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Tying Down Loose Ends on Medicare

July 24, 1986|DON G. CAMPBELL | Times Staff Writer

Question: In your recent column on supplemental medical insurance, the example you gave for Medicare did not address the fact that most local practitioners have agreed to accept whatever Medicare considers "reasonable." What amount does the patient have to pay under this condition?--R.L.D.

Answer: Several readers raised the same point, so the primary question here is the validity of the adjective "most." According to retired insurance man Jules Klowden, who has turned his interest in Medicare and supplemental Medicare insurance into a second career as a consultant to the El Cajon-based publication Senior World, the phrase used to describe doctors who agree to accept Medicare's fee schedule is that he or she will "accept assignment."

In other words, if Medicare deems that this or that office procedure justifies a $100 fee then that's what the doctor who accepts assignment will bill you: $100. But of course, that still doesn't knock out the desirability of supplemental insurance, because Medicare will pay 80% of this reasonable fee which, in this example, still leaves the patient with a $20 shortfall. And this is the gap that Medicare supplemental insurance fills by paying that difference.

In the example you mention, I cited a case where Medicare considered $150 to be a reasonable fee for the doctor's services, but his own customary fee was $200. Again, Medicare would pay 80%--not of the $200 billed, but of the $150 allowed by Medicare--and so the shortfall would not be $30 but $80. A difference, again, that only supplemental insurance will pick up.

Who will "accept assignment"--a worthwhile quest, certainly--seems to depend in large measure on geography. "In San Diego County," Klowden says, "about 60% of the doctors, as far as we can determine, accept assignment. I understand that they're not nearly that liberal in Los Angeles County."

And you will find too that some doctors, here and there, simply refuse to accept Medicare patients, period.

Q: What constitutes "legal estate" as far as the lottery is concerned? I am single and I do have a will but no living relatives. Can my friends who are named in the will then receive the remainder of the prize that goes to the estate?

Secondly, if I turn in a winning ticket and win a big prize (such as $11 million), can I then add a person who is not a relative to the ticket? Or do all names have to be on the ticket before it is sent in?--L.H.

A: OK. As far as your "legal estate" is concerned, your will is the determinant as far as the disposition of all future pay-outs are concerned (assuming that you, as the named winner, subsequently turn up your heels).

It's a good argument, certainly, for having a will, because if you die intestate (without one) and there are still several million dollars to be dispensed over the next 18 or 19 years--it will be the state of California that determines who gets what on the basis of a rather inflexible formula.

You say you have "no living relatives," but isn't it possible that, somewhere, you've got an obscure second or third cousin lurking in the background?

If, sure enough, you have no living relatives anywhere , then the state is going to end up with it, which, with so many worthy causes floating around, would be nigh on to criminal.

No, you can't add another name to the ticket after it's been plucked out for the Big Spin--and it's a matter of physical space limitations as much as anything else, Bob Taylor of the state lottery commission adds.

However, the state recognizes that there is a lot of group activity going on in the buying of lottery tickets--two or more individuals going together, pooling their money and buying as partnerships, syndicates or what-have-you.

"And a lot of them," Taylor says, "are extremely well organized with a formal contract spelling out whose name the tickets will be in, who does the spinning if they get that far and how any winnings will be divided."

A written agreement of some sort should certainly be a must for any group pooling its money, according to I. Nelson Rose, a professor of law at the Whittier College School of Law and author of the definitive book "Gambling and the Law."

"It isn't really necessary," he continues, "that it be drawn up formally, by a lawyer--just as long as it spells out the important features and is signed by everyone. It's just so there won't be any misunderstandings."

There have already been some fractured--or at least badly sprained--friendships, Taylor adds, because of these misunderstandings, although none of them, so far, involving any Grand Prizes.

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