Senior Health Insurance with Jonathan Macavoy

Confused about Medicare, Advantage Plans, or Supplements? In our premiere episode of Caring Table Podcast, I sit down with Jonathan Macavoy of Members 1st Insurance Services, a health-insurance professional with over 20 years of experience, to break down everything seniors and their families need to know for the 2025 enrollment year.

Jonathan explains the difference between Medicare Supplements and Medicare Advantage Plans, why annual plan reviews are essential, recent plan cancellations, prescription drug tier changes, and what rising supplemental premiums mean for seniors. He also shares expert guidance on enrollment windows, pre-existing conditions, out-of-network costs, drug deductibles, and how to prepare before turning 65.

Whether you're a current Medicare recipient, helping a parent navigate their options, or planning ahead for your own retirement, this episode offers clear, practical, and timely insights to help you make confident coverage decisions.

Topics Covered

• Medicare Supplements vs. Advantage Plans explained
• 2025 enrollment changes you need to know
• What plan cancellations mean for seniors
• Prescription drug tiers, deductibles, and out-of-pocket maximums
• Why annual plan reviews can save you money
• How pre-existing conditions affect your options
• When to start planning as you approach age 65

Interested in learning more? Contact Jonathan Macavoy at: 717-319-7332 or email him at Jonathan.Macavoy@M1stInsurance.org.

Episode Sponsored by:

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Our Mission encourages vibrant, healthy, and productive living through stories about people we meet and serve.

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Transcript

00:00:01:15 - 00:00:37:15

Welcome to Caring Table. I am Dianne Frana, your host. Having real conversations about real topics shaping lives in the Lehigh Valley and beyond. I like to introduce our guest today, Jonathan Macavoy, member, First Insurance Services. His experience is 20 years in the health insurance industry. Personal and professional connection to senior community and Medicare products. Welcome, John. We're here to find out about Medicare and Medicare supplements.

00:00:37:16 - 00:00:57:00

Tell me, what is the purpose and reason to have a Medicare supplement? Well, the key factor, looking at either option is what's going to fit you as an individual. When becoming Medicare eligible, you have two options. Kind of a fork in the road to go the path of the supplement or the path of the advantage plan.

00:00:57:01 - 00:01:24:06

Medicare itself only covers 80% A and B. The purpose of the supplement is to pick up the 20% difference that Medicare does not pay. So with that explaining, there's an open enrollment period from December 15, October 15th through December 7th through December 7th. Yes. Every year the same time. Yes. It's an annual enrollment period. So what is the purpose of this enrollment period?

00:01:24:07 - 00:01:50:06

So this is to review any plan changes, make sure you're comfortable into the next year. Every year you will receive an annual notice of change. You want to make sure that your benefits are fitting your needs and any maybe new or upcoming possible medical issues. So also, people may be one year with one insurance plan and the supplement and they can change.

00:01:50:06 - 00:02:14:03

They always have that option to change during the open room window. That's exactly what it's here for. When you select a Medicare advantage or supplement, it's not necessarily for life. Just as any other insurance product. It's always good to review annually. Make sure your coverage is fully being met and that you're in the most beneficial plan for the following year.

00:02:14:06 - 00:02:40:00

So what has recently there has been several insurance plans that have been canceled. Plans? Yes. A lot of things that I've seen personally in the market, kind of to enriched in the benefit, which had too much enrollment by the members. And since kind of stretched themselves a little thin, hence some of the more enriched enrolled plans being canceled for the following year.

00:02:40:03 - 00:03:09:18

That's why it's so important to do these reviews not only benefit changes, but plan terminations and new plans coming up as well, so they can start looking sooner than the enrollment period. No, that is actually when the time to start is. So the new plans, you're not even rolled out until October 1st being able to be discussed. October 15th is the start of being able to be enrolled into for a January 1st effective date.

00:03:09:18 - 00:03:33:06

So how can you help the people out there? How I can help, in many ways here, certainly review what you currently have, your costs, your benefits, and any changes, especially if your cans plan is being canceled or your premium has seen a drastic increase. Now, if your coverage has certainly met all your needs. I'm not here to sell.

00:03:33:12 - 00:03:58:18

I'm here to provide information. And if you're in the plan that fits you for the following year, I'm going to say, keep doing what you're doing. Give me a call next year and we'll review again. So how would this affect the current generation and the issues that they are facing with Medicare and Medicare supplements right now? The trend we're seeing is on the supplemental plans.

00:03:58:18 - 00:04:24:01

They are increasing cost every year more and more. So, when you're up into your 80s upwards, you may be in the three, $400 a month premium. We do see somewhat of that. Moving over to the advantage plan side, where you do not have such a high premium, but you may pay per service. Those are the things that we look at on the dollar comparison to make sense leading into the next year.

00:04:24:03 - 00:04:50:01

So in the advantage plan I have a question. If they have preexisting conditions, that's one of the great things, with advantage plans, there's no preexisting condition clauses. If working going from supplement to supplement, we may have underwriting which is answering the health questions that come up, which make it a little more difficult to change from supplement to supplement.

00:04:50:03 - 00:05:37:06

So someone with, say, a-fib. Is that a situation that it would be difficult or depending on the carrier, they are questions that have to be asked. If answered yes to any one of the medical questions, it does stop the application and you would either continue with the supplement you have or looking at an advantage option. Do you have a suggestion for someone say that is entering between 80 and 90 and they're a cancer survivor or, you know, COPD and each individual that sits in front of me, we start the slate clean and review what they have currently to what we might be able to fit next year.

00:05:37:07 - 00:06:06:12

I can't say for a broad spectrum because the premiums vary so much by carrier and each individual having that different carrier would be determining what we're looking out against as a comparison. So we're talking about the carriers. Do they have an option to drop you the carriers? It's an involuntary termination. As we did touch on, we have seen some of the advantage plans themselves, no longer continuing into the next year.

00:06:06:15 - 00:06:34:19

That would have been, your notification during the start of the season and your Norman period, making you aware that it is necessary to make a choice for the following year. So not necessarily. We have to compare against what you have. We have to compare the new plans to make sure you have coverage for the following year. Interesting to me, I was just wondering, and it's a good thing, though, that no preexisting conditions.

00:06:34:21 - 00:07:04:06

Correct. That with the advantage plan is the nice thing and why we do these reviews every year, with the supplemental side, unless looking to potentially move into an advantage plan. A plan letter is a plan letter is a plan letter. The only difference between a Medicare supplement carrier? The carrier is the cost. So when you say a plan letter, are you referring to Medicare AB.

00:07:04:09 - 00:07:28:09

So they do like to make it, about as clear as mud. Medicare A, B, C, and D are these standard letters for the Medicare products, but they also use letters for the supplemental plans as well. Those can go g an f determining on plan benefit structure and availability. So you need to know your alphabet then.

00:07:28:12 - 00:07:56:07

Very much so. Yes. So all right moving on. So for future generations. So say children of our seniors now and even their children or the one, you know, 30, 40 years planning ahead. You know, we don't nobody knows what the future is. But they do have to be aware of what is out there and what they may need as well.

00:07:56:09 - 00:08:28:12

Very much so. We are kind of subject to year to year changes. So I'm myself be 42 and a week. I could not say what's going to be available come 65. With the way that the benefits do change from, from year to year, that's something that when reaching that mark, good time to reach out to me about three, three months before your 65th is the best way I can put that and only start looking three months before.

00:08:28:13 - 00:09:07:09

And why? Well, three months before your 65th birthday starts, your eligibility to even enroll into the Medicare AB program. We have its, seventh month window. It's three months before the month of your 65th in three months after that, we would be able to start the Medicare process and then in turn, see where your personal situation may be, whether you are continuing to work, want to look at benefits outside of an employer plan, or maybe have a significant other that is has their own benefit structure as well and may be affected by that.

00:09:07:12 - 00:09:34:10

So it's not so much that they they just need to be aware of when to start looking, but they don't know the aware what's out there because everything changes from year to year on the on the ancillary benefits, to Medicare. Yes. The A and B of Medicare is the initial step to look beyond anything else. Because without Medicare A and B, you're not eligible for a supplement or a advantage plan.

00:09:34:12 - 00:10:04:10

And then for the seniors that are on Medicare currently from year to year, they need to be aware of the changes that are occurring as well and what the changes with the different supplements out there. Well, again, the supplements don't change just the dollar amount. So be aware of what your plan is going to be increasing each year because that will happen and that comes out the changes in the cost of the supplements determined based on the year, the month when you enroll in them.

00:10:04:10 - 00:11:07:06

It's not a set dollar change on the calendar basis, whereas the advantage plans may change, increase or decrease their premiums. But they're set and goes January to December 31st. So can any of the companies insurance companies? Can they cancel their plan mid-year from the time frame till open enrollment? If the plan or the insurance carrier were to go out of business or under, that would be potentially a reason.

00:11:07:06 - 00:11:31:19

But they cannot just drop someone mid-year. So they do have that security. There. Yes. So no. And not for any health reasons whatsoever either. So what happens if they do go out of business through that year? Then what? Just like with what we're seeing, with some of the carriers now, it is an involuntary dis enrollment, which would allow you to make the change into a new plan option.

00:11:31:19 - 00:11:58:15

Yes. Other and not waiting for the open enrollment. Correct. Which is always October 15th to December 7th. Correct. And any changes made during that window would be affected January 1st. So what are some key insights that you would like to recap through this conversation for the seniors to take away and be aware of with the Medicare, the supplements, the advantage plans?

00:11:58:16 - 00:12:24:22

The biggest thing I would say is please look to have your benefits reviewed. We certainly see and I do hear a lot that I've been on the same plan since I've started on Medicare, and I'm good. Well, we don't know if we're good, if we don't look at the other options that are available. We certainly want to give you the most benefit for the least amount of cost, and make sure that your needs are being met at the start of beginning of each year.

00:12:25:00 - 00:12:47:13

So, John, looking at the advantage plan, what are the key benefits that we like to share with our listeners and what they need to be aware of? The main thing is making sure that you really have full coverage. We want to make sure that the physicians, doctors, hospitals are all within the network of coverage for the plan.

00:12:47:15 - 00:13:22:00

If going out of the network, see where and what that cost may be, some of the carriers have a 40% plus minus. Out of network costs, whereas others, it's the same cost as being in network. They do vary from plan to plan and carrier to carrier. Some of the other things are, if you're more interested in the additional benefits that the advantage plans provide, such as dental, vision, hearing, along with the prescription coverage that may come with that particular plan as well.

00:13:22:03 - 00:13:49:10

So what is the changes in the prescription plan? That is a big thing that we do want to always take. Time to look at. And almost as a starting point, if anyone is taking maintenance medications, for next year, the maximum amount of pocket has been increased to $2,100, with a lot of the carriers implementing a deductible, typically on tier three and higher.

00:13:49:12 - 00:14:21:21

Now these do vary again from plan to plan, and that is whether it is a advantage plan prescription or a standalone drug plan. So what's a what do you mean by tier. As you said tier three. So what is so all of the prescription plans tier there for the drugs being prescribed. Typically we do see a 1 to 5 potentially 1 to 6 tier program, whereas the first two being preferred generic tier three typically being your brand preferred brand name.

00:14:22:00 - 00:15:01:21

We have Non-preferred and then they get into the specialty drugs. Each level in tier has a different copay or set dollar amount co-insurance. So generic versus name brand. To my knowledge, the doctor has to prove that a generic can supplement the name brand. Am I correct? It could replace. I believe you're getting to what they call step therapy, where typically if we do have a brand name medication out there with generics available, the generics would need to be tried first if any adverse or counter reactions to them.

00:15:02:00 - 00:15:27:09

You may take the next step up to that next tier to get something that does help with no adverse side effects. Okay, well thank you. That's important to understand that. And note be aware of the difference and what is happening with the prescription plan. Yes, very much so because based off of tier and deductible of plan that will forecast your out of pocket cost for your prescriptions and drugs next year.

00:15:27:12 - 00:15:56:06

So what is the current 2000? Is the maximum out of pocket okay for the 2025 plan year okay. Once hitting that max out of pocket. Then the plan comes in paying 100% of your drug cost and we're there was there always a deductible? There was not. We've seen this, some plans may have this year. The drug deductible is well, I'm sorry, this AEP into next year is max at $615.

00:15:56:09 - 00:16:19:18

Some plans do have this, some do not. It depends. Carrier by carrier and products by product. So cost of Medicare. So what should someone be expecting to be paying for their Medicare. So if you are the average individual Medicare eligible and had put your 40 quarters in your part, A comes to you at no cost at 65.

00:16:19:18 - 00:16:47:21

Part B for next year does come in at a premium of $206.50. Now that is based off of an income tier. This is income based. So depending on what your taxable income is for the following two years and two years back determines your part B premium for the year going in. No. Do you want me okay. Yes I want you to repeat that please.

00:16:48:00 - 00:17:19:19

So the part B cost standard is $206.50. It is determined individually by your taxable income two years back. So for 2026 if you were in a higher income tax bracket, the in 2024 that would be determining your cost. So they go back to your back income. So then if you're less yes. Which we do see typically when you retire you do make less money.

00:17:19:21 - 00:17:47:16

There is an option that you can appeal that increase in your cost and explain obviously due to less making less income now being retired to see if you can be reduced to the standard 206 50. So what are their chances of the appeal? I am not on the determining side. I would say the more information you can provide, the more they would be able to review to have a potentially positive outcome.

00:17:47:18 - 00:18:18:00

So my next question is what's the difference between the advantage plan and to me, the previous two supplement Medicare supplements out there. So with your advantage plan to supplement typically the advantage plan has copays per service. So think pay at time of use with the supplemental side. Typically as long as Medicare approves payment, the supplement comes in paying the difference after.

00:18:18:00 - 00:18:44:09

If a deductible needs satisfied. But they're following the Medicare allowed charge and the benefit to an advantage plan. There's pros and cons of both sides. With the supplement, you're paying a higher premium. Whether you use the benefit or not, your premium is constant. On the advantage plan side, typically you're paying a lower premium but paying per service.

00:18:44:09 - 00:19:06:21

So if not necessarily utilizing the benefit, you're not paying per service. Those cost analysis we do take into effect on the one on one, based off of what your premium is for your supplement compared to the plan that we're looking at that may fit for the advantage plan. So it's each either advantage or supplement depends on the individual and their care needs.

00:19:06:21 - 00:19:51:18

Their care needs, their region, their physicians, the network, the drug cost. It's not just looking at if they offer additional benefit or potentially a, what they refer to as a part B give back, which may reduce that part B premium. Typically when that comes into play, you may see an offset of benefit costs. So it is important for everybody during the open enrollment period to get as much information as they can and review their current Medicare supplement or advantage plan, because the information changing and they need to be aware of the difference and what is available out there.

00:19:51:19 - 00:20:24:12

Very much so. If your new plan now, does not work with your current network of doctors, if the co-pays are increasing or decreasing, if the added dollar benefits have been reduced, all of these things are taken into account when looking at plans to make a change for the next year, or stay where you may be. So the advice to the seniors is to find someone like yourself who is a broker that can help them.

00:20:24:15 - 00:20:53:07

It does not hurt having a plan review and it does not cost anything either. If you are having your benefits fully met and it is a plan that fits all of your needs, then someone like myself would say, keep doing what you're doing and roll into the new year. Continuing. If we have something that is more suitable and has more options and cost saving benefits, then we may look at that to make the change.

00:20:53:09 - 00:21:30:07

And your contact information is I can be reached my phone number (717) 319-7332. And my email is Jonathan.Macavoy@M1stInsurance.org. Well, thank you John for being on our first episode. Our pilot episode. I appreciate it. I feel this is important information for the seniors to know and their families as well, to help them make the right decision and what works best.

00:21:30:07 - 00:22:00:15

And for them to reach out to people like yourself, you and others to get the correct information. Very much so. This does not cost anything, and it could significantly impact your benefits. Not reviewing or plan changing for us all in year. So today's key takeaways are just to review what plans are available against your current coverage. You certainly don't want to be left out in the cold, and certainly want to be getting the most out of the plan available in your area.

00:22:00:16 - 00:22:18:13

If anyone listening has any questions or input, please reach out to us. Listen to our podcast Caring Table on YouTube and all other major podcast platforms. Thank you for listening. Talk to you next time.