The Health Care Reform Law will be cutting payments to Medicare Advantage plans, but some plans may actually get more money – if they are highly-rated, meaning they are the best of the best when it comes to patient care, illness prevention, and customer satisfaction.

Unfortunately, the Medicare Advantage plans we have in Tucson are not highly-rated.

If you go to Medicare.gov and click on “compare health plans”, you will be asked to enter a zip code.  Put in any Tucson zip code and you will get a list of  all the Medicare Advantage plans offered in Pima County (or any county in the country based on the zip code you use). The rating system is based on five stars:

5 = excellent
4 =  very good
3 = good
2 = fair
1 = poor

No Tucson Medicare Advantage plan is rated higher than 3 stars, meaning our plans are okay but not great.  Health Net and Secure Horizon plans get 3  stars, while Humana and Evercare get 2.5.

In Phoenix, the Cigna Medicare Advantage Plan gets 4.5 stars. This is better than Kaiser in California, which gets 4 stars.  I mention Kaiser because their plans, where doctors are employed by Kaiser, are supposed to be the standard bearer for managed care plans.

CareMore in California gets  4.5  stars for all  its Advantage plans, most of which are for people with chronic illnesses such as heart disease, diabetes, and breathing disorders. The CareMore plans in Tucson are too new to be rated as this is their first year in operation here.

I read somewhere that long-running Medicare Advantage plans tend to be the better plans, so I don’t know why our Tucson plans are merely “good”. Tucson has had Medicare HMO plans since the early 1990′s and in a March, 1996 article, The New York Times said Tucson’s Medicare HMO plans would be the model for saving Medicare.  I wonder what happened in Tucson?  Getting 2.5 and 3 stars is not going to gain our Medicare Advantage plans any favors from Medicare when it comes time for payment cuts.

The Medicare.gov website explains the ratings:

This summary rating gives an overall score on the health plan’s quality and performance on 33 different topics in 5 categories:

• Staying healthy: screenings, tests, and vaccines. Includes how often members got various screening tests, vaccines, and other check-ups that help them stay healthy.
• Managing chronic (long-term) conditions. Includes how often members with different conditions got certain tests and treatments that help them manage their condition.
• Ratings of health plan responsiveness and care. Includes ratings of member satisfaction with the plan.
• Health plan member complaints, appeals, and choosing to leave the health plan. Includes how often members have made complaints against the plan and how often members choose to leave the plan.
• Health plan telephone customer service. Includes how well the plan handles calls from members.

The information described above is gathered from several different sources. In some cases it is based on member surveys, information from clinicians, or information from plans. In other cases it is based on results from Medicare’s regular monitoring activities.

FOR MORE INFORMATION ON MEDICARE CHOICES IN ARIZONA check out my website.

Open Enrollment for Medicare Advantage plans has ended, and most people are locked into their plan for the rest of the year.  But there are exceptions for people with certain chronic illnesses or low income subsidies.

CareMore has Medicare Advantage plans for people with diabetes or breathing illnesses, and because these are “special needs plans”, people can enroll in them all year long.  In order to qualify for these plans, a doctor must sign a form confirming that the Medicare beneficiary has the chronic illness.

Evercare has Medicare Advantage plans for people with certain chronic illnesses such as heart disease, respiratory disease (such as asthma), high blood pressure, diabetes or dementia.

Low Income Subsidies: Medicare beneficiaries who are getting help with their Part B premium or Part D drug costs can change Medicare Advantage plans throughout the year.

People who have monthly income of  less than $1,354 (for a single person) or $1,821 (for a couple) can get help with their Part D premium and their prescription costs.  This help is received through an application to Social Security.

AHCCCS (Arizona Medicaid) will pay the Medicare Part B premium for a single person living on less than $1,218 per month, or a couple with monthly income of less than $1,639.  An application for this help is made to AHCCCS and usually requires a copy of the annual letter from Social Security that shows how much a person receives and what is deducted from that amount. The qualifying amount is the gross Social Security payment – before $96.40 (or $110.50) is taken out for the Medicare Part B premium.

If AHCCCS approves the application for “Medicare Cost Sharing”, they will notify Social Security that the individual or couple also qualifies for help with their Part D premium and drug costs.

FYI:  AHCCCS stands for Arizona Health Care Cost Containment System and is pronounced “access”.

So, while the vast majority of Medicare Advantage enrollees are “locked into” their plans, about 30% of seniors qualify for the low income subsidy, and many have chronic illnesses that would allow them to join a special needs plan.

FOR MORE INFORMATION ON MEDICARE CHOICES IN ARIZONA, check out my website.

Medicare Advantage plans are run by insurance companies and they are complex. Rules must be followed and enrollees must stay in network, or they will face complicated billing problems.  Sometimes, when you call the insurance company, they don’t seem too clear on the rules themselves.

I was talking to a couple who have homes in Tucson and Missouri, so they signed up with Evercare, which is a PPO Medicare Advantage plan here in Tucson. A PPO (Preferred Provider Organization) allows people to go out- of-network for a higher co-pay, so people who travel think this serves them better than an HMO.  These folks did not really understand how their Advantage plan would work out-of-state, so I called the company to ask a few questions.

I asked the customer service rep what these folks would have to pay if they saw a doctor in Missouri and was told they would be charged 30% of the actual doctor bill.  That’s not too bad.  Then I asked about hospital charges.  The answer was that they would pay 33% of hospital charges.

I then asked about emergencies. The representative, who sounded like he was in his twenties, said emergency room visits have just a $50 co-pay, but if they are admitted to the hospital, the co-pay would be 33%.  I knew this was wrong, but he insisted he was right. So I told him to go talk to a supervisor and get me the right answer.  He came back on the line to say he was mistaken and that emergency hospitalizations out-of-network are covered at the in-network co-pay.  However, a doctor will determine when the emergency is over, and then the patient has to leave the hospital or start paying 33% of the charges. 

Emergency hospitalizations out-of-network are tricky, and I have another client (enrolled with another company) who ran into billing trouble when some of the bills related to his out-of-network emergency hospital stay were not paid.  The insurance company sent him a notice saying certain tests were not part of the emergency.  Apparently he was supposed to call and ask the insurance company to approve certain tests – while he was lying in a hospital bed in agonizing pain.

This man was so mad at the insurance company he only made one attempt to get them to pay the bills.  The rules say he must file an appeal with the insurance company, and fill out specific forms, and send them to a specific department in order for the company to review his case.

These problems must arise often enough that all the Medicare Advantage companies have told insurance agents to be sure to review the appeals process with their clients.  Talking about how to appeal billing issues is supposed to be part of every discussion with clients.

I haven’t had many clients who have reported problems to me, but the ones that did have problems were very frustrated and, come to think of it, they never did get the problems resolved to their satisfaction.