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.
