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Traditional Medicare Vs Medicare Advantage Plans: Which is better?

There are a lot of ways to potentially fall through the gaps when many people are involved in executing a plan.

When I first started doing Home Health, one of those conversations I had every visit went something like this:

“ Wait, Medicare will pay for a 1500$ wheelchair, rent me hospital bed, send me a potty chair but not cover the cost of a 45$ shower chair to stop me from falling?!”

Medicare seemed out of touch so I was so excited to discover Medicare Advantage plans had a pharmacy stipend that could cover the cost of shower chairs.

I think I might have changed my mind on this.

These plans are great if you want to pay less for meds but not so good if you need home care services.

The process can be convoluted and frustrating.

My client wanted badly to come home after being in a skilled nursing facility for many weeks after a fall.

Here’s what it took to finally get her home:

  1. The skilled nursing facilities’ social worker gets facility doctors to sign an order for Home Health.
  2. The discharge notes and order get sent to the community social worker.
  3. That social worker sends it to the managed healthcare plan.
  4. The managed healthcare plan looks at all the notes and decides what how many visits they will authorize.
  5. Once approved, they send the referral to an approved Home Health partner.

We wanted to make sure this process went smoothly so we had also made a virtual appointment with the primary care doctor who

confirmed that she had already sent the order for Home health.

However, 24-48 hours came and went from discharge and no calls from Home health were received.

After several hours on the phone with the insurance plan to figure out what went wrong, it turned out that the ball had been dropped.  

The doctors order had been bundled with the equipment order so was in the DME department. That needed to be sent to the home health department.  

The home health department said they never got anything from the community social worker and there was also no active plan to send Home Health out to her house because their system said Home Health was already out.

The original home health company had never called to tell them she was not at home so had we not followed up, she would have gone weeks without care.

Once we figure it out what it happened, the social worker resent the documents but this time she did it directly to the person we were talking to.

The plan was to send this ASAP to the home health agency but then the home health agency did not receive anything so couldn’t provide care because it needed prior authorization per insurance.

Finally, after many hours of phone calls the glitches have seemingly been ironed out. My client has a nurse coming out today!

Traditional Medicare may not pay for shower chairs but they don’t require pre-authorization before treatments.

When you go to select a new plan in November, it’s important to consider whether your priorities will be getting that pharmacy stipend or getting hassle free services!

I’m grateful that I was able to meet the patient at her house right after discharge so I could give her some quick lessons on how she was going to dress her self without risk of falls, transfer into the shower and help her get more comfortable with her space!