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Posted by Rich Carreiro on December 12, 2009, 10:49 pm
I'm trying to help my mom figure out a few things (so there will likely
be more posts in this thread as time progresses :).
One bit of simplificiation to get out of the way up front -- neither
the "when you first sign up for Medicare B" Medigap guaranteed issue
condition nor the "tried Medicare Advantage for the first time and
have been in it less than a year" guaranteed issue condition (or any
of the other guaranteed issue conditions) apply.
So, some questions:
1) You can always (during the annual open enrollment) switch from
Medicare Advantage to Original Medicare regardless of age, health,
etc., correct?
2) If you do so, you have the guaranteed right to also join Medicare D
prescription coverage?
3) However, you have no right to be issued a Medigap policy? (I
imagine that's true, unless state law provides to the contrary).
4) Is there any guaranteed right to be able to join a Medicare
Advantage plan?
5) If you switch from Medicare Advantage to Original Medicare (with or
without an associated Medigap policy), do you have a guaranteed
right to go back to a Medicare Advantage plan in the future
(including the same plan you were previously in if it is still
being offered)?
6) You often hear about doctors refusing to take Medicare patients.
Is that in the context of Original Medicare, Original Medicare +
Medigap, or Medicare Advantage? Or with all of them?
7) How do pre-existing exclusions work when switching between Medicare
Advantage and Original Medicare (in either direction) or between
Medicare Advantage plans, or between Medigap plans, assuming you
have been in the plan you're switching from at least 6 months and
have no gaps in coverage?
I'm sure I'll think of more questions :)
--
Rich Carreiro rlc-news@rlcarr.com
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Posted by Elle on December 12, 2009, 11:45 pm
Do you have your mother's copy of "Medicare & You 2010"? This should
have arrived in October by snail mail. You may also try the
Medicare.gov site's downloadable, quasi-generic edition at
http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf . Be aware the
manual your mother received is state specific and may be preferable
for answers to some questions.
> 1) You can always (during the annual open enrollment) switch from
> Medicare Advantage to Original Medicare regardless of age, health,
> etc., correct?
Short answer: In general, yes. See page 58 at the link above.
> 2) If you do so, you have the guaranteed right to also join Medicare D
> prescription coverage?
With original Medicare and to get Medicare Part D, you must have
Medicare Part A and/or Medicare Part B. See page 63.
> 3) However, you have no right to be issued a Medigap policy? (I
> imagine that's true, unless state law provides to the contrary).
Page 43 says those with Original Medicare can choose to buy a Medigap
policy to get coverage that fills the gaps in Original Medicare.
> 4) Is there any guaranteed right to be able to join a Medicare
> Advantage plan?
See page 52. To be guaranteed the right to join a Medicare Advantage
plan, your mother has to have Part A and Part B; live in the service
area of the plan; not have end stage renal disease (ESRD) with some
exceptions for ESRD as explained on page 53.
> 5) If you switch from Medicare Advantage to Original Medicare (with or
> without an associated Medigap policy), do you have a guaranteed
> right to go back to a Medicare Advantage plan in the future
> (including the same plan you were previously in if it is still
> being offered)?
See 4) above.
> 6) You often hear about doctors refusing to take Medicare patients.
> Is that in the context of Original Medicare, Original Medicare +
> Medigap, or Medicare Advantage? Or with all of them?
I do not have experience with this.
> 7) How do pre-existing exclusions work when switching between Medicare
> Advantage and Original Medicare (in either direction) or between
> Medicare Advantage plans, or between Medigap plans, assuming you
> have been in the plan you're switching from at least 6 months and
> have no gaps in coverage?
See page 58.
Caveats:
1.
A social worker friend of mine who works with the elderly explained to
me that there is a huge shakeup nationwide with Medicare, due to the
recession. I know this sounds vague, but after working with the
Medicare system for about a year now on behalf of a relative, I am
astonished at how chaotic the system seems, in particular with
Medicare Part D. My friend assured me that the system is far more out-
of-whack now than it was a few years ago.
2.
Medicare Part D went into effect just four years ago. I am sure you
have read of people's annoyance with it. It is difficult to
understand, due to for example, the same plan taking different names;
the vocabulary being inconsistent among representatives; the same plan
switching subcontractors (the subcontractors being the actual drug
insurer, if this somehow makes sense). My personal contact with
Medicare Part D providers (on behalf of a relative, as POA) has been
nightmarish. One gets different information on the same subject from
different reps. Some Part D repts will try to sell you something;
remember they are not the government but for profit companies. They
tend to be slippery, in the used car salesmen sense of the word.
Document every call you have with Medicare Part D. Keep phone records.
Speak with the pharmacy who supplies your mother's drugs and make sure
they know exactly which Medicare drug insurance coverage she has, so
they bill the Medicare plan and not your mother.
3.
1-800-Medicare is in fact a very good resource. The catch for you may
be that you may lack POA and/or being the Social Security
Representative Payee (an SS term) and so they are not authorized to
tell you anything specific to your mother. She however may call and
you can listen on an extension.
4.
www.medicare.gov also has an online calculator site to help people
pick between Part D plans. There are dozens, typically, from which to
choose for any given part of the country. Many recommend this online
site. I thought it good or at least better than nothing.
5.
I try to find logic in this system. It is very hard to do. At this
point it is no wonder to me that there is so much Medicare fraud.
Good luck.
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Posted by Reed on December 13, 2009, 7:34 am
SNIP
>
>> 6) You often hear about doctors refusing to take Medicare patients.
>> Is that in the context of Original Medicare, Original Medicare +
>> Medigap, or Medicare Advantage? Or with all of them?
>
>
My personal experience (and understanding) is that providers can pick
and choose which, if any, plans they accept. Having just turned 65
last August, I was surprised to learn that my regular doc only accepts
2 specific Advantage plans No Traditional, No Medigap !
(I had planned on the Medigap route). A friend had the opposite
situation. His doc accepted Medigap but no Advantage plans.
In addition to the sources Elle mentioned, each state also has a
program called SHIP "Senior Health Insurance Assistance Program," that
you can call and get answers specific to your state.
Find yours here
http://www.medicare.gov/Contacts/staticpages/ships.aspx
Having spent the previous year studying up on Medicare, I found it to
be exceedingly complicated to understand the choices, only to find out
my doc had made my "choice" for me. I've only been on for 5 months
with no needs as yet. What worries me some is I may be moving out of
state soon, and am not looking forward to finding a provider who is
accepting new Medicare patients. (BTW, my current doc does not)
Good luck
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Posted by Elle on December 13, 2009, 7:50 pm
> In addition to the sources Elle mentioned, each state also has a
> program called SHIP "Senior Health Insurance Assistance Program," that
> you can call and get answers specific to your state.
> Find yours herehttp://www.medicare.gov/Contacts/staticpages/ships.aspx
Thanks, Reed, for adding this. I agree it is another resource to
consider. Anecdotally, my relative's SHIP gave me grossly incorrect
information, costing me about two hours more labor of chasing one's
tail. I eventually tried the Federal 800-Medicare number. The federal
representative accessed my relative's file (with me on record as POA/
SS rep. payee) and within five minutes explained to me exactly what
was going on with my relative's Medicare Part D plan, including
relating the specifics about her new and very much state-specific plan
(starting January 1), its toll free number, and what to look for in
the mail from the plan. The federal representative knew his stuff. The
lesson to me is to call the federal number first and see whether the
federal Rep can answer the question or questions at hand. If not, then
I trust they will send clients to the appropriate SHIP.
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Posted by rick++ on December 14, 2009, 1:10 pm
Right now the HMO's love the Advantage program.
They get the whole premium upfront and dont have to bill
the government per service.
Plus they are getting a 14% sweetener to take patients.
But most of the health reform bills phase out the sweetener.
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