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Hartford Courant (Connecticut)

Elizabeth and John Zealor tried to follow the rapid-fire sales pitch of the insurance agent who came to their door unannounced last January hoping to enlist them in a Medicare Advantage health plan.

The Danbury couple, both with brain injuries from previous strokes, eventually signed the paperwork just to get the agent to leave.

“I had no idea what the thing was; he said it was a new kind of Medicare,” said Elizabeth Zealor, 77, who has diabetes and Parkinson’s disease. “He said a lot of things my husband and I couldn’t comprehend. After a few sentences, it becomes just a blur.”

Within months, the Zealors learned their new Medicare Advantage plan wasn’t going to cover the $3,000 worth of shots John Zealor, 86, received to combat his myelodysplastic syndrome, a precursor to leukemia.

They were told the doctor who administered the shots wasn’t part of the new plan’s “network.” It took six months and the help of an attorney with the Center for Medicare Advocacy in Mansfield for the couple to finally get back on Medicare and settle their outstanding bills.

“People really don’t know what they are getting into,” said Judy Stein, the advocacy center’s executive director.

Stein and other advocates are worried that there will be more stories like the Zealors’ if Connecticut goes ahead with a plan to allow private insurers to offer Medicare Advantage plans to some of the state’s neediest citizens — elderly and disabled people with low incomes currently relying on federal Medicare and state-funded Medicaid.

In a move that went largely unnoticed, Connecticut legislators approved spending $25 million last month to help subsidize a pilot Medicare Advantage program for those elderly and disabled individuals, many of whom have significant medical problems or are mentally impaired and who have never dealt with privately managed health care before.

Medicare Advantage, also known as Medicare+Choice, is a managed care version of federal Medicare that is part of the latest push nationally to privatize health care. Of the approximately 90,000 Medicare recipients in Connecticut, about 60,000 of them would be eligible for the Medicare Advantage pilot, advocates estimate.

Proponents of the program say allowing private insurance companies to manage care for people with complicated medical issues receiving both Medicare and state Medicaid will save taxpayers money and provide more efficient and broader services.

Unlike traditional Medicare, Medicare Advantage often offers clients lower premiums and expanded health coverage for such preventive measures as hearing tests and dental exams. In return, the patient’s health care is arranged by the primary doctor, who decides what care is reasonable and necessary. Medicare Advantage plans require clients to stay in the plan’s “network” of care, unlike traditional Medicare, which allows patients to see any doctor who accepts Medicare.

Critics of Medicare Advantage say the state is moving too fast. They believe the proposal should have been subjected to a public hearing instead of being tucked into the state budget at the last minute. They claim there is no evidence that Medicare Advantage plans provide better services, even though they cost on average 20 percent more to subsidize than traditional Medicare.

Those critics also fear that insurance companies will deny or limit services to boost profits. They worry that confused elderly and disabled individuals will lose the Medicaid safety net that has always backed them up when services lapse. Folks who sign on to Medicare Advantage lose access to Medicaid.

“The threatened harm to the most vulnerable members of our society is just too great to let this proposal, which had no public hearing, go into effect,” said Sheldon V. Toubman, an attorney with the New Haven Legal Assistance Association who represents clients who will be affected by the change.

Although lawmakers point out that enrolling in Medicare Advantage will be voluntary, advocates say insurance companies have been zealous about tapping into the lucrative new market. And they say congressional hearings have been launched because of growing complaints about marketing abuses and strong-arm sales tactics, similar to what the Zealors experienced.

State Sen. Toni Harp, D-New Haven, the co-chairwoman of the legislature’s budget-writing appropriations committee, said the money is earmarked for a limited pilot program and isn’t necessarily a done deal.

Although the money is there, the state Department of Social Services, which would oversee the pilot, has yet to say whether it will go forward with the proposal.

Matthew Barrett, a DSS spokesman, said the agency is evaluating the concept and expects to make a decision in the coming weeks after meeting with legislators to understand their intent.

“Certainly there is a budgetary provision that directs the department toward implementing Medicare Advantage in Connecticut,” Barrett said. “We’ll be able to say more about it over the next several weeks. DSS and health care advocates are combing through the budget document and getting further clarification from the legislature.”

Harp said the low-income elderly and disabled targeted for the Medicare Advantage pilot have greater health needs, which would benefit from the kind of intense case management the private managed care organizations provide.

“The programs have exactly the kind of system in place [these individuals] need: chronic care and disease management that are not available through regular Medicare,” said Mohet Ghose, a spokesman for America’s Health Insurance Plans, a Washington-based organization representing 1,300 health care companies that
provide coverage to more than 200 million Americans.

But Jerry Flanagan, health care policy director at the Foundation for Taxpayer and Consumer Rights in Washington, says what sounds good is not necessarily so.

In another Connecticut case, an elderly man racked up $13,000 worth of bills during a stay at a nursing home — only to find out later that his Medicare Advantage plan wouldn’t cover the out-of-network cost, Stein said. In a third instance, an elderly patient was encouraged to sign up for Medicare Advantage while receiving dialysis treatment, only to learn his treatments were not covered at that particular facility, Stein said.

“The Faustian bargain is that while you have the impression of a short-term savings for the state, seniors find they are paying a little less for health care and they are getting less in services,” Flanagan said.

Medicare usually allocates about 3 percent of taxpayer dollars for overhead costs, private insurance can take up to 30 percent for administrative costs, Flanagan said.

Offering Medicare Advantage makes good business sense for private insurance companies, Flanagan said, because the companies with contracts are assured taxpayer dollars. Companies selling Medicare Advantage are paid a flat fee for every client under their contract regardless of the clients’ needs. In return for the state and federal subsidies, the companies pledge to provide services more efficiently and at less overall cost through expanded services and reduced premiums.

Because the Medicare Advantage plans tend to pay health care providers less, Flanagan said, the providers in turn are not able to keep as many doctors on staff or provide as many services. Seniors and disabled people then wind up waiting longer to see a doctor, he said.

Harp said Massachusetts manages a successful Medicare Advantage program for low-income elderly that was developed seven years ago.

She would like to see Connecticut follow suit.

She said the $25 million for the pilot was transferred from state Medicaid money that would be spent anyway. The pilot is just a new way of spending the dollars to see if it results in any substantial savings or better care.

“We would still be paying these individuals health care costs whether it is managed or not,” Harp said. “It seems to me that it would be good to at least give DSS a chance to try to do it.”

She added, “For some types of folks this type of system may make sense, for others it will not.”
Contact the author Colin Poitras at [email protected]

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