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

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.