I never thought it would be upon me, but the time has come to sign up for Medicare. (I turn 65 in March 2012.) Saying the word is depressing, not to mention trying to figure out Part A from Part B, Part C from Part D, Medicare Supplement from Medigap and Medicare Advantage, and which of the zillion drug plans makes sense for my needs.
This much I’ve learned: There isn’t a single Medicare plan that reimburses me if I see doctors who do not opt into the Medicare network. I would have to stop using some of the doctors I now use. I’ve been told that well over 90 percent of the country’s doctors accept Medicare, but it seems that those who don’t are all located on the Upper East Side of Manhattan. Oh well, I guess I’ll be able to find competent docs who aren’t greedy, unless I want to continue paying for a private plan through my company, which is around $1,000 a month.
When the public relations people from health care organization, Kaiser Permanente, asked if I wanted to talk to someone about “Medicare Star Quality Ratings,” I said “Sure.” Why not learn anything I could about the subject?
I interviewed Agnes Strandberg, an intelligent, supremely patient woman, who is KP’s vice president of Medicare in California. I say patient because I ask an overwhelming number of questions when my thick skull can’t absorb a concept right away.
Me: What are the fundamental points I need to understand about Medicare?
AS: Part A covers hospitalization. You automatically get it when you turn 65. It’s free.
Part B covers doctor visits, outpatient care and some preventative services. It’s optional and has a monthly premium (around $100).
Part C, also called Medicare Advantage, is a privately run alternative to Parts A and B,and often includes additional benefits, such as wellness programs and prescription drug coverage. Advantage plans are structured like HMO or PPO plans, and they either require that you choose a primary care physician or use the plan’s provider network. Monthly premiums could be higher than Part B but the deductibles and co-payments are usually lower.
Part D is privately run, optional and covers prescription drugs. It has a monthly premium, which is based on deductibles and medications covered.
Medigap, also called Medicare Supplement, is available through private insurers and helps pay for many costs not covered by Parts A and B, such as deductibles and co-payments. Supplement plans (there are 10 options, each with different deductibles and benefits) are regulated by the government and are precisely the same from state to state (Massachusetts, Wisconsin and Minnesota are exceptions).
Me: Is Medigap better than Medicare Advantage?
AS: Some people believe that the ability to choose their own doctors is superior to getting care in a controlled setting (through an HMO, for example). They want to go wherever they wish and they don’t care to have a primary doctor coordinating their health care. But KP believes that integrated care — one person monitoring all your medicines, for example — becomes more important as our functionality becomes more challenging with time.
KP is a health care organization that’s committed to a highly coordinated and integrated approach, so we have a clear picture about your multiple health conditions and can ensure that we’re delivering the right care at the right time. Supplements let you go anywhere to see a doctor, but you don’t capture a holistic picture of a person’s health. We own our hospitals and have exclusive contracts with the Permanente Medical Group.
Me: Now that I understand this much, tell me about the Medicare Star Quality Ratings.
AS: The Centers for Medicare and Medicaid Services (CMS), which oversees Medicare Advantage and Medicaid plans across the country, created the system to measure comparative quality of health care and service among providers. Five areas are covered:
- Performance in preventative care, including screenings and vaccinations. How does a plan ensure that its members stay healthy?
- The plan’s responsiveness to needed care and chronic conditions. For example, is it providing diabetic patients with eye exams on a regular basis?
- The number of complaints that CMS catalogs relative to other health plans
- Pharmacy benefits
- Customer service
After rating providers on 53 individual quality measures, CMS provides overall summary ratings of one to five stars. All of KP’s plans received at least 4.5 stars for 2012. There are 1 million people covered overall by five-star plans and we have over 900,000 of them.
Me: So Medicare Supplements aren’t rated?
Me: OK, I’m sold. I want to sign up for a KP Medicare Advantage Plan now.
AS: You can’t since we don’t offer Advantage Plans in New York. We don’t have a national footprint because we want to make sure we have great control over our integrated services. Being everywhere would make it challenging to maintain the level of service and consistency we want. KP is in California, Oregon, Washington State, Colorado, Georgia, Ohio, Washington DC, Maryland and Hawaii.
Me: What are some other five-star plans?
AS: Group Health Cooperative (GHC) in Washington State; Marshfield Clinic in Wisconsin; Gundersen Lutheran Health System in Iowa, Wisconsin and Minnesota; Martin’s Point Health Care in Maine and New Hampshire and Bay State Health in Massachusetts
Me: I’m moving!