Medicare decision calls for deliberation

Like many older Americans, my husband and I have been struggling with Medicare decisions this month.

Although we’ve had traditional Medicare and a supplement, we’ve spent the past few weeks looking at Medicare Advantage programs.

Here’s why. We are currently in good health. Our only visits to the doctor last year were for a routine physical and renewal of maintenance prescriptions.

If next year is the same as this one, we could save more than a $1,000 each by switching to a Medicare Advantage plan. That plan would also pay $300 toward dental cleanings as well as our fees at a local fitness center, $30 each per month.

It all sounded so good as we listened carefully to the presentation by a salesperson detailing the $15 a month plan.

Visits to our family physician will have a modest co-pay that triples for visits to a specialist. If hospitalized, we’ll pay $100 a day for the first three days and then the insurance picks up the balance.

However, one phrase in the sales pitch could not be ignored: “You must show your Medicare Advantage Card every time you go in to see your physician or seek medical care and ask if they will accept the plan.”

If they say, “yes,” no problem, she explained. But that can change at any time. There is no guarantee the coverage will be accepted. If we’re told the clinic or physician or hospital no longer accepts this plan, than we should, she said, “just go to another doctor.”

Well, that sounds very good in theory. But as most seniors know, there are many physicians and medical clinics that do not accept any Medicare patients and others that are not accepting any new Medicare patients. So finding another doctor isn’t always that easy.

Medicare Advantage plans are a fee-for-service insurance plan. By subscribing to one of these, we are opting out of the traditional Medicare plan and choosing an insurance plan managed by a private company, not the federal government. This is referred to, in Medicare lingo, as Plan C.

The private insurance carrier receives all the money deducted from Social Security for Medicare’s Plan A and Plan B, as well as additional money from the feds for managing our health care.

If we receive medical care regular Medicare would have covered, then the private Medicare Advantage insurance should reimburse our doctor and medical facilities the same amount.

The difference, our salesperson explained, is that there is less paperwork and reimbursement is faster. (A clinic administrator in south Snohomish County told me exactly the opposite is true in the case of one company selling Medicare Advantage plans).

Several major insurance firms are heavily advertising these plans right now. But, as we also know, not all of these plans are acceptable to the folks providing our medical care.

And, one plan is not directed by an insurance company. Essence Health Plan is sold and managed by a group of doctors who operate several medical clinics in the Seattle area. Only five states, including Washington, have this type of physician-directed Medicare Advantage plans.

This plan is accepted by the Everett Clinic, which recently announced there are four Medicare Advantage plans it has contracted with: Regence/Blue Shield, Secure Horizons, Evercare and Essence.

Senior Services of Snohomish County has held informational meetings going over all the options and explaining the difference between traditional Medicare and Plan C.

Your local senior center is a good place to start if you’re looking for basic information. Workshops and informational meetings offered by the companies selling these plans will also aid in your decision.

As part of my Medicare homework, I called our doctor’s office, the specialist my husband saw for prostate cancer and a few other caregivers to see if the plan we were considering was on their “accepted” list.

In each case, the billing department told me they did accept the plan we were considering and had no problems with the company. I was also told that because we live in a “rural area,” reimbursement is somewhat better than in large urban areas such as Everett.

Then I came to the list of “ifs.” If one of us should have a major medical problem such as cancer or a heart condition requiring hospitalization and many follow-up visits, it would be less expensive to stay with our traditional Medicare supplement plan.

If there is a chance one of us might require long-term care in a convalescent care facility, the same holds true.

Thus, there is a financial risk in choosing the Medicare Advantage plan.

If we stay healthy, exercise regularly and have good dental care, the Medicare Advantage plan is the best choice. We can put the $2,000 we don’t pay for premiums into a savings account for medical emergencies.

For each of us wrestling with Medicare choices, it comes down to this: a personal choice based on past and present health issues, the facts we have gathered and our comfort zone when it comes to taking risks.

So I’ve decided to switch and put the difference in premiums directly into a savings account.

My husband, more conservative and with a history of cancer, has decided to stay with his present, traditional Medicare coverage.

Now we just have to focus on staying healthy. At least the stress of making a decision about an insurance plan is behind us.

Linda Bryant Smith writes about life as a senior citizen and the issues that concern, annoy and often irritate the heck out of her now that she lives in a world where nothing is ever truly fixed but her income. You can e-mail her at ljbryantsmith@yahoo.com.