Posts Tagged ‘Medicare Advantage Plans’

Coastal Senior is a monthly periodical published in Savannah, Georgia and circulated throughout the Georgia and South Carolina low country. Bob Mason is its legal columnist.

In case you missed my last column, I am not a fan of Medicare Advantage Plans. Proponents of the plans will tell you they offer “more options” to seniors. In my experience “more options” often is code for “more complex”.

Advantage Plans also cost the taxpayers more. The government pays about 20% more to insurance companies for each Medicare beneficiary than it pays directly to doctors and hospitals on behalf of Medicare beneficiaries under traditional Medicare.

I came down particularly hard on Medicare Advantage “Private Fee for Service Plans” – a type of plan that promises much, often comes up short, and has been accused by the government of using overly aggressive (not to mention illegal) sales techniques (like forgery).

All of this is my opinion. I imagine there could be reasonable people who would disagree – and there actually may be some happy Medicare Advantage enrollees who have experienced some – umm – advantages to Medicare Advantage.

Some Important Considerations

In case you really want to take a look at a Medicare Advantage Plan, consider the following:

• Are your favorite doctors and hospitals covered by the plan? Do they accept the plan’s terms and conditions?

• Do you need a referral to see a specialist?

• Can you get care outside the plan’s service area or network? How?

• What costs are involved in the plan (premiums, deductibles, copayments)?

• Are there copayment requirements for lab tests, diagnostic tests, x-rays, MRI scans, or CT scans?

In case you want that “nice young man” from the insurance company to come by, consider:

• It’s OK to have someone with you when you discuss a Medicare Advantage Plan or any insurance product with an agent. If an insurance agent comes to your home uninvited, make an appointment to meet the agent at a time and place that is convenient to you. Do not invite strangers into your home.

• Obtain the agent’s business card so you can contact him or her later.

• If you are satisfied with your current coverage, you do not need to change.

Bailing Out

Speaking of changing, you need to get a handle on how (and how often) you can change from one type of plan to another – say from traditional Medicare to an Advantage Plan and back. Oh, alas! More complexity.

If you enroll directly in an Advantage plan for the first time upon becoming Medicare eligible or you have dropped a Medigap (Medicare Supplement) ONCE, you can voluntarily disenroll from their plan anytime within the first 12 months of enrollment. If it has been more than 12 months since enrollment, there are limitations as to when you may disenroll. Read on.

First you have an Annual Election Period (AEP), which runs from November 15 through December 31. If you are in a Medicare Advantage Plan you can switch to Original Medicare (and a Part D Prescription Drug Plan) or you can switch to a different Medicare Advantage Plan. Changes will take effect January 1 of the following year.

Next you have an Open Enrollment Period (OEP) for Medicare Advantage that runs from January 1 through March 31 of each year. If you are in a Medicare Advantage plan with Prescription Drug coverage you may switch to another similar plan offered by another company or return to Original Medicare and select a stand-alone Part D Prescription Drug Plan. You may not switch to an Advantage Plan that does not provide Medicare Prescription Drug coverage.

There are a host of other complexities on the types of plans you may switch from or to. Remember: all of this is meant to provide you with options! Just imagine the vista of possibilities opening before you!

My best advice is to be aware that November 15 begins a time when you can make some changes. Do your homework and explore those changes.

Unfortunately, I do not have space for specifics. But once you locate a new plan, you’ll need to notify both your old plan and Medicare. KEEP COPIES OF EVERYTHING.

Get help from a knowledgeable friend, adult child, or counselor.

Occasionally government does work well. The US Marines are one example. Another good example is federal funding of state programs to help seniors with Medicare and other health insurance issues. They work well and have trained counselors.

In Georgia you may find help through the Coastal Georgia Area Agency on Aging. Call them at 1-800-580-6860 and scream “HELP!”. You can also call the GeorgiaCares State Health Insurance Information Program at 1-800-669-8387.

In South Carolina call the low country office of Insurance Counseling Assistance and Referrals for Elders Program (I-CARE) (whew!)at 843-726-5536 and scream “HEY-YELP!” (They sound different in South Carolina – my opinion). By the way, the South Carolina I-CARE website is excellent: www.state.sc.us/ltgov/aging/Seniors/ICARE.htm.

We need a KISS Program (Keep It Simple Silly), but I’m NHMB (Not Holding My Breath).

Next month, one of my favorite topics: Living Trusts . . . you might just be able to live without them.

Bob Mason, certified elder law attorney by the National Elder Law Foundation, practices in Savannah, Georgia, and Asheboro, North Carolina. Email Bob at ram@masonlawpc.com or visit www.masonlawpc.com.

Coastal Senior is a monthly periodical published in Savannah, Georgia and circulated throughout the Georgia and South Carolina low country. Bob Mason is its legal columnist.

Medicare can be confusing enough as it is. The past few years Medicare has gotten even more confusing with new “Part D Drug Plans” and the somewhat older “Medicare Advantage Plans” (which until recently had been called Medicare+Choice Plans). Whew.

To the chagrin of some insurance professionals, I am going to take a two-part swipe at Medicare Advantage Plans in this and my next column. Medicare Advantage Plans have been under scrutiny lately, and for a reason. If you are covered by one (and I bet you are not thrilled with it) or if you are thinking of switching to one read my words carefully.

Very aggressive (as in illegal) sales tactics have lured some seniors to switch to Advantage Plans, and then when the bloom is off the rose (and they realize they’ve been hoodwinked) many have difficulty backing out.

First, a bit of background on Medicare (I’ll try to keep this simple). The law divides Medicare into four parts. Part A and Part B are what many think of as “traditional” Medicare. Tried and true, they’ve been around for years. Part C covers Medicare Advantage Plans (under my knife below). Part D constitutes the newer prescription drug plans (I will not touch that here).

Medicare Part A has been the traditional route for medical coverage needed by the elderly and disabled in medical facilities. Part B applies to services provided by physicians and other medical practitioners, home health services, durable medical equipment and other services not covered by Part A. (For a more complete discussion of Medicare simply Google “Medicare” and read until you drop).

When combined with good Medicare supplemental insurance policies (popularly called Medigap policies) and the new Part D Drug plans, Part A and Part B provide fairly complete coverage. There are gaps, however.

Traditional Medicare, for example will not pay for most dental care, vision care, hearing care and preventive care. On the other hand, many Medicare Advantage plans offer to fill some of those gaps. But at a cost (and often hidden). For example there may be higher coinsurance amounts or deductibles, or other restrictions on who may provide services.

Some of the newer Medicare Advantage Plans may be patterned after health maintenance organizations, which offer a wide variety of services as long as the member uses participating providers.

Other Advantage plans may be patterned after preferred provider organizations and managed care organizations that offer broader service but hold down costs by preapproving services or placing other restrictions on the medical providers.

Most of the abuses do not involve these plans; they usually involve a type called a “Private Fee-for-Service” plan. These are sometimes called “PFFS Plans”.

So what IS a PFFS Plan? A PFFS Plan is a health plan offered by a private insurance company under contract with the Medicare program. This insurance plan is not a Medigap plan, and it works very differently. You must continue to pay the Medicare Part B premium to participate in the PFFS plan in addition to any additional premium the Private-Fee-for-Service plan may charge.

You may receive services from any doctor, hospital or other provider willing to accept your PFFS plan’s terms of payment. You may get, say, dental coverage . . . but end up paying very high co-insurance amounts for other services. Or you may find that your favorite doctor does not participate in your Medicare Advantage Plan. Or you may find that you no longer have drug coverage that you need.

Even though the marketing problems have involved PFFS Plans, do think very carefully before switching to any type of Advantage Plan; the deal may not be as “advantageous” as it first seemed.

Recently Medicare Advantage plans have come under close scrutiny by authorities after discovery of abusive PFFS hard-sell tactics by private insurers. In April, two Wellcare insurance salesmen were arrested in Columbus, Georgia, for a variety of aggressive and fraudulent sales tactics, including forging the signatures of elderly customers. Shortly after that authorities arrested another salesman after a series of forgeries and misrepresentations by the salesman to residents of a Suwanee (just north of Atlanta) nursing facility.

As a result of the increased “heat” from regulators, UnitedHealth Group Inc., Humana Inc., Wellcare Health Plans Inc., Universal American Financial Corp., Coventry Health Care Inc., Sterling Life Insurance Co. and BlueCross BlueShield of Tennessee recently agreed to suspend marketing of private fee-for-service Medicare plans because of complaints of deceptive practices by some of their agents. The suspensions will remain in effect until regulators are convinced that the companies have cleaned up their sales act.

That’s good news. The problem is that many seniors who are in Medicare Advantage Plans and who may want out are having a terrible time trying to get to the exit.

Stay tuned . . . I’ll cover that in next month’s column. In the meantime: Be careful. Look carefully before switching from traditional Medicare to a Medicare Advantage Plan.

Bob Mason, certified elder law attorney by the National Elder Law Foundation, practices in Savannah, Georgia, and Asheboro, North Carolina. Email Bob at ram@masonlawpc.com or visit www.masonlawpc.com.