Too Much Mystery to Medicare

Do you understand Medicare? This simple question recently posed to California senior citizens drew a discouraging response.

Almost half, 49%, said they had little or no knowledge of the nation’s biggest health program, a fixture of American life for a generation.

Anyone who reaches age 65 has a guaranteed right to health services under Medicare. But rights, like muscles, aren’t worth much if you don’t know how to exercise them.

A hefty majority--60%--agreed with the statement, “I often feel confused about what is happening in the health care system.” The depressing news came from a poll by the Medicare Project, a division of the California HealthCare Foundation, which is helping consumers cope with the health care system. The poll of 755 California residents covered by Medicare was conducted in March and April.

Medicare helps pay doctor and hospital bills for 40 million Americans, 36 million who are 65 and older, and 4 million disabled people of all ages. Anyone who becomes eligible is faced with a bewildering array of choices.

The regular, traditional Medicare program allows a participant to select any doctor or hospital agreeing to participate in the program--the majority of doctors accept Medicare patients.

About 85% of beneficiaries nationally are in regular Medicare. The rest have joined health maintenance organizations that have been created to serve Medicare patients. Before you join a Medicare HMO, check with your doctors, particularly the specialists you have been seeing for years. Find out if they participate in the HMO you are considering, so you can continue the relationship.

“Too often people do not understand that they may not be able to see the doctors they want to see,” said Diane Archer, executive director of the Medicare Rights Center, a New York-based consumer advocacy organization. Even if one of the doctors you want to retain is listed in an HMO directory, call the doctor to find out if she or he is taking new patients. When you join the HMO, you become classified as a new patient.

The HMO advantage is big savings. It will cover Medicare co-payments and deductibles and, most important, offer benefits such as coverage of prescription drugs, which is not included under the regular Medicare program.

Medicare HMOs are especially popular in California, where about 40% of Medicare recipients have enrolled, drawn by the prescription drug benefit. This is a strong incentive, because the average person on Medicare would spend about $900 a year out of pocket for prescription drugs. By contrast, HMOs usually charge only a co-payment of $5 or $10 for a prescription. (This figure could increase next year, because drug costs are climbing rapidly.)

Information on Medicare choices is available from the federal government hotline at (800) MEDICARE (633-4227). Comparisons of Medicare HMOs are available on the Web site https://www.medicare.gov.

If you don’t like the HMO, you can quit, and you will be enrolled back in the regular Medicare program in the next month.

For those who decide to stay with the majority of Medicare recipients and remain in the traditional system, there is another important decision to face. Should you buy a supplemental policy, called “Medi-gap insurance,” which will pay for some of the expenses Medicare won’t cover?

For example, under regular Medicare, you must pay for the first day in the hospital (anywhere in the country), a $768 deductible. The next 59 days are free, but then you would face a big co-payment of $192 daily. And when you go to the doctor’s office, you have to pay a $100 annual deductible and co-payments of 20% of doctor bills.

There are 10 Medi-gap policies, A through J, which are standardized under federal law. They offer an increasing array of benefits, with three of the plans, H, I and J, including drug coverage. Medi-gap Plan B, for example, would cover the hospital deductible, the annual deductible for doctor visits, and co-payments for hospital stays beyond 60 days.

Although the plans are standard, the prices vary dramatically depending on the insurance company selling the policies. It makes no sense to pay more for the product, which is the same no matter which firm sells it. Weiss Ratings, an independent organization, will provide a shopper’s comparison, based on an individual’s age, ZIP code and gender, for all plans in your county. The cost is $49 and reports are available at (800) 289-9222.

In Los Angeles and Orange counties, according to the Weiss report, the annual price of a Medi-gap “A” policy for a 65-year-old man would range from $554 by USAA Life to $1,464 by United HealthCare. Medi-gap policies, which might be comparatively cheap for a 65-year-old customer, can skyrocket in price when an individual hits 85 and is more likely to have serious health problems. The policy charge for an 85-year-old would vary from $1,504 by USAA Life to $3,764 by Central States Life, the Weiss report said. Most prices increase with age; however, United HealthCare doesn’t have ratings by age.

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Getting your Medicare coverage is just the first step. Using it effectively is another exercise of your rights.

Suppose you are hospitalized, and the hospital wants to send you home, but you feel too sick to leave. There is a right of appeal. Ask for a discharge notice in writing, a document called a “Notice of Noncoverage” or a “Denial Notice.” Call California Medical Review Inc., an independent agency that oversees the quality of services under Medicare, to handle the appeal. The CMRI help line is (800) 841-1602.

“While you’re in the hospital, CMRI will review your condition to see if you still need to stay,” the organization says on its Web site, https://www.cmri-ca.org. “It may take a few extra days. But you cannot be sent home or billed for the extra days you’re in the hospital while CMRI reviews your case,” the Web site says.

CMRI also handles appeals for help by individuals who are having disputes with their Medicare HMOs. First, call the member services department of the HMO if you believe care has been denied or delayed. Both you and your doctor have to ask for the appeal. If your “condition may get worse by waiting too long,” you are entitled to an expedited appeal in three days, according to CMRI. If the health plan is unresponsive, call CMRI.

A good general source of help on Medicare issues in Los Angeles is the Center for Health Care Rights, (213) 383-4519, a state-funded counseling program.

For help with a wide range of issues affecting seniors, including health, call the Eldercare Locator, (800) 677-1116, which can provide links to local groups with information on numerous community and government programs.

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Last month’s column about HMOs and prescription drugs drew lots of phone calls and e-mail messages. If an HMO has a drug on its approved formulary list, and then drops the drug, HMO members who have been taking that medication are entitled to keep getting it. This applies to HMO contracts renewed or amended after July 1. Some readers say their HMOs are pleading ignorance of the law. If you are having trouble, cite Section 1367.22 of the California Health and Safety Code. The California Corporations Department enforces the law.

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Question: My father is in a nursing home, and his insurance company does not want to cover him because it is considered custodial care. I need help in locating good elder-care lawyers and financial planners to distribute remaining financial assets before they are gone.

Answer: You have discovered the costly reality of the health care system for the middle class. Medicare covers hospital and doctor bills, but doesn’t pay for custodial care in a nursing home. The government will pay for this under Medicaid (called Medi-Cal in California), but a person has to “spend down,” wiping out virtually all financial assets before becoming eligible. You can get some expert advice through the National Academy of Elder Law Attorneys, whose members have expertise in these complex and arcane issues. Call (520) 881-4005, or write 1604 N. Country Club Road, Tucson, AZ 85716. The Web site is https://www.naela.org.

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We welcome your suggestions, questions and tips about the fast-changing world of health care. Write to Bob Rosenblatt, Health, Los Angeles Times, Times Mirror Square, Los Angeles, CA 90053. Or e-mail to bob.rosenblatt@latimes.com.