“My dad doesn’t have Medicare!” A friend said to me on the phone a few months ago.
“What?” I responded. Thinking: This seems unlikely. Pretty much everyone over age 65 has some form of Medicare and my friend’s dad is at least 90 years old.
Then he explained, “Dad has something called ‘Blue Cross advantage.’”
“Ohhhhh…. Okay.” I got it now.
I explained that his dad does have Medicare but it’s a particular form of Medicare that private health plans (like HMOs) offer. It’s called “Medicare Advantage” and people eligible for Medicare can sign up for it instead of the original or traditional Medicare.
Medicare Advantage plans often fill the gaps in traditional Medicare coverage — like vision or dental coverage– and often at a lower price than the supplemental “Medigap” policies older adults typically buy to get these benefits and cover Medicare cost-sharing.
Medicare Advantage can be a simpler and more streamlined way to deal with Medicare. You get everything — usually including drug coverage — in one big package. That can be nice because traditional Medicare is a complicated alphabet soup of different parts that Congress keeps tacking onto the program.
So, your dad automatically gets something called “Part A” coverage. This is the part of Medicare that pays for hospital and post-hospital care.
But, THEN, to get coverage for physicians, he’ll sign up for Part B, which requires a monthly premium payment to the government that gets deducted out of his social security check.
To get drug coverage, he’ll go out and buy “Part D” benefits from a private health plan, appropriately called a “part D plan” or PDP.
And, then he might get a whole separate, other private policy called (also appropriately named) “Medigap” to cover the holes – the stuff that is amazingly not included in Parts A, B, and D.
What happened to Part C you ask? Oh, well now we are back to Medicare Advantage part of Medicare where you can turn all your coverage over to one plan – you pay your Part B premium and one other premium to the plan and you’re done.
Sounds GREAT! Sign Mom up for Medicare Advantage.
Not so fast.
As with everything in your world now, this is COMPLEX. There are trade-offs and challenges in choosing Medicare Advantage.
Here’s one more thing you probably don’t feel qualified to be in charge of but you are. It’s your job to figure out how to navigate the Medicare Advantage plan coverage that your Dad – who is now frail – signed up for 10 years ago when dental coverage was his biggest health worry. Or, figuring out how to switch plans or disenroll altogether!
So, I’m going to boil it down here. Whether or not your mom or dad is in a plan now, or if you are considering one for them, you DO have power and you DO have choices.
The trick is knowing how and when to take control. Here are four things you CAN do to get what you need for your parents.
Push Back on the Plan’s Coverage.
Medicare Advantage plans are not usually super flexible organizations.
And, while some of their rules for covering services can work in your favor (for example, most plans do not require a 3-day prior hospitalization for skilled nursing care), they also limit your parent’s network of providers, and impose rules that reduce access to services your parents might need.
For example, another friend thought his dad should have been discharged from the hospital to a special rehabilitation center but this center isn’t part of the plan’s network. So, his dad ended up going home without any post-hospital care.
Someone else I know thought her mom was discharged much too early from a skilled nursing facility. However, when she questioned this, she was told that this was as much care as the plan would cover, even though it was far fewer days than is usually paid for by traditional Medicare.
What you need to know is that you have the RIGHT to ask your parent’s plan to provide or pay for services you think should be covered or continued.
And, if the plan won’t cover what you ask for, there’s a four step appeals process, you can pursue, you know… with all your extra leisure time.
So all is not lost….except maybe your time and sanity.
Get Expert Help Picking a Plan
Your parent will get a lot of lovely, glossy marketing materials from some of the plans. And it would be easy to see one that looks good and sign up.
But, be cautious here. These plans can be so different in what they cost and cover — and marketing materials aren’t the best way to pick the plan that will work best for your individual circumstances.
Please don’t feel like you have to do all of this by yourself. It’s really okay to ask for help.
You can start by using the government plan finder! It’s at www.medicare.gov. Click on “Find health & drug plans” on the home page.
But, before you do this, invest in AARP’s Medicare for Dummies, and consult Chapter 11 as you go through the plan finder. The author guides you through the process. And, this is just a good book to have as a general reference on Medicare.
But there’s no substitute for sitting down with a live person. And, the good news is that the government funds a resource in every state called the state health insurance program (SHIP). SHIP is a FREE, confidential and unbiased insurance counseling service.
Go to this website and call to make an appointment with your expert and free SHIP counselor. This can be especially helpful if your parent is also eligible for Medicaid, which is available to individuals whose income and assets are below certain levels. When your parent is eligible for BOTH Medicare and Medicaid, the SHIP can help you find special programs for “dual eligibles” that may be available in your state — like my very favorite, the Program for All-Inclusive Care for the Elderly (PACE).
Know the Rules for Making Changes in Coverage
You can make changes if you don’t like your parent’s plan or situation. But you need to just know the general rules about when and how to do it because there are restrictions.
Here’s the way it works. If you want to sign up for Medicare Advantage, change plans, or change back from Medicare Advantage to traditional Medicare, the general time to do that is during the annual open season, which runs from mid-October to early December.
As Patricia Barry, author of Medicare for Dummies explains, in addition to the open season, there’s also a special season devoted exclusively to dis-enrolling or switching out of Medicare Advantage and into traditional Medicare. During this season that starts January 1st and runs through mid-February, you can even drop Medicare Advantage if you just signed up for it!
Okay – as if this wasn’t already really complicated, there are a bunch of special enrollment periods that provide additional opportunities for changing your situation if… you move permanently outside a plan’s service area, you move in or out of a nursing home, you are new to Medicare, your plan withdraws from the program or somehow misleads you…and there are more.. all explained in Patricia Barry’s book.
Remember Not to Be Too Hard On Yourself
I have worked for 25 years on various aspects of Medicare (and Medicaid) and this was a hard blog to write. A good friend of mine, who has has even more experience with these programs, reported that figuring out her Medicare coverage was a nightmare.
What that means is that you should not feel frustrated with yourself if you have to struggle to understand all the options. You could go to Medicare SCHOOL and still flail around.
Handling your parents’ insurance coverage will be one of the most time-consuming and anxiety-producing parts of your new job as their care manager. So, give yourself permission not to get it just right, to let something slip through the cracks, and to need help!
Your efforts ARE enough and, more importantly, just being there for your parents — all of the paperwork aside — is what matters most.
I’d LOVE to know your experiences figuring out your parents’ insurance options. Please go to the comments section and share what has helped you.