Caveat Emptor

Caveat Emptor [Buyer Beware]… ‘Tis the season for open enrollment which runs from November 15^th through December 31^st, 2010.

Those that are Medicare eligible have been receiving tons of mail for weeks and many may feel a bit confused regarding the actual task at hand. Making the “RIGHT” decision about healthcare insurance seems more important than ever, so the pressure is on.

And here come the “ADVANTAGE” plans: with fliers, letters, booklets, television and newspaper ads, seminars and telephone calls all proclaiming that their

Products are somehow superior to your original Medicare and a Medigap policy.

Yes, it may look like a good deal-and oh! There are perks! Health club memberships…and you always got your money’s worth out of your health club memberships, didn’t you? Maybe a little vision or dental benefit. When young and healthy, these policies may even be a great deal, and quite satisfactory for many. That’s mostly because it is unlikely that you will need skilled nursing care right off the bat.

Under original Medicare skilled nursing care in a qualifying facility is covered for the first 20 days at 100%, and the next 80 days at 80%. That’s one of the places that the Medigap coverage is important; the other being the 20% not covered under Part A for hospital care [and more], and the 50% of Part B for outpatient care [and more].  In contrast to having up to 100 days of skilled care and rehabilitation following an illness, injury or surgery, one plan being marketed as “sooo great” covers only seven (7) days of skilled care. For the subsequent [up to] 93 days a $100/ day co pay is needed. Whoa! You could be billed much as $9300 out of pocket if you were ill or injured and needed all 100 days of coverage for your care and rehabilitation.

Well… not to worry.

Advantage Plan benefits, already much reduced compared to original Medicare, are also vigorously managed. Your healthcare provider must persuasively argue on a daily to weekly basis to justify your continued care. The chances of receiving all 100 days-or even that entire first 20 days- are not great.

In spite of frail health- physically, emotionally, and cognitively- criteria for continued care are rigorous. There is less and less tolerance for the seemingly inevitable run of “bad days,” slow progress, and “plateaus” in progress. The provision of physical, occupational, and speech therapy “to maintain functioning and prevent further decline” is rare, although it is a documented Medicare benefit. Thus, lengths of stay in Medicare-funded skilled care are often much more limited than patients and families anticipate.

 Another reason to hang on to your original Medicare? Your doctor, favorite hospital, skilled nursing facility or other provider may not accept your particular Advantage Plan. For example, providers in the Summit Medical Group, right here in K-Town, will be accepting only Humana Advantage Plans after January 1. Many unsuspecting older patients will find themselves without access to their longstanding, trusted primary care docs unless they make the change to Humana.

(Summit will continue to accept original Medicare and your Medigap policy.)

 If these Plans aren’t advantageous why not just return to original Medicare? That can be done. However, once past your initial option to purchase a Medicare supplemental or “Medigap” Plan, your ability to access this very valuable secondary coverage becomes increasingly expensive and downright unaffordable for many. Medical underwriting may even deem you ineligible due to advancing age and increased health issues. However, if income  assets are ample, doing without the supplemental may be an option.

 So what if you have an Advantage Plan?

All is certainly not lost. Even though it’s not the best thing, it’s also not the worst thing.

During open enrollment sign up for the bestest/ mostest of it you can have: the most precious metal or gemstone offered by your carrier.  Also, families must be prepared to advocate for their loved one’s needs. Whether original Medicare or an Advantage Plan, it is important to speak up if you believe you or your loved one is being discharged prematurely from any service covered under your plan. We have found that appeals are indeed considered, and sometimes successful in gaining more time for needed care.