Open enrollment for “Medicare Advantage” begins January 1
By Margie Ware
Many consumers have received advertising from Medicare Advantage programs such as Tufts, Aetna, Blue Cross, Humana and Harvard Pilgrim. Many call the SHINE (Serving Health Information Needs of Elders) program and ask some version of the question, “Do you think I should do this?” or “What is this about?”
SHINE counselors provide neutral, unbiased information to Medicare beneficiaries and elders on their health insurance choices. We don’t give opinions. We try to explain what the pros and cons and nuances are of various choices and then help the consumer decide what would be best for him/her.
Almost all Medicare beneficiaries have Part A (Hospital Coverage) and Part B (Medical Coverage). If one wants to cover the “gaps” in Parts A & B, one can purchase supplemental insurance, often termed “Medigap” coverage, because it covers the gaps in Parts A and B. In addition, Medicare beneficiaries are now urged to purchase Part D prescription drug coverage.
A number of years ago, Medicare introduced what were termed “Medicare Advantage” plans, designated as Medicare C. “Medicare Advantage” has consumers deal directly with insurers, with the insurers in charge of cost control. In other parts of the country, and even in other parts of Massachusetts, these Medicare Advantage plans have flourished. Beneficiaries reading the “Medicare and You” booklets are often confused because the service areas of the “local plans” never include Berkshire County. Due to financial problems, the last HMO left Berkshire County in 1999, and since then only “Original Medicare” has been offered.
In 2007, companies decided to market what is called a “Private Fee for Service Plan” (PFFS) in Massachusetts. It was a concept new to this area, and during the last two years it was embraced by a few consumers who tended to fit a particular demographic. It is not for everyone. It appeals primarily to “healthy seniors” who use the healthcare system infrequently and want a safety net against catastrophic costs.
The PFFS plans are totally different. As opposed to HMO’s and Preferred Provider Organizations, healthcare providers do not “belong” to a PFFS. Each provider may, on an individual basis, decide to accept the insurance on a case-by-case basis. Companies who market these products say that in other parts of the country, where these plans have been available, they are generally accepted once the providers understand the benefits. In essence, the providers are contracting with a private organization, rather than with Medicare and possibly a supplemental plan, to be paid directly (as with an HMO) without waiting for longer processing times.
The PFFS plans offered in Berkshire County sometimes combine supplemental Medicare A & B coverage with drug coverage; other plans can be purchased without a drug plan if the individual has other coverage, such as from the VA. PFFS plans often include additional benefits like health clubs, annual physical exams, dental cleanings and occasional vision services. The total price of the package can be less than what a consumer would pay for the least expensive supplemental Medigap insurance, known as “Core.”
“Core” insurance covers the 20% of doctor’s bills and co-pays for tests not covered by Medicare. So, on the one hand, receiving extra hospital coverage, drug coverage, and maybe a health club for the same price sounds like a good deal. This works as long as you’re healthy. What PFFS plans do not emphasize is that there are co-pays for therapy visits, hospitalizations, etc. that one would not experience with a traditional Medigap. A round of chemotherapy or rehab for a hip replacement could end up costing you more than you expected. And if your health status changes, you may have to wait six to 12 months to switch plans to something more cost-effective.
Of course, for “healthy seniors,” particularly those newer Medicare beneficiaries between 65 and 70, the chances of a hip replacement or a course of radiation are low -- unless you have already experienced significant health issues even before age 65.
Medicare beneficiaries will notice seminars advertising these Private Fee for Service plans as well as information from insurance agents licensed to sell these products. Many companies send mailings asking you to return a card for more information. The plans are not allowed to “cold call” you or knock on your door without being invited. For some individuals, they could provide comprehensive coverage for a relatively reasonable price. But buyers should be sure they understand the structure of the plans before they make a commitment to a plan. SHINE does not recommend discussing these plans with sales people in your home unless you have someone else with you.
As always, a call to Elder Services SHINE program at 499-0524 or 1-800-544-5242 can at least give you a “second opinion” about your choices for a Medicare supplement. Medicare Advantage plans can sometimes offer a safety net, but do your research before you make a decision. Insurance salespeople often work on commissions and may not give you all the information that you need to make an informed choice.
Medicare Part B open enrollment begins January 1
By Margie Ware
Medicare Part B covers some medical expenses not covered by Medicare Part A (hospital insurance) such as doctors’ fees, outpatient
hospital visits, and other medical services and supplies. If you are eligible for Medicare Part B medical insurance, but you didn’t sign up for it when you first became eligible for Medicare, you will have another opportunity to apply. Open enrollment for Medicare Part B runs from January 1 until March 31, 2009. Better to act early than late; if you miss the deadline, you will have to wait until 2010 to apply. When you first become eligible for basic Medicare hospital insurance (Part A), you have an initial enrollment period of seven months in which to sign up for Part B medical insurance. After that, you have to pay a higher premium, unless the reason you declined Part B was because you were covered through an employer’s group health plan or a group health plan based on a spouse’s employment. You are given another opportunity to enroll in Part B during the general enrollment period, from January 1 to March 31 of each year. But each 12-month period that you are eligible for Medicare Part B and do not sign up, the amount of your monthly premium increases by 10 percent. Medicare is made up of four parts: Hospital insurance (Part A) that helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care; Medical insurance (Part B) that helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance; Medicare Advantage (Part C) plans are available in many areas. People with Medicare Parts A and B can choose to receive all of their health care services through one of these provider organizations under Part C; and Prescription drug coverage (Part D) that helps pay for prescription medications. In addition, some people with limited income and resources may qualify for extra help to pay for the costs such as monthly premiums, annual deductibles and co-pays, related to their Medicare prescription drug plans (Part D). You can learn more about the extra help at www.socialsecurity.gov/prescriptionhelp. You can learn more about Medicare with our online booklet, “Medicare”, at www.socialsecurity.gov/pubs/10043. html You also can call us toll-free at 1-800-772-1213 (TTY 1-800-325-0778) to ask for a copy. Or visit the Medicare website at www.medicare.gov. You also can call Medicare at 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048). Just remember the Medicare Part B open enrollment runs from January 1 to March 31.
Margie Ware is Elder Services SHINE Coordinator.
