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A fraud alert has just been sent out by the Yolo County District Attorney Elder Protection Unit. The open enrollment period for Medicare recipients to re-evaluate and change their health care coverage is upon us again, from November 15th to December 31 of 2007. As most people know, Medicare is government run health insurance coverage for senior citizens. Medicare Part D is the federal government’s new prescription drug plan for the elderly.
Unfortunately the Medicare Part D plan is extremely complex and difficult to assess when it comes to finding the best fit for a particular consumer’s specific situation or medical condition. Scam artists and questionable insurance agents begin crawling out of the woodwork during open enrollment season like cockroaches. These predators prey on the most vulnerable among us, the frail elderly, without mercy or compunction.
An older gentleman with severe Parkinson’s Disease was cold-called by an insurance agent one morning. The gist of the conversation between the two was a misleading “Have we got a deal for you!” on the one hand, and a naïve “Sign me up!” on the other. An agent was immediately dispatched to the consumer’s home, an apartment nestled within a seniors-only apartment complex. The insurance agent who spoke to the consumer had a heavy Russian accent. The Hispanic consumer spoke broken English - hardly a good combination for fair play.
The Russian speaking salesman insisted if the consumer signed up for a private pay health insurance policy immediately, and disenrolled himself from Medicare, he would have no premiums or co-pays (share of costs). Since the consumer was a dual eligible on both Medicare, and Medicaid (health insurance for the poor), the desperate man signed on the dotted line. No insurance premiums and no co-pays sounded disarmingly appealing.
Documents were delivered on the spot, all of this transaction taking place in a single day. The consumer did not bother to read the contract before signing. He hadn’t understood all the details, his shaking hands not allowing him to hold the papers long enough to read the fine print. The one thing the consumer had latched onto were the $0 placed in the blanks describing how much the consumer would have to shell out. Sounded like a great deal.
However, after perusing the contract twenty-four hours later, in the morning when his body was not as enveloped with shaking from Parkinson’s, something clicked. Somewhere in all that minute verbiage, the consumer discovered statements that were at odds with the $0 penned in by the insurance agent. It was at that point that the consumer called me, a pro bono attorney (volunteer lawyer who charges no fee) who assists with cases involving financial elder abuse.
It was subsequent to that the nightmare truly began. Over a period of months I was on the telephone, emailed and wrote letters to Medicare, MediCal (CA Medicaid program), the consumer’s original health insurance company, his new insurance company, the insurance agent that sold him the product, the consumer’s pharmacy, Health Care Hotline housed in Sacramento, California Health Advocates and the California Department of Insurance. To make a long story short, the consumer was disenrolled from Medicare for one month, but re-enrolled in Medicare retroactively at different dates depending on which computer was involved.
When medical bills came due at varying intervals, one agency or company would deny coverage depending on what their particular computer showed. Repeatedly I would be referred to someone else to address the issue. Even within Medicare itself, I would have personnel input a correction, only to have it not reach another department, which ultimately disallowed the consumer from insurance coverage. Medicare is horribly labyrinthine and unnecessarily complicated, with layer upon layer of bureaucracy. A patient can get completely lost in the system.
My client went without medication for a day or two, until I insisted he borrow the money if necessary to ensure continuation of his drugs. At one point I telephoned the insurance agent myself, and in no uncertain terms lambasted him. I made it clear he was responsible for my client’s drug coverage. I warned this manager if anything happened to the consumer because of a failure to provide medicine, a wrongful death suit would be forthcoming. It was no surprise the insurance company eventually paid for the consumer’s pharmaceuticals through reimbursement, but the lab fees and costs of doctor’s visits have yet to be taken care of.
Ironically, this same insurance agent insisted the consumer not only sign a statement he wanted to withdraw from the private pay insurance plan. My client was expected to draft the letter himself, then have it signed by two witnesses as well. When I pointed out that such niceties had not been required for my client to initially sign onto the policy, the head of the insurance agency claimed it was a Medicare requirement. I checked this alleged claim out with the proper authorities, only to find out Medicare required no such thing.
Another unsettling matter came up. If the consumer purchased drugs under the new private pay plan, the pharmacy would charge the insurance company for insulin at twice the price the drug sold on the open market. It sounded to me as if there was illegal gouging going on, but by whom I was not sure. Suffice it to say, the lowly consumer would be the one to ultimately pay in the end for such questionable goings on.
In closing, I would like to reflect on a few final thoughts. Any consumer considering a change in their Medicare coverage, or any health insurance coverage for that matter, should tread carefully. Be clear about your current terms, and those of any you are contemplating a transfer to. When in doubt and it involves Medicare coverage, seek assistance at any one of Yolo County’s focal point senior centers or check out appropriate government websites (see below). If it sounds too good to be true, it probably is.
In my client’s case, the insurance agent lied about $0 premiums and co-pays. Not only were there insurance premiums to pay, medications were much more expensive on the new plan. The insurance company where the coverage emanated from admitted getting vast numbers of complaints about insurance agents selling their product. However, personnel there did not give any indication they were making attempts to correct the problem. The insurance agency that sold the policy is now under investigation by the California Department of Insurance.
Lesson to be learned: Think long and hard before changing a Medicare policy, because it may be very difficult to retroactively re-enroll if you become dissatisfied. Should any consumer be sold something door-to-door in the home, generally he or she has three days to rescind (cancel) the contract. However, any rescission (cancellation) must be in writing - generally a phone call is not legally sufficient.
For further information, contact a Health Insurance Counseling and Advocacy Program of Northern CA (HICAP) representative at:
- Davis Senior Center (530) 757-5696
- West Sacramento (530) 376-8915
- Woodland Senior Center (530) 661-5890
Check out the following websites:
- www.medicare.gov
- www.opa.ca.gov or telephone 1-866-466-8900
Comment to the comments: There was an interesting discussion in the readers’ section after my last monthly article on transportation for the elderly. I want to thank everyone who contributed for their kind words in appreciation of my having spoken out when our Davis Senior Citizens Commission was under fire. The commission was slated for elimination as we knew it around the first of the year 2007 by the Subcommittee on Commissions (Asmundson and Souza). I think the disingenuous words used at the time were “merger”; “subcommittee of three members”; “evolving process”, among others.
It is my opinion our Davis Senior Citizens Commission survived because the elderly, a pretty sizeable and feisty group, spoke out and refused to be marginalized. It seems as if the politicians and campaign supporters have recognized this fact. The latest ploy by developers is to suggest the need for more senior housing - as a way of establishing a toehold to begin projects previously resisted. As a commissioner, I have been bombarded with requests to join focus groups or contacted via letter by other developers about their latest proposal for senior housing.
My concern here is that government process is being usurped. End runs are being made around the General Planning Commission, City Staff, or the City Council - in the name of “a desperate need for more senior housing”. While I am not necessarily opposed to the idea of more lodging for the elderly, it needs to be carefully planned and appropriate for our area. Several of my readers suggested the same thing (including our Mayor of Davis).
Eleanor Roosevelt Circle (ERC) is a perfect example of questionable planning for senior accommodations. While ERC should eventually be an excellent facility in time, the concept of mixed income housing within the same complex was a flawed conception from the start. And it was not what was originally intended. As I understand it, the initial proposal was for affordable middle income housing for older adults. The analysis, forecasting how many seniors would flock to the eventual mixed income facility, was seriously flawed.
The result was a high vacancy rate, which had to be addressed by the city, which decided to make ERC open to outsiders with low incomes. Otherwise the city would have spent a good deal of its housing funds for naught. This brought in indigents from all over - placing further burdens on our cash-strapped city. The egregiousness of this situation is particularly poignant because Eleanor Roosevelt represents an innovative model for disabled seniors in particular. This is because it has an on-site social worker, who is especially useful for seniors with mental/physical handicaps that require some supervision below the level of an assisted living facility.
Elaine Roberts Musser is an attorney who concentrates her efforts on elder law and aging issues, especially in regard to consumer affairs. If you have a comment or particular question or topic you would like to see addressed in this column, express your concern at the end of this column in the comment section.
