MEDICARE THE PROGRAM IS NOT the problem.
Dealing with Medicare Advantage plan providers IS the problem.
MY SPOUSE IS becoming eligible for Medicare and I’m looking for a new plan provider.
We each have specific criteria.
I go through this exercise almost every year, so I know where to look for answers to me requirements. For the record, I check each providers’
Most recent Evidence of Coverage (EOC)
Providers’ List
Formulary.
- The EOC tells me what the plan promised Centers for Medicare and Medicaid Services, a/k/a CMS. (What happened to the second “M” is beyond my ken.) The EOC is the one document that is cast into concrete and cannot be changed from January 1 to December 31.
The Providers’ List tells me who I can have as my Primary Care Provider (PCP), what specialists I MAY be able to see, what hospitals are contracted with the plan vendor, what urgent care facilities, and similar information. This list is “subject to change”; the vendor may add/change/delete providers on a whim.
The Formulary is the list of prescription drugs the plan will cover and what the co-pay is for each. Different plans rate the same drugs at different “tiers” or co-pays. As with the Providers’ List, the formulary is “subject to change.” (The co-pays are fixed by the EOC, but the drugs, and their “tiers” can change.)
Since my Spouse’s coverage start date is at hand, I checked several plans.
Most plan vendors are willing to send a sales person to the prospective customer. In an area with a high “geezer” population, Medicare Advantage vendors are highly competitive.
Still, it pays to follow the Coast Guard (and Boy Scout) motto: Be Prepared.
With the Spouse’s requirements before me I went to the Florida Blue Cross/Blue Shield, a/k/a Florida Blue, site.
Blue forces prospective clients to travel to one of its often inconvenient offices to confirm what it promises on the web.
Armed with a list of things to be confirmed, things I culled from Blue’s web site, we made an appointment and fought traffic to one of Blue’s sales offices.
When we arrived at the agreed upon hour, we discovered that keeping appointments is NOT important to Blue sales folks. After about a 10 minute wait we were shown into a cube where we met a gentleman with English as his second language. (My Spouse speaks several languages [to my two], none of which was the sale clerk’s primary language.)
The clerk looked at our list of concerns – things we read were available from Blue’s web site – and one by one he ticked them off as “not available.”
Apparently everything on Blue’s web site is a lie . . . or perhaps the sales clerk lied to us. We’ll never know, and frankly, Scarlet . . .
In any event, we decided Blue as not suitable.
We had two other primary options.
AvMed and Humana.
Both plans offered the providers we want, and both plans sent sales people to the house.
Humana – a company with which I have a year’s experience – limits its Primary Care Provider (or Physicians or Practitioners – take your choice) to specific specialists.
My critical specialist is on Humana’s Providers’ List, but he is not on my PCP’s capitated list. (I like my PCP, but because of the Humana limitation, this will be the second time I leave his practice for the same reason.)
AvMed, my first Advantage plan, has a lot going for it, but it, too, is starting to limit the specialists to whom a particular PCP can refer.
My problem with AvMed is that it charges a co-pay for one of my medications that is greater than the retail cost at Publix, my favorite pharmacy.)
Humana’s co-pay for the same medication is US$0 if I use the plan’s captive mail order pharmacy.
Humana offers my Spouse her preferred PCP and has other PCPs who can refer to my critical specialist.
- Never mind that I had to contact the PCP candidates on my own to ask about a referral to my critical specialist.
AvMed has some additional charges Humana does not.
For example, AvMed gives hospital in-patients the first 5 days with zero co-pay. As my first AvMed sales person told me, and as my experience proves, most acute hospital stays are five days or less.
With Humana, on the other hand, all in-patient days are free of co-pays.
As good as Humana looked on paper, we had some concerns.
Humana’s sales person sat at out dinner table and electronically completed my Spouse’s application for coverage.
He confirmed that her PCP choice was on the vendor’s Providers’ List. He confirmed that a critical specialist also was on the Providers’ List.
When he pressed SEND we thought everything was in order.
AND THEN
And then the Spouse received a letter from Humana telling her that her PCP “couldn’t be found” on the vendor’s Providers’ List.
- I found the physician in the Providers’ List sans problem. Am I smarter than a Humana clerk? Rhetorical question.
Of course when I tried to log on to Humana’s site using the Spouse’s ID – a temporary one issued a week before – the system returned “ID unknown.” I managed to get to the Providers’ List claiming to be a potential customer (which I was).
The Clerks-on-the-loose, since they were unable to find the PCP I so easily found, took it upon themselves to assign my Spouse to a PCP in another town, probably going by the ZIP code.
The Spouse called Humana’s main office and, after telling the clerk that yes, the PCP she wants IS on the list and “here is his Humana ID.” The Humana clerk, confronted with the evidence – the PCP’s Humana ID – agreed to change her PCP back to the one originally agreed upon and a new ID was sent out.
Humana sent my Spouse her ID card, but addressed to our street in a neighboring town. Again, a ZIP-code assumption. Somehow, the local post office distribution center went only by the 5+4-digit ZIP and delivered the card to the correct address. (Since some of our letter carriers cannot read NUMBERS, the fact that the USPS got the mail to the correct address is noteworthy.)
The Spouse called again to straighten out the address.
We know the sales person entered the information correctly because he was sitting with us when he keyed the data.
This does NOT bode well.
Granted, the clerks at Humana HQ are fixing the problems, but meanwhile the Spouse is wasting time having to call to correct clerical errors that should never have been made in the first place.
My concern is that as a Humana subscriber, if she uses the plan she’ll have to waste more time with the clerks to get the plan to do what it promises in the CMS-approved Evidence of Coverage.
- On the other hand, she can sign up with a different provider until December 7, 2018 for the coming year.
My only complaint with Humana when I had it for a year was discovering that my PCP was unable to refer me to my specialist. That problem never occurred when I had AvMed “back in the day.” Then, as now, the AvMed’s medication co-pays caused me to look elsewhere.
- AvMed had, perhaps still has, another problem that bothers this former Enterprise Risk Management practitioner. It gives – gave? – each customer a personal customer service person. Great idea.
The problem was that this person would get sick or go on vacation and no one was assigned to handle that person’s email and phone calls.
It you promise customer support, provide it; make certain someone fills in for the missing support person. AvMed failed to understand that.
AvMed apparently also fails to do any competitive analysis.
MEANWHILE there are fewer and fewer independent Advantage companies. Major players, such as Anthem and Aetna, are buying up smaller, usually local area companies. Most of the Anthem and Aetna properties are similar to Humana in that they limit their PCP’s referral options.
TO THEIR CREDIT, both Humana and AvMed – unlike Florida Blue – web sites are accurate; the information is confirmed by their sales staffs, albeit sometimes with a little “encouragement” from the consumer.
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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