Episode 74: Medicare, the Basics

 Medicare is a government-funded health insurance program for people over 65. It consists of four parts: Part A (hospitalization), Part B (outpatient), Part C (Medicare Advantage plans), and Part D (prescription drugs).
Sheri Sisler Moore, LUTCF, FLMI. of Sunshine Insurance Brokerage explains the confusing world of Medicare. She also alerts us to Medicare scams and the importance of not choosing a plan yourself.
You can reach Sheri here: 407-920-1323 or  sheri@sunshineinsbrokerage.com.

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Transcript

Medicare
Robin Rountree: [00:00:00] Welcome to Informed Aging, a podcast about health help. And hard decisions for older adults. I'm Robin Rountree. I'm a former family caregiver. I've worked in the home care industry and now work for the Alzheimer's and dementia resource center with me is my co host.
Edith Gendron: Hi, thank you for joining us today. I'm Edith Gendron, executive director of Alzheimer's and dementia resource center. I have 40 years of working with adults, primarily with seniors and elders in need. I'm a certified positive approach to care trainer and consultant. And ADRC is a designated positive approach to care agency.
Also, I'm a certified trainer for savvy caregiver. 
Robin Rountree: The thoughts and opinions expressed here belong to Edith and I, not our wonderful employers and sponsors. This podcast is a service of the Alzheimer's and Dementia Resource Center. We are not affiliated with the Alzheimer's Association. Before making any [00:01:00] significant changes in your life or your person's life, Please consult your own experts.
Today. Our guest is Sheri Moore with Sunshine Insurance Brokerage. She's got 30 years of experience in the insurance world, and she's going to try to explain Medicare to me. This could be very interesting. Stay tuned. We'll be right back
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Robin Rountree: We are back with Sheri Sisler Moore and you are the owner of Sunshine Insurance Brokerage. So that's 30 years you've been in business. 
Sheri Sisler Moore: 30 years in the insurance business, five years as my independent owner of Sunshine Insurance Brokerage. 
Robin Rountree: So you do a lot of things when it comes to insurance. , you can do long term care insurance, dental, medical, a little bit of this, a little bit of that, but your primary is Medicare.
Sheri Sisler Moore: That's correct. And you get [00:03:00] Medicare when you turn 65 or once you retire, if you're still working with a large employer. 
Robin Rountree: Okay. All right, so how does it all work and is it different in every state? 
Sheri Sisler Moore: The basic of Medicare can be, is the same, Medicare A and B, because that is a government provided plan, but the plan options to supplement that coverage, whether that is a Medicare supplement with a standalone Part D prescription drug plan or a Medicare Advantage plan are different in every state.
Robin Rountree: Okay, so what is Medicare? Medicare. Part A. 
Sheri Sisler Moore: Medicare Part A is your hospitalization coverage. People are entitled to that coverage for no cost as long as they've worked 40 quarter hours and are a U. S. citizen. So that covers your hospital, skilled nursing, which is not long term care. It is rehab center and some hospice coverage as well.
But if you only [00:04:00] have the Part A coverage, you will have deductible and co pays along with that, if that's all you have. 
Robin Rountree: Okay. So then you say, maybe I need a Part B as in boy. What does that get you? 
Sheri Sisler Moore: Part B with Medicare is your, think of it as outpatient type coverages. So that's your doctor's visit, your lab works, testing, durable medical equipment, and that works like an 80 20 plan.
Robin Rountree: Okay, so 80 percent is covered, you pay 20%. That's correct. Now, part A, is there any cost? 
Sheri Sisler Moore: There's no cost. 
Robin Rountree: No cost. Part B? 
Sheri Sisler Moore: Part B, there is a cost, and that is based on your income for most of the population. It, this year, 2024, is 174. 70. That will be going up. Oh, okay. 
 And based on your income currently?
Yes, based on income currently. And based on how you file your taxes. 
Edith Gendron: Excuse me, I've never had anybody say that before. So I find that I always learn something new whenever I listen to someone that [00:05:00] knows what they're talking about. So is it ever lower than based on your income? 
Sheri Sisler Moore: Never lower unless you're on Medicaid.
Edith Gendron: Okay, but it could be higher? 
Sheri Sisler Moore: Could be higher. Okay. Interesting. 
Edith Gendron: Very interesting. I did not know that. 
Robin Rountree: No. Is there a Part C? 
Sheri Sisler Moore: Part C would be a Medicare Advantage plan that you would, uh, Supplement or replace your Medicare with, because actually the way that a Medicare Advantage works is it will take your A and your B, put it together in a plan, many times offering the prescription drug plan coverage Part D in that, and that's labeled as Part C, Medicare Advantage.
Robin Rountree: Oh my gosh, it's so confusing. So Part D is your, Prescription drugs. That's correct. Okay. So what we see advertised on TV is going to be all the Part C, the Medicare Advantage plans. I'm, I, based on what I know, I'm not a huge fan of Medicare Advantage plans. Okay. Edith would agree with me. 
Edith Gendron: Yep, I sure [00:06:00] would.
Robin Rountree: And that's just based on our experience with Medicare Advantage plans. What is your honest opinion? 
Sheri Sisler Moore: Honest opinion is I think the plans have a place for the people that are interested in them. Maybe that's income driven. They don't want to have to pay a premium for a Medicare supplement if their doctors are in the network.
But that is a big part of a Medicare Advantage. It does not give you freedom of choice. to go to any doctor, any hospital, like a Medicare supplement. With a Medicare Advantage, you have to stay in those networks, or you can go outside of a network with a PPO, , but you'll pay higher costs to do that in the co pays.
Robin Rountree: And you're not guaranteed the same coverage as Medicare, correct? Or is that, like, let's say Medicare will give you, I don't know, 50 days in skilled nursing. Would a Medicare Advantage plan give you that same thing? Or it depends plan to plan? 
Sheri Sisler Moore: Medicare gives you 20 days in [00:07:00] skilled nursing facility and then days 21 through 100, you're paying a co pay for.
Robin Rountree: Okay. 
Sheri Sisler Moore: So, Advantage Plans would come on and still give you those 20 days and you, but you'd still have the copay for days 21 through 100. 
Edith Gendron: See, that's something else I didn't know. I 
Sheri Sisler Moore: didn't. 
Edith Gendron: I'm serious. I mean, I knew you had to pay that copay afterwards and it can be pricey, like 250 a day, 250 a day. Right. I know that.
But I did not know that with Advantage Plans. Keep talking. Educate me. I will also 
Sheri Sisler Moore: say on the Medicare Advantage Plans, these skilled rehab facilities. usually have an allotment of beds for, by the plan. Not going to really mention names, you know, but the different carriers, they have allotment of the beds and if those beds are full, you can get declined service at those facilities if you're on a Medicare Advantage plan.
Robin Rountree: So Betty Jo, Has insurance with Company X and she lives in this part of town, but Company X doesn't have any beds available, so she may have to go [00:08:00] across town to get a bed nowhere near where her family lives, but if she were on Medicare, she would have more choice. 
Sheri Sisler Moore: Could have more choice. Could have more choice.
Medicare alone plus and or add in a Medicare supplement as well. 
Robin Rountree: And I do see the advantage of Medicare Advantage if you literally are counting your pennies and money is very, very tight. I can see the advantage there, but if you're not counting your pennies, I mean, if you want to save a little money, I don't know, look at your cable bill.
But don't, my advice is don't take it off of your health insurance unless you have to. 
Edith Gendron: Often, at least, let me say that better, in my limited experience with Medicare, you know, I used to say I made it my life's work to not understand it because people would ask me questions. I have no clue. I'm sorry about that attitude.
But anyway, it is my limited understanding that people sometimes choose Advantage Plans because they have perks. [00:09:00] Um, you know, you get a card for so many groceries a month, or you get other things that Medicare doesn't always cover. Is that correct? 
Sheri Sisler Moore: That is correct. And right now it's coming up on the Open Enrollment or Annual Enrollment period.
So the commercials you're talking about, they definitely promote those added benefits like dental, vision, hearing, um, over the counter benefits, which you can buy supplements and things like that, gym memberships and food cards. Yeah. But also in those same commercials, they'll say, well, you might have your
medicare Part B premium paid for. And you could be entitled to get your prescriptions paid for, but in the fine print on the bottom of the screen is you have to qualify for that part of it being low income or on Medicaid. 
Robin Rountree: Okay. Okay. And then, I heard the phrase today, like, you kind of renounce Medicare when you go to a Medicare Advantage plan.
Does that [00:10:00] make, like, you come off of Medicare, you go on a Medicare Advantage plan? Can you go back? You can. You can.
Sheri Sisler Moore: Uh, there are certain times of the year that you can choose to go back to original Medicare, like annual enrollment period, and then January through March, you're entitled to make a one time change as well.
Edith Gendron: Even if you've chosen Advantage plans the entire time you've been, that was my understanding, that's why I'm asking. Even if you've chosen Advantage plans from the beginning, you can still, without penalty or any other negative. Impact switch back to straight Medicare. Original 
Sheri Sisler Moore: Medicare. Yes. 
Edith Gendron: Hmm. Now that's really good information.
Robin Rountree: So you're not locked in a hundred percent. You may have to wait to a certain point on the calendar to change. I have heard of people going to rehab and the social worker, [00:11:00] okay, maybe skilled nursing, something like that. Social workers switching their plan while they're in there. What's going on there? 
Sheri Sisler Moore: So some of the facilities do not take some of the Medicare Advantage plans and recommend that they are better off switching back to a just straight Medicare.
Robin Rountree: Okay. 
Sheri Sisler Moore: With straight Medicare, though, there are a lot of deductibles and co pays that come into play. , they could opt to change their Medicare Advantage plan, especially going into rehabs or assisted living. That can also dictate the cost. A special enrollment period of a move, , but yes, a lot, some of the facilities that do not take that specific carrier plan will recommend they just go straight Medicare.
. You have to be 
Edith Gendron: 65, but you don't wait until your birthday, correct? 
So you, well, Two things, two things. Technically somebody under 65 could be eligible for Medicare if they are disabled.
Right. End stage renal [00:12:00] failure and Lou Gehrig's disease. Can qualify them for long Medicare. Sorry. Um, and a few other things if they're on disability, but yes, turning 65 is what dictates your initial enrollment period and you can apply for your Medicare 3 months before the month of or 3 months after it will always be effective.
Well, not always. The three months before, if you enroll, it will be effective on the first of the month of your birthday. If you're enrolling after, you still have that three months after as well. And why that's important is because during that time, when you're turning 65, your guaranteed issue Meaning I could have a major health condition and if I want to go on Medicare plus a Medicare supplement, I do not have to go through those questions that could kick me out eventually if I wanted to change over to them.
I'd have to go through underwriting. 
Robin Rountree: Alright, wait a second. So I got A, B, C, and D. Now there's a [00:13:00] supplement? 
Sheri Sisler Moore: There is. 
Robin Rountree: Okay, what's that? 
Sheri Sisler Moore: People know it as a Medicare supplement or Medigap. Pfft. Okay, so that is coming on top of your Medicare A and B and supplementing it gives you freedom of choice to go to any doctor, any hospital, as long as they take Medicare.
You will pay a premium for that, but many people that travel or that want that freedom of choice don't want restrictions. they're going to usually choose a Medicare supplement. 
Edith Gendron: And how much is a premium? Is it a range or? 
Sheri Sisler Moore: That really comes into play where you're located like you had asked Robin and you know it can be different by state, it can be different by county, um, carriers usually are issue age pricing or age banded pricing.
But to give a range so even you. To confuse it more between the A, B, C, and D, under the Medicare supplement plans, you have a range from plan [00:14:00] A, B, C, G, F, L, M, N. But C and F, you had to be 65 by January 1st, 2020. People that are turning 65 after that usually are going a G or an N, and I'll just throw out a range of anywhere from 180 to 220 here in Florida.
Edith Gendron: In addition to, per month, but that's in addition to the 170, whatever you said, 174. 
Sheri Sisler Moore: 70, yes, 
Edith Gendron: so pushing what, 400 a month? 
Robin Rountree: Yeah. 
Edith Gendron: Potentially. 
Robin Rountree: But then you wouldn't have to worry about co pays, right? And the, your 20%. It's kind of a backup insurance. 
Sheri Sisler Moore: It's a supplement to the Medicare, um, depending on the plan you choose, you might have a annual deductible.
Ah. This year's 240. Next year could be different. First time you go to use it, going to the doctors or getting MRIs, lab work, things like that. But once that's paid, the plan will pay everything. 
Edith Gendron: 240 as [00:15:00] in 240 or? 
Sheri Sisler Moore: 240. Oh, annually. Annually. You meet that and then the plan comes in and pays everything. 
Robin Rountree: Okay, so you're paying a monthly amount and then you've got a deductible.
Okay. So, wow, it's so much. I'm just trying to understand it. When people are shopping, when they're about to turn 65, what mistakes do you see them making? 
Sheri Sisler Moore: some of them, When they're turning 65, if they are still working, which we are seeing more and more people working beyond 65 these years, um, and they're with a large group employer of 20 employees or more, we will do a review for them complimentary.
We do not charge for our services to weigh. What would it be going over to Medicare versus continuing to be on your group coverage? Many times, they're better off staying on group coverage, and we'll tell them that. Don't take your Part B. If you want to stay with your group coverage, [00:16:00] you don't need to be paying your group coverage plus the 170, 470.
Does that make sense? 
Robin Rountree: Yeah, but you do still have to sign up for Medicare. 
Sheri Sisler Moore: They should sign up for Part A. Part 
Robin Rountree: A. Part A. 
Sheri Sisler Moore: And then when they go to retire, they'll have credible coverage if they're with that large group employer of 20 employees or more. That gives them credible coverage. They take their B at that time, and then they have that initial enrollment of guaranteed issue.
But going back to your question, sorry, a little diversion there, , original mistakes I think that People try to do it themselves, and there is so much information out there. , we do educational workshops on this a lot, and what we tell people is like, as we're growing up, we're guided on our health insurance choices, right?
When we're children, our parents are, we're on our, with our parents. When we go out to the workforce, we have our employer that's usually offering coverage, and we have somebody coming in and talking to us about that. But when you go on Medicare And now it's about at least a year [00:17:00] out, you're getting inundated with mailing, with phone calls, with texts, unfortunately, with people knocking on your doors, not as much now, but they should not be doing this.
People are supposed to have consent to contact you. You're just, it's overwhelming because you're getting email from or mail from all the carriers from agents and brokers. It's a lot. So my advice is just don't try to do it by yourself. Um, I would recommend seeking an independent broker because brokers can offer and shop for you with all carriers or most carriers., Versus a captive, if they're only with one carrier, what are they going to do? They're only going to represent that one carrier. 
Robin Rountree: Okay. 
Sheri Sisler Moore: And you're with, 
Robin Rountree: you're a broker with Sunshine Insurance Brokerage. Yes. How do you determine if it's a good brokerage? Because Edith, didn't you have a bad experience? He had a 
Edith Gendron: really, really unpleasant experience and maybe you can help me understand what happened.
Ended up Uh, was covered under the large group, right, um, [00:18:00] as a spouse. And then when it came time for Medicare, something wasn't done correctly and I ended up having to pay, I couldn't come off the group insurance and I still had to pay the Medicare premium for a year, for a full year. That is a very puzzled look right now on 
Robin Rountree: Sheri's face.
Edith Gendron: I know, I know, I know. Trust me, I was more than puzzled and not very happy. Um, and that was the Group health insurance's position. No, you can't come off because you didn't tell us in 30 days or something like that. So we ended up paying that premium for a year. And well, I was also paying the Medicare premium.
Sheri Sisler Moore: So that does go back to the group policy format. They have certain times when they're doing their annual enrollment and a window of when you have to let them know of, like, a life changing event, which coming on or off Medicare is a life changing event, but you have a certain period of time to do that.[00:19:00] 
Edith Gendron: So pay attention. 
Sheri Sisler Moore: Pay attention. Yeah, absolutely. Well, 
Edith Gendron: see, I was just going to say do it yourself. I think I would have caught that if I had, but I went back. by someone who said, I'll take care of it and just sign here. I was like, okay. So anyway, we'll just leave that there. So folks know your group policy requirements.
Robin Rountree: And also know your person. Like looking back now, you're like, oh, they're taking my, this problem off my plate. Just sign here, but you need to be more involved in that. Yes. Right. Yes. Okay. Absolutely. Absolutely. So how much time. Okay. So I come to you, I go, Sheri, I'm turning 65. Help. Is that like a one hour appointment?
Six hours? What am I looking at? It 
Edith Gendron: was 72 hours for me. 
Robin Rountree: Well, you are special. I'm 
Sheri Sisler Moore: very special. would say that depends on the person. Um, we do prefer to do most of our appointments in [00:20:00] person. We do virtually though as well because, you know, technology today allows us to do that. Um, but I would say on average it's about an hour.
Sometimes it takes two. We really get to know our clients. , we will ask because plan A for Edith may not be the right plan for you, Robin. So, it's You know, we gather information based on their doctors, based on their prescriptions. So we're doing all the research for them on those different plans and come trying to come up with different options.
We present it to them and then it's ultimately their decision. , but we show them what's best for them. The cost will be with their prescriptions involved. If it is Medicare Advantage, what other benefits are involved? And then if it's Medicare Supplement, which plan within the Medicare Supplement do you want to go with too?
So, and what deductibles or 
Robin Rountree: co pays would there be with that? Yeah. So I think that's what you want to look for in an agent is that they, they do the homework and provide you with the options and can give you the positives and negatives of [00:21:00] each choice instead of really pushing you. toward, I don't know if they're, if they only represent two insurance companies and they're really going to hit those two hard.
So you want to make sure that, cause you represent all companies? 
Sheri Sisler Moore: Most 
Robin Rountree: companies. Most. Okay. Okay. We can't 
Sheri Sisler Moore: say all anymore. Okay. Cause there are a few that the smaller carriers that we may not have a contract with, but most of the companies. Yes. 
Robin Rountree: All right. What, what is the biggest change people say about going on Medicare?
Is it relief that they don't have to? You know, get the health insurance anymore or 
Sheri Sisler Moore: once they're on it, once they're on, I think it would be relief. I think making the choice, they're overwhelmed, they don't know where to turn. It's so confusing. , but then once they do find a broker, they feel confident with or an agent, , they do feel a little more, you know, relieved.
, We, in our brokerage firm, and I do have a team with me, too, [00:22:00] we offer handholding. , like I said, and it's customized to them as far as finding the best plan for them. And we stay in touch with our clients. We do annual reviews again. They don't pay us for our services. We get paid by the carriers. , we stay in touch with them every month with newsletters or updates.
Definitely around this time of the year with the annual enrollment period, reaching out to them. Hey, any changes to prescriptions or doctors? Let us do a quick review. Okay, you're good. Stay right where you are. This year, this carrier's come out with this. It might be worth looking at because every year, and going a little bit back to the prescription drug plans, every year formularies can change.
So, what does that mean? So that's how the carriers rate the prescription drugs based on the prescriptions that the client is on. It could be preferred generic, but then that could drop down to a brand name just because every year they're going through these changes. 
Robin Rountree: So if you're on [00:23:00] medications, and some of them can be very expensive, you really need to keep track of what's going to be covered and what's not.
Yes. And that's how you help. And that's how I help. How do people get a hold of you? 
Sheri Sisler Moore: , well, my cell phone is 407 920 1323. We do have a website, which is www. sunshineinsbrokerage. com, or you can email sheri, S H E R I, at sunshineinsbrokerage. com, and we'd be happy to help. 
Robin Rountree: Thank you so much.
I think I almost understand it. I got a little while to turn until I turn 65. So I got a long while. 
Edith Gendron: And trust me, it'll all be changed. 
Robin Rountree: Just throw these notes away. Thank you so much. Please make sure to subscribe to our podcast, Informed Aging. Tell your family and friends about us. If you'd like to support the work that we do at the Alzheimer's and Dementia Resource Center, we'd Please go to [00:24:00] adrccares.
org slash donate. Today's episode was recorded at ADRC's podcast studio. That's it for now. We're looking forward to our next visit.