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‘Look at big picture,’ says Bradenton Medicare expert

Sue LaMastro, above, is the Manatee County coordinator for SHINE, which stands for Serving Health Insurance Needs of Elders. It's part of the Florida Department of Elder Affairs. SHINE is hosting 11 workshops on Medicare open enrollment from Oct. 13-Nov. 14.
Sue LaMastro, above, is the Manatee County coordinator for SHINE, which stands for Serving Health Insurance Needs of Elders. It's part of the Florida Department of Elder Affairs. SHINE is hosting 11 workshops on Medicare open enrollment from Oct. 13-Nov. 14. rdymond@bradenton.com

Sue LaMastro is the Manatee County coordinator for SHINE, which stands for Serving Health Insurance Needs of Elders.

Her organization, which is part of the Florida Department of Elder Affairs, is available for people who want help with Medicare enrollment choices, which they must make between Oct. 15 and Dec. 7.

Changes they make go into effect on Jan. 1, 2017.

LaMastro, who has been with SHINE for 13 years, says SHINE counselors answer questions on the phone and at workshops but can also schedule face-to-face meetings. SHINE has been in existence for about 20 years in Florida.

LaMastro visited the Herald last week for an interview:

Q: First, can you explain all the parts of Medicare for us?

A: Sure. You may access your Medicare benefits two different ways.

We like to call the first way traditional because it’s the Medicare most seniors remember their own parents and relatives having. Traditional Medicare is accessed by that lovely red, white and blue card that comes from Social Security. It has a Part A and Part B.

Part A covers hospitals and nursing homes; Part B covers doctors, outpatient surgery, durable medical equipment, and other items in that vein. Part A, if you have fulfilled all the criteria, is free. There is no monthly premium for that. But for Part B, everyone must pay. So, the people who have been on it a long time right now are paying $104.90 a month for it. The ones who came on in 2016 are paying $121.80 a month.

But traditional Medicare does not cover drugs. So, if you are using traditional Medicare, you must also buy a Medicare-approved Plan D. Plan D as in drugs. Plan D is sold by individual, private insurance companies.

Right now in Manatee County, we have about 20 individual, private insurance companies that are selling Part D plans. Part D plans are very individual. There are no two people who will have the same plan because they have different drugs. That is the most important thing that people need to do during this annual enrollment, to become educated on their specific needs.

Q: You mentioned that there is another way to access Medicare benefits.

A: Yes, the other way is through a managed care plan, otherwise known as an HMO or a PPO. The managed care plans are actually a combination of a Part A hospital coverage, a Part B doctor and outpatient, and a Part D, drugs. So, if you chose the managed care plan, also called Medicare Advantage, to access your benefits you do not need to buy a separate drug plan. It is already in the mix. Some clients would like to not worry about deductibles or high co-payments, so some of those people buy private insurance through a private insurance company like Humana or Blue Cross Blue Shield, and that is called a Medicare Supplement Plan. In other words, it supplements what Medicare pays.

So, if you go to the doctor and the bill is $100, and Medicare will pay $80, which is usual and customary, you have $20 left. That is what the Medicare supplement plan will pay. It also pays the deductibles that come with Medicare such as $1,280 for Part A and $166 for Part B. Those plans are separate and not mandated by the government. If someone wants a little extra insurance, they may buy them.

Q: So what’s new and important for 2017?

A: An important thing for 2017 is to see if the preferred drug store that goes with the drug plan you sign up with will waive the $400 deductible that plans are putting into effect in 2017 for drugs.

What I mean by that is that in some plans, the tier one and tier two drugs will not incur the $400 deductible in that drug store. In other words, if clients are on the right plan, they will pay their usual co-payment, which could be zero or $3.

Q: What does SHINE do?

A: We are all volunteers, trained by the Florida Department of Elder Affairs. We don’t sell anything. We don’t promote any plans, but what we do is give information to seniors or anybody that is Medicare eligible, and we try to give them the best information we can so they can make the best decisions for them, not necessarily for their neighbors or spouses, but for them.

Q: So, now we are coming up to the Medicare Open Enrollment period. What do you think the biggest mistakes people make during open enrollment?

A: They don’t look at the big picture, at everything.

For example, I think one of the biggest mistakes is that clients often choose insurance companies with low monthly premiums or no monthly premiums because they seem attractive. That might be OK if they stay healthy. But if they use the services a lot, the co-payments start to add up. There’s $50 if you go to a specialist. There’s $30 there. They don’t realize that and they become unhappy.

Then, of course, choosing the right drug plan is always important. People will come to workshops and tell me, “My plan dropped my drugs. They are instituting quantity limits that they never did before. They also also instituting step therapy.”

All of that could have been avoided by research. For instance, step therapy is where the client wants the more expensive drugs but the insurance company is forcing them to try a cheaper alternative for a while to see if that works. Clients are often not happy with that.

Also, where you buy your drugs, what drug stores, is also important. Oftentimes, these companies, these plans, have a handshake or a special deal with different drug stores, and the drug store is willing to give an extra discount for people who come to that plan.

All these things could be discovered during open enrollment by looking at everything. We don’t just look at the cheapest monthly premiums for a drug or insurance plan. We look at the co-payments. In the case of drugs, we look at the tiers of drugs that are part of the plan. We look to make sure that step therapy is not something that is impacting this client.

Q: That seems almost impossible to calculate. How do you do it?

A: The answer is we kind of look at four or five or six parameters, and we put them all into the Medicare.gov computer and start to look at the information that comes out of it. You can’t just look at one number. You have to take a little time to poke around because, as I always say, the devil is in the details.

Richard Dymond: 941-745-7072, @RichardDymond

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