If you’ve ever received a medical bill (I imagine that’s everyone!), you know just how confusing healthcare insurance can be. For Medicare beneficiaries, it’s tough enough to remember terms like “deductible,” “co-insurance,” and “enrollment period”, let alone keep track of all of their plans’ details and benefits. That’s where our Navigator Team comes in.

Our Navigator Team proactively checks in with clients after they enroll in a plan through one of our independent Spark agents. They also act as the agent’s personal assistant by fielding questions from clients about everything from Medicare bills to Medicaid waivers. In general, the most common support categories include:

• How to use benefits in a Medicare Advantage plan
• How to find an in-network provider and/or service
• How to understand a Medical bill and resolve a discrepancy

In this post, we’ll break down actual examples of the work that our Navigator Team does every day in support of our agents and their clients. We’ll focus on the most frequent experiences, and save the more complicated ones for a follow-up post.

Case 1: Helping a member use a plan’s over-the-counter benefit

To stay competitive, insurance companies are expanding their Medicare Advantage plans to include “ancillary” benefits that aren’t covered by Original Medicare. More than 75% of plans now offer some dental, vision, and hearing benefits, and are quickly adding meal, transportation, and in-home support benefits (see the benefits breakdown below).

One of the most popular benefits is called the “over-the-counter” (OTC) benefit, which enables beneficiaries to purchase up to a fixed amount of health-related products from a pharmacy. For example, a plan might offer a $75 allowance every quarter from an online OTC catalog. The benefit varies considerably across plans, with different (a) allowances (b) benefit periods (c) reimbursement methods (d) shipping times and (e) quantity limits. These details can cause a lot of disappointment for beneficiaries when they walk into a store and try ordering an item from the OTC catalog, only to discover they’re disqualified for one reason or another!

Consequently, our Navigators help members set up their over-the-counter orders. In some cases, our Navigator will walk the client through the self-serve carrier portal. But often our Navigator will share the pdf version of the catalog via email so that the client can print a physical version and place an order by phone. Because allowances typically renew every quarter or every month (and don’t carry over!), we’ll also remind clients to place their orders in time.

Case 2: Helping a client find an in-network nursing facility

Medicare Advantage plans that are “Health Maintenance Organizations” (HMOs) restrict beneficiaries to visiting specific facilities and doctors. “Preferred Provider Organizations” (PPOs) are less restrictive but incent beneficiaries to go to a lower-cost “preferred provider.” One HMO client who was seeking to transition into a skilled nursing facility called our Navigator Team since she was unable to reach the facility that was recommended by her doctor. In addition to contacting that particular facility, we compiled a list of alternatives based on the estimated out-of-pocket cost, location, and quality. The client selected one of the facilities we recommended, and then requested we investigate longer-term assisted living facility options.

After performing these tasks, our Navigator Team shared the information with the client’s independent Medicare agent and asked the agent to double check that the client was on the right plan based on her anticipated health needs and expected cost. In this case, we saved the client time and the headache of navigating all their options.

Case 3: Clarifying a billing issue

Every year, Medicare Advantage and Prescription Drug Plans will notify beneficiaries about plan changes through a “Annual Notice of Change Letter”. Oftentimes the drug formulary and pricing will change, but the beneficiary won’t actually be aware of it until they start receiving bills the following year.

One client called our Navigator Team about a medication that he thought suddenly jumped up in price, from approximately $50 to $100 per month. He had asked his pharmacy about it, but they told him they were just following guidance from the insurance plan. Our Navigator reviewed all the medication information, confirming the drug tier, deductible, and coverage limit. After double checking with the insurance company, our Navigator determined that he was not using an “in-network” pharmacy like he had been in the past, causing the price increase. He was also in his “coverage gap”, which causes the price to fluctuate during the year depending on how much has been spent out-of-pocket already.

Our Navigator explained this to the client, and identified in-network pharmacies that he could use instead to reduce the cost.

Ultimately, our Navigators and Spark agents act as an extra level of support for clients who would otherwise fend for themselves with endless insurance company phone trees, confusing jargon, and “he-said she-said” between providers, payers and pharmacies. The examples shared above are the most common types of questions that our Navigators resolve, but in a future post we’ll share more cases that reflect the incredible complexity in the healthcare system!

If you’re interested in joining our team please find open roles here, and if you’re an agent or agency looking to add these capabilities, get in touch at james@sparkadvisors.com.