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Tips
on Choosing a Medicare Managed Care Plan
from Nolo
Make
sure a Medicare managed care plan meets your needs before you sign
on the dotted line.
To
evaluate a Medicare managed care plan, get a complete written explanation
of its coverage, costs, and procedures. These are usually contained
in a printed brochure called a summary of benefits. Also, get a
chart showing premiums and copayments. Compare that written information
with each important category discussed in this article.
If
you do not understand exactly what the coverage, costs, and procedures
are, ask a plan representative to point out where they are explained
in the written information. If you can't get an important piece
of information in writing, don't join the plan.
Look
at a number of specific factors when evaluating a managed care plan.
Choice
of Doctors and Other Providers
For many people, the most important factor in choosing a Medicare
managed care plan is whether the doctors, hospital, and other providers
they already use and trust are in the plan's network of providers.
If your hospital or doctors are not in the network, you will have
to find new doctors, which is never an easy or comfortable process.
And you might have to use a hospital that is more distant from your
home.
The
problem is not quite as great with PPOs or HMOs with a Point-of-Service
Option (PSO) as it is with regular HMOs. (For an explanation of
the difference, see Medicare Managed Care Plans: An Alternative
to Medigap Insurance.) PPOs and PSOs permit you to use providers
who are not in the plan's network. So, if you want to continue with
a particular doctor or provider who is not in the network, you may
do so, but with a higher copayment each time you use the non-network
provider. If you are treated by non-network doctors very often,
the extra payments may wind up canceling out the cost advantage
of managed care.
Access
to Specialists and Preventive Care
The requirement that you must visit your primary care physician
to obtain specialist referrals is one of people's main objections
to managed care. Try to learn how difficult it is to get a referral
to a specialist with any plan you are considering.
Total
Cost
Many managed care plans charge no premium to members. Other plans
charge a relatively small premium -- especially PPOs, and HMOs with
a point-of-service option or deluxe coverage, such as unlimited
prescription drugs. Usually, these premiums are lower than for Medigap
policies. But premiums don't tell the whole story. You must add
up other costs -- such as copayments for doctor visits and prescription
drugs -- to see whether a plan is worth your dime.
Review
Process
About 30% of Medicare managed care patients report having been denied
coverage for treatments their plans deemed to be medically unnecessary
or experimental. And if you are denied coverage for a treatment
or service, Medicare will not help you. The appeals procedure is
run by the plan. The prospect of having your wishes and those of
your doctor overruled by the insurance company is always enraging.
And when the treatment is for a serious illness, the plan's rejection
can be devastating.
Before
joining any managed care plan, explore its appeal or review process.
The procedures should be explained in the summary of benefits booklet
the plan gives to potential members. If the review process is not
fully explained, request written information from a plan representative.
Extent
of Service Area
Consider the extent of a plan's service area, particularly if you
live in a rural or spread-out suburban area. If the service area
is not broad enough to include a good selection of specialists,
you may find your future care choices limited.
Also,
see whether the plan has what are called "extended service
areas." Some plans permit you to arrange medical care far from
your home if you travel frequently or spend a regular part of the
year away from its primary service area. This allows you to take
care of non-urgent medical needs, even if you are not at your primary
residence.
Other
Plan Features
Many managed care plans offer a variety of other features beyond
basic Medicare coverage. Such benefits include: short-term custodial
care, medical equipment, chiropractic care, acupuncture, acupressure,
routine physical exams, foreign travel immunizations and emergency
coverage, eye examinations and glasses, hearing tests and hearing
aids, dental work, after-hours advice and treatment, chronic disease
management, and wellness programs. If you are likely to use any
of these benefits, the plan that offers them may be more attractive
to you.
Where
to Get More Information
Useful sources of information about managed care plans are available
almost anywhere you live. One is Medicare's website at www.medicare.gov.
The website has a link called "Medicare Personal Plan Finder"
that allows you to find all the Medicare managed care plans that
serve your geographic area. The information includes the outlines
of each plan and its costs, as well as the address and phone number
of the plan's representative in your area. Always double check the
information on the website, however, since it may be out of date
or fail to mention how many seniors were dropped from the program.
Another
great help to seniors trying to sort out the managed care maze is
the State Health Insurance Assistance Program (SHIP). SHIP is funded
by government grants and private donations; it has no connection
to the healthcare or insurance industries. SHIP provides free counseling
to seniors about Medicare managed care plans and Medigap. The staff
knows how the plans and policies work and whether people in your
area have had good or bad experiences with particular plans. To
find the SHIP office nearest you, call the toll-free line for your
state's central SHIP office, listed in the state government pages
of the telephone book.
For
an extensive discussion of managed care plans, along with guidance
in choosing one that fits your needs, you may also want to read
Social
Security, Medicare & Government Pensions: Get the Most Out of
Your Retirement & Medical Benefits, by Joseph Matthews (Nolo).
