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Your Letters: Sept. 11

7:13 PM, Sep. 10, 2013  |  Comments
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Beware of 'replacement' Medicare plans

If you are in the process of considering Medicare enrollment and reviewing the many offers of companies attempting to sell you a Medicare replacement plan, look carefully and think long and hard about being persuaded not to have a traditional Medicare plan. Medicare replacement plans can be the devil in disguise and rarely deliver on their advertising promises.

Medicare is a federal program with a complex set of guidelines. For example, if you are in need of skilled nursing in a nursing home for rehabilitation following a joint replacement operation, Medicare may approve your stay for physical, occupational and/or speech therapy and, perhaps, nursing if needed. There are parameters about how many days can be covered depending upon the progress you achieve towards goals. At day 21, if you need to stay longer, there are co-payments to be made, and if you have a supplemental plan, it may cover the co-payment. Many people say, "Well, I know I have 100 days of Medicare," but that is NOT the case. One hundred days of care ARE available according to specific guidelines as well as other factors, but 100 days is no absolute guarantee.

Replacement plans do not operate on those same guidelines. They may not even approve your stay, in which case you are informed your stay is out of pocket. Their guidelines are not the same as Medicare. Replacement plans aim to insure healthy seniors, anticipating they are so healthy they will not need to file a claim.

However, when that unexpected event occurs, a fall and broken hip or ankle, new knee, stroke, etc, and the hospital/MD suggests discharge for therapy in a nursing home, the replacement plan is reluctant to "ante up." The replacement plan case manager may reluctantly approve three to five days, want a progress report on their set of forms, run it past their physician adviser, and suggest that you can go home and some family member take care of you with out-patient therapy. Oh, and the case managers for the replacement plans want prior authorization before leaving the hospital, which virtually never happens. You, the policy holder, are accountable. Appeals are possible but rarely reversed.

Be aware, if you have chosen not to have a traditional Medicare A and B plan, and opted for a replacement plan, you may not be able to go back. That may be the case if you now have a condition/diagnosis that is considered a "prior" illness and it is not covered.

Research replacement plans very carefully before signing anything. Do not be confused about a supplemental plan versus a replacement for Medicare. A replacement is not a supplement. It is a replacement. Medicare isn't a perfect system, but it far exceeds any replacement plan of which I am aware. Don't be fooled.

There is an Insurance Commission of Wisconsin where complaints can be logged, or you can express your concerns to your Senator or Representative's office. Don't be silent. What is happening to seniors is not healthy care; it is leaving vulnerable seniors confused and depressed, without needed coverage and financially distressed.

Kathy Wagner

Sister Bay

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