Opuscula Being ignored Does not win My business

IT IS THE FINAL DAYS OF THE Medicare Advantage plan sweepstakes.

I have a plan that automatically will roll over to the insurer’s 2020 plan, so I’m covered.

But there is a plan that offers more of that I want and, as a bonus, savings, too.

I have the preferred plan's Evidence of Coverage (EOC) and its Formulary (drug list) from the internet.

I lack the company’s list of providers: PCPs, specialists, hospitals, urgent care facilities, etc.

My PCP’s web site shows he accepts this company. The insurer’s site confirms it works with my PCP.

The preferred hospital likewise lists the company on its web site; however, the insurer’s site omits the hospital. Since my primary specialist is a hospital employee, if the insurer doesn’t have a contract with the hospital, then I can’t be referred to that specialist.

My PCP, who CAN refer me to the hospital and specialist under my current plan may NOT be able to refer me — assuming the hospital has a contract with the insurer — due to this company’s “capitation.”

I DID WHAT any sensible person would do: I sent an email to the insurer asking “What is the location of the Providers’ List for (plan ID)?”

I prefer email since I will have a written record of the exchange.

The email was sent on December 1.

Today is December 3.

I still am waiting for a response.

The deadline to make a decision is, for me, Friday, December 6.

Medicare Advantage selection deadline

If the insurer cannot respond to my simple query “What is the URL (web site) for the 2020 Providers’ List for (plan name)” then I have no confidence the company will respond to me if I have a concern with the plan and its benefits.

I COULD have called and talked with a sales person, but then I would lack a written record, and frankly, I have concerns about information from sales people, many of whom are engaged just for the “season.” In any event, all I want is a URL, an internet address to which I may point my browser.

Granted, provider and drug lists are “subject to change” throughout the contract (calendar) year, but its been my experience that most insurers make changes near the end of the contract period. Only the EOC is cast into concrete.

I can get EOCs, Formularies, and Providers’ Lists online for most plans. It is becoming more difficult — why this is so is beyond me — and based on a comparison spreadsheet, I make a decision that is best for me. I do this exercise every year between October 15 and November 30. (I also compare auto and home insurance when renewals come due.)

IF the insurer provided me with a URL to a PDF or other searchable file, I would check with my PCP if, under this insurer, he can refer me to my necessary specialist. “Capitation” — limiting PCPs to a sub-list of the Providers’ List — is the standard for most Advantage insurers today as a way to boost profits.

Bottom line: Ignoring potential customers is a sure-fire way to gain customers … for a competitor.

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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.
Web sites (URLs) beginning https://tinyurl.com/ are generated by the free Tiny URL utility and reduce lengthy URLs to manageable size.
 


Comment on Being Ignored

Opuscula It pays To check The “facts”

’TIS THE SEASON FOR MEDICARE sign-up.

Geezers, and I’m happy to report I am one (it ”beats the alternative”) have from mid-October to Pearl Harbor Day to change plans. (If no change is recorded by the Centers for Medicare and Medicaid Services (CMS) the person automatically is re-enrolled in whatever plan is in effect at the end of the year.)

THIS YEAR, AS I DO EVERY year, I started comparing plans.

First question: Does the plan have the specialists I need?

Then I create a spreadsheet (I use LibreOffice’s Calc) listing in Col. 1 the benefits as they are listed by CMS’s Medicare & You booklet; it comes to my mail box shortly before the sign-up period commences.

This year I found two Medicare Advantage companies who claimed to have my specialist on their Providers’ List. Each got a column on my spreadsheet.

There are three documents every Advantage plan (potential) subscriber needs.
* Evidence of Coverage (EOC)
* Formulary (drug list), and
* Providers’ List (doctors, hospitals, urgent care, etc.)

One of the plans is new to my area (but well established elsewhere). It allows its PCPs to refer to any doctor on its Providers’ List.

One of the plans limits its Primary Care Physicians (PCPs) to an abbreviated list of specialists.

Both plans’ “beyond Medicare requirements” benefits were comparable.

Checking with the one plan’s prospective PCPs to see which could refer me to my specialist I discovered one who told me her practice referred to my specialist, but a patient reported that the specialist did not accept the insurer’s subscribers.

What to do?

Go visit the specialist’s office and ask “What’s going on between the office and the Advantage insurance company?”

The answer: “We HAD a problem, but that has been resolved.”

OK, I continued, what about the other Advantage company, the one that allows a PCP to refer me to any specialist?

“Sorry, we don’t accept that plan.”

But the company rep insisted the specialist was on the list.

The company’s Providers’ List listed my specialist.

I’m not blaming the company rep. She only repeated what she was told, AND she had the Providers’ List to support her position.

THE BOTTOM LINE

The bottom line, at least for this scrivener, is “Check with the specialist.”

It the specialist is critical to your well-being, a phone call, or better, a visit to the specialist’s office, is worth your time.

In the end I signed up with the company that limits its PCPs since I had found several local PCPs who assured me they refer to my specialist. (The one who told me about the insurer-specialist mix-up is about to become my new PCP. My current PCP, who also accepts this Advantage company will not/cannot refer me to my specialist. Pity.)

THE OTHER SIDE OF THE COIN

My spouse and I used to share an excellent ophthalmologist who somehow became a resident of a Federal gaol. The reason he was incarcerated was non-medical; no one ever has questioned his professional skills.

Because of his residency at a Federal facility, Medicare banished him from its list of acceptable practitioners.

Apparently the doctor is back in Medicare’s good graces.

The doctor’s staff said he was again accepting Medicare patients.

Hard to believe.

BUT, I found this gentleman’s name on the Providers’ List of the plan to which I just appended my (digital) signature.

I wonder if the PCP I selected can refer me to my preferred ophthalmologist as well as my preferred vascular surgeon.

If truth be told, it’s the surgeon’s team anesthesiologist I want at the head of the table. The surgeon’s good, but the anesthesiologist has the patient’s life in her (or his) hands.

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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 Check the facts

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.

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 Medicare

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

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.

Comments on Medicare plans

Opuscula Medicare Advantage Annual plan review

Comparing plans

IT’S “THAT” TIME OF YEAR AGAIN. No, not halloween nor Thanksgiving. It’s Medicare Advantage plan decision time.

Like any annual (or in come cases, semi-annual) contracts, Medicare plans need to be compared.

This concerns only Medicare ADVANTAGE plans. Extra cost Medicare “Supplement” plans are noted only in passing.

ANYONE WHO THINKS THEIR monthly $104 (plus or minus) payment to Medicare pays for Advantage (or Supplement) plans is mistaken. The government pays the private insurers — and pays them handsomely — for each Medicare customer the insurance companies sign up, ergo in some “senior-heavy” areas, competition for customers is fierce. It’s a toss up who pays for more tv advertising: car dealers introducing the new model year or insurance companies trolling for customers.

Evidence of Coverage

All Medicare Advantage and Supplement plans must be certified by Medicare. Most insurers put their Medicare-approved plans on-line. Once approved, the plan benefits cannot be easily changed. (Providers — physicians, medical facilities, pharmacies — may change and certain prescription drugs may be changed, but the basic benefits are “cast into concrete.”)

Medicare.gov’s Advantage¹ information is the best place to start to find plans by ZIP code and insurers².

Since I do this exercise annually for myself and some friends, I create a spreadsheet. My spreadsheet starts off with things critical to me:

Primary Care Provider/Physician (PCP): Is my PCP listed?

If not, am I willing to change? Plans normally make their list if providers (ibid.) available on-line.

Specialists: Do I have any specialists I need to continue seeing? Is the specialist on the provider’s list?

If not, am I willing to change?

Medications: Are all my medications listed and how much is my co-pay. Prescriptions are “tier” based; the higher the “tier,” the higher the co-pay.

All of my medications are Tier 1 or Tier 2 ($0 co-pay) for all but one plan I reviewed; that plan has the same medication listed as Tier 3 with a $47-a-month co-pay.

Finally, I try to see if the plan’s PCPs are capitated. “Capitated” means that while the plan may list hundreds of specialists, a plan PCP may refer only to a limited number of these specialists.

I had a capitated plan — once. Never again. If I want to see Specialist “A” who is on the plan Provider’s List, I don’t want to be told my PCP cannot refer me because that specialist is not on my PCP’s list. (I kept the PCP and changed plans.)

The Evidence of Coverage (EOC) lists the co-pays by tier. In order to find out (a) if a drug is supported and (b) what tier the insurer has assigned the drug (Tier 1, 2, 3, 4, or 5) you need the plan’s Formulary — drug list — this also should be on-line.

EOC standard format

MOST EOCs follow a standard format. For 2018, I found only one that fails to follow the standard Medicare EOC format. Because the one offering failed to follow the standard format, I eliminated it from consideration.

Since most plan EOCs follow the standard alphabetical format — albeit some with very minor variations — it is relatively easy to compare benefits. Medicare requires that many benefits have $0 co-pay and $0 deductibles.

Two areas potential customers need to address are hospital costs and outpatient surgery costs.

My first Advantage plan (AvMed) had $0 co-pay for the first 5 in-patient days, and then $40/day for Days 6 through 20, than back to $0 co-pay for the remaining days. The sales person told me that most hospitalizations were for 5 days or less; three operations later, the sales person’s statement has proved to be 100% correct. The same concern applies to mental health care.

For some reason, most plans charge a higher co-pay for outpatient surgery at a hospital and substantially less at a stand-alone day surgery facility.

All plans discourage trips to hospital emergency rooms (ERs). In lieu of running to the ER, plans promote use of urgent care clinics. Some plans have a $0 co-pay for visits to clinics while requiring an $80 (or more) co-pay for ER visits.

On the other hand, if the ER visit ends up with an admission to the hospital, the ER co-pay is waived, so any “life-threatening” issues still should be taken to the ER.

Ambulance co-pays also vary widely by plan.

Some plans offer an Over-the-Counter (OTC) medicine benefit. For 2017, one plan offered to pay up to $45-a-month for OTC products. The same plan for 2018 is offering $25 for three months , the suggestion is that Medicare Advantage and Supplement plans are “bleeding money” and looking for ways to reduce costs.

Insurance, even Medicare Advantage and Supplement plans, is a profit centered business, ergo the number of local and national (e.g., Aetna, Blue Cross, Humana, United Healthcare) insurers are aggressively seeking new members (customers).

A quick comment on referrals. Most Advantage plans now require PCPs to refer patients to specialists. In my opinion, this is a good thing. The PCP is the patient’s primary medical contact. It is for the patient’s benefit that the PCP knows what a specialist ordered — especially medications — so assure that there are no contra-indications. (Actually, when it comes to drug interactions, the pharmacist is the best source of information.)

Advantage or Supplement plan

Many — most — Advantage plans are zero EXTRA cost — they are not “free” or “no cost” since the customer still must pay the monthly Medicare fee. All Medicare Supplement plans have a “supplemental” fee.

(Supplement plans also are called “Medigap” plans.)

Some plans, such as UnitedHealthcare’s AARP Supplemental plans, require membership in the related organization (e.g. AARP).

According to Mediare.gov³, Every Medigap policy must follow federal and state laws designed to protect you, and it must be clearly identified as "Medicare Supplement Insurance." Insurance companies can sell you only a "standardized" policy identified in most states by letters.

All policies offer the same basic benefits but some offer additional benefits, so you can choose which one meets your needs..

Each insurance company decides which Medigap policies it wants to sell, although state laws might affect which ones they offer. Insurance companies that sell Medigap policies:

• Don't have to offer every Medigap plan
• Must offer Medigap Plan A if they offer any Medigap policy
• Must also offer Plan C or Plan F if they offer any plan

The Medicare.gov site has an internal link to a list of Supplement plans by ZIP code and by cost, along with a list of companies offering each plan type.⁴

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CAUTIONARY NOTE: The most reliable sources for Medicare Advantage and Supplement plans is Medicare.gov. Some commercial (not “.gov”) sites fail to include all available plans since not all insurers are willing to pay to be listed. Medicare.gov lists ALL plans available in a particular ZIP code.

Medicare Resources

1. Advantage: http://tinyurl.com/opgeeqz

2. Available plans: http://tinyurl.com/2c6o5fh

3. Supplement: http://tinyurl.com/h5vfups

4. Compare plans: http://tinyurl.com/y8ooewmj

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.

Comments on Medicare

Medicare Plans Getting plan info Is not an easy task

 

IT'S THAT TIME OF YEAR when geezers, I proudly include myself in that group, look at Medicare plans - Medicare Advantage and Medicare Supplement plans from sundry providers.

Such plans are profitable for the providers - health insureance companies; if you don't believe me, look at the numbere of companies advertising their wares for the $100-plus dollars geezers pay into Medicare each month.

But it isn't the "dues" the companies want; it’s the additional revenue from D.C. they are after - substantial additional revenue.

Over the years I've signed up with two different providers; I'm currently back with my original provider.

But my original provider changed the fees for some of my medications; the co-pay went from $21 for a 90-day supply to $105 for the same amount. That was enough to send me in search of "options."

What I want to see - and some providers make it easy - are three documents:

1. Evidence of Coverage
2. Providers' List
3. Formulary

Evidence of Coverage The EOC tells me what the plan covers and what it pays. All plans seem to cover everything Basic Medicare covers, but usually offer additional coverage and lower co-pays.

For example, Medicare covers in-patient hospital care at $0.00 for the first 60 days (https://www.medicare.gov/coverage/hospital-care-inpatient.html), but there is a nasty $1,260 deductable for each benefit period. My current provider gives me Days 1 through 5 at $0, but my co-pay for Days 6 through 20 is $80/day, dropping back to $0 co-pay for the rest of my stay. My deductable: $0.

Many plans charge $100-$200-a-day for the first days and then drop the co-pay to $0.

Over the last few years I have been a hospital "guest" twice; the first time for 5 days (=$0) and the second time one day (again, $0). When I initially signed up, the sales person told me "most hospital stays are 5 days or less." So far he's been proven correct.

Providers This lists all the physicians, hospitals, pharmacies, and other health care people and organizations with contracts with the plan.

Back when I had a really great PCP, I would first check to see that he was on the list. Then he and my current provider failed to reach an agreement and he was dropped from the plan's proivider list. (In a fit of pique I went with another plan only to fiind out that while it had lots of providers, my access to them was limited by my PCPs' personal list. I went through 5 PCPs in a year with that plan. When enrollment time arrived, I was back with my original plan and yet another PCP who seems to be at least "OK.")

Since I've learned to live with other than my preferred PCP - his office operation was, and remains, a total disaster - I now assure that my vascular surgeon is a plan provider; that he's "on the list." Because he is associated with the hospital where my surgeries are performed, the hospital automatically also is on the list.

Two medical professionals are important to my well-being; the vascular surgeon and the anesthesiologist - I have the scars to prove it.

Formulary The Formulary is a list of medications the plan is willing to provide; some for $0 co-pay and some for co-pays ranging upward from $35 for a 30-day supply.

The cost of medications links back to the Evidence of Coverage. The EoC shows how much the plan provider will pay toward medications. When that limit is reached - it seems to vary between $2750 and $3500 depending on plan - the plan member - the geezer - falls into the "Donut Hole" and has to pay "45 percent of the negotiated price and a portion of the dispensing fee for brand name drugs. You pay no more than 58 percent for generic drugs and the plan pays the rest." The "Donut Hole's" official name is "Coverage Gap Stage."

The Gap comes into play when the plan and the member together have paid the plan's limit - e.g., $3000 - for perscription medications and continues until the member (geezer) has paid a total of $4850 from the member's pocket. Most plans will estimate the total cost of medications - based on the geezer's medications list - before asking for a signature on the virtual dotted line.

UNFORTUNATELY some providers, even some "Big Name" providers, hide the information from prospective clients. Rather than make it easy for geezers to review their plans they hide the information. On-line chat is no help for some. Calling likewise is a waste of time. (I encounted both earlier today.)

My recommendation: If you have a physician that you consider critical to your well being, GO to that practitoner and as what Medicare policies he or she accepts, then, if necessary, contact the providers' local offices and demand to see the three critical documents. Medicare - read taxpayers - pay the providers to prepare and distribute those documents for current and potential plan members.

On the other hand, any plan management too stupid to make the documents available on-line in PDF format probably isn't a plan worth having.