Opuscula Patience main Requirement For Medicare

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.

Comments on Medicare Advantage

Opuscula I really hate Telephones

THERE ARE SEVERAL REASONS I DISLIKE DOING BUSINESS via the telephone.

1..Noise on hold
2. People who don’t speak my language
3. People who are not even on my CONTINENT
4. Having to explain my situation again and again as each new person pretends to care
5. Knowing in the end it will be a (s)he said-I said confrontation.

I much prefer written communications.

Email is great. It is fast, it is (relatively) free, and a complete history of the conversation can be kept together as one contiguous “string.”

Snail mail is OK; it’s slow and increasingly expensive. (I remember 7¢ airmail stamps and “penny” post cards.)

When it is in writing, there is less opportunity for “weasel wording.” No “You misunderstood” or “The issue was not fully explained.” There is proof, be it pencil, pen, or crayon on paper or digital images that can sent back and forth or printed on paper.

The main problems with email are two:

1. The email address of the actual responder is is hidden from the person who wants to communicate via this medium (e.g., Joe CustomerService), and
2. The email is ignored at the destination.

Even with Delivery and Read receipts, the email version of certified and return receipt mail there is no absolute proof the missive was read and acted upon. ’Course that can happen with snail mail, too, but it has proven to be less likely.

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What prompts this rant?

Medicare; specifically Aetna Coventry’s Summit Medicare Advantage plan.

My Spouse has a Coventry “regular” plan via her employer.

She’s about to (reluctantly) turn 65 years young and she wants to change to a lower cost coverage (than her employer-subsidized) insurance.

The problem is that Coventry is a capitated plan. (See Medicare plans: Beware the plan is not “capitated” (http://tinyurl.com/ycmmlw42) for a explanation of “capitated.”)

While it has the providers my Spouse wants and needs, her Primary Care Physician (PCP) cannot refer her to a critical specialist. This specialist is so important to her that she is – albeit most reluctantly – prepared to give up her excellent long-time PCP to keep the specialist.

That’s just half of the problem.

IF she gives up her long-time and trusted PCP, where will she go?

She will have to call each prospective Coventry PCP to ask: Can you refer me to my critical specialist? (She already asked my PCP’s office if he could refer a Coventry-covered patient to the Spouse’s critical specialist. The answer: “No.”)

Coventry sales people cannot (or will not) tell her which PCPs can refer to which specialists.

Can I go to the hospital with which I have a positive experience?

Both the specialist and the hospital are on Coventry’s Providers’ List.

HOWEVER, the hospital’s list of accepted insurances shows the Coventry plan is accepted only at a limited number of facilities in the hospital system; not the nearby main hospital.

Trying to contact Coventry via email is “mission impossible.”

Coventry is – alas – not unique. It may be one of the worst in so far as getting a written response to a written question, but it is NOT unique.

She has called Coventry and failed to receive a satisfactory response.

Can she go to her hospital of choice? According top Coventry, yes; according to the hospital (see image above), no.

Since that discussion was on the phone, who knows what actually was said. No record.

Could my Spouse’s PCP try to get permission from Coventry to refer her to the critical specialist, even though the specialist is not on the PCP’s capitated list? According to the PCP’s referral person, “We can try.” The logic being that the Spouse has been under the specialist’s care for several months, with many more months’ care anticipated.

Still, Coventry seems better than Florida Blue. The Blue Cross/Blue Shield’s web site shows that all of her doctors are available, but when we talked with a Florida Blue representative (see Don’t trust Medicare info On the Internet at http://tinyurl.com/y8yzl4eh ) we found out that NONE of what appeared on the firm’s web site was accurate. The Florida Blue clerk with whom we spoke told us that the hospital was not on the plan’s list, yet the hospital’s list of insurance shows that almost ALL of the Advantage plans ARE accepted. Of course the hospital system’s web site could be wrong.

Even when dealing with a representative “face-to-face,” there is no guarantee the information will be accurate; they are, after all, only sales people, and likely only part-timers or new hires, depending on the “season.” The Medicare “season” starts in mid-October and ends on Pearl Harbor Day; somehow that day seems appropriate.

I have had Medicare Advantage plans since 2010. None provide everything I want in a plan. One was capitated and limited my ophthalmologist options. Another, although not capitated, didn’t cover my specialists, and the most recent – and soon to be history -- has me traveling out of county to see most specialists. (The county to which I would need to travel has both high crime and terrible traffic, two reasons I am reluctant to travel to practitioners in that county.) The one plan that DOES meet 90% of my requirements insists on a prescription co-payment of $100 while almost every other plan offers the same medication at $0 co-pay.

Even in the heart of “Geezer County” there is no “perfect” plan, but I keep hoping and every year I compare many plans. I also compare auto and home owner plans – that’s just good business.

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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.

BCPLANNER: Comments on I hate telephones

Insurer proves Don’t trust Medicare info On the Internet

I’VE SPENT SEVERAL DAYS staring at Medicare Advantage providers.
I THOUGHT I found a provider that met the basic requirements:

PCP-check
Specialists-check
Hospital-check.

I checked and double checked the information.

But just to be sure . . .

THIS MORNING THE SPOUSE and I drove into another county to sit with a Florida Blue representative. We had an appointment, but the clerks were not ready for us.

Off to a bad start.

I explained that I had checked and rechecked my information early on the day of the appointment. All the doctors and the hospital checked out for both Florida Blue’s Premier and Classic Advantage plans.

We gave the clerk our list of things to confirm. The list started with the doctors and hospital and went on from there.

Absence of the doctors and hospital from the Florida Blue Provider’s List is a show stopper.

The clerk started down the provided list.

NONE of the doctors the Florida Blue web site repeatedly showed me as available on the Premier and Classic plans showed up for on the clerk’s computer.

Not one.

They DID appear for OTHER Florida Blue plans, the “extra cost” PPO plans.

“Well, the site is updated overnight,” the clerk told us.

OK, but I checked less than an hour ago, at 10 a.m. I replied. No overnight update here.

On line, all indications are that the practitioners found on the Provider’s List – accessed from the specific plan’s page – are for that plan. There is NO indication on the provider’s list that the provider is available only on a plan other than the plan which accessed the list.

BOTTOM LINE: NEVER trust a vendor’s web site.

I fail to see how lying to potential customers can benefit anyone; not Florida Blue nor the prospective client.

As soon as mid-October rolls around the “victim” of Florida Blue’s web site will have an opportunity to select another provider.

Florida Blue is not the only web site of which to be wary.

Other sites tell me that many of the doctors we want are on their list.

HOWEVER, some of these sites are capitated. See Medicare plans: Beware the plan is not “capitated” (http://tinyurl.com/ycmmlw42)

True, Doctor A IS on the plan’s provider list, but PCP B cannot refer a patient to Doctor A since Doctor A is not on the PCP’s abbreviated (capitated) list.

It is a pain in the posterior – that is not covered by any plan – but prospective clients need to beard the lion and visit the insurer’s physical site as my Spouse and I did this morning. Alternatively, have a representative make a house call. (Florida Blue does NOT offer this convenience; AvMed does and an AvMed representative is scheduled to visit. Will AvMed have the providers we need; its Provider’s List claims it has almost all the doctors. (Sadly, the list lacks an excellent PCP. Maybe it and the PCP’s practice will get back together for 2019.)

I am certain our experience with Florida Blue, AvMed, and Aetna’s Coventry – the capitated plan -- are not unique to the companies or to the geographic area.

How can you know if your PCP can refer to Doctor A? Ask the PCP’s referral person. The referral clerk is the only person guaranteed to know; the PCP probably has no clue – that’s why there is a referral person.

We almost signed up with Florida Blue because the web site showed us it has the doctors and hospitals we need. Had we signed up, in November the plan could have been unceremoniously dumped in favor of a more honest plan.

No matter what a vendor's web site claims – and this applies to ANY vendor – confirm your understanding with a person who has the authority to “put it in writing.”

Thanks to Florida Blue, lesson learned.

It will be interesting to see if Florida Blue does anything with its web site to correct the mis-information – assuming the clerk with whom we spoke this morning escalates the problem.

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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.

Comments on Medicare plans – Part 2