Oct. 2, 2023

Open Enrollment Explained

Open Enrollment Explained

With the Open Enrollment Period fast approaching, Levi Peterson, a Resource Coordinator for our Patient Helpline walks us through what everyone needs to know about Medicaid and Medicare eligibility, PPOs and HMOs, and how to pick a health plan that...

With the Open Enrollment Period fast approaching, Levi Peterson, a Resource Coordinator for our Patient Helpline walks us through what everyone needs to know about Medicaid and Medicare eligibility, PPOs and HMOs, and how to pick a health plan that best fits your needs.

We also discuss a so-called ICER update that doesn’t do much updating and still doesn’t help patients.

Patients Rising Now Statement | ICER ‘Updates’ are Thinly Veiled Strategy to Continue Discriminatory Tactics 

ICER’s Updated Treatment Assessment Still Ignores Patient Concerns 


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Have a question or comment about the show, or want to suggest a show topic or share your story as a patient correspondent?

Drop us a line: podcast@patientsrising.org

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.



Levi Peterson  0:03  
I can't tell you how common it is to have a sweet elderly woman who's maybe 66 years old who should be on Medicare yesterday isn't and doesn't think that maybe she's eligible and you know for a fact that she is because your work in navigation you know that this is something this person should be on yet they've been told by whomever, whether it's family or someone else that they're not eligible. And so it's really up to us to be able to, you know, explain how to enroll and make sure these people get the care that they need.

Terry Wilcox  0:30  
This week on the patient's rising podcast, Levi Peterson, one of our trusted patient navigators from our patients rising helpline dives into some of their most called about topics as we enter the busy season of open enrollment. What you need to know to be prepared is up next. Welcome to the patients rising podcast. I'm your host, Terry Wilcox, CEO of patients rising. I'm joined by my co host, who is just as shocked as the rest of us at the Travis Kelce and Taylor Swift news. He's Bob Gilbert, co founder of the Center for medicine in the public interest. Now, Bob, how are you taking the latest news about her relationship?

Bob Goldberg  1:08  
Well, Terry, I was betrayed at first I thought I was getting emails regularly. And it turned out it wasn't Taylor Swift, it was a coupon for a swifter. Like, okay, maybe I was reading too much into it. But when I saw Taylor in the skybox with Travis's Mother, you know, half the Swifties thought this was a great love story. The other half thought, What a cruel summer or maybe till December, but alright, enough of the T swift puns, we have more important things to talk about today on the podcast, especially with open enrollment right around the corner, and I am one of those people experiencing open enrollment for Medicare. So this is a really important show for me.

Terry Wilcox  1:55  
Well, that's right. And to help our listeners through this process is today's guests, Levi Peterson, a resource coordinator for our patients rising helpline. Now, as we gear up for open enrollment season, we thought now was a great time to bring Levi on to discuss some of the ins and outs of, you know, the different plans and to answer some frequently asked questions we get asked about on the helpline. Now, the first big question is, how do I know if I'm eligible for Medicare, Medicaid. And here's Levi. So with

Levi Peterson  2:27  
Medicare, it's a federal insurance program. And it has the same program nationwide benefits people over the age of 65. So that's the biggest difference between Medicare and Medicaid is that Medicare is age based typically or on disability. Meanwhile, Medicaid, even if you're disabled, you need to hit a certain dollar amount when it comes to falling, approximately, I want to say is 306% below the poverty line, because it's very much income based. So basically, what they're going to do is they're going to go through every single asset you have, if you're working currently, whether it be part time full time, they're going to take all that into consideration and decide whether or not you're going to be able to get on Medicaid.

Bob Goldberg  3:10  
Well, another complication patients need help with navigating is the difference between PPOw and HMOs. preferred provider organizations or health maintenance organizations.

Levi Peterson  3:23  
Essentially, with HMOs, you're looking at lower or no premiums, lower out of pocket costs, lower co-payments, it's a smaller network, and it doesn't cover things that are out of network. So it's, you're still getting your essential care, this is a lot better for someone where you know, maybe they only go to the doctor, sometimes they don't really deal with a lot of health concerns. They're trying to save money, this is a much more fiscally relaxed plan. But with PPOs, you get out of state network coverage, it's state or nationwide. So you can go anywhere in the country, and you're covered. And also, you know, your provider network is a lot larger and you don't require a referral to see a specialist. So if you're a patient with a more complex condition, and you know, hey, I need to see a neurologist, you don't have to wait to go to your primary care to get a referral. You can just find the person that you want and make an appointment. Very, very easy to use. 

Terry Wilcox  4:16  
So Bob, my question for you is what's your plan? You know, Levis explained. PPO is HMOs. When you go to select a Medicare plan, there are depending on your state. Now, some states have more options than others, but there are a myriad of options. So what did you How does your plan setup? And what are the pros and cons?

Bob Goldberg  4:38  
Well, do I have a Preferred Provider Plan with an out of network benefit. So the advantages that I do have a lot of flexibility in terms of the types of providers that I can see, obviously pay a little bit more if I go out of network, but at least it's there. And in terms of the prescription cover --I haven't looked at what's happened in 2024. And I would encourage everybody who is on Medicare to make sure that with their current plan if their medicines are covered, that goes without saying. So my medicines have been covered pretty regularly. The prior auth process has been pretty painless. And thank goodness, I don't have any truly serious diseases. So I think increasingly, that's the plan of choice for lots of people. 

Terry Wilcox  5:31  
Yeah, I agree. I mean, those of us who live this every day, you know, I see it right now, even when you're on Medicare, which, to your point, there are a lot of good plans that cover a lot of things my mother in law has as a fairly good one, except for when it comes to one medication that she's on. And actually, when it comes to generic medications that she's on, we've often been able to get the generic medications out of plan for way cheaper than what the plan wanted, which is ironic. It's something that we're really cautioning seniors about this year. And now, Levi just took us through the specifics of some of the different programs that exist. But what's right for you? What questions do you need to ask? Here's Levi.

Levi Peterson  6:17  
Honestly, I think the first thing you need to think about is your own personal health care needs, are you someone that has a chronic condition, are you someone who maybe goes to the doctor rather frequently, because you've been sick your whole life, and maybe you're diagnosed, if you're dealing with something more specialized, it's going to be really important to you that you have doctors in your network that can cover your care. So it's really all about making sure that you have both the experts you need. Also, if you're switching insurance, if they are going to be able to cover the same primary doctor that you've had your whole life, if that's something that's important to you,

Bob Goldberg  6:53  
Knowing your medical history is important, but it's also important to have an idea of what you want in the future.

Levi Peterson  6:59  
I would say honestly, just to sit down and make a list of your healthcare needs in its entirety, you want to make sure that you are checking everything from stem to stern, and that you're getting all of the benefits that you need. Whether it's you know, making sure that your prescriptions are going to be covered, just like you know, making the list of your medications, making sure that you have everything that you need. And you know, even just having a conversation with your current doctors, if you're planning on switching over and saying, hey, you know, or are you in this network? What kind of insurance do you take? A lot of people don't necessarily jump to that as the first thing that they do whenever, you know, open enrollment happens or whenever they're going to a new provider. So it's always important to ask that question.

Terry Wilcox  7:43  
So Levi, and Samantha who also helped out with our helpline, the patient's rising helpline, it's actually called the patient helpline, it's very simple. They answer these kinds of questions every day, in their roles, his patient navigators. Now Levi says the biggest thing about being a patient navigator is at the end of the day, making sure the person on the other side of that phone call or email is taking care of. Take a listen. 

Levi Peterson  8:10  
So it's really making sure that we're looking at that big picture and addressing every single concern they might have in their health care journey. And sometimes that starts just with hearing what conditions are dealing with. And with Samantha and myself, both being patients who have been on Medicare and Medicaid who've been through the disability system, you know, for us, it's very easy for us to identify what those problems are, and really kind of help these people to advocate for themselves.

Bob Goldberg  8:37  
So what makes Levi and the other navigators in the team invaluable, Terry, is that they've been through these hoops in most cases. And that's really important. They are patients navigating and being pathfinders for fellow patients and helping them that way. 

Levi Peterson  8:53  
I would say if it wasn't for my experience, as a patient, I don't think I'd be as decent as a navigator. And that's even with like just having past healthcare experience, I think there are things that you don't understand until you truly go through it. And I think it's you learn the most when you're put in a situation where every single bit of the education that you give yourself counts. And you're going to advocate 10 times harder for yourself, you're going to advocate 10 times harder for family. So when you're first going through that process yourself, and as you're still going through that process, you're picking up all these skills, and you know, for myself for Samantha for the rest of the helpline staff, I know that to us, keeping that kind of knowledge to ourselves would feel basically criminal. So we're always very much into the idea of making sure that we're passing that knowledge on because the burden of having that knowledge is ensuring everybody else has it.

Terry Wilcox  9:50  
You know, one of the things that we often talk about at the helpline, Bob, is that the helpline really isn't set up like we've said before, it's not set up to actually provide direct assistance, we don't provide funding for anyone but we are set up, to Levis point, to make sure that we give the patients who call us really good directions for their next steps. And that's really the goal of the helpline, which is why our initial when we first founded the helpline, our email was ask us anything at patients rising.org Because that was really our goal. Navigation is so important. Patients are confused in a myriad of ways. And it's important to have someone to reach out to and just so everybody who's listening right now, the helpline is always here to help. That's what it's for the patient helpline. It's not even called the patient's rising helpline. It's called the patient helpline. So, if you know, if you or anyone you know is in need of any support, please reach out because Levi and Sam are standing by and they're definitely ready to help.

Bob Goldberg  10:55  
And you can learn more about the patient's health line by using the link in the show notes.

Terry Wilcox  11:06  
This episode of the patient's rising podcast is brought to you by the patient's rising helpline, which you just heard all about transportation issues, confusing health insurance questions, general questions about caregiving best practices, the patient's rising helpline helps you to all of these issues and much much more, all completely free to get in touch, leave us a voicemail, or send us an email using the link in the shownotes.

Terry Wilcox  11:36  
And before we go today, we have some important stories in the news this week for the chronic disease community.

Bob Goldberg  11:41  
Yeah, that's right, Terry. One of the favorite topics of the show is the ICER, the Institute for Clinical and Economic Review. It makes recommendations on the price new matter whether you should cover new medicines if your insurer and people will use that to grant or deny coverage of a new drug to patients. So it updated its assessment. Sounds like a good thing, right, but far from it.

Terry Wilcox  12:10  
Well, that's right, Bob. And as we see time and time again, these organizations rarely do anything right by the patient. I serve at least an update to how they measure things. But it's really a sham because they didn't really update anything. They'll continue to use the quality, a discriminatory metric, and continue to have only the interest of insurers in mind. So we have patients rising, are calling it a foe update. And McKay Jemison, our patients rising now executive director actually had this to say about the updates. In a statement he said, "most of today's tweaks were just a PR effort, a thinly veiled strategy to continue its discriminatory tactics, and ICER has not solved any of its fundamental flaws."

Bob Goldberg  12:58  
Well, its most fundamental flaw is that it exists. That's a big one. But at least as McKay alluded to it sort of made its business model clear. They're there to benefit, the least from their mind, the insurers, they're wedded in trying to position themselves as default price setter for Medicare. And a very least they did spell out that they will continue to prejudice toward there'll be favoring Health System budgets at the expense of the total value of new treatments, and therefore continue to use the discriminatory measures of which QALY is the biggest offender? Well,

Terry Wilcox  13:43  
absolutely. And just so everyone, you know, if anyone's listening to us for the first time, or hasn't heard us talk about ICER before or QALY before. Just everyone knows ICER, the Institute for Clinical and Economic Review is a non governmental, unregulated, and non appointed organization that puts out reports that are very biased against patients. That's just I can't say it any other way. Yeah, it's not that all of them come down negatively for patients, or even if they don't give lip service to supporting and helping patients. But at the end of the day, when you look at the whole picture of the reporting process at ICER, in its totality, you are ending up with a process that is not geared towards the patient. It's geared towards health systems. It's biased towards the systems themselves. And it's not really in favor of supporting patients and looking at patient outcomes and really examining what's best for the patients the systems are acting as payers for and until that is fixed, until more patient involvement and other types of metrics. are measured seriously like caregiver benefit and actual patient value benefits for the patient. We're just spinning our wheels. We're just putting things forth that are not going to move the needle for patients in this country. But please know we're working on this. We've released a statement and we are going to continue fighting for what's best for patients. And this is not that. We'll have a link to our statement in the show notes.

Bob Goldberg  15:32  
And more episodes are on the way so make sure to follow us and follow the podcast on your favorite podcast app, so you can be tuned in for the next episode.

Terry Wilcox  15:41  
Until then, for Bob and everyone at patients rising, I'm Terry Wilcox, stay healthy.

Levi PetersonProfile Photo

Levi Peterson

Behcet's, Parkinson's, and IIH patient advocate
Resource Coordinator at the Patients Rising Helpline.