My husband is retiring at the end of this month, which means we lose our excellent insurance coverage through his employer. Medicare will be our default insurance after that, but all advice suggests that Medicare will not cover everything we need. So we went down the rabbit hole of learning about Medicare Parts A-D and additional available plans. We are two highly educated individuals, familiar with complicated regulatory programs, and we were both very confused. So. Very. Confused.
We ended up comparing four different plans. Each plan offered something of benefit, but no single plan offered everything we wanted. Below are the decision-making factors we finally decided are most relevant for AFib patients.
Seek professional advice. Friends used a Medicare consultant to help them figure this out, but that person was an insurance agent who stood to benefit from the recommendations. After a little googling, I found that the government provides this service free of charge in some jurisdictions. In Washington, the Statewide Health Insurance Benefits Advisors (SHIBA) program provides “free, unbiased Medicare counseling” to anyone, regardless of income level. We were matched with a PhD/MD professor volunteer who gave us timely, concise, understandable information about our choices (and identified choices we had not come up with on our own). Look to see whether your state or county offers a similar service.
Medigap or Medicare supplement plans vs. Medicare Advantage plans.Medigap or Medicare supplement plans pay for costs not covered by Medicare Part B (such as co-pays). Medicare Advantage plans are a replacement for Medicare Part B, paying for what Medicare Part B does PLUS paying for many other things. Advantage plans do usually require a co-pay. There is amazing choice within each of these types of plans, so read the fine print. We opted for a Medicare Advantage plan because it covers medications.
Is your doctor in-network? Each plan has their own network of care providers. Some networks are more extensive than others. Although most plans cover some of the costs when you use an out-of-network doctor, your co-pay may be much higher than for an in-network doctor. The electrophysiologist I see for my AFib was covered by all four plans.
Are your medications covered? Each plan had a different list of medications they do and don’t pay for, and different levels of reimbursement for each medication. This can end up being a significant annual cost if you’re not careful. I take heart rate meds. I’m allergic to the generic and have to take the name brand. Under one plan, the generic was covered, but the name brand was not. Meaning I’d had to pay full price for that medication. Under another plan, both generic and name brand were covered, but at different rates. Meaning that I’d pay a larger co-pay for the name brand. Under the plan we ultimately picked, both the name brand and the generic are covered at the same rate.
Can you see a specialist without preapproval? Under some of the plans (often called HMOs), all medical decisions have to go through your primary care doctor. You cannot make an appointment directly with an EP cardiologist without your primary care physician giving the OK. And in my experience for a different medical condition, the primary care doctor thinks they know enough and resists giving that approval. Under the plan we ultimately picked (a PPO plan), I can make appointments directly with a specialist and the costs will be covered (minus my copay).
Are outpatient procedures covered? Are inpatient procedures covered? Say you have an AFib episode and you need to go in for a cardioversion. Is that considered an outpatient procedure? Is that an inpatient procedure? What if they keep you overnight for observation? Which type of procedure is that (inpatient or hospitalization)? Are any or all of the options covered? We couldn’t figure out the answer to those questions, so we picked a plan that offered good coverage for all of the above.
Is hospitalization covered and in what amount? Medicare Part A supposedly covers hospital costs. But when I recently had my gallbladder removed and was in the hospital a total of 5 nights (2 different hospitals), Part A did not consider that “hospitalization” and did not cover one cent. At least one of the Medicare additional plans did not cover hospitalization at all (because that’s covered by Part A!). The other plans had different daily rates and total number of days covered. We did the math and discovered that the plan that covered more days at a lower daily rate actually gave better value than the one that covered fewer days at a higher daily rate (if you end up being hospitalized for more than a few days).
Are your CPAP (sleep apnea device) and supplies covered? This is one thing we never got clear on. I think it is considered “durable medical equipment,” which some plans covered and others did not. Guess I’ll find out!
There are, of course, many other differentiating factors between the many plans that are not specific to AFib. Size of copays for various services. Annual deductibles. Annual maximum payments, after which the plan covers 100% of some costs. And whether the plan covers vision, dental, hearing.
See, I told you it was confusing. This is what we did to manage the confusion:
- Sought professional advice to narrow down the plans we wanted to compare to a very few.
- Created a spreadsheet to help us do the comparison.
- Used our calculator to play out some possible scenarios and see how much we’d have to pay.
- Made our decision.
And we know that if we made a less-than-optimal decision, or if our medical situation changes, we can always change our plan next year during the general enrollment period window (Jan. 1-March 31 of each year).
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