Explaining the New Medicare Mess
J. Greene


       They said it couldn't be done. But through the concerted efforts of the federal government and HMO executives, Medicare is now more confusing than ever before. Here's a look at what's ahead.
For most people on Medicare, all you have to do is sit tight and try not to get alarmed when you get a brochure in the mail from the federal government explaining new choices for Medicare coverage that you will supposedly have in early 1999. Don't take them too seriously, because the choices in question haven't really panned out just yet. More on that later  -   But for about 440,000 Medicare HMO members who have just received notice that their health plan is dumping them at the end of the year, they'll need to pay close attention to their options. Most will have the chance to switch to another Medicare HMO, but 47,000 won't. Instead, those folks will have no choice but to return to the world of regular Medicare.
      If you're one of the dumpees, here are two things to remember: No. 1, don't panic — You'll still be insured through Medicare, although it might cost you more money — and, No. 2, don't quit your current HMO until the end of the year, or you'll lose an important guarantee of Medigap coverage in the future.
      The whole mess has come about because last year Congress, in an attempt to save money on Medicare, changed the way it pays HMOs. Many of the health plans have responded by canceling coverage for people in rural areas, where reimbursement rates from the federal government are lowest. In fact, 43 health plans quit the program altogether, and another 53 plans withdrew from certain areas.
      This seems strange coming at a time when many health plans are advertising and marketing heavily to Medicare recipients, luring them into their health plans with promises of low costs and coverage of many items regular Medicare doesn't pay for. Now many people, particularly those on limited incomes, have become dependent on the low costs of a Medicare HMO and have accepted the trade-off of less choice of doctors and other services.
Unfortunately, this constant change is a new reality in a health-care system that relies so heavily on the marketplace: If a health plan can’t make money, it drops members. But don't be surprised if Congress beefs up the amount it pays these HMOs and they start leafleting the town again, promising the moon.
      Meanwhile, the people losing their coverage have some decisions to make. Here's what to know:

bulletYou should receive a letter by Nov. 2 stating that your coverage has been terminated. Hold on to that letter, because you may need it later. Also, check through the package for information about your options, such as other HMOs you can join or available Medigap coverage.
bulletFind out whether there are other Medicare HMOs in your area. Check with a local senior center, with the state health insurance assistance program (click your state flag) or in the Medicare Compare listing of health plans on the agency's Web site.
bulletWhile you're deciding, don't disenroll from your old health plan, which must cover you until Dec. 31, 1998. Under federal law, if you decide to go back to traditional Medicare and buy a Medigap supplemental policy, you are guaranteed certain types of policies even if you have pre-existing health problems.
bulletIf you don't enroll in another HMO, you will automatically be enrolled back in traditional Medicare. If you're worried about finding another doctor, consumer advocates say that probably won't be a problem. In fact, your HMO doctor may be available on a fee-for-service basis, and would probably be more than happy to take care of you at the higher rates that traditional Medicare pays.

      However, for those folks who've gotten used to having their drugs mostly paid for by the HMO, Medigap policies that include prescription coverage are expensive, and they are not among the four types that must be made available to you if you've lost your HMO. To buy one of those four (designated A, B, D or F), be sure you apply for the Medigap policy within 63 days after your HMO coverage terminates on Dec. 31, 1998. The insurance company cannot deny you one of those policies based on your health or claims experience. If you have a problem, be sure to get help from a senior center, state insurance or aging agency, or HCFA.
      If you dropped a Medigap policy before joining your HMO and want to return to it, you can do so if the insurance company is still selling that policy, you haven't been in the HMO more than 12 months and if you disenroll from the HMO before Dec. 31. But check with Medicare or an insurance counselor first. You should also get help if you are enrolled in Part B of Medicare only, because you'll have to enroll in a new HMO by Dec. 1.
      Now, back to that brochure you're going to get about new Medicare choices. Congress set up something called Medicare+Choice, which was supposed to add new options for Medicare beneficiaries. For instance, they could switch over to a Medical Savings Account, which uses an enrollee's Medicare contributions to buy a high-deductible catastrophic plan, with the rest going into a tax-free account for medical expenses. Or beneficiaries could join an HMO that is run by doctors and hospitals rather than insurance company executives.
      These programs were supposed to get started in early 1999, but they probably won't appear for quite some time. For one thing, there will be no MSA option because none of the insurance companies decided it was financially worthwhile to offer them. And most of the doctors and hospitals thinking about going into the HMO business got cold feet, so only a few have applied to set up health plans.
      So when you get the Medicare+Choice brochure in the mail, don't take it too seriously. They just want you to know what the options are likely to be in coming years. If you want to know more about it, check out Medicare's Web site and look at the "Medicare and You" brochure.

             Other resources of information:

bulletU.S. Administration on Aging referral line to local agencies on aging, toll-free (800) 677-1116
bulletA detailed explanation of Medicare and recent changes is on the New York State Office for the Aging Web site.


Medicare Return
Medicare Return