55 Million People are Medicare Eligible... Are Your Patients Making the Right Medicare Decision? You Can Help Them Get All of the Facts!
By Barbara Carey and Mike McCall
The story of Richard Timmins of a rural community outside of Seattle may be typical of some of your patients who have signed up for Medicare Advantage Plans lured into those plans by lower fees and extra benefits. They find that when they need to use their healthcare plan for a serious condition, there are obstacles that may delay their care or deny the services that their doctors say that they need. Providers have known this situation for a long time, but consumers are generally unaware of the significant differences between Original Medicare and Medicare Advantage Plans.
Mr. Timmins’ story was reported by Sarah Jane Tribble, a South Florida reporter. Mr. Timminssigned up for a Medicare Advantage planbecause of its broader coverage and lower cost.He was healthy at the time that he signed up.Then, he was diagnosed by his doctors with malignant melanoma, which is common in his family. He said, “It started to grow and started to become rather painful.”
He discovered that his enrollment in his Medicare Advantage plan meant a limited network of doctors and the potential need for preapproval or prior authorization from the insurer before getting care. He said that his insurer made it more challenging to get care for a variety of reasons including the difficulty of finding and getting to see specialists. Note that some providers have stopped taking Medicare Advantage Plans. He said he felt that, “I have very little control over my actual medical care.”
He now wants to go back to Original Medicare. But he can’t and he’s not alone. Traditional Medicare can be too expensive for beneficiaries switching back from Medicare Advantage because they may not get accepted for Medigap insurance that covers the 20% of their medical expenses not covered by Original Medicare. A senior is automatically accepted by Medigap insurance if they apply to Original Medicare when they turn 65. But that acceptance is not guaranteed if they try to switch back after being in a Medicare Advantage Plan. Medigap insurers can consider pre-existing conditions like Mr. Timmins’ malignant melanoma at that time and deny coverage. Only Connecticut, Maine, Massachusetts and New York prohibit insurers from denying a Medigap policy if the enrollee has a pre-existing condition. So many seniors sign up for Medicare Advantage plans then are indeed trapped as they age and require more medical care. Seniors with chronic conditions like heart disease and diabetes unknowingly select Medicare Advantage plans and find out later the restrictions on their physician network and preapprovals for procedures and treatments that are often required.
What Can a Provider do to Prevent Patients from Falling into this Trap?
TCI has observed the disparity in public information on comparing Original Medicare objectively with Medicare Advantage plans. We feel that providers need to be proactive in giving consumers the education that they need on a consumer level so that they can make the right decision for their individual circumstances.
TCI has prepared consumer directed educational materials that are simple, ready to use and accurate to help providers educate older patients on their Medicare options. TCI's Education Tools are available at tcishop.com. Watch our video below.
We Help Our Clients Understand Their Environment and to Find Solutions.
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