Thursday, October 30, 2014

Advantage ours

Things to consider
In a Medicare plan


Over the years I have had two Medicare Advantage plans.

For several years I had a plan from AvMed. When AvMed failed to renew its contract with my long-time, and excellent, Primary Care Physician (PCP), I signed up with Humana.

Humana had some economic benefits and its Providers' Directory listed both my vascular surgeon and my long-time ophthalmologist.


Humana has a program called "capitation" that basically restricts its PCPs - and there were 108 in the plan I had - to referrals to specific specialists; even if a specialist is on Humana's Providers' List, the PCP may not be able to refer a patient to that specialist.

Human warns prospective clients in its Provider Directory, under the heading Getting Care from Specialists that: "Each PCP may have certain network specialists they use for referrals. This means that the specialists you can use may depend on which person you choose to be your PCP.

If there are specific specialists you want to use, find out whether your PCP refers patients to these specialists. You can change your PCP at any time if you want to see a network specialist that your current PCP does not refer to."

The problem is, how to find out which PCP can/may refer to which specialist. Humana Customer Service can't or won't tell the client; is the client supposed to contact and query each of the 108 PCPs?

    I contacted seven other Medicare Advantage providers and only one had a similar "capitation" arrangement.

      Aetna: Any PCP may refer to any specialist (both within the same plan)

      AvMed: Any PCP may refer to any specialist (both within the same plan)

      BCBS: Any PCP may refer to any specialist (both within the same plan)

      CarePlus: Any PCP may refer to any specialist (both within the same plan)

      Coventry: Any PCP may refer to any specialist (both within the same plan)

      HealthSun: Depends; if the PCP is part of an independent practice association (IPA) group, then any PCP may refer to any specialist within the same plan; otherwise similar to Humana, PCPs have limited options. However, HealthSun will provide a list of IPA PCPs upon request.

      United Healthcare: Any PCP may refer to any specialist (both within the same plan)


Humana and at least one other Advantage plan (Preferred Care Partners) offer $0 co-pays for hospital stays from Day 1 through discharge. Other plans charge from more than $100 to slightly les than $300 for Days 1 through 5. AvMed charges $0 for days 1 through 5, $80/day for Days 6 through 20 ($1,200), then $0 to discharge.

When I initially signed up with AvMed I asked about this and was told that typical hospital stays were 5 days or less. Two surgeries later, one "major," I have to admit the sales guy was 100% correct. (When the hospital over-charged, AvMed resolved the issue in our - AvMed's and mine - favor.)

It's a good idea to check costs for Skilled Nursing Facilities (SNF) as well; some plans charge for the initial days, other do not.


It pays to check a potential plan's "Formulary" - list of prescription medications - before signing on the dotted line.

For two reasons:

One, to assure the medications are on the list and

Two, to see what LEVEL the plan lists for the medication. The "level" determines the cost to the patient and, in some cases, the amount of medication that may be dispensed at one time (e.g., 30 days or 90 days).

AvMed, for example, fails to list one of my medications, a Level 3 on Humana's list. It does offer an identical generic version, If I order the medication via AvMed's mail order pharmacy, my cost is $0 for 90 days. Mail order usually is slightly less expensive for the patient. (Some local pharmacies may offer some common medications, e.g., Metformin, gratis. It's convenient for the patient and a way for the local pharmacy to get the patient inside the store.)

Before signing on the bottom line, check with the prescribing physician to see if there are alternatives to your current medications and then check to see if the alternatives are listed by the plan's formulary.

Some plans include a small ()$5, $10) monthly allowance for Over-The-Counter (OTC) medications.


Most plans offer dental coverage; my experience is that this coverage usually is wanting; of little value.

Most plans also offer hearing services that cover exams and hearing aids. The plans I have reviewed seem generally the same.

Vision plans for optometrists and opticians are OK if your area lacks a "2 pair for $69 with a free eye exam" outlet. The plans cover the optometrist's fee and the cost of one pair of glasses or contacts. If you want "designer" frames or frames not made in China, expect to pay more at all opticians.

While podiatrists are covered, acupuncture and "alternative medicine" are not.

A number of plans offer patient transportation to and from specific locations; sometimes the number of trips is limited. If you lack transportation to a doctor's office or hospital, this may be a benefit to consider.


Unless you are employed by a plan provider - e.g., AvMed, Humana - it pays to annually review your current Medicare Advantage plan with other plans. It helps to put everything on a spreadsheet to compare plans item-by-item, side-by-side. In the Benefits column, add your PCP and specialists and your medications so you'll remember to include them. Conveniently, all Advantage plans follow the same presentation format (different from 2014), Select one and list the benefits as they are presented to create the Benefits column.

You do the same thing with your health - you see your PCP at least once a year.

You probably do the same thing with your car and homeowner's insurance.

Plan benefits are "subject to change." (Case in point, AvMed dropped one of my medications from its 2015 drug list.)


There will be surprises. The purpose of this rant is to help eliminate some of these surprises by knowing the questions to ask. If I never had Humana, I would never have known to ask about "capitation" or how to find out which PCPs referred to which specialists (I still don't have the answer to that). Capitation may not be an issue for you, but it's worthwhile to ask "Can any PCP refer me to any specialist listed on this plan's provider's list?" If the answer is "No," your next question is "How do I know which PCP refers to which specialists?"

You can change PCPs during the calendar year, but unless a plan is cancelled - and Medicare makes this difficult for the insurers - you are "stuck" with your plan until December 31. (You may do your homework and sign up for a new plan from October to Pearl Harbor Day for the coming year.)


Medicare is, in my opinion, a great - albeit not perfect - thing and if the politicians will stop chipping away at it, well worth the price.

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