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Medicare+Choice Benefits Are Permitted To Vary By Region

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In 1997 Congress created a new range of managed care choices for Medicare beneficiaries. The new options, dubbed “Medicare+Choice,” were intended to give seniors (and the disabled) a range of options for delivery of health care services. The success of the program has been limited, and the availability of different choices varies widely across the country.

In addition to Medicare Health Maintenance Organizations (HMOs), Medicare+Choice was expected to provide “Private Fee for Service,” “Preferred Provider Organization,” “Point of Service” and other variations on managed care plans for Medicare beneficiaries. As it turns out, however, the result in most areas has been a reduction in choices—in Tucson, for example, while a single “Private Fee for Service” program has become available, the number of Medicare HMOs has shrunk from four (with several different plan options) to two.

In addition to fewer choices in most areas, there is tremendous variation from one locality to another. Part of that difference (and much of the difference in benefits actually offered to participants in different plans) stems from Medicare’s complicated system of determining the amount it pays managed care plans for each Medicare enrollee in a given jurisdiction.

In Broward County, Florida, for example, the 1999 reimbursement rate for a Medicare HMO was $676.64 per month; in Dakota County, Minnesota, the rate was $394.92. Not surprisingly, the benefits offered by HMOs in Broward County were substantially better than those in Dakota County. As one stark example, while HMO participants in Broward County paid no annual premium for membership, it cost a Dakota County participant $1,137 in premiums just to belong to a Medicare HMO.

That was why Mary Sarno, a Florida resident, sued the Medicare program administrator. She argued that her constitutional right to travel was infringed by the program’s structure; while she wanted to visit (and possibly live near) her children in Minnesota, she could not afford to do so if the Medicare benefits in Dakota County were so much more expensive than those she enjoyed in Florida.

Ms. Sarno’s complaint was dismissed by the federal judge in Minnesota, and she appealed. The Eight Circuit of the Federal Court of Appeals agreed with the District Court judge and threw her case out of court. Even if she was right about the disparity in benefits in different regions, said the Court of Appeals, she had no claim against a federal program. The section of the U.S. Constitution which prohibits laws that interfere with a citizen’s right to travel is directed toward actions by State governments, not the federal government and its programs. Minnesota Senior Federation v. United States, December 13, 2001.

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Robert B. Fleming


Robert Fleming is a Fellow of both the American College of Trust and Estate Counsel and the National Academy of Elder Law Attorneys. He has been certified as a Specialist in Estate and Trust Law by the State Bar of Arizona‘s Board of Legal Specialization, and he is also a Certified Elder Law Attorney by the National Elder Law Foundation. Robert has a long history of involvement in local, state and national organizations. He is most proud of his instrumental involvement in the Special Needs Alliance, the premier national organization for lawyers dealing with special needs trusts and planning.

Robert has two adult children, two young grandchildren and a wife of over fifty years. He is devoted to all of them. He is also very fond of Rosalind Franklin (his office companion corgi), and his homebound cat Muninn. He just likes people, their pets and their stories.

Elizabeth N.R. Friman


Elizabeth Noble Rollings Friman is a principal and licensed fiduciary at Fleming & Curti, PLC. Elizabeth enjoys estate planning and helping families navigate trust and probate administrations. She is passionate about the fiduciary work that she performs as a trustee, personal representative, guardian, and conservator. Elizabeth works with CPAs, financial professionals, case managers, and medical providers to tailor solutions to complex family challenges. Elizabeth is often called upon to serve as a neutral party so that families can avoid protracted legal conflict. Elizabeth relies on the expertise of her team at Fleming & Curti, and as the Firm approaches its third decade, she is proud of the culture of care and consideration that the Firm embodies. Finding workable solutions to sensitive and complex family challenges is something that Elizabeth and the Fleming & Curti team do well.

Amy F. Matheson


Amy Farrell Matheson has worked as an attorney at Fleming & Curti since 2006. A member of the Southern Arizona Estate Planning Council, she is primarily responsible for estate planning and probate matters.

Amy graduated from Wellesley College with a double major in political science and English. She is an honors graduate of Suffolk University Law School and has been admitted to practice in Arizona, Massachusetts, New York, and the District of Columbia.

Prior to joining Fleming & Curti, Amy worked for American Public Television in Boston, and with the international trade group at White & Case, LLP, in Washington, D.C.

Amy’s husband, Tom, is an astronomer at NOIRLab and the Head of Time Domain Services, whose main project is ANTARES. Sadly, this does not involve actual time travel. Amy’s twin daughters are high school students; Finn, her Irish Red and White Setter, remains a puppy at heart.

Famous people's wills

Matthew M. Mansour


Matthew is a law clerk who recently earned his law degree from the University of Arizona James E. Rogers College of Law. His undergraduate degree is in psychology from the University of California, Santa Barbara. Matthew has had a passion for advocacy in the Tucson community since his time as a law student representative in the Workers’ Rights Clinic. He also has worked in both the Pima County Attorney’s Office and the Pima County Public Defender’s Office. He enjoys playing basketball, caring for his cat, and listening to audiobooks narrated by the authors.