Every fall in early October, private insurance companies “open” their virtual doors to new subscribers until mid-December. They ramp up their advertising to convince trusting seniors that their company has something better to offer them than classic Medicare.
For insurance brokers, this is the annual rush for clients and commissions that will sustain them for the rest of the year. For some brokers, this is shark feeding time as they visualize the mass of confused seniors as an ocean predator sees a shoal of fish.
It’s not like Medicare makes it easy for seniors to understand all the types of plans to choose from because if you choose the wrong one, you’re stuck and a government agency like CMS (Centers for Medicare and Medicaid Services), where if they make a mistake on your application, YOU have to live with it until the following year. If you’re lucky to get help, it may take hours of calling, being placed on hold, then talking to twelve people along a calling tree you were afraid to leave just in case the next person could be “the one” who solves your problem.
Insurance companies LOVE the Medicare confusion because it helps them to access Billions in Medicare funds annually which they should not be allowed to do because it amounts to theft. They entice brokers with high commissions for peddling their “Advantage” plans as better than classic Medicare.
The privatization of Medicare allows FOR-PROFIT COMPANIES to take the hard-earned benefit that we all pay into from our first to last paycheck so that we can be entitled to healthcare in our old age when we no longer earn salaries and may live on a modest or low budget.
But that alone does not make it completely evil. What takes it the pinnacle is that they get to decide who gets to subscribe because they want to keep as much of that money as possible. They accept healthier seniors who are less likely to use their Medicare funds.
Then the “Advantage” plans will enroll anyone willing to not only hand over their funds every month for the company to profit from, some charge seniors a monthly premium, annual deductible (paid in cash for healthcare until it is met before enjoying the benefit of insurance coverage), and hefty co-pays of $30-45 per therapy or specialist visit. Add up therapy twice a week for 6-8 weeks, that may leave a senior having to make the decision of not buying groceries, paying utilities, or not getting further rehabilitation after a hospital or in-patient stay. This puts them at risk for falls and failure to age at home safely.
This article may not answer all the questions but should make the reader ask why a private company would want to offer something better than classic Medicare when it first has to answer to stock-holders and provide salaries with benefits for thousands of employees.
After 20 years of seeing my senior patients live with bad Medicare management plans like Humana and HMOs like Kaiser, I finally found an honest broker who put her clients ahead of her commissions. Even when seniors find out that they are on the wrong plan, some still take that information to their broker – the one who sold them out, to give them a chance to put them on the right plan. This always leaves a palm print on my forehead.
Some seniors are blessed to not have to worry about having to pay $45 per therapy session 2-3 times a week for several weeks after a fall or to prevent falls due to weakness and balance disorders, but most could not afford this.
Here we have a brief synopsis of Medicare plan choices and it is up to the reader to determine if they have been well-served or if they now realize that with age, illness and the need for specialists and therapies become a bigger reality.
A.Original Medicare (A & B)
Part A: covers 80% of services provided by many healthcare providers for
hospital in-patient stay
skilled nursing facility for up to 90-day stays
in-patient physical rehabilitation for as long as deemed medically necessary and making gains toward discharge goal (hence, “skilled” therapy)
B. Part B: A monthly premium supplement to Part A that covers 20% remaining cost and also covers
(Part B - this is a supplemental plan and THE HOOK for private insurances to take your Medicare account for their profit)
Doctor’s visits for preventive and management of health conditions (100%)
Medicare Supplement Plan F vs Plan G: they provide the exact same coverage, except for one thing: Plan F pays the annual Medicare Part B deductible, while Plan G does not. The Part B deductible is $185 for 2019.
C. Part C: Medicare Advantage plans replace Original Medicare but with out of pocket costs and limitations
PRIVATE FOR-PROFIT INSURANCE COMPANIES – their bottom line is your Medicare fund!
Requires In-Network providers that accept Medicare AND the for-profit company’s LOWER reimbursement rate (more on this later).
In some plans, the senior pays a hefty co-pay (aka co-insurance) for every office visit at doctors and therapies
United HealthCare co-pays for therapy are $45 per visit;
Aetna, Blue Cross, etc. may vary from $30 to $45 co-pay per therapy session.
An ADDITIONAL PREMIUM to the Part B premium!
To justify the additional premium, they offer “additional benefits” such as gym memberships for “Silver Sneakers” and other senior fitness programs – more on this later.
Medicare Advantage Pros and Cons
+Many plans cost $0 a month
+Usually includes drug coverage
+Many include hearing and dental (with limitations- usually cleanings, annual x-rays)
+Can include gym discounts
+Can switch to another Medicare Advantage plan during open enrollment
- Out-of-pocket maximum is $6700 a year
- Still requires you to pay copays and coinsurance fees
- Plans are difficult to compare since no two Advantage
plans are alike
- Usually no nationwide coverage
- Mainly HMO plans that require referrals to see
- Plan can change drug and medical coverage each year
- Hard to switch to plans like Medigap
D. Part D: Medicare Prescription Drug Plan
*Additional premium to Part B
Covers prescription drugs – ONLY if the medication is on their formulary
Some Advantage Plans may include this as one of their benefits – it’s up to the subscriber to find out if their medication is on their formulary, otherwise, they will have to pay out of pocket and full price for their meds anyway.
E. Medigap Insurance –also offered by Private Insurance Companies
Fills in gaps in Medicaire
Monthly premium (usually) in addition to the Part B premium
costs vary by insurance companies and policies
doesn’t work with Medicare Advantage plans
*Per Medicare.gov: If you join a Medicare Advantage Plan for the first time, and you aren’t happy with the plan, you’ll have special rights under federal law to buy a Medigap policy. You have these rights if you return to Original Medicare within 12 months of joining.
If you had a Medigap policy before you joined, you may be able to get the same policy back if the company still sells it. If it isn’t available, you can buy another Medigap policy.
The Medigap policy can no longer have prescription drug coverage even if you had it before, but you may be able to join a Medicare Prescription Drug Plan (Part D) .
If you joined a Medicare Advantage Plan when you were first eligible for Medicare, you can choose from any Medigap policy.
Some states provide additional special rights.
Medigap Pros and Cons
+Plans cover all or part of Medicare additional fees
+Plans are easy to compare
+Guaranteed 6-month enrollment when 1st eligible
+Some plans offer extras like excess charges, foreign travel, and Silver Sneakers program
- Monthly premiums can be pricey
- Plans difficult to switch once enrolled
- May not be able to enroll after initial enrollment period.
- All plans offer an additional 365 days in hospital
- Not all plans cover hospital deductible
- Does not include drug coverage
- Doesn’t cover acupuncture
Privatized Medicare Plans in the state of Washington are offered through UNITED HEALTHCARE (UHC) and KAISER. They both require that you see IN-network providers and you cannot see out-of network providers. They are very different in the following:
United Healthcare will have a monthly premium,
$45 co-pay and they limit each out-patient therapy session to 1 hour (or less depending on the documentation time at the point of service and the provider’s original fee schedule point of value).
They only reimburse therapy providers $75 per session goes below 50% of therapy fees. Many private practice clinics – both medical and therapy have and are opting out of this company because of the loss in reimbursement and the limitation that this places on the delivery of services. Some specialists need more time than 45 minutes to address a complicated condition.
Kaiser has their own locations and limited contracted providers outside their facilities. You do not have the option of choosing or keeping your own healthcare providers if they are outside of the Kaiser family. Their #1 goal is cost containment so you will rarely be offered anything outside of basic and absolutely necessary, and in some cases, the patient is forced to become a strong self-advocate to be approved for certain durable medical equipment (insulin pump, Bi-Pap, or other device).
JUST FOR YOUR INFORMATION on other Medicare Programs based on financial need:
Programs of All-inclusive Care for the Elderly (PACE)
Medi-Medi (combines Medicare and Medicaid as the supplement plan)
provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid benefits;
comprehensive service package enables them to remain in the community rather than receive care in a nursing home;
must meet financial need criteria and a disability for early eligibility (age 55+);
is not offered everywhere – there are PACE communities that are served by service providers;
includes coverage for nursing home care with the goal of returning home in the community after an illness or injury;
May include Community Options Program Entry System (COPES);
The Community Spouse Resource Allowance—allows the healthier spouse to continue to afford to live independently;
also covered are certain funeral related expenses or trusts;
The value of one's home, if the applicant or their spouse lives in it and the equity value is not greater than $585,000, and a primary vehicle are exempt;
For married couples with just one spouse applying for Medicaid, income of only the applicant is considered. However, in some cases, the applicant spouse is able to transfer a portion of their monthly income to their non-applicant spouse (also called a community spouse).
As of 2019, up to $3,160.50 / month can be transferred to the community spouse.
Community Care now available through Washington's Community First Choice (CFC) Progra
Non-Medical Transportation Assistance
Personal Emergency Response Services
Home Delivered Meals
Home Care / Home Health Care / Skilled Nursing
Environmental Accessibility Modifications to one's Home or Vehicle
Durable Medical Equipment
Community Support: Goods and Services
Community Choice Guiding
Assisted Living / Adult Family Homes
Adult Day Care / Adult Day Health Care
Individuals approved for the COPES Waiver can receive any of the following services. Case-by-case approval may be required.
MUST BE DISABLED: requiring assistance with two or more Activities of Daily Living, such as bathing and getting dressed, and needing a nursing home level care, individuals must be financially qualified for Medicaid. This is a complicated process involving a review of a couple’s or individual’s income, bank accounts, investments, and properties.
Washington Apple Health Medicaid waivers have an individual income limit in 2019 of $ 2,313 / month ($12,490 / year). Separately, there is a countable asset limit in 2019 of $2,000.
Eligible applicants can have no more than $2,000 in all their bank and retirement accounts. However, both these limits have some flexibility for a variety of reasons.
Persons with higher incomes may qualify as "medically needy" should they have unusually high recurring medical expenses, such as medications or home health care.
To drive my point home about "Advantage" plans, imagine that you set aside money out of each of your paychecks, from the very first one to the last one when you retired. You set this money aside for a car that would not breakdown when you could least afford to buy a new one or get it repaired.
The day you turned 65, it was paid in full and instead of driving it home, you drove it to a rental car agency and GAVE IT TO THEM, asking that they allow you to drive it to medical appointments. They agreed to let you RENT IT FROM THEM - but only for a limited time because they now had rights to it, and they are going to make a profit off it for themselves.
They may add a few perks to thank you for signing it over to them, like a senior fitness program that would cost you $30-50/month if you had to pay for it, but THEY control your car for every year you sign it over to them and they only give you one opportunity a year to take it back from them.
While some insurance companies throw in basic dental, gym/fitness class memberships, OUR Medicare funds should be off limits to greedy for-profit companies, and I blame corrupt politicians for being enticed by lobbyists for the insurance industry into selling us out for their gain.
If this article has opened your eyes, please contact your local legislator/state representative and tell them to stop this corruption and theft of our hard-earned healthcare fund. Please share this article to help us reform our abused Medicare system.
If you would like to know who we at Integrative recommend, contact our office manager at Integrative.Manager@gmail.com and we will give you the name and contact info for the most ethical and compassionate broker we know in the state of Washington.