insurance

Beware Medicare fraud risk

Holland advises seniors to be especially suspicious of any unsolicited contact with an agent.

An agent's cold call or a knock at the door is a bad sign. In July, Congress passed the Medicare Improvements for Patients and Providers Act of 2008. The law provided marketing restrictions including prohibiting telemarketing and door-to-door solicitation, and providing meals to prospective clients as part of marketing activities.

Outside help is also available. To help Medicare beneficiaries navigate the many health insurance options, the federal government offers the services of senior health insurance program counselors, also known as SHIPS.

SHIPS counselors go through a five-day crash course on health insurance options. Many are volunteers. Others are social workers who have taken the training to better serve their clients.

These counselors do not choose a health insurance plan for inquiring seniors and have no financial stake in a senior's final decision.

"We don't have that bias," said Darlene Sampson, who directs Pennsylvania's SHIP, which is called the Apprise Program. "We're able to review the risks and benefits to the consumers."

Links to all 50 states' programs are available at the Centers for Medicare and Medicaid Services Web site. Medicare has made "Medicare and You 2009," a 128-page summary of the program, available for download at its Web site.

You can also call 1-800-Medicare for more information.

One of the best ways to avoid being ripped off is to know your current plan's coverage details before considering making changes, Holland says.

She suggests seniors and their caretakers review premiums, deductibles, co-pays (including those for prescription drugs) and the general scope of coverage, including which types of doctor and hospital visits are eligible for coverage.

It is also helpful to know of any limits on coverage for medications, such as whether or not prescriptions are covered if they are refilled while traveling outside of enrollee's home state.

Before switching to a new type of coverage, seniors should make sure that their current physicians or other health care providers are included in the new plan's health care provider network.

The Center for Medicare Advocacy, a Connecticut-based nonprofit organization founded to educate seniors about health care issues, has made Medicare Advantage information available at its Web site.

Seniors who feel they have been victimized in a scam involving a federal health care program are advised to contact the U.S. Department of Health and Human Services Office of the Inspector General at 1-800-447-8477.

Fighting back

What should seniors do if they sign up for a Medicare Advantage plan, only to discover it may not be in their best interests?

Kuchler advises seniors who need help with leaving a Medicare Advantage plan to call the U.S. Department of Health and Human Services Medicare hotline at 1-800-MEDICARE.

Under certain circumstances, patients are able to switch back to their original Medicare coverage or a different Medicare Advantage plan, Kuchler says.

In addition to the upcoming open Medicare enrollment period (Nov. 15 to Dec. 31), there is a Medicare Advantage open enrollment period from Jan. 1 to March 31 of each year, he says.

During this time, beneficiaries can join, switch to or drop a Medicare Advantage plan. Any changes go into effect the following month. However, in order to join or switch to a plan with prescription drug coverage, beneficiaries must already have Medicare prescription drug coverage.

Patients in special situations are sometimes permitted to join, switch or drop a Medicare Advantage plan at times outside of the enrollment periods. This includes circumstances such as a patient moving outside of the plan's coverage area, the plan reducing its services or the plan leaving the Medicare program, he says.

In addition -- as mentioned earlier -- seniors enrolled in both Medicare and Medicaid are able to change their plans once every month.

However, in other circumstances, seniors are locked into the plans the same way beneficiaries covered by health insurance provided by employers are committed to a particular plan, Kuchler says.

These consumers will have to wait until the next open enrollment period before they are allowed to change their coverage option.

And even seniors who have the right to change their coverage may sustain some collateral damage as they switch back to their original coverage, Precht says.

"The damage is patients can be caught without coverage and get stuck with medical bills," Precht says. "They can no longer see the same doctor, or their relationship with their doctor can be interrupted."

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