How Medicare Works and When To Start

Welcome, David, to the podcast. I'm so excited for the listeners to number one, hear your story, but also learn from you as they're headed into retirement and really curious about Medicare, can you share, start by sharing a bit about yourself and how you came to learn so much about Medicare? Well, first of all, daily, thank you for having me and I am very happy to share my story. I grew up as a privileged young man in Lancaster County, red meat four nights a week and through high school and you know, I was always the big kid. You know, I was always the big kid. As we played football and we got into our working careers, I got into manufacturing and kind of gained a lot of weight. As my responsibility rose, my physical labor lessened, and 20 years later, that took me to about age 40, I was at 430 pounds. At that point, I decided to have gastric bypass. That took me to approximately 300 pounds for the better part of 15 years. Beginning of COVID, I was placed on Ozempic. For my type 2 blood sugar that my diabetes was out of control, that has taken me from 300 pounds down to about 205. In that process, While I was 400 pounds and on the way back down to 300, there were multiple joint replacements back surgeries. So I kind of feel I'm uniquely qualified to, to counsel people on health insurance. Yeah. Yeah. It's very good. It's quite the story. What was your first experience with Medicare? Now I understand you were on disability, but you also speak to regular Medicare, correct? Yeah, yeah, I never was on a Medicare disability plan. I got involved with Medicare when I started in financial services industry. I got out of manufacturing and I went to work for Prudential, The Rock. There, we were talking to people about life insurance and annuities, you know, and investments in retirement planning. And well, I knew how to do that, but I didn't know about Medicare. And that's what clients were asking. What about Medicare? Here are people at 62, 63 years old who've amassed piles of money. But don't have any knowledge of health care. I took advantage of that. And after this, this'll be my 14th, 13th open enrollment this year. So thank you, God. Awesome. Awesome. I love that. I am so glad to have you here to help educate the listeners as far as Medicare. Cause I know of one myth, one belief, a lot of people believe that Medicare is free. Now, as I say that, would you care to explain that thought and then, you know, educate listeners a little bit further? Sure. And that was the, that was the response I got when I started in the financial industry in 2011 ish, 2012. Medicare is free, right? And I said, well, it couldn't only be farther from the truth. You have your Medicare A and B. Medicare A is free. For the amount of quarters that you and or your spouse worked in your lifetime and Medicare be going into 2025. It is 185 a month. So there you have a is hospital and B is doctor that only covers 80 percent of your costs. So there's where you have a choice to make. There are literally 2 choices. Choice. A is Medicare supplement. You have a Medicare supplement. Those are plans G F. And you hear of and they team up with a drug plan. That's kind of the Medicare buffet. You pay a little more for a Medicare supplement, but once you pay your Part B deductible of 250. You do not pay a medical bill the balance of the calendar year. I can't, there are no better plans. And then you can add a drug plan to that. This year in 2025, drug plans are priced in from 30 to 50, even up in the hundred dollar range. A lot of changes to Medicare Part B this year. The other choice would be Medicare Advantage, and those are the commercials that Joe Namath and Jimmy Walker used to do, and they're out of business now, which is good, but those are the, the health plans that come on, and they, they tout the dental, they tout the vision, they tout the extra benefits, and you know what? They are good plans for the right clients. So, they're really tools, and my job is teaching you how to understand how to use each of those tools for your needs. Great. Where does a listener start? Where is their level of understanding? And how do they begin making the choices within this Medicare umbrella? Well, I would definitely look at a, you know, at a six month timeline out, you know, six months before you're 65 years old, you know, if not sooner, you should start looking. And with that said, you need to consider your medical needs. One of the first things I ask people, what are your needs? You know, do you take daily meds, et cetera? But with that 6 month time period, that gives you 3 months to look at plans and gather information, and then 3 months prior to the 1st of the month you turn 65, you are entitled to enroll into Medicare, unless you're drawing social security. If you're drawing social security prior to age 65. You will automatically be enrolled in Medicare, but if you're not, you have to make a conscious effort to enroll. SSA. gov makes it pretty easy. Yeah, that's interesting. I know I have a brother in law who is almost 70, but he's still working. And they keep reaching out to him, like, you need to get on Medicare, you need to get on Medicare, but he already has health care. Obviously, they're doing their job in getting you enrolled, but we need to make sure we're taking those right steps. Do you have anything to add to that? It's interesting, you mentioned your brother in law and working to age 70. There's penalties that do occur in Medicare, and when those penalties occur, it's when a client goes a period of time without credible coverage. Clients are able to work In the workforce, as long as they stay on group health plans. But when they leave that and go to Medicare, they have a 60 day window to leave that group plan and to get in into a Medicare plan to not have a penalty occur. If they go 60 days without a drug plan or without Part B coverage, then penalties would occur. Good to know. Okay, so let's get to the specifics of Medicare, how it works, how do individuals, you know, work with doctors and other providers, any things they need to expect or plan for or be aware of. Really, it depends on which plan you take that the supplement plans, Medicare supplement plan G and F and N those plans have no networks. Any doctor that accepts Medicare will accept your plan. And then those plans are teamed up with drug plans. That are nationally recognized and we pick your drug plan, depending on which drugs you take and how that plan treats them more favorable than others. Some plans treat drugs like eloquence more favorable. than others in our areas. So you actually go through medicare. gov, enter the client's medications, and then look at what comes out as far as the most efficient, lowest cost for the drugs and cost of the monthly premium. Good to know. With Medicare Advantage, then every time you use a benefit on the Medicare Advantage side, you have to think network, network, network. The two major differences. Medicare Advantage is a pay as you go kind of plan. You pay for services as you use them. You know, hospital stay. It's a plan in our area this year. Hospital stays are 175 a day for the first seven days. You know, rehab facility after, you know, after a Medicare client would leave, you know, a hospital, they may not be able to go back home right away. So they may need to enter a rehab facility. Under Medicare Advantage plans, those copays are 10 a day for the first 20 days. Under a Medicare supplement plan, there are no costs. Once the 250 deductible is met on Part B, it pays for everything. Oh, good. So what, what advice would you give to someone who is unsure as they're hearing you talk about the different coverages, how they would understand better the best coverage for themselves? Wow. Needs based. I mean, you know, if you're in your early 60s and say you have some healthcare needs. I mean, myself, I'm type 2 diabetic. I use Ozempic. And that's a very important part of my medicine regimen. I chose an individual plan on penny that covers my Ozempic. Now, when a, with a client on Medicare, If they're using Ozempic, you know, there's plans that treat that well, but it's really a needs and medication based start is how we do it. We take a client's meds, put them in medicare. gov and then, but if they come in and they don't have any meds and they appear highly inappropriate and perhaps are wearing a gym outfit that they just came from working out, you know, that that person has taken their healthcare serious. And and is planned properly for those golden years. Good to hear. Open enrollment happens once a year. As people, you know, become on, they come onto Medicare and they're on it. How should they, or should they take advantage of this open enrollment? You know, it's what happens when we're working. There's always this open enrollment and reassess. Can you kind of guide listeners as to what that means for Medicare? You're referring to the fall annual open enrollment, October 15th to December 7th. And with that said, I mean, everyone's needs change and Medicare drug plans are showing significant changes this year, along with advantage plans. If you are currently in Medicare and you are going into, into an open enrollment or in an annual enrollment, you would receive what's called an annual notice of change, an ANOC document. And that would tell you about changes in your plan. You would call me, you know, and make an appointment for October 15th, first day of open enrollment, and we come, you come in and sit down, and one of my first questions would be, what did not, what didn't you like about your plan last year? Well, I just want something better. Get that answer all the time. So address the needs, you know, some people different advantage vendors are cutting back on what are called over the counter benefits where clients can go in and pick up personal care items at pharmacies and drugstores. But they looked at that benefit and saw that it wasn't being used to its fullest extent. So they reduced it. Other clients look for a dental benefit where in our area, Aetna has really reduced their dental benefit down to a thousand dollars a year, but we have a local provider, UPMC, that literally has a 5, 000 dental benefit in their advantage plan. So it's really what, it's really what the client's needs are, is what drives your healthcare decisions. In my mind. Yeah. Very important. I know as I got off with employer benefits and onto my own, I discovered my dentist had a dental plan. It's also wise to check with your dentist who you might already be seeing. What do they have and can that serve you better? I think that's so important. I can get you the greatest dental plan in the world, but if he doesn't take it, it's, it's not, it's not worth anything. Yeah, I know we already talked about one misconception about Medicare. Are there any others that people come to you and you're like, yeah, that's not true? Or, oh, that's an assumption a lot of them make. Just to kind of, you know, kind of help listeners understand better. I think the people that just think they only need Medicare A and B, but those people may not necessarily be Be in your audience because your audience is looking at financial responsibilities. It's, it's the people that don't, don't have the bait, you know, after it, Medicare a and B and no one sat down with them and explain things to them. Those are the ones that I kinda, I feel sorry for because they're not aware. People that, that, you know, read recent publications about retirement planning are going to be, you know, and especially if they've, they've disciplined themselves to save and prosper financially. They're preparing for this, and my job's to guide them the right way. Yeah. Yeah, so other than maybe their, you know, employer benefit with their 401 and not giving them some financial planning advice, is there a better place or another place individuals can go learn more about Medicare or healthcare, you know, as a retiree? Find a local trusted Medicare advisor. You know, someone like myself. I mean, I sit down with people at kitchen tables, you know, throughout the, throughout the annual enrollment period. I work in the central Pennsylvania area. I don't know where your clients are located at. But, you know, that's what I would say. Find a, find a local professional. Medicare. gov is a great resource, but that's almost Too much information that could cause someone to overanalyze it. Don't overanalyze it. The supplement advantage, there's some Medicare supplement differences, a high deductible plan, and there's Medicare savings plans. I can sign you up for Plan G and you can set it and forget it for the most part. Well, as you're saying, you know, the letters, I remember my parents had Part D and I don't know about the evolution of Medicare. I really don't know, you know, much more, but I know how important an additional supplemental is. And I shared that with a coworker who was, you know, finishing up ready to, I think he was in his seventies. He was ready to head out. And I said, Hey, you're going to need this. He had not a clue. But I think it's important as you're talking about these letters to have listeners when they meet with somebody. Usually you're going to find them at an insurance agency. That is where I found my medical benefits person. You know, you can do an arm, I always call them an arm's length referral, ask around people you trust, people you care about, who they work with and what they've learned, and then go and sit with them. So I think that's very huge. But as you're They hear these parts and as they hear this advantage do they just need to sit with that person and ask more specific questions? It's really needs focused. I mean, I've recently sat with a family, you know, husband, wife, that she was leaving commercial or, you know, work sponsored insurance and You know, her husband has been on. He's 61. He's been on dialysis for 10 years. So, can you imagine the questions that they had? Four trips to their home, and the last three, they were smiling and laughing when I left, but the concerns came back, and we just readdressed them, and It's just a, it's a matter of trusting your agent and it's a personal relationship that my people have a guy. If you have a question, you call David. I can help you. When you have unique needs, you know, that client with, with the dialysis, medication needs, treatment needs, utilitarian needs for supplies. We reviewed it all. They're very happy with their coverage. Good, good. Ask questions, dive into it. We have some knowledge about healthcare. As we take our employer sponsored healthcare knowledge, is there much that changes and headed into Medicare? You know, other than knowing these different parts, does it function pretty much the same way? It does. A lot of work sponsored plans are going to be, you're going to see the words PPO, HMO, EPO. PPO is a preferred provider organization. EPO is exclusive provider. HMO is a home maintenance. These are all restrictive networks that if you use advantage plans, Those summary of benefits are going to look very similar because you're going to have a copay type of system like you did in your workplace insurance Whereas with medicare supplement plan the chart is pretty basic and it covers, you know It covers everything it covers a dish excess part b charges. There's even benefits for International travel a lot of people don't know that if you leave the united states medicare a and b do not cover you at all So Advantage plans and Medicare supplement plans pick that up for you with limitations. So please check your plan before you travel. Yeah. Yeah. That's good to know. That's really good to know for retirees to be able to do that. I guess my next question that I know with working with doctors and hospitals, as far as billings and anything left over to pay, you know, with Medicare, Does that become an issue? Like how the process of that, you know, I, they submitted to Medicare. I'm watching for something. And then if there's a balance left over to pay, how do I know, how can I educate myself in being able to pay what's appropriate? Okay. With the Medicare advantage plan, you're going to get an explanation in EOB explanation of benefits once the service is performed, and then they're going to show you who is paying what that EOB. You'll have to digest for a few weeks until you get your bill. Advantage plans are copay based. You're going to get your, every service is a copay and they're generally pretty good on, on they, how they build through that, through that process. Obviously you want to check your receipts there, but that would be the advantage process. The supplement process is. Pay the 250 deductible to Medicare Part B and there is no bill. You show your Medicare Plan G, there is no bill. So it makes, it makes it very simple. If it's not a financial hardship, the supplement plan is the way to go. You can always go back to a Medicare Advantage plan. You can't always leave a Medicare Advantage plan and go to a supplement plan. Good to know. All right. As we're winding down, any last thoughts or advice for people wanting to feel more confident or and informed about medicare as part of their retirement journey. Any last thoughts? I actually work in central Pennsylvania in the Lancaster area and I'm licensed in Delaware, Maryland and soon to be Florida. My business is lakeviewbenefits. com And my email is listed there, David at Lakeview benefits. I'd be more than happy to answer anyone's questions about Medicare and guide, help guide you in your goals to retirement, healthcare, and retirement. Also work with individuals and small businesses as well. Always happy to share what I know to help other people navigate healthcare better. Thank you for that. I know my journey has all been about financial knowledge, and I think that's the same with healthcare, being able to learn as much as you can. I always tell people don't just get it from your co workers. Don't just get it from your siblings. Take it to somebody who's a little more versed in that, you know, area and really dial in for yourself. So I thank you for that. And listeners, please reach out today. But if you have any questions about today's episode or Medicare in general, and if he's got somebody that supports you in a different state, I'm sure he'll refer that person to you. Absolutely. Thank you so much, everyone. I appreciate your time.