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Deadline Looms for Medicare Choice
By Donna Wright, Bradenton Herald
March 9, 2008
Pat Schaefer and her
husband Ken work out with the Silver Sneaker program at
Lifestyle
Family
Fintess
Center
Friday in
Bradenton
.
Ken and Pat Schaefer may be pushing 80, but for the past six months, they have been pumping iron at the gym three times a week.
"The payoff is tremendous," says Pat Schaefer, who admits she never was keen on exercise in the past. "I just had my blood pressure checked. It's improved so much my doctor changed my medication."
What prompted the Schaefers to get off their couch? The answer is Silver Sneakers, a senior fitness program and an added benefit on the Schaefers' Humana Medicare Advantage plan.
"The Humana plan and Silver Sneakers have changed my life," Pat Schaefer says.
Such accolades please David Steege, a Humana sales manager who has been holding Medicare Advantage seminars almost daily at area restaurants.
Seniors have just three weeks to make changes to their Medicare health plan coverage. Those seniors who like their plans do not need to worry about the deadline. But after March 31, which marks the end of the open enrollment period, seniors will be locked into their choices for the calendar year.
And like most Medicare choices, this decision is a complex one.
"I would like to tell you I have the perfect plan, but I don't," Steege told about a dozen seniors who met him for lunch last week at the Golden Coral. "Humana offers several different plans - good plans - but you must decide what is best for you. And it may be that original Medicare with a supplemental Medigap plan works better for you."
The choices are staggering. Manatee residents on Medicare can choose from among 37 private Medicate Advantage plans, plus 27 special needs plans. Some cost practically nothing. Others are more expensive. Coverage varies as does benefits.
So where to begin? Seniors first need to decide if they want to stay in the original Medicare plan - a good idea, Steege says, for someone who has complex medical problems and an established team of doctors coordinating their current care.
But for those who are in good health and go to a doctor maybe three or four times a year, a Medicare Advantage HMO might be the right choice, Steege notes.
Humana's HMO, like many of those offered by other insurance companies, has no premium while traditional Medicare costs $96.40 a month for individuals who make less than $80,000. Private companies can offer zero-premium HMOs because Medicare pays the insurer between $800 to $900 a month to write the policies, Steege said. The privatization of Medicare began in earnest with the 1997 Balanced Budget Act, which allowed private companies to develop their own Medicare plans.
The zero premiums offered through Human and other companies amount to big savings, but there is a trade-off, Steege warns: You can only go to doctors within the local HMO network except for emergency care.
For Medicare recipients who spend several months up north, it may be better to pick a PPO (Preferred Provider Organization) plan which allows policy holders to see any doctor, including specialists, anywhere in the country at any time, Steege says. But again, there is a trade-off - if you see a doctor not in the PPO network, your out-of-pocket costs will be much higher.
Bottom line: Look at your health costs, your health care needs and what you can afford in deciding which plan works best for you, say the experts at the Medicare Rights Center, a national consumer organization that helps people solve Medicare coverage problems.
And be wary of plans that promise too much, the experts warn. Here's what several local residents have to say about the choices they made.
Paul Beyer, 71, Bradenton
"You have to do your homework," said Paul Beyer, who attended Steege's seminar. "I've been to dozens of seminars. I've got all the plans and I compare one against the other."
In the end, Beyer decided to stay with his current Medicare Masterpiece Plan offered by Universal Healthcare. While he was impressed with Steege's presentation, it made more sense to Beyer to stay with his current doctors while recuperating from knee replacement surgery eight weeks ago. His current Masterpiece plan picked up almost all of the costs.
"I had absolutely no problems," Beyer said. "I had one of the best orthopedic surgeons - Dr. Arthur Valadie. He did an excellent job. My health plan was the way to go."
The plan's premium is $60 a month or $120 for Beyer and his wife. The Beyers' annual premium cost is $1,440. Beyer figures that if he had standard Medicare and a supplement policy he would be paying about $7,700 a year.
"That's $6,000 savings," he says. "That's a lot of money."
Earl Crawford, 76, Sarasota
Private Medicare plans don't impress this retired insurance broker, who in the fall of 2006 opted for the Any, Any, Any HMO plan also offered by Universal Healthcare."They told me I could go to any doctor I wanted to, but my doctor would not accept this plan," said Earl Crawford. "I had to pay the doctor and then get the insurance company to reimburse me."
Crawford is still waiting, nearly two years later. He is among more than 70,000 Floridians who purchased the popular Any, Any, Any plan attracted by its promise of unfettered choice coupled with a full rebate of their Medicare Part B premiums.
But many doctors and many hospitals - including Sarasota Memorial Hospital - refused to accept the plan's coverage.
Crawford dropped the plan one month after signing on, and returned to the original Medicare plan with a supplemental Medigap policy. He was one of many policy-holders who had problems that eventually shut down the plan.
On Feb. 27, 2007, the state placed sanctions on the private, fee-for-service Medicare Advantage plan after studies showed it was severely underfunded.
One month ago, the federal government gave Universal the go-ahead to offer its Any, Any, Any plan once again. But there have been some changes. The plan now offers three levels of coverage with Part B rebates ranging from $0 to $40 to $60, depending on the benefits desired and the member's county of residence.
Crawford is not impressed. Whether it's a fee-for-service plan or an HMO, patients lose control over their health care, Crawford said.
"The problem with HMOs is they determine what service you can get," he said. "To go to a specialist, you have to have a doctor recommend you, but that does not mean that an HMO is going to pay. You have to get prior authorization before they will pay. I talked with some doctors who said that with some HMOs it is like pulling teeth to get paid."
The important thing to remember: When you enroll in a Medicare private plan, you drop out of Medicare, Crawford said. Your carrier is the private insurance company whom the government pays to cover you.
Crawford admits original Medicare with a supplement is expensive. He and his wife pay almost $600 a month on Medicare premiums, plus their supplemental policy through AARP and their stand-alone drug policy.
"That's a heavy load, but I've got good coverage and there won't be a penny out of my pocket if we have to go to the hospital and there is no limit on what Medicare or my supplemental policy will pay," he said.
Ken and Pat Schaefer, 78 and 79, Bradenton
Ken Schaefer's former employer in Wisconsin made the Medicare choice for him. Until this year, the Schaefers had original Medicare plus a Blue Cross Blue Shield supplement policy.
"My husband's company chose to drop the Blue Cross Blue Shield policy and go with Humana's Private Fee for Service plan through retiree benefits," said Pat Schaefer. "It's worked out very well. The prescription coverage is fabulous."
The Schaefers each pay $90 a month for their plan. "We can go anywhere in the country and not worry," said Pat Schaefer. That's a big advantage since two of their grown children are in Wisconsin and the other in California.
"The Humana cost is close to what we would pay for a gym membership," said Pat Schaefer. "We got many notices with this deadline coming up. We've gone to six different seminars and we have decided we are much better off with what we have."
Lee Cora Goff, 86, Rubonia
The Medicare Care Rights Center was a godsend for Goff and her daughter Vanzetta Evans, who lives in Hollistan, Mass. Evans, a registered nurse, has to coordinate her mother's care long-distance.
Nobody is quite sure how or when Goff was signed up for a United Health Care private Medicare plan in the spring of 2007, Evans said. "My mother gets confused and forgets things, but my brothers and sister who live close by are sure she never went to a seminar, she could not have gone on her own."
But last summer, when Evans called her mother's doctor to arrange for visiting nurse services, she was told her mother was no longer on the original Medicare plan but under United.
"They said she had been enrolled as of April 2007," Evans said. "But my mother can't remember if someone came to her home or how she enrolled."
Evans was upset. "None of her doctors, including her cardiologist, were covered under the United plan. It was terrible."
After several calls to the insurance company and to Medicare, Evans called the Medicare Rights Center for help.
On Aug. 9, a caseworker from the center contacted Evans and said she would work with Medicare to get her mother retroactively disenrolled from the United plan and back on original Medicare.
Nearly two months later, Goff was finally reinstated to her original Medicare plan.
"This took too much of my time and other people's time to correct," said Evans.
Doris Robinson, 76, Parrish
Regardless of the savings, private Medicare plans do not appeal to Robinson. "I want a straight Medicare plan, no HMO," said Robinson, who has a supplemental plan through United Americans. "I want to know I can go to any hospital or any doctor I want to. I want to have any treatment I think is necessary."
Robinson and her husband pay about $600 a month for their supplemental policies and Medicare premiums, plus a drug coverage plan through Humana.
"I can only say good things about United Americans," she said. "They pay immediately. A real person answers the phone after two rings. With many insurance companies, they put you on hold."
The Humana drug policy is working well for the Robinsons, too. "I think I am paying less per prescription and I never have had a problem with drugs not being on the list," she said.
It is all about freedom to choose. " I don't want anybody managing my health care, I want to manage it myself," Robinson said. "It's my medical freedom and it's worth paying more." Medicare
LAST CHANCE TO CHANGE MEDICARE HEALTH PLANS
OpenEnrollment ends March 31: Medicare recipients have three weeks left if they want to change the health coverage they receive. The open enrollment period covers health plans only, not Medicare drug plans.
TYPES OF PLANS AVAILABLE
Original Medicare Only: You can go to any doctor, including specialists, anywhere in the country at any time. Monthly Part B premium $96.40. If your annual income is above $80,000, Part B premium is calculated on a sliding scale.
Original Medicare + Supplemental Coverage: You can see any doctor, including spe1cialists, anywhere in the country at any time. Premiums vary with policies. Plans usually cover most charges Medicare does not cover.
MOST COMMON MEDICARE ADVANTAGE PLANS OFFERED BY PRIVATE COMPANIES
Medicare HMO: You can see doctors in the HMO network and service area. Most require referrals from a primary care doctor to see a specialist. Most have no premiums and some small co-pays.
Medicare PPO: You can see any doctor, including specialists anywhere in the country at any time, but if you see a doctor not in the PPO network, your costs will be much higher. Monthly premium generally less than Medicare.
Medicare Private Fee-for-Service Plan: You can see any doctor, including specialists, anywhere, anytime, but make sure they are willing to accept the plan's fees and conditions. Generally these plans cost more than PPOs but less than original Medicare.
HOW TO CHOOSE THE RIGHT PLAN
• Calculate current health costs, copays and premiums.
• Ask if your doctors are in the plans you are considering.
• Ask how many area doctors/specialists/hospitals are in the plan network.
• Ask if the plan provides coverage away from home and what conditions apply.
• Make sure the plan covers any specific treatments or care you need.
• To find and compare Medicare Advantage plans, visit www.medicare.gov.
• Use the Medicare Rights Center's checklist to determine the best plan for you at www.medicarerights.org
• Call the state's SHINE hotline (Serving Health Insurance Needs of Elders) to speak to a counselor - 1-800-963-5337, or visit www.floridashine.org.
HOW TO SPOT FRAUD
Private plans cannot:
• Enroll over the phone
• Ask for financial or personal information over the phone
• Request payment by phone
• Provide gifts or prizes worth more than $15
• Send unsolicited e-mails
• Compare their plan to another by name
• Label plans as "Medicare endorsed"
Brokers cannot say:
• You must sign up for a Medicare private health plan to get drug coverage
• You will pay a higher Medicare Part B premium unless you sign up for a private plan
• A plan representative must come to your home
• Certain doctors and hospitals are in the plan when they aren't
• Describe standard Medicare-covered benefits as special benefits of their plan.
• You can always return to the original Medicare plan without advising you that changes can be made only during open enrollment periods.
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