Opuscula Medicare plans: Beware the plan Is not “capitated”

CAPITATION: of, relating to, participating in, or being a health-care system in which a medical provider is given a set fee per patient (as by an HMO) regardless of treatment required1

WHAT THAT MEANS TO the person considering a Medicare Advantage plan is that the plan may have 10,000 providers – physicians, hospitals, etc. – but an individual Primary Care Physician (PCP) may have a highly abbreviated list of only a few hundred specialists and a handful of hospitals from the plan’s Provider List.

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Double-checking a Medicare plan: Read Don’t trust Medicare info on the Internet (http://tinyurl.com/y8yzl4eh)

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HOW TO SELECT A PLAN
There are three plan documents to review before any decision is made. In order of review:

First: Provider’s List
Second: Formulary (drug list)
Third: Evidence of Coverage (EOC)

If the potential plan subscriber lacks any preferences re doctors and hospitals, it makes no difference which plan is selected.
On the other hand, if the potential subscriber has a preference for a particular PCP or specialist, or even a hospital, then the first thing to do is check the plan’s Providers’ List.
PROVIDERS’ LIST.
If all, or at least most, of the desired providers are listed, contact the plan and ask “Are the PCPs capitated.”
Very likely the prospective subscriber will have to explain to the sales person – sales folks always are the initial contact – about capitation. The easiest way is to ask: “Can the PCP refer to ALL providers listed on the Provider’s List? If the answer is “Sure, they can refer to all on the list,” you might want to get that in writing. About 50 percent of the plans reviewed this week are capitated. Of the non-capitated plans, only two claimed they had the required providers. One of the two did not, despite its web site's listings.

There is no need to list plans here since what is available in one area may not be available in another.

Once the plans have been winnowed out, the next step is to check the plan’s Formulary.
FORMULARY
A formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.²
Are the pharmaceuticals – prescription drugs – needed on the list?
If they are, check the TIER LEVEL.
Tier levels determine the drug’s copay; the higher the tier, the more expensive the copay.
Be aware that not all plans are equal. One plan lists a specific drug as a Tier 2 for which there is zero copay. Another plan for the same geographic area lists the same generic drug as Tier 3 and demands a $100 copay for the same 90 day supply. (As it happens, a neighborhood pharmacy sells the same drug in the same quantity for less than $50.)
What is the copay for each tier? For that information the potential subscriber needs to locate the plan’s Evidence of Coverage.
EVIDENCE OF COVERAGE.
The Evidence of Coverage, a/k/a EOC, is the most important document the plan produces. The EOC tells everyone what benefits it will provide and what copays the subscriber must pay. The Formulary is “subject to change” as is the Providers’ List. Not so the EOC.
Most EOCs follow a fixed-by-Medicare alphabetical presentation.
That’s convenient when comparing plans. (LibreOffice Calc’s spreadsheet is great for this, and it’s free.)
Copays vary by plan. The ONLY document in which copays are “cast into concrete” is the EOC. Summaries are nice, but they lack the authority of the EOC.
GET THE DOCUMENTS
All the critical documents should be available online at the plan’s site. New documents usually are available in mid-October of each year. Medicare enrollment for people already with Medicare is between Oct. 15 and Dec. 7 (Pearl Harbor Day). For people joining Medicare at other times, check with Medicare.³
Plan documents normally are available online in PDF format. (Most browsers can display PDF, but in some cases the free Adobe Reader may be needed.) The documents also can be mailed on request.

The selected plan will send a printed copy of its EOC, Providers’ List, and, usually, its Formulary.

OTHER OPTIONS
There are two other options to a Medicare Advantage plan.

1. Original Medicare.
2. Medicare Supplement plans.

Original Medicare usually has higher copays and sometimes fewer benefits. The main advantage of Original Medicare is that it’s good everyplace Medicare is accepted: doctors offices, hospitals, etc. No concerns about “Will my plan cover this doctor or this hospital.”
Medicare Supplement plans are similar to Original Medicare in that the plans are accepted everyplace Original Medicare is accepted.
Supplement plans are provided by insurance carriers, many of which also offer Medicare Advantage plans.
The drawback to Supplement plans is they cost more than an equivalent Advantage plan; the user is paying for the freedom to go to almost any practitioner or facility.
THE PLACE TO START
Beware of commercial sites that offer to find the “right” program. They often don’t include ALL available plans.
The absolute BEST place to start looking for a Medicare Advantage or Supplement plan is the Medicare site, http:\\www.medicare.gov Accept no substitutes.

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Sources
1. http://tinyurl.com/y7pmhbp8
2. http://tinyurl.com/yavjkaeb
3. http://tinyurl.com/ybof3f5a

PLAGIARISM is the act of appropriating the literary composition of another, or parts or passages of his writings, or the ideas or language of the same, and passing them off as the product of one’s own mind.
Truth is an absolute defense to defamation. Defamation is a false statement of fact. If the statement was accurate, then by definition it wasn’t defamatory.

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