Letter to the Editor: Medicare Open Enrollment

To the Editor:
I belong to PNHP (Physicians for a National Health Program) This is a national group advocating for universal health coverage in the United States. As a retired physician who has worked in both rural and urban areas with widespread poverty, I fully support the idea. This group is also concerned about the future of Medicare. I thought a short summary might be useful to your readers.
Now is the open enrollment period for Medicare (October 15 thru December 7). There is a tremendous media blitz going on, and we must use caution that our choices are made based on real information and not glitzy ads, or even worse, ads disguised as government documents with similar logos. The Senate Finance Committee has been investigating what they consider deceptive advertising. We have all heard the admonition: If it sounds too good to be true, it probably isn’t true. There are unbiased sources to get help, notably the SHINE counseling system in Massachusetts. They are free and available through most councils on aging and can be located online. There are many insurance brokers out there (just google medicare.gov and the ads will come up before the actual website.) Many of these agents are okay but be aware that they are paid more for enrolling you by Medicare advantage plans (part C) than by original Medicare (parts A and B).
HERE IS A REVIEW OF THE TWO CHOICES:
Original or Traditional Medicare (parts A and B)—The government pays your medical bills. 98 % of the costs go directly to patient care. Part A covers hospital care, and Part B covers doctors and outpatient care. However only 80% of the costs are covered. You have to buy a supplement or medigap policy to cover the other 20% and you have to buy part D drug coverage. While technically these are not required, you would have to be either very crazy or very brave to ignore these additional coverages. (20% of a surgical procedure, hospital stay, or MRI can be quite expensive and there are penalties for not enrolling in part D)
Positives of Original Medicare:
–You can go to any hospital or doctor who accepts Medicare anywhere in the country.
–Your costs are predictable (with my Medigap policy, I have paid almost nothing extra in the 9 years I have been on Medicare. This includes one hospitalization, visits to specialists, and 2 MRIs. I don’t think the “core plan” existed when I joined but even its costs are somewhat predicable)
–Medicare guidelines as to what they will pay for are based on medical evidence and these are generally very reasonable and transparent. There are few needs for prior authorizations which means that you usually get the care you and your doctor think you need.
–Every Medigap program with the same letter covers the same things regardless of cost or insurance company
Negatives of Original Medicare:
–It does not offer any coverage for dental, vision or hearing
–In Massachusetts the average Medigap cost is about $230/mo which is $2,760/yr and Part D coverage runs about $30-50/mo) However there are government programs to help with the costs.
Medicare Advantage (part C)—This is administered in an entirely different way. The government pays insurance companies to manage your care, whether you use it or not, so your premium can be as low as $0. The insurance company contracts with the doctors and hospitals and pays them. Only 85% of what the government pays goes to direct patient care.
Advantages of Medicare Advantage
–some dental, vision, and hearing coverage much of the time
–lower initial cost to join the program
Disadvantages of Medicare Advantage
–the available choice for doctors or hospitals may be quite limited
–out of network care can be expensive
–visits to the primary are often free but there are usually copays for specialists, tests or procedures.
–most expensive xrays, procedures, and tests require “preauthorization” which means they decide what care you can have. There can be delays and denials of care
–unlike Medicare, the guidelines as to what will or will not be covered are not clear
–Your expenses may be somewhat unpredictable although there are caps as to how much you need to spend out of pocket, usually $10,000- 16,000/ year. I tried to figure out what my last year of care would have cost if I had Medicare Advantage rather then original Medicare. I really could not.
–There are 113 different Medicare Advantage programs is Massachusetts, all offering different networks and coverages.
In summary, please try to be aware of what you are purchasing and what your costs might be. Get unbiased help if you need it. Do not let the advertising fool you.
Sincerely,
Mary F. Buechler, MD, FACEP – Georgetown, MA