Medicare Advantage Enrollees Can Still Switch to Original Medicare
This article is the second of a series designed to highlight the pros and cons of Medicare Advantage plans. The Author is a former hospital administrator who spent over ten years as Executive Director of a state-wide industry group dedicated to home health & hospice prior to becoming an administrator for a home health agency. The views expressed here are intended to be factual, but I will give you my honest opinion as well.
Pros and Cons of Medicare Advantage Plans
Medicare Advantage Enrollees Can Still Switch to Original Medicare
– Todd Stallings, FACHE
Disclaimer: I write this as a provider of home health services to Medicare and Medicare Advantage patients. I readily admit that I have a biased view of Medicare Advantage because it has made it harder to deliver high-quality care that patients need and yes, it is less financially beneficial for my home health agency than original Medicare.
Many Seniors and Medicare beneficiaries have chosen to switch from their original Medicare (I call it “traditional” Medicare) to a Medicare Advantage plan sponsored by a commercial insurance company. These can be HMO or PPO plans and while they do not replace Medicare – an enrollee still “has Medicare” – we often refer to them as “Medicare Replacement” plans because they DO replace the usual workings of Medicare with something that works like commercial managed care. Let’s face it – Medicare Advantage is Managed Care. If you want to read my previous post about Medicare Advantage, click here.
Medicare enrollees who have joined a Medicare Advantage plan have an additional Open Enrollment Period during which they can switch back to original Medicare or to a different Medicare Advantage plan. This Open enrollment runs from January 1st through March 31st and is only for those already in a Medicare Advantage Plan.
Here are some examples of why a Medicare beneficiary might wish to switch back to original Medicare:
Network limitations: A friend of mine recently learned she needs a major surgery that is not routine. Her condition requires a top-flight surgeon who specializes in her condition. Unfortunately, her plan was an HMO and did not cover out-of-network providers and the top surgeon in the area does not contract with Medicare Advantage plans. My friend’s plan directory contained a handful of doctors with his specialty. One of those had closed their practice, one had moved his practice out of the area, and one that she contacted informed her that he did not do that procedure. During Open Enrollment in the Fall, she switched to another Medicare Advantage plan that will pay 60% for out-of-network in order to use the surgeon that she wanted. That will bring her share down to around $7500. However, this top surgeon does participate with original Medicare. Even with a deductible from Medicare, she stands to get the care she needs without bankrupting her if she switches back to original Medicare.
Utilization “Management”: Remember, Medicare Advantage is Managed Care. Perhaps more accurate, Medicare Advantage is Managed Cost – for the insurance company. Every dollar they save on your care falls to the bottom line. Utilization Management as it is currently practiced for home health seems to focus on limiting visits and thus limiting the cost of care. Note this NOT the same thing as assuring that the appropriate care is delivered, just less. Home health agencies must obtain authorization to make visits to the patient in small quantities – often as little as one visit is approved. Home health must then go back time and time again to justify continuing to care for the patient. This delays care and increases the risk of hospitalization.
Misinformed sales representatives: I maintained my health insurance agent license for several years. During that time, I received training on sales of Medicare Advantage and supplements. I can tell you the amount these hardworking agents receive for each policy they sell is small. In order to make a living, they need to “write” many policies to survive. I never met a licensed agent who intended to mislead a Senior to sell a policy. However, I met many who had a limited understanding of the consequences of leaving original Medicare for Medicare Advantage. Their job is to be an agent of the insurance company and meet the government requirements – not be your personal advisor and advocate. They are great at showing the benefits of a Medicare Advantage Plan, just not so great at discussing the drawbacks.
How to switch from Medicare Advantage to Original Medicare: The Medicare Advantage Open Enrollment Period runs January – March. If you believe you made a mistake in signing up for Medicare Advantage or you are simply not happy with the coverage and benefits, you may call 1-800-MEDICARE (1-800-633-4227) and request to go back to Original Medicare.
Next: In my next post, I’ll discuss under what circumstances you can make the change outside the Open Enrollment Period. This is harder to do, and you must meet certain conditions.
Resources:
Here’s What You Need to Know About Medicare Advantage Open Enrollment –Motley Fool
Medicare Open Enrollment FAQ’s –Kaiser Family Foundation
Joining a Health or Drug Plan – Medicare.com
As a practicing Registered Nurse, Etelka was keenly aware of a void in quality patient care that could be provided in the home. She embarked upon a journey to develop a home health care agency that would exceed all expectations and become a trusted partner to physicians and patients.
A Distinguished Career From Nurse to Director of Nursing to President of Home Services Unlimited
Etelka’s distinguished career followed a logical progression to her position as President of Home Services Unlimited. She graduated as a nurse practitioner with a Bachelor of Nursing (RN) in 1972 from Meshgorya University in the Ukraine, close to where she lived with her family. She married her husband Phil in 1973 and decided in 1977 that they would relocate to the United States to be closer to family and to come to this land of opportunity. With an eagerness to continue her budding career, Etelka sat for and passed her Boards in the U.S. in 1979.
A Love and Talent for Working with the Elderly
Etelka began her nursing career in the U.S. at Colonial Crest, now part of Golden Living, where she was the In-service Coordinator, the Director of Training and Education and Director of Nursing, a position she occupied for several years.
With a group of partners, she co-founded Adept Corporation, which operated group homes for the mentally challenged. The business was successful and in 1996, Etelka sold her share to return to her roots, caring for the elderly.
In January of 1997, Etelka opened Home Services Unlimited as a fully licensed business to provide home health care. In her quest to learn to do better for her patients, she had already obtained a Masters in Healthcare Administration (MHA) in May of 1990 from the College of St. Francis. As President of Home Services Unlimited, Inc., Etelka guides the trusted, experienced care model Home Services Unlimited uses to continue providing excellent home health care.
Giving Back to the Community of Indianapolis
Volunteering for community services is a high priority for Etelka. Her memberships include the Indiana Association of Rehabilitation Facilities, Executive Women in Health Care and the Indiana Association for Home and Hospice Care, where she is a member of the Board of Directors.
Etelka has also served on the Board of Directors with Hooverwood Home, a highly regarded geriatric facility, since 1997 and as the President for 2005-2006. Through her community work, she has received several awards and accolades, including the Nora McFarland award in 2002, from the Indiana Association of Home and Hospice Care.
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