For many it is a right of passage. For typical Americans upon reaching 65 years old, we are able to sign up for Medicare services as our health insurance. This has been the gold standard insurance coverage for many generations.
Different parts of Medicare
Medicare consists of different “parts”. These parts consist of different coverages and costs. Medicare A is commonly referred to the hospital coverage part. This is the part that covers any services for a hospitalization as well as aftercare such as rehabilitation. Medicare part B is considered the outpatient part of Medicare. We have to opt in for Medicare B when signing up for Medicare. Medicare B covers doctor appointments, outpatient therapy, as well as some other medical services.
This was the standard for many years as the Medicare program. Over the years there have been some changes in the Medicare system which added other parts.
In 1999 Medicare part C was established. This new section of Medicare established what is now known as Medicare Advantage plans. Medicare part D became available in 2006. Medicare part D is the optional prescription drug coverage part of Medicare.
Medicare Part C
I bet there has not been one day when you are watching TV that you have not seen some comercial for one of the Medicare Advantage plans. This is especially true during Medicare open enrollment from October through December.
The shear amount of advertising by Humana, United Healthcare, and Aetna, to name a few, easily out paces any other brand of item on TV.
These advertisements focus on “the benefits you might be missing”. They love to stress the “added” dental coverage or vision coverage if you sign up for these plans. In essence Medicare pays these companies a set amount for their care for the year.
For many Seniors they do not fully understand the choices they have. They are reliant on the salespeople, whose job is to sell a health insurance plan, to help them decide what exactly is the best coverage for their situation.
Most Seniors as well as their families think they still have Medicare. They do not realize that they are now covered by a for profit insurance company in a Managed care plan. This managed care plan includes restrictions like any other commercial insurance. There are networks of providers, the need for pre-authorization for services, as well as the use of benefit management companies dictating your care.
But I have Medicare…..
All too often we hear this from residents and family members upon admission to a Skilled nursing facility for post hospital rehabilitation. Many assume that the “Medicare ” rules apply. They assume they have 20 days of full coverage and a copay starting on day 21 until a maximum of 100 days if medically necessary.
They are often in disbelief when they are advised that medical records are submitted to a benefits “gatekeeper” the day after therapy evaluations and are often updated every 3 to 4 buisness days. They don’t understand how the insurance is cutting services in 10 to 14 days.
But they are not ready to go home yet. They can’t….
Frequently we hear this from many family members. They wonder how the insurance is cutting services when they are not back to their pre hospital level of function. They continue to need assistance with aspects of daily care. They would not be able to return to home without outside caregivers.
Is this the future?
So is the future of Medicare going to be Medicare Advantage plans? There have been and continue to be those in our Congress that believes it is best for our country to privatize Medicare by only using Medicare Advantage plans. Nationally there has been a steady increase of people who have signed up into these plans.
So what do we do? Well we need to be advocating for our elderly that deserve what Healthcare they were promised. We need to make it very well understood by our government entities how poor oversight and a focus on pure cost control versus quality care. These insurance companies need to be held accountable to provide the benefits that are part of traditional Medicare and actually follow the rules and guidelines established by the Centers of Medicare and Medicaid Services.
The squeaky wheel gets the grease
Without input from the community these for profit companies have the ability to influence those that write and enforce the rules they have to follow. We need to hold them accountable to allow for Medicine to happen and not be a revenue producer for themselves and investors. So please contact your local representative and senator to hold them accountable to the elderly generation that deserves and desperately needs proper health coverage. Remember eventually it will be your coverage.
