PacifiCare Health Systems Inc.'s Medicare + Choice members will not pay more for their health insurance benefits in 2004 despite rising costs.
In fact, they will receive more benefits and the new Medicare law could additionally strengthen their benefits package in March.
Those were the messages PacifiCare customers heard Monday during two meetings in the Las Vegas Valley that the insurer organized to discuss next year's benefits for Secure Horizons members and implications of the new Medicare law.
About 600 people attended the meetings to ask questions about their personal situations and learn what lies ahead for their benefits. There are about 25,000 members in Clark County on Secure Horizons, the Medicare + Choice plan.
Traditional Medicare is a federal government health plan for people age 65 or older, some disabled people under age 65 and people with end-stage renal disease. Medicare helps defray the costs of medical expenses such as doctors' visits, hospital stays and medical equipment. It does not provide any coverage for prescription drugs, but the new Medicare law will include prescription drug coverage beginning in 2006.
Medicare recipients will pay $66.60 per month for their medical insurance premium in 2004. They can use any physician, specialist or hospital that accepts Medicare. In 2004, they also will have a $100 deductible for non-hospital medical expenses and an $876 deductible for hospital stays. After 61 days of being admitted into a hospital within the benefit year, additional fees are charged per day. Once the deductibles are met, recipients pay 20 percent of the Medicare-approved expenses for physicians' visits, outpatient services, medical equipment, emergency room visits and ambulance services.
Medicare + Choice is a privatized Medicare plan offered by insurance companies. PacifiCare and Sierra Health Services Inc. are the only Medicare + Choice providers in Nevada. Insurance companies that offer private Medicare receive money from the Centers for Medicare and Medicaid Services, the federal agency that oversees traditional Medicare. Medicare + Choice plans cover everything traditional Medicare covers and then some.
Medicare + Choice members will pay $66.60 per month for their medical insurance premium in 2004, which is the same as the traditional Medicare monthly premium. In some PacifiCare markets -- but not Clark County -- members pay an additional $85 per month in PacifiCare premiums.
Secure Horizons members in Clark County have a $200 fee for each hospital stay, but the number of days they can be admitted is unlimited. Secure Horizons members in Clark County also pay $10 for each primary care physician's visit, $20 for each specialist visit, $50 for ambulance services and $100 for outpatient services. Medical equipment costs vary by type.
The biggest drawback under Medicare + Choice plans is that recipients are limited in what physicians they can visit and a referral for specialists is generally needed.
Medicare + Choice plans do cost less for doctors' visits and hospitals stays. They also cover many prescription drugs and some vision services. Anyone who is eligible for Medicare medical coverage and resides in an area with Medicare + Choice plans available is eligible for them. Those with end-stage renal disease are ineligible and must use traditional Medicare.
The main hindrance to Medicare + Choice plans is the limited network of doctors, said Marilyn Wills, director of the State of Nevada Health Insurance Assistance Program. She works with people to determine what Medicare plan would best meet their needs.
"Most people either love or hate HMOs," Wills said. "They usually love them because they offer benefits they wouldn't have. The ones who hate them do because they're locked into that pool of doctors and may not include doctors they've had for years."
Dawn Maroney. vice president of Secure Horizons, said PacifiCare expects an increase in its Medicare reimbursement rate from the federal government in the next few weeks. Then, the company will look at providing additional benefits and expanding its physicians' network in Clark County.
In 2004, Clark County Secure Horizons members will also be eligible for a discount of up to 30 percent on brand-name and generic drugs used for maintenance through PacifiCare's mail-order pharmacy. Currently, Secure Horizons members pay the full price for drugs not on the approved-drug list and when they exhaust their maximum limit of $1,000 annually for brand-name drugs.
Another benefit that begins in January is free transportation for non-emergency trips to doctors' offices, pharmacies or PacifiCare's contracted medical facilities. Members are allowed six round-trip or 12 one-way rides during a year.
Secure Horizons will also offer a free attorney consultation to create a simple will and a living will.
Las Vegas resident Edward Bowes said he was happy with the coverage he and his wife have received through Secure Horizons for more than 10 years. He said he was hoping to get more information on how the Medicare law will affect his coverage in the coming years, but not everything has been fleshed out yet.
Robert May, of Las Vegas, said Secure Horizons has saved him thousands of dollars on his medical and prescription expenses in the last eight years. He has needed coverage for treating cardiac conditions and diabetes.
"Together all those things added up to a lot of money that we could have never have afforded," May said.
May said he is concerned that some of his nine brand-name prescriptions are not covered by Secure Horizons. But, he will be eligible for a discount on prescriptions in 2004 through the Secure Horizons mail-order pharmacy. He can receive assistance with prescriptions through the Veterans Administration, too.
May was able to discuss Medicare concerns with President George W. Bush on Nov. 25 at Spring Valley Hospital. He was one of seven participants at the meeting and the only one on a Medicare + Choice plan.
"I definitely had the best (health plan) choice," May said, referring to the seniors who met with Bush. "I would think that every senior in this valley would want to be on a Medicare + Choice plan. A lot of them don't understand it or don't look into it. Maybe that's because they think it's an HMO and HMOs got a bad name at one time."
Patricia Painter, of Las Vegas, said she found the PacifiCare meeting "enlightening."
"Any time they do have a question-and-answer (session) like that it does help," she said. "There is always some little thing that you learn."
She said she is happy with Secure Horizons, but is looking forward to additional benefits next year.
Painter said the prescriptions she and her husband take are covered on the Secure Horizons plan, but they would like to see lower co-payments.
Although the Medicare law is still being interpreted, Medicare + Choice plans are not likely to be hurt with the additions to traditional Medicare.
Even though many people join Medicare + Choice plans because they cover prescription drugs, the plans will continue to add benefits and the Medicare law might increase competition, which would be good for the market, Maroney said.
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