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
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
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
surgeon who takes Medicare assignment but does not participate in
Medicare Managed Care – and moved to a Medicare Managed Care rehab
Alice was advised that this was her problem to unravel. Her new Medicare
Managed Care insurance plan vacillated between advising her she was not
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/