December 2, 2013 | Aging Life Care
“I have an HMO Medicare plan (Medicare Advantage Plan). How can I switch to traditional Medicare, so that I can have a mobile physician service that will come to me?” This was a recent issue with which one of our clients recently presented me. Answering this seemingly simple question, it turned out, was anything but simple.
The Medicare Open Enrollment Period (October 15 – December 7, 2013) is an opportunity to take a look at your current coverage and make any changes desired, which will become effective January 1, 2014. During the annual open enrollment period, you may make the following changes:
- Change from Original Medicare to a Medicare Advantage Plan (HMO or PPO)
- Change from a Medicare Advantage Plan back to Original Medicare (our client’s goal)
- Switch from one Medicare Advantage Plan to another
- Join a Medicare Prescription Drug Plan
Our client has been happy for several years with his medical team. But due to declining health, he is having increased difficulty getting to medical appointments. He learned of a mobile MD service, and is interested in changing his coverage to allow for this.
This would likely mean leaving his Medicare HMO and joining traditional Medicare, as most HMO policies (including his current plan) do not cover visiting physicians. An option for him is to enroll in traditional Medicare and purchase a Medigap policy that covers the 20% that traditional Medicare parts A and B do not cover.
Only those enrolled in traditional Medicare may purchase a Medigap policy. It is not a government-run program, but rather private insurance that covers many of the out-of-pocket expenses that Medicare doesn’t cover. These may include Part B costs, like the 20 % you’d otherwise pay for physician visits and other outpatient services, and hospital deductibles.
Eligibility for Medigap insurance is not assured, however. If one is outside the “guarantee issue rights” or “protection rights” he or she will be subject to medical underwriting, charged a higher premium, or denied coverage. These insurers can deny coverage based on pre-existing health conditions. If denied Medigap coverage, you are on the hook for 20% of your healthcare expenses, which is cost prohibitive for many.
Medical underwriting does not apply to any other type of coverage when making a change (traditional Medicare, or Medicare Advantage plans – HMO’s and PPO’s). The only medical question that may be legally asked is whether you are receiving treatment or benefits for end-stage renal disease or kidney failure.
There are some circumstances that “guarantee issue rights,” meaning that you cannot be denied Medigap coverage, including a) an initial enrollment period that falls close to your 65th birthday, b) one’s current Medicare Advantage Plan no longer being offered where they live, and c) the unique regulation known as the “California Birthday Rule.” For more information about these exceptions, you should consult with an expert.
Our client had several options. He would most likely be denied a Medigap policy based on pre-existing health conditions, and keeping his medical costs relatively stable was important, so he was inclined to stick with his current plan. But after extensive research, we identified an HMO that does contract for reimbursement for home and facility MD visits. He also had the option to enter a PPO, where a wider range of participating physicians is available (including mobile physicians), but monthly premiums would have been higher.
We recommend that our clients consult their Care Manager when making these important decisions, and that they access local resources such as the Health Insurance Counseling & Advocacy Program (HICAP). We help clients navigate the complexities of the healthcare system, act as advocates, and save time and frustration by knowing the important questions that need to be asked.
The next open enrollment period begins October 13, 2014. For more information, visit the Medicare website, consult a Medicare insurance specialist, or speak with a Care Manager.