One of the ways I test my students’ working knowledge of Medicare eligibility is by having them engage in a Medicare insurance counseling simulation. This is no easy undertaking. Medicare’s “layer cake” approach (one layer for in-patient benefits, one layer for out-patient services, a third layer for prescription drugs, a fourth for Medicare Supplemental Insurance (popularly known as “Medigap”)) makes for a complicated, fact intensive approach to insurance counseling. Of course, that is part of the lesson. Are America’s seniors well equipped to choose, choose, and choose again on each layer of the cake? Is the Medicare layer cake a splendid edifice to insurance design or a horse designed by a committee?
The second biggest takeaway from the Medicare counseling simulation is that original Medicare is a relatively thin benefit. The fact that the vast majority of Medicare beneficiaries supplement with some type of Medigap plan (employer sponsored or sold by commercial insurers in a structured marketplace with a wide variety of price points) does not mean the original benefit is not thin. At the very end of the financial continuum, Medicare beneficiaries who have very low income and assets may qualify for Medicaid simultaneously, making Medicaid a kind of Medigap for them. This is what it means to be “dually eligible."
What about the seniors too well off to be dual eligibles but too low income to be able to afford Medigap? They gravitate to enrollment in Medicare Managed Care.
The way I see it, if you understand that Medicare Advantage (Medicare Managed Care or Medicare Part C) may require that you trade in your traditional Medicare (Medicare fee for service) poker chips for a Medicare managed care plan poker chip that serves to insulate you from original Medicare’s thinness, you are not only learning something about how Medicare works, you are also learning something about how we ration care. Under Medicare Managed Care – as with all managed care – we hide the hand of rationing by saying the insurance company is engaging in utilization review. Of course they are, but the explicit purpose of managed care is both to lower cost and improve quality. These goals remain constant in the Medicare form of managed care, the plan of last resort for the those too poor for Medigap but too rich to be dual eligibles. And so we ration Medicare unevenly.
So, who is Alice? Alice is my own insurance counseling non-simulation.
Alice is a friend – a remarkably robust and lively octogenarian -- who contacted me around Christmas to let me know that she had fallen outside her home, broken her hip, had surgery, and was now in rehab for her Medicare sanctioned 21 day stay. Her next missive let me know that, during Medicare’s open enrollment this past fall, financial exigencies had pressed her to abandon fee for service Medicare for a Medicare Managed Care plan. And, you guessed it, the Medicare Managed Care plan kicked in mid-treatment on January 1, 2013.
Health insurance policies sometimes make provisions for the continuation of care of procedurally based medicine (but not so much chronic care treatment) that straddles enrollment in two different health insurance plans. Not so Alice’s new plan.
Alice is in no-woman’s land. Disenrolled from fee for service Medicare – and unable to keep the surgical follow-up appointment from a surgeon who takes Medicare assignment but does not participate in Medicare Managed Care – and moved to a Medicare Managed Care rehab funded facility, Alice was advised that this was her problem to unravel. Her new Medicare Managed Care insurance plan vacillated between advising her she was not an enrollee in their plan and advising that, even were she an enrollee, no follow up post-surgical appointment was necessary.
Alice, a wise women, approached me to ask if the best way out of the mess was to charge forward with her new Medicare Managed Care plan or to use the 45 day cancellation option of Medicare Managed Care and regroup in Medicare fee for service for a few months.
Although the thought of Alice having to argue with her new insurance company from the comparative disadvantage of her painful position made me uneasy, I wondered if cancellation made any sense. Alice has had to sort through whether she could afford traditional Medicare’s costs for her hip fracture in a system with precious little price transparency. She has had to guess at her anticipated exposure. The projected answer: without a Medigap policy, she probably cannot afford to regroup in traditional Medicare for another few months.
So Medicare Managed Care it is, if she can persuade them she is an enrollee. Of course, she can always appeal the decision to deny services and put together the records for an appeal -- from her rehab bed.
Bear in mind that Medicare is that portion of our health care system that ranks highest in patient satisfaction data.
Or, you can go ask Alice.
x posted at http://prawfsblawg.blogs.com/