Sample Letter for Physicians – Medicare Open Enrollment

Via Marilyn Tavenner,  Acting Administrator, Center for Medicare Services 

It’s picking season – pumpkins, apples, Halloween candy…and a Medicare health or drug plan. Today is the start of Medicare Open Enrollment!

In my work with Medicare, one of the questions people ask me often is which plan is the best one. That’s not something I can answer, because picking a plan is an important and personal decision. Each person has a unique set of priorities. How do you weigh your options? Now’s the time to think about what matters to you, and pick the Medicare plan that meets your needs.

When you sit down to review your Medicare health and drug plan choices this year, keep track of the things you may want in a plan, and pick one that’s right for you. Here are some things to keep in mind while you consider your choices:


You should look at your current health care costs to find coverage that works with your financial situation. How much are your premiums and deductibles? How much do you pay for hospital stays and doctor visits? Just like with everything else, the lowest-premium health plan option might not be the best choice for you.


Are the services you need covered? We know future health care needs can be hard to predict, but changes happen. Maybe your doctor changed your prescriptions this year or you have different health concerns. Make sure you understand what services and benefits you’re likely to use in the coming year and find coverage that meets your needs.


Your time is valuable. When comparing plans, make sure you check which doctors and hospitals you’ll be able to use. Where are they located and what are their hours? Check which pharmacies you can use. Can you get prescriptions by mail? Remember that even if you’re happy with your current plan, these answers might change from year to year.

Quality of care

Ask yourself whether you’re truly satisfied with your medical care. Not all health care is created equal, and the doctors, hospitals and facilities you choose can impact your health. Look for plans with a 5‑star performance rating — the right expertise and care may help speed your recovery and improve your outcomes.

It’s worth your time to take a look and compare coverage between now and when Open Enrollment ends on December 7. Use the Medicare Plan Finder to look at all of the health and drug plan options in your area. If you still need help comparing, call 1‑800‑MEDICARE (1‑800‑633‑4227).

Only you know what’s most important to you and your family – that’s why I want to make sure you have all the information you need to make the best decision. Before you consider your Medicare plan options, think about your personal priorities so you can be sure your plan meets your unique needs.

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Medicare Open Enrollment – What Physicians Need to Know

With special thanks to Dr. Brent Schillinger

The open enrollment period for Medicare Advantage plans runs from October 15 through December 7, 2012.  That is precisely the reason why every form of communication—– be it internet, television, radio or your mailbox is loaded with recruitment messages from the big and not so big companies.  Medicare Advantage Plans is the contemporary name given to the old Medicare HMO insurance programs.  The difference is that today the marketing is particularly intense and slick because under current federal legislation, passed several presidential administrations back, the profits for the commercial insurers is huge.  When the first Medicare HMOs appeared on the scene, they were providing care to seniors at an average cost savings (to the federal Medicare budget) of 5% less than traditional Medicare.  Today, they provide care at upwards of 115% of the average cost per patient per year for traditional Medicare.

The plans market themselves to seniors offering more services for less money than a person would have to pay under traditional Medicare.  In most cases there are savings in terms of reduced monthly out of pocket costs.  And there may be extra services I such as a gym membership or a low-priced pair of eyeglasses.  But there are many tradeoffs for patients tradeoffs that are not referenced in the marketing material.  Patients are limited to doctors who are specifically contracted with the plan, specialist referrals are generally rationed, and it may be difficult, should a person desire care in a specific hospital if that facility is not contracted.

Seniors have options. They can choose from many different Medicare Advantage Plans and probably save some money, but they  need to understand that they are giving up many of the choices they have with the other option, keeping traditional Medicare and adding supplemental medical and pharmaceutical insurance. Identified problems include:

  1. Care can cost more than  it would under original Medicare
  2. Private plans may not be stable and may suddenly cease coverage
  3. Members may experience difficulty in getting emergency care
  4. Continuity of care may be broken if the plan drops a provider
  5. Members have to follow plan rules to get covered,
  6. Members are restricted in their choices of doctors, hospitals, and other providers
  7. It can be difficult to get care away from home
  8. The extra benefits offered often turn out to be less than promised.

Physicians will be approached by patients about the confusion in the choice of the Medicare Advantage plans vs. traditional Medicare.  As your patients’ advocate you should become knowledgeable about the different plans so you can give reasonable guidance to your patients.   This would also be a good time to review your contracts and reimbursement schedules as well the ability to obtain authorizations for prescription drugs and specialist referrals.

From an economic point of view, most physicians, in our area who participate in these Medicare Advantage plans receive reimbursements that are substantially lower than traditional Medicare.   Take the United Health Care product for example.  While United is paid by the government upwards of 115% of the average traditional Medicare cost, many specialists receive less than 70% of the normal Medicare allowable.   Some of the Blue Cross plans work with a number of tightly restricted capitated networks so patients may not be able to see the doctor of their choice, individual physicians may not be able to join these restricted networks,  and the same time the reimbursements through the capitated networks are pathetically low, often less than half of the traditional Medicare allowable.

Doctors need to take all of these factors into consideration in order to give their patients good advice.  For additional information and patient resources you can visit or email Dr. Schillinger at