Mastering Medicare: Elders Learn About Their Options

By Jan Howard

Two additional Medicare managed care plans (HMOs), ConnectiCare and MedSpan, have withdrawn from the Medicare market in Connecticut, leaving only two HMOs, Health Net (formerly PHS) and Oxford Health Plans, in the state. Only Health Net/PHS covers Fairfield County.

This action has sent another 39,000 people scrambling for coverage, according to Betty Scheithe, CHOICES Program assistant for the Western Connecticut Area Agency on Aging.

“Our phones are ringing off the hook,” Ms Scheithe said.

Ms Scheithe spoke about “Medicare: Your Rights and Options” at a Lunch and Learn program October 9 sponsored by The Learning Center at Ashlar of Newtown. It is part of a series of programs designed for mature adults about living and aging well.

Only Health Net serves Fairfield County, and Ms Scheithe said it is likely that its enrollment will be closed when capacity is reached. Current members will not be affected. She noted that Danbury Hospital may not renew its contract with Health Net.

Ms Scheithe explained that CHOICES counsels senior citizens about insurance rights and options, and screens people for programs that are available to them. These include information on abuse, adult day care, exploitation, health care costs, housing options, job training, nutrition services, respite care, and others. A pilot program is in effect at Nunnawauk Meadows in Newtown that helps people stay in their home for home care, she said.

People who have lost their HMO coverage may return to Medicare, Ms Scheithe said, but should consider purchasing a Medicare supplement (Medigap) policy.

Medicare Part A covers inpatient hospital, skilled nursing facility, home health, and hospice services. Medicare Part B covers a variety of outpatient and physician services plus some home health care, durable medical equipment, prosthetic devices, supplies incident to physician’s services, and ambulance transportation.

Medicare Part A has a hospital deductible for each benefit period of $792; Medicare Part B has a $100 deductible. A supplement or Medigap policy would pay the deductible, Ms Scheithe said. It also would cover gaps in coverage.

Some of the gaps of coverage in Medicare Part A, in addition to the deductible of $792, are as follows:

Hospital coinsurance payments. Medicare covers the first 60 days in full after the deductible has been met. The daily co-insurance rates in 2001 are $198 per day, days 61-90, and $396 per day, days 91-150.

Hospital services beyond 150 days.

Skilled nursing facility co-insurance payments. Medicare covers the first 20 days in full. The co-insurance rate is $99 per day, days 21-100.

Skilled nursing facility services beyond 100 days during each benefit period.

Home Health aide services when skilled nursing or therapy is not required.

Home health care services that are provided on more than a part-time or intermittent basis.

Some of the gaps in Medicare Part B, in addition to the $100 deductible, are:

Part B 20 percent co-insurance payment. Medicare pays 80 percent of the approved charge for all Part B services and items; this amount varies according to the services and items provided.

Billing above the Medicare-approved charge. Many physicians and providers charge more than the amount Medicare approves.

Prescription medications. Medicare pays for prescription medications only in very limited situations, such as chemotherapy administered incident to a physician’s services. Also, some oral chemotherapy drugs are covered.

Medigap Plans

If a person is being dropped from an HMO, as long as he or she enrolls in a Medigap policy within 63 days, pre-existing illnesses do not exist and there is no limitation on coverage or requirement for a health examination, Ms Scheithe said.

There are ten standardized Medigap plans, from Plan A to Plan J. Plan A contains basic or core benefits. The other nine contain the core benefits plus one or more additional benefits.

Core benefits include hospital coinsurance, days 61 to 91; hospital coinsurance, days 91 to 150; hospital payment in full, 365 additional days; Part A and Part B blood deductible, first three pints of blood; Part B 20 percent coinsurance, physician and other services.

Only Plans H, I, and J include prescription benefits, Ms Scheithe said. Each has a $250 deductible and the insured pays 50 percent of the prescription drug costs. Plans H and I have a maximum benefit of $1,250 annually, and Plan J a maximum benefit of $3,000 annually.

Ms Scheithe said it is almost guaranteed that all Medigap providers will be raising their rates. “They will be serving 39,000 more people,” she noted, explaining the companies can go before the state Insurance Department for approval for an increase in rates. “Last year, some got as much as a 45 percent increase,” she added.

She cautioned seminar participants to make sure they have enough coverage because the 20 percent that Medicare does not pay can add up very quickly if extensive tests are required.

Though Medicare does not pay for an annual physical, it is beginning to provide some preventive health benefits, Ms Scheithe noted. They include annual mammograms, pap smear and pelvic exam every two years, colorectal cancer screenings, colonoscopy screening, diabetes management training, diabetes screening tests, bone mass measurement, and prostate cancer screening tests. Additional benefits available in 2002 will include glaucoma screening and medical nutrition therapy. Medicare coverage continues to be available for influenza vaccines, pneumococcal vaccines, and hepatitis B vaccine.

Ms Scheithe urged seniors to write to their congressmen and senators regarding the need for prescription coverage.

It is recommended that Medicare HMO members losing coverage should begin researching Medigap options as soon as possible. A Medicare beneficiary can purchase a Medigap policy as early as this month, and have the policy begin on January 1.

Ms Scheithe also explained ConnPACE, which helps senior and disabled persons pay for certain prescription drugs, insulin, insulin syringes, and needles. Participants pay $12 for each prescription and ConnPACE pays the rest. To be eligible, a person must have lived in Connecticut for at least six months before applying. He or she must be at least 65 years old, or disabled and over 18 years old. Adjusted gross income for the previous year plus Social Security (minus Medicare Part B premiums) must be less than $15,100 if single, $18,100 if married. Income limits are expected to go up to $20,000 if single, and $27,000 if married, she said.

“More people will be able to have ConnPACE,” she said.

Ms Scheithe also discussed Medicare savings programs, such as QMB, SLMB, and ALMB, which, if people qualify, can help pay for Medicare premiums and, in some cases, for Medicare coinsurance and deductibles. To qualify, a person must be eligible for Medicare Part A, and income and assets must be within program limits

CHOICES enables senior citizens to understand and exercise their rights, receive benefits to which they are entitled, and make informed choices about quality of life concerns. CHOICES programs are managed by the Elderly Services Division of the Connecticut Department of Social Services. Operation is funded, in part, by a grant from the Centers for Medicare and Medicaid Services (CMS), and Title III, Older Americans Act Funds.

Connecticut’s Area Agencies on Aging are private, nonprofit organizations that serve the needs of older persons as a focal point and resource center for information, program development, and advocacy.

The Western Connecticut Area Agency on Aging is located at 10 Progress Lane, Waterbury, CT 06705. CHOICES can be reached by calling 1-800-994-9422.

 For information on upcoming programs at Ashlar of Newtown, call Hilda DeLucia at 364-3127.