October is here and with that the barrage of infomercials and advertisements for Medicare Plans. Insurance companies are hitting consumers hard to vie for their business. Open enrollment for changing between Original Medicare (A&B) and Medicare Advantage Plans ( C) or back to Original Medicare begins on Oct. 15 and ends Dec. 7. It is also the time to review and change Part D plans if beneficial.

Unfortunately all options are not created equal and it may be difficult to understand the language and the hidden restrictions and pitfalls of various plans.


If you have followed my column you know that I occasionally succumb to a rant when I become totally frustrated with the health care system or Centers for Medicare and Medicaid (CMS). Warning … this is not a rant, rather a full-out tantrum of epic proportions. Yes a major travesty within our health care system happens with all of us paying for it, all the while we worry about our failing Medicare system.

First a recap of the ABCD's of Medicare is necessary. Part A is hospitalization insurance. Part B is medical insurance, which covers a portion of physician visits, outpatient services (including hospital observation). Medicare A and B are referred to as "Original Medicare".

Part C or a Medicare Advantage Plan is another option instead of taking A and B and usually includes Part D (medication plan). These plans are private insurance plans.

Medicare Part D, a prescription drug benefit is a federal government program to subsidize the costs of prescription drugs.

Here it comes, the total frustration at what is completely unknown to most consumers who are wooed by the private side of Medicare plans commonly known as Medicare Part C or Advantage Plans.

In 1997, The Balanced Budget Act, created Part C of Medicare called Medicare + Choice. In 2003 this program name was changed to Medicare Advantage. Under the Medicare Advantage (MA) program, The Centers for Medicare & Medicaid Services (CMS) contracts with private insurance companies or institutions to offer coverage for Medicare beneficiaries.

The program was designed after private insurers convinced Congress that they could provide an option to the elderly and disabled that would be more cost effective than what the standard government "Original Medicare" could offer. These private entities also convinced the government that not only could they provide a cost effective, high quality product they could do it well and make a profit. Big promises and small returns … and they couldn't live up to the hype.

Many of the companies with the big dreams left the program. In an effort to keep the program alive and bring these entities back on board, the federal government began paying insurers a bonus every year in the form of overpayments. It is reported that between 2004-2008 alone overpayments totaled more than $32 billion.

Guess where that money is coming from? You and I my taxpaying friends!

So one of the reasons that Medicare is costing us all more is because the private insurers participating in the Part C program are being overpaid by the government to provide lower cost health benefits than the government can. Does anyone else see robbing Peter to pay Paul here or the rationale? So the government is now paying more to the private insurers that promised to save the government money.

Here's the real kicker, Medicare Advantage plans, in my humble opinion, folks, are not the high quality package that they are touted to be. These plans, which actually cost the government more, often offer less to the sickest and most disabled.

Advantage Plans, as HMO and PPO plans do, may restrict physicians, providers, and referrals out of network, hospitals and Skilled Nursing Facilities. Patients often suffer from the cost cutting.

Here's a personal experience. I had a client in Anne Arundel County transferred to Harford County after a hip fracture because her Advantage Plan would only pay for limited Skilled Nursing Rehabilitation facilities. Many facilities refuse to participate in the Part C programs. If you were to ask many in the long-term care world, Advantage Plans would get a thumbs down when it comes to coverage of quality facilities and in many cases do not allow care in higher acuity medical facilities.

There are many facilities, Johns Hopkins included, that only accept their own Advantage Plans. Don't plan on getting care at many of the hospitals, which are teaching facilities with specialties for rare or serious cancer diagnoses.


The fact is that dis-enrollment rates from Advantage Plans back to Original Medicare correlate to dissatisfaction. The Government Accountability Office (GAO) reports, "Beneficiaries in poor health were substantially more likely (on average, 47 percent more likely) to dis-enroll relative to beneficiaries in better health. Such disparities in contract dis-enrollment by health status may indicate that the needs of beneficiaries, particularly those in poor health, may not be adequately met."

Have you read the words from my lips to my fingers on the computer? Do you get my drift?

If I hear one more commercial that wants me to scream back at the TV screen I will scream! Buyer beware! These plans may look great, lower costs and more services promised but read the information. The manuals for these Advantage Plans may be so arduous to read and comprehend that it's impossible to decipher and many have outdated information about participating providers. If you decide to go with the private Part C program be sure what you are buying into!

To evaluate your Medicare Plan or Part D Plan make an appointment at the Bureau of Aging during open enrollment. State Health Insurance Assistance Programs, or SHIPS, can offer help with choosing a plan. These programs provide free insurance counseling to Medicare beneficiaries in all 50 states. Call 410-386-3800.

Jill Rosner is a registered nurse, certified geriatric care manager and owner of Rosner Healthcare Navigation. She provides patient advocacy and care management services to clients with health and aging issues. Contact her at JillRosnerRN@aol.com.