Oct. 15 marks the start of Medicare's seven-week annual election period, when current beneficiaries can add, drop or switch prescription-drug plans and make other coverage changes.
In Medicare, individuals must choose one of two paths: original fee-for-service Medicare, or a federally subsidized Medicare Advantage plan, which typically operates like a health-maintenance or preferred-provider organization. Many who opt for traditional Medicare also purchase a private "Medigap" policy, as well as a separate prescription-drug policy, to patch holes in their coverage.
In recent years, Medicare Advantage plans have gained in popularity, in part because, when compared with a Medigap policy, they generally cover a wider array of benefits, often including prescription drugs and dental care. Many also charge lower premiums, but require members to use the plan's network of providers.
The Affordable Care Act has sparked fears that Medicare Advantage plans, which cover about 30% of Medicare beneficiaries, will raise premiums, reduce benefits and pare their networks of doctors and hospitals. The reason: Under the law, Medicare will reduce payments to Medicare Advantage plans by some $156 billion by 2022, to bring per-person payments in line with those of traditional Medicare.
Citing the ACA, the nation's largest Medicare Advantage insurer, UnitedHealth Group, has cut an estimated 10% to 15% of the doctors and hospitals from its nationwide network. Consumer advocates say the insurer targeted providers with the sickest and most expensive patients, leaving patients in the middle of treatments in the lurch. The company says the changes enable it to better coordinate care and denies that patients in the middle of treatments are adversely affected, extending exceptions to members in active treatment.
Because some of the cuts occurred at times of the year when patients are unable to switch plans, Sen. Sherrod Brown (D., Ohio) and Rep. Rosa DeLauro (D., Conn.) recently introduced legislation that would bar insurers from dropping providers outside of Medicare's annual open-enrollment period.
Because Medicare Advantage can change annually, it's important to examine your options during open enrollment, from Oct. 15 to Dec. 7. You should call your providers to make sure they still participate in your plan. You can also use the "Plan Finder" tool at medicare.gov to compare premiums, copayments and deductibles for Part D prescription-drug plans in your area.
During open enrollment, you can switch to either a Medicare Advantage plan or to traditional Medicare, which allows you to see any doctor who takes Medicare. From Jan. 1 to Feb. 14, Medicare Advantage participants may switch to traditional Medicare.
Medicare beneficiaries whose claims are denied should also know that, despite rising backlogs in Medicare's appeals system, two recent lawsuits indicate that those who press their cases have a good chance of success. The procedure differs depending on whether you're in traditional Medicare, a Medicare Advantage plan or a Part D prescription-drug plan. Typically, each appeal can be heard five times, the last time in a federal court.
Since 2010, success rates in the first two rounds of appeals of denied claims for home health-care coverage have plunged to 5% or less, according to a class-action lawsuit the nonprofit Center for Medicare Advocacy in Willimantic, Conn., filed on June 4 in the U.S. District Court in Connecticut against the Department of Health and Human Services, which oversees the agency that administers Medicare.
The center's director of litigation, Gill Deford, told the Wall Street Journal that consumers who want a "meaningful review of their Medicare claims" should continue to the third round of appeal—before an administrative law judge—where odds of success jump to 40% or more.
The average wait for a decision from an administrative law judge is 398 days, up from 95 days in 2009, according to HHS. In a federal lawsuit filed Aug. 26, also in Connecticut, the Center for Medicare Advocacy seeks to force the government to take steps so that appeals can be decided within the 90 days the Medicare statute requires.
When appealing, ask your doctor for a letter explaining why you need the treatment in question. Those who go before an administrative law judge may benefit from retaining a medical or legal advocate. Most State Health Insurance Assistance Programs provide free counseling.
This post is based upon a Wall Street Journal article which can be read here.
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