Medicare Advantage Plans - Caution
Medicare Advantage Plans are a very popular option for many people who are 65 years old or older or are disabled prior to turning 65.
Some of the reason they are so popular are for the following reasons:
- Many Medicare Advantage Plans come with no additional monthly premium to obtain these plans.
- Many of these plan have $0.00 co-pays for many of the services you might seek out.
- Low Max Out of Pocket plan options.
- Low or no cost basic dental plans
- Low or no cost vision coverage
- Part D prescription drug coverage is included at no additional premium
- Many additional added value benefits that are included at no additional premium
When a consumer see all of these value added benefits they ask themselves why would I not go this direction. Or they might think this is the only option they have as that is what their friends did or the perception of this is what everyone else is doing.
On the surface one could say, I would have to be crazy not to obtain a Medicare Advantage plan.
Many Medicare Agents only sell Medicare Advantage plans because they don’t know better, as the Medicare Insurance Companies main focus in their required training only goes over Medicare Advantage plans.
If the Medicare Insurance Agent is not shown or taught about the Medicare Supplemental plans there focus will only be Medicare Advantage plans. In addition they are not taught how to sell a Medigap plan. So these Agents are required to conduct a lot of independent research on their own.
Many Medicare Insurance Agents only present and sell Medicare Advantage Plans and may briefly discuss a Medicare Supplement plan if asked about it, as they are not as confident in the Medigap plans.
I wanted to share a piece that was done by Good Morning America and posted on YouTube back in 2013.
Good Morning America: High Risks of Medicare Advantage Plans
In this News Report, Good Morning America interviews a patient who was experiencing major medical issues in which she sought medical attention at a Hospital. Her Private Medicare Advantage Insurance plan refused to allow her to be treated at the Hospital for her medical condition. The Medicare Advantage plan stated it was not “medically necessary” as defined by the Medicare Advantage plan medical group NOT her Doctor or Hospital. However after a second visit to the Hospital with a new problem in addition to the prior issue (a week later) she filed an appeal to the insurance company which took another month for them to provide a decision on.
I don’t know about you but being in so much pain that you had to go to the hospital twice and then live with the pain for 40 or so days for something that was deemed not medically necessary by the insurance carrier / medical group sounds pretty NOT OKAY to me.
In addition they reversed their decision which means it actually was MEDICALLY NECESSARY on day 1. The Hospital was shocked of the denial as they knew if this person had been covered under Original Medicare with a MediGap policy it would have been taken care of on day 1 and would have prevented the addition issue that developed. This is because under Original Medicare the Doctor decides what is or what is not medically necessary not the insurance company. Enjoy the news cast below.
Inspector General Reports on Medicare Advantage Plan Denial of Coverage
Our job is to educate our clients and then allow you to make a decision. If the news report from 2013 was not alarming enough for you as it was for us, this next report which is from September 2018 might help you make your decision for you a bit easier. I know, I know, 2013 was so long ago I am sure the Medicare Advantage carriers have fixed that issue right? WRONG
I love how on page 2 of the report it states: “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials”. I don’t know about you but that is not a good starting point for a 35 page report.
Following are a few Highlights of the report. I have attached to the right the full report for your review.
- Medicare Advantage Organizations (MAOs) overturned 75 percent of their own denials during 2014–16, overturning approximately 216,000 denials each year. The total denied was approximately 288,000 people. This means that 72,000 of the denials were not overturned and those individuals had to remain in pain indefinitely.
- Medicare Advantage beneficiaries (This is you) and providers were initially denied services and payments that should have been provided. (Meaning you had to pay out of pocket at 100%)
- Beneficiaries and providers appealed only 1 percent of denials to the first level of appeal.
- Don’t Forget that 1% represents a whopping 288,000 denials (which means there were approximately 28,800.000 denials). Could you imagine if everyone appealed these denials based on the 75% rule 21,600,000 people would have been treated for the very thing the insurance carrier told them no.
- Centers for Medicare & Medicaid Services (CMS) audits highlight widespread and persistent MAO performance problems related to denials of care and payment.
- In 2015, CMS cited 56 percent of audited contracts for making inappropriate denials.
Are their Disadvantages to joining a Medicare Advantage Plan?
The word Disadvantage or Advantage can bring about many different viewpoints. One person’s view of a disadvantage may not be viewed as a disadvantage to someone else. For instance many people like how an HMO works (or maybe they like the lower monthly premium). They don’t mind being apart of a specific network as it has always worked out just fine for them in the past through their employers plan. While someone else has had either one bad experience with an HMO or several bad experiences and would not touch them with a ten foot pole.
Below we will share a story from Dr. Brent Schillinger and we will do our best to list disadvantages that people have shared with up over the years.
In 2012, Dr. Brent Schillinger, former president of the Palm Beach County Medical Society, pointed out a host of potential problems he encountered with Medicare Advantage Plans as a physician. Here’s how he describes them:
- Care can actually end up costing more, to the patient and the federal budget, than it would have under original Medicare, particularly if one suffers from a very serious medical problem.
- Some private plans are not financially stable and may suddenly cease coverage. This happened in Florida in 2014 when a popular MA plan called Physicians United Plan was declared insolvent, and doctors canceled appointments.
- One may have difficulty getting emergency or urgent care due to carrier rationing.
- The plans only cover certain doctors, and often drop providers without cause, breaking the continuity of care.
- Members have to follow plan rules to get covered care.
- There are always restrictions when choosing doctors, hospitals, and other providers, which is another form of rationing that keeps profits up for the insurance company but limits patient choice.
- It can be difficult to get care away from home unless it is deemed an Emergency.
- The extra benefits offered can turn out to be less than promised.
- Plans that include coverage for Medicare Part D prescription drug costs may ration certain high-cost medications.
In addition to the above items listed a few more items have been mentioned by people who are on Medicare Advantage Plans.
- Your Doctor does not decide what is deemed “Medically Necessary” but rather the Insurance Carrier / Medical Network makes that decision.
- Your Medicare Advantage plan can deny coverage that would have otherwise been covered by Original Medicare.
- If you go outside of the Network for non-emergency services (as deemed by the Network) you could be responsible for the entire bill
- By joining a Medicare Advantage plan you give up your right to a guaranteed issue MediGap plan.
- Prior authorization may be required under a Medicare Advantage plan to include an Ambulance ride and many other medicare services.
Author Wendell Potter explains how many Medicare Advantage enrollees don’t find out about the limitations of their Medicare Advantage plans until they get sick:
“Although Mom saw her MA premiums increase significantly over the years, she didn’t have any real motivation to disenroll until after she broke her hip and required skilled care in a nursing facility. After a few days, the nursing home administrator told her that if she stayed there, she would have to pay for everything out of her own pocket. Why? Because a utilization review nurse at her MA plan, who had never seen or examined her, decided that the care she was receiving was no longer ‘medically necessary.’ Because there are no commonly used criteria as to what constitutes medical necessity, insurers have wide discretion in determining what they will pay for and when they will stop paying for services like skilled nursing care by decreeing it ‘custodial.’”
Medicare Advantage Plans include Step Therapy.
Medicare Advantage plans may implement mechanisms to manage or control the utilization of a covered service that do NOT apply under Original Medicare. This means that under Original Medicare this restriction does not apply.
One such mechanism includes the requirement for you as the beneficiary to obtain a referral to see a specialist. In addition, the Medicare Advantage plan can require prior authorization to obtain a needed service such as a medically needed surgery.
Medicare Advantage plans can also implement step therapy This is when a Medicare Advantage plan requires your Doctor to start with lower cost saving drugs that are offered through your Part B or Part D coverage. Your Doctor may want to start with a more aggressive drug as they believe that is your best option, however they may not be allowed too.
If, you were under original Medicare with a Medigap plan, this would not be an issue that you as a Medicare Beneficiary would have to deal with.
