Throw Momma From the Plan

Have you ever bought something that sounded sooooo good at the time but later regretted it? Perhaps that salesperson made it seem absolutely wonderful but neglected to tell you a few things. You know, stuff that, had you known at the time, might have led you to a different decision. But the salesperson kept talking and talking and talking.

Some people without brains do an awful lot of talking, don't they? - Wizard of Oz

One of InsureBlogs favorite curmudgeon's, Wendell Potter, penned an article for Medicare Resources that caught my eye. Recent discussions with fellow agents regarding how Medicare treats SNF care led me to an article titled "Why Mom Went Back to Traditional Medicare".

This is allegedly a true story and the names have not been changed to protect the innocent.

As it seems Wendell's real mom had a real Medicare Advantage plan. At age 91 Mrs. Potter is in relatively good health for someone her age. But according to her son she might not have been so lucky had she stayed on a Medicare Advantage plan. Like a good son, Wendell switched his mom from the Advantage plan to original Medicare when she was "critically ill".

Many Medicare Advantage enrollees do exactly what Mom did after a serious illness or injury, and the MA plans they “disenroll” from couldn’t be happier to see them go. When they go back to traditional Medicare, the MA plans are off the hook for covering expensive care.

(The Medicare Advantage disenrollment deadline is Valentines Day every year, so mark your calendar for 2/14/2018).

According to Wendell, his reason for throwing Momma from the plan was this.

the head nurse took me aside and told me that another nurse – not at the facility but at Mom’s Medicare Advantage plan – had come to the conclusion that the skilled nursing was no longer “medically necessary.” This other nurse – a so-called “utilization management” nurse – had never laid eyes on my mother, much less treated her. But she was able to insert herself between my mother and her treating physician and, for all practical purposes, determine whether or not she would get the care her doctor said she needed.

Beyond being a dutiful son, Mr. Potter had RESEARCH to back up his decision.

Kaiser Health News quoted J. Michael McWilliams, the Harvard professor who led the research team, as surmising that “beneficiaries who developed serious ailments might leave the (MA) plans to get unfettered access to physicians and treatments through traditional Medicare.”

Unfettered access as opposed to managed care that is baked in to Advantage plans.

Claims submitted to original Medicare are still required to meet medical necessity standards, but there are no utilization monitors overseeing the ongoing claim. Claims are adjudicated AFTER THE FACT rather than ongoing when you have an Advantage plan.

That's not as bad as it sounds.

If the attending physician cannot prove medical necessity for the treatment under original Medicare the beneficiary is not responsible for the claim. An exception occurs if the patient signed an Advance Beneficiary Notification form PRIOR TO the procedure or treatment.

ABN applies to claims with original Medicare, but not Advantage plans.

So Wendell was able to use the system to get Momma off the managed care plan and into an un-managed plan with original Medicare.

But he neglected to mention one thing.

Disenrolling from the Advantage plan the way she apparently did negated any guaranteed right to purchase a Medicare supplement plan. The way his article is worded it appears this was a VOLUNTARY disenrollment, not one triggered by moving out of the service area or because her current plan was discontinued.

Perhaps his mother was healthy enough to qualify for a Medigap plan, or perhaps not. He does not elaborate on this point.

Disenrolling from an Advantage plan does allow you to go to original Medicare without answering health questions. But without the protection of a supplement plan the beneficiaries exposure on Part B is unlimited.

Or as I like to explain it, your 20% share of Part B expenses continues until you get well, run out of money or die.

Only one of those results is optimum.

While the saga of Mrs. Potter and the nursing home makes for an interesting read it can be a bit misleading to those who think disenrolling means you can automatically enroll in a Medigap plan.

But now you know.

#MedicareAdvantageDisenrollment  #ManagedCare  #NursingHomeCoverage