Friday, October 26, 2012

Prepare for Medicare Open Enrollment

From October 15th to December 7th, Medicare beneficiaries will have the opportunity to switch or enroll in Medicare Private Health Plans (Medicare Advantage Plan) and Prescription Drug Plans (PDP), as well as switch back to traditional Medicare A & B.  The Open Enrollment Period (OEP) is a risk free time to evaluate your current plan. New choices can be made regarding plans that would be effective as of January 1, 2013.

Specifically, here are the available options you have during the OEP:

(1) Dis-enroll from a Medicare Advantage Plan (MAP) by enrolling in a Part D-PDP. This automatically allows you to go back to the original Medicare Part A & B, and then purchase a Medicare Supplement.
(2) Change from your present PDP to another PDP.
(3) Enroll in a MAP with Prescription Drug coverage.
(4) Change from your present MAP to another MAP.

Let's explore these scenarios in more detail.

(1)  Dis-enrolling from a MAP and purchasing a Medicare Supplement. What goes into the process of effectively selecting a supplement? The first thing you should understand is that Medicare Supplements, sold by private insurance companies, are standardized.  This means that all the supplement plans labeled A to N have the same benefit structure regardless of the company selling the plan. For example, if you chose Plan F from the "X" insurance company, the benefits for Plan F are exactly the same for any other insurance company selling Plan F.  Once you decide on the appropriate benefits, you are selecting a plan based on  the service and price, which varies from one company to another.  You may also want to consider those plans that cover the additional 15% charged above the Medicare approved amount by those providers who do not accept Medicare assignment.

(2) Selecting the right PDP for you can be tricky. 

For example, Florida has 16 different insurance companies offering 34 different PDPs!  All Plans are not equal. In selecting a Plan, you should do an analysis of Plans in your geographic area by going to

Do not choose a PDP based on premium only.  The total annual cost is the best indicator for decision making. Other variables to consider are the deductibles and co-payment amounts. The latter can differ among plans, as well as among pharmacies, depending on whether the pharmacy is part of a preferred network.  Not all drug plans cover the same drugs equally, so some of your drugs may be covered under one plan; but not another. In select instances, you may also need mail order options for some of your drugs.  Not all Plans make this option available.  Also, certain drugs need pre-approval.  Finally, learn how to file an appeal if the PDP doesn't pay for your drug. ALWAYS APPEAL DENIED CLAIMS AND DRUGS.

(3)  If you decide to enroll in a MAP, you should be aware of the trade-offs involved.  

In most cases, these plans limit the availability of providers to a specific network.  As long as you stay in the provider network, you may only be subject to the Plan's co-pays and deductibles.  However, if you go out of the network, in a worst case scenario, you may not have reimbursable coverage. At the very least, your co-pays and deductibles will be greater than if you stayed in the network.  

MAPs operate in sharp contrast to the original Medicare Part A & B which allows freedom of choice. 

If you have original Medicare Part A & B and a Medicare Supplement that covers the 20% not covered by Medicare, and your provider accepts Medicare Assignment, you should never have any out-of-pocket costs with the exceptions of those few services not covered by Medicare.  

If you see a provider who does not accept Medicare Assignment, then you are subject to an additional 15%  charge above the Medicare approved amount.  This cost is a real out-of-pocket expense to you.  

If you see a provider who has opted out of the Medicare program entirely you would have no coverage and all charges would be out-of-pocket.  

The bottom line:  If you have original Medicare and want no out-of-pocket costs, you must obtain a Medicare Supplement that covers the 20% Medicare does not allow, and only visit providers who accept Medicare Assignment.  If you see providers who do not accept Medicare Assignment, be certain that your Medicare Supplement covers the additional 15% charged above the Medicare approved amount. Call your medical supplement to verify.

(4) Changing from one MAP to another should only relate to network availability and co-pays.  Perhaps your doctors and hospitals are in one MAP provider network and not the other.  These factors, along with premium costs, are the key considerations when selecting one MAP over another.

Remember, once you make your decision to enroll in a new plan effective January 1, 2013, you are locked into this Plan for the coming year, until the following Oct. 15 of every year, when you once again can re-evaluate and make any necessary changes through December 7th. As always, the more knowledge you have the easier it becomes to navigate the selection that is best for you..

Stay informed. Stay positive. Stay healthy.
-  The Patient's Advocate

Monday, October 1, 2012

Improving America's Health Care System

While health insurance coverage, including accessibility and availability, is currently at the forefront of political debate, often overlooked is how you improve the actual care we receive.  At the core of the health industry crisis in this country is fixing a system that will ultimately be more efficient and at the same time, provide better health care to patients at lower costs. America's health care is ailing and needs critical treatment, now.

As reported in a recent New York Times article, the Obama administration is setting up a new service for consumers to report issues and problems related to their health care.

A lot of folks thinks government should stay out of the private sector entirely, but this is a perfect example of a public agency seeking to protect its citizens. Nancy E. Foster, VP of the American Hospital Association says "it's a great concept. The idea is welcome." Anything that makes hospitals and doctors more accountable helps minimize errors and makes health care safer.

However, the role of government in our health care system raises another important question for this country. Is proper health care a luxury item or an entitled right? The answer is not necessarily a political one, but a moral one.  Where do you stand on it? How do you view your health care? And at what cost?

The United States is the most powerful, most advanced and most recognized country in the world; yet, its health care system ranks 37th according to the World Health Organization's 2000 rankings. A lot of factors went into the ranking; but above and beyond anything else, the most significant factor was expenditure per capita. breaks down the costs of care from 2010.

How is the U.S. health care dollar spent?

Hospital care and physician/clinical services combined account 
for half (51%) of the nation’s health expenditures.
National Health Expenditures, 2010

Total = $2.3 Trillion

What is driving health care spending?

While there is broad agreement that the rise in costs must be controlled, there is disagreement over the driving factors.  Some of the major factors that have been discussed in cost growth are:
  • Technology and prescription drugs - For several years, spending on prescription drugs and new medical technologies has been cited as a primary contributor to the increase in overall health spending; however, in recent years, the rate of spending on prescription drugs has decelerated.[1]  Nonetheless, some analysts state that the availability of more expensive, state-of-the-art medical technologies and drugs fuels health care spending for development costs and because they generate demand for more intense, costly services even if they are not necessarily cost-effective. [6]
  • Rise in chronic diseases – Longer life spans and greater prevalence of chronic illnesses has placed tremendous demands on the health care system.  It is estimated that health care costs for chronic disease treatment account for over 75% of national health expenditures. [7]  In particular, there has been tremendous focus on the rise in rates of overweight and obesity and their contribution to chronic illnesses and health care spending.  The changing nature of illness has sparked a renewed interest in the possible role for prevention to help control costs. 
  • Administrative costs – At least 7% of health care expenditures are estimated to go toward for the administrative costs of government health care programs and the net cost of private insurance (e.g. administrative costs, reserves, taxes, profits/losses).[1] Some argue that the mixed public-private system creates overhead costs and large profits that are fueling health care spending.[8]

ACA and Cost Containment

The nation’s efforts to control health care costs have not had much long-term effect [9], prompting a debate over what proposals are actually able to reduce costs for the long-term.  Approaches are largely divided by debate over a stronger role for government regulation or market-based models that encourage greater competition.  Costs emerged as a central element of the national health reform debate that ensued before the passage of the Affordable Care Act (ACA) of 2010.  Major ACA measures aimed at cost containment include[10]:
  • Greater government oversight and regulation of health insurer premiums and practices
  • Increasing competition and price transparency in the sale of insurance policies through Health Insurance Exchanges
  • Payment reforms that aim to reduce payments for treatments and hospitalizations resulting from errors or poor quality of care
  • Funding for comparative effectiveness research (CER) that compares different interventions and strategies to prevent, diagnose, treat, and monitor health conditions.[11] The Patient-Centered Outcomes Research Institute (PCORI) was established by the ACA to commission CER guided by patients, caregivers, and the broader health care community. [12]
  • Refocusing medical delivery systems to be patient-centered and improve the coordination and quality of care (e.g. ACOs, medical homes). [13]
Other proposals and practices directed at controlling costs exist, such as support for wider use of health IT in the delivery system, increasing consumer out of pocket costs, improving health efficiency and quality of care, reforming the tax treatment of health insurance, and a single payer plan.  As the nation struggles with a faltering economy, health care costs will surely continue to be at the forefront of policy debates.
Regardless of your position on health care as a right or privilege, we can all agree, the greatest challenge we face together, is how we continue to improve quality and lower costs. The Obama administration's new plan to monitor and track personal health care is a step in the right direction.

Stay informed. Stay positive. Stay healthy.
-  The Patient's Advocate