Wednesday, October 21, 2015

Medicare Plans

Getting plan info
Is not an easy task


IT'S THAT TIME OF YEAR when geezers, I proudly include myself in that group, look at Medicare plans - Medicare Advantage and Medicare Supplement plans from sundry providers.

Such plans are profitable for the providers - health insureance companies; if you don't believe me, look at the numbere of companies advertising their wares for the $100-plus dollars geezers pay into Medicare each month.

But it isn't the "dues" the companies want; it’s the additional revenue from D.C. they are after - substantial additional revenue.

Over the years I've signed up with two different providers; I'm currently back with my original provider.

But my original provider changed the fees for some of my medications; the co-pay went from $21 for a 90-day supply to $105 for the same amount. That was enough to send me in search of "options."

What I want to see - and some providers make it easy - are three documents:

  1. Evidence of Coverage
  2. Providers' List
  3. Formulary

Evidence of Coverage The EOC tells me what the plan covers and what it pays. All plans seem to cover everything Basic Medicare covers, but usually offer additional coverage and lower co-pays.

For example, Medicare covers in-patient hospital care at $0.00 for the first 60 days (, but there is a nasty $1,260 deductable for each benefit period. My current provider gives me Days 1 through 5 at $0, but my co-pay for Days 6 through 20 is $80/day, dropping back to $0 co-pay for the rest of my stay. My deductable: $0.

Many plans charge $100-$200-a-day for the first days and then drop the co-pay to $0.

Over the last few years I have been a hospital "guest" twice; the first time for 5 days (=$0) and the second time one day (again, $0). When I initially signed up, the sales person told me "most hospital stays are 5 days or less." So far he's been proven correct.

Providers This lists all the physicians, hospitals, pharmacies, and other health care people and organizations with contracts with the plan.

Back when I had a really great PCP, I would first check to see that he was on the list. Then he and my current provider failed to reach an agreement and he was dropped from the plan's proivider list. (In a fit of pique I went with another plan only to fiind out that while it had lots of providers, my access to them was limited by my PCPs' personal list. I went through 5 PCPs in a year with that plan. When enrollment time arrived, I was back with my original plan and yet another PCP who seems to be at least "OK.")

Since I've learned to live with other than my preferred PCP - his office operation was, and remains, a total disaster - I now assure that my vascular surgeon is a plan provider; that he's "on the list." Because he is associated with the hospital where my surgeries are performed, the hospital automatically also is on the list.

Two medical professionals are important to my well-being; the vascular surgeon and the anesthesiologist - I have the scars to prove it.

Formulary The Formulary is a list of medications the plan is willing to provide; some for $0 co-pay and some for co-pays ranging upward from $35 for a 30-day supply.

The cost of medications links back to the Evidence of Coverage. The EoC shows how much the plan provider will pay toward medications. When that limit is reached - it seems to vary between $2750 and $3500 depending on plan - the plan member - the geezer - falls into the "Donut Hole" and has to pay "45 percent of the negotiated price and a portion of the dispensing fee for brand name drugs. You pay no more than 58 percent for generic drugs and the plan pays the rest." The "Donut Hole's" official name is "Coverage Gap Stage."

The Gap comes into play when the plan and the member together have paid the plan's limit - e.g., $3000 - for perscription medications and continues until the member (geezer) has paid a total of $4850 from the member's pocket. Most plans will estimate the total cost of medications - based on the geezer's medications list - before asking for a signature on the virtual dotted line.

UNFORTUNATELY some providers, even some "Big Name" providers, hide the information from prospective clients. Rather than make it easy for geezers to review their plans they hide the information. On-line chat is no help for some. Calling likewise is a waste of time. (I encounted both earlier today.)

My recommendation: If you have a physician that you consider critical to your well being, GO to that practitoner and as what Medicare policies he or she accepts, then, if necessary, contact the providers' local offices and demand to see the three critical documents. Medicare - read taxpayers - pay the providers to prepare and distribute those documents for current and potential plan members.

On the other hand, any plan management too stupid to make the documents available on-line in PDF format probably isn't a plan worth having.

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