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Medicare clients face important decisions

November 25, 1998

It's been three weeks, two public hearings and a couple of hundred phone calls since the furor began over the fact that two of the three health-maintenance organizations that serve Washington County's Medicare patients are pulling up stakes at year's end. I'm writing it about this again because I have some personal experience with what can happen if a senior citizen makes the wrong choice.

When my father retired from the federal government after more than 35 years of service, he was told that he didn't need to sign up for additional Medicare coverage. When he was diagnosed with an inoperable brain tumor, he quickly lost the ability to function on his own and was transferred to a nursing home, where the cash meter began running big-time. No one, including Sen. Barbara Mikulski's office, could get him enrolled in Medicare retroactively. If he'd lingered for six months or a year. my mother would have lost the house, and everything else.

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According to Katrina Eversole, coordinator of senior health insurance counseling at the Washington County Commission on Aging, if you are currently enrolled in Mid-Atlantic Medical Services' "Optimum Choice" HMO or United Health Care's "Medicare Complete," your coverage will end Dec. 31.

Why is this happening?

United Health Care didn't return phone calls, but Beth Sammis of Mid-Atlantic sent me their Oct. 1 press release. It said that because so many HMOs are leaving the Medicare market, remaining one of the few active organizations would "have significantly increased the risk for OCI."

To offset that risk, OCI went to the federal Health Care Financing Administration for a rate increase. HCFA denied the request and OCI decided to leave the Medicare market.

What happens to those seniors whose HMOs will cease doing business in the county on Dec. 31?

Eversole says they can join Medi-Care First, an HMO run by Blue Cross & Blue Shield, which provides health care and up to $1,000 a year in prescription coverage. There's a catch, though. It costs an additional $75 a month. For seniors who had been receiving other HMO services without paying anything out-of-pocket, Eversole says this is a shock. Some seniors are telling her they're holding out for another free package, while others are saying they'll go back to traditional Medicare coverage.

Neither strategy is a good idea, she said, because these plans are renewed on an annual basis, and nothing new will be available in time to cover those whose HMOs are leaving the market. As for traditional Medicare, there's an in-patient hospital stay deductible of $764, and that can be applied up to five times a year!

To fill in those gaps, there's the aptly named medi-gap insurance, which cost $75 to $100 per month, depending on the options you choose, Eversole said.

"Three high-end prescription packages have some prescription coverage," she said.

Is anyone trying to change the law to improve the situation?

You bet, but even though the problem involves insurance companies doing business in the state of Maryland, aides to Del. Michael Busch, chairman of the House Environment and Economic Matters Committee, say that because it's a dispute over how much reimbursement the federal government will pay these HMOs, it's a federal matter.

Busch's office refers concerned constituents to Maryland's U.S. Senators, Paul Sarbanes and Barbara Mikulski, or to their local member of the House of Representatives, who in this case, is Rep. Roscoe Bartlett, R-Sixth.

Lisa Wright, a spokesman for Bartlett, said that the matter is of "deep concern" to him, and that he will continue to pursue a strategy with Reps. Wayne Gilchrest, Benjamin Cardin and Steny Hoyer. The four wants to build a coalition of rural lawmakers whose constituents have lost coverage, which Wright said is the opposite of what Congress envisioned when it changed the law to encourage insurers to offer more choices.

Writing in Monday's Washington Post, Robert Kuttner said that because less-healthy seniors who couldn't get the treatment they wanted were switching back to traditional Medicare and leaving the HMOs with the healthiest (and most lucrative) patients, in 1997 Congress cut back on the amount the HMOs could be reimbursed.

Instead of tightening their belts, the HMOs are opting to leave the market instead. Kuttner suggests the solution is to improve the basic Medicare program. Asked about this, Wright said that Kuttner is not suggesting a practical solution to the problem. Instead of the competition Congress envisioned, Wright said Kuttner is proposing a one-size-fits all solution.

No matter how this shakes out - and given the number of seniors affected nationwide it's certain there will be a shakeout - the important thing to do if you're a senior citizen, or the children of one, is to make sure mom and dad are covered by calling the Eversole at the Commission on Aging at (301) 790-0275. Making the wrong decision - or doing nothing - could cost you everything.




Bob Maginnis is the editor of the Herald-Mail's Opinion Page

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