Should I opt out of my Medicare Advantage Plan if I am expecting a major procedure in 2016? -Timothy J., Peoria, IL

This is a great question, and involves a bit of number crunching on your end. The first thing to note is that this will vary on a case-by-case basis, but looking at potential costs, especially between Medicare Advantage Plans (MAP, or MAPD with prescriptions) and Original Medicare with Supplemental Plans and Part-D for drugs, is something I get asked about quite a lot. Here is how to think about this to find the best solution:

First – If you are thinking of switching now, you are acting at the right time. You have until February 14, 2016 (it is always January 1^st to February 14^th each year) to opt in or out of MAPD, without special exceptions granted in certain circumstances year-round.

Second – This is truly a numbers game, if number crunching is not your cup of tea, please consult a professional, the following is for the DIY folks only!

To figure out if switching is right for you, find out approximately how much it will cost for your procedure, new medication, and each day you expect to spend in the hospital under MAPD and add all of that together (do not forget to take in to account your deductibles, out of pocket maximums, etc.). Now, divide that number by 12 and add it to your monthly premium, this number is your expected cost per month under MAPD. Now, if you find that your expected monthly costs are far higher under MAPD than Medicare with supplemental plans, then your answer is simple.

Finally – If you want to disenroll from an MA-only or a MAPD plan and return to Original Medicare during the allotted time mentioned above, you have a special election period (SEP) to join a Part D prescription plan.

• If you have a MAPD plan, you can either 1) submit a disenrollment request to your MAPD plan and then enroll in a Part D plan, or 2) the easiest way is to properly enroll in a Part D plan first, which then automatically disenrolls you from your MAPD.
• If you have an MA only plan, if just going back to Original Medicare - you must request disenrollment from your MA plan.  If also enrolling in a Part D (RX plan), you may properly enroll in a Part D plan and that will cause your dis-enrollment in the MA plan.

Of course, you should always speak to a professional before committing to any large changes such as this, but it is always a good thing to have a general grasp on your insurance coverage for the year at the start of the year.

My son is turning 26, and this year will become ineligible to remain on my employer-provided health insurance. He has a low/moderate wage job (makes about $30,000 a year) that does not offer health insurance as an option, and is considering using Healthcare.gov to get insured. Are there any pros or cons we should be aware of? -Lynn G., Peoria, IL

First off, Healthcare.gov is an extension of the Affordable Care Act (ACA), also known as Obamacare. ACA was made to be an option for those, especially in an income range up to 138% of federal poverty level (a range up to about $47,000 for a single person), to receive coverage with reduced cost. This cost comes in the form of a tax-break or subsidy to be applied directly to premiums or when filing taxes at the end of the year.

It is important to note, however, that insurance agents can still be involved in this process, and many resources can be used other than Healthcare.gov. We advise you always speak to an ACA insurance professional to find what coverage you need and help to navigate this process beyond just pricing premiums.

Also - Open enrollment ends very soon, January 31^st, 2016, meaning that unless your son, or any party interested, were to meet the specific criteria to apply out of the enrollment season - the window to apply for ACA insurance is closing fast.

As with any insurance, consider what level of coverage is needed for the individual. Many healthy 26 year-olds only seek catastrophic insurance with minor coverage for things like visits, and little worry for out of network services. This will vary radically on a case-by-case basis, so figure out what level of coverage works best for you. Of course, talking to a professional agent will likely be a huge help.

My parents are aging and still live in my childhood home. I feel that they should not stay there much longer, but am unsure when the right point to have that conversation is. What should I look for? –Bridgette R, Bloomington IL

Often times this does become a tough issue for both parties. They may feel the same way you do, but be unsure of what that could mean to the children and grandchildren. Things like ‘but where will we celebrate the Holidays?’ often prevent grandparents from downsizing their homes, shift to living with family, assisted living or other options.

Look for the signs.

• Are they using the rooms upstairs or having difficulty doing so?
• Is the yard as maintained as it used to be?
• Is there a risk of falling in the home?

Sometimes the answer is not for them to leave, but to augment the environment. Being vigilant about the signs of your parents being overburdened and assisting with altering their environment can keep them happy and healthy in their home longer.

Whatever happens, research assisted living homes now for the future. Figure out who offers what and where, and have an idea long before anyone needs a facility which you may prefer. Living By Your Design has a free senior community referral service that can help you match your needs and wishes with available communities in the area.

I will soon take start my Social Security collection, what are some tips to help offset some costs post-retirement? -Deborah G, Peoria IL

On top of your regular finances in the later years (pension, 401k, social security, etc.), it is wise of you to consider other ways to help mitigate costs in retirement. Here are some things we recommend frequently to help with just this:

•  Schedule an appointment with your insurance agent to update policies every year.  At this point in life the needs of your care will change over time, and your insurance coverage will likely need amending to accommodate that. Always make sure you have the best coverage for your needs and medication, your plan should feel yours.
•   If you or your spouse is a United States Veteran and either of you require daily assistance with medications or self-care, you may be eligible for a monthly Veteran’s pension to augment your Social Security or other pension income.
• Consider long-term care policies.  If you already have it, read the fine print. These products have changed over the years so review your coverage to make sure you understand what it does and does not cover.
• Seek out a trusted third-party specialist to help navigate these things. There is a community of professionals that want to help you.

My Medicare Annual Enrollment Period packet has arrived, it seems like a lot of information, what should I watch for? Kathleen W., Morton, IL

These plans can change yearly, so review your plan’s annual renewal information carefully.  Some people may receive a letter from their MA (Medicare Advantage) or Part D (Medicare Drug Plans) company discontinuing their plan for 2016. If this happens to you, you will need to take some action or you will be put back into original Medicare by default.  On the other hand, this letter will guarantee that you can move to any plan in the state, so do not throw it away.

Additionally, ensure that you:

·         Review your benefits, they may have changed

·         Check to make sure that your providers are still listed as in network

·         Make sure your drugs are covered, watch for any new restrictions

·         Look at your copays for the new year

·         Contact your insurance company with any questions

·         Consider consulting a  local insurance agent, they know the environment for the new year as it applies locally, typically better than someone from a national organization

·         Be an advocate for yourself, ask questions about what matters to you and take the time to get answers

·         Remember that nothing comes ‘free,’ a low-cost plan is likely that way for a reason

What is patient advocacy, really? Is this service for me? –Melanie J., Bloomington, IL

A patient advocate is a consultant who supports a client with a variety of needs, both in a medical setting and at home.  They may be a medical professional, a social worker, or a lay person with experience with chronic disease or with helping a loved one navigate their own health journey.

In a medical setting, patient advocates can accompany clients to doctor appointments or outpatient rehab sessions.  As a result, they can communicate with medical staff and family members about the patient’s ongoing condition, medical compliance and related concerns.  They can also help with the filing of insurance and medical claims.  Through home visits, they develop a relationship with the patient and monitor health progress by taking vitals, overseeing the correct use of medical supplies and equipment as well as keeping track of medication usage.  They may also make suggestions for physical changes to the home environment to ensure safety by assessing fall risk and potential hazards due to limited mobility.

Ultimately the patient advocate can serve many functions, but their primary function is to advise and assist throughout the treatment process. Patient advocates are often vital for major decisions in the change of care or environment, such as when it is too risky to have a patient living alone, or when to begin worrying about quality of life over aggressive treatment. Ultimately, it is the job of the advocate to help patients and their families navigate the healthcare system.

Is it in my best interest to utilize a private patient advocate, even when advocacy has been assigned through my insurance already? –Carlene G., Peoria, IL

While any patient advocate will help in navigating through tough medical struggles, both at home and in the hospital, it is important to note that there is often times a level of loyalty toward the wishes of whoever is ‘footing the bill,’ so to speak.

For instance, an insurance appointed advocate will likely have some level of the insurance company’s interests in mind. While it is unlikely they would ever provide bad or dangerous advice for the patient, they will likely have the reduction of cost to the insurance company in mind.

Advocates can also be appointed by the hospital itself, but they may also have their own goals in mind. Many hospitals receive a small penalty for patients being readmitted to the hospital within a certain period, and a hospital appointed advocate may have this or other things in mind when recommending a course of action.

While the difference may be slight, being the sole employer of a patient advocate does insure that their allegiances lie solely with the patient and their families. Perhaps just receiving a consultation from a private advocate to supplement your appointed advocate would suffice, but it is definitely something to keep in mind.