Don’t Ignore The Fine Print In Medicare

The Merriam-Webster Online Dictionary defines fine print as “something thoroughly and often deliberately obscure; especially a part of an agreement or document spelling out restrictions and limitations often in small type or obscure language.”

You know all about this. You’re trying to purchase something online and then, at the last minute, you have to check a box saying that you’ve read and agree to the terms and conditions. If you don’t check the box, you can’t pass go. So you check it and move on.

But chances are, you didn’t read the terms. You’re not alone. A recent study reported that just 0.07% of users (fewer than one in a thousand) click on the link before checking the box. You probably won’t experience any repercussions if you don’t read the terms and conditions when shopping. However, in the world of Medicare, you can get caught. Medicare’s fine print may not be small, but the important information sometimes seems to be hidden away where it’s likely to go unnoticed.

Here are some recent examples that others have shared with me.

In the first two, the “fine print” spelled out something that had to be done. If the individuals did not act, the plan took charge.

A retired teacher in a Midwestern state had the option of a retiree PPO (preferred provider organization) plan or one that resembled a Medicare supplement. Digging through the documents, she read that if she did not choose one by the specified date, she would be enrolled automatically in the PPO plan.

Turning 65 and trying to decide what to do about Medicare, a man in Florida was comparing his retiree plan to Medicare. He discovered the following in the plan’s summary of benefits.

“You may get two 30-day supply fills of the same maintenance medication at a retail pharmacy. Prior to your 3rd fill, you must call us and tell us if you would like to keep getting your maintenance medications from a retail pharmacy or if you would like to use home delivery. If you do not contact us, you will pay the full retail cost of any maintenance medication until you inform us of your decision.”

Wonder how many are shocked when they get the bills for the third month of medications?

These next examples show why it’s extremely important to check plan documents for information about coverage rules.

A recent retiree was considering a Medicare Advantage plan, sponsored by his former company. He searched the summary of benefits for the words “Authorization required” but didn’t find them so he thought the plan would work. However, buried in the introductory section of the document, he read that an asterisk identified prior authorization requirements. Searching for asterisks revealed that the plan required approval for several services. He would have seen the asterisks, but would he have known that they designated prior authorization?

Finally, a woman in Pennsylvania had knee replacement surgery and then discovered that the Medicare Advantage plan had not authorized the procedure. She was getting bills for $60,000. She wasn’t the one who could submit the authorization so how could the plan hold her responsible?

Unfortunately, the insurance company can bill her in this situation. She would have known that had she read the plan’s Evidence of Coverage (EOC). The Centers for Medicare and Medicaid Services (CMS) established an EOC template for Medicare Advantage plans, so all plans contain the same important information. The relevant language in Chapter 3, Section 4.2 reads something like this. “You are responsible for paying the full cost of services that aren’t covered by our plan, either because they are not plan-covered services, or plan rules were not followed.”

The last five words in that sentence made this woman responsible for her surgery. Even though her healthcare providers are the ones to submit the prior authorization requests, she is ultimately responsible for ensuring compliance with the coverage rules.

To avoid unpleasant and possibly costly surprises, read the fine print in plan documents. Otherwise, things might not turn out so fine.