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AARP Article 071010 Don't Fall for the Hard  Sll Some Beneficiaries

4203 -
4203 -    ..
4204 - Summary/Objective
4205 -
420501 - Follow up ref SDS 7 0000, ref SDS 5 H75F.
420502 -
420503 -
420504 -
420505 -
420507 -  ..
4206 -
4207 -
4208 - Progress
4209 -
420901 - HMO Managed Care Insurance Policies Misleading Sales Representations
420902 -
420903 - During treatment today at UCSF, Flora showed Millie an article in AARP
420904 - on confusion in health care insurance sales representations.
420905 -
420906 -           http://www.aarp.org/bulletin/medicare/dont_fall_for_the_hard_sell.html
420907 -
420908 -    1.  Don't Fall for the Hard Sell
420909 -
420910 -        Some beneficiaries have been duped into buying Medicare
420911 -        Advantage plans. ref OF 1 0001
420913 -         ..
420914 -        By Patricia Barry
420916 -         ..
420917 -        October 2007
420919 -         ..
420920 -    2.  Annual enrollment for Medicare's medical and prescription drug
420921 -        plans begins next month-and officials are scrambling to stop
420922 -        deceptive and fraudulent tactics some salespeople have used to
420923 -        sell beneficiaries Medicare Advantage (MA) plans they don't
420924 -        want or understand. ref OF 1 Q84M
420925 -
420927 -         ..
420928 -        Misleading Marketing HMO Insurance Not Medigap Policy
420929 -        New Rules Require Accurate Sales Representations HMO Policies
420930 -        Marketing Sales Misrepresentations Misleading HMO Managed Care
420931 -        Misrepresentation HMO Managed Care Not Medigap Supplemental Health Insurance
420932 -
420933 -    3.  The Centers for Medicare & Medicaid Services (CMS), the federal
420934 -        agency that oversees the private insurers offering the plans,
420935 -        has issued new rules aimed at ensuring that salespeople give
420936 -        honest, accurate information so enrollees know what they're
420937 -        signing up for. ref OF 1 6U5H
420939 -  ..
420940 - The article goes on to report Medicare patients are incurring charges
420941 - for coinsurance in the range of $16K per year. ref SDS 0 CS4T
420943 -  ..
420944 - On 070917 research shows Kaiser tells customers they can cancell
420945 - supplemental Medicare policies for Medigap after signing up for Kaiser
420946 - Senior Advantage. ref SDS 2 EZ56
420948 -  ..
420949 - On 070927 Millie was advised in 2004 that Kaiser Senior Advantage
420950 - would continue care for her continuing cancer condition. ref SDS 5
420951 - MS3K
420953 -  ..
420954 - On 071006 Millie received billings for coinsurance that cost $15K -
420955 - $20K per year above insurance premiums paid to Kaiser and Medicare.
420956 - ref SDS 6 PRWW
420958 -             ..
420959 -            [On 071128 Kaiser Appeals Committee approved payment for
420960 -            Millie's care on referral to UCSF. ref SDS 8 JZ5R
420962 -  ..
420963 - AARP article on HMO sales abuses confusing coverage continues...
420965 -         ..
420966 -        Kaiser Senior Advantage Not Supplemental Medicare Insurance
420967 -        Customers Baffled Differences HMO and Supplemental Medicare Insurance
420968 -        Confused Customers Differences HMO and Supplemental Medicare Insurance
420969 -
420971 -         ..
420972 -    4.  Many consumer advocates say, however, that while the rules will
420973 -        help reduce marketing abuse, they don't address underlying
420974 -        issues in the 2003 Medicare legislation that gave rise to it in
420975 -        the first place.  An AARP Bulletin investigation, based on
420976 -        complaints from readers, bears out that conclusion.  It also
420977 -        shows that many beneficiaries are baffled about the differences
420978 -        between the kinds of Medicare insurance and need a better grasp
420979 -        of how private Medicare Advantage plans work and how to avoid a
420980 -        hard sell. [see "How Do Medicare Plans Differ?"] and how to
420981 -        avoid a hard sell [see "Don't Get Tricked or Pressured"],
420982 -        ref OF 1 006N
420983 -
420984 -           [On 090604 1534 60% bankruptcies due to medical billings,
420985 -           Reuters article reports study. ref SDS 9 QW5H
420987 -         ..
420988 -    5.  The scale of abuse came to light earlier this year when the
420989 -        insurance commissioners of 37 states reported that thousands of
420990 -        beneficiaries had fallen victim to illegal or unethical
420991 -        hard-sell tactics used to sign them up for Medicare Advantage
420992 -        plans, which cover everything the original Medicare plan covers
420993 -        and often cost less but have more restrictions on access to
420994 -        doctors and hospitals. ref OF 1 008O
420996 -  ..
420997 - On 070917 confusion about Kaiser Senior Advantage not being Medigap
420998 - supplemental Medicare policy evident from letter to UCSF demanding
420999 - billings for coinsurance go to Kaiser. ref SDS 3 I53Y
421001 -  ..
421002 - On 070924 UCSF responds cites Millie's insurance coverage Kaiser
421003 - Senior Advantage does not provide supplemental Medicare policy
421004 - coverage commonly called medigap. ref SDS 4 EZ5J
421006 -  ..
421007 - AARP article on HMO sales abuses confusing coverage continues...
421008 -
421009 -    6.  "In the most troubling of these cases, unscrupulous agents have
421010 -        enrolled beneficiaries with dementia into an inappropriate
421011 -        plan," Wisconsin insurance commissioner Sean Dilweg told
421012 -        Congress in May. ref OF 1 OU7K
421014 -         ..
421015 -    7.  Some people said insurance agents told them original Medicare
421016 -        was "closing down," so they should join an MA plan to keep
421017 -        coverage.  Others thought they were buying medigap
421018 -        supplementary insurance or a drug plan but found later they'd
421019 -        been enrolled in an MA plan covering all their medical care.
421020 -        That meant they were automatically moved out of original
421021 -        Medicare and, in some cases, lost their retiree health
421022 -        benefits. ref OF 1 004Q
421024 -         ..
421025 -    8.  About 7 million of Medicare's 43 million beneficiaries are in
421026 -        MA plans.  Dilweg and other experts emphasize that most people
421027 -        are not tricked into buying such plans, and that enrollees
421028 -        pleased with their care need not be alarmed.  But when abuse
421029 -        does occur, the consequences can be devastating. ref OF 1 9W8M
421031 -         ..
421032 -    9.  Bobby Box, 76, a retired construction worker in Chickasha,
421033 -        Okla., was content with coverage from original Medicare and his
421034 -        veterans benefits.  But last December a saleswoman sold him a
421035 -        plan for a Medicare HMO that he didn't want. "She said it was a
421036 -        supplementary insurance that paid what Medicare didn't," he
421037 -        says. "She lied to me." ref OF 1 00EJ
421039 -  ..
421040 - On 071006 Millie received billings for coinsurance that cost $15K -
421041 - $20K per year above insurance premiums paid to Kaiser and Medicare.
421042 - ref SDS 6 PRWW
421043 -
421044 -            [On 071128 Kaiser Appeals Committee approved payment for
421045 -            Millie's care on referral to UCSF. ref SDS 8 JZ5R
421047 -  ..
421048 - AARP article continues...
421049 -
421050 -   10.  Soon afterward, Box was rushed to the hospital in a coma,
421051 -        running up a $45,000 bill during a 10-day stay.  Only when the
421052 -        plan refused to pay did Box realize he was in an HMO, which
421053 -        limits treatment to doctors and hospitals in its network.  In
421054 -        fact, all MA plans are obliged to cover emergency care, and
421055 -        Box's plan eventually did so-but only after his state insurance
421056 -        office intervened. ref OF 1 8X9O
421058 -         ..
421059 -   11.  In addition, while still believing he was in original Medicare
421060 -        and able to use any hospital, Box had begun radiation treatment
421061 -        for prostate cancer at a facility outside the HMO's network.
421062 -        "Now I'm still stuck with a $16,000 bill," he said in August,
421063 -        four months after disenrolling from the HMO. ref OF 1 00GN
421064 -
421065 -           [On 090604 1534 60% bankruptcies due to medical billings,
421066 -           Reuters article reports study. ref SDS 9 QW5H
421068 -         ..
421069 -   12.  Evan Edwards, of Ruby, Mich., has been dunned by a debt
421070 -        collection agency for over $800 in bills run up after being
421071 -        enrolled in an HMO by a saleswoman who told him it was a
421072 -        special MA plan for veterans that would cost him nothing.  No
421073 -        such plan exists.  The actual plan she enrolled him into had
421074 -        all the usual HMO charges. ref OF 1 QX5H
421076 -         ..
421077 -   13.  CMS officials say that Box, Edwards and others who incur
421078 -        expenses after enrolling in an MA plan under false pretenses or
421079 -        because of confusion over its terms won't have to pay those
421080 -        bills. "They need to contact us and ask for a retroactive
421081 -        reenrollment into original Medicare," says Abby Block, director
421082 -        of CMS's Center for Beneficiary Choices. "Their bills will be
421083 -        paid by Medicare." ref OF 1 00AP
421084 -
421086 -         ..
421087 -        HMO Customers Can Cancel Medicare Advantage Policies
421088 -
421089 -   14.  In July, in response to the crescendo of complaints, CMS also
421090 -        decreed that beneficiaries who believe they've been misled into
421091 -        joining an MA plan have the right to apply for a special
421092 -        enrollment period in which they can return to original Medicare
421093 -        (and their supplementary medigap policy if they had one) or
421094 -        switch to another MA plan. ref OF 1 606L
421096 -         ..
421097 -   15.  Beneficiaries who are aware of this new policy could be saved
421098 -        from the hassles others have had in trying to disengage from an
421099 -        offending plan.  Elinor Hogan, a retired nurse in Sarasota,
421100 -        Fla., knew she didn't want the HMO plan that the "pushy"
421101 -        saleswoman was trying to sell her. "But I was recently widowed,
421102 -        grieving and stressed in the aftermath of caring for my
421103 -        husband, who died of cancer," she says. "I signed just to get
421104 -        her out of the house." ref OF 1 00CT
421105 -
421107 -         ..
421108 -        HMO Insurance Policies Some Have No Doctors to Provide Care
421109 -
421110 -   16.  A few days later, after finding that none of her doctors or the
421111 -        local hospital accepted the plan, Hogan withdrew her
421112 -        enrollment, as the agent told her she could, thinking that was
421113 -        the end of it.  It wasn't.  It took six months of phone calls
421114 -        to finally disenroll and get back onto original Medicare.
421115 -        ref OF 1 834F
421116 -
421118 -         ..
421119 -        PFFS Private Fee For Service Medicare Some Have No Doctors
421120 -
421121 -   17.  "I should never have had to go through this nightmare," Hogan
421122 -        says, "all because of that insensitive, fraudulent agent." The
421123 -        vast majority of complaints about marketing abuses, according
421124 -        to CMS and state insurance commissioners, are directed at a new
421125 -        Medicare Advantage product, private fee-for-service (PFFS)
421126 -        plans, which now have 1.5 million enrollees.  The main sales
421127 -        pitch for these plans is that enrollees can go to any doctor or
421128 -        hospital they choose, anywhere in the country.  But in
421129 -        practice, many people have found that the providers they want
421130 -        won't accept PFFS plans. ref OF 1 015W
421132 -  ..
421133 - Kaiser may have presented Millie to UCSF under PFFS requirements
421134 - related to Kaiser's incorrect "self-referral" theory, resulting in
421135 - payment below market rates at UCSF, illustrated by spreadsheet
421136 - reviewed on 070830. ref SDS 1 WP5I
421138 -  ..
421139 - AARP article on HMO sales abuses confusing coverage continues...
421140 -
421141 -   18.  The plans "are now required to have a disclaimer in all of
421142 -        their marketing materials saying that not all providers will
421143 -        accept a PFFS plan," says Block of CMS, and that enrollees will
421144 -        be covered only if the providers agree to the plan's terms and
421145 -        conditions. ref OF 1 01EW
421147 -         ..
421148 -   19.  Physician groups and consumer advocates say, however, that this
421149 -        requirement will not change a fundamental problem: that by law
421150 -        PFFS plans (unlike MA managed care plans) do not have to
421151 -        contract with any providers before policies are sold.  Instead,
421152 -        a doctor or hospital that treats an enrollee is automatically
421153 -        "deemed" to have agreed to the plan's terms and payment
421154 -        conditions-without any negotiation between the provider and the
421155 -        plan having taken place. ref OF 1 L56F
421157 -         ..
421158 -   20.  Consequently, says Elizabeth McNeil, vice president of the
421159 -        California Medical Association, many doctors will have nothing
421160 -        to do with PFFS plans. "It isn't a good arrangement," she says.
421161 -        "PFFS plans must have to adhere to the rules that other [MA]
421162 -        plans must adhere to or they should be eliminated." ref OF 1
421163 -        01HQ
421165 -         ..
421166 -   21.  It can be difficult if not impossible for beneficiaries to know
421167 -        in advance whether a doctor or hospital will accept a PFFS
421168 -        plan.  Moreover, the law allows providers to decide if they
421169 -        will accept the plan each time the patient seeks treatment.
421170 -        People enrolled in a PFFS plan sponsored by employers or unions
421171 -        may be stuck with it, like an 80-year-old former teacher near
421172 -        Phoenix (who doesn't want her name used).  A breast cancer
421173 -        survivor who needs an annual mammogram and has an ailing
421174 -        husband who can't be left alone, she was horrified to find that
421175 -        the nearest hospital that would accept her PFFS plan was 70
421176 -        miles away. ref OF 1 DB7J
421178 -         ..
421179 -   22.  Her retirement system switched its enrollees from supplementary
421180 -        insurance to a PFFS plan this year. "They've put me in a
421181 -        position where I'm paying my monthly dues for health insurance
421182 -        and I'm unable to use it," she says.  Her only option, she
421183 -        adds, is to cancel the benefits she worked for and paid into
421184 -        for 35 years. ref OF 1 01BW
421186 -         ..
421187 -   23.  Only about 15 percent, or 225,000, of PFFS enrollees are in
421188 -        employer-sponsored plans, but this is a new market that could
421189 -        rapidly expand.  The plans' sales pitch that enrollees can see
421190 -        any provider is attractive to employers or unions with retirees
421191 -        scattered all over the country. ref OF 1 KB9G
421193 -         ..
421194 -   24.  Block of CMS acknowledges a lack of providers in some areas.
421195 -        But she says that educating providers and PFFS plans to become
421196 -        "more comfortable" with each other will change that. "If
421197 -        providers better understand the [PFFS] product and the payment
421198 -        mechanisms and get appropriate assurances that this is
421199 -        something they can work with, we will see very different
421200 -        attitudes in the provider community," she says. "So I think the
421201 -        situation will get a lot better." ref OF 1 01DY
421203 -         ..
421204 -   25.  David Lipschutz, staff attorney for California Health
421205 -        Advocates, who has studied PFFS plans, disagrees. "Unless
421206 -        there's a fundamental sea change in providers' attitudes toward
421207 -        these plans and the way the plans operate," he says, "they will
421208 -        continue to cause problems for people." ref OF 1 01FX
421210 -         ..
421211 -   26.  As for marketing abuses, the American Health Insurance Plans
421212 -        trade group has "zero tolerance" toward them, says spokesman
421213 -        Mohit Ghose.  Earlier this year the major insurers that sell
421214 -        PFFS plans-BlueCross BlueShield of Tennessee, Coventry, Humana,
421215 -        Sterling, United HealthCare, Universal American Financial Corp.
421216 -        and Wellcare-voluntarily agreed to suspend marketing while
421217 -        drawing up a new code of conduct to curb abuse.  CMS has since
421218 -        made these practices the rule. ref OF 1 PC5F
421220 -         ..
421221 -   27.  But this doesn't satisfy state insurance commissioners who
421222 -        complain that federal law doesn't allow them to pursue Medicare
421223 -        Advantage plans for fraud or head off some abuses in advance,
421224 -        as they can in other insurance markets. "Our hands are tied,"
421225 -        says commissioner Dilweg, who has 22 companies offering 92
421226 -        Medicare plans in his state and received more than 700
421227 -        complaints about them in a single year. ref OF 1 01H2
421229 -         ..
421230 -   28.  Nor does the insurers' new code of conduct change the fact that
421231 -        agents are paid much higher commissions for selling MA plans
421232 -        (especially PFFS plans) than for drug plans or medigap
421233 -        insurance-a practice that critics say only encourages hard-sell
421234 -        sign-ups. ref OF 1 2D6L
421236 -         ..
421237 -   29.  By way of full disclosure, AARP is making available in 2008 a
421238 -        Medicare Advantage managed care plan underwritten by United
421239 -        HealthCare. ref OF 1 01KU
421241 -         ..
421242 -        Copyright 1995-2007, AARP. All rights reserved, ref OF 1 ZE3K
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