Patrice King Brown: Whether you’re new to Medicare, exploring your options, or just want keep up with the latest in Medicare news, we've got you covered.
Stacy Smith: No fluff. No jargon. Just real conversations to help you navigate Medicare with confidence. I’m Stacy Smith.
Patrice King Brown: And I’m Patrice King Brown. Welcome to Medicare for the Record brought to you by UPMC for Life.
Patrice King Brown: Hi, and welcome back to “Medicare for the Record.” In today’s episode, we’re going to take a look at the best way to shop for a Medicare Advantage plan. And joining us we have Lance O’Brien. Lance is the Chief Executive Officer at MediConnect; that’s a licensed brokerage agency in southwestern Pennsylvania. And Lance is going to share some of the most important things that you should know while you are looking to choose a Medicare Advantage plan. First of all, welcome Lance. Good to have you with us today. How long have you been helping people with Medicare and how did you get involved in it?
Lance O’Brien: Sure. So thank you for having me today, excited to talk about Medicare all the time. I actually first got started and involved in it when my mom passed away, unfortunately. She didn’t understand her health coverage and she wasn’t comfortable with it and it caused her not to use it in a time when she really needed it. And that kind of sparked a passion in me, as you could imagine. So I started down the journey of really helping people—educate them, help them understand how it works. And that was about 10 years ago and I’ve learned a lot and I’ve been able to pass a lot of that knowledge on. So very exciting.
Patrice King Brown: So in the last few episodes, we’ve talked about a lot of things. We’ve talked about some of the larger changes that were happening, but Stacy, you had some items for him as well today.
Stacy Smith: Yeah. It’s interesting you talk about your mother like that because Medicare can be confusing. And what we’re trying to do with this podcast is help people understand—especially coming into the new year of enrollment, how they can choose a particular kind of Medicare Advantage plan. So if you are in that age group, you’re looking to choose a Medicare Advantage plan, what should you consider? What are the things you should be looking at?
Lance O’Brien: Yeah, I really think that there’s a number of factors, right, and it’s, “where to start?” And I think where most people start is, ”What’s this going to cost me?” And when they ask that question, a lot of times they’re thinking about the premium because that’s what they notice the most. How much is this going to cost me every single month? What they don’t think about is all the additional costs, like does my plan have a deductible? What is my co-insurance or my copays? What about a max out-of-pocket? Is there a ceiling? So when we talk about cost as it relates to Medicare, the premium is what jumps out right, but it is really all those other factors that the individual should consider as well.
Stacy Smith: Such as if you have a hospital stay coming up, some plans will pay more, some plans will pay less?
Lance O’Brien: Absolutely. I mean, there’s almost 70 plans to choose from in our area. So the question would be, does your plan have a per day stay where they pay a fee every day or is it a per stay, a fee for the whole time? So there’s a lot of factors that go into it, but it’s not just the premium, it is those other options that are really important.
Patrice King Brown: You mentioned 70 different plans. I mean, that’s so confusing. This can definitely be overwhelming. I know that it can be. So how can people even begin the process of determining and comparing the options so they know which one works for them?
Lance O’Brien: Yeah, and I think that’s really the rub, honestly, is when we don’t know what to do, that’s when we kind of push away from the table. And think about it this way— when they were in their working years, they had an HR department that did all the homework for them. When they go to Medicare, they don’t necessarily have that. And I think what’s going to be super important for someone looking this year is finding a trusted resource, people that they can really help walk them through that process.
Patrice King Brown: What are some of the common questions that you are asked in helping somebody put this all together and figure it out?
Lance O’Brien: Yes, so it’s different depending on where they are in the journey. And what I mean by that is if they’re new to Medicare, a lot of the questions are, “Do I have to sign up for Medicare right now?” And it’s actually really tied to another question, which is they hear about these penalties and they’re like, “I can be penalized for Medicare. I don’t want to make a mistake.” So a lot of times if they’re new to Medicare, it’s around do I really need to do this and am I going to get penalized? If they already have Medicare, honestly, the most common question we get is, “What’s the best plan?” And the answer to that is there is no best plan. That’s really a part of what we’re talking about today, is what journey do you walk through to identify what’s the right coverage for you? Because no best plan really exists.
Stacy Smith: Does Medicare Advantage take care of the Part B of Medicare?
Lance O’Brien: So that’s a great question. It’s actually a lot to unpack. So a Medicare Advantage plan actually has to cover everything that Parts A and B covers. So yes, it kind of picks up or comes in where Part B was, but you’re not actually on A and B anymore. The Medicare Advantage plan replaces Original Medicare, so you’re getting your coverage through the private insurance company. So they are covering the Part B services, but not technically as Original Medicare.
Stacy Smith: Well, one of the interesting things I have found about Medicare Advantage, when you take a look at it, are some of the benefits that are being offered by these different plans. Can you talk about that a little bit?
Lance O’Brien: Yeah, so again, we think health insurance, the first thing we think is medical benefits. So Part A covers inpatient services. Part B covers outpatient services. So when someone does select a Medicare Advantage plan, they are getting those inpatient and outpatient services, right. But the advantage or one of the things I think is really a plus when it comes to Medicare Advantage is the extra benefits, which you just alluded to Stacy. So they can get dental, vision, hearing, over-the-counter, what is that? They can get an allowance to actually purchase vitamins and other things of that nature. Some plans provide transportation. The thought process behind Medicare Advantage when it was initially introduced was to make it easier for people to access their health care. So, provide them a way to get to the doctors, provide them vitamins—which will keep them healthier. That’s a lot of what goes behind some of the thinking with Medicare Advantage.
Stacy Smith: Now we have different plans, as you pointed out. If you’re looking at trying to figure out which plan, does it make a difference whether your doctor is in a network? I mean, are these all based on networks?
Lance O’Brien: Yeah, so when you go into a Medicare Advantage plan, you’re actually leaving Original Medicare. So Medicare is no longer your network because when Medicare is your network, you can go to any doctor or hospital that accepts Medicare. When you go to an Advantage plan, now you’re entering into a network. Usually it’s an HMO, Health Maintenance Organization, or a PPO, Preferred Provider Organization. And based on which type of plan you choose, that actually dictates some of your access. And it is very, very important to make sure that when you’re selecting an Advantage plan that you have the network access that you want.
Patrice King Brown: So that will give you your providers?
Lance O’Brien: Yes. So again, what we do or what happens when someone’s looking to select one of these plans is they’ll want to check all their doctors to make sure that they’re in-network. Because if they go out-of-network, there will be or could be additional costs. The only time that wouldn’t happen is if they’re in an emergency situation. Example, say I live here, I get my Advantage plan here, but I’m in—I don’t know, Texas, we’ll pick Texas today. So I’m there, I have an accident, emergency, I go. They’re probably not in-network, but I’m covered with the Advantage plan in that emergency situation because Medicare requires the Advantage plans to do that.
Stacy Smith: So you have some people though who go to Florida for the winter. Does that make a difference in choosing which plan?
Lance O’Brien: Absolutely makes a difference, and that’s why understanding all the options in the area—some carriers will give you access down there where you’re in-network still, even though you’re not in your state. So understanding your network needs, whether you’re a snowbird or you travel a lot—that would be a big thing to consider when choosing your plan.
Patrice King Brown: Do you have to be in a plan with your spouse? Does it have to be an identical plan?
Lance O’Brien: No, Medicare is very individualized. Right, so we see a lot of times because prescriptions—which we haven’t talked about yet—can dictate what plan might cover it better. And not all spouses or couples have the same doctors, right. So we see people all the time where one might be with company A and the other might be company B.
Stacy Smith: So one of the questions I asked one of our previous guests, and that has to do with if you’re going to have some sort of treatment coming up in the next year, how will you use that to decide which plan?
Lance O’Brien: Sure. Well, again, the Advantage plans—and I think this is a great question and a really good point—they are required to cover everything that Medicare covers, but then they have freedom after that to add different benefits or have different copay structures. So for instance, if you’re going into a year where you’re going to maybe have a surgery that’s going to require you to have physical therapy, you’re going to want to look for a plan that maybe has the lowest physical therapy copay, as well as the other things that might impact. Maybe the extra benefits we talked about earlier today where, you know, you have a lot of dental work coming up. I say this all the time, and that’s: Number one loyalty is to yourself when picking your health insurance. So when you’re shopping, you really should be looking at what is coming up for you this year and select a plan that actually benefits you the most.
Patrice King Brown: It can be, again, overwhelming. There’s so much to this plan and we look for different resources. There are many people who have difficulty just thinking about sitting down at a computer and trying to figure the whole thing out. I know that you have offered some ways that can make a difference for them.
Lance O’Brien: Yeah, there’s a lot of things that people can do. The first one is they could call different carriers and request plan information. That’s a lot of homework. People do it. I have one guy that I met with years ago. I got to his house and he had a whole spreadsheet of every carrier, the copays, the plans that he was [researching]. So there are some people out there that are very, very committed to that.
Another way they could do it is go to Medicare.gov, because there’s tools there where they can look at their prescriptions and they can begin to go through that list of all of those doctors. Honestly, to me, the easiest way to do it is to find someone who works with all of those carriers that’s a licensed broker, that’s an expert, that can actually take the needs analysis from you and know where to go to narrow down those 70 plans to two or three. We believe that the choice is always yours, but let us do the homework to get in front of you the options that would make it the easiest for you to make a great decision.
Stacy Smith: Lance there are a lot of changes coming up in 2026 for Part D in Medicare. Explain that a little bit to us. What’s happening there?
Lance O’Brien: Sure. So Part D is the part of Medicare that covers prescriptions, right? So people can get their prescriptions in the Medicare Advantage Plan. They could get it in a standalone prescription drug plan. But when the Inflation Reduction Act went into law a few years ago, it did some really good things, right? It lowered the and capped insulin at $35 for life-sustaining insulins. It offered the ability to eliminate the donut hole to negotiate additional prices on Part D drugs. So there was a lot of changes that are very good. Now it’s implementing those changes, right? Legislation is great. It’s then making sure that we’re able to get it to the people. So there are some changes that are definitely coming to Part D this year around deductibles, copays, and the formularies. It’s going to be very, very important for people to actually make sure they’re reviewing their prescription coverage this year.
Patrice King Brown: So because it is changing and it actually seems to be changing rather rapidly, you recommend, I’m assuming, to speak to the professionals that may be willing to help you just work through the murkiness?
Lance O’Brien: Yeah, so I would say for the last six or seven years, we kind of went through the golden age of Medicare. And what I mean by that is there was price compression. The price of plans was coming down and there was benefit expansion. The options and the benefits were getting better for people. We’ve seen a little bit of a change with that and it’s creating some confusion in the marketplace. And I definitely think this year, especially with the changes to Part D, the network changes that are happening, that it’s going to be really important to get in touch with somebody and work with somebody who’s going to help you walk through the process.
Patrice King Brown: But you also recommend sometimes for some people, the Medicare Advantage plan makes life a little simpler.
Lance O’Brien: I mean, Medicare Advantage has really grown. It’s about 54 percent of all the Medicare beneficiaries in America now are on Medicare Advantage, and it’s almost 70 million people now that are on Medicare. So it’s growing. And for a lot of people that are healthy that don’t have a lot of physical issues or a lot of need for it, and they’re looking for the extra benefits like dental, vision, and hearing that original Medicare doesn’t cover, it’s a very attractive option for them to consider.
Patrice King Brown: I’ve heard that some of them even offer help for if you need gym memberships or something to help with prevention of the need for medical care.
Lance O’Brien: Yeah. So with the Medicare Advantage plans, they have a set that Medicare has given them of preventative services they have to cover. So every plan is required to do that. But yeah, there’s different health programs out there, SilverSneakers®, Silver&Fit®, to just name a couple. And they will allow you to go to the gym—which, again, what’s the most cost-effective health care? Preventative health care. If you can keep people healthy, again, that goes back to why we’re giving them the ability to buy vitamins and other things. That’s why we’re giving them transportation so that there’s the ability for them to be willing to go see their doctor. That’s why we’re providing copays at a level that it’s like, oh, it’s only 20 or 30 or 40 dollars to see my doctor. They’re like, I can afford to do this. And it actually saves not just them, but our health care in America money in the long run.
Stacy Smith: Is there a price differential considering whether you get all of these benefits or you don’t get all of these benefits in the plan itself?
Lance O’Brien: There is a very wide range of premiums with those 70 options that I mentioned before. Many of them have a zero premium, believe it or not, which a lot of people are like, how is that possible? I could unpack that if you guys want me to, but there’s zero premium, but they can range all the way up to over $200, believe it or not. And it’s not always the most expensive plan that provides the right value for the individual either.
Patrice King Brown: So we have to keep in mind, again, what works for you.
Lance O’Brien: Love it. I’m tracking with what you’re saying, what is, because again, think about it, when people go to Medicare, they’re getting together at Panera, they’re getting together at other places, and they’re talking about their health care, and they’re talking about their plan and what they think is the best plan. And just because it might be the right plan for your best friend or your brother or your sister, doesn’t mean it’s the right plan for you because they don’t have the same budget that you do. They don’t have the same doctors, they don’t take the same prescriptions, they don’t have the same health needs. So it really is a very personal situation.
Patrice King Brown: You’re also saying that getting Medicare, signing up for a Medicare Advantage plan doesn’t have to be a frightening experience.
Lance O’Brien: No, I mean, our whole philosophy is make Medicare simple. Right, like it is overwhelming. We actually had an individual, a lawyer, who writes Medicare law, came to us and said, “Can you help me walk through this process?” So it can be overwhelming and daunting, but it doesn’t have to be if you can connect with the right person.
Stacy Smith: We’re in the period right now, Lance, of the Annual Notice of Change—people get these notices. What should they be looking for?
Lance O’Brien: Yeah, I think the big thing to think about related to that, Stacy, is it’s only the changes with their plan. It’s not the changes across the macro spectrum of what’s going on. So it’s not the other carriers that are available and the plans that they offer. It’s literally just the changes to their plan. So it’s very important to read through it and see what might be going up, what might be going down, right. But it’s also important to remember that there might be other things that I want to look at based on what I see in my own Annual Notice of Changes.
Patrice King Brown: But we don’t all need a spreadsheet.
Lance O’Brien: No, no. That’s a lot of work.
Patrice King Brown: Thinking somebody who did that is somebody who had formerly done that.
Lance O’Brien: He was an engineer.
Patrice King Brown: There you go.
Lance O’Brien: That explains it all.
Stacy Smith: All right. Lance, if someone wants to contact you, what should they expect?
Lance O’Brien: Great question. So again, we always start with a needs analysis because we want to know what’s important to them. Right, like, do they have changes in their health for this coming year? Are they now on prescriptions that they didn’t take last year? So it always starts from our perspective with a needs analysis. How do we understand what’s important to you? Once we get that information, then we always kind of what I talk about a funnel effect. We’re going to start with their prescriptions because the prescriptions is where a lot of costs can differentiate. So we always start with their prescriptions, then we look at their physicians. We want to make sure that they are actually in the network of the plans that we’re looking at, and then we get down to plan benefits. So for us, it’s starting at the top of that funnel with 70 plans to choose from and then bringing them down through the prescriptions, through the physicians, and then the plan benefits into where now they’re looking at two or three plans to actually make a decision from.
Patrice King Brown: How long do you think people need to allow to process all of this, to process as best they can before signup?
Lance O’Brien: Man, I love that question. You know, for me, when we have an appointment with someone, it’s about an hour of walking through information, and we like to give them the opportunity to think on it if they would like. A lot of times people will make a decision in the moment because they see clearly what is the right decision for them. But sometimes we have people take a week or two to really process, and I think it really is up to the individual, what do you need to feel—because really this should be, at the end of the day, it should be about them walking into 2026 with peace of mind. So whatever time it takes for them to be able to get to that place, that’s the amount of time they should have.
Stacy Smith: Now, do you do it by phone or how do you do it?
Lance O’Brien: We do it both ways. We do have a licensed call center, so we do help a lot of beneficiaries over the phone, but we also have a field team. We do a lot of in-home, across the kitchen table. That’s how I started. I’ve sat in the home across from thousands of people, literally, then became a manager at MediConnect where I was training and developing our team. We have a team of about 30 people, and now running day-to-day operations. So I’ve seen it from start to finish.
Patrice King Brown: It’s pretty amazing how it all goes. I’m sure there are many people though, Lance, who think that there’s a huge expense to that. So they don’t necessarily think they should contact somebody like you?
Lance O’Brien: Yeah, there’s never a cost. Medicare does not allow brokers to charge people for their services. So they get expert advice at no cost to them. There is compensation that is given to the individual broker if they enroll in a plan, but that comes from the company. So the individual, I say it this way, I go to my mechanic, I get a free estimate. I love that, but if they do the work for me, I got to pay, right. In this scenario, you’re getting a free estimate and you’re getting free work. It’s really win-win. It was a smart design by CMS, which is the Center for Medicare and Medicaid Services.
Stacy Smith: We’re dealing with a population such as myself that likes to have a piece of paper in their hand to take a look at it. Is that possible?
Lance O’Brien: Absolutely. So all the plans have kits. A lot of it is moving to online materials, but for anybody, when we have a plan—when there’s a plan they’re looking at, we provide them a summary of benefits, and that goes over, actually, what’s my specialist copay? What’s my primary care? If I need blood work? So they get that in the appointment. And one of the things that Medicare does require is we review that Summary of Benefits with them in the appointment, whether it’s in person or over the phone.
Patrice King Brown: Again, just to make sure it’s clear, as clear as it can be for them, and they can make a decision without fear. Because it is for many people, very intimidating. I, like you, Stacy, am about having a piece of paper, and I think many in our generation are like that.
Lance O’Brien: I think it’s very important for them to be able to look at what they’re signing up for so that they can feel like I know what my coverage is.
Patrice King Brown: But to have the convenience of a Medicare Advantage plan to know that it’s together and it’s covering so many different options and so many things all at once is, I think, very comforting.
Lance O’Brien: It is. And again, I think one of the important things, because you’re going over a lot in an hour, it’s important to follow up with them so they’re not just signing up for a plan, but they’re understanding how to utilize their benefits. Because if they’re able to utilize their benefits when they need them, that’s when, again, I think they’re going to be at their healthiest, have the most peace of mind, and it’s going to be a win-win.
Stacy Smith: There is another question I have for you, Lance, and that is if you’re on a plan right now, you can change that plan, right?
Lance O’Brien: It depends. So we’re moving into what is known as the Annual Enrollment Period. That runs Oct. 15 to Dec. 7. Everybody who’s on Medicare has an opportunity to change their plan during that time. Changes or decisions made then go into effect Jan. 1. For people who have Medicare Advantage plans, they also have another enrollment period from Jan. 1 to March 31 called the Open Enrollment Period where they could reach out to a broker and review their plan. And then there’s also SEPs, Special Enrollment Periods, and there’s a lot of them. But a lot of times people make their main decision in the Annual Enrollment Period, and if something comes up during the year, if they do have that relationship with a trusted broker, they would be able to reach out and say, “Do I have an opportunity at this time to actually consider a change?”
Patrice King Brown: But it’s nice to know that there is that option for many people.
Thanks again, Lance, for joining us.
Lance O’Brien: Thank you.
Patrice King Brown: And we want to thank you for joining us today. We have some things for you to remember. A reminder, first of all, that the Annual Enrollment Period is just around the corner, and this is your chance to change or to enroll in a Medicare Advantage plan for 2026.
Stacy Smith: Also, a recap of what you should be looking for in a plan—and that is price, provider, and prescription. So Lance, if somebody wants to get in contact with you, how do they do it?
Lance O’Brien: Sure. Two ways I would recommend. First is they can call our main number, (888) 818-6334, or they can go to our website, mediconnectinsurance.com. They can start a chat with us there, set an appointment. We look forward to talking with them and helping them this enrollment season.
Stacy Smith: Lance, thanks.
Lance O’Brien: Thank you.
Patrice King Brown: Thank you. And thank you for joining us. We hope you’ll join us next time for “Medicare for the Record.”
Thanks for tuning in to Medicare for the Record brought to you by UPMC for Life. To learn more about your Medicare options, visit: upmchealthplan.com/fortherecord
This podcast is provided for general informational and educational purposes only. It is not medical care or advice. For questions regarding medical care, please consult with your health care provider.
Views and opinions expressed by the participants are solely on their own and do not necessarily reflect those of UPMC Health Plan, its subsidiaries, parents, or affiliates.
UPMC for Life has a contract with Medicare to provide HMO, HMO D-SNP, and PPO plans. The HMO D-SNP plans have a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal. UPMC for Life is a product of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., UPMC Health Benefits Inc., UPMC for You Inc., and UPMC Health Coverage Inc.
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