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Question on Medicare vs private Medicare PPO
Old 05-09-2014, 12:53 PM   #1
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Question on Medicare vs private Medicare PPO

I was not planning on becoming a Medicare expert for many years since Iím still almost 20 years away from being eligible for it, but my Dad now has full on dementia and canít make decisions for himself anymore, so Iím finding it necessary to become an expert on Medicare on his behalf. And Iím finding it very challenging to get accurate information. Here is my problem:

My Dad is eligible for health care benefits as a retiree of a Megacorp. For the past fifteen years he has been on their health care plan, which is United Health Care Medicare Advantage PPO, along with Express Scripts for prescription drugs. Somehow he became un-enrolled in the plan earlier this year, and his nursing home ended up enrolling him in Medicare, along with Humana Walmart RX for prescription drugs. I have been working with his former employer to get him back on United, but a few of his doctors are asking me why I would do this, because they believe that direct Medicare is better than a managed plan.

He currently pays $98.00 for United HealthCare and Express Scripts. Humana charges him $12.60 per month, and Medicare appears to be $105.00. So the costs are about the same. However, I can not figure out which coverage is better, and I canít seem to find the answers anywhere. United can only tell me what they cover, and Medicare can tell me what they cover, but is there any difference between these two plans?

What questions should I be asking to determine which plan is better? His megacorp claims the total cost of the plan is $300.00, and they are subsidizing it down to $98.00 as part of his retirement benefits. But if Medicare only cost $105.00 plus $12.60 for drug coverage, why would the United plan be valued at $300?

I have 30 days to get him back on United or he permanently loses his right to be on the plan and will have to be on Medicare for the rest of his life. Should I be trying to get him back on United or just leave him on Medicare?
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Old 05-09-2014, 01:23 PM   #2
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If he needs to go into a nursing home and has to use Medicaid to pay for it, he has to have regular Medicare not part c (medicare advantage). We just went through this with my FIL, who had to dump his medicare advantage plan to qualify for Medicaid. At least that is how it works in Florida.

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Old 05-09-2014, 01:27 PM   #3
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There is something about preexisting conditions not being covered for a few months under medicare if you switch from an advantage plan to regular medicare. Check on that?
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Old 05-09-2014, 05:14 PM   #4
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Here are a couple URLs that might help.

Elder Law, Medicaid, Estate Planning and Long-Term Care | ElderLawAnswers
Senior Care Directory | Find Senior Care Services
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Example of retiree medical coverage & Medicare
Old 05-09-2014, 06:32 PM   #5
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Example of retiree medical coverage & Medicare

I am a retired Fed who has been on their health insurance program (which is the same for employees as retirees) for many years after turning 65. I have Medicare A & B but I had to sign up for Medicare part B when I turned 65. It is my understanding you can enroll in part B later by paying a penalty. One of the Federal health plans eliminated copays for those who have Medicare part B.

My father was also a retired Fed employee but he did not sign up for part B or D because he was on Fed Kaiser Permanente which provided comparable benefits.

It would be very unusual if your father wasn't covered by Medicare part A (the hospitalization program) and everyone who is covered and is retired Medicare is primary for any hospitalization. Health care providers who accept Medicare, all of them, send bills to Medicare first, then Medicare pays their portion and sends the bill to the health insurer who pays their portion.

Most Medicare Advantage programs provide benefits to those who have Medicare A, B & D (pharmacy benefit). It may be possible to demonstrate that you have had the equivalent of parts B & D through his retiree insurance to avoid having to pony up $ to make up for not signing up. Medicare makes the determination.

For example I have been covered by GEHA with Medicare A & B, no co-pays. Recently I signed up with Kaiser's Medicare Advantage program and had to demonstrate that my GEHA pharmacy benefit was at least as good as Medicare part D. Once I had proof of coverage by the Kaiser Medicare Advantage program I could suspend my Federal Employees Health Insurance.

To give you time to figure this out for his specific circumstances I would get him back on the United insurance. Then, after analyzing all his options, you can drop the United insurance a Medicare Advantage program works better. None of them will provide much in the way of nursing home or dementia facility care - except for medical and pharmacy.
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Old 05-19-2014, 11:22 PM   #6
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The MD visit portion is paid by Medicare Part B. Depending on where in the country your father lives, regular straight Medicare is taken by a larger array of doctors than a Medicare Advantage plan or sometimes a private plan especially if it is an HMO. In a nursing home setting you will need the medical doctor, probably a geriatric psychiatrist or nurse practitioner and possibly psychologist covered by his plan. In addition patients are often sent out to specialists such as cardiologists, neurologists, ophthalmologists and it is usually, but not always, easier to find docs who take straight Medicare than an Advantage or HMO plan. With dementia as it advances he probably will need geriatric psychiatry and psychology services to deal with depression, agitation, psychosis.

I work as a geriatric psychiatrist in nursing homes for a national behavioral heath company and there are private Medicare insurances that we just can't get covered on. Please work with the facility social worker and/or business manager about his medical needs and what might be covered. If the medical director has a nurse practitioner assigned to the facility, that person would also be helpful to speak with, to see who they refer to and if they've had a problem with his employer's retiree insurance.
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Old 05-20-2014, 12:13 AM   #7
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I agree with iac1003. Getting medical and pharmacy paid when in a care facility can be a challenge when you are in a preferred provider insurance program. In my area Kaiser really works to serve that population but, based on my experience, other insurers are a PITA.

Watch the institutional pharmacy like a hawk. While your state law may allow a patient to choose their own pharmacy the nursing home will set up all kinds of barriers to anyone but their preferred provider. They told me that their intuitional pharmacy would courier meds needed for hospice care for my Mother but when the day came that she needed meds in the middle of the night... forget about it!! If at the end he needs something extra to make the exit smoother have them on hand even if hidden. What are they going to do if you slip a couple to him at the end, kick him out?
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Old 05-20-2014, 10:45 AM   #8
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Thanks for the info everyone. I'm continuing to work with United to determine what to do next. He is still on straight Medicare with Humana for prescription drugs, and now I'm being told that a drug he needs to live will not be covered. Complicating matters is the facility is telling me he has been banging his head against the wall and telling people he doesn't want to live any more. Dementia is a dreadful disease.
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Old 05-20-2014, 10:52 AM   #9
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Check with his physician as there may be a med on Humana's formulary that will do the same job. Also, he may benefit from an anti-depressant.
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Old 05-20-2014, 01:48 PM   #10
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If there is no substitute, the physician can fill out paperwork for your father to receive the medication as nonformulary and see if Humana will approve. Your copayment will be at the highest tier but won't cost as much as if you were paying for it completely out of pocket. Changing a Medicare D plan is usually done during open enrollment toward the end of the year. And the formularies for all these insurances change so what an insurance covers this year, they may not cover the next.
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