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Health 411: How to shop for best ‘Medigap’ coverage

I’m an 84-year-old man on Social Security with original Medicare and Mutual of Omaha gap insurance. My insurance premium was raised from $262 to $363 a month, a 39% jump. After all my monthly expenses, I have just $240 left. What can I do in the event of another increase in my premiums?

If you’ve had your current Medicare supplement plan for years, it’s not surprising that you’ve seen your costs steadily rise, says Steve Zaleznick, senior Medicare advisor at PlanPrescriber, a Maynard, Mass.-based online provider of Medicare education and plan comparison tools. “If you got it at age 65, by the time you hit 84 it’s going to have a noticeable impact on your budget,” he says.

That’s why experts say it’s so important for all Medicare beneficiaries to continually evaluate their supplemental coverage to see whether another plan may meet their needs at a lower cost.

So-called Medigap plans are private insurance plans that work with original Medicare. “Medigap wraps itself around Medicare and covers some or all of the out-of-pocket cost-sharing,” says Hilary Sohmer Dalin, director of benefits access policy at the National Council on Aging, a nonprofit advocacy organization in Washington, D.C.

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All insurers offering Medigap have the same standardized packages, though the price can vary greatly, so it’s worth shopping around. But beware: Although insurers cannot deny you Medigap coverage within the first six months of your turning 65, after that — with only a few exceptions — they can take your health into consideration when deciding whether to extend coverage.

That’s not the case with Medicare Advantage plans, another option for filling in gaps in coverage. If you apply for a Medicare Advantage plan during annual open enrollment periods, you’re guaranteed coverage.

These plans are administered by private insurance companies that typically provide all of your benefits under one roof, usually Medicare parts A (hospital care), B (outpatient care) and D (prescription drug coverage). Many also offer extras that Medicare typically does not cover, such as dental and vision benefits and help paying for a gym membership.

Unlike Medigap, Medicare Advantage plan benefits differ dramatically from one plan and insurer to another, so you need to review carefully what each offers.

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There are other differences between these two types of plans as well. With original Medicare and a Medigap plan, you can see any doctor who accepts Medicare; with Medicare Advantage, you’ll probably be limited to a network of participating physicians.

In terms of cost, Medigap plans tend to cover more out-of-pocket expenses — including co-pays and co-insurance — than Medicare Advantage plans do. The trade-off is that their premiums tend to be higher.

Finding the best Medicare supplement and drug benefit plan can be tricky: You need to simultaneously consider which benefit package will meet your medical needs while fitting within your budget. Sohmer Dalin and Zaleznick strongly advise people to get help navigating through the maze during open enrollment, which this year runs from Oct. 15 through Dec. 7.

You can compare plans and their costs side-by-side at the Medicare Plan Finder (go to Medicare.gov and look for Medicare Plan Finder under the Resource Locator heading on the home page) or by going to PlanPrescriber.com. PlanPrescriber also has licensed agents able to guide you at no charge, at (800) 404-6968.

Free personalized assistance is also available through your State Health Insurance Counseling and Assistance Programs (SHIP), which you can find by visiting the Medicare.gov Medicare Helpful Contacts page (click on the Help & Support tab on the home page, then select Useful Phone Numbers) or by calling (800) MEDICARE.

Sohmer Dalin also suggests you look into Medicare Savings Programs (MSPs), which help low-income seniors cover the cost of Medicare Part B premiums for outpatient care and may also help with co-pays, co-insurance and deductibles. And Medicare Extra Help offers assistance paying the premium for Part D, the Medicare drug benefit program. Both programs have income and asset limits.

To find out if you qualify, you can do a self-screening online at benefitscheckup.org, a service of the National Council on Aging. A SHIP counselor can also help with this process.

To apply for a Medicare Savings Program, contact your local Department of Social Services. Click on the Medicare Basics tab at Medicare.gov, then select Help with Medical and Drug Costs followed by the Medicare Savings Program menu item to find contact information in your area.

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I had a family doctor for eight years with whom I became very friendly. He invited me to parties at his home, and we would meet for dinner and shop together. He once asked to borrow $5,000 to leave his wife. I didn’t lend him the money. He later reconciled with his wife, and she forced him to terminate his relationship with me as a friend and doctor.

The California Medical Board would not take any action against him, and I found myself without a family doctor. Lesson learned: Be cordial with your doctor, but if you find yourself becoming too close, distance yourself.

Suggesting that others avoid getting too personal with their doctor is good advice, according to Dr. Charles Rosen, co-founder and president of the Assn. for Medical Ethics in Manhattan Beach. “Doctors aren’t supposed to treat family and close friends,” he says. “The reason you don’t is because you lose objectivity.”

The California Medical Board likely didn’t take action in your case because, based on your description, your physician’s behavior represents an ethical breach rather than a violation of medical practice, says Jennifer Simoes, the board’s chief of legislation in Sacramento. “We have to show that the offense bears some relation to the practice of medicine. We don’t police physicians’ private lives,” she says.

Sexual relationships, however, are against the law and would prompt the board to take action, she adds.

Often, ethical complaints are accepted by medical associations, such as the American Medical Assn., which will work with a doctor to alter his or her practice.

A doctor does have the legal right to drop a patient from his or her practice. “There is nothing saying a physician has to keep a patient forever,” Simoes says. However, they are required to follow protocol when discontinuing care.

A doctor must notify his or her patient in writing, providing at least 15 days’ notice so that the patient is covered in case of an emergency. A doctor cutting ties also needs to refer his or her patient to another physician and provide the patient with information about how to access the medical records that accrued under his or her care.

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Even if nothing illegal took place between you and your doctor, the behavior you describe can be an indication that he has deeper problems, says William Heisel, whose “Doctors Behaving Badly” series appears on the website of Reporting on Health, a project of USC Annenberg’s School for Communication & Journalism.

“Spending a lot of time outside of the medical office with one of your patients is risky, and asking your patient for a loan is definitely risky,” Heisel says. “These are exactly the types of behaviors that are often accompanied by other problems that usually get medical boards more excited.”

Patients who are concerned about a doctor’s behavior can consult the AMA’s Code of Medical Ethics at https://www.ama-assn.org (click on the Physician Resources tab).

Simoes also encourages consumers in California to file a complaint with the state medical board. The board reviews each complaint and will help guide patients to the appropriate place, even if it falls outside its purview.

Zamosky has been writing about how to access and pay for healthcare for more than 10 years. She may answer your question in a future column but regrets that she cannot personally respond to all emails.

Got a healthcare dilemma? Email health411@latimes .com or write to Health 411, Los Angeles Times Health, 202 W. 1st St., Los Angeles, CA 90012.


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