Oct. 16, 2023

Get Covered

Get Covered

Open enrollment is officially here, so this week we do a deeper dive on everything that you need to know to help you choose the right plan. Samantha Sauer, the Director of the The Patient Helpline here at Patients Rising, helps us navigate the...

Open enrollment is officially here, so this week we do a deeper dive on everything that you need to know to help you choose the right plan. Samantha Sauer, the Director of the The Patient Helpline here at Patients Rising, helps us navigate the different types of Medicare, the options that come with employer or private insurance, and why patients with chronic illness should ask a few more questions.

Also, we have an update on the Medicare price negotiation as part of the IRA.  


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The views and opinions expressed herein are those of the guest(s)/ author(s) and do not reflect the official policy or position of Patients Rising, nor do the views and opinions stated on this show reflect the opinions of a guest’s current or previous employers.



Samantha Sauer  0:03  
The first thing is cost. I will always say cost is the very first thing because you don't want to choose something that you won't be able to afford down the road health care costs are horrid as they are now. So if you get a bill down the road that you can't pay, because you didn't pay attention to all the costs, that's going to be frustrating for anybody.

Terry Wilcox  0:23  
This week on the patients rising podcast, open enrollment season for health coverage is here. So this week, we dive deep into what you need to know. Welcome to the patients rising podcast. I'm your host, Terry Wilcox, CEO of patients rising, I'm joined by my co host, who spent all weekend catching up on the new gold, golden bachelor series. He's Bob Goldberg, co founder of the Center for medicine in the public interest.

Bob Goldberg  0:51  
Well, I'm always trying to sort of benchmark myself against other guys. And I think I could do a really good job. They're talking about patient issues on the golden bachelor series, because I'm already in love with my wife, of course, but I do love being here with you. And I think we ought to do sort of a golden patience rising or,

Terry Wilcox  1:13  
You know, Bob, we're already started doing that. Today we're talking about Medicare. Oh, good, good. So I love being here with you every week. And I love helping patients navigate issues, just like the ones we're going to talk about today. And today, we're looking at open enrollment. We know it's so important to choose the right plan for you. But it's a pretty complicated, confusing process. Samantha Sauer is the director of the patient helpline here at patients rising, and she helps patients navigate through these decisions every day.

Bob Goldberg  1:45  
Well, yes, I am a Medicare patient too. So this is gonna I'm really gonna look forward to this show. But for our listeners, Terry, what is the patient helpline?

Terry Wilcox  1:55  
Well, we set up the helpline in 2020, to offer free help for patients to get the answers and the resources they need when it comes to their health care. Surprisingly enough, we did this right before the pandemic, it was not as the result of the pandemic. Now, we help them with everything from understanding the differences between health plans and open enrollment, to finding transportation to appointments to finding local legal help for patients in the workplace, and so much more. They do it all, and it's free to patients. Now, Sam answers those phone calls and emails and works with patients all day long. But as she's helping patients navigate the open enrollment season, we thought it would be great to have her on the show to walk us through it all. Now first, we asked her about all the different types of Medicare.

Samantha Sauer  2:44  
So Medicare in itself straight Medicare, Original Medicare, whichever you'd like to call it is part A and B that your hospital insurance and then you have your medical insurance. Some people only have Medicare Part A some people have both. Medicare Part C is a Medicare Advantage plan and a Medicare Advantage Plan is a Medicare approved private insurance plan. I myself use medicare advantage because it offers me more coverage. And that is what the advantage plans can sometimes do like dental, vision, some other perks, but you do have to pay a premium out of pocket that's determined by that individual plan. Part D is your prescription plan, something that you can purchase as well. But again, with the advantage plan that will have its own prescription plan associated with that.

Bob Goldberg  3:36  
So, of course, those aren't your only options. There's more to choose from.

Samantha Sauer  3:42  
When it comes to different types of insurance for the Advantage plans or for just employer or private insurance. You have four different types. So you have an HMO, which basically means that you have to stay within a smaller network of doctors for services. If you want to go outside to see another specialist you have to get a referral and it may or may not be covered. A PPO is a Preferred Provider Organization, something I personally use because I see a lot of specialists outside of that small area. You don't need referrals to see specialists either in that one. You also have a POS it's a point of service plan. That's kind of a hybrid of the HMO and the PPO. So you stay within a certain network, but you're allowed to go out of it just a little bit. You've also have an EPO, which is exclusive provider organization. So it's basically what it's called that you go and get services with only those particular providers.

Bob Goldberg  4:45  
Oh, Terry, I gotta say, like, you know, I've been doing this show for three years I've been in healthcare, you know, for more than three decades. I was involved in helping write and get past the Part D I still need I've been navigating this stuff

Terry Wilcox  5:02  
I know. And now there's a whole new thing. I even learned something in this whole process. Like, I know what a PPO is, because that's what we have personally for our family. I know what an HMO is. And the EPO was a completely new thing for me. And exclusive provider organization,

Bob Goldberg  5:21  
right. That's a very, very closed network. And then there's also a Medicare SNPs, which are special need programs, which are the dual eligibles, which of course, Samantha can help you with as well. And that's for people who qualify for Medicaid, but are Medicare eligible. So there's those plans, as all and you do not get taught those things? So I guess the question is, you know, I'm a relative thing.

Terry Wilcox  5:49  
So Bob, just FYI, there's also the opposite of that, which is there's those folks who are qualified for disability who qualifies as Medicare, but they may not be Medicare age, but they qualify for those plans, because they're on disability. They're on disability. You know, there's some outliers that are special cases. But given the fact that our helpline is, in fact run by folks who have been on disability before who who are patients themselves, they have a lot of knowledge. So, I mean, this whole thing, and you and I both talked about this before, it's all kind of in another language, if you don't know what you're doing. There's all sorts of rules around Medicare, or how soon you have to sign up all of these things that you don't even think about. And then each year, you have to kind of go back and and assess is this plan still right for me, given where I am with my health? Do I want Medicare Advantage? Do I want Medigap? Do I want straight Medicare, all the things Sam talked about? Now Sam also says patients with chronic illness should ask a few more questions. So take a listen.

Samantha Sauer  6:51  
If you have preexisting conditions like myself, and a lot of the people we talked to at the Hepline, you want to consider what doctors you need to see do you need specialists outside of a certain area, you might want a PPO plan, if you need some extra coverage or medications, treatments aren't covered by straight Medicare, maybe you want to do a Medicare Advantage plan.

Bob Goldberg  7:13  
Samantha also discussed people looking to enroll in private insurance plans. And she adds that with for those individuals, especially those with pre existing conditions, you have to make sure to see if there's any limitations, or waiting periods, that would affect your ability to obtain or receive coverage.

Samantha Sauer  7:35  
If you have pre existing conditions, some insurance plans, like private plans can reject you. But recently, I just found out that there are four states that make sure that that doesn't happen. So you have New York, you have Connecticut, Maine, and Massachusetts are the four states that have protections against that. So a lot of people listening, a lot of people we talked to that's important for them to know, if they're from those states. I would also say that you want to check your doctors who you're already seeing, are they in the network? Are they outside of the network and your prescriptions because everyone takes different things. There's different tiers, you want to know what's covered and what isn't, and essentially determining what your out of pocket cost will be.

Bob Goldberg  8:24  
So Terry, what Sam was talking about really applies to the Obamacare or the Affordable Care Act plans. And those protections are critical. And I know the patient's rising, is working hard to make sure that more states have it. So that's great information to have.

Terry Wilcox  8:44  
So the other thing that we haven't talked about, we've talked about Affordable Care Act, we've talked about Medicare plans, but we haven't talked about your employer plans which employers provide the most health insurance in the country. They are the biggest payers and providers of coverage in this country. So here's Sam with more on that.

Samantha Sauer  9:09  
There's usually different tiers, once your employer has picked a plan or an insurer, there's like your platinum, your gold, your silver plan, do you have a family? Do you go to the doctor a lot? You know, you want to go through all of those plans to choose which is there. Are there any add ons available that you might want to do like Aflac has different add ons for disability insurance and cancer assistance. So you want to consider all of that when choosing your plan. And your employer should also have an insurance rep with that company that you can always ask to be connected with. With an employer you want to consider cost How many employees do you have? Do your employees have family? Is there a pharmacy benefits? You know, how will the plan keep employees healthy? Are there any perks that the employees would benefit for Um, they have to look at it a little bit more holistically so that way the employee has more options when they want to choose their plan.

Terry Wilcox  10:09  
Well, my closing thoughts for this are, you know, this is a time of year when you really need to assess more than we ever have had to, to be honest. I mean, like I said, we've always talked about this when I was a kid, there was no health insurance as we know it today, it was all catastrophic health insurance, and you just went in and wrote a check to the doctor. And now we're at a much different place where you can get all kinds of things covered. And that's great. But you really need to look at your plans. And there's all sorts of different types of Medicare plans. There's Medigap plans, there's Medicare Advantage plans, all the things Sam talked about in the beginning, then when you look at your employer plans, there's High Deductible Health Plans that usually are attached to a health savings account, or there's, you know, PPO plans, or HMO plans are these even more restrictive networks to make it even cheaper, where you can just go to this really small network of doctors, and there's all kinds of things in between. And then there's what folks will call junk plans. And so look at those, if you're in between jobs, you know, the thing it all boils down to, is that you must, you are in charge of your health care. And unfortunately, no one has given you a class on this. You know, there are tons of not just patients rising, though we do have quite a bit of information on this. Medicare actually does a pretty good job themselves, if you can find it, of educating and we'll link to as much as we can on all this in the show notes. But you have to do your research. Yeah, especially if you have a chronic or rare or life threatening condition. If you're going through any kind of health issue, you must understand your insurance.

Bob Goldberg  11:50  
And I would add one other thing, Terry, and that is people that are transitioning to Medicare for the first time who check in I know, Sam has talked about this and work with patients on this, check to see if your drugs are covered. And remember that your ability to use copay assistance goes away under Medicare. So you've got to do some careful planning. If there are medications that you benefit from, you want to check to see where your drug falls in on and how much is being covered by the planet right at the outset. So that's why we have Sam and the patients helpline. And thank you to Sam for speaking with us. And you can learn more about the patient helpline, or contact them with an issue you might need help with by using the link in the show notes.

Terry Wilcox  12:49  
This episode of the patient's rising podcast is brought to you by the patient helpline. If you have a question or challenge or problem accessing the care you need, our team is here to help. After working with more than 6500 patients, our crew of patient navigators have narrowed down the best local, state and federal health care resources to solve your biggest challenges. That includes food or housing insecurity, overcoming insurance, obstacles and so much more. To get in touch, leave us a voicemail, or send us an email using the link in the show notes.

Bob Goldberg  13:28  
So, Terry, before we go today, we've already told you that the Biden administration has announced the first 10 drugs up for Medicare price negotiations, I guess their negotiations was part of the inflation Reduction Act. And now, Terry, all the companies that make the drugs have agreed to negotiate that's amazing.

Terry Wilcox  13:50  
Or rather, they had no choice. Bob either agreed to negotiate, pay steep fines, or withdraw their products from the Medicare and Medicaid markets. At negotiation, that's

Bob Goldberg  14:03  
That's hijacking. That's extortion. And it's why several of the same companies have filed briefs challenging the constitutionality of this provision of the Affordable inflation Reduction Act. In general, these negotiations are not going to lead to lower out of pocket costs. Simple as that. And in many, many cases, people are paying $35, $50 a month for the drug in the first phase. The problem comes in the out of pocket cost gap, the so called done at home which sort of cause I exist. But once you reach a certain level, you still have to pay up to $2,000 out of pocket. And none of this money is earmarked for reducing the cost to patients 

Terry Wilcox  14:53  
And none of it this is one of the major problems that we are really trying to get folks to understand and it's going to take time A lot of education on our part and probably many more podcasts. But when you look at things like the inflation Reduction Act, and if you go to the state level, and look at what's called drug pricing review boards, if you look at using an ICER report, which we have talked about a lot on the show, to figure out, you know, how to lower the cost of drugs, or to come up with ways to lower the medication spend, whether it's at the state, federal or even employer level, most of the time, it's not going all the way to the patient, the patient's out of pocket cost is not going to be that different, if at all different.

Bob Goldberg  15:45  
It's cutting your nose off to spite your face. Right. And I think as we've mentioned before, down the road, it'll dry up biosimilar research, because if you're just gonna knock down the price to the generic level, then why have generics in the first place? 

Terry Wilcox  16:02  
I also think one of the big things missing here, Bob, and we'll have deeper shows on this because I know it's going to be a huge topic. But do we really have to negotiate it all? I mean, shouldn't all of these questions be answered in the data?

Bob Goldberg  16:15  
Yes, there are already groups that are patient centered or patient focused, that are collecting and analyzing the data in real time to show the total impact on an individual level based upon not just the drug, but the nature of the disease that the patient is dealing with.

Terry Wilcox  16:39  
So we'll have a link folks to the story about the first 10 medications up for negotiation as well as some information on that process. And the input from patients which is minimal at best, again, while the link to that story in the show notes.

Bob Goldberg  16:56  
So before we go, Terry, both you and I have, I have a son and you have a cousin that actually already is in Israel, and I just wanted to share our thoughts and prayers with people that are in the middle of this horrible conflict that was not asked for. So our thoughts and prayers are with them, and will be next week as well, because we'll be back again with another episode. So make sure to follow the patients rising podcast on your favorite podcast player, so you can be notified as soon as a new episode goes live.

Terry Wilcox  17:35  
Until next week for Dr. Bob and everyone at patients rising. I'm Terry Wilcox, stay healthy.