Medicare & Medicare Plans

“Do you take Medicare?” “Will you still see me when I go on Medicare?”

When patients face the transition from private insurance to Medicare questions and uncertainties arise. There is noting wasy or intuitive with the process.

Yes, we take Medicare. We are Medicare providers. We will submit claims to Medicare for you. This form of Medicare is the classic, traditional, “Red, White & Blue”, government-adminstered Medicare plan. Medicare had two (2) components: Part A, which covers hospitalization costs and Part B, which covers out-patient care. This is the standard Medicare plan and does not include extensive pharmacy coverage. Patients who have Medicare as the sole and only insurance coverage will face a the costs of their medications, especially if they have medications that are expensive, like insulin or blood thinners. The pharmaceutical benefits can be exhausted within 3 months and then a patient falls into the “doughnut hole”. This is essentially a deductible. The patient is then responsible for 100% of their drugs costs until they meet that deductible. And the cycle repeats every year.

This is argument for and advantage of buying a supplemental Medicare Rx plan to cover the cost of chronic medications. The cost of that extra plan is often less than the out-of-pocket costs of the actual prescriptions when a patient ends up in that “doughnut hole”. Now, with drug companies raising the prices of their medications, the costs are unpredictable making that “doughnut hole” variable each year – sometimes each month.

Patients who retire often maintain their health insurance as a benefit of retirement. That private insurance should become the “secondary insurance”. It picks up costs that are not paid by Medicare. This means bills “roll to the secondary” insurance.

Now, there are new products, new insurance plans that add complexity and often confusion to purchasing insurance and selecting plans. These Medicare Advantage Plans are created by private insurance companies that have contracted directly with the government to sell an insurance plan to patients. Almost every insurance company offers them. The tricky and misleading part is that when they are marketed and sold to patients, patients do not always fully understand the coverage, benefits and limitations. And sometimes, even the doctors are not clear as to the networks they have joined. The Advantage plans operate like HMO. Patients have to follow referral networks, get authorizations for procedures and may have limitations to covered services.

For example: Primary Care Physicians participates in the Florida Blue Medicare Advantage Plan called the F Plan. This product is a supplemental plan that can be added to or conjoined to a patient’s standard Medicare. It is also called a Medigap plan. So, Jane Doe has the regular Red,White & Blue Medicare and also purchases the FloridaBlue Plan F. She can see us for care and we submit her bills to Medicare and then to the Plan F for payment.

But, Blue Cross Blue Shield of Florida also sells a Medicare Advantage Plan called FloridaBlue Advantage Plan that is a PPO. This is a substitute for enrolling in the standard government Medicare program. A patient on this plan doe not have “Medicare” coverage. Their health insurance is BCBS of Florida. And BCBS has a narrow network of providers for this plan and Primary Care Physicians is not a network provider for this advantage plan. The insurance cars for the F PLan and the FloridaBlue Advantage plan look identical.

It gets confusing. Even we have been confused. It has taken hours of investigating how a patient can be assigned to our panel of patients and yet not have coverage to be seen by our office.

There has to be a better, more simplified process. But, until that day arrives, if you are going onto Medicare or thinking of changing your plans, you can call the office and ask if we accept your insurance.

August 2019