New Medicare Enrollment Process Gives Its Members a Voice

For the first time, America’s massive and popular Medicare program is about to do something private health care plans have been required to do for decades: hold what is commonly known as open enrollment. During that period, most enrollees in urban areas are free to choose among any of Medicare’s participating health plans. There are now enough different health benefits and providers available to the elderly and disabled under the nation’s largest health care program that it makes sense for Medicare to begin regularly presenting its managed care options to eligible beneficiaries.

For those who have not experienced open enrollment under a health insurance plan, it’s a little like signing up for classes on the first day of school--except that if you claim a place in a plan of your choice during the annual election period, it has to make room for you. Although there are other designated periods Medicare calls open enrollment, if you need guaranteed access to a Medicare managed care plan, the annual election period, which lasts the month of November, should be on your calendar.

This reform is part of a new effort to make the federal program operate more like private sector insurance. It seeks to offer beneficiaries options for care that reflects cost savings driven by Medicare’s direct participation in the health care market.

So in a few weeks, those of you in or eligible for Medicare will commence a new annual rite of passage in health insurance: voting with your feet (and your dollars) for the medical providers and kind of care you want.

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If you are a Medicare beneficiary or responsible for helping a beneficiary make Medicare decisions, you should look closely at the options available before making changes. The most important thing to remember is that, if you are happy with the care you are getting now, you don’t have to do anything. You can stay with traditional fee-for-service Medicare or your current plan, unless it has left your Medicare service area (only United Health Care has pulled out of the Medicare market in Los Angeles County, effective Jan. 1; 11 plans remain in the county).

To begin researching Medicare options and rules, call the independent Health Insurance Counseling and Advocacy Program toll-free at (800) 434-0222. If you are interested in managed care, request information on all Medicare managed care plans that serve your county and the contact information. To help you think about what is appropriate for your situation, seek answers to the following questions:

1. Ask the HICAP counselor what the out-of-pocket costs would be for each plan you are considering. This information is also available on the Internet at https://www.medicare.gov. When you are connected to the Web site, click on “Medicare Compare.” (Out-of-pocket costs include monthly premiums, deductibles, co-payments when you visit the doctor, and your share of costs for other services such as outpatient prescription drugs.)

2. What has been other Medicare beneficiaries’ experience with a particular plan? What is the annual disenrollment rate of Medicare beneficiaries for the plan? Ask for patient satisfaction survey data for each plan. Your HICAP counselor can answer these questions.

3. Be sure that you know what services Medicare covers. Ask each plan what additional services it offers. Are dental services, eyeglasses or mental health services covered?

4. Because of prescription drugs’ high cost, pay close attention to your present and future needs. Ask each plan if it provides for outpatient prescriptions. If outpatient drugs are covered, is there a maximum drug benefit and/or is a co-payment required to get a prescription filled? Are the medications you are taking now on the plan’s list of approved drugs?

5. Will you have access to the health care providers you want? If you have a personal physician, ask which managed care plan(s) he or she is affiliated with. If you currently use (or want to be able to use) any specific specialists, hospitals, nursing facilities or home health agencies, find out if they are in the plan’s network.

6. What, if any, are the limitations on access to specialist care? Does your personal physician have the right to approve access to specialist care or is the plan’s prior permission needed? Can you choose a specialist (such as an Ob-Gyn or cardiologist) as your personal physician if you need to do so?

7. Does the managed care plan restrict the care your doctor wants to provide? Are the financial arrangements between your personal physician and the plan such that your doctor is hurt financially for referring you to a specialist or admitting you to a hospital?

8. If you travel, how will your health care needs be met while away from home?

Health insurance beneficiaries are often nervous about choosing a plan during open enrollment and, particularly, about switching plans. What if the new plan pulls out of your service area? Or stops providing the benefits that made the plan attractive at the time you enrolled? Such concerns are real because managed care plans contract with Medicare on a year-to-year basis. They are permitted to change the benefits they offer annually as well as the premiums and co-payments they charge.

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For those who want to stay in traditional fee-for-service Medicare, be aware that at present it does not cover prescription drugs and you will pay a higher share of costs for physician visits. To help meet those costs, there are 10 Medigap policies available in California with standardized benefits designed to cover some of the costs that traditional Medicare does not. They are guaranteed by law to be renewable at no greater premium than that paid by other Medicare beneficiaries living in the service area. Nevertheless, the Medigap policies that cover crucial benefits like outpatient prescription drugs are expensive (for example, $3,600 per year for a 65-year-old and more than $5,000 a year for a 75-year-old in Los Angeles County). Thus, despite the greater stability of Medigap policies’ benefits and prices, a Medicare managed care plan is likely to be the better deal for most Medicare beneficiaries--better in terms of benefits and lower out-of-pocket costs.

In exercising your options under Medicare, you should compare what you are paying now for doctors’ visits, prescription drugs, eyeglasses, dental care and other health-related expenses with what you would probably pay under any Medicare alternative you are considering. Talk to your physician about medical needs you may not anticipate. And remember, if you decide you have made the wrong decision regarding your Medicare coverage, talk to a HICAP counselor before making a change.