Medicare Policy Notes From the Medicare Rights Center
SENATE PANEL INVESTIGATES MEDICARE PRIVATE PLANS
In recent years enrollment has surged in Private-Fee-for-Service (PFFS) plans, Medicare private health plans that operate without provider networks. They allow enrollees to visit any doctor who agrees to the plans' terms and conditions, but have no minimum network of providers. The plans cost taxpayers on average 17 percent more than the cost of care under Original Medicare, Mark Miller, executive director of the Medicare Payment Advisory Commission (MedPAC), told the Senate Finance Committee at a recent hearing.
Miller also expressed concerns over lenient federal standards regulating the quality of care provided by PFFS plans. Currently, PFFS plans are the only type of Medicare private plan not statutorily required to provide federal agencies with data on the quality of coverage provided to enrollees.
Providers at the hearing disclosed that they are increasingly severing their financial relationships to the plans. The medical director of the Everett Clinic in Washington State, testified his clinic would no longer accept coverage provided by PFFS plans due to to PFFS plans' refusal to negotiate "acceptable [reimbursement] rates" with the clinic that compensate doctors for providing coordinated care.
Elyse Politi, a health care counselor for Virginia's State Health Insurance Assistance Program, testified that the benefit plans and lack of provider networks can lead to problems for people with Medicare who enroll in the plans. "People who gave up their Medigap policies suddenly had to pay these large, unexpected costs out of their own pocket," Politi testified. "Other people find out that a health care provider will not accept their PFFS plan just as they are scheduled to receive a needed health care service." Politi recommended that Congress provide for standardized benefit packages for Medicare private health plans, require PFFS plans to have a minimum network of providers and exercise tighter control over marketing activities by insurance agents selling these plans.
STUDY: COPAYMENTS LIMIT ACCESS TO ROUTINE MAMMOGRAMSWomen in Medicare private plans are less likely to receive routine mammograms if their plans charge copayments for preventive screenings, according to a study recently published in The New England Journal of Medicine.
From 2001 to 2005, a Brown University-based research team followed 366,000 women in their mid- to late-60s who were enrolled in Medicare private plans. Seventy-eight percent of participants in plans without copayments received mammograms, compared to 69 percent of women in plans that charged copayments ranging from $12.50 to $35 for preventive screening.
The percentage of women in plans with copayments who received mammograms decreased by 5.5 percent during the course of the study. Women in plans without copayments saw a 3 percent increase in mammography usage over the four-year investigation.
Researchers also found that low-income and minority women were more likely to enroll in plans with preventive mammography copayments. As a result, the effect of cost-sharing on low-income and minority populations was "magnified," according to the study.
The research team concluded that the data justifies eliminating copayments for certain preventive services under private plans and Original Medicare. Original Medicare currently charges a 20 percent coinsurance for routine mammograms, which would have been eliminated under the Children's Health and Medicare Protection (CHAMP) Act of 2007. Head researcher Dr. Amal Trivedi explained that at least for mammography, "exempting elderly adults from cost-sharing may be warranted."
CASE FLASH: LOW-INCOME PROGRAMS AND PRIVATE PLANS
This January, Mr. B spoke with an insurance agent about a Medicare private health plan. Mr. B had been having trouble paying his monthly Part B (medical insurance) premium and his monthly Part D (prescription drug insurance) premium. The insurance agent told Mr. B that if he joined this particular plan, he would be eligible for a program that would eliminate his monthly Part B premium, would pay for his Part D monthly premium, and reduce his prescription drug copayments dramatically.
Mr. B called the Medicare Rights Center to ask about his Medicare health plan options and if the private health plan was too good to be true. The hotline counselor asked Mr. B about his monthly income and his assets, and determined that Mr. B was eligible for a Medicare Savings Program (MSP). The counselor explained that an MSP is a government program that pays the Medicare Part B premiums for individuals with low incomes.
If you enroll in an MSP, you are also automatically enrolled in Extra Help, a federal program that helps people with low incomes pay their Medicare drug coverage premiums and out-of-pocket costs. Everyone who meets the eligibility guidelines for an MSP or Extra Help is entitled to this assistance, not just people who are in particular plans.
The counselor said that if the insurance agent had told Mr. B that these programs would only be available him if he joined the plan, he should call the Health and Human Services Office of Inspector General's TIPS Hotline at 800-HHS-TIPS to report the deceptive marketing.
Mr. B decided to stay in Original Medicare and apply for an MSP.
-All three stories adapted from: Medicare Watch, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 11, No. 3: February 5, 2008.
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