Seniors Beware – Medicare (dis)Advantage Plans – Part Two.

If you’re not worried about your Medicare Advantage plan, a recent article from The Washington Post, “Hospitals and doctors are fed up with Medicare Advantage,” might motivate you to check on your Medicare plan before the open enrollment period ends – next Thursday, December 7.

While Medicare Advantage plans have about 31 million members (nearly half of all Medicare enrollees), many doctors and hospitals have had their fill and refuse to accept the plans – even from companies like United Healthcare and Humana.

Consumer policy representatives say today’s pushback has changed as doctors and hospitals become more vocal about their frustration with the insurance companies’ cost-control efforts.

In Louisville, Baptist Health, which runs nine hospitals, clinics, and physician groups, says it will cut ties with Advantage plans from UnitedHealthcare and WellCare Health Plans starting in January unless they can come to terms. The plans “routinely deny or delay approval or payment for medical care recommended by your physician” was the message to patients from Baptist Health. Those are strong words from one institution to another.

Baptist’s medical group of 1,500 doctors and other providers left the Humana network in September.

Scripps Health in San Diego said they accept no Medicare Advantage plans because “revenue doesn’t cover the cost of patient care.”

Last year, the Health and Human Services Department’s inspector general published a study finding some Advantage plans improperly denied covered care coverage created under Medicare’s new rules. The Biden administration’s new rules, set to take effect in January, are in part a response to the OIG report.

Virtually all Medicare Advantage enrollees are in plans requiring the insurer to sign off in advance for at least some of the care. The insurance sector says the process ensures treatments are coordinated and appropriate. In 2021, Medicare Advantage participants submitted over 30 million requests for approvals, according to the KFF, an independent, healthy policy research, polling, and journalism organization. 11% of those denied filed appeals. Upon final determination, the review organization reversed 85% of the denials.

Bottom line: doctors and hospitals have many complaints about original Medicare, but approvals and claim denials are much more limited.

Make an informed choice about your healthcare by researching original Medicare and Medicare Advantage. 

Medicare Advantage Free Consultation

Does Medicare Advantage Make Your Medical Coverage Better or Worse?

Some of the smartest people we know find enrolling in Medicare confusing and overwhelming. Despite the warm and fuzzy commercials from insurance companies, Medicare Advantage plans are tricky to figure out. And sometimes, Medicare Advantage can be more expensive than traditional Medicare.

You want to go into the Medicare enrollment process with information to prevent yourself from making expensive mistakes. This is why we are offering area residents a free Medicare consultation—we do not want to see seniors spending more than they need by selecting the wrong plan.

Medicare Advantage plans can have higher copays and other costs. And if you switch back to traditional Medicare, you may not qualify for the supplemental policies, or the premiums may take a huge jump.

The first part of understanding the process is understanding how these pieces work:

There are three parts to Medicare coverage:

  • Part A covers hospitalization and is premium free.
  • Part B covers outpatient care, including doctor visits. The monthly premium for Part B is based on your income two years before this year. It starts at $144.60 and is based on income tops out at $491.60.
  • Part D covers prescription drugs.

Most doctors still accept traditional Medicare, so you probably can continue with your caregivers. The same may not be true for Medicare Advantage.

Part D is for prescription drug coverage. That is provided by private insurers, and it gets complicated. In Nassau County, there are twenty-seven Part D plans available. The drugs covered by each plan are different, as are the copays and deductibles. Premiums can range from $30 per month to over $150.

Traditional Medicare also has deductibles, copays, and co-insurance. To cover the cost of these “gaps,” private health insurance companies offer supplemental plans known as Medigap. These plans are lettered from A through N to make comparisons easier. For example, every insurance companies A plan must provide the same basic benefits. One good thing: If you apply for a Medigap policy when you are first eligible for Medicare, the insurance company must accept you and cannot charge for preexisting conditions.

Medicare Part C is also known as Medicare Advantage. It is a program where your Medicare premiums are given to private insurance companies to provide the services. Medicare Advantage does not add to other parts of Medicare, but it replaces them. If you enroll in a Medicare Advantage plan, your insurance company must provide you with the benefits of Medicare Parts A and B.  Most Medicare Advantage plans include Part D –drug coverage. Most plans (but not all) cover other expenses that Medicare does not, like hearing, vision, and dental care. However, you will have a copay for most services.

While some Medicare Advantage enrollees in 2020 did not pay an additional premium for coverage over their regular Part B. premiums, these plans are usually limited in the number of health care providers and can have significant copays.

So, should you consider Medicare Advantage?

Medicare Advantage plans are like employer-provided health insurance. You must choose providers in the network, which may be limited especially if the plan is an HMO (health maintenance organization) or less limited if it is a PPO (preferred provider organization). Certain kinds of care may need approvals, and specialists may need referrals. Go out of network, and your costs may not be covered, or the cost may not be applied to your out-of-pocket limits. And Medicare Advantage providers can stop offering coverage in your area at the end of any year, leaving you out in the cold

Just because your provider was in your network one year does not mean they will be in your network the following year. And the plans are regional, so if you move out of the area or spend a lot of time on another state, you may not be covered.

On Long Island, there are 30 Medicare Advantage options, and networks, coverage, deductibles, copays, and co-insurance are very different in each plan. But if you need a lot of medical care, Medicare Advantage costs less upfront and possibly more overall.

Medigap plans have higher upfront costs but cover most if not all expenses if you need care.

Here is another thing to remember: To switch from one Medicare Advantage program to another, you may do so during open enrollment periods. However, to switch from Medicare Advantage to traditional Medicare, you may not have access to a Medigap policy. The insurance company may charge you more, exclude preexisting conditions or deny coverage completely.

Confused? Call our office at 516-307-1236 for a free consultation about your Medicare coverage. We are not an insurance agency, so we have no bias for or against any insurance plan. We do want to help seniors make the right choice.


Reference: Yahoo Finance (Sept 17, 2020) Are Medicare Advantage Plans Worth the Risk?”