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Medicare Advantage Plan Spoils Client’s Choice Of Nursing Homes

I recently had a situation occur that I’d like to share, lest the same circumstances arise for you.

My client’s were a family whose Mother was living in an independent living retirement community with a full-time caregiver. Her health issues had escalated to the point where she could no longer perform any activities of daily living on her own. She was approaching the point where she was a two-person assist. The cost of two full time caregivers plus the independent living rent was prohibitive. Therefore, the family retained me as a senior living advisor and certified care manager to find a nursing home for her.

I actually anticipated that the placement was going to be fairly easy. They wanted a private room for their Mom, with specific location parameters, and a certain religious affiliation if possible. Sounds easy, right?

I put together a presentation based upon three communities that fit their specifications and arranged for them to begin the tours. All three were high end nursing home communities with a reputation for delivering excellent care.

After the first tour had been completed, I received a phone call from one of the family members. She told me they loved the community. But, the Admissions Director informed them they were no longer accepting the Medicare Advantage insurance plans that happened to be her Mom’s insurance provider. I called the other two communities that I had recommended. They had made the same decision.

How do these plans differ from a regular Medicare supplement plan? First of all, these plans are underwritten by private insurance companies, and Medicare is not the primary payor, The insurance company pays according to the rules of Medicare Parts A and B. But, they can offer different plans and normally the programs are a form of managed care like a PPO or HMO. The result is a savings in cost. In order to receive full benefits, the insured has to utilize providers within a list of Doctors, hospitals, and long- term care communities that are approved. Failure to utilize one of the approved providers could result in denial of benefits. However, if your health care providers are in the network, the insured receives the benefits in full. Sometimes prescription drugs are covered in the plans. For further information on how these plans work, click here.

So what does this mean for the long term care communities? It means that if they aren’t contracted with the insurance company as a provider, they have to call to obtain an approval. This results in hours of calling on the phone and even necessitates having to hire a full-time employee to obtain the exceptions.

You might think the easy solution would be to change the senior from a Medicare Advantage program into a regular Medicare supplement. The problem is that many of the Advantage programs pay full benefits if you use the network. I have heard horror stories from other colleagues in the industry that several of their clients chose to exercise the option of changing to a Medicare supplement. They were deluged with deductibles and out of pocket costs that they had not incurred with the Advantage plans.

So what did I do to solve my client’s problem? I obtained a list of preferred nursing homes from the carrier, and recommended the homes that were acceptable. However, this list was only comprised of “acceptable” nursing homes, and not the stellar providers I recommended originally.

Before you purchase one of these plans, please be certain to speak with someone who knows what the pros and cons of Medicare Advantage plans will be.

For all your senior living needs, please contact Andrea Donovan of Andrea Donovan Senior Living Advisors.