Frances Barczak, sitting in the front row at a meeting in a storefront Highlandtown health clinic, puzzled over a cost-comparison chart for Medigap policies.
"This only goes to age 70," she said. "I'm 90."
It is a small confusion in a universe of major quandaries.
For many senior citizens, this is a season not just of fretting over unfamiliar paperwork, but of making difficult choices. This year in Maryland, the options have narrowed and the complications have broadened.
The exit of three Medicare HMOs from the state, scheduled to take effect at the end of the year, has left about 55,000 elderly looking for alternative coverage. They are also looking for help - at sessions such as the one Barczak attended in Highlandtown and from county offices on aging and other sources of assistance.
"We were flooded with phone calls when those announcements came out," said Arnold J. Eppel, deputy director of the Baltimore County Department of Aging. His office recently sponsored a meeting on Medicare changes at a Towson senior center that brought out 300 people.
In addition to the big meetings, there's a lot of one-on-one counseling for perplexed seniors, such as the couple who, at the end of the Highlandtown meeting, sat down with insurance counselor Kisha Winston. From a plastic shopping bag they produced a rubber-banded packet of a dozen letters, all received in the past month from the federal government, their HMO and their doctor, and asked Winston to explain what's going on.
Medicare HMOs have left the market in Maryland and elsewhere each of the past two years, but this year's round is much worse, and the situation in Maryland is worse than that in most other states, said Joe Baker, associate director of the Medicare Rights Center, an advocacy group in New York.
Nationally, he said, nearly a million of the 6.5 million enrolled in Medicare HMOs are being dropped - more than in the past two years combined.
In Maryland three key factors have made the situation even more severe, according to Baker and local advocates and health insurance counselors:
Maryland seniors have just one option in signing up with another HMO. Only Kaiser Permanente will remain after Dec. 31, and it is raising premiums, will offer care only from staff doctors at its own centers and is seeking federal permission to cap its enrollment, meaning that those seniors wishing to do so may not be able to switch to Kaiser from one of the departing HMOs.
"There are a lot of people in urban and suburban areas that are really hurting," said Charles Culbertson, president of United Seniors of Maryland. "They can't really pay for prescription drugs, and that's the major benefit they were after when they joined the HMOs." The average senior spends $1,205 a year for prescriptions, more than double the $559 spent in 1992, according to the advocacy group Families USA.
In addition to the HMO pullouts, some large physician groups have been canceling contracts with the HMOs. Like the HMOs, the doctor groups have been saying they are losing money because federal Medicare rates haven't kept pace with medical inflation. This leads to situations such as that experienced by Alan Crumbaker, 56, of Armistead Gardens, who got a letter from UnitedHealthcare Aug. 14 telling him he had to select a new doctor by Aug. 21 in order to stay in the HMO for the rest of the year.
"It's one thing to be told my HMO is leaving at the end of the year. I can live with that," says Crumbaker, who is eligible for Medicare coverage because of a disability. "But to be told my doctor is leaving four months earlier, that just doesn't make sense." Patients such as Crumbaker can drop out of their HMO and keep their doctor - but then face out-of-pocket costs for seeing that doctor, as well as for prescriptions and other benefits covered by the HMO.
Some seniors, bouncing from plan to plan and doctor to doctor over the past few years, are suffering from a kind of Medicare fatigue.
Alma Barb, 69, also of Armistead Gardens, describes her Medicare experience as a "merry-go-round."
She had a doctor she was comfortable with, but when she retired five years ago after 37 years as a machine operator at PolySeal Corp., she lost her health coverage. She started going to a health center in Highlandtown where she could receive care at lower cost.
The health center, however, didn't offer hospitalization benefits beyond what is already covered by Medicare. She was treated at a hospital and got a $400 bill, which she paid off over time.
Then, she heard about Medicare HMOs, which covered those hospitalization costs. She called Prudential, "and they had a rep come to the house and all. She was real anxious to get me to sign up." Barb joined. "They gave me a big book and I picked a doctor" - she went back to the same one she had gone to when she had insurance through PolySeal.
Then, Prudential left Maryland. She decided to join another HMO "and the doctor said to take United, so I picked that." She was satisfied, and her April gall bladder surgery was fully paid for. But now, her doctor is leaving United's network. And, at the end of the year, United's Medicare HMO will be out of Maryland.
Barb decided to go back to the Highlandtown Community Health Center. But to do that, she had to disenroll from United, because the center dropped its United contract. She was able to join a special program at the center - run by the city health department with a federal grant - that gives her prescription benefits, as well as some dental and eye care. It still doesn't include hospitalization, however.
Her story is a microcosm of the history of Medicare HMOs. Once HMOs decided they could manage medical costs and make a profit from Medicare patients, they began aggressively recruiting seniors, enticing them by offering benefits, such as prescriptions, not included in standard Medicare. Between 1994 and 1998, enrollment jumped from 2 million to 6.5 million nationally and from 1,000 to 90,000 in Maryland.
Then, the federal government, concerned that it was paying the HMOs too much, cut some of its payments, and began increasing them more slowly. HMOs said they were losing money, and began dropping out of the program.
Barb is one of only 1,600 Maryland seniors being dropped by HMOs who were eligible for the special program because she had been a patient at one of the participating health centers in the past.
Most of the rest face a big increase in out-of-pocket expenses - either for deductibles and co-payments that would have been covered by the HMO or for Medicare supplemental insurance, called Medigap and which can be quite expensive. Cost depends on which of 10 plans (with different levels of benefits) the person selects, and on age, but all cost more than HMOs, and offer a less-rich benefits package.
Standard Medicare coverage leaves patients liable for 20 percent of hospital costs.
"You almost have to have Medigap coverage," advised Charlie Gerhardt, president of Maryland Patient Advocacy Group, which provides counseling on Medicare and other health insurance problems. "If you don't and you go into the hospital, you could get wiped out."
As an example of the difficult choices, consider Cathy and William "Bud" Willinghan, who live in the Colonial Landing senior housing in Elkridge.
When they first retired, they had a Medigap policy, "but it got so expensive we couldn't afford it," she said. So they joined United - but their doctor's group canceled its United contract, and United is leaving at the end of the year anyway.
They don't want to change doctors, but they want to keep their United membership as long as possible because of prescription and hospitalization benefits.
How many prescriptions do they need? Reaching into her wallet, Cathy Willinghan unfolded a paper and counted - 11 prescriptions. Her husband has four. Over the past four years, they spent $1,200 out of pocket on prescriptions, over and above what their HMO covered.
They did try calling to a number of drug chains to see if they were getting the lowest price. "There was one that Kmart had for $20 less," she explained, "but mostly, the prices are all the same." Cathy Willinghan said she asked her doctor if she could get by with fewer medications, but he told her, "Not if you want to be able to walk around."
A World War II veteran, Bud Willinghan has started going to a Veterans Administration facility to fill his prescriptions, and he pays only $2 for a 90-day supply of each. His wife can't fill her prescriptions there, however.
Willinghan has had surgery on his left knee, and the right knee will have to be done soon - but not until after the first of the year, when his HMO will be gone. He could go to the VA for his surgery, but would prefer to stick with the doctor who did a good job on his left knee.
The Willinghans, both in their 70s, could buy a Medigap policy, which would protect them on hospitalization. Some Medigap policies - the more expensive ones - also provide prescription benefits. But many insurers require a medical exam for those who didn't apply for Medigap in the period when they first became eligible for Medicare, and they might refuse to issue the Willinghans a policy because of their multiple health problems.
Under federal rules, they can buy Medigap in the 63-day period after their HMO drops them - but not now, when their HMO is still here but their doctor will no longer participate. Also, the guarantee covers only the more basic policies, not the ones that include prescriptions.
In a recent session at the Florence Bain Senior Center in Columbia, Jeannette Krapcho, insurance counselor for the Howard County Office of Aging, handed the Willinghans a rate guide for Medigap policies, showing costs ranging from $37 a month to $400 a month per person, depending on age and range of benefits. The most common policies, Krapcho tells them, are in the range of $150 to $200 per month per person. (This is in addition to the $45.50 a month most seniors pay for Medicare Part B, which covers doctor charges, outpatient treatment, medical equipment and lab tests. Part A, which covers hospitalization, has no premium, but comes with deductibles and co-payments.)
Some seniors are eligible for medical assistance to cover health costs, but the Willinghans, with Social Security and his pension through the Graphic Communications International Union, exceed the income ceilings. (Kisha Winston, the Highlandtown counselor, estimates that she has met with more than 300 seniors dropped by HMOs, and that fewer than 50 in that blue-collar community qualified for medical assistance.)
They can try to enroll in Kaiser Permanente, but the HMO wants to limit its enrollment. Plus, with no Kaiser center in Howard County, they would have to go to Woodlawn or Silver Spring to see a doctor. To top it off, the only hospital in the county, Howard County General, is not in the Kaiser network. They're not sure what they will do.
"I don't know who started calling old age 'the golden years.' It couldn't have been an old person," Bud Willinghan said.