To Dis-enroll or Not? Searching For Answers with an AI Assist

by Gregg Anthony Masters, MPH

Some of you may have heard about the whining by UnitedHealthcare’s leadership on a recent earnings call which included the required ‘management’s discussion or operating results and market conditions’ analysis. A BIG WHAAAA!

Overfunded since inception and having perfected the art of ‘upcoding‘ (i.e,, severity of illness and intensity of medically necessary services) Medicare Advantage (MA) operators with often market-specific and generous redistribution of the Center for Medicare and Medicaid Services (CMS) funds thus enabling Zero premium plans with expanded benefits, I’m totally fed up with the relentless ‘ad copy’ of my current health plan (KP San Diego) where I’ve been a loyal member and advocate of their ‘best in class’ IDN status and outcomes performance. They are NOT, and my journey into ‘e-patient‘ hood affords me this opportunity to opine in public.

So, here’s the first installment:

Prompt

I am 72-year-old man in good health. Open enrollment for Medicare ends tomorrow (12/7/2023). I need to make a decision whether to dis-enroll from a Medicare advantage program and return to statutory Medicare, not a term based, private contract with a Medicare advantage operator. I was recently diagnosed with prostate cancer with a Gleason score of 7 (3+4) and am in active monitoring & surveillance (including periodic PSA, mpMRI & targeted biopsies) and am not under treatment, yet. What are the pro’s and con’s of staying with my current health plan (Kaiser Permanente, San Diego) vs. opting for Medicare plus a supplement? What are my best choices? Do you need additional context or prompting? Do you understand?

ChatGPT

I understand your situation and the importance of making an informed decision about your Medicare options, especially in light of your recent prostate cancer diagnosis. Here’s a general overview of the pros and cons of Medicare Advantage plans versus Original Medicare with a Supplement (Medigap) plan, particularly in the context of your condition and current health plan with Kaiser Permanente in San Diego.

Medicare Advantage (like Kaiser Permanente):

Pros:

1. All-in-One Plan: Medicare Advantage plans often include Part D (prescription drug coverage) and may offer additional benefits like dental, vision, and wellness programs not covered by Original Medicare.
2. Cost-Capping: These plans usually have an out-of-pocket maximum, which can help manage costs.
3. Provider Networks: Plans like Kaiser Permanente often have a network of doctors and facilities, ensuring coordinated care and sometimes easier appointment scheduling.

Cons:

1. Limited Provider Networks: You may be restricted to doctors and facilities within the Kaiser network, limiting your choices for specialists, especially if you need specialized cancer treatment.
2. Referrals Required: Some plans require referrals for specialist visits, which might delay access to care.
3. Plan Restrictions: Some treatments or medications might not be covered, or may require prior authorization.

Original Medicare with a Supplement Plan:

Pros:

1. Wider Network: You have the flexibility to see any doctor or specialist that accepts Medicare, which can be beneficial for specialized cancer care.
2. No Referrals: Generally, no referrals are needed to see specialists.
3. Predictable Costs: Supplemental (Medigap) plans can help cover Medicare Part A and B deductibles, co-insurance, and other out-of-pocket costs, making expenses more predictable.

Cons:

1. Additional Premiums: You’ll likely pay a premium for both Medicare Part B and the Medigap policy.
2. Separate Drug Plan: You’ll need to enroll in a separate Medicare Part D plan for prescription drugs.
3. Potential Gaps: Some Medigap plans don’t cover extras like dental, vision, or wellness programs.

Considering Prostate Cancer Treatment:

• Access to Specialists: With Original Medicare and a Supplement, you might have more flexibility in choosing specialists for your prostate cancer treatment.
• Coverage for Treatments: Check the specific coverage details for cancer treatments under both options to understand potential costs and restrictions.

Making Your Decision:

1. Compare Costs: Consider premiums, deductibles, co-pays, and out-of-pocket maximums.
2. Evaluate Provider Network: Ensure your preferred doctors and hospitals are covered and consider the ease of access to specialists.
3. Review Drug Coverage: If you’re on medications, check how they’re covered under each option.
4. Consider Future Health Needs: Think about potential changes in your health and how each plan would accommodate those needs.

Given your specific health situation, it’s crucial to consider how each option would cover your ongoing monitoring and any potential future treatments for prostate cancer. Additionally, it might be beneficial to consult with a healthcare advisor or a Medicare specialist who can provide more personalized advice based on your health status and needs.

Please remember that this is a general overview and not personalized medical or insurance advice. It’s important to review the specific details of your current plan and compare them with the benefits offered under Original Medicare plus a supplement.

You

continue. if i dis-enroll from current health plan and given the current prostate cancer diagnosis, will I qualify for a Medicare supplement via community rating? Or will I be medically underwritten and potentially denied coverage? And will the rate be adjusted to reflect pre-existing conditions? Do you understand or need further prompting?

ChatGPT

Yes, I understand your question regarding eligibility and rates for a Medicare Supplement (Medigap) plan after disenrolling from a Medicare Advantage plan, particularly in the context of your current prostate cancer diagnosis. Here are the key points to consider:

Medigap Eligibility and Underwriting:

1. Guaranteed Issue Rights: Normally, when you first enroll in Medicare Part B at age 65 or older, you have a 6-month Medigap open enrollment period where you can buy any Medigap policy sold in your state without medical underwriting. During this period, you cannot be denied coverage or charged more due to pre-existing conditions.
2. Switching from Medicare Advantage to Medigap: If you are in a Medicare Advantage Plan, you can switch to Original Medicare with a Medigap policy under certain conditions. These conditions generally include moving out of your plan’s service area or if the plan stops providing care in your area. However, these situations would grant you a Special Enrollment Period with guaranteed issue rights for a Medigap policy.
3. Medical Underwriting Outside of Protected Periods: If you’re switching from Medicare Advantage to Medigap outside of these specific periods, insurance companies may use medical underwriting. This means they could charge higher premiums based on your health status, or potentially deny coverage due to pre-existing conditions.
4. Community Rating in Some States: Some states, like New York and Massachusetts, use “community rating” for Medigap policies, where premiums are not based on age or health status. In these states, your prostate cancer diagnosis would not affect your premium rates.
5. California Rules: Since you are in San Diego, California’s rules for Medigap plans apply. California uses a “birthday rule,” allowing Medicare beneficiaries to switch to a Medigap policy with the same or lesser benefits during the 30 days following their birthday each year, without medical underwriting. However, this is only applicable if you already have a Medigap policy.

Considering Your Situation:

• Current Health Status: Given your prostate cancer diagnosis, if you are outside of a guaranteed issue period or special enrollment period, there is a risk of higher rates or denial of coverage due to medical underwriting.
• Advice: It’s highly recommended to consult with a Medicare specialist or insurance advisor who can provide detailed information based on your specific situation, including your current health status and the rules in your state.

Remember, these are general guidelines and may not cover every nuance of your situation. It’s important to get personalized advice before making a decision, especially given the complexities surrounding health conditions like cancer and their impact on insurance eligibility and rates.

You

continue: create a blog post titled: “Medicare Open Enrollment: To Dis-enroll or Not? Searching For Answers with an AI Assist”. Use the above query and explanation. Create in witty yet professional tone. Do you understand or need further prompting?

ChatGPT

Absolutely, I understand your request. Here’s a blog post based on our previous discussion:

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Medicare Open Enrollment: To Dis-enroll or Not? Searching For Answers with an AI Assist

Welcome to the rollercoaster ride of Medicare open enrollment! It’s that time of the year when we, the silver-haired brigade, scratch our heads, pore over pamphlets that might as well be written in Klingon, and try to make sense of our health insurance options. Fear not, dear reader, for today we have a secret weapon in our arsenal – an AI assistant (that’s me, by the way)!

The Great Debate: Medicare Advantage vs. Original Medicare with a Supplement

Imagine you’re at a health insurance buffet. On one table, we have Medicare Advantage plans, like the one from Kaiser Permanente in sunny San Diego. It’s like a combo meal – a bit of everything in one package. On the other table, there’s Original Medicare with a side dish of Medigap (Supplement) plans. More à la carte, you pick and choose what suits your palate.

The Medicare Advantage Plate: A Mixed Bag

Pros:

1. Convenience: These plans roll your Medicare Parts A, B, and often D into one. It’s like getting a burger, fries, and a soda in one go.
2. Cost Caps: There’s a limit on out-of-pocket expenses. It’s like knowing you won’t spend more than $20 on your meal, no matter how many extra fries you grab.
3. Extra Goodies: They often throw in benefits like dental and vision – the cherry on top.

Cons:

1. The Network Maze: You might be restricted to their network of doctors. It’s like only being able to eat at restaurants in one neighborhood.
2. Referral Hoops: Need a specialist? Get ready to jump through some referral hoops.
3. Coverage Caveats: Some treatments or drugs might not be on the menu.

The Original Medicare with Supplement Platter: Customize Your Meal

Pros:

1. Freedom of Choice: See any doctor who accepts Medicare. It’s like having a pass to dine at any restaurant in the city.
2. No Referrals Needed: Straight to the specialist you go, no pit stops.
3. Predictable Costs: Supplement plans can cover those pesky out-of-pocket costs, making your expenses more like a fixed-price menu.

Cons:

1. Extra Bills: You’re paying for two plans – think of it as buying a main dish and a side separately.
2. Drug Plan Detour: You’ll need a separate plan for medications – yes, another dish to order.
3. Extras Not Included: Want dental or vision? That’s another order you’ll need to place.

The Plot Twist: A Prostate Cancer Diagnosis

Here’s where the plot thickens. With a recent prostate cancer diagnosis and a Gleason score of 7, the decision gets more nuanced. You want a plan that covers your needs, like a chef who can cater to your specific dietary requirements.

Dis-enrolling and Medigap: Navigating the Maze

If you’re thinking of waving goodbye to your Medicare Advantage plan and waltzing over to Original Medicare with a Medigap policy, hold your horses. There are things to consider:

• Guaranteed Issue Rights: This is your golden ticket to get a Medigap plan without being penalized for health issues. But it’s time-sensitive.
• Medical Underwriting: Miss the golden period, and insurers might look at your health as closely as a chef inspects produce. This could mean higher rates or a polite “no thank you” to offering you a plan.
• California’s Birthday Rule: In the Golden State, you get a chance to switch Medigap plans around your birthday without medical underwriting. It’s like getting a free dessert on your special day – but only if you already have a Medigap plan.

The Verdict?

It boils down to personal preference, health needs, and a bit of timing. Think of it like choosing between a set menu and a build-your-own meal. Each has its perks and drawbacks.

So, dear readers, as you navigate these choppy waters of Medicare decisions, remember: it’s about finding the right fit for your health and lifestyle. And while I, your AI assistant, can provide a map, it’s always wise to consult a human expert – think of them as your personal health insurance sommelier.

Happy enrolling! May your health insurance choices be as satisfying as your favorite meal.