they're going to add some other bells and whistles, right? Dental, vision, hearing, that kind of thing. But a private insurance company is in the driver's seat. However, just like when we're working for most of us, a private insurance company is in the driver's seat. And so freedom and flexibility, that would be another thing. So do you live in Florida. Do you winter in Florida? You know, I would want to know that because if you're spending half the year in another part of the country, then we're going to need something that is going to be able to be portable and move with you. So that would come into play. But I think one of the biggest things that I see too, is drug coverage. The formularies on a Medicare Advantage prescription drug plan sometimes cover tier three expensive medications better than an individual drug plan.
Pam: [00:23:59] Wendy, just I'm sorry to interrupt, but could you just explain to our listeners what that formulary is and what that means with the insurance companies?
Wendy: [00:24:08] Absolutely. So each drug plan, whether it's a standalone drug plan or a combo plan, Medicare Advantage prescription drug plan. And it also could be with the same company. Each plan dictates what your deductible is when you have to meet that deductible, what the premium is, whether or not you pay a co-pay for certain medications. The only thing it doesn't dictate is your max out of pocket for covered medications. So when I'm looking at this, it is a financial decision to me. So it's like, okay, I like the freedom and flexibility over here with original Medicare. That's really cool. But I take some really expensive inhalers and injectable medication like the Ozempic's and tirzepatide, things like that. And it's going to be covered a lot better over here on this combo plan. So at the end of the day, where am I going to be best protected? And when it comes to, oh, go ahead. Sorry.
Pam: [00:25:09] No, I was just going to say I just wanted to add one. One thing to that before we continue is that not every insurance company. I mean, and you may know better than me, but in assisting our clients to and working with patients, if there are similar medications, is it correct to say that still some insurance companies will not have maybe one of the two popular ones in their formulary and not the other? Or are they now normally covering all?
Wendy: [00:25:39] No, you are correct that sometimes I might look at. I looked at a plan recently for a diabetic that was looking at what's called a chronic needs plan, Medicare Advantage plan. And in one company, that diabetic plan was having this person meet the standard deductible. The first month they filled the medication. I think they were paying like, I don't know, 700 and something dollars and then like a couple of hundred bucks for a few months. And it kind of trailed off. On the exact same type of plan with a different company, it was 47 bucks a month for that same medication. And then I've also seen it where some of them just will not cover one med or another. So it's just super important. And the only other thing I was going to touch on is like when people talk about your first choice, like original Medicare, picking up a drug plan, you can. But the gaps in Medicare are unlimited. So you can go out and get part A, pay your premium for part B, get a drug plan and don't get a supplement or an advantage plan if you want. And you can pay cash for the gaps in Medicare, but there's no limit to that. So that could be a 20% gap in a $1,000 procedure, but it could also be a 20% gap in a $1 million problem, right? So just something to keep in mind whilst making those decisions.
Pam: [00:27:04] Okay. Kevin, could you maybe touch on the big differences between the Medicare With a supplement or Medigap and then the Medicare Advantage plans. Why and and not that choosing one or the other is right or wrong, but what influences people to choose between those two different plans?
Kevin: [00:27:25] Yeah. And, you know, part of the thing that I think is interesting in bringing up in a situation like this too, is it's evolving. I mean, frankly, I think this is a good time to kind of bring that up. Like traditionally, like Wendy was talking about the idea with the supplement is original Medicare is, is your primary insurance. And that's been preferable. You'll hear a lot of healthcare professionals talk about it because they don't apply some of the same standards. You know, wherever those standards come from, you know, I'll let people make that decision for themselves, but they don't apply some of the same standards. And frankly, it's a lot easier to get stuff approved through original Medicare than it is through a health insurance company sometimes.
Pam: [00:28:09] Are there financial differences between the two plans?
Kevin: [00:28:14] Yes, absolutely. I just want to bring up though that's kind of changing though. Starting this next year they're actually piloting Medicare, starting to apply more similar standards for prior authorizations and stuff that private companies are doing. So I mean, it's something important to think about and something important to watch if you're planning on retiring soon or, or have a supplement, that might be something that's coming to you, or you might see a cheaper supplement because of that. But you know, I.
Wendy: [00:28:41] Started that this year here in Oklahoma.
Kevin: [00:28:45] Yeah. It's common. So there is a big financial difference between them too. And, you know, I think part of the reason why, at least in my practice, advantage plans have been a little bit more popular is because there's a big difference in the investment. You can be healthy as a horse and you're going to spend, you know, an extra 1500, $2,000 on your health insurance that year. You know, if you don't ever see the doctor on an advantage plan, you're probably, in most cases, having a $0 premium. You didn't pay anything out of pocket or you just went for your annual physical. You know, I think it's really you know, it's a budgetary conversation. I agree. I'm a very, I'm a very much, you know, what can we do to maximize your value from your premium and all that type of stuff standpoint? But it's also kind of a philosophical person, you know, are you a spender? Are you a saver? Like if it's comfortable for you to have a supplement and you know, if you got suddenly a few thousand dollars worth of bills and you wouldn't be happy for that, maybe you just want to do that, you know, are you, are you bothered by the fact that you had a network or preauthorization? If you're not like what, you know, why do you make that extra investment? So and then of course, pragmatically too, you know, there's a period where having the locked amount of money on a supplement is cheaper than if you max out on a Medicare Advantage plan. You know. So are there fixed medical and doctor costs that we need to consider in this? And are we you know, is it smarter money initially to do the supplement?
Pam: [00:30:19] Thank you for clarifying that. I know people ask a lot of questions about that. You know, what's the difference between the two? Why does one cost more than the other? So thanks for, for clarifying that. So let's move on to the next question in this topic. But what do you think people misunderstand about zero zero premium plans?
Wendy: [00:30:39] This is it to me.
Pam: [00:30:41] Oh yeah. Go ahead Wendy.
Wendy: [00:30:45] Well I think they think it's free which it's not. So a zero premium Medicare Advantage plan is just how they structured that plan. Because Medicare Advantage plans get a monthly stipend from Medicare, the center for Medicare and Medicaid Services in exchange for administering our health care coverages and paying our claims. So they just structure those to a different way. So that's why you'll see, you know, some plans might have a tiny premium. Like there's one here that's like 36 bucks with UnitedHealthCare, but it's got a $5000 dental benefit on it and a very relatively low max out of pocket there because they're, they're going to do what they have to do, right? Like that they're structured that way. It's a contract, but the zero premium just means you don't pay an additional premium for that particular plan on top of your part B premium that you have to pay in order to have it. Yeah.
Pam: [00:31:46] Thanks. Yeah.
Kevin: [00:31:47] Yeah. I like to tell people that, you know, it's, it's like, it's almost like getting insurance through work. Again, if you choose the advantage plan, like you think of your 200, I mean, this isn't exactly the way it works. There's a lot of complicated math behind it. But for the average consumer, think about you taking your 20290 or wherever your part B premium is paying your portion of the premium for your health insurance and then Medicare kicking in the rest.
Pam: [00:32:12] Okay. Thank you. Move on to the last question in my section here is what should families ask about networks, especially if they travel or live in two states? And I know, Wendy, you touched on that just slightly, so I'm going to ask you to answer that one first.
Wendy: [00:32:27] Sure. I, you know, man, that's a little bit loaded. I ask people if you are going to be traveling and or living elsewhere, are you also going to establish a primary care and or a specialist that you are going to see on a regular basis while you're there? And the reason I ask that is because that's going to be a massive difference in whether or not an HMO or a PPO or original Medicare and a supplement is going to work best. If you're traveling, and the likelihood of you going to the doctor is only going to be because it's an emergency, then any plan is going to cover you for an emergency wherever you are. So it just depends on the arrangements you have while you're traveling.
Pam: [00:33:13] Yeah. And, and I think one of the things too, people don't understand is and please, you know, clarify this or correct me if I'm not on track here, but if they have a Medicare Advantage plan and they're going to, you know, go for four months to Florida and they live in Wisconsin here, and they're going to Snowbird. I mean, they can't. I mean, can they get their medications refilled or do they need to travel with enough medication?
Wendy: [00:33:38] Yeah. You can get their meds refilled. They can change their address and do mail order. They can go to a retail pharmacy that's in network with their plan.
Pam: [00:33:46] And so that wouldn't affect them at all, being out of state.
Wendy: [00:33:49] I mean, unless Kevin knows something, I don't like the medication part. To me, it's more about like, are you going to seek routine medical care while you're there? The medication. Yeah. Go ahead sir.
Kevin: [00:34:00] Yeah. And, you know, one thing to consider too, or one thing to possibly look at. You know, if you know, again, kind of looking at the budget again, more and more companies, especially if they're a national carrier, they do technically have a national network with their, with their. So if you indicate to them that you're traveling like you're a snowbird, that's something you can tap into. I mean, it's important if you're, especially if you're on an HMO to make sure that you're reviewing both of the home locations where you'd want the care. But I mean, if you, you know, if you can be pretty flexible with your plan option, you just have to kind of know the ins and outs and know the places you want to go. If you're, if you're going to be more tied to a network.
Pam: [00:34:43] Awesome. Linda. I'm going to go ahead and turn it over to you for our next section.
Linda: [00:34:48] Okay, so in this next section, I kind of wanted to go over, you know, what to watch for, not predictions, but what we're going to watch for in 2027 that could change and could affect your current plan or new plan. So, I mean, we can't promise or we really don't know everything that will change, but we can tell you what categories that you should be looking at each year. So I'll be focusing on both of you, but medication coverage changes. So the types of formulas that they're going to put together, the tiers, are going to change. Prior authorizations. You alluded to that earlier that now with the supplements, there could be some prior authorizations that they didn't require before. Quantity limits. If your drug was covered last year, it doesn't guarantee that it's going to be covered this year. And some premium and out of pocket costs. So like, what are those plan premiums going to look like? And what should you be looking for in regards to a deductible and a copay or co-insurance and max out of pocket, especially with the advantage plans and are the provider networks and hospitals still systems that you're using going to be the same? Will there be a network shift or will your clinic change contracts? And that actually happened to one of my clients last year, that her clinic no longer is part of that plan anymore.
Linda: [00:36:09] The other clinic that she went to in the same system is part of it. But the clinic where she went and got her mammograms and that was no longer participating in that network. But yet her other two clinics that she went to for pain and endocrinology were. So it was very interesting to see how some of that stuff flips, and you don't necessarily know it until you're making an appointment. And sometimes benefits that sound great, but don't really fit real life. So dental, vision, hearing allowances, over the counter cards, gym benefits, you know, how do you evaluate the value versus, you know, are you going to use them? So some of the questions I have for you, there's three of them that I have for you. And so what would your step by step checklist look like for reviewing drug coverage during the annual enrollment period? Kevin, do you want to start?
Kevin: [00:37:04] Yeah, sure. For drug coverage, the main thing is having the most current and up to date list and current, including, pardon me, the dosage and the form, believe it or people are shocked. There's a couple I can sometimes remember where like you pull up the capsule, it's like $2, you pull the tablet, it's $500. So I can make a big difference. I know.
Pam: [00:37:26] And then yeah, we ran into it. And Kevin, I just want to. I'm hoping it'll touch on that you were Wendy. But I ran into that with my own mom. When I was setting up her medications, I put in Lasix, which is the trade name for the water pill furosemide. And there was a huge difference in price. I'm like, oh my gosh, she's got to pay that. And I went in and put furosemide. I says, oh there's no, no co-pay to that. So the drug name and the generic does make a difference.
Kevin: [00:37:56] Absolutely. That's a great point as well. Yeah. And then the other big part of that, when you're specifically looking at drug coverage is the pharmacy. It needs to be a network. And then places will have a network. And some places will also have a preferred network where you can get even a little bit of better pricing there. Mail order is 100% in all the time. That's where they prefer you to go. But sometimes, you know, if you're with the right company, CVS or Walgreens or one of those will be one to where you can go and, and even get a couple extra bucks off your scripts.
Pam: [00:38:30] Wendy, anything to add to that?
Wendy: [00:38:32] Well, ditto, but also keeping in mind like this year in particular, there are some tax subsidies for drug coverages, specifically part D that are ending. And so those were kind of stabilizing some of those individual drug plan premiums. So I'm telling you, you want to be, you know, you want to do a review because it could be, again, that it's fine to stay where you're at. But because of those subsidies ending, there's going to be a little bit of a shake up in January. The other thing is you had touched on a program that I guess it's starting in some other states in January. That program that Kevin was talking about with more prior authorizations, launched in eight states in January of 2026. And the only reason I know that is because Oklahoma is one of them. So I completely agree with him that the trajectory of our landscape, of the olden days of like, everybody gets everything on original Medicare's probably not going to look like that over the next several years.
Linda: [00:39:39] So in going along with that, what do you think is one red flag in plan documents that makes you want to slow down and double check? We know about the medications, but I mean, what are some of the other red flags that somebody should really take a look at and really double check on those things?
Kevin: [00:39:58] For me, my number one is the doctors. Some people are comfortable saying that, well, you could have this if you change your doctor. That's never been me. I like to keep my ideas the same. If you like things the same and then we can figure out how to add the bells and whistles after that.
Linda: [00:40:20] Yeah. Especially if people have been with their physician for 20 or 30 years and they're very comfortable with them. You know, it's very hard for people to kind of change all of a sudden and say, well, now you want to send me where? Now you're going to tell me I need to go there or this isn't going to be covered if I stay in this network. So I think it's really important that these documents and what they have currently, that they bring that up to you as they work with an advisor. This is what I have. It's kind of like when you buy a house, these are the must haves and these are what the, you know, I'd like to have. And this is really, I don't really need it, but it's a great want.
Wendy: [00:41:01] I completely agree. I had a doctor try to get me to refer people to him. I was like, bro, all the time. I'm like, no, but also I don't want to forget. I made a note and I keep forgetting to mention this. Everyone will get an annual notice of change, whether it's a standalone drug plan or a Medicare Advantage plan. And that deadline to get that annual notice of change is September 30th. So do not trash it. Like read through that because those companies are going to outline. Here are some things that are changing. And if there is a network upheaval, you will typically get notified by mail. We get inundated with so much junk anyway, and especially Medicare recipients. I know, like it feels like the peanuts teacher at some point, you know. But this time of year, don't throw that stuff away if you're not sure if it's junk or not, call me or Kevin or somebody you trust to look at it, but you're going to get some very important information in the coming weeks.
Linda: [00:42:03] So that's really good advice, really good advice. And yeah, I think a lot of people, we get inundated with so much stuff. It just goes in the G file before we even open it. Right? Yeah.
Kevin: [00:42:13] So definitely a whole podcast just about how maybe Medicare could optimize their communication.
Linda: [00:42:22] So in saying that, how do you help someone estimate the total yearly cost, not just the monthly premium? How would you help somebody estimate their cost of these plans or the plan that they choose? Kevin.
Kevin: [00:42:40] So I would, yeah. So with that one, you're just asking the questions. You know, you're not you're not trying to diagnose their conditions, but you do need to know how do you anticipate using your plan that you're particularly if you're on an advantage plan? You know, there's things that are pretty close to the same. I mean, it's probably not going to bankrupt you if you pick plan A or plan B, but like plan B could sure save you a few hundred dollars over the course of a year. It might have that slightly better dental benefit. So yeah, that's, that's where I would, you know, that's, that's what I need you to come to the table with, not the doctors and the meds that we've talked about.
Linda: [00:43:16] So it's important to kind of look at what you have planned, any surgeries for this year? Are you planning on getting implants? Are you planning on getting dentures? Do you need eye exams? Are you needing cataract surgery? What are your health care goals for this coming year? Because I think that will also help estimate the cost and the type of plans that you choose. Wendy, do you have anything to add to that?
Wendy: [00:43:41] I agree, I actually had a couple in here yesterday and I said, how often do you go to the doctor? And he's like, wow, every three months. And his spouse looked at him and I and then he's like, oh, I go a couple of times a year. And I was like, okay, so you should be going right? Like every three months, right? So let's just pretend you're gonna. Right. You know, so it's that kind of thing for sure. And also, I always, if somebody is kind of on the fence and they can afford, that's a lot of it too. Sometimes people can't afford a supplement premium. But if you can and you're just not really sure and for whatever reason, it just feels better and it's going to make you sleep better at night to make one decision or another, then do that because the next fall we can make some adjustments if you want to. I have a ton of people who started on a supplement and just every, you know, and then those premiums go up just like anything else, and then they get to a point where they're paying just as much in premium as they would if they maxed out an advantage plan. So we switch them because that doesn't make any sense anymore. So you can start with one and change later if you want to also.
Linda: [00:44:54] And tell me if I'm oversimplifying this, but to put it into the simplest terms that I can think of for our listeners. So on a Medicare Advantage plan, you pay less upfront, but maybe more if you go in the hospital or you utilize it more. And if you have a supplement, you pay more upfront, but then less as you use it. Is that a very simple explanation?
Wendy: [00:45:19] Yeah, that's almost how I explain it. I explain it like, and maybe I'll, maybe I'll steal yours, but I'll just say, hey, do you want to pay in advance just in case? Or do you want to pay as you use it? And then if we're paying as we use it, are you going to be okay if you hit this $4,000 max or 3000 or whatever that is, right? Can you pay that out if you need to through co-pays?
Pam: [00:45:48] So all the more important for every single person that's Medicare eligible to meet with an advisor, because I can't imagine that there are two situations exactly the same, right.
Wendy: [00:46:01] Which is why we don't ask our friends. Right. Unless your friend is an agent or broker. Right.
Pam: [00:46:08] Alright, we're going to move on. We're getting a little bit short of time here. So Linda's going to end with some rapid fire questions, but I just have a couple of questions on topics that we don't need to discuss at length, but just a couple of quick questions. So I think we've talked enough about the travel and living in multiple states and snowbirds. We talked about their preferred doctors and hospitals, but what if, what advice would you give an adult child that's helping an agent, an aging parent, choose without really talking over or helping them stay in control. What advice would you give to that adult child? Go ahead Kevin.
Kevin: [00:46:51] I think the biggest thing that I try to do is just, you know, try to try to put yourself in their shoes sometimes really try to be empathetic and, and understand that, you know, they're entering a period of their life where they're needing more assistance, but needing more assistance is, can be a little bit of a scary thing if you're a very independent person. So making sure that they have the space to be heard and feel validated in that decision. You know, I think that is the biggest thing I would say.
Pam: [00:47:19] Great. Wendy. Is there something you want to add to that?
Wendy: [00:47:23] I agree, I also, I think it depends on what level you are helping them, you know, are we just helping translate what I'm saying to make sure that mom or dad understands? Then I would just be like, come to the meeting, ask the questions, be as involved as possible. Are you also going to be helping to pay bills and dealing with prior authorizations? Because that's a different thing. You know what I mean? Because you might not want to do that. You might want to just say, nope, we're doing a Medicare supplement. I don't care if I have to pay your premium with you. You know, so just things to keep in mind.
Pam: [00:48:01] Awesome. And my last question before we move into our closing questions is if someone has had a rough year with maybe billing or denials, what would be important that they review differently or, or they look at going into 2027? Wendy, you want to go first?
Wendy: [00:48:20] Sure. Did you see my face? I don't run into that a lot. I just don't. I mean, I also and probably Kevin does the same way. I make sure that if if something is going south, it is not because the plan was a poor match to my client or they didn't understand that because, I mean, I take 2 to 3 meetings before usually we're doing an enrollment based on how well the client is grasping what we're talking about and feels comfortable doing an enrollment. However, if that were the case, then I would.
Pam: [00:48:55] Wendy, just to clarify that. So say they were they went to someone else who maybe didn't do as good a job and yeah, and they're coming to you as a new client and they talk about a bad year with billing and denials. How, how would you approach that?
Wendy: [00:49:12] Well, first of all, welcome and thank you for being here. But I would have to know the details of the circumstances. So typically, if there's a billing issue, if it's on a Medicare supplement, usually it's not a bill. Usually it's bits and pieces of like a deductible for your part B deductible, most likely because that doesn't always come all at once. Or sometimes the billing department builds the supplemental company first before original Medicare. I've had that happen. So I would dig in to figure out, I need to see exactly what got denied, or we're going to make a phone call to the company and figure this out together so that I can better inform them. And then if it was just, you know, this company, maybe this company just stinks and maybe we just go find a different company. That's the beauty of working with a broker. So.
Pam: [00:50:04] So if I'm understanding you correctly, a lot of people don't understand their EOB forms or explanation of benefit forms from their insurance company. A lot of people toss them, a lot of people. And this is something that they really should hang on to and save for the year in case there's any discrepancies. Is that valid?
Wendy: [00:50:23] I mean, I would yeah. And that's also especially if you're coming to somebody new, working with somebody like me or Kevin and you've had another agent and or just have been doing it on your own. Without that information, we're going to have to be hard pressed to help figure out what happened. But nine times out of ten, it's just a misunderstanding of an EOB or a misunderstanding of how the part B deductible really gets people. You know, it really does, because that $283 for 2026, just as an example, doesn't come all at once. And so they'll get a bill for $32. And they're like, you told me I wasn't going to get a bill, you know, and I'm like, well, it's not a bill really. Yeah. Yeah. So a lot of times it's just not really understanding it. But keeping those EOBs is fantastic. Bringing it to somebody. You can also call Medicare, you know, you can call 1-800 Medicare and say this happened. And, they can kind of help you understand what is going on.
Pam: [00:51:20] Got it. Thank you. Kevin, anything you want to add to that?
Kevin: [00:51:23] Yeah. No, I think it's very important. Before you get too frustrated with any type of situation like that, it's important to know what's going on. I mean, part of the reason why, you know, it's, you know, again, I'm not always defending the insurance company here, but part of the reason why they have those things in place and some of those private options is because there's been a lot of fraud in Medicare in the past. And sometimes if a code that somebody's trying to use in a hospital is too generic for something that will get flagged. Sometimes, so like I said before, you get frustrated and before we need to throw the whole plan away, it is important to just give us a call and be like, I don't understand what's going on here. Because I mean, you know, the last time I got that was like you said, they're just confused. The person told them, make sure, make sure you know what your co-pay is. And then all of a sudden he thought that the insurance was denying it. You know, it's what people are told. What people hear sometimes can be kind of a big oof.
Wendy: [00:52:18] So make some videos, put them on social media. You'll get a whole bunch of that man.
Pam: [00:52:22] So to clarify, I think what I'm hearing with the two of you on this, and then we're going to move on to Linda with rapid fire. So I guess it's safe to say that you don't reach out. You don't necessarily have to reach out to your Medicare advisor just during these open or annual enrollment periods. You're accessible to them for the entire year. Is that safe to say?
Wendy: [00:52:46] I think full time, full service agents or brokers are. I think there are a lot of agents that get in this business and work for seven and a half weeks and then go skiing, and nobody hears from them for a year.
Pam: [00:52:57] Yeah. Okay.
Wendy: [00:52:57] So I would be asking, when you're looking for somebody, is this like a full time career for you or is this a side job? But yes, you can call me and Kevin anytime.
Wendy: [00:53:09] Yes.
Pam: [00:53:10] Awesome. Thank you. Alright, Linda, we're going to move on to wrap it up with our rapid fire questions. So these are going to be really quick, really short answers. Maybe we'll just alternate Linda with Kevin and Wendy on these as we're running a little bit short on time, but I'm going to go ahead and turn that over for you to get this wrapped up.
Linda: [00:53:27] Okay. Well, I think we've already discussed what we need to bring when they meet with someone, which is their medications, their doctors, what has happened during the year, if they've had any billing issues in that. So I want to move on to what question would you want to have them? You know, what questions should they ask about their prescriptions? What's important to ask about the prescriptions. Kevin. Wendy just real quick. Kevin, you want to start.
Kevin: [00:53:54] Yeah. I think the biggest thing is just making sure that they've been reviewed with the doctor at some point that you have an accurate list. I know I've had an example in recent years where I was quoting medications that the woman was taking anymore. Some of these lists get very big. You know, it's important to know exactly what we're working with and make sure that that preparation is done before the meeting.
Linda: [00:54:14] Wendy.
Wendy: [00:54:16] Leave out your vitamins and supplements and over-the-counter stuff. We don't need that. Yeah.
Pam: [00:54:21] Okay.
Kevin: [00:54:22] That's a very good one.
Linda: [00:54:22] Okay. Good So what? One question everyone should ask about their doctors or their hospitals. Wendy?
Wendy: [00:54:33] Do they accept the plan that you are on and do they accept Medicare assignment would be those those would be the two the two questions I would ask.
Linda: [00:54:44] Kevin.
Kevin: [00:54:46] Yeah, I would agree with that. In some markets, it's important to know that as well because they may have partnerships with the insurance company. If you happen to be in that place, that's the only place to go. You could actually save some money.
Linda: [00:54:58] So give me a reason that you'd recommend re shopping? Even if they say they tell you, oh, we're happy enough, what would be a reason that you they should re shop even if they were happy enough? Kevin?
Kevin: [00:55:12] I would say it's just because, especially over the last few years the market's just been too turbulent for that. I mean, there's an example of a plan in Wisconsin where physical therapy and occupational therapy was literally $0 dollars. And in the course of a year, it went from being the cheapest thing on the market to the most expensive thing on the market. And like, if you had that mindset before you've even looked at the plan, like you're, you're setting yourself up for a big, nasty surprise that you might not be happy about later.
Linda: [00:55:47] Wendy.
Wendy: [00:55:48] The government, they're going to make changes. You should know about them whether you like them or not.
Linda: [00:55:55] Yeah. Okay. Pam, I'm going to give it to you for the takeaways.
Pam: [00:55:59] Alright, so I'm just going to recap. I just want I just had one question on the medications that we were talking about with Linda when we were talking about whether or not your doctor or hospital system, the clinic system, whatever, accept it. I mean, I have seen both in Wisconsin, Illinois and Minnesota, where big systems are not accepting some dual Medicare Medicaid plans. Are you both seeing that? Kevin.
Kevin: [00:56:37] I think what you're seeing more is maybe the insurance companies are kind of trying to decouple from some of these areas a little bit.
Pam: [00:56:49] I don't think so. I mean, I worked at a hospital where they will not take a certain dual advantage plan or dual Medicare Medicaid plan. And in Minnesota, the Allina health system, you know, and also when we were helping Georgia, looking at that, we were asking if there were any Medicare or Medicaid plans, dual plans that they didn't take. And they did share a few. So we're seeing that more personally.
Kevin: [00:57:16] No, no, no doubt as well. I'm just, I'm just saying there's, there's areas in the in the state to where I know where I know that stuff that may have worked out in the past, like the way that the market's been the last few years, I mean, you have markets where people, where insurance companies are trying to get out, you're going to see one thing that we didn't really talk about this year, where some of these companies are going to have caps on enrollment. So if they hit the number of people that they're taking for that year, even if it's the best plan for you, there's a 0% chance you're getting it unless somebody happens to make a different decision later.
Pam: [00:57:52] So the bottom line is just know if your plan is going to be covered. I mean, basically that's the bottom line. Yeah. Okay. Go Wendy.
Wendy: [00:58:01] Go ahead just real quick. And this, you can cut this out if you want to, but it's the truth. The Medicare and Medicaid cuts that took effect in January of this year are also like, I'm not experiencing what you described, but what I am experiencing is certain plans pulling out of counties all over the country. So plans will see that, and a lot of them are dual eligible. So just, you know, for a thought, you can cut it out if you want.
Pam: [00:58:29] No. No worries. Alright, so just quick recap just looking at so review your medications and your providers. Be prepared before you go to see your advisor. Make sure you're re-shopping even if you were happy with your plan because as Wendy said, you know, everything changes. You want to maybe compare your total yearly cost. How did you utilize your healthcare last year? So do you need to make some changes because maybe you got a new diagnosis or, and then look at choose based on real life, whether it's travel, health, your social, your lifestyle preferences and really not marketing. So in wrapping up Wendy or Kevin, do you have anything that you'd like to specifically comment on? And just a quick recap.
Wendy: [00:59:17] Really, just don't be afraid of agents and brokers. Most of us do not charge a fee. And if you will get a vibe for some from somebody you know that you connect with and trust. But don't be afraid to use us just because we happen to make a commission off of some of these plans that we enroll you in. You know, we gotta eat to know.
Pam: [00:59:37] And I think that's important. And we didn't really talk about that because I'm sure that's a question that comes up. So Kevin and Wendy, how do you both get reimbursed for your services?
Kevin: [00:59:48] Yeah. So when we place with somebody with a plan that we're contracted with, we're, we're compensated by the plan for that. So you shouldn't, you should not. I mean, there might be certain life and other products where you're allowed to do that type of stuff. But for a health insurance that should not be something that you pay for if you pay for. That's a violation for the health part.
Pam: [01:00:12] Wendy.
Wendy: [01:00:12] Yeah, yeah. I mean, I didn't even know that. I just know I don't do it. Yeah. We, I, we get, I get a commission. So if I do an enrollment now, not every single Medicare plan is commissionable. However, if it is the best plan, I mean, I have a CRM that I literally show people. And if that's the one, it literally says non commissionable right there. Because the point for me isn't getting money every time I do an enrollment. The point for me is to help educate people and empower them to make the best decision they can for themselves regardless.
Pam: [01:00:43] That's right. Okay, so Wendy and Kevin, I just want to thank you both so much for being here and for bringing such, I mean, practical, educational and guidance with your expertise. So thank you so much.
Wendy: [01:00:58] Thank you for having us.
Linda: [01:01:00] Yeah. Thank you so much, both of you.
Kevin: [01:01:02] Thank you.
Linda: [01:01:02] So if today's episode helped you share it with a friend or caregiver who's trying to make Medicare decisions without a roadmap.
Pam: [01:01:10] And, you know, just a reminder to, as we wrap up today was educational only. Like we said, everybody has different. So this is not legal, financial and medical advice. Talk with a qualified professional. Talk to a Medicare advisor about your specific situation. Like we said in the show notes, we're going to include information for both Kevin and Wendy.
Linda: [01:01:31] So check the show notes for resources and ways to connect with our guests.
Pam: [01:01:36] You know, and if you want to support as you navigate, if you are looking for support as you're navigating aging, caregiving, or any health care decisions, we're certainly here at your nurse advocate consulting.
Linda: [01:01:48] So please subscribe to Healthcare Redefined so you don't miss what's next.
Pam: [01:01:53] And until next time, take care of yourself and the ones you love. We'll see you soon. Take care.
Linda: [01:01:58] Take care.