Interesting Articles about Advantage Plans

[midwestbroker]

MA plans cover skilled nursing (100 days max). There is a point to where they are going to be discharged. Nursing home is where that is their home. There are some cases where the skilled nursing is done at a nursing home, but that person is not a resident, only a patient.

The story sounds like it was done about a HMO based MAPD plan. There is going to be a limited network, since it is an HMO plan. They should have reviewed that with the clients and shown them the locations for care, as it is listed in the book.

 

[senior-advisor-indiana]

I can't think of any HMO's in ft wayne, IN

 

[midwestbroker]

Are there PPO's, or only PFFS plans? I would think that a PFFS plan would have more options.

 

[senior-advisor-indiana]

I only know of PFFS

 

[Cenla Agent]

I agree that it was a very poorly written article, unfortunately par for the course in the confusing world of Medicare Part C and D.

I think probably what they were getting at is that MA plans generally cover skilled nursing facilities (SNF) differently than does Medicare Part A. (BTW SNF can take the form of a rehab unit in a hospital, a stand alone rehab hospital, or a SNF contained within a nursing home. Medicare of course has NOTHING to do with a nursing home unless it is designated as a SNF). Part A, after a 3 day covered hospital stay, will cover up to 20 days at no copayment and then it is $124 per day up to the maximum of 100 for 2007. Most MA plans require a copayment after anywhere from 3-11 days (basically the ranges I've seen). So it appears that the MA plan is inferior to Medicare in this instance, and this is often the way that the SNF's see it, since Medicare pays 100% much longer. However, one possible advantage is that most if not all MA plans do not require the 3 day hospital stay before paying for a SNF.

With Home Health, on paper MA's cover it the same way Medicare does, but as the article suggests, MA companies will typically give much closer scrutiny to Home Health charges than Medicare does. Home Health Care is one of the biggest areas of fraud under Medicare, with Home Health agencies apparently not infrequently billing things like housekeeping, etc that are not supposed to be covered by Medicare.

The At-home recovery mentioned earlier is a term used in Supp plans D and G and is care that is not covered under Medicare but is paid for in part by those plans. Reading "Medicare and You", the "Guide to Choosing a Medigap policy" (both CMS publications, the latter of which should be provided to every supp enrollee) and your supp outline of coverage should clear up any confusion about the difference b/w "Home Health Care" and "At Home Recovery".

What the article failed to point out of course is the much lower out of pocket costs for hospital stays vs. Original Medicare.
So while Original Medicare may have paid better at a SNF, you have to look at what OOP would have been overall.

 

[James]

But in October, his mother broke her hip, requiring surgery, hospitalization and rehabilitation. Perkins was then told the hospital could not get the private Medicare company to approve in-hospital rehabilitation, something traditional Medicare covered when she broke her other hip a few years back.

So it was off to a nursing home for rehabilitation. That's when the real shocker came, Perkins said: "There was only one nursing home in Fort Wayne that was in [the company's] network."

No, it isn't all that complicated, this part is fairly clear, the hospital did offer SNF services but the carrier wouldn't pay the cost of the Hospital and I really can not figure that one out? Then there was only one Nursing Home SNF that would except payment from the carrier as in acceptance issues which is still the point (at least most complaints I hear of) with MA plans.

 

[Frank Stastny]

It appears that there are two major problems. We are assuming that the son had the facts straight and the reporter understood what he was saying. The second is that it is obvious that the reporter didn't know what she was talking about and didn't do any research to try to find out.

Advantage plans do not have a "network", HMO's have a "network". Advantage plans have providers who will bill the company and providers who refuse to bill the company. A huge difference.

Another thing that is inconsistent, why would the company approve the surgery for the broken hip but not the rehabilitation?

There is a lot more to this story than what is in the article. We can speculate from now until hell freezes over but without more accurate information we will never know what the rest of the story is.

Cenla summed it up best when he said, "unfortunately par for the course in the confusing world of Medicare Part C and D."

 

[policy doctor]

I prefer to sell Medicare supplements.....and the least problematic for the client.

So far, I have just sold people who had no insurance, or preferred one MA to another.

 

[Cenla Agent]

I prefer to sell Medicare supplements.....and the least problematic for the client.

So far, I have just sold people who had no insurance, or preferred one MA to another.

After having been captive with an MA company and then independent for the past 10 months, I also am leaning toward supplements and in most cases it is now the first option, especially for those aging in. As you say it is far simpler and the cost difference b/w a supp and the MA's I sell (at least for this year) is not that big, especially not for those turning 65.

 

[Cenla Agent]

From reading the article, I thought the plan in question might be a PPO or HMO, but someone here has said there is only PFFS in that area.

I have seen supplement companies and marketing organizations deride MA as managed care. Other than Sterling, of course most of them were indeed managed care until 2006, but most plans available now are Private Fee For Service. Like them or not, PFFS is not managed care.