“Last month, Squared Away
published a primer for new Medicare
enrollees choosing between their two available options: an Advantage plan or
traditional Medicare plus a Part D drug plan and/or supplemental Medigap
policy.
“Millions of beneficiaries receive
their Medicare benefits without any major problems. But today’s blog [Sept. 3rd]
is about a report detailing complaints
to the national telephone hotline operated by the Medicare Rights Center, a
non-profit patient advocacy organization. Two of the top issues reported
by seniors were denials of coverage and rocky transitions from employer or
other health insurance into Medicare.
“Here are some of the findings [Sept. 3, 2015]:
- Sixty percent of calls about Advantage plans involved denials of coverage for physician care, home care, therapy, medical equipment, tests and other services. Some calls about coverage denials also involved traditional Medicare. However, in contrast to private Advantage plans, Schwarz said that private Medigap plans must follow Medicare’s lead in determining what’s covered. ‘If Medicare pays, then Medigap pays,’ she said.
- The majority of denials of drug coverage involved medications not on the list approved by the senior’s drug plan. This primarily affects either seniors starting new medications or new plan enrollees who learn that their plan doesn’t cover all their medications. Advantage and Part D drug plans are not permitted to deny coverage in the middle of a plan year if they’ve been covering a drug for a specific medical condition, unless the drug is removed for a specific reason, such as the appearance of a new generic. They can, however, remove the drug from the list when the senior’s annual policy expires, Schwarz said.
- An easy place to make a mistake is delaying enrollment in Medicare Part B (outpatient care, lab work, equipment and services) because the person has another type of health care coverage, including employer insurance for active employees, retiree health care provided by employers, disability, and COBRA. The typical mistake, Schwarz said, is ‘assum[ing] their other coverage is adequate when it is not.’ For more information, see page 5 of the report and watch this video.
- A ‘significant portion’ of calls were about switching between Advantage plans or from Advantage to traditional Medicare. Seniors’ complaints included learning their plan is too expensive, has denied coverage, has dropped a provider, or did not provide a clear explanation of cost-sharing during the enrollment period.
- One common theme running through the complaints is inaccurate information provided by various people advising Medicare enrollees, including human resources personnel, consultants, insurers, and even government officials.
“The hotline calls reviewed in this
report are by no means representative of the experiences of all Medicare
beneficiaries – the calls are skewed geographically to New York and other
places where the center has a physical presence. But the complaints indicate
the types of issues retirees can face. Choosing between Medicare
Advantage and traditional Medicare is a complex decision, and those approaching
retirement should start their homework now.
“The Medicare Rights Center's hotline number is 1-800-333-4114. And stay
tuned – the center plans to update its report in the fall with 2014 data.”
The above information is from the
Center for Retirement Research at Boston College, Squared Away Blog.
It is very complex, and the BILLING choices allowed to Medicare Advantage plans for out-of-network healthcare are quite arbitrary. It is imperative to get their billing agreement in writing or you personally may be billed.
ReplyDeleteIf you go out of network, despite the wording of "any provider", you, personally, may be billed for a full retail amount that is different from the in-network amount. Once you send the bill to the Advantage Plan, they will pay what Medicare would pay, and YOU WILL PAY THE REST of whatever the full bill was for."
Here is my full blog which explains the possible choices for billing that an out-of-network provider has.http://reclaimreform.com/2015/09/05/illinois-retired-teachers-are-the-details-regarding-our-medicare-advantage-ppo-misleading/