Keep your doctor separate from your Managed Care Organization in the “My Care Ohio” program

In my prior four posts on My Care Ohio, I’ve described the new (in Ohio) program for people on both Medicare and Medicaid (people called “dual eligibles.”)  On February 21, 2014, I tried to provide an overview on how the My Care Ohio program will work  (Managed care for Ohio Medicare/Medicaid “Dual Eligibles”.)  On February 28, 2014, I explained how My Care Ohio is an attempt to cut costs through insurance company command and control methods rather than empowering people to choose lower cost care by making it easier to qualify for in-home care Medicaid through PASSPORT or for the Assisted Living Waiver instead of maintaining the current financial incentive to choose a nursing home, with its higher cost per person (My Care Ohio: A Triumph of the Stick over the Carrot.)  On March 7, 2014, I described the decisions that dual eligibles must make when My Care Ohio comes to their county:  (1) whether to accept managed care for Medicare for this first year; (2) which Managed Care Organization to join; and (3) whether to accept managed care for Medicare for years two and three.  (Your Options in “My Care Ohio,” managed care for Medicare/Medicaid “Dual Eligibles”)  On March 13, 2014, I outlined what to choices to make when enrolling in My Care Ohio.  (What to choose in “My Care Ohio,” managed care for Medicare/Medicaid “Dual Eligibles”)  Now that My Care Ohio has actually started in all of the counties to be included (in the three-year pilot program, anyway,) I want to revisit these issues, revise one of my suggestions, and highlight what I consider to be the most important suggestion.  (I plan to resume the series on how to buy long term care insurance wisely next week.)

My biggest fear for people in the My Care Ohio program is that their managed care organization (i.e., the insurance company to which they are assigned) will reduce services (in order to cut costs) that the managed care organization/insurance company deems unnecessary.  (For the sake of brevity, let’s call the managed care organization/insurance company the “MCO.”)  For example, if the person is in a nursing home and is doing well, the MCO might decide that the person can go home and receive home care (with a resulting big reduction in costs.)  If the person did well in a nursing home because of the 24 hour supervision, sending them home would be a mistake.  However, I fear the cost-cutting motive of the MCO’s management and fear that some people will be sent home that should not move home.

The best protection against unwise cuts in services is the person’s doctor.  If, though, the person’s doctor gets his or her payment from the MCO, the doctor may be hesitant to question or oppose the MCO’s decision to reduce services.  To avoid MCO influence over the doctor, I urge all people in the My Care Ohio program to:

  • Opt out of the Medicare portion of My Care Ohio; and
  • Choose an MCO different than the insurance company through which they have their Medicare supplement or advantage plan.

For example, a person who has United Health Care for a Medicare supplement should make sure NOT to include Medicare in their My Care Ohio program and also make sure NOT to choose United Health Care for their My Care Ohio MCO.  That way, the doctor is paid by someone other than the MCO and would be immune to perceived pressure from the MCO to acquiesce to questionable care decisions.

It’s not too late to change MCOs.  Every My Care Ohio participant has 90 after coverage starts to change MCOs and possibly to opt out of Medicare coverage.  My Care Ohio started on May 1 for the first group (Cuyahoga, Geauga, Lake, Lorain, and Medina counties,) so people in those counties have until July 29 (assuming I counted 90 days correctly) to switch.  (The other groups started in June and July, so their 90 day period to make changes still has lots of time.)

I also withdraw my earlier suggestion not to renew your Medicare supplement or advantage plan for next year.  After watching the first weeks of My Care Ohio, I feel that the separation of the doctor from My Care Ohio in the way suggested above is sufficient.  Withdrawing completely from supplements and advantage plans would accomplish no more toward this goal and would add more expenses to people’s annual health costs.

For more information, visit Jim’s website.

Jim Koewler’s mission is
“Protecting Seniors and People with Special Needs.”

For help with long term care or with planning for someone with special needs,
call Jim, or contact him through his website.

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