MEDICARE - - Stop HMO Lock-in

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" Magginkat " <magginkat

Thu, 29 Jun 2006 17:50:08 -0500

MEDICARE - - Stop HMO Lock-in

 

 

 

 

 

Your Weekly Medicare Consumer Advocacy Update

 

 

Stop HMO Lock-in

 

June 29, 2006 • Volume 6, Issue 26

 

Two days from now, on July 1, most people with Medicare who have

joined an HMO will be locked in for the remainder of the year.

Although HMOs have been part of the program for over a decade, people

with Medicare have always had complete freedom to leave these private

plans and return to Original Medicare. This vital consumer protection

disappears on Saturday.

 

For over 15 years, the Medicare Rights Center has helped people

disenroll from HMOs so that they could receive coverage for the

medical care they needed under Original Medicare. New HMO enrollees

were often surprised to learn that the doctor who has cared for them

for years was not part of the plan's network. Other disenrollments

were prompted by the discovery that care from a recommended specialist

or cancer center was unavailable under the HMO.

 

Often, upon admission to the hospital or a diagnosis of cancer, the

person learns that the HMO imposes much higher cost-sharing for that

type of care. Often, these individuals had joined specifically because

they thought it was the most affordable option. Now, a return to

Original Medicare may be the only option to continue an expensive

course of treatment.

 

Cases like these, along with marketing abuses that push our most

vulnerable citizens into health plans that do not meet their needs,

are detailed in a report issued this week by the Medicare Rights

Center. These stories are compelling, but there is broader evidence of

both deceptive marketing of HMOs and other Medicare Advantage plans,

and of the coverage problems that can result from choices made under

the influence of such marketing.

 

In testimony before the House Ways and Means Committee earlier this

month, Wisconsin's insurance commissioner described a situation

familiar to social workers and counselors across the country:

marketing representatives have signed people up for HMOs and other

Medicare Advantage plans when what they really wanted and needed was

prescription drug coverage.

 

Commissioner Jorge Gomez goes on to detail how state regulators have

been stymied in their efforts to rein in such abusive marketing by the

Centers for Medicare & Medicaid Services and by the drug benefit

statute, which pre-empted their authority.

 

These unscrupulous marketing representatives capitalized on the

confusion surrounding Part D and the panic inspired by the enrollment

deadline and late enrollment penalty to dupe consumers into an HMO.

For individuals who enrolled just before the deadline, June was their

first month of coverage. If they did not visit the doctor this month,

or have yet to receive a bill for a doctor visit, they still might not

know they have joined an HMO or what the plan's restrictions are.

 

Many newspapers have reported on the confusion experienced by people

with Medicare when faced with an array of drug plans, each covering

different drugs and charging different copayments. It is even harder

to figure out the health coverage offered by a Medicare Advantage

plan, and the consequence of a bad choice can be financially devastating.

 

In a groundbreaking study by the Commonwealth Fund, researchers found

different Medicare Advantage plans imposed sharply different levels of

cost-sharing on individuals with high medical needs. On the high end,

one of the more popular plans charged its sickest members over $7,500

for hospital stays, prescription drugs and other medical care. For the

same care, another plan charged less than $1,400. The effect of a bad

plan selection can put the cost of needed care out of reach for many.

 

Lock-in freezes those bad choices in place. It removes the most

effective remedy people with Medicare have had against abusive

marketing. Congress should lift lock-in and restore the ability to

return to Original Medicare.

 

 

Medical Record

 

" Ms. S lives in Ohio. In December 2005 she was hospitalized twice in

one month. Her member's manual stated `if there were less than 60 days

between two hospital admissions, they counted as a single benefit

period.' As a result, Ms. S assumed that she would have only one

copayment for both admissions. However, the same page of her member's

manual also stated that each hospital stay costs $750. Ms. S was

actually responsible for $1,500 for the two admissions, even though

they were within one single `benefit period'; which, in this context,

meant little. If Ms. S had been with Original Medicare, she would have

paid one $952 deductible for the two admissions. Payment would be

based on the fact that the admissions had been within a single benefit

period " ( " Elimination of HMO Lock-In: A Vital Consumer Protection, "

Medicare Rights Center, June 2006).

 

" There are brokers and agents using Medicare Part D as a pretext to

inappropriately get in the doors of Medicare-eligible consumers, then

selling them a variety of unrelated and sometimes unsuitable insurance

products. There are Medicare beneficiaries who have been placed in a

Medicare Advantage policy without their knowledge, or at least their

understanding, when they thought they were signing up for a PDP

[prescription drug plan] " (Testimony of Jorge Gomez, National

Association of Insurance Commissioners, Before the House Committee on

Ways and Means, June 14, 2006).

 

" Given the current potential for confusion regarding MA [Medicare

Advantage] plan benefit packages and the risk of substantial

out-of-pocket costs for sicker enrollees, the policy that locks in

Medicare beneficiaries to an MA plan for an entire calendar year—which

began in January 2006—could be suspended until new limits on

out-of-pocket costs and improved risk adjustment are implemented "

( " Medicare Beneficiary Out-of-Pocket Costs: Are Medicare Advantage

Plans a Better Deal? " The Commonwealth Fund, May 2006).

 

* * * *

 

Fast Relief: Part D Monitoring Project

 

The Medicare Rights Center (MRC) needs to hear about all the problems

with the Medicare Part D benefit, whether they happen to you or

someone in your community. With this information, we will be armed

with the needed evidence to push for a Medicare-administered drug benefit.

 

Submit your story at www.medicarerights.org/partdstories.html

 

* * * *

 

The Louder Our Voice, the Stronger Our Message

 

Asclepios—named for the Greek and Roman god of medicine who, acclaimed

for his healing abilities, was at one point the most worshipped god in

Greece—is a weekly action alert designed to keep you up-to-date with

Medicare program and policy issues, and advance advocacy strategies to

address them. Please help build awareness of key Medicare consumer

issues by forwarding this action alert to your friends and encouraging

them to today.

 

* * * *

 

The Medicare Rights Center (MRC) is the largest independent source of

Medicare information and assistance in the United States. Founded in

1989, MRC helps older adults and people with disabilities get good,

affordable health care.

 

Visit our online subscription form to sign up for Asclepios at

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