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Alarming Restrictions of a Geisinger Medicare Advantage Plan

If you are enrolled in Geisinger’s Gold Medicare Advantage plan, you will not be able to obtain insurance payments for rehabilitative care during 2015 from any skilled nursing facility that is located in Carlisle or Shippensburg.   We have not fully researched the Medicare Advantage plan restrictions of all insurance companies.   You now have options, but you should explore them carefully with your insurance advisor.

Medicare open enrollment began on October 15th and ended on December 7th.  It is not possible to switch from one Medicare Advantage plan to another until the next open enrollment period begins in October.   However it is possible until February 14, 2015 to disenroll from a Medicare Advantage plan and enroll in traditional Medicare.  Doing so has potential risks and complications. For example, if you disenroll now, you might incur costs and limit your options in the next open enrollment period.

Traditional Medicare coverage is comprised of three parts: hospital (Part A), medical (Part B), and prescription (Part D).  Part A is provided to people age 65 or older that are eligible for Social Security or Railroad Retirement benefits. Part B has a monthly premium of $104.90, often deducted from your Social Security or Railroad Retirement monthly benefit.  Part D premiums may be paid directly to an insurance company or deducted as with Part B.  Because of deductibles and co-pays with traditional Medicare, it can be wise to purchase supplemental insurance, which can be available outside of an open enrollment period; but it is subject to medical underwriting provisions.

A Medicare Advantage plan is an option by which an insurance company, such as Geisinger Health Plan, contracts with Medicare to combine the traditional Medicare coverage with supplemental coverage, and then issues their own single policy.  There are a variety of Medicare Advantage plans.  With some, a member may incur a financial penalty or a denial of reimbursement for services provided by an out-of-network provider.  Such is now the case with those who are members of the Geisinger’s Gold Advantage plan, due to their inability to use the services of any skilled nursing facility in Shippensburg or Carlisle during 2015.

All local seniors who have traditional Medicare coverage have the option to be discharged from a hospital for rehabilitative care at any Cumberland County nursing facility, if rehabilitative care in a nursing facility is needed following the hospitalization. In this type of case, Medicare will pay the cost of rehabilitative services for up to 100 days, subject to a 20% co-pay.   Geisinger’s members do not have this option, and their options are very limited.

In Cumberland County, a member of Geisinger’s plan may receive rehabilitative care following a hospital discharge in either of the Golden Living Centers located in Camp Hill, or from VibraLife in Mechanicsburg.   There are no other options. These facilities are licensed to provide skilled nursing and provide long-term care for those whose condition cannot be rehabilitated to enable discharge; however VibraLife has only ten long-term skilled nursing beds and does not qualify to accept Medical Assistance to pay the $300 per day average cost of nursing home care after Medicare stops.   After Medicare funding has been exhausted, it is difficult to place a patient in a long-term care facility if the source of payment will be Medicaid funding.

According to spokesperson Amy Bowen of the Geisinger Health Plan, Geisinger routinely studies patient outcomes from provider services.  Geisinger concluded that the more than 1,000 skilled nursing beds Geisinger previously insured in Cumberland County was excessive given expected rehabilitation demand, which according to Ms. Bowen, was limited to only three of Geisinger Health Plan’s approximately 1,000 Cumberland County residents utilizing skilled nursing services in 2013. That usage statistic of 0.3% is far below comparable data published by the Family Caregiving Alliance and other credible sources of expected demand.

Ms. Bowen said the needs of Geisinger’s Cumberland County members can be met by the 450 beds located at the two Golden Living facilities and VibraLife.  According to the Department of Health, there are 2,008 licensed skilled nursing beds in Cumberland County; so Geisinger cooperates with less than 25% of them, with little apparent consideration to geographic proximity.  Data were not available from Ms. Bowen about Geisinger’s 2014 usage or present membership in Geisinger’s Gold Advantage plan.   Geisinger will pay for hospital care at Holy Spirit or Carlisle Regional, but not for care provided by the Harrisburg Hospital or the PinnacleHealth West Shore Hospital.

The clients who recently made us aware of these limiting circumstances were switched to the Geisinger Advantage Plan in relation to a retirement package offered in one case by IBM, and in another case by the Commonwealth of Pennsylvania Employees Benefits Trust Fund.  The clients said the information provided to them at the time of enrollment was confusing, and they were not sure if additional choices had been offered to them.  No client recalled seeing a warning or disclaimer from Geisinger or the previous employer that rehabilitative nursing services would be restricted geographically.

If you are enrolled in a Medicare Advantage plan as part of a retirement benefit, you should contact that employer and get detailed information about your options.  In most cases, if you opt out of an Advantage plan you should be able to get all levels of traditional Medicare.  Whether your retirement plan will pay for that if you opt out of the Advantage plan they now provide you is something you must explore on a case-by-case basis with the administrator of your retirement benefits. Be careful to understand if a decision to opt out of an Advantage plan now could affect your present costs and future choices.

If you purchased an Advantage plan outside of a group, explore your options with the agent who sold it to you.  Laurie Schoeller of the Benefit Connections Independent Insurance Agency in Carlisle has expertise in this area, but will not advise an individual member of a group plan managed by a retirement program.

By Attorney Dave Nesbit