At the time of year when those 65 and older ponder changes to their Medicare coverage, Mary Washington Healthcare is making its first foray into the insurance business.

The company unveiled a Medicare Advantage plan in time for open enrollment, which runs annually Oct. 15 to Dec. 7. The local health care organization has been laying the groundwork for the plan for seven years, said Travis Turner, chief operating officer.

The plan is offered through Mary Washington Health Alliance, a provider network owned by MWHC and consisting of more than 600 local doctors. The alliance, formed in 2013, has worked to meet what Turner calls Medicare’s “triple aim—providing the right care at the right cost at the right time.”

A partnership with a Medicare Shared Savings Program demonstrated the health care organization was on target, Eric Fletcher, the chief strategy officer for MWHC, told a business gathering last month.

MWHC saved Medicare $20 million during three years in the program and got back a portion of the savings to invest in its own infrastructure, Fletcher said.

Eliminating redundancy accounted for part of the savings, said Dr. Thomas Janus, a family physician for more than 20 years and the medical director of the Medicare Advantage program. Instead of three doctors ordering the same expensive tests, physicians were encouraged to get out of their “silos” and communicate with each other to know what already had been done.

Patients also were asked to see a family doctor about chronic conditions instead of letting problems worsen to the point they visited the emergency room, where care is 10 times more expensive, Janus said.

Mary Washington’s Medicare Advantage plan will take on similar strategies, as those enrolled must pick a primary care doctor. That physician will be “captain of the ship” and authorize each level of care, Janus said. It also includes no premiums or annual deductibles, but has two versions that offer different co-pays and yearly out-of-pocket limits.

As the alliance asked its doctors what kind of benefits should be included in the Medicare Advantage plan, Turner said physicians suggested offering free rides to medical appointments. The 2020 plan includes 20 free trips per year.

A patient with a chronic condition such as congestive heart failure should be checked regularly, Janus said. Paying a service such as Uber to get the person to the appointment is cheaper than what could happen if the patient gets sicker and needs hospitalization, he added.

From his years in practice, Janus said private insurers never asked him or other doctors what benefits should be included in an insurance package.

“That’s the beauty of this being homegrown,” he said.

TAKING ADVANTAGE

About 44 million Americans are enrolled in the federal government’s health care plan for older residents, but that doesn’t mean Medicare is easily understood, even among medical officials.

“It’s as foggy as a London street,” Janus said.

Traditional Medicare typically covers 80 percent of a person’s hospital bills under Part A. The cost of physicians, tests and screenings are covered by Part B, and its monthly premiums are expected to rise from $135.50 to $143 next year, Janus said.

Then, there’s Part D for prescriptions, which averages about $50 a month in Virginia. People often pay for a supplemental insurance to cover what Medicare doesn’t, and Janus said those plans average about $180 in Virginia.

The separate costs can add up to more than $365 a month for health care that’s supposed to be free, Janus said.

Medicare Advantage plans have become appealing because they offer all the aspects of Medicare rolled into one. They often have lower premiums and more coverage, including vision, dental and hearing aid benefits, according to the financial website, The Motley Fool.

There will be more Medicare Advantage plans in 2020—about 1,200 more than in 2018—and they’ll cost 23 percent less than two years ago, according to the Centers for Medicare and Medicaid Services.

“The average monthly premium will be the lowest in the last 13 years for the more than 24 million people with Medicare who are projected to enroll in a Medicare Advantage plan for 2020,” states a press release from CMMS.

Locally, Medicare recipients “are always curious about a Medicare Advantage plan, since it includes all your health care, usually at a lower premium,” said Patricia Holland, executive director of Health Generations Area Agency on Aging.

But there are downsides, she said, including which providers accept the plan, the cost of co-pays, and a difference in how treatment is covered. For instance, some Medicare Advantage plans don’t cover skilled rehabilitation for 20 days like original Medicare does, Holland said. That could be a burden for patients who need to enter a rehab facility after joint replacement surgery, she said.

“If the plan provides local, all-encompassing care, it should be welcome in the community,” Holland added.

CAPS AND CO-PAYS

The alliance has scheduled two community meetings every day in October, except Sundays, where there’s only one, to explain its Medicare Advantage plan. It will continue to hold sessions until the Dec. 7 deadline.

Speakers will tout the two versions, which both place a cap on out-of-pocket expenses a patient has to pay annually. That’s unlike traditional Medicare plans that have no ceiling.

“You could end up draining your retirement savings if your health care costs escalate within a given year,” states The Motley Fool website.

While there’s no monthly premiums with the Mary Washington plan, anyone enrolled in a Medicare Advantage plan must still pay for Part B coverage.

Mary Washington Medicare Advantage Rewards plan offers participants a $50 credit each month toward the Part B payment. However, it also has a higher maximum out-of-pocket limit ($5,600 per year) than the Mary Washington Medicare Advantage Complete ($3,400 per year).

Mary Washington Medicare Advantage is available only to residents in Fredericksburg and the counties of Caroline, King George, Orange, Spotsylvania and Stafford. That’s an estimated 75,000 people, and MWHC hopes to enroll about 1,000 the first year, Turner said.

More information on community meetings is available online at mwmaplan.com or by calling 855/919-0826. Those interested also can request an information kit over the phone or online.

Healthy Generations also plans informational meetings on Medicare enrollment. A schedule is available at healthygenerations.org or by calling 540/371-3375.

Cathy Dyson: 540/374-5425

cdyson@freelancestar.com

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