What Medicare Pays for and What You Pay for

with Robin Peconge,

Naviguide, United Church Homes

This week on Ask a NaviGuide, we chat with Robin Peconge, one of the NaviGuides at United Church Homes. Robin and Ashley chat about the complexities of Medicare and help individuals understand who is paying for what as part of the coverage. All that and more on this week’s episode!
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Highlights from this week’s conversation include:

  • Robin’s background in healthcare (0:26)
  • Common costs that payers incur in Medicare plans (1:01)
  • Medicare co-pays and supplements (3:45)
  • In-network vs. out-of-network, HMO and PPO (4:21) 
  • Contacting your health plan with unexpected charges (6:35) 

The Abundant Aging Podcast is a podcast series presented by United Church Homes. These shows offer ideas, information, and inspiration on how to improve our lives as we grow older. To learn more and to subscribe to the show, visit abundantagingpodcast.com.


Ashley Bills 00:07
Hello and welcome to Ask a NaviGuide part of the Abundant Aging Podcast series, where we talk about aging and family caregiving and how to work through stressful situations with the help of United Church Homes team of NaviGuides. Our NaviGuides have decades of experience helping families work through difficult situations. And today, we have Robin with us who will help us understand what Medicare pays for and what you pay for. Welcome, Robin,

Robin Peconge 00:35
Thank you very much.

Ashley Bills 00:36
Would you like to kind of kick us off today by giving us a little bit about your background?

Robin Peconge 00:40
Sure. I was in senior health care sales for about 20 years and then included advantage Medicare Supplements, life insurance, long term care insurance, kind of the whole gamut. I loved working with seniors, I have a little bit of experience working in claims as well, as well as being the billing manager at a health care prior to becoming an APA guide.

Ashley Bills 01:00
Awesome. So that basically covers a lot of places and healthcare. So it’s great to have you with us today. So Robin, we know that health plans generally have rules and conditions which you agree to when you sign up as a member that layout what costs that they’ve agreed to pay for and the financial responsibility that we would have to pay for. So what are some of the most common costs that one would be responsible for?

Robin Peconge 01:29
Well, with Medicare, that’s one thing that’s very nice. It’s very straightforward. It’s the same across the board, and you typically have for hospitalization. So Part A covers hospitalization. Part B, traditionally covers outpatient, so that would be doctor’s office specialist, MRIs, things of that nature. So if you’re in the hospital, you’re first going to have a deductible of about $1,600. After that your stay is covered up for 60 days, if you need medical equipment, it’s just a flat at 20. So the person would pay 20%. If you’re in hospice that has a benefit all itself, you would pay nothing out of pocket. If you have to go to a skilled nursing facility with traditional Medicare, the first 20 days are covered in full, and then days 21 through 100. Right now, it’s a $200 copay per day. So you can see where some of those costs can add up. Home health care typically also is covered in full, it goes by 60 Day episodes, as long as you’re continuing to recuperate. So with home health care, that means that it’s physical therapy, nursing, occupational therapy, speech therapy, there’s lots of different kinds of home health care, but that type of home health care that’s covered under Part A is typically that it’s not the someone that’s going to come in and help someone, they either maybe cook meals and that sort of thing. So there’s a couple of different types of home health care with Part B, which again, is outpatient services, then you do have a premium that comes out of your Social Security check every month, and right now that is $164.90. After that it typically is a 8020 percentage, again, cost sharing minus A 226 deductible at the beginning of the year. So once you meet your deductibles, it’s pretty much at 20.

Ashley Bills 03:11
All right, gosh, that’s a lot. There’s a lot of numbers to digest, our listeners are gonna have to go back and listen again. That’s great information, though. So in terms of the out of pocket costs, are they continuous, no matter how much care you need? Or is there a cap on what you spend out of pocket?

Robin Peconge 03:31
It’s either looking at a Medicare supplement or a Medicare Advantage, because with Medicare, there is no maximum out of pocket that those that 20% can go on forever. So that’s where you do want some help. And that’s when you would go to your broker, maybe call your ship office first and see which direction might be best for you. Got it.

Ashley Bills 03:51
So I think most of us are familiar with co-pays and how they work. But do they exist with Medicare and managed care plans?

Robin Peconge 03:59
So a Medicare Supplement, there would be no co pays. It’s just whatever Medicare pays for the 80%. The Medicare Supplements going to pick that up and you will not see any out of pocket. However those premiums are a lot higher each month. With a Medicare Advantage plan. It is a lot more like what you’re used to when you were in your working years, you do have deductibles, copayments and coinsurance so you might be already comfortable with that. If you have a little bit of a nest egg built up. Those plans are perfect for you.

Ashley Bills 04:27
So what about the concept of being in network and out of network and how might that affect whether you choose an HMO or a PPO get tricky because HMOs are the ones that are more strict.

Robin Peconge 04:37
HMO means that there are no benefits out of the network you can’t appeal to. It’s just the way it works. However, those plans typically have richer benefits. When what I mean by that is some of the extra benefits that we’ve talked about in previous podcasts, the grocery benefits the over the counter benefit that fitness benefits that those things typically are a little bit better with HMOs, which makes people want to vote for them. But you do have to be careful. An example would be, let’s say you had an elective surgery coming up. And you were good to make sure that the surgeon was in network and the hospital was in network. But your anesthesiologist, you didn’t check them. And next thing, you know, you’re getting a $1,500 bill, because you’re gonna see theologist was out of network. So that’s where that can be a little tricky.

Ashley Bills 05:25
Yeah, so can you then just switch between a PPO and HMO if you, I guess, have the ability to really do that

Robin Peconge 05:34
Enrollment periods. Unless, of course, that like I mentioned before, there are those instances, if you have state health coverage, if you’re in a certain income guideline, you might be or if you move, you might be able to switch during the year. But generally, it needs to be during that annual open enrollment, or the one time change after the first of the year, but during that first three months, so you really need to make sure you’re working with someone you trust, maybe get a second opinion with your local ship office, that you will have a decision of what could happen. And again, if you are someone that you know, had a nice career and you have a nice nest egg built up, you may want to have the no premium or very low premiums with a Medicare Advantage plan. Because if you did have those costs, that’s not an issue, you’d rather do that than pay one to two to $300 a month for a Medicare Supplement. But as long as you know that going in and you’re you don’t have any surprises. That’s what we want.

Ashley Bills 06:29
Yeah, I can see where that can be really helpful, you know, depending on what your health needs are, and what’s coming to be able to kind of navigate and manage that. But yeah, kind of being limited to that open enrollment period might be a problem. But if you do have out-of -network charges, like we talked about, how would you alert your health plan and deal with that sort of thing?

Robin Peconge 06:50
While going into it, I mean, you just do the best you can, which is calling most any of the Medicare Advantage plans that I’ve contacted on behalf of someone with someone and their customer service reps are great. You know, you just have to, unfortunately, I guess you just have to know what questions to ask. But you just have to give them as much information as you can. I’m going in for this surgery. This is where you know, this is the place that I’m going to, this is the network that I’m in, is there anything that you can foresee that I need to check with the doctor? Because they will call to get prior authorization. But you rarely when you go to your doctor’s office? Do you speak to anyone that’s from that department, you’re going to speak to the receptionist, to the medical text to the nurses, and they really don’t know any more about insurance than what you do. And that but unfortunately, that’s the people that you’re asking. And you assumed that they would know if you’re there and they took you. That means that they know that they take your insurance and that’s not the case. You definitely always want to speak to either the billing departments or directly to your insurance provider.

Ashley Bills 07:47
Tell us a lot of information. Thanks, Robin, so much for your insight today. It’s been great. You’re welcome. And thank you for listening to another episode of Ask an NaviGuide part of the Abundant Aging Podcast series brought to you by United Church Homes. If you like the show, please like, share and subscribe so we can bring you even more content. For more information about the UCH NaviGuide program, visit uchnaviguide.org. And for more information about United Church homes, visit UnitedChurchhomes.org. We’ll see you next time!