Opuscula Selecting A Medicare Provider

IT’S THAT TIME AGAIN, time for geezers (like me) to review Medicare options.

The top four are

1. Plain ol’ Medicare
2. Medicare with a drug plan
3. Medicare Advantage plan, and
4. Medicare Supplement (Medi-Gap) plan.

THE PLACE TO START IS medicare.gov. Medicare puts out a booklet titled “Medicare & You” that includes a wealth of information about Medicare AND plans available to people in different parts of the country. The booklet is free from the Centers for Medicare and Medicaid Services, a/k/a CMS. (What happened to the second “M” is beyond me.) The booklet is available on line or may be requested from

U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore MD 21244-1850

MAKE A LIST, CHECK IT TWICE

No matter if you are a Medicare innocent or an old hand, there is some information you want at the ready.

Do you have a family physician, a “Primary Care Physician”?
If you do, write down the doctor’s name.

Do you have any specialists on whom you depend?

Write down the specialists’ names.

Do you take an prescription medications?

Write down the names of the drugs and their potency.

WHAT PLAN TYPE?

After looking at “Medicare & You” (ibid.) decide what plan option suits your needs. Medicare Part B will cost you at least $135/month no matter the plan option.

Yes, you paid into Medicare all your working life or at least from 1958, and no, it doesn’t seem reasonable that you have to keep paying, but ...

A Medicare Supplement (Medi-Gap) plan will cost you the monthly fee PLUS an additional fee.

If you want to see ANY practitioner, usually sans a referral, the Supplement plan may be right for you. However, don’t be talked into a Supplement plan because you like to travel. Medicare and most Medicare Advantage plans cover you wherever you go in the U.S. Most Advantage plans provide coverage outside the U.S. as well, albeit there will be paperwork on your return to the U.S.

Once you decide on the plan (Medicare, Medicare with Rx, Medicare Advantage, or Medicare Supplement) see what plans are available for your ZIP code.

There are two basic “variations on a theme” with Advantage plans.

There are plans for people with limited incomes; these are identified as “SNP” plans.

There are HMO and PPO plans. HMOs generally are “plain vanilla” and require subscribers to see a limited number of doctors while PPO plans offer a greater number of physicians – at a cost.

My preference is Medicare Advantage HMO.

WHICH PLAN SUITS BEST?

Each Advantage plan has three (3) main documents. All of the documents are online or may be ordered from the company offering the plan.

Evidence of Coverage
Forget about “summaries” or “plan overviews.” They are useless. The controlling document is the EVIDENCE OF COVERAGE, the EoC. The EOC is the agreement between the plan provider and CMS. Once approved by CMS, it is “cast into concrete” for the calendar year. Get a copy of this document (digital or paper) and guard it well.

Providers’ List

The PROVIDERS’ LIST identifies all the physicians, hospitals, urgent care clinics, pharmacies, and, often, optometrists and opticians, and dental providers. This list is “subject to change” during the year.

Formulary

The FORMULARY lists all the prescription drugs the plan will provide and the tier level for each drug. Most advantage plans have four or five “tiers”; each tier has an associated price. The PRICE for each tier is listed in the EoC. The drug list is “subject to change” during the year.

ITEM BY ITEM

Most plans’ EoCs conform to an alphabetized list.

Many of the service’s fees (co-pays) are determined by Medicare. Common immunizations are $0 co-pay because Medicare requires it. Mammograms, PAP smears, prostate tests are sans co-pay.

But there ARE differences among plans.

I usually create a spread sheet starting with my critical requirements. For me, those are three things: my specialist, my hospital, and the tier level of my most expensive medication.

After that, I simply go down the list.

Some plans will have extra services, and some plans are more generous that others. For example, one plan gives the first five inpatient days as $0 co-pay; another gives all Medicare days (90) as $0 co-pay, and another EoC promises $0 co-pay for unlimited inpatient days. (It turns out that most acute hospital stays are five days or less.)

Given my personal priorities – specialist and hospital – I quickly reduce the field.

ACCESS TO SPECIALISTS

Many, in fact almost all, Advantage plans have a great number of specialists on their Providers’ List. HOWEVER most plans allow the PCPs to refer to a “sub-list” that may, or may not, include a specialist you want to see.

To find out is a particular PCP can send you to the specific specialist you have to ask the PCP’s office administrator. (Most PCPs haven’t a clue.) If you are willing to accept an alternate, well and good; but if you are committed to one practitioner, you will need to select a different PCP.

REFERRALS ARE A GOOD THING
Referrals can be a pain in the posterior, but they actually are a good thing. The PCP should be the center of your health care and should know who you’ve seen and the results of the visit. A good PCP will aggressively follow up with the specialist to make certain the PCP gets a complete report.

Do NOT, however, depend on the PCP to be up to date with medications. If you take multiple pharmaceuticals and over-the-counter (OTC) drugs, talk to your pharmacist. The pharmacist is more likely to be aware of any contra-indications than the PCP. (However, make the PCP aware of ALL prescription and OTC drugs you take.)

YOU AND THE PCP

Your PCP should be your adviser; he or she should be your medical consultant, just as you (may) have a financial or mechanical consultant. Consultants recommend, they are not paid to dictate. It’s your health, after all.

If you have a PCP that insists on something with which you have an issue, change PCPs. Medicare Advantage plans allow subscribers to change PCPs once-a-month. You are “stuck” with the plan for the calendar year, just as the plan is “stuck” with you. The only “out” is to move out of the plan’s coverage area.

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