Dangers of compartmentalization UHC finds another way To discourage business

UNITED HEALTH CARE, or United Healthcare – either way, UHC – provides several Medicare Advantage plans in South Florida and perhaps elsewhere.

On its web site it lists two email addresses for its Preferred Choice and Medica plans: MemberServices and Enroll, both @UHCsouthflorida.com.

Member Services is for existing members. The Customer Service Representative with whom I dealt either (a) didn’t know what customer service means, (b) considered the answers to questions I asked a state secret, and (c) lacked initiative.

Still, that was better than the Enroll address. Several emails sent to Enroll bounced.

I mentioned that to the Member Services CSR and her reply: We have nothing to do with Enroll or IT services (ergo my comment re lack of initiative). Were you or I alerted to a problem with customer or prospective customer support we would have quickly escalated the issueto a supervisor. An Enroll CSR I contacted by phone put me on “hold and forget.”

The dangers of compartmentalization.

Granted, with enough digging a determined person probably can find most sought-after information.

But some information won’t be found.

Some plans from Humana, and Aetna's Coventry Summit Ideal plan “capitate” their Primary Care Physicians (PCPs).

What is “capitate” you ask?

Basically it means that while the plan may list 1,000 specialists, a specific PCP may refer to only 100 specialists on the plan list. It’s a “sub-network.”

Some plans, such as HealthSun – that, incidentally has good customer service – has some “capitated” and some non-“capitated” PCPs. An email to HealthSun CSRs with a short list of prospective PCPs will generate an answer: who is “capitated” and who is not “capitated.” (There is a temptation to wonder: If a “capitated” PCP becomes a non-“capitated” PCP, does that mean the PCP was “decapitated?”)

Both Preferred Choice and Medica plans have extensive provider lists, but finding out if

Any
Some
None

of the PCPs is “capitated” is an impossibility except by phone. (A call to Aetna's customer service for Coventry's Summit Ideal was answered promptly; there was no email option. All Summit Ideal PCPs are "capitated.")

The reason it is an impossibility for a "some" answer is volume.

As an example, a prospective member checks the PCP options. The prospective member (hereafter “PC”) fails to find his/her current PCP – everyone should have a personal physician – so the PC looks at the plan’s provider list and selects 8 or 10 plan PCPs within the PC’s area. Few people want to travel 20 miles, or even 10 miles, to visit a PCP.

Admittedly the PC could call the number associated with Enroll, but then, if the plan has both “capitated” and non-“capitated” PCPs, the Enroll CSR would have to write down the names of “n” PCP candidates, check while the PC is on hold (more often “hold and forget” as happened when I called the UHC Enroll number), and then have the Enroll CSR read back the list noting who is, and who is not, “capitated.”

Medicare Advantage plans are “big bucks” business. The plans’ owner gets far more federal dollars than a we pay Medicare – currently slightly more than $100/month. Apparently for some, such as AvMed, the formulary is a major money maker.

The sad thing about the UHC plans is that while their Evidence of Coverage and Formulary contain information that I can appreciate, I can’t contact anyone who can – or perhaps will – answer my questions without a run-around or “hold and forget.” AvMed had email accessible CSRs and even assigned a “personal” CSR (who, when she vacationed, failed to have a backup to check her emails). HealthSun’s CSR response is a great marketing tool for the plan.

The bottom line for me regarding UHC’s Medica and Preferred Choice plans is that while they both are pretty good, the lack of customer support is a show stopper, at least for this scrivener.

Opuscula You’d better Shop around

WHEN IT COMES TO MEDICARE ADVANTAGE plans, Smokey Robinson and the Miracles got it right: “You got’ta shop around.”

This scrivener seconds that emotion.

A LITTLE HISTORY

I had an “regular” AvMed plan when I was working for a now-defunct company called DMR. When I signed up for Medicare years later I ended up with an AvMed Medicare Advantage plan. We had a decent relationship until AvMed cancelled my PCP, a doctor who was an excellent diagnostician.

Miffed, I signed up with Humana – for a year.

With Humana I discovered “capitated” PCPs.

Capitated & Decapitated

With AvMed, my PCP could refer me to ANY specialist on AvMed’s Providers’ List.

Not so with Humana.

While Humana had a lengthy Providers’ List, the doctor who became my PCP had a very much reduced list of specialists to whom he could refer.

Humana was unable to tell me which doctors could refer me to my vascular surgeon (Abdominal Aerobic Aneurysm, FemPop Aneurysm); it was left to me to contact PCP prospect after PCP prospect until I found a PCP whose personal specialists list included my vascular surgeon.

Fortunately, with Medicare, a patient can change PCPs every month. I did. During the year I was a Humana client I changed PCPs three times.

As soon as October rolled around, I signed up once more with AvMed.

Prescription “tiers”

Medicare Advantage programs have multiple “tiers” for prescriptions. “Tier 1” usually are free to the plan client. These typically are low cost generic medicines. Publix, a supermarket chain in Florida and Georgia, fills some prescriptions for “Tier 1” drugs at no cost to plan or plan client; consequently Publix gets ALL my prescriptions.

I started the year with a Tier 2 medication. The next year, AvMed jumped it from Tier 2 to Tier 4. Tiere 2 cost me $7 for a 30-day supply of pills; AvMed now demands a $75 copay for the same number of pills. Quite a jump.

I checked some discount pharmacy offers and discovered that a number of sources offer the medication at prices LESS THAN AvMed’s $75 copay.

Did all Advantage plans list my medication as a Tier 4? I already knew Tier 4 copays varied by plan provider.

Turns out different plans put the medication at different tiers. I found one – HealthSun – that showed the medication as a Tier 1 (no copay) on its Formulary list. Others listed the medication as Tier 2 or 3.

THINGS TO CHECK

When comparing Medicare Advantage plans, ask the competing providers for

EVIDENCE OF COVERAGE; this commits the plan to provide the things it promised Medicare to provide. Skip any overviews; they are just marketing.

FORMULARY; this lists all the medications the plan covers. If your medication is missing from the list, ask why; is there an alternative. The Formulary also tells you the medication’s tier level. (The Evidence of Coverage sets out the copay for each tier level.)

PROVIDERS’ LIST; this identifies all the physicians who work with the plan - BUT CHECK FOR “CAPITATION” - as well as hospitals, urgent care centers, pharmacies, and other suppliers.

In most cases, the information is online. You may have to contact the plan to find out the URLs, but usually they will be provided quickly. AGAIN, check about capitation.. If you have specialists who have been treating you and you want to keep them, this is a critical question. Some plans have a mix of capitated and non-capitated PCPs and many plan Customer Service reps will tell you which are capitated. If you select a capitated PCP, you need to call the doctor and find out if you can be referred to your preferred specialists. (HealthSun, ibid., has both and CSR Malissa Soriano has proven to really provide “customer service” in sorting out who is and who is not capitated.)

Medicare Advantage programs can be wonderful things, but as with any insurance – home, health, auto, etc. – keep in mind what Smokey Robinson and the Miracles advise: “You better shop around.”