Medicare Open Enrollment Blues

This is the year I became eligible for Medicare, and I started my research in October. I decided on a Medicare Managed Care (Part C) PPO option that allowed me to see any clinician I choose but with a higher co-payment for out-of-network care. I knew if a doctor practiced in more than one health system, the doctor, hospital, and diagnostic centers could be in different networks. Though the out-of-network office copayments weren’t burdensome, if I needed tests, a sub-specialist, or a hospitalization, an out-of-network choice could be very costly.

Since I had moved and needed to find a new doctor anyway, I decided to choose a highly-rated, in-network local health system and look into doctors who practiced there. The insurance company would neither give me access to their online information, nor mail me a copy of their network list until I enrolled in the plan and received an insurance card, so I called customer service. Unfortunately, the representatives were all salespeople who are paid to enroll clients. They also work off a rigid script that requires the client to choose a doctor first.  Though I tried several times, none of the representatives understood that I wanted to know which hospitals (and diagnostic centers) were in-network before I chose my doctor. When I explained that an in-network doctor might inadvertently send me to an out-of-network hospital, one rep said, “That’s news to me. Why don’t you go with the HMO? It gives you so many benefits including….” She became sarcastic when I interrupted her description of hearing aids and fitness club memberships to say, “Excuse me, but my question is…”

My next step was to call the area hospitals. Despite several transfers, even the staff of departments that verify insurance coverage did not know whether their hospital was in-network for my plan. A colleague recommended a primary care doctor whose office staff said she was in-network. It turns out that she was not. Even so, once I met her, I felt complete trust and decided to pay the out-of-network copayment. I also finally found a reputable in-network hospital nearby and made sure that referrals for tests and subspecialists would go to the in-network facility.

If a triple-board certified physician with managed care experience has this much trouble, what chance does the general public have? The best option is to contact the State Health Insurance Assistance Program (SHIP) advisors through, or your local area agency on aging and try not to pull out your hair.

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