My First Blog Post

The appeals process

Be yourself; Everyone else is already taken.

— Oscar Wilde.

If you’ve at least completed AHIP, you’ve heard of the grievance and appeals process. If you haven’t, you may not be far enough along as an agent for this blog to help you. I recommend you go to the video on our website about getting started as a Medicare Geek.

A sales manager for a certain carrier told me never to underestimate the power of the appeal process. I took that to heart and started helping members submit grievances and appeals when they are warranted. I thought I’d share this success story to bring it home:

In 2017, one of the HMO MAPDs that I represented had a hearing aid benefit– $1000 per ear! The problem: there were no providers on our island, so any provider her would be out of network. A long-time member of the plan talked to customer service at the provider and was told that if he went to Costco, he could just mail it in as a claim and it would be paid since there was no network provider. When he called me, I originally chastised him for calling customer service before me– with this carrier, CS was notoriously bad. Nevertheless, since he had documented that phone call with customer service, I told him I’d help. We completed the simple claim form and mailed it in. Within about a month, he got his reimbursement. Miracles do happen.

Then enter customer B. They did the same thing about purchasing a hearing aid at Costco. I told them it normally wouldn’t be covered but since the carrier had reimbursed customer A, we might as well give it a shot. This was fall of 2017. We completed the claim form and mailed it in.

After about six weeks, customer B’s wife called me. They had heard nothing. Could I help. I emailed agent support at the carrier. I got a volley of conflicting emails over time– I’d used the wrong claim form. It was out of network. There weren’t any diagnosis or billing codes on the claim, etc. Each time, I calmly pointed toward customer A where none of these questions has been asked. Some things I wrote in never received a response.

Eventually, I told customer B it was time to draft an appeal letter. We gathered all of the documentation. Got permission from customer A to use his story. (Without this permission, it would be at least a HIPAA violation to bring him up. ) He said, “Absolutely!” I helped the members draft a letter and we sent it all in.

45 days later they received a curt response: Since it had been more than 60 days from the original service, the appeal was denied based on timeline alone. (This meant they ignored the merits of the appeal.) This decision was final unless we wanted to appeal it to an outside government contractor called Maximus. Member B was devastated. I said, “Let’s keep going. We have nothing to lose.”

We drafted a letter to Maximus including all of the info and pointing out the absurdity that the insurance company denied it based on timing since we’d been in communication from the moment we sent the claim in– within 30 days of getting the hearing aids. Member B eventually got a letter from Maximus that Member B didn’t understand. This was the gist: It was favorable. But this didn’t mean they were for the reimbursement. It meant the 60 day thing was stupid so they were sending it back to the carrier to reconsider based on the merits. I wasn’t hopeful: Since we’d seen excuse after excuse not to appeal, we just assumed that the carrier would find another stupid reason to deny the claim.

We were wrong! About another month after that, they member got one letter saying the carrier was giving them a favorable decision on their appeal. A separate envelope in the same batch of mail had a check for over $1700! (For some reason they wouldn’t pay the tax but the member was fine to let that slide.)

Don’t give up on grievances and appeals if you have a good case. Insurers make a lot of money off of these government contracts. They don’t want too many complaints going directly to CMS or HHS. Also, consider the business smarts of this: How likely is this member to ever switch to another agent over a catchy sales presentation alone when I walked side by side with them for this long: They got the check in October 2019. (We started in November 2017!) It’s the right thing to do by people and it’s the smart thing to do for your business.

Go help some people and make some money.

Why you need to get to 500 Medicare members

If you’re an insurance agent, or even if you’re not, I want to make real to you why you should be working in the Medicare marketplace and how it can change your life.

In most states, a new Medicare Advantage plan pays the agent $539 year-one commission in 2021. If you were changing someone from one Advantage plan to another, you’d receive half of that. So, whether it took you one year– or ten years– to get to 500 Medicare Advantage members, you would have in first year commissions earned between $134,750 and $269,500. But that’s only the beginning.

After year one, your per member renewal will be at least $22.45 for life. “What?” you say. You’re only used to five- or ten-year renewals on your contracts. That’s not so with Medicare. Most plans are or have already moved to lifetime renewals. That means if the member stays on that plan with you as their agent, you’ll receive $22.45 every month for the rest of his or her life. Once you get to 500 members, that will be monthly renewals of at least $11,225.

How would your life change if you had over $11K coming in each month before you even started working? Would you be disappointed if it took you a whole decade to get there? Would you move to a different neighborhood? State? Would you put your kids in different schools? Would you contribute to your community in different ways? Would you make charitable contributions you can’t now? What would be possible? Here’s the deal: It is possible. I’ve done it and I know dozens of agents who have done it. We can substantiate it with commission statements proving this is true. How often does that happen in multi-level marketing scams? Almost never because no one is really making any more.

If you’re not even an insurance agent, it’s not too late. 10,000 people turn 65 every month in the United States and become eligible for Medicare. That trend will continue till 2029. What do you think will happen if Biden is elected and allows people to sign up for Medicare as early as age 60? Even more opportunity. If you’d like to find our more, check out our YouTube Channel at https://www.youtube.com/channel/UCmcf7Q9ct-O7TcSILp0JTsA/videos?view_as=subscriber or our training website at https://themedicaregeek.com/. Feel free to email with any questions at themedicaregeek@gmail.com.

We’re halfway through 2020 and a global pandemic. Start now for success in 2021 that will move you beyond what you ever thought was possible. One way or another, you’ll be ten years older in ten years. Will you have the renewals to make it worth it?

How fast can you start a new career?

My last sales job fell apart in 2010. I lived on a tiny island with an economy based mainly on real estate and tourism. Neither of those were doing good. There were few job listings. I even mailed custom letters and resumes to the 50 top companies on the island and got zero results.

At the same time, I had seen an ad on Craigslist about becoming an insurance agent who focuses on Medicare Supplements, Medicare Advantage Plans and prescription drug plans. The money sounded good– it sounded too good to be true, which was a red flag– but I did not have any other real options. I spoke to the recruiter with a few questions. She told me about her easy success. I asked, “What’s the catch?” She said, “I honestly don’t know. It was easy for me. But statistically, 80% of new agents don’t make it.” I really appreciated her honesty on the statistics and thought, “What the heck? I might as well give it a go. I have no other options right now anyway.”

I knew little about insurance except some about my health insurance and a little about term life insurance. I paid my car and renter’s insurance. That was about it. I scheduled my insurance exam for two weeks away. I got a book from the library about how to study for it and crammed using that and by looking up the statutes on our state website, comparing it against the outline for the test. I passed the exam two weeks later. (In most states, you only must make around a 70% to pass.)

I then had to get my license. That took mailing in my licensing paperwork and fee, around $200. Within two weeks, my license was live in the system. Then I could be contracted with the carriers. Some carriers had me in the system in a few days, some in a couple of weeks. As soon as I was contracted, I could start their online trainings and the AHIP Medicare Training, which is the basis of my industry. I passed all of that within the next two weeks.

I wrote my first new business within the first month. That fall I was volunteering at the Medicare booth at Walmart, giving presentations for one of the major carriers and receiving leads directly from a couple of companies. Within a year, I had a living wage close to what I had recently left.

Now a decade later, my renewals– the amount I get paid whether I write new business or not– is over $20,000 per month. I also write new business of around $3000-8000 per month. None of this includes the overrides I make from agents I train and support.

If the future looks uncertain for you like it does for so many, there is a new career you can start and be up and running in a couple months. The industry projects that 10,000 people per day will turn 65 until the year 2029 and they all need help making their Medicare decisions. In fact, we have had an uptick in business as people are being laid off and need to start their Medicare. Many things are uncertain in the world right now. Medicare and people needing help with those decisions are a sure bet at these times.

Feel free to reach out if you have questions about the industry or want to know how to get started. You can also subscribe to my YouTube Channel: Med Geek YouTube or subscribe here: The Medicare Geek.

If you’re an insurance agent and you’re not in the Medicare marketplace, you are missing the boat.

Yes, there’s more regulation in the Medicare insurance marketplace. Yes, there are annual certifications you have to take. Yes, it takes a few years to become an expert and build a decent-sized book of business. But it’s all worth it.

Nobody gets rich the first couple years doing Medicare. But the renewals are the best in the industry– in most cases, renewals are 50% of the first year commission and they last a lifetime. If an agent grows a book of 500 Medicare Advantage plans, their monthly renewals are about $10K per month… for the life of the client. It’s insane.

The picture above is a glimpse of my calendar from this month. By tomorrow, I’ll have at least 18 new Medicare Advantage clients this month. In the middle of a global pandemic where people still need insurance. Three of those came from a lead source. The rest were all referrals from existing members or people in the community who know I can help with Medicare. This one month with be $8-9K first year income and $4-5K annual income as long as I take care of these members. Imagine what your life would be like if you grew your book to well over 1000 members. I have.

If you don’t know where to get started, check out our YouTube Channel here: https://www.youtube.com/channel/UCmcf7Q9ct-O7TcSILp0JTsA/videos?view_as=subscriber. We also have a website, where you can contract with us or pay a monthly subscription fee for the best training in the industry. Period. That’s here: https://themedicaregeek.com/. 10,000 people will turn 65 and become eligible for Medicare every day in the United States and that trend will continue to 2029. Will you get your share or will you miss it?

Feel free to reach out if you have questions or want to discuss at themedicaregeek@gmail.com.

Saving with Medicare Part D

Many people are having to add Medicare coverage after being laid off and losing workplace insurance. Many people are already using Part D but their income has gone down and some medications may be cost-prohibitive. This is a list of ways to help with costs with Part D. If you need help doing any of these or picking a plan, feel free to reach out.

Generics: Many fancy brand names have very low cost generic alternatives. If your brand name drug is too expensive, check in with your doctor or pharmacist about alternatives.

Extra Help with Prescription drugs is a supplement to Part D administered by the Social Security administration. If approved, drug costs are lowered across the board. Find out if you qualify here: https://secure.ssa.gov/i1020/start.

If you don’t have many medications, you may be able to get a “tiering exception” from your Part D drug plan. A great example is some people need synthroid and can’t tolerate the more affordable levothyroxine. Using the plan’s “formulary exception” process, a prescriber can request that the medicine be lowered, for instance, from tier 3 to tier 2. If that happens, it often will mean taking away a high deductible and can even be free through mail order with some carriers.

Patient Assistance Programs: For mostly brand name medications, moderate or low-income people can often get medications absolutely free directly from the manufacturer. Sometimes these programs will help from dollar one. Sometimes they’ll want the person to have spent a certain amount on prescription drugs for the year. To see if it’s possible for your medication, just Google the name of your medication followed by “patient assistance program” and see what you find.

When all else fails, sometimes it’s cheaper to order some medications directly from Canada without insurance than it is to get the medication in the US with insurance. (This can also help you stay out of the donut hole.) There are a few high quality mail order pharmacies in Canada that deliver to the US. Sometimes their brand names cost much less. Sometimes they have generic versions that haven’t been approved in the US. If you need a recommendation, reach out to us at themedicaregeek@gmail.com.

On being a medical professional…

I’m a little behind on blog posts. Please forgive! Beginning of the year is always tough and busy for anyone really “in” this business.

There are lots of business-building ideas I could give but it’s time for a more important conversation: If you’re a Medicare insurance agent, you need to be a professional and rely on the available science. This doesn’t mean science doesn’t evolve and we learn more but you also don’t let pass ideas like “flu shots aren’t important” or “it’s okay not to take your hypertension medicine if you have enough tumeric.” Nor should you ever play the role of doctor. You are a support piece in a confusing world of ever-evolving medicine and science and your job is to support best practices.

With that said, the most important thing I can do today is point you toward what we know about coronavirus (and what we don’t know.) You being a beacon of facts and best practices is a valuable role you can play in society in this business. Read this and check it every day or two. This is your best source for information: https://www.cdc.gov/coronavirus/2019-ncov/about/index.html.

Be safe out there!

How I Spent My Day…

My first appointment was at 8:30am. I rent a shared workspace that’s connected to a groovy coffee shop. I met a business owner at 8:30am there. She’s turning 65 in May. I helped her register for SSA.gov and apply for Medicare A&B. She’s going to wait until at least age 66 to get Social Security retirement benefits. We figured out what the right plan fit was for her. As soon as her Medicare ID shows up on SSA.gov or her physical Medicare card arrives, we’ll sign her up for the plan. I left it up to her: We can meet again in town. I can drive to her. Or we can do it over the phone and she can complete an email confirmation.

I had a nice break so I went to the gym. Today was back and triceps.

After that, I went back to my coffee shop and worked for just over an hour. I ran by the house, scarfed a microwave lunch, said hi to our sometimes dog walker and hit the road 20 minutes later.

My next appointment was about 25 minutes away. On the way, I returned a couple of informational calls to members, listened to a podcast and talked to my friend Peggy. The lady I met was an existing, long-term member. She’s doing well but recovering from a recent stroke. She has somewhere between $500-$1000 due for her care at the local hospital system. She makes about $1800 per month total and has low assets. She makes too much for Medicaid but she will qualify for the financial assistance program at our local hospital system. I helped her apply for this as a kindness, because I know it’ll help her and because I know if I just told her to apply she’d feel weird asking for help or be overwhelmed with the paperwork. It’s easy for me and creates a fan for life. Plus, I feel like I’m treating people like I’d want my grandmother to be treated.

Next stop was about ten minutes away. The husband is an existing Medicare member and the wife will turn 65 in May. We figured out what plan would be really good for the wife. They were worried because a psych med she’s on retails for about $1400 per month. The worst-case-scenario is that she’ll pay year-long for that medication about $2K on the right plan. The best-case-scenario is I’ll help them get it for free through the manufacturer’s patient assistance program, which they’ll likely qualify for. They told me they went from terrified to relieved during this conversation. When her Medicare card arrives, we’ll enroll her in that plan and apply for the patient assistance program. I also shared how they’ll probably qualify for an 85% bill reduction in the financial assistance program from the hospital system I talked about earlier.

I drove home. Returned a few more calls. Did some required paperwork. Took a nice walk and listened to a nice guided meditation. Had dinner with my honey. Did my next online newsletter and wrote this blog post all while having a little Maker’s Mark to celebrate.

If the problems in our healthcare system weren’t so real, I might think I’d already died and gone to heaven. It’s a joyous career!

Be helpful and be available

If you’re seriously working this industry, your availability, knowledge and helpfulness are your greatest values. There are only two days left in the year. Some people need January 1 coverage. If they are willing to meet and you can make the time, I recommend you do. Yesterday, I had two appointments before lunch. That will provide one person turning 65 a savings of about $400 per month in premium costs and another who is dual-eligible will get on a plan that adds free dental, gym membership, acupuncture and over the counter benefits she wasn’t receiving before. Another person lost coverage at the end of October through his employer. By meeting with him before the end of the year, he’ll have some additional benefits and part d drug coverage. If we didn’t do it by 12/31/19, he’d be shut out until AEP for 2021– a full year without prescription drug coverage.

If you graduate from another industry, you may be used to having the couple of weeks around the holidays completely cleared– endless time for family, friends, movies, parties, etc. I have plenty of time for all of those things and enter the New Year with the same weight loss goals as you. But I’ve also learned by being available when people need it grows goodwill, my reputation, my referrals and my business. This is an industry where you never go wrong in putting the member first.

Merry Christmas and Happy New Year! (Plus all the rest, whatever you celebrate!)

Be thankful and go help a senior…

Within a year of starting this work, I became how aware of how many of our seniors (in Hawaii we say “kupuna”) live at or below the poverty level. It’s staggering. I

According to the Kaiser Family Foundation, as of 2017, about 7 million people age 65 or older had incomes at or below the Supplemental Poverty Measure: https://www.kff.org/medicare/issue-brief/how-many-seniors-live-in-poverty/.

Let’s look at what the 2019 Federal Poverty levels are. We’ll look at single people because over time, we all end up single eventually as will the people you are helping. In Georgia, where I grew up, or Chicago where I lived before Hawaii, the 2019 FPL for a single person is $12490. That’s $1040.83 per month. Here in Hawaii, it’s $14,380 annually or $1198.33. I know even in our senior living properties– for which there is a long wait to get in, the cheapest rent is $500-600 per month. Imagine trying to make ends meet on that?

So, this is why it is imperative that you, as a Medicare Geek, become expert at saving your members every penny you can.

— That means putting them on the right plan.

— That means telling them that blood work at a lab outside the hospital will probably have a lower copay than blood work at the hospital and other savings tricks like this.

— It means learning the best ways to help them on their prescription drug costs. Can they get any at no cost through mail order? Do they qualify for Extra Help? Do they need to sign up for a patient assistance program for their brand name drug(s)? Do they need to order that one drug from Canada because it’s cheaper to buy there without insurance than it is to get in the US with insurance?

— It also means learning your state’s level of Medicaid. The plan you put them on may save them $10 on a PCP visit. That helps. But if you get them qualified for a Medicare Savings Program and their Social Security deposit goes up by over $130 per month for life, you have literally changed the fabric of his or her life.

I always tell my members, “Part of my job is to be cheap on your behalf” because for many of them every penny every month matters. Also, in my entire career, no one has ever said they wanted a meeting to last longer, for me to make it more complicated or wanted me to raise their healthcare costs. Consider that as you go along.

Spend time with your loved ones. Celebrate all you have to be grateful for. Then tomorrow go back to helping people and saving them money. Along the way, you get to make money. Isn’t that a dream come true?

Working with Part D

So, Part D is wonderful… and horrible. It’s better than the prescription drug coverage Medicare had before– none. But that’s about it. Many people said it was a gift to the pharmaceutical companies in that the legislation doesn’t allow Medicare to bulk negotiate with pharmaceutical companies– they can basically charge what they want. FYI, there’s a bill that has currently passed the House– that Mitch McConnell won’t bring to a vote in the Senate: It would save Medicare over $350 Billion over ten years and consumers over $150 Billion on the same time. Call or write your Senators!

One had to be creative when making the best of part D. I met with a low-income beneficiary who is going off of Medicaid– all meds free– and onto Medicare. (Some people qualify for Medicare AND Medicaid. He does not.)

He takes four medications for heart stuff– heart disease and hypertension, plus levothyroxine for thyroid issues. He takes generic Norco, alprazolam for sleep, desvenlafaxine (generic for Pristiq) and Trintellix, a very new, very good, very expensive medication for major depressive disorder. Using the Medicare.gov website, he found that the most affordable plans still had his out of pocket for drug costs at over $4000 per year– way too much for someone making about $1600 per month. Here’s the solution I came up with:

— The four heart medications and levothyroxine are all tier one or tier two with one of our Medicare Advantage plans. If he uses the plan’s mail order, they’ll be delivered to him every 90 days until if/when he hits the donut hole.

— Norco, desvenlafaxine and alprazolam were all listed as tier 3s. This is probably because the company wants to discourage their use or their costs. Either way, they’re not costs meds– each cost a maximum of about $15 per month. He could purchase that without his insurance and it will a) cost him the exact same and b) those costs won’t drive him into the donut hole.

— Trintellix is now the big issue: We’re applying for the manufacturer’s patient assistance program. If he’s approved, they’ll mail it to him every 90 days. If not, he can use his insurance and it’ll probably cost less than $100 per month.

So with a little creativity, we’re taking his estimated drug costs from $4000+ to less than $2000 and if he’s approved for the PAP, his costs will probably less than $500 for the year.

For better or worse, this is how you make the most of Part D plans.

On Veterans Day…

It’s November 11, 2019.  This is a day we honor those who have fought and sacrificed for our country.

It’s also a great day to remind people how VA coverage and Medicare work together… or don’t.  This is what the VA says about people considering dropping Medicare because they have access to the VA system:

“This is your decision. You can save money if you drop your private health insurance, but there are risks. We encourage you to keep your insurance because:

  • We don’t normally provide care for Veterans’ family members. So, if you drop your private insurance plan, your family may not have health coverage.
  • We don’t know if Congress will provide enough funding in future years for us to care for all Veterans who are signed up for VA health care. If you’re in one of the lower priority groups, you could lose your VA health care benefits in the future. If you don’t keep your private insurance, this would leave you without health coverage.
  • If you have Medicare Part B (coverage for doctors and outpatient services) and you cancel it, you won’t be able to get it back until January of the following year. You may also have to pay a penalty to get your coverage back (called reinstating your coverage).”

And if you have VA coverage but are turning 65:

“Yes. We encourage you to sign up for Medicare as soon as you can. This is because:

  • We don’t know if Congress will provide enough funding in future years for us to provide care for all Veterans who are signed up for VA health care. If you’re in one of the lower priority groups, you could lose your VA health care benefits in the future.
  • Having Medicare means you’re covered if you need to go to a non-VA hospital or doctor—so you have more options to choose from.
  • If you delay signing up for Medicare Part B (coverage for doctors and outpatient services) and then need to sign up later because you lose your VA health care benefits or need more choice in care options, you’ll pay a penalty. This penalty gets bigger each year you delay signing up—and you’ll pay it every year for the rest of your life.
  • If you sign up for Medicare Part D (coverage for prescription drugs), you’ll be able to use it to get medicine from non-VA doctors and fill your prescriptions at your local pharmacy instead of through the VA mail-order service. There’s no penalty for delaying Medicare Part D.”

Medicare insurance agents should take the attitude of do no harm.  What does this mean?  If someone has Tricare For Life, you don’t put them on an MAPD, which would give them inferior drug coverage.  If someone has traditional VA coverage and Medicare A&B, you perhaps help them get additional benefits and sometimes even lower drug costs on an MAPD.  If they have TFL, you can put them on an MA-only plan.

The main thing is to do your research and make good recommendations before enrolling someone.  It’s okay to say, “Let me research this a little further” before making a recommendation that could have harmful effects.  You also might find something better for the person– like the Humana Honor plan that is being rolled out around the country that includes strong benefits and a Part B giveback.  If you have specific questions, feel free to email me at themedicaregeek@gmail.com.