It was an eye-popping number: About $500 a month for a brand-name prescription drug. The Medicare beneficiary made an appointment with a Senior Health Insurance Benefits Assistance (SHIBA) counselor to see if the damage could be reduced.
The individual had excellent medical insurance, but for years had had no insurance for prescription drugs. As a result, Medicare would levy a lifetime late-enrollment penalty if the beneficiary enrolled in drug coverage. A call to Medicare found the penalty would be about $37 a month.
Checking with the Oregon Prescription Drug Program (OPDP) produced a better price, about $260 a month. Going online to the Medicare website produced an even happier result. With insurance, the combined cost for the drug, the insurance premium and the late-enrollment penalty should not exceed $170 a month.
Because of the need to wait until Jan. 1 for the drug coverage to start, the Medicare beneficiary is using the OPDP state program during the interim.
If you would like to make a SHIBA appointment, or to ask a question to be answered here, please see the end of this column.
I’m about to turn 65. I’ve figured out the Medicare website for reviewing my Medicare Advantage options, but how do I get Medigap supplemental premiums?
A SHIBA counselor can obtain premiums for every type of Medigap supplemental policy sold in Oregon, or a state-certified insurance broker can give you rates for the companies the agent represents. In either case you would need to share only your age, ZIP code, gender, whether you are a tobacco user, the type of Medigap policy you want and when you would want the insurance to start.
Medigap policies are explained on pages 32-48 of the 2022 Oregon Guide to Medicare Insurance Plans, with an especially helpful grid on pages 38-39. These pages include premiums, too, although you would be better served to get up-to-date prices from a SHIBA counselor or an insurance broker.
You’ve made SHIBA appointments sound fairly attractive, but how much personal information would I have to share?
That’s your decision. SHIBA counselors must pass a criminal-records check, sign a confidentiality statement and take annual confidential training to retain certification. That said, you could have a somewhat productive conversation sharing no personal information, although sharing some information could reward you with greater detail about insurance options, income-related benefits and such.
If you wanted to review premiums and benefits for Medicare Advantage or prescription drug insurance, you would share your ZIP Code, the prescription drugs that you take and your preferred pharmacy. If you wanted to see Medigap supplemental premiums, you would need to share your age, gender, ZIP code and whether you are a tobacco user.
If you wanted to know whether you qualified for an income-related income benefit – such as reduced drug prices at the pharmacy – you would disclose your marital status and answer a yes-or-no income question. For example: “As a married couple, is your gross monthly income more than $1,980?” For one such benefit, you would also be asked a yes-or-no question about assets. If you wanted the SHIBA counselor to check whether you already had an income-related benefit, you would need to share your birthdate.
If you wanted the SHIBA counselor to enroll you in insurance, you would share your Medicare number, address and answers to a half-dozen questions. But you could instead enroll yourself either online or by making a phone call to the insurance company.
I’ve had insurance through my employer, so many Medicare insurance terms are new to me. For instance, please define premium, co-pay and deductible.
The premium is the monthly price you pay for Medicare insurance or for Medicare’s Part B premium. Although the Medicare beneficiary has options, both usually are paid by deducting the premium from the monthly Social Security benefit.
The co-pay is what you pay when you visit the doctor’s office, are hospitalized, have lab tests or receive other medical services. It’s also your share of the cost of prescription drugs that you get from the pharmacy. A deductible is an amount that you must pay before Medicare or the insurance company starts paying.
But that only scratches the surface. For a multi-page glossary of Medicare-related terms, see page 89 of the 2022 Oregon Guide to Medicare Insurance Plans.
Jim Sellers of Salem is a certified Medicare counselor with the Senior Health Insurance Benefits Assistance (SHIBA) program. To ask a question to be answered in this column, e-mail [email protected] To schedule a free SHIBA phone appointment with a volunteer Medicare counselor, call 800-722-4134.