• Medicare is complicted, ctd.

    It has been fascinating to show people the CHRT‘s chart of how people would get health insurance under the ACA, and to listen to what they see (complicated; simple; clear; confusing; Medicare much simpler; no it is more complicated; it is simple in one sense, complicated in another, etc.).

    Austin’s take was that the chart is misleading because it says “if age 65 plus or otherwise eligible for Medicare, then you have Medicare” while it then provides a flow chart for everyone else. Essentially, the box “to Medicare” could have an asterisk that says “flip to the back for the Medicare flow chart.” Recently, I helped an age-eligible Medicare beneficiary decide what to do inside the “Medicare” box of the chart.

    • She had been covered by a combination Medicare supplement/prescription drug plan for the past 6 years, provided by the company from which her spouse retired 19 years ago; this company decided to drop all employee health insurance benefits beginning Jan. 1, 2012.
    • That means that she can sign up for a Medigap plan and a Part D prescription plan with no penalty for late sign up so long as she does so during the Medicare open enrollment period (Oct 15-Dec 7, 2011).
    • She could also sign up for one of 19 Medicare Advantage plans available in her zip code (private option that combines Parts A, B, D and Medigap).
    • After talking with her I concluded several things: physician choice was very important to her, to an extent that I consider to be the extreme, so this tilted me away from Medicare Advantage plans, some of which had either/or choices in terms of one health system on another where she lives and she currently sees docs in both systems.
    • Picking the Medigap plan to cover what Part A and Part B do not cover was fairly straightforward, and plan F was the one for her given historical use patterns. There was one that provided the most physician choice available to her. Interestingly, it also had the lowest premiums so it was an easy call. This turns the more choice/higher premium assumption on its head. I think this is due to the fact that it is by far the dominant insurance carrier in this state. update: In theory all Medigap plans cover all docs that accept Medicare, but there was a therapeutic example in this person’s medical history related to the application of a non-pharmaceutical therapy in which a plan stipulated they would supply the needed factor, and some physicians will not do it this way.
    • Prescription drug plans were trickier. This person takes 14 prescriptions, several of which are very expensive; she refuses to do mail order; she insists on using one pharmacy that is very small. These preferences (esp mail order) trimmed the list quickly and left 4 options.
    • I used an online tool and entered the pharmaceuticals taken and got a clear out of pocket and premium estimate. I also checked with her pharmacy to ask a few questions.
    • I picked the best one and it was offered by a company she had told me at the beginning of the process that she would “never do business with them because they were in business with the government.” I showed here that the second best plan would cost her about $1,100 more in out of pocket costs in a year and she changed her mind.
    • Bottom line: it was easy finding a Medigap plan and coverage is about the same as what she had. The prescription plan she had before was tons better (for her) than any Part D plan available; I see why the company wants out of providing that to spouses of retirees (also, the initial company has now been sold 4 times and the helpful person on the telephone said it was easier (and of course cheaper) to get out of the retiree health insurance business than to try and unify all the plans).
    • I spent 5-6 hours investigating this and around 2 hours over three conversations to convince the Medicare beneficiary that my suggestions represented the best route.

    This is what Austin had in mind when he said Medicare is complicated.


    • Annual enrollment period does not apply to Medigap policies; it only applies to advantage plans & part d. This appears to be a point of confusion for many people. She can still pick up a supplement with no penalties if her current coverage dropped her through no fault of her own for up to 63 days after her coverage ends.

      • @Red Chamber
        she is losing creditable health coverage provided by an employer, and per the documentation she received she would have 63 days after Jan. 1, 2012 (date of loss) as you say. However, the communication of the open enrollment period is powerful to her and in any event she is a high user and needs the cover on Jan. 1.

    • Are physicians compensated fairly, if at all, for the time the spend helping patients choose heath plans? If not what do you think would be fair compensation, given that many elderly patients are likely to need assistance?

      • @George
        I was helping someone else and didn’t consult a physician, but did consult a pharmacist. Neither are compensated to help patients pick Medigap plans and Part D so far as I know. I am not sure what fair compensation would be. I suspect it would also be hit or miss how helpful docs would be in any event, esp for picking Part D plans.

      • I’ve never heard of physicians assisting patients in choosing plans. Does that happen? If so, how it is not a conflict of interest? That is, wouldn’t the physician be biased toward plans that include him/her in the network and cover his/her services most generously?

        • @Austin Frakt
          On part D plan side, a couple years back asked a doc on behalf of this person about price of two different pharmas and how they would work with her insurance and he quickly said “that is not my dept.” So, I wouldn’t ask because i wouldn’t expect useful info (there were online tools where you put in your meds and it maps how it will work with different plans). I guess a potential conflict would be strongest for a Medicare Advantage plan if they were in more than 1 and they paid the doc differentially. I don’t think I have ever read any study on whether patients ask docs for Med Advantage v. FFS Medicare

    • Yes, Medicare is complicated. Just in the past few days, one of my colleagues (intelligent and well educated, of course) has asked for help in making Medicare decisions for a parent. Many other readers have doubtless had similar experiences. A relevant fact is that many Medicare beneficiaries are unable to make the necessary decisions on their own. Limited networks are also a special problem for frail beneficiaries, for whom just getting to a medical office is a huge production.

      • @Paul Van de Water
        I knew there were options and it was complicated, but doing this and having someone say “pick for me” was a sobering experience. It is highly questionable many Medicare beneficiaries can navigate these choices reasonably. Access to the physical doc building is a good point that shows that choice of provider not necessarily just a preference. In the case I was assisting with there is a “factor” that is sometimes injected for this person. Some Medigaps only allowed this if they sent the factor to the doc to be injected. The doc who had done it in the past will only do it if they supply the factor. Just an example of the weeds of the details being important