The Medicare Menu

For those with Original Medicare or one of the newer Medicare Advantage private plans, the typical time to change plans, add a drug plan, or get out of the private plans during open enrollment runs from Nov. 15 through Dec. 31. Enrollees then have one chance to change health plans again from Jan. 1 through March 31 but cannot add on a drug plan at that time.

Under Medicare Advantage, private insurers provide Medicare-covered benefits as an alternative to Original Medicare. Available since the 1970s under different names, the program has expanded rapidly since 2003, with more than 600 plans now offered nationwide and one in five senior citizens now enrolled in the plans. Once enrolled, participants are subject to the individual terms of their plan and can change only once a year to another private plan or back to Original Medicare.

The plans received congressional scrutiny this year amid allegations that high-pressure marketing and unscrupulous sales tactics were being used to sell the plans for high commissions. The consumer watchdog groups California Health Advocates and the Medicare Rights Center reported a range of marketing abuses, including agents posing as Medicare representatives going door-to-door unsolicited and telling consumers they will lose Medicare or Medicaid if they do not sign up for a particular Medicare Advantage plan.

As a result, federal guidelines issued in July eliminated for the rest of 2007 the lock-in period for those who made a case that they were duped into a Medicare Advantage plan that didn’t meet their needs. Also, a number of major insurance companies, including UnitedHealth Group, Humana and WellPoint, agreed to temporarily stop marketing their private fee-for-service Medicare Advantage plans from June until late September while working on new sales guidelines with Medicare.

The private health plans also have come under fire by government oversight groups and healthcare advocates for a lack of coverage and high out-of-pocket costs, despite often being marketed as lower-cost and more benefit-rich than Original Medicare. In a study by the Medicare Payment Advisory Commission, some Medicare Advantage plans have high cost-sharing for “nondiscretionary” services, such as chemotherapy.

“You can’t believe much of what advertisements or brokers peddling private plans are saying,” says Robert M. Hayes, president of the Medicare Rights Center, a national consumer service organization. “You need a dose of luck in choosing a Medicare Advantage plan because healthcare needs are by definition unpredictable: It may be that in January you’re in the right plan, but by May things have changed and you are falling through one of their many trap doors.”

Another study by the Commonwealth Fund, a nonpartisan research foundation, found out-of-pocket costs in Medicare Advantage plans varied widely by a person’s health status and the plan’s benefit package. “These plans may not always be a good deal for sicker beneficiaries who use more health services,” the study reports.

Original Medicare has more consistent coverage with fewer traps, Hayes says. Add on a Medigap policy — if, as a cancer survivor you are lucky enough to have an affordable option in your state — and as a senior citizen you can have more secure coverage with Original Medicare than with Medicare Advantage, he says.

As for Medicare Part D drug coverage, whose enrollment period ends Dec. 31, cancer survivors and others who may need high-cost drugs for treatment could be out of luck. Next year, there will be fewer insurers willing to cover the gap in coverage — the so-called doughnut hole — at any price, Hayes says. In previous years of Part D, more plans covered brand-name drugs in the gap in coverage that occurred once drug expenses including co-pays reach a threshold of around $2,400 ($2,510 in 2008). At that point coverage stops for nearly all plans now, and patients pay 100 percent of the cost of covered drugs and monthly premiums until $3,850 ($4,050 in 2008) in out-of-pocket costs is spent and coverage again resumes. In addition, some cancer-fighting drugs are not covered at all or have high co-payments, Hayes says.

“Only sick people go into the doughnut hole, and no one wants to cover sick people,” he says.

Medicare recommends moving to generic drugs or less expensive alternatives, when feasible, to avoid the doughnut hole. Patients can also apply for assistance called Extra Help from Social Security for drug coverage. (Go to www.ssa.gov and search for “prescription help.”)

To check Part D coverage for drugs that are essential to your care, Hayes suggests looking for the language “subject to prior authorization.”

“That is usually a de facto management denial,” he says, meaning that the plan is not likely to approve the drug.

Enrollment deadlines for Medicare, Medicare Advantage and the various drug plans available to people 65 and older are fast approaching. Cancer survivors should be particularly careful when making their choices.

Chart: Proceeding with Caution