Even doctors wonder how Medicare works

Stephen Hansman, a steelworker-turned-doctor, shot me an email a few weeks back after I wrote a column about approaching Medicare as a soon-to-be 65-year-old.

“I am a family physician and I have tried to understand Medicare from both sides — as a physician but also as someone who is now nearing retirement and will need Medicare coverage,” said Hansman, 67.

So began a monthlong dialogue. But first, some background.

Hansman grew up in Baltimore, the son of a couple who hadn't graduated from high school. He earned an agricultural and life sciences degree from the University of Maryland in 1974, then started thinking about medical school.

To raise money for the next phase of his education, the 20-something took a job as an $11,000-a-year foreman trainee at the sprawling Bethlehem Steel plant at Sparrows Point in Baltimore.

But he eventually joined the Air Force, which paid for the degree he earned at the University of Maryland School of Medicine. He did his residency in family practice at Andrews Air Force Base — known primarily as the home of Air Force One — then served a five-year stint as an officer and a doctor.

Hansman spent most of the next four decades in private practice in the Annapolis area, including 24 years at Johns Hopkins Community Physicians. More recently, he has worked as medical director of primary care at Anne Arundel Medical Center in Annapolis, overseeing about 80 physicians.

He's now planning to retire at the end of the year.

He is well versed in the red tape, both as a care provider and as a consumer trying to navigate the labyrinth that is Medicare — the federal health insurance program for people 65 and older.

When we spoke recently, Hansman was still smarting from his initial encounters with the system. He was venting about a recent telephone call with a Denver-based Medicare representative who'd informed him that he could not enroll in the all-important Part B (medical services and supplies) online, and, instead, had to show up at his local Social Security office (in Maryland, not Colorado) in person. He also had to run back to his human resources office to correct a form required for Part B before the agency would process the application.

“As much as I have run into it as a provider, you just don't know how it works until you start doing this stuff,” he said, seated on the other end of the line with, “2020 Medicare and You,” the official U.S. government Medicare handbook, in front of him.

But Hansman has enough of the system figured out to dispense some advice to people who have a modicum of familiarity with the various parts of basic Medicare. (I know enough to be dangerous.) Here are six areas he'd like you to ponder:

What can you afford?

Part C plans — all-in-one coverage known as Medicare Advantage — offer a wider range of benefits for less money but have their perils, especially when it comes to physician choice.

All Part C plans have a network of participating physicians.

“Unlike standard Medicare [Parts A and B only], which probably 90% of doctors accept, the number of doctors to choose from in Advantage is much lower,” Hansman said. “Your readers should know if they are thinking of participating in an Advantage plan, then they would need to find out if their doctor is participating as a provider in the plan.”

As an example, he talked about patients who were in the University of Maryland Advantage Plan when it shut down at the end of 2018.

“You had these patients who had signed up and were seeing a doctor in the plan, and now they were in limbo, without their former doctors available under that plan,” he said. “Some had signed up with the Johns Hopkins Advantage product ... Many of the patients were unaware that their former doctors were not in” the Johns Hopkins network.

When you are signing up for Medicare Advantage, he emphasized, “you are signing up for what we call a 'narrow network,' which means fewer physicians to choose from and a more limited geographic area.

“That's important to remember. They may have a cardiologist they like. And now they change plans. Maybe their usual cardiologist doesn't see people at [a participating] hospital. This happens all the time.”

Do you have a chronic illness that will require frequent doctor visits?

“If so,” Hansman said, “a higher-coverage supplement plan [also known as Medigap] or a Part C plan [Advantage] is desirable because it will save money on the frequent copays and deductibles.

“One of the things Medicare Advantage likes to tell potential customers is you will have lower or zero co-payments for doctors.”

Hansman said you can buy supplemental Medigap insurance that doesn't require a co-pay for primary-care visits. “Paying more up front may be worth it,” he said. “If you are a diabetic who has chronic kidney disease, chronic lung disease and have had, by the way, a few heart attacks, you might have 25 or 30 doctor visits a year. You could end up paying something for each visit if you don't get the right supplemental plan.

“If you can afford a supplement, you can save,” he said, and “if you don't mind the narrow network on Medicare Advantage,” that's another alternative. “You could be better off.”

Take a deep breath and look at the big picture: 'How healthy am I?'

If you are healthy and take few or no medications, then you probably only need basic Medicare and a low-level Part D prescription plan, Hansman said.

“If you really take care of yourself,” he said, “and you are fit, healthy and only go to the doctor once a year or so, then you don't need to pay a lot of money to cover copays for office visits. Why pay for the extra benefit if you're hardly ever going to use it?”

The problem, he acknowledges, is that you have to be a bit of fortuneteller. “You don't know what's going to happen tomorrow,” he said. “You have to think of the family history. What did the ancestors die from? How long did they live? If everybody in the family died of a heart attack in their 60s, maybe you want to have a little higher coverage.”

Educate yourself

State Health Insurance Assistance Programs are free and available to everyone.

“It was very helpful,” Hansman said of a Medicare presentation he attended at the Anne Arundel Medical Center.

“You can make an appointment and go in and talk to them,” he said. “It doesn't cost you a thing. I went a year and half ago. There were 25 people or so in the group. It gave me a good handle on Medicare.”

Going cheap early may cost you in the end

If you start with an inexpensive supplemental plan and later think you need something more comprehensive, it will likely cost you a lot more, Hansman said.

“Not only are you a lot older,” he said, “but the insurer can look up your health history. A big mistake would be to delay the supplement if you think you are eventually going to get one anyway. Apply for it initially, because they may not even sell it to you later.”

He added: “If you take multiple or expensive medications, look at how those drugs are covered under any plan that you are considering. The differences in cost can be large.

Like your local pharmacist?

“Be aware. Not all plans will cover drugs filled there [at a local pharmacy],” he said. “They may require mail-order or certain pharmacy chains to be used. Many pharmaceutical companies hand out coupons to doctors to give to their patients to help defray the cost of new drugs. Those coupons are almost never usable under Medicare drug plans.”