Medicare Advantage

There are times when I wish Congressmen had no staffs. Then when some family member needed help selecting an insurance plan, they couldn’t turn it over to someone else, who would then call a friend who would call a friend, eventually reaching someone who helped write a 1,100 page law and knew the right person in the industry to issue the perfect policy for the relative.

Understanding the simple basics of medicare options took nearly two full days of surfing the web when my boss thought I was doing something worth my salary. I finally found that, like IBM programming manuals, everything on websites made sense once I had already figured things out for myself, but nothing made sense until then.

I had always assumed that medicare coverage just happened when I turned 65, and I could afford the smaller social security paycheck because I wouldn’t need to pay so much for private insurance.

I also assumed my mailbox would be filled with circulars from various medicare providers. When I got nothing, I called by insurance agent to get advice on what I still called supplemental medicare insurance, only to be told (1) my agent didn’t handle medicare related policies, (2) I had to register with social security, and (3) the best thing to do was call AARP.

Calling social security was easier than AARP, and within minutes I was registered. It took three weeks, however, to receive a piece of cardboard that confirmed my account. It came the same day as a notice from my current insurer saying my rate next year, if I were still 64, would rise from $366 a month to $453 and convert from a PPO to an HMO. It would only be $405 if I lived in a more metropolitan area, filled with more accidents and pollution.

The first thing I had to learn was the meaning of medicare parts A and B. The first covers hospitalization and is free. The other covers medical needs and costs $96 a month. It rises to $110.50 next year, but no one at Medicare seemed to know that. It only found out when I got my first bill.

That’s $1,326 a year. If I remain healthy and only see my doctor once a year for a physical, supported by blood work and an every other year bone density test, I’m essentially paying all my own medical expenses. The physical is explicitly not covered by Part B, and it’s still not clear if the geriatric lab work would be covered.

However, someone rear-ended my car some years ago, and three times in the last ten years I’ve had to go through physical therapy to overcome muscle problems caused by the whip lash. Each clinic charged at least $100 a visit, in addition to my co-pay. If that happens in the future, as it may, I’ll get some benefit on my $110 a month investment.

The next thing I had to learn was that what my father had as supplemental insurance no longer existed after Bush added the drug benefit. Now, one must choose between a heavily advertised medicare advantage plan or a secretive medigap policy. The one is essentially a nicely packaged HMO or PPO that front ends medicare, handles the drug benefit and may add a few other things. Real coverage is only available from an insurance company.

In this state, there are several bottom feeders, defined as those who are working to sabotage health care reform, who offer medicare advantage plans. In addition, there’s a local HMO I vowed to never use after a one year stint when they seemed more interested in generating cash in the form of co-pays required to get referrals than in serving my needs. I finally found my own doctor and paid my own expenses for the rest of the year.

There’s the PPO I currently have who did not have a service agreement with the primary hospital in this region until this spring. Confirming that took some phone calls. The company’s central office said that it was true, but no one at the hospital had worked there long enough to understand my question. As my insurance agent said, that agreement isn’t strong enough to use as the basis for a decision - it could be cancelled any time by either side.

Blue cross simply says they’re no longer offering a medicare advantage plan in the state next year.

When I talked to people who are already on medicare, I found they have no idea what they have. My boss’s mother only knows what she has is free and I must be some kind of fool to be paying anything more than the deeply resented monthly fee.

When she got bubonic plague this year and was hospitalized for five days, she says she only had to pay a few co-pays for follow-up appointments and part of the price of the ambulance because it wasn’t an emergency. Why getting an 80-year-old woman having trouble breathing and a high fever to the hospital isn’t considered an emergency, I don’t know, especially when they discovered e-coli had broken from its confinement as a consequence of the plague.

She says she has no drug coverage, but also says she’s a member of that HMO I boycott who offers medicare advantage with or without drug coverage. The one has no premium, which means she is essentially getting only medicare part B, with no assigned doctor.

Another friend’s father put her mother into a dementia care center this year, and discovered none of the costs are covered by his policy. He won’t tell her any more than that it’s with the HMO/PPO that didn’t have an agreement with the hospital in the state capital, so I know it’s medicare advantage and not the supplemental he may have thought he had.

Once I made the decision to use medigap instead of an advantage plan, I learned why the HMO’s and PPO’s are popular. My current physician doesn’t accept Medicare. I can still see her if I’m willing to pay my expenses. When I called the first name on the list of doctors she recommended, his receptionist said he also did not accept Medicare. The other two aren’t accepting new patients. Or rather, I can make an appointment in November for March or May, two months after my current prescriptions expire.

Even having good insurance isn’t enough to guarantee treatment in this part of the state.