I got a call on Monday, December 10th from Bob, who said he needs to change his Medicare Advantage plan. He said he has a problem with  his current Medicare Advantage (MA) plan and wants to move to another MA plan. He said he knows the December 7th deadline for the Medicare Open Enrollment Period might make that impossible. I told him he is correct, so we had a discussion to see if he has any options.

Chronic illness Medicare Advantage plans

Medicare allows people to enroll in Medicare Advantage chronic illness plans throughout the year (but this “special enrollment period” is only allowed once per person).

Bob is in his late-70′s and has a variety of health issues. I asked him if he has chronic heart failure.  The Medicare Advantage company he wants to change to has a special needs plan for people with this condition. If he has chronic heart failure, he could change to that special needs plan for a January 1st effective date.  It turns out he has heart problems, but not chronic heart failure, a condition where the heart is too weak to pump sufficient blood flow throughout the body.

I asked Bob if he has Diabetes. The same company he wants to change to (because of its doctor network) has a special needs plan for people with Diabetes. He does not have Diabetes, so the chronic illness plan option will not work for him.

Medicare Advantage Disenrollment Period (MAPD)

Generally, people enrolled in a Medicare Advantage plan are “locked into” that plan for all of 2013.  But Medicare came up with the MADP to give people an escape route if they realize (early in the new year) that they made a mistake by enrolling in Medicare Advantage.  Medicare allows people to get out of their Medicare Advantage plan from January 1 to February 14.  But, people need to think twice before making this move.

During the MADP, a person enrolled in a Medicare Advantage plan (MA) may disenroll from that MA plan and return to Original Medicare.  But, they cannot switch to another Medicare Advantage plan. Their only option during this period is to go back to Original Medicare. Then they are allowed to enroll in a stand-alone Part D plan (PDP).

Medicare supplement companies can deny you coverage.

Anyone thinking about using the Medicare Advantage Disenrollment Period (MADP) must make sure they can get a Medicare supplement when they drop their Medicare Advantage plan.  A person with health problems like Bob can be refused a Medicare supplement policy – and then they will have only Medicare.

Medicare alone is not very good coverage – especially if you have chronic health problems, are diagnosed with cancer, or have a serious illness that requires surgery and/or a lengthy hospital stay. People with only Medicare are responsible for 20% of their medical bills (beyond what Part A of Medicare covers), and that can add up to tens of thousands of dollars. There is no cap to this 20% co-insurance.

Bob and I reviewed the medical history questions on a Medicare supplement application. I told Bob that if he answered “yes” to any of them, he would be denied coverage. But… there are two companies I know of that will take him on… but….they will charge him a much higher premium.

I told Bob he could get a Plan F Medicare supplement for around $300 per month. If he were healthy, the same plan would cost him around $215 per month.  Bob’s wife got on the phone and said $300 per month sounds pretty good to her.

So I will meet with Bob and his wife to explain the Plan F Medicare supplement, which will allow him to see any doctor who accepts Medicare. With Plan F, Bob will have no co-pays for medical services that are covered by Medicare. Medicare will pay first and the supplement will pay second, leaving him with no bills. Bob’s wife said she tracks his co-pays on his Medicare Advantage plan and they probably reach $300 per month when averaged throughout the year.

One more thing I almost forgot.  Bob will need to get a Part D drug plan – and that will add $30 to his monthly premium costs. I’ll need to get a list of his prescriptions and do some research on his Part D options so I will have this ready when we meet next week.

The latest Medicare star ratings are available for Medicare Advantage plans – and there are changes for plans in Tucson. One company’s plans that received 4 stars for 2012 are now rated 3.5.  Health Net plans are now rated 4 stars, the highest in town.  The ratings are based on data from 2011 for some plans and early-2012 for others.

Here is a list of plans available in Tucson, AZ and their star ratings (out of a possible 5 stars).

CareMore Value Plan:  3.5 stars
CareMore StartSmart: 3.5 stars (This is new to Tucson for 2013, so how is it even rated???)

Health Net Ruby 1 and 4: 4 stars
Health Net Jade:  4 stars
Health Net Ruby Select: 4 stars (This plan is not even in place until January 2013, so how is it rated?)

AARP Medicare Complete Plus:  3.5 stars
AARP Medicare Complete 1: 3.5 stars

Humana Readers Digest… HMO:  3.5 stars
Humana Regional PPO ($154/month): 3.5 stars
Humana Local PPO ($92/month): 3 stars

SCAN:  3 stars

Abrazo: 2.5 stars (This plan does not yet exist in Tucson, so the rating must be based on their plans in Phoenix.)

Universal Any Any Any PFFS: 2 stars
Universal Hassel-free PPO: too new to be measured

So how do they come up with these scores? Here is a list of some of the things that are considered:

-Screenings received by plan members for:  breast cancer, colon cancer, cholesterol, diabetes, glaucoma, osteoporosis
-Flu vaccines received by plan members
-Medication reviews received by plan members
-Customer Service
-Getting appointments and care quickly
-Complaints about the health plan
-Members choosing to leave the plan
-Plan makes  timely decisions about appeals

Complaints and people leaving the plan are the most important rating factors for me.  Getting appointments and care quickly seems to be beyond the control of most Advantage plans (in my opinion).  Most Advantage plan are insurance companies that contract with doctors.  So how can Advantage plans control doctors’ schedules when the doctors are not their employees?

As for all those screening tests:  If you wondered why your Medicare Advantage plan has been calling you about getting a flu shot or mammogram, now you know. Medicare is grading the plans on how many of their members get preventive screenings and tests.  So be a good team member and get that flu shot! Your plan needs your help!

Go to Medicare.gov and use the Plan Finder to compare plans.  The star rating data can be found on the CMS website.

Health Net’s Amber plan, a Medicare Advantage plan for low-income Medicare beneficiaries, is changing drastically for 2011.  I haven’t talked to one person enrolled in this plan who knew about the changes and understood that they had to find a new plan.  My question to Health Net and Medicare is:  How can you get away with this?

Health Net’s Amber plan has been a God-send for many of my clients who have incomes below $1,240 per month. The plan is also open to Medicare beneficiaries who make less than $930 per month and get cost sharing help from AHCCCS (Arizona Health Care Cost Containment System, Arizona’s Medicaid). Health Net is changing the Amber plan for 2011 such that it will only serve this lowest income group whose cost sharing is paid by AHCCCS (pronounced “access”).

I have been able to get in touch with most of the people I enrolled in this plan over the last three years whose income (above $930 per month) will require them to enroll in a new plan.  I have had to explain that the Amber plan will require them to pay 20% of the cost of any medical service.  This is just like having only Medicare.  Just about everybody I’ve told this to has looked back at me with a blank look that tells me that don’t fully grasp why they need to leave this plan. The Amber plan has worked so well for them because it has had no, or very low co-pays and $1,500 of dental coverage each year.

The vast majority of my low-income clients are challenged to understand what the plan changes mean for them. And none of them can afford the co-pays that come with standard Medicare Advantage plans:  $40 co-pays for specialists; $250 per day for a hospital stay; no dental or transportation benefit.

So why has Health Net made this change?  Medicare pays Health Net a lot of money for each person enrolled in the Amber plan, and the payment is higher than what Health Net receives for enrollees its “standard” Ruby plans.  With this change, Health Net can dump enrollees who have paid only a $20 co-pay to see a doctor or $100 per day for a hospital stay.   Instead Health Net can get more money from the state of Arizona (AHCCCS) which will pay 20% of the charge for all services.  While this benefits Health Net, thousands of people enrolled in the plan, whose 20% co-pays will not be covered by AHCCCS, must move to another plan – if they have figured this out.

Because so many people enrolled in the Amber plan are old, sick, and sometimes mentally challenged, I do not understand why Medicare is allowing Health Net to force these vulnerable people to change plans.  I have a client on the Amber plan who is on a transplant waiting list at University Medical Center, and Health Net is the only Advantage plan that contracts with UMC.  There is no good second choice for this man, yet he’ll be thrown off the transplant list if he has to pay 20% of his medical bills.

The big change to the Amber plan is probably a good business decision for Health Net, but it’s a very bad deal for thousands of people enrolled in the plan whose higher than $1,240 monthly income will force them off the plan – if they even know they need to change to another Advantage plan.

UPDATE:   Humana is now contracted with University Medical Center, so their Medicare Advantage plan is the one alternative for my client on the heart transplant waiting list – if he can afford all the co-pays that come with this plan.