What is Your Medicare Coverage? Can You Afford It?

Kathy needs triple by-pass surgery and is supposed to go into the hospital next week.  She has been told by the hospital that she must pay $695 before the hospital will admit her. Kathy’s mother, Lucille, called me yesterday to ask if I could sort out her daughter’s confusion over this required payment.   This was a case of putting together clues I got from Kathy and Lucille in order to figure out what kind of coverage Kathy has and why she was told she must pay a $695 advance payment to the hospital.

Clue # 1:  $695 is the hospital co-pay for Health Net’s Ruby 3 Medicare Advantage plan. Kathy did not have her Health Net card with her, so she couldn’t tell me for sure what plan she is enrolled in – but she said she is enrolled with Health Net.

Clue# 2:  I asked  Kathy if she pays a monthly premium for her Health Net plan.  She said she thought it is thirty-some dollars per month.  Last year Ruby 3 had a $38 premium (but it was raised to $59 this year).  Kathy has the premium taken out of her Social Security check, so she probably didn’t notice the increased premium.  (Note: This plan includes dental, vision, and hearing aid benefits, which is why it has a $59 monthly premium).

With  these clues, I was able to tell Kathy that she is probably enrolled in the Health Net Ruby 3 Medicare Advantage plan.  I told her she needs to carry her Health Net card with her at all times, because this is her Medicare coverage.  I said that if her doctor said she would be in the hospital for 5 or 6 days, the $695 co-payment is actually a good deal.  Most of the other Medicare Advantage plans in Tucson have a hospital co-pay of $200 per day or more,  which would cost a patient $1,000 or more for a 5-day hospital stay. Under her Medicare Advantage plan, every service Kathy receives in the hospital will be paid by Health Net, so this is a pretty good deal for a $695 co-pay.

The problem for Kathy is that she  doesn’t have $695.  And if she can’t give the hospital $695 up front, she doesn’t get the heart operation she needs.

So my questions are:  Why is Kathy enrolled in a plan she doesn’t understand?  And why is she paying $59 per month ($59 x 12 = $708 per year) if she doesn’t have $695 in the bank for her hospital co-payment? Who signed her up for this plan knowing that she lives on a Social Security check that is around $1,300 per month? And finally, will she be denied a life-saving operation if she can’t come up with $695?

I told Lucille that Kathy’s plan requires the $695 co-pay, and that it is a very reasonable co-pay for a hospital stay of 5 days (or more). Lucille felt better because she understood her daughter’s coverage –  and she said she’d find a way to get the money.  She said this is a life or death situation for her daughter, so she’d do what she could so Kathy could get the operation.

I always say to people that you don’t know how good (or how bad) your insurance coverage is until you need it. This is the case with Medicare Advantage plans.  And while a $695 co-pay for major surgery seems very reasonable, there are many people who just don’t have this kind of money on hand.  What are they to do?

Medicare Advantage plans save seniors (and people on Social Security Disability) a lot of money – as long as they are healthy.  But when they have health problems, the co-pays for specialists, tests, and hospital stays can add up.  Kathy is about to learn this, the hard way.  And what kind of health care system do we have if a person is refused life-saving surgery because she doesn’t have enough money to pay a $695  hospital co-payment?

What Next?

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5 Responses to "What is Your Medicare Coverage? Can You Afford It?"

  1. medicareblogger says:

    AN  UPDATE ON KATHY:   I talked to Lucille today and she said the hospital allowed Kathy to get the operation with just $200 paid up front.  I guess they figured Health Net was paying all but $495 of the operation, so they could go ahead.  Lucille is worried what the follow-up care will cost in co-payments, but she is relieved that her daughter has received the life-saving operation.
    I met a man two years ago who had only Medicare and did not qualify for “full AHCCCS”. This man needed a heart transplant and was told that he could not get a transplant if he only had Medicare.  This is because Medicare leaves the patient to pay 20% of surgeon and physician fees – which would be so large for a transplant that they knew the patient would not be able to pay his amount.  This man got qualified for Medicare Cost Sharing help from AHCCCS based on his limited income.  (The income limit is $1,218 per month for an individual.) He then qualified for a “special needs plan” for people with limited income. And he got on the list for a transplant.  I guess I should find out if he got his transplant – but I know he at least had the chance because he was enrolled in a Medicare Advantage plan that would limit his co-payment for the surgery.  Medicare does not have a limit on the 20% co-insurance.

  2. alan says:

    Here in South Carolina,  I haven’t heard of hospitals asking for payments upfront from Medicare Advantage insureds.    When my client had heart surgery, out-of-network, she was home 8 weeks and pretty well recovered when the bill came.

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