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Interesting Articles about Advantage Plans

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Your Money: Medicare replacement policies often fall short

By Jennifer L. Boen
Fort Wayne News-Sentinel
Published on: 04/22/07

Fort Wayne, Ind. --- Franklin Perkins of Fort Wayne has learned the hard way that not all Medicare-type plans are created equal. His message to others: Buyer beware.

When the federal government implemented the Medicare prescription drug, or Part D, plan in January 2006, the focus was to provide beneficiaries with drug coverage, something previously available only through private supplemental plans. But the government also allowed private insurance companies, approved to sell Part D, to sell their own comprehensive health plans that replace traditional Medicare. Last winter, when an agent selling private Medicare plans called Perkins' mother, Gertrude Jenkins, who was then living at home, Perkins listened to the agent's spiel.

"They said they could give her a good break if she took the Part D and the medical," he recalled.

His mother, 88, also of Fort Wayne, was taking only a few medications at the time. The $12 monthly cost for Part D "looked really good," Perkins said. Her co-pay for doctor visits was just $20.

"So I signed her up," he said.

But in October, his mother broke her hip, requiring surgery, hospitalization and rehabilitation. Perkins was then told the hospital could not get the private Medicare company to approve in-hospital rehabilitation, something traditional Medicare covered when she broke her other hip a few years back.

So it was off to a nursing home for rehabilitation. That's when the real shocker came, Perkins said: "There was only one nursing home in Fort Wayne that was in [the company's] network."

It was not the one he wanted to take her to, "but I had no other option," he said.

If he moved her to an out-of-network facility, any one of the county's 24 other nursing homes, the out-of-pocket cost for his mother would be $150 per day, or 10 times the cost of the in-network one.

If his mother had kept the traditional plan, Medicare would have paid all costs for the first 20 days in the nursing home and all but $124 a day after that. Medicare pays part of the cost up to a possible 100 days for a nursing home resident who comes directly from the hospital.

The fine print

Mary Jo Burden is the bookkeeper for Woodview Healthcare Center in Fort Wayne. What once involved billing one single Medicare source has turned into hours spent sorting out what is covered and for how long by various private companies.

Most people who sign up for the private plans have been living in the community, she said.

"The problem is when they go to the hospital or a nursing home. People are looking at their outpatient costs --- their doctors visits --- and the Part D costs. They are not being told what may or may not be covered under the private insurance. It's probably there in the fine print, but most people don't know what to ask."

Perkins, 68, said in his conversation with the insurance agent that "the word nursing home never came up."

Fred Taube is a volunteer counselor with the Senior Health Insurance Information Program, which assists older adults with insurance issues. The program has fielded some complaints about private policies, particularly early on, he said.

At one nursing home, an agent sold residents a private plan. Taube said nursing home officials told him not only did the agent fail to ask permission to meet with residents, the policy sold did not cover that particular nursing home.

"When I first started doing this and when someone would come in and go on Medicare," Taube said, "I'd say, 'Here are the 10 standard Medigap [Medicare supplemental] plans.' I'd tell them to call the agent, get a quote and then pat them on the head and send them on their way.

"Now you've got to tell them about Medigap, preferred providers, private fee-for-service companies --- and there are two or three [permutations] or combinations of each of those. It's very confusing."

Ignoring what-ifs

Betty Foy, deputy commissioner of Consumer Services for the Indiana Department of Insurance, said her department has not logged many complaints but that it's likely people don't know where to turn.

"It's such a combination of a variety of issues. Most seniors make decisions based upon the dollars. Most won't say, 'What happens if ... what happens if ...' "

Not every private plan is laden with problems, Burden said, but she relayed some additional red flags to be aware of:

Weekly or biweekly preapproval requirements

Varying guidelines for what therapies are covered

Lack of response by companies when problems arise

Varying co-pays for different plans sold by the same company

When needing information on a plan, Burden said an agent recently told her: "I don't know. I just sold the policy."

'They are shocked'

Tina Morgan works for A Step Better in Fort Wayne, which sells special shoes and inserts for people with diabetes. She previously worked for a home health company.

"These plans are not the same as traditional Medicare," Morgan said. "They're signing up people who are really not capable of [making] these decisions. I've been there, heard them in senior or apartment complexes saying, 'Throw away all your [Medicare] cards. We'll take care of everything.' "

Under some private plans, she said home health companies are asked to tell insurers how much service patients will need before they are even seen. Under traditional Medicare, doctors write the orders and nurses visit patients to assess their needs.

Many home care clients are not told or do not know to ask which companies are in their network, Morgan said. "They are shocked," she said, when told they cannot continue with their former caregiver, who works for a non-network provider.

Eventually, Franklin Perkins was able to move his mother to another nursing home, his first choice. Once someone is in a nursing home 30 days, a different Medicare plan can be chosen.

"We went back to [traditional] Medicare," he said

I find this article a little confusing. Did I miss something here? Part D is Medicare drug coverage.

The care they are speaking of is part of Medicare (Part A & B), Gap polices or Medicare Advantage Plans (Part C). First, Medicare and MA plans do not cover nursing homes. Only Long-term-care covers nursing homes. Or, Medicaid.

Skilled nursing coverage does vary GREATLY plan-to-plan under MA. Many times with less coverage that regular Medicare. It has been, IMHO, the biggest risk the MA plans have. The only positive is many have the annual maximum out-of-pocket, which will offset this risk. It just needs to be explained carefully. $2500 in deductibles and co-pays are accumulated quickly once a person is this ill.

At-home coverage also is not covered by most Medigap plans and is not covered by Medicare. Correct?

If someone sells a person a plan that is obviously inappropriate, like not covering the facility that they are in, this patient has the right to cancel their plan and that agent has a big complaint coming for not knowing their product was inappropriate. This is part of the Guaranteed Renewability all States have. I would hope that such a facility would know enough to not let this happen to their patients.

Am I the only one who thinks the article is very poorly written and extremely confusing especially to those who are not agents familiar
with the options available to people on Medicare?

I don't believe the reporter really understands the difference between Part D, Advantage Plans and HMO's. There are so many inconsistencies in her article they are too numerous to mention.

Jennifer L. Boen should have taken some time to do a little research before writing the article. Had she done so, she could have accurately portrayed
the particular kind of policy the person had as well as what Part D actually covers. Her article makes it sound like taking Part D is what caused all the problems.

It was very irresponsible of the paper to publish the article.

I think I suggested that one has to look at plan exceptence more than once here and have talk to various agents selling MA's about this issue. It usually met with a "What about it?". "My plan is cheap and pays me good what else do I need to know? All plans are basically the same in design and obviously the provider will take the money! So shut up I'm busy selling my plan."

Well gee whiz people where do these agents come from???:no: I've sold Sterling for a short time and was thinking about selling Advantra which I basically did to a very few because many of these plans are simply not accepted by "key" providers in my area. The idea of "Providers" bending to the needs of the client is simply not reality, in other words there is no shortage of patients for the most part and providers have a working system that more than likely they'll not change for any one or two clients. Untill these carriers spend the big bucks to break into local areas that they market into there will be no shortage of these type of stories. Such as Sterling, their view was to sell the plans and they will take care of billing as the issue comes up, guess what? Lot of people backing out and quickly going back to their original plan are if they went pass the time allowance were just basically screwed till they had a chance of changing plans during those periods allowed by CMS. Untill CMS and Congress allows change at any time these plans are nothing but disasters waiting to happen.
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Skilled nursing coverage does vary GREATLY plan-to-plan under MA. Many times with less coverage that regular Medicare. It has been, IMHO, the biggest risk the MA plans have. The only positive is many have the annual maximum out-of-pocket, which will offset this risk. It just needs to be explained carefully. $2500 in deductibles and co-pays are accumulated quickly once a person is this ill.


While the story may of been poorly written this is my point. It doesn't matter what your plan covers (most are very common in conditions covered), OOP or MOOP doesn't matter if the providers will not bill your carrier, they will simply not except you as a patient unless you pay with cash. This is the very point I was making. People want choices, something that many MA plans simply can not offer unless they have done the leg work in the local area that you sell it in. Around here if you don't a medigap plan or very few MA plans (Cariten or John Deere) many providers will not accept you as a patient, may you or your client have Advantra, Sterling, Humana etc etc... Yet the plans are being pushed heavily and the low or no premium is what is being pushed. Now agents are pushing MOOP, great if you have a chance of actually using the plan then it's wonderful! Problem is if you can't use your plan in your selected Dr's office or Home Care Provider than it much to do about nothing except for some pissed off clients.
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