What No One Tells You About Medicare Coverage -- Carol (Vol. 2)
The following is an excerpt from Phillip Moeller's Get What's Yours For Medicare: Maximize Your Coverage, Minimize Your Costs, out now on Simon & Schuster. This is the second of a three-part series on Medicare coverage.
The Medicare rules say that private Medicare Advantage insurance plans must cover at least the same things that Original Medicare (Parts A and B) covers. Many people naturally assume this means the two approaches to Medicare are the same.
Big mistake.
Phillip Moeller
(Photo courtesy of Simon & Schuster)
Carol's husband, Ernesto, had a Medicare Advantage plan in Texas, when he was diagnosed in June 2014 with pancreatic cancer. Little more than six months later, Ernesto would be dead following complications from surgery. During this time, when Carol wanted to spend as much time as possible with her partner, she instead had to fight insurance company rules and respond to unexpected surprises about what his Medicare Advantage plan did not cover.
Even after she learned about some limitations, new ones kept cropping up.
Her problems stemmed from the fact that Medicare Advantage plans restrict coverage to those doctors, hospitals and other caregivers who are in the plan's provider network. Original Medicare, by contrast, insures covered medical services from any provider who accepts Medicare. When Carol was forced to take over as the main caregiver for her husband, she didn't know about these restrictions. Even after she learned about some limitations, new ones kept cropping up.
"The gastroenterologist who diagnosed my husband met with us, explained the diagnosis, and called MD Anderson [the University of Texas MD Anderson Cancer Center] to refer him to a specialist. He was told that neither the doctor nor the facility accepted Medicare Advantage. Medicare, yes; Medicare Advantage no," she recalls. His insurer said it could not help her find a center with pancreatic cancer expertise, and that Carol would have to make these calls herself, which she did. "All the time I took to figure out how to track down information and to do it, took time away from being with my husband.
Get What's Yours For Medicare book cover. (Courtesy of Simon & Schuster)
"We even found that the local oncologist we chose told us that he would accept the plan and was 'in-network,' " she adds, "but for the entire six months he saw my husband for chemotherapy and related studies," the benefit statements from the insurer showed he was not. Inaccurate billing statements flew back and forth, making it impossible for Carol to keep up with expenses and payment schedules.
"In the meantime we paid bills, got refunds, and completely lost track — if there really was a track — of where we were on the maximum out-of-pocket payments," she says. "Incidentally, this was not how I wanted to spend my time, and was not what either my husband or I needed in order for him to continue to live well and enjoy life as long as he possibly could."
It can be difficult in the midst of a crisis to figure out what you can control and what you cannot.
Carol, not surprisingly, thinks that no one should ever get a Medicare Advantage plan. But millions of people do and find no problems with their coverage and service. However, if a serious medical issue arose, they may be no more equipped to deal with possible shortcomings in their plan's provider network than was she. "It can be difficult in the midst of a crisis to figure out what you can control and what you cannot," she cautions.
"My husband and I shared a great life," Carol now says. "He lived well up until the moment he died, and even his manner of dying was a gift to me. Mostly what I relive are warm and appreciative memories. Occasionally, of course, the bad stuff surfaces..."
Phillip Moelerr is the author of Get What's Yours For Medicare: Maximize Your Coverage, Minimize Your Costs. He writes about retirement for Money and authors the Ask Phil Medicare column for PBS. He also is a Research Fellow at the Center on Aging & Work at Boston College and the founder of Insure.com, a leading site for insurance information.
The views, opinions and positions expressed within this guest post are those of the authors alone and do not represent those of CBS Small Business Pulse or the CBS Corporation. The accuracy, completeness and validity of any statements made within this article are verified solely by the authors.
