Ep 514: Demystifying Medicare with Phillip Moeller

Are you confused about Medicare? Want to know how it can benefit you and which options best suit your needs? In this episode of The Health Fix Podcast, Dr. Jannine Krause interviews award-winning journalist and Medicare expert Phillip Moeller. Phillip is a coauthor of the New York Times bestseller Get What’s Yours: The Secrets to Maxing Out Your Social Security and author of Get What’s Yours for Medicare: Maximizing Your Coverage, Minimizing Your Costs, and Get What’s Yours for Health Care: How to Get the Best Care at the Right Price. He also writes the “Ask Phil” feature for PBS NewsHour and shares Medicare and Social Security insights in his Substack newsletter, Get What’s Yours.

Resources from the Show:

• Phillip Moeller’s Website: GetWhatsYours.org
• Phillip’s Book: Get What’s Yours for Medicare
• Phillip’s Newsletter: Get What’s Yours on Substack (excellent free posts on Medicare updates)

Tune in to get clear guidance on evaluating Medicare and understanding which options work best for your unique health needs.

Our Partners

Podcast Transcript

5:02 – Phillip’s background

11:29 – Understanding what medicare covers

13:30 – Medicare part A

13:44 – Medicare part B

14:22 – Medigap

24:08 – Practitioner acceptance of Medicare

27:01 – Medicare late enrollment penalties you should be aware of

39:08 – Medicare non-medical coverage

53:31 – “Aging in America”

54:18 – Where to find Phillip online

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[Preview] There is a free program funded by the government that’s called the State Health Insurance Assistance Program.

It’s a real mouthful.

The acronym is SHIP, which is a little bit easier.

So if you Google SHIP online, you’ll see these state programs all around the country

that are manned by trained volunteers who are supposed to be able to help you understand

these basic rules.

That’s really important.

MediGAP is a private insurance plan that helps close a lot of the costs that basic

Medicare covers but doesn’t fully pay for.

It’s a big thing to understand.

The biggest gap in basic Medicare is it only pays 80% of these outpatient expenses.

Only pays 80% of doctors bills, 80% of medical equipment, 80% of those expensive drug infusion.

[Intro] Welcome to The Health Fix Podcast, where health junkies get their weekly fix of tips

tools and techniques to have limitless energy, sharp minds, and fit physiques for life.

JANNINE: Hey, health junkies. On this episode of The Health Fix Podcast, I’m interviewing Phillip

Moeller. He’s an award-winning journalist, and he co-authored New York Times bestseller Get What’s

Yours, the secrets to maxing out your social security. And he’s the author of companion volumes,

get what’s yours for Medicare, maximizing your coverage, minimizing your costs, and get what’s yours

for healthcare, how to get the best care at the right price. He also wrote the Ask Phil feature

for PBS NewsHour and has also worked for Money and U.S. News Report as well as several newspaper.

He writes the Get What’s Yours newsletter on Substack and provides updates on Medicare and

Social Security on his website, getwhatsyours.org.

And today we’re going to be talking about Medicare and his new book Get What’s Yours

for Medicare It’s Revise since 2016.

And gosh, he is a lot like just a wealth of information when it comes to understanding

Medicare and Medicare Advantage plans and also understanding MediGap and how this all plays

out.

Now we go through making choices when it comes to Medicare, what’s most advantageous.

Also talk about alternative care, which unfortunately is not covered by Medicare.

Acupuncture is for just low back pain.

That is it.

So those are types of things that unfortunately when it comes to the alternative healthcare

world, it’s hard to get care within the Medicare system.

So you do have to fund for that outside of it.

In some cases, you may be able to keep your medical providers, if they’re medical doctors

or nurse practitioners, something to think about.

Really looking at what are your healthcare needs for the future?

How is your health right now?

What family history do you have?

What could develop in the future?

And really just thinking about what is it that I need right now?

what is it that I may need in the future when you go to create your plans?

I definitely think that folks should take advantage of Medicare.

You paid into it.

Mine as well use it, but also thinking about what do you need?

Are you more concerned with having a big injury of some sort or needing to go to

the hospital or are you more concerned with making sure that you’re well taken

care of within a health plan?

We’re going to talk about that today.

We’re also going to talk about the biggest holistic plan right now going with Medicare

in terms of ACOs, which are accountability programs that are set up within Medicare-specific

clinics.

So, these are all the things that are on a lot of folks’ mind as they start to transition

into Medicare H and things that I wanted to bring up because I get these questions a

lot. And even if you’re not of Medicare age, this may be able to help your parents and something

to really think about. So, Philip has a great book. He’s got a website and he even offers

you to email him questions. So, he’s got a lot to offer. Let’s introduce you to Phillip Moeller and

the conversation about Medicare. Philip Moeller, welcome to The Health Fix Podcast.

PHILLIP: Thanks for having me, my pleasure.

JANNINE: Well, you know, the topic of Medicare is starting to come up in my office because this

time with Open Enrollment, a lot of folks are asking me, “What do I do?

How do I figure this thing out?”

And honestly, the truth is I am Just as clueless everyone else is.

So your book is very helpful to me as a resource for patients.

So first and foremost, I’d like to hear what was the impetus for getting so interested

in Medicare. What brought, what’s the story behind your book?

PHILLIP: You know, about 10 years ago, I co-authored a book about Social Security. It sort of had a magical moment.

It came out right as baby boomers were turning 65 in droves. It was about a program that everybody was affected by, but very few people understood.

It was sort of, oh, it’s Social Security.

I guess I’ll get some retirement money, but people didn’t understand how to use the program.

They didn’t understand the wealth of benefits it offered.

It turns out Social Security is a surprisingly complex program that can not only get you

retirement benefits for yourself, retirement benefits for your spouse, retirement benefits

for your kids based on your earnings record. Retirement benefits for your divorce spouse.

Retirement benefits for your deceased spouse. All of these benefits combined in a way that

people just didn’t know about. And so I had two co-authors, an economist and a very well-known

journalist Paul Solomon, who’s been the economics correspondent for PBS since before God invented type.

I mean, Paul’s been there since 1985.

And we just sort of did this book that made the program understandable to real people.

Anyway, a lot of people bought the book. It was a bestseller. It was one of these magical moments.

So here I am at the age of 68 being a New York Times best-selling author.

But it seemed to me after that book came out that Social Security was not the end all of

a successful retirement, that you needed to have Medicare, the healthcare piece in place

as well, that those two programs, Social Security and Medicare, were what I called the book

ends of successful retirement.

You got to get those things right in order to have a good foundation or a successful

later life.

Whether you’re retired or not, however you want to choose to live your life, making

the right decisions sets you up for having the kind of independence and freedom of choice

that everybody wants as they get older.

So I wrote the Medicare book.

That was in 2016.

A lot of people bought that book too, not as many as Social Security, but here we are

fast forward to 2024.

And Medicare is so different from what it was eight years ago.

So I prevailed upon my publisher to come out with a revised edition.

The book is largely new.

There’s some elements that haven’t changed.

You have to enroll in Medicare.

When you turn 65 things happen, you need to be aware of those things.

And fundamentally, Medicare continues to be a very comprehensive healthcare program.

It does cover a lot.

Some things it doesn’t cover, which people also need to know.

So the book was published.

I think it came out of October 8th, so it’s been about three weeks.

I’ve been doing shows like yours and talking to folks.

My objective, of course, is to sell out of books,

but it’s also to have the opportunity

to explain to people how Medicare works.

That has become sort of my second job.

And it’s very rewarding.

Talking to people after a while,

you can sort of see light bulbs turn on when they say,

“Oh, I didn’t understand this.

I didn’t understand that.”

In fact, the title of the opening chapter

of the original edition of my Medicare book

was “No One Ever Told Me.”

Medicare doesn’t go out and tell you all this stuff.

And one of the reasons is that the government

just doesn’t market itself very well.

That’s not what it does.

And so Medicare has this extensive set of rules and coverages

and things you need to know.

But it doesn’t tell you this.

The people who tell you this are the private insurers

who come out with private part D drug programs for Medicare.

They come out with what are called Medicare Advantage plans,

which are a different kind of Medicare

offered by private insurance companies.

They are inundating you every fall.

So one of the things that your folks probably need to know

is that there’s an annual enrollment period for Medicare

for people who already have Medicare.

And during that period, which begins October 15th and runs till December 7th, people are

just inundated with these private marketing and advertising messages from healthcare plans,

from the insurance brokers who offer these plans and pebble them on behalf of insurance

companies.

And this can be really confusing to people.

And what is important to know is that this is only one side of the story, that there’s

this traditional Medicare program that exists side by side with Medicare Advantage, and

you need to know how that works as well.

So I’ll stop there.

So that’s sort of the background of why I did the book and where we are right today in

late October as you and I are speaking.

JANNINE: Well, we appreciate it.

We appreciate it.

We’re definitely going to get this pushed out as fast as possible because I do think

think that this is with with so much of my patient population getting older and with a

lot of the folks who are listening to my podcast, you know, they’re they’re thinking about it

or they have parents that are are thinking about what do we do. Now, the first thing

that you brought up is is the Medicare Advantage plans because a lot of people are like, do

I even need this? Can I get away with just basic Medicare? And the reason where I’m

common from this is because I’m a naturopathic doctor, we’re not covered under Medicare.

I do acupuncture, but I can only do back pain.

I’m trying to help folks understand what they would want to look at.

So let’s explain why you would want to look at an advantage plan and what it really is

an advantage for you.

PHILLIP: Sure.

So let’s just take a classic situation.

You know, you have a patient who’s about to turn 65.

They will, they either don’t have employer health coverage

or they’re going to lose their employer health coverage

when they retire.

So they have to decide what to do about Medicare.

When, and this is sort of known as aging into Medicare.

So when you age into the program,

you have decisions about enrolling.

You have a window of enrolling in Medicare,

several months where you have the option

of enrolling in Medicare or not.

You don’t have to do it right away.

But my advice for people is to engage

with this decision early and don’t wait.

The worst thing in the world is to lose

your employer health coverage and be uninsured.

Some people, this happens unintentionally.

So Medicare becomes effective pretty soon.

But they allow you to, your enrollment window

extends past the time when you lose your employer coverage.

And so my question is, why would you wait for that?

Even though Medicare rules say you can,

I urge people not to wait.

So the first thing is,

is don’t expose yourself to not being covered.

So whether you’re into natural medicine or not,

If you step off a curb and break your ankle,

you’re gonna need some sort of healthcare.

It doesn’t matter what kind of healthcare you’ve had.

And of course, this is exactly when people

step off a curb and break their ankle,

is when they’re exposed.

So my first thing is that make sure you have the basics covered.

So what are the basics?

Traditional Medicare offers part A coverage

for hospital and nursing home costs.

That charges no premium for people who’ve worked long enough

to qualify for Social Security, which most of us have.

Medicare also covers what’s called part B,

which are outpatient expenses for doctors,

medical equipment, and things like drugs

that are infused in a doctor’s office.

So, you know, whether you have patients who get cancer,

it just happens.

I mean, it doesn’t, you take great care of yourself,

but you get really sick.

So a lot of those really expensive,

cancer medications are administered

in an outpatient setting.

They’re incredibly expensive.

Part B covers most of the costs of those medications.

People on traditional Medicare also often get

what’s called a Medigap supplement plan.

Medigap is a private insurance plan

that helps close a lot of the costs

basic Medicare covers but doesn’t fully pay for, it’s a big thing to understand. The biggest gap

in basic Medicare is it only pays 80% of these outpatient expenses, only pays 80% of doctors

bills, 80% of medical equipment, 80% of those expensive drug infusions. Getting a Medigap plan

can close nearly all of that cost gap. And so for example, my wife and I both have

traditional Medicare and a Medigap plan. It’s called a letter G plan. It’s the most comprehensive

Medigap plan. We pay literally no out-of-pocket Part B expenses once we paid our annual deductible,

which is a couple hundred bucks a year, something like that. So what do we pay? We pay for the Part B

premium, which has been about 170 bucks a month. It goes up a little bit every year, 5, 6 percent.

And we have Part D private drug plans. And we pay a copay, well we pay a premium for those,

and then we pay an annual deductible. The annual deductible for Part D is going up. Drug

prices are going up. So that Part B deductible or Part D rather can be as much as $500 a year.

So switching from that, the alternative is Medicare Advantage. And you asked your question

about Medicare Advantage, but to understand that, I had to sort of tee up what basic Medicare is

all about. So Medicare Advantage plans to do some things that traditional Medicare is not

allowed to do. They can cover routine dental hearing and vision expenses. That can be a big

thing for people because traditional Medicare is not allowed to cover those. As you and I know

dental hearing and vision needs become much more important later in life and they’re so closely

correlated with quality of life. If you can’t hear properly, you can’t communicate properly,

you become more isolated.

Same thing with vision issues.

Same thing actually with dental issues.

These needs are what allow us to say socialize

as we get older and interact with people

and feel comfortable about that.

Not having these basic needs met

has a really deleterious effect on your health

in many respects.

I think it’s a big mistake

that basic Medicare doesn’t cover these things.

But that’s my own soapbox.

that’s not today necessarily, it would be very expensive for Medicare to cover them all,

and money does get involved here. So the reason that Medicare Advantage plans can cover these things

is that the payment rules from the government for Medicare Advantage plans are really different

than for traditional Medicare. So if you have traditional Medicare and you have a covered

procedure. Medicare is going to pay for it. Pretty much no questions asked. It’s covered by the

program you apply for it. They’re going to pay you for it. That’s not the case with Medicare

Advantage. Medicare Advantage plans are paid by the government on a per capita basis based on the

health profile of the people that are insured. This has implications that go well beyond just sort of

what you might think about if you sort of say, hmm, what does that mean? Yeah. These plants get paid

at an amount of money and they have the freedom to use that money to offer benefits in a much

more flexible way. So what ends up happening is that Medicare Advantage plans actually get paid

more money than it costs them to ensure their folks. They get these bonus payments and subsidy

payments and they’re free to use these monies for things like routine dental,

vision, and hearing coverage. So that’s what they use some of these extra monies for.

They also get to use them for things like subsidizing premiums. So if you have a lower income person

who is thinking about Medicare and they don’t have substantial health needs, Medicare advantage

you can be a real bargain for them because some of these plans offer, they not only offer zero premium

but they’ll help pay for some or all of your Part B expenses. Now, traditional Medicare will also

have some low-income benefits that can help offset some of these things. So people on low-income

need to get some real good help in terms of understanding these rules. There is a free program

funded by the government that’s called the State Health Insurance Assistance Program. It’s a real

mouthful. The acronym is SHIP, which is a little bit easier. So if you Google SHIP online, you’ll see

these state programs all around the country that are manned by trained volunteers who are supposed

to be able to help you understand these basic rules. That’s really important. So the first thing

people need to do is there is help for them. They can get help in understanding some of these things.

But in the area of Medicare Advantage, you have the potential of getting very inexpensive health

coverage. Is there a catch? There’s always a catch. The catch is that one of the reasons

Medicare Advantage plans can offer these benefits is that they set up health provider networks

of doctors who agree to offer Medicare Advantage benefits and hospitals that agree to participate.

So these networks agree, you know, they exist at the local level where you live. They’re sort of zip

code-based. What does that mean? It means that these plans drive really good deals with these

doctors and hospitals because they’re very, the plans are big. They have sort of economies of scale.

If you’re a doctor group, a hospital, there’s reason for you to want to offer these,

participate in these networks because you’re almost guaranteed a customer base because the

plans are going to send their people to you. If you’re a member of these plans, you have to agree

to get your care within these networks. If you go outside the network, your care may not be covered.

You may have to pay a bundle for that. So another thing that Medicare Advantage plans can do is

they can use that subsidy I spoke about to really offer less expensive drug coverage under the

Part D program. They have to cover the same stuff as traditional Medicare does, but they have the

flexibility to change what they charge you. So many Medicare Advantage plans offer zero premium

Part D plans. They still have some deductibles and they’re going to get their money from you one

way or the other, but they’re very attractive because their entry costs, so to speak, are very low.

So you end up with, in some cases, you may not pay as much for your Part B monthly premium.

That’s the one that’s backed out of your Social Security every month that you used to pay that

Part B premium. You might not pay as much for that. You might pay much less for your drug coverage.

So these plans have become really popular and they now ensure more than half of everybody

who’s on Medicare. I’m going to stop there because I talked a lot.

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So let’s get back to the podcast.

JANNINE: No, I mean, it’s great.

It’s great for us to hear that because I think a lot of people

are convinced that they absolutely need the Medicare Advantage plans.

And it sounds to me, you know, for a lot of folks,

they want the flexibility to see whatever doctor they want to see.

So we have to see that or understand that that is a,

with some of the Medicare Advantage plans,

that’s you’re going to be stuck within a parameter there

of certain doctors. Now, I think that gets a little tricky because a lot of doctors are

now opting out. If they’re independent, they’re opting out of Medicare or like myself,

we are not able to accept Medicare. 

PHILLIP: Yeah. So most doctors still accept Medicare.

I mean, most of the people who use healthcare in this country are older. And so the heavy

Healthcare users are the older population. If you’re a doctor or if you’re a hospital,

this is a market that you really sort of need to pay attention to. It’s hard for you not

to do that. What happens is that I find that doctors who are really in demand have the

freedom to sort of go private pay. They tend to deal with a more affluent clientele. They may

look at concierge medicine. I was in a concierge practice for a while, but it still took Medicare.

I mean, because it could augment what it provided and still help its clients get paid for certain

covered services. So even if you’re not a fan of Medicare as a doctor, there are really

strong reasons why you still want to take the program. The real challenge with health care

at this age is really not whether the doctor accepts Medicare, but whether the doctor is

so good you can ever get in for an appointment. Wait times are horrendous in health care all

across the board. It’s not just Medicare. So we have a shortage of health care practitioners

in this country. We have a particular shortage of really good health care practitioners.

This has always been the way it is. If you want to go for the best folks, you’re going

to have to wait in line. The lines that the popular movies are longer, the lines for the

popular doctors are longer. So that’s a problem that really transcends Medicare. So the big

message I think I want to get across to folks who who listen to this is that

I don’t think you can afford not to enroll in Medicare. If you fail to enroll in Medicare because

you say, well, I don’t need, I don’t use much health care. My medicine needs are really modest.

The message I send to people is that your Medicare decisions are based on the future you,

not the present you. And guess what? The future you is going to need health care.

It’s actually true that the healthier people are, the more they use health care in the future,

not the less. And so because healthy people are sort of smart about taking care of themselves,

they see where the lines converge, they see what kind of prevented health care they need,

and they take advantage of that. So it turns out that if you don’t enroll in Medicare when you age

into the program, you can get sucked with really steep late enrollment penalties later in life.

These penalties can be pretty substantial and they don’t go away. They’re with you the rest of

of your life or as long as you’re using a Medicare service.

So the penalties for part B are 10% a year for your premium depending on how many years you’re late in signing up.

So I said the part B premium is about 170 bucks a month.

So you can be paying an extra 17, 18, 20 bucks a month for each year you fail to enroll.

for the rest of your life.

So say it doubles your Part B premium.

If you’re 10 years late, your Part B premium

will be doubled for the rest of your life.

Maybe you can afford that, maybe you can’t,

but you should be aware of it before you decide your decisions.

There’s also a late enrollment penalty

for Part D drug program, not as onerous as for basic Part B,

but it still exists, you need to be aware of it.

My belief is that knowledge is sort of power

and you can make, it’s hard to make good decisions

if you don’t know the full informational impact

of what’s going on here.

And so maybe it’s okay, maybe you don’t wanna get Medicare.

The other issue is people with traditional Medicare

do like the advantage of going to any doctor they want.

Getting a meta gap plan can close those coverage gaps.

However, medigap is not cheap.

So my meta gap, so I’m 78 years old.

I have the normal range of things

that you would think that people need at 78.

My meta gap cost me

26, $2,700 a year now.

It’ll go up a few percentage points.

Well, that’s not free and that’s a big hunk of money

for a lot of folks.

Medicare Advantage plans have their own out-of-pocket ceilings

that protect you from the things

that basic Medicare doesn’t cover.

The out-of-pocket ceilings though have gone up over time.

They can, for people who aren’t low income,

they can sometimes be approaching $8,000, $9,000 a year.

That’s only for services in network.

If you go outside of network,

there can be higher out of pocket ceilings.

But you do get some protection

from catastrophic health expenses,

which of course is one of the things

that insurance is all about.

You wanna protect yourself

from those really life changing financial exposures

where you have a cancer diagnosis, you need surgery,

you need expensive medications.

they can ruin your life financially if you’re not protected.

So people should look at what’s my worst case?

What do I need to protect myself in that worst case situation?

And again, there are lots of great reasons

why people should take advantage

of the kind of healthcare you offer.

And I have friends who are great believers in that.

And I have a friend of mine who literally lives

in the forest in Northern California.

And she uses bark. I mean, she really understands and there’s this is not silly stuff. This is like

There’s there’s great clinical evidence that these products are really

associated with health

Better health outcomes in later life. There’s a reason Native Americans were really healthy

They understand what nature provided them. So I you know

I’m a big believer in this but not an uninformed believer. You have to understand

What what can help you and what can’t?

You know and there are miraculous drug treatments that are helping to cure cancers these days

They really are major improvements in targeted therapies that allow your body to fight cancers

But they’re really expensive. Oh

JANNINE: Oh, of course, of course.

Yes, there’s, there’s a lot of money involved.

So, so I’m guessing, Phillip, if I, if I’m understanding this right and help me, help me to, and in the audience to kind of understand, if you are wanting to see, you know, stay with your same doctor, you want to stay kind of in your choice and in the ability to have a choice, it may be better to have the basic Medicare plans and then have a MediGAP to cover.

or should there be some really big expenses?

But if you’re not particular about your doc,

but you have maybe eye issues,

you’ve got some hearing aids you need to re-up on

and maybe your teeth are not so great,

maybe always having the basic,

but having the advantage plan,

maybe the direction to go in that case.

Would that be two different scenarios, for example?

PHILLIP: Yeah, it’s starting to be two different scenarios

and the priority of the dividing line for you

probably depends on your income levels,

how affluent you are.

It depends on your health needs, as you noted.

It also depends on something that people

people exhibit this all the time,

but don’t acknowledge it,

which is what’s your tolerance for risk?

And in practical terms, I call this

head on the pillow test at night. When you go to sleep at night, what do you worry about?

With original Medicare and a really good Medicare plan, I don’t worry about much in terms of

affording healthcare. I worry about getting sick, but I don’t worry about the financial

consequences of my healthcare needs. Some people don’t have that kind of concern about risk.

So as you said, for people who like their doctors, and this can be a very Medicare

advantage, be a very solid choice. So the interesting thing is, every year during open

enrollment, that’s the period I said has just begun where you get all these messages.

Every year during open enrollment, people who have Medicare have a chance for what I call a doover.

It’s actually pretty important because during open enrollment, if you have original Medicare,

you can switch to Medicare Advantage.

If you have Medicare Advantage, you can opt for original Medicare.

You can opt for a different Medicare Advantage plan.

And your choices are guaranteed to you.

You can’t be denied coverage because of a pre-existing condition.

So the plans have to ensure you unfavorable, sort of what I call underwriting terms.

There’s words for this that have a little asterisk in them in terms of getting financially

chaffed.

And you can’t be so adversely underwritten, which is sort of the buzz phrase.

So what happens?

So say you have Medicare Advantage and you’re concerned that your health needs are getting

more substantial.

Plus, so what do you do?

Well, you call your Gixing Doctors and say, “Are you still going to be in my Medicare Advantage

plan next year?”

You want to make sure if you like your doctors or at least you tolerate them.

As you said, it’s not a big deal for you, adoxidoc,

and then you’re going to want to make sure they’re

still in your plan.

But what if your health care needs are shifting?

And you start to see the lines converging.

And you say, man, I’m going to need some specialists.

I’m not sure who these people are,

whether they’re in my network or not.

Then you just start calling some of these specialists.

And this is a big thing that people have resisted.

People hate to talk to health care professionals.

They hate to talk to insurance companies.

It’s not pleasant duty.

Get over it.

Take care of yourself.

Look out for yourself.

And so, these are free choices

that people get to make every year.

There’s one big asterisk that I need to mention,

which is,

Medigap supplement plans do not offer you

the same free do-overs every year at Medicare plans.

These plans are regulated at the state level.

They do not have to offer you what I call

advantageous underwriting terms when you buy them.

So if you have a Medicare Advantage plan

and you wanna go to original Medicare,

you may face underwriting restrictions

that you should be aware of.

However, this is sort of one of these sort of obvious things

that people don’t think about.

Insurance companies are in business to sell insurance.

They don’t make a lot of money when they don’t sell insurance.

So even though they may put some restrictions on you,

they’re probably gonna sell you a Medigap plan.

It may cost a little bit more,

but medicare.gov, which is where Medicare lives

online has really great tools that help you look at all these plans available where you live.

So you can look at all the Medicare Advantage plans in your zip code. You can look at all the

Part D drug plans in your zip code. You can enter your drug needs in a Medicare tool and

that set of drugs will follow you as you make your decisions, will automatically get programmed

into the various plant choices where you live. You can also look at the metagap plans where you live

and find out which plants are available where you live. The tool will show cost based on what

I’ll call advantageous underwriting. So don’t accept those because you may not be in that boat

if you’re moving from Medicare Advantage back to Ridge or Medicare. So call the plans. Wait it

been on hold for a while, get used to crummy music, playing over the earphone, and just

talk to them.

And they’re real people who work for these plans.

You know, health insurers get a bad rap for many good reasons.

They can be hard to deal with.

They can charge you more.

They can deny you coverage.

All these nasty things you read about in the press, and they’re real problems.

But they’re also real human beings who work there.

They know what they’re doing.

If you’re patient, you can end up talking to people who know what they’re talking about.

Use the SHIP program if you have basic questions and you can find answers to what you need.

You’re going to have to do some work for it.

So what else is new in life, right?

You’re going to have to do some work to get what you need.

JANNINE: Right, right.

No, I mean, it’s definitely they speak in code.

I always talk to folks about CPT codes and ICD-10 codes if we’re talking procedures.

PHILLIP: Absolutely.

JANNINE: You know, speaking, speaking their language and you’re going to get the best answers.

Now, another question I have for you is the non-medical coverage because I hear little

inklings of things that are, that are covered and I know you highlighted on your website in your

book and this is something that I don’t think a lot of people are aware of of different programs

they can take advantage of as well. 

PHILLIP: Understood. So this sort of, I’ll go back to sort of

tutorial mode here. Medicare’s line in the sand over what it covers and what it doesn’t is medical

necessity, right? It used to be pretty clear what that meant. It’s not so clear anymore because

over the years it’s become abundantly clear that there are things that aren’t viewed as medically

necessary that are strongly associated with your health.

So the rules for these Medicare Advantage plans gave them the flexibility to cover things

like health club memberships and routine dental vision and hearing.

coverage of those three things wasn’t viewed as medically necessary by Medicare.

Well, dot, they are medically necessary.

It’s very clear.

So these Medicare Advantage plans have also moved into other so-called non-medical benefits,

especially for lowering compute.

So people on Medicaid, for example, are among the most medically needy people in the country.

They are the sickest.

They live in substandard housing.

They can’t afford healthy food.

Their health suffers because they’re lacking some of these fundamentals that most of us

take for granted, and which Medicare takes for granted.

Medicare assumes that you can pay for decent food.

care assumes that you live in decent housing. So those things aren’t covered by insurance

and for people of means they probably shouldn’t be covered by insurance. But for people who can’t

afford it, helping them with food needs is a medical benefit. Helping them with decent housing,

helping them avoid unsafe housing, whether it’s living conditions,

Berman, you name it, not insufficient heating and cooling.

That’s a medical necessity for them.

So these Medicare Advantage plans have sort of led the way in offering some of these non-medical

benefits.

Now let me take a step back and say, they’re not doing it either.

Goodness, they’re hard.

They’re doing it to make money.

they didn’t find a way to make this profitable, they couldn’t afford to offer these non-medical

benefits. So what’s happened over the sort of 10 years or so period when we’ve been tippy

towing into these non-medical benefits is that the insurance industry has been figuring

out which of these make money. Right? And they’ve been doing it mostly with low-income populations

because these are people who are the heaviest needs medically speaking and for whom

these traditionally non-medical benefits can provide the greatest payback. What’s payback

mean? It means that these people get healthier and they don’t have to use medical services as much.

So their health benefits pay for these so-called non-medical benefits.

So let me shift back to traditional Medicare, which doesn’t offer any of these things.

Well, the learnings from Medicare Advantage plans have started to filter back into

and the decisions made by Medicare regulators.

And there are efforts underway

to start to create mechanisms where traditional Medicare

can offer some of these kinds of benefits as well.

This is a very slow process.

It’s being able, and the later chapters

in my book get into this,

and this is probably way too in the weeds

for our discussion today.

but there are organizations of doctors and hospitals

that are being formed called accountable care organizations.

Accountable care organization are potentially

a game changer for healthcare or the Medicare population

because they can start to have the same flexibility

or the benefits they offer as Medicare Advantage plans.

Accountable care organizations

are only available in traditional Medicare.

They are sort of the flip-flop of the benefits

that Medicare Advantage plans have.

So potentially, countable care organizations

can start to do the same things with traditional Medicare

that Medicare Advantage plans have done.

But they have to do the same heavy lifting.

They’ve got to figure out what are the sweet spots here?

What non-medical benefits pay for themselves?

And how do you incent accountable care organizations

to wanna offer these benefits?

So it turns out that one of the most boring things

in healthcare is developing win-win payment mechanisms.

You know this as a doctor.

You know, you’re not gonna offer this stuff for free.

So what works here?

Well, this is not easy stuff.

This is trial and error.

And although Medicare doesn’t call it this,

they basically throw stuff on the wall all the time

and test it.

What stuff sticks on the wall, what stuff doesn’t,

what stuff works, what stuff.

And this is a laborious trial and error process.

But over time, excuse me,

it’ll lead to some conclusions about

what do we have to do to provide

what I call win-win situations

so that healthcare providers get paid off our service,

that health insurers make money offering this service,

and that patients get the care they need.

So is this, the outcome of this is in no way certain,

but the Medicare regulators,

the Centers for Medicare and Medicaid Services,

which is the regulatory overseer of Medicare,

has issued a position that everybody with traditional Medicare will be in an

accountable care organization in six years. This is pretty, this is like a

moonshot for basic for traditional Medicare. It turns out that a lot of

people are already in one of these and they have no idea they’re in it. And the

doctors who are technically offering an accountable care organization are still

sort of playing with what that means. They’re doing all this trial and error

stuff. They’re trying to figure out, but what you’re seeing is that these non

medical benefits, which now go under the trade name of social determinants of

health. That’s a buzz phrase you may have seen. The social determinants of health,

you will see that if you’re a patient and you’re in one of these ACOs, even though

you don’t need it. When you go in for a doctor’s appointment, your doctor may say,

“Do you feel safe at home?” He may ask you social questions that they never would have asked you

before, and you sort of may say, “Well, why do I get to ask these questions?” Well, that’s why

you’re getting asked these questions because these guys are sort of tippy towing around of

trying to find out from their patient population of things the patients are experiencing that

may be things that they can help them with down the road

and things that they need to know more about

and things that Medicare is asking them to find out

as part of this movement into accountable care organization.

This is all things that in theory,

patients should know,

consumers should know this stuff upfront,

but this is not things that Medicare is very good

explaining and telling you about.

So they’re so tippy towing backwards in the future,

if you will, and patients are sort of saying,

well, I’m not sure I understand what’s going on.

And so the book tries to say,

well, this is sort of what’s going on.

And so the book finds examples

of these accountable care organizations actually get it

and have been offering these really interesting ranges

of services around the country.

And so while much of what we know about health insurance

Medicare is based on what I call horror stories of when the system doesn’t work.

My book is based on the premise that how can you make smart decisions about health care

unless you know what successful health care looks like? How can you become an informed consumer

unless you know what to ask about? How do you buy a car unless you know how a good car works?

you can’t. So the book tries to find examples of practitioners who basically have sort of been

early people who’ve cracked the code, so to speak, and they have figured out ways to make these

programs work. And so the book explains to you how they do what they do and why you might want to

look at that yourself in the future. 

JANNINE: That’s really a smart way to look at things because, of course,

on my end, I hear from patients, you know, all the negative, all the horror stories, all of the

of things that hang us up.

And of course on the practitioner side of things

in my friends, we also, I also hear the all the paperwork

that comes with taking Medicare and yes,

the accountability questions are always hot topics

amongst the community.

PHILLIP: They are, but just as an aside, you know,

when you get into one of these really highly functioning

and they’re called ACOs, those are the initials

for accountable care organization,

It turns out that they work with medical billing companies.

They work with people who do the heavy paperwork lifting.

The doctors sort of don’t have to do that anymore.

The system will help compensate the practice

for those expenses that are the ones you really love.

I know everybody loves doing this stuff.

And so the programs that really work well

provide assistance to the doctors.

The patients are provided with social workers

who can help give them counseling.

They’re provided with nutritionists

who can help do them things.

And the ACOs that are working are slowly figuring out

how to pay for these things.

So on the upside, it’s pretty exciting.

On the downside, we have a long, long way to go.

we’re really in the early years.

And this is true not just in Medicare,

it’s true throughout healthcare,

trying to figure out a combination

of what would be called traditional insurance

and non-traditional benefits

that help keep people healthy,

help make them healthy when they get sick,

and are really sort of holistic healthcare,

which is what you’re all about,

but which the system doesn’t support.

So in an ideal world, everyone will be you in the future, right?

They’ll be able to offer people a form of health care

that’s based on their needs and that provides them benefits

that the system will fund.

Again, is this sort of utopia?

Well, yeah, in a sense it is.

And it’s something you worked toward and you struggled for.

I’m just– when I have my good days,

I’m saying, well, this is pretty exciting.

I have my bad days, we’re never gonna get here.

It’s a slog, it’s really hard work to get to this point.

JANNINE: Well, and I think at the end of the day,

like you had said before, you have to put in your own effort

and you have to put in your own effort

to learn about the Medicare system,

but you also have to put in your own effort

to learn about how the system can work for you.

PHILLIP: And I think, yeah, and I think one of the big issues,

and this is goes way beyond healthcare,

I’ve come to believe that life is a contact sport.

You know, you don’t just go in, watch your own life like you’re sitting at a football

game and it’s somebody else running on the field.

No, you have to get in the game.

You have to participate.

It’s certainly true in healthcare.

But you know, again, I think it’s true across life.

And I think healthcare was sort of sold to us historically as a passive process.

Your doctor will take care of you.

Your hospital has your best interests at heart.

Dr. Wellby is going to come to your house and make you feel all better. Dr. Wellby, for those who

don’t know, was a staple in 1950s and 60s television. We don’t live in Dr. Wellby land anymore. So

you got to get in and look out for yourself. 

JANNINE: Absolutely. Absolutely. Which is where your book

comes in, where the website comes in, and all the information that you have. I mean, I was

loving just looking at get yours. You get what’s yours.org guys forward slash Medicare there to get to

the specific because you have social security on there. You have all of the other topics on your

website there. And then of course your book which it looks like available on anywhere you could

possibly get– 

PHILLIP:  It is. You know I have a major publishing house Simon Schuster. There’s a lots

of problems with big publishing houses and that my book has to be ready way way ahead of time.

But the benefit is when it’s released, it’s available all over the place.

The other thing I would sort of alert people to is,

I do a newsletter called Aging in America.

It’s available on a publishing platform called Substack,

which thousands and thousands of writers and professionals are now using.

You can access a lot of this content at that newsletter as well.

It’s where I keep up with new developments in this space.

So it’s where I do on my open enrollment updates and all things like that.

JANNINE: Awesome.

The stuff that I mean, this is, this is what people are looking for, especially

the folks who just feel lost in general, which I think is a very high percentage,

at least from what I’ve seen in, in my population.

So Phillip, great stuff you’re doing here.

And definitely guys, we want to remind you, get what’s yours for Medicare.

It’s revised.

It’s updated since 2016’s release and the getwhatsyours.org website is also going to have all kinds of good information there.

And then of course, sub stack anywhere else folks can find you anywhere else they can get glean more information.

PHILLIP: No, that’s where I’m really appearing these days.

I get quoted occasionally as an expert and that’s fine.

But no, I think those are the standard places that people can go.

And I do answer emails.

It’s one of my life jobs is to answer people’s questions.

And as you get a little bit older,

that ends up being a form of income in itself.

I get paid by helping people turn on light bulbs in their heads.

And it’s very rewarding for me.

And so I look forward to that stuff.

And I have no interest in stopping.

And this is something I enjoy doing.

and I appreciate your interest and you ask great questions.

And again, if you get questions from people,

you can forward them to me.

And my email is available on my website

and I don’t shy away from answering questions.

JANNINE: Love it, love it.

Yes, this is something we definitely need the stay in ages

of place to bring some of the tough questions that come out

and what to do.

And right now is go time to figure out

what we’re going to do for the next year.

PHILLIP: Yeah, it is.

One last piece of advice.

JANNINE: Yeah.

PHILLIP: This can be overwhelming when it comes at you.

Take a step back, break it down into pieces, which

is how I do my writing.

Break it down into steps and pieces,

and then get answers to pieces.

And after a while, this huge informational mountain

that seems too high to climb becomes more of a hill

than a mountain.

And then it becomes something you’ve been walk

and something you understand.

and you actually can see to the other side of the hill and sort of get a view of what it’s going to look like.

So don’t panic and just take your time.

Take deep breathing is always helpful.

JANNINE: Love it. Love it.

Thanks again, Philip, for coming on.

I appreciate all your advice.

This has been a great informative interview.

Thank you.

PHILLIP: You’re welcome.

Take care.

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