What Advantage?

Lucretia Ryan

WHEN MY FATHER DIED, my mother moved to be closer to me. I didn’t know anything about Medicare, but I knew she needed health-care coverage.

I would call up Medicare and ask questions, and the phone reps would read me a script. I’d ask another question and they’d read me the same script. Rephrase the question, and I’d get the same useless scripted responses.

I had no idea about the difference between traditional Medicare and Medicare Advantage. I chose Anthem Blue Cross Blue Shield, since it was a familiar name. I was steered toward a Medicare Advantage plan. It was touted as convenient and low cost, with additional benefits such as vision care, dental and reimbursement for gym fees. Who wouldn’t want a Medicare Advantage plan instead of some other costly, more confusing plan?

Initially, the Medicare Advantage plan worked well for my mother—that is, while she was relatively healthy. Then she moved into an assisted living facility in Stamford, Connecticut. None of the doctors, podiatrists and physical therapists who came to her facility would accept Medicare Advantage plans, because the plans paid them far less. I had to find doctors that would take her Advantage plan, and then drive her to her appointments.

My mother had quit smoking 20 years earlier. Still, prior to that, she had smoked for almost 50 years. She developed COPD, or chronic obstructive pulmonary disease. I had to get her an oxygen concentrator. Unfortunately, her Medicare Advantage plan would only pay for a huge oxygen concentrator, not a portable one. This meant that, if she wanted to breathe well, she had to stay in her room. She couldn’t go anywhere unless she wanted to go without oxygen.

The pulmonary specialist and I appealed and appealed this decision to her Medicare Advantage plan. I finally got the portable oxygen concentrator approved, but the only company that would accept Medicare Advantage was a poorly run medical supply company. After calling every executive at the company, I got her the portable unit. If she’d had traditional Medicare, the portable oxygen concentrator would have been authorized much faster and I could have dealt with better-run medical supply companies.

My mother developed pneumonia and the assisted living facility sent her to Stamford Hospital. Medicare Advantage did a good job of covering her hospital expenses. Since she was in bed for more than a week, she needed to go to a rehabilitation facility to avoid being wheelchair-bound for the rest of her life. She was transferred to a rehab facility that took Medicare Advantage. The rehab facility and I had to keep calling Anthem Blue Cross Blue Shield to get her stay extended.

Eventually, her time ran out and she was transferred back to assisted living. Unfortunately, the physical therapist who worked at my mother’s facility wouldn’t take Medicare Advantage because of the low payments.

My son Jake had recently graduated college and wasn’t starting his job for a few months. Every day, he went to visit his grandmother to get her walking. He was the only one who could get her out of her wheelchair.

The final straw: I was notified by Anthem that my mother’s Medicare Advantage plan would no longer pay for her COPD inhaler that she needed daily to breathe. Then came a pleasant surprise. By pure dumb luck, my mother was living in one of the four states—New York, Connecticut, Massachusetts and Maine—that required Medigap plan providers to accept seniors without regard to preexisting conditions.

Why is that important? If you’re in a Medicare Advantage plan, it’s often effectively impossible to switch to traditional Medicare because you can’t qualify for an accompanying Medigap policy. Indeed, in any state other than the four states mentioned above, it’s highly unlikely that an insurance company would sell a Medigap plan to a woman in her 90s with COPD.

We had to wait a number of months for the annual enrollment period. I then switched her to traditional Medicare, plus a Medigap plan from Blue Cross, plus a drug plan. Big difference. Any doctor who came to my mother’s facility was thrilled to take traditional Medicare.

Instead of driving her to the nail salon to get her toe nails trimmed, the podiatrist who came to her assisted living facility every week took care of this. Similarly, the doctor who came to the facility now saw my mother, so I didn’t have to drive her to appointments.

What Medicare plan am I going to choose when I turn 65? I know the plan I select during the initial enrollment period is likely to be the plan I’ll have for the rest of my life. It’s an easy choice: traditional Medicare.

I’m willing to forgo Medicare Advantage extras such as vision care, dental and gym fees. I’m also willing to pay higher premiums to ensure that I have the best medical and drug coverage. My priority is a plan that’ll allow me to choose the best facilities and doctors. I’ll also pick the most comprehensive Medigap plan available, which is currently Plan G.

Lucretia Ryan is the founder of A graduate of Cornell University, she spent her career at IBM.

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