Monday, October 27, 2014

Experience writes



Funny thing about the Medicare "Select your plan" deadline: it falls every year on December 7th - Pearl Harbor Day, the day that then-president Franklin Delano Roosevelt said would "live in infamy." Infamy apparently is a very short time; ask a 20-something "What is the significance of December 7?" and all you'll get is a blank look.

I have had a Medicare Advantage plan for a number of years.

For most of the years I had AvMed. AvMed cancelled my Primary Care Physician (PCP) so I cancelled AvMed. Seemed fair at the time.

I did my homework and compared Medicare Advantage $0 cost plans - that's not exactly true, $0 cost, but that's what is claimed - side by side. Set up a spreadsheet and listed the categories in Column 1 and the vendors in the columns to the right.

At the time, and even today, Humana seems to offer the best economics with $0 co-pay for hospital stays. (There is at least one other plan that makes that offer.) Humana also could save me a little on my pricy prescription.

One of the selection criteria is the presence of my specialists on the plan list. If one or more of my specialists are absent, the plan is removed from consideration. If a person has no specialist relationships, this is a non-issue. I have such relationships.

Another selection criteria is in-patient hospital costs.

Humana, and at least one other plan, offers $0 co-pay from Day 1 to the end of the hospital stay. Many plans have a first days (typically Day 1 through 5) co-pay of more than $100/day to a bit less than $300/day.

Before I signed up with AvMed years ago I raised that issue with its sales person and was told that in most cases in-patient stays are 5 days or less - "no co-pay" days with AvMed. I think the sales guy probably was right; I have been an in-patient twice (open AAA repair and hernia repair) and paid $0 both times; the first time I was in the hospital 6 days (the discharge day doesn't count, so only 5 full in-patient days)). As it happened, the hospital billed me for two extra days and AvMed resolved that issue in my favor.

Still, having decided to "punish" AvMed for cancelling my PCP - a guy who I credit with saving my life - I compared other plans and settled on Humana.

WHAT I DID NOT KNOW ABOUT is a thing called "capitation".

Humana is about the only Advantage provider that utilizes capitation.

Translation: No matter if a practitioner is on a Humana plan's list of providers, you have access to that specialists only if the your PCP has that specialist on his or her personal referral list.

This came as an unpleasant surprise when I asked my first (of four) Humana PCPs for referrals to my specialists. The first told me to either use the specialist he used or to find a new PCP. He didn't explain that he choice of specialists was restricted by Humana. I never was sure if the restricted referral lists were the practitioner's choice or Humana's decision.

One PCP never addressed the issue; he simply made a referral to his (assigned?) specialist and ordered tests without consulting my specialist who wanted the tests.

My Humana plan lists 108 PCPs.

Bait and switch? False advertising?

To Be Fair On Page 4 of Humana's Provider Directory, under the heading Getting Care from Specialists it states: "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."

Not exactly "small print", but based on a survey of seven (7) Advantage providers one of only two that need the caveat.

I queried Humana's Customer Service on more than one occasion, asking it to identify PCPs who could/would refer me to the specialists I named. I was told to direct my issue to another Humana department.

The other Advantage provider who uses capitation said that it has PCPs that are not "capitated" and that the insurer will provide a list of non-capitated PCPs upon request.

A THIRD QUESTION to consider when selecting an Advantage plan: If the patient needs a service from a specialist who uses modern methods - e.g., laser-assisted cataract surgery - or special devices - e.g., multifocal intraocular lens (IOL) - will the plan pay the basic, Medicare-approved fee and allow the patient to pay any additional charges, assuming, of course, that the specialist agrees to the arrangement.

Humana allows the patient-paid extra costs; AvMed prohibits it. (If a specialist is willing to take the additional payments "under-the-table" will AvMed, if it discovers the transaction, penalize the patient and/or the practitioner?)

A QUICK FEW WORDS about so called "$0" Advantage plans.

The Medicare participant must continue to pay his/her Medicare fee, for most people, roughly $105/month. Additionally, Medicare Advantage providers - the AvMeds and Humanas, and many others, receive additional taxpayer dollars for each person they sign up. Now you know why there is so much competition for a geezer's signature on the dotted line. Certainly $0 additional out-of-pocket cost is a good thing, but it's not exactly true; still for a person watching "pennies," it is a consideration.

There are other concerns to consider, among them

  • Dental coverage (typically of little true value)
  • Drug costs and specific drugs' classification
  • Geezer health club membership
  • Hearing services coverage
  • Skilled Nursing Care facilities (like hospital in-patient days needs to be checked)
  • Transportation to/from and how often
  • Vision services coverage

When I signed up for my Advantage plan I didn't know the questions to ask; hopefully the above will give you something to consider before signing on the bottom line.

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