Yesterday I blogged about my business’s fifth birthday … and this week, it turns out, marks six months before I turn 65!
And that means I go on Medicare.
I’ve learned enough in these five years to know at least two things:
- You’re a patsy if you think the American medical system will necessarily take care of you. It might, but if it does, it may be in the process of making itself a boodle of money.
- Yes, there are many exceptions – individuals and organizations who care and who work hard. But I’ll repeat: you’re a patsy if you sit back and assume the system will take good care of you.
- When it comes to money in American healthcare, don’t expect anything to be explained clearly.
- 18 months ago I blogged about a famous policy paper, Hospital Pricing in America: Chaos Behind A Veil of Secrecy by Princeton economist Uwe Reinhardt. That paper was published 8 years ago, and hardly anything has changed. (The title of the article is real and not an exaggeration.)
- In 2013 I lived the chaos and the veil myself, in my own shopping for everything from CT scans to shingles vaccines to skin cancer treatments. I saw at close range that Reinhardt was not exaggerating, and I blogged it in a series called “cost-cutting edition.”
There are signs of hope, such as ClearHealthCosts, but although I work for change, I’m not waiting for the posse to save me.:-) I’m gonna be pro-active, engaged, empowered, responsible! I want to get educated, because I’ll be on Medicare for the rest of my life. And I want to approach the education from the patient’s perspective … not what the system wants to tell me, but what people like me have found necessary.
So, you who’ve been through it: what do I need to be aware of? What choices will I need to make?
I do know these things about Medicare:
- Medicare comes in a crazy Alice-in-Wonderland list of benefit “parts,” a plan that was most certainly not created by us out here and is not subject to free-market simplifications. (See this summary of the Parts: A, B, C, D, F, G, and K … no E, H, I, J.) And I know it has a “doughnut hole.”
- It is a cesspool of money, run by the people who get the money. Did you know that in 2003 Congress passed (and the President signed) a law that prohibits Medicare from negotiating better prescription prices? A cesspool run by the money people. (And every attempt to fix that law has been blocked – in Congress.)
- Medicare is also a cesspool of policies that block you and me from knowing which doctors are better, for our own benefit. Are you familiar with “never events” – the list of things that should never, ever happen in medicine? The list includes things like amputating the wrong leg, operating on the wrong patient, being electrocuted by cardioversion (“get the paddles”), giving you the wrong baby, etc.
- I mean, really, these should never happen, right? You’d want to avoid places who do a lot of these, right??
- Well, just this month Medicare announced that it will no longer publish the facts on which hospitals do never events! That certainly wasn’t decided by someone with my interests at heart. So I want – and you should want – to be as responsible for yourself as you can.
But I also know this: people love their Medicare. In 2012 I heard a speech by the great author and columnist T. R. Reid, who toured the world living in different countries’ health systems and wrote The Healing of America. In his talk he said (paraphrase):
Medicare in America looks like socialized medicine – it’s government-run universal coverage. But we also know it can’t be. Why? Because Americans hate socialized medicine, but they love their Medicare. So it must not be.
Yes, I know people love their Medicare – even if they act crazy in their thinking. So I’m not approaching this without hope – I’m just approaching it with my eyes open. :-)
I assume people will try to sell me various plans. Which do I need? How do I decide what I need?
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p.s. If you want a great description of which countries do what in universal coverage and socialized medicine, read this discussion on the PBS Frontline site, Does Universal Coverage Mean Socialized Medicine?, between T.R. Reid (above), and Uwe Reinhardt (above), and others.
First tip from Emily on Facebook:
“One very important thing for me was …my health portal was closed with my insurance company. So make sure you have your complete records before it may be shut down.”
I replied: ” I never would have thought of that – thanks! –You’re still entitled to get the info, of course, Emily. But you’re saying it’s not as easy?”
You can get a hard copy of your history, but what you miss is, if you are on a referral basis with your ins. Co. You won’t be able to get that list. I actually emailed the CEO of my ins co ….subject line….I DON’T die because I turn 65.
So action happened…portal for Medicare should open by January, however I get an individual statement of referrals and billings. I check monthly on their activity. :)
Emily, I don’t understand some of the lingo. What is “on a referral basis with your insurance company,” and what “that list” would I be unable to get?
Take some time to decide which plans work best for your needs. If you take multiple medications, you’re going to want a good part b/d plan that will give you great prescription options. Also keep in mind there is a deadline once you’re eligible, don’t take too long or a plan will be chosen for you!
Thanks, Tiffany! This is exactly why I asked this – I don’t even understand some of the things you veterans are talking about.
“Take some time to decide” is why I’m starting 6 months in advance. Question: how will I *know* what plans work best?? What are the gotchas?
What do you mean by “great prescription options”? I have no idea how to evaluate that.
DEADLINE FOR ME TO CHOOSE, OR THEY’LL CHOOSE FOR ME?? Yikes!
Maybe there’s a “decision tree” website to help us choose.
The health space is very unstable now due to the ACA. What you get in Medicare may not be the same next year. Medicare has become politicized and corrupted. Advantage programs can be very good but you need to check out the companies that are contracted where you live. All have coverage for emergencies until you can get back home. You are smart enough to figue this out but many of our readers are not. We now have added to the equation the costs of marketing these different plans. While change is good, each time we redesign health care it costs more to implement to the point where there are little if any savings. Good luck and happy ePatient birthday
Thanks, Gary – I’ll need to look up what Advantage programs are, and how to check out the companies. No idea what to check out! Suggestions?
First….don’t stress about the confusing choices. As you get closer the insurance companies will be blitzing you with ads and information sessions.
I’ll write more later, but don’t stress about the confusion we all got it, and you certainly need to not stress about what you can’t control. More on my experience later when time allows. D (PS: I am a MA resident, so I can only reflect on my MA experience.)
Not stressing – just exploring.
I am in no way reassured to know that companies will be blitzing me with their opinions of themselves… as with any other consumer movement, I want the lessons learned by my peers – “what I wish I’d known back then” stuff.
Standard Medicare pays for rehabilitative care up to 100 days if you’ve been admitted to the hospital for 3 days. When in a hospital always ask if you’ve been “admitted” or if you are “under observation.”
Medicare does not pay for long-term care services. If you are considered chronic and need help with 2 out of 6 Activities of Daily Living and are not expected to get better for over 90 days, individuals are required to pay for services to help them with their ADL’s
Randi, thanks for the reminder about being “admitted” vs “under observation.” I remember hearing about that billing scam (IMO) in the news recently – many patients and families rudely discovering that although a hospital actually admitted them, they did it in a way that wasn’t reimbursable! Disgusting.
After you get a list of the Medicare things that are free or low cost, the biggest thing to know about is the wide range of Advantage programs. They vary by county (yes!), but some add valuable coverage at $0 (yes, zero). Others are like $100 per month, but add coverage that is important for certain situations and life styles. Lots of analysis and thinking is necessary to get a package suitable to each person’s needs, at a given point in time.
Thanks, Mike. How will this list of free stuff (and low cost) come to me – or is it something I go get myself?
Re Medicare Advantage plans: Googling for plans in my state http://lmgtfy.com/?q=medicare+advantage+plans+in+nh gives me a nice reading list.
!! .. I laud this official government page for its clarity on what Medicare Advantage is! Look, all:
I’m already feeling more hopeful. Great start.
People who join “Advantage” programs belong to a category of Medicare encouraged by Medicare. They are private contracts with Medicare. The companies offer very good benefits on a closed panel of hospitals and providers. Frequently there are no copays or very low co pays.
If you are on one of these programs, technically you no longer have Medicare. One program you can look at is SCAN in Southern California. Just google Medicare Advantage. They are local and differ from area to area. I joined one this year and it has proven to work well since I checked who the providers are in my region. As it turned out a large medical group of 150 docs accept this plan. They also provide 12 free transportation rides to providers and hospitals on the plan. It is a managed medicare plan, like an HMO. You must see your PCP for specialty referrals, which has not been a problem for me.
I am a high user (frequent flyer) since I have several serious medical conditions. These are probably best for those on low fixed income plans. There are also LISP (low income subsidy programs from various states that will pay the premium, copays, very low RX co-pay programs. It takes careful research to find out what each one provides.
Dave,
One of the big needs is excellent explanations of Medicare benefits and holes, and plenty of practical help in evaluating and choosing a supplement/advantage plan. Your network could help here by publicizing the best links.
Many people I know aren’t even aware of the basic Medicare provision that it only pays 80% of approved non-inpatient costs — with no cap — so without a supplement a serious illness still has the potential for grave financial damage.
The enrollment window starts 3 months before the month you turn 65, e.g. 10/1/14 if your 65th birthday is during 1/15, so don’t delay once the clock starts running. If you don’t enroll within the 7 month initial period, you have to wait and pay extra.
John, your post is a perfect example of what I was looking for!
I was in fact aware of the 3 month enrollment period, and given how fun it was to research my Obamacare options I decided to start early. (I was very happy with the outcome of that process – I’m just not leaving it to when the weeks get short.)
From my adventures in Medicare you’ll want to be careful about a few things:
1. Know that there are quota systems in medicare, and if a doctor is currently seeing his quota of medicare patients (or a clinic or hospital is), they can refuse to see you!
2. For part D, find your most expensive medication that you currently take, or may have to take, and use that as your guide to which Part D coverage to get. For example, I used to take a rare daily adrenal medication that other insurances would have charged me hundreds of dollars for, except one that had it listed at $60. I was sold.
3. Ask your pharmacy which Part D plans they work with, and which give the greatest discounts. I was going to Walmart originally but discovered my local grocery store pharmacy charged *much* less, and once my deductible for the year was paid, many medications became free!
4. If you can afford supplimental insurance, GET IT. People like myself who are only on Medicare are notorious for not paying their bills, which can put you at a disadvantage when dealing with doctors, climics & hospitals. Supplimental insurance lets them know immediately you’re not in the “potential problem patient” category.
5. Review your coverage every Nov-Dec! This is the time when you’re allowed to switch plans, and this is also when plans can change their coverage. Keep close tabs to make sure all your needs are still covered.
Welcome to the system! (Only sligtly sarcastic ;)
Thank you, Pam! Great practical advice!