Disadvantages Of Medicare Advantage Plans
In general, Medicare Advantage Plans do not offer the same level of choice as a Medicare plus Medigap combination. Most plans require you to go to their network of doctors and health providers. Since Medicare Advantage Plans cant pick their customers , they discourage people who are sick by the way they structure their copays and deductibles.
Although Mom saw her MA premiums increase significantly over the years, she didnt 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.
The Best Medicare Advantage Plans For 2020
There really is no simple answer for which Medicare Advantage plans are the best for 2020. Thats because every person needs different things out of their plan, so what works best for one person wont work best for the next person.
Like any other major purchase, youll need to do some shopping and compare plan features, coverages, costs and more before deciding.
Also remember that not all plans are available in all geographic areas, so finding the perfect plan means nothing if you cant access it because of where you live.
Not all plans offer the same benefits, so you need to consider how your needs have changed, and what kind of benefits you must have to meet your unique needs.
Review your current coverage, if applicable, and talk to experts who can determine if new plans are on the market and how these plans best work with all of your other possible coverages for the coming year.
What About Medicare Select Plans
Medicare SELECT plans are a type of Medigap plan that is sold in some states in addition to the traditional Medigap plans. SELECT plans are not very commonly sold or purchased, but in some states, they are an option. What is a SELECT plan and how does it differ from a regular Medigap plan?
SELECT plans provide the same coverage as traditional Medigap plans however, they have a network that you must stay within to receive those benefits. The networks are usually statewide or regionally specific. If you are out of the area/out of network, you may still receive some benefits but those benefits will be much more limited than if you were in network.
Medicare SELECT plans are the only type of Medigap plan that has a network, and they are not commonly sold or purchased in most states.
Not As Compatible With Other Forms Of Retiree Coverage
There are also some limitations in how MA works with other types of retiree coverage. For example, beneficiaries with Tricare for Life need to enroll in Original Medicare in order to keep their Tricare coverage. Before you enroll in an MA plan, be sure to explore how it will work with other types of retiree coverage you may be using.
The Fine Print Of Medicare Advantage Plans
Medicare Advantage plans, usually bundled with prescription drug coverage, typically require you to use health care providers in their network. The policies limit your annual out-of-pocket costs for covered services.
“People need to go beyond the commercials” to understand the fine print of Medicare Advantage plans, Omdahl said. “There are indeed zero-premium Advantage plans and many of the plans do not have any deductibles. But the zero co-pay is misleading. Zero co-pay is for your primary doctor depending on where you live, co-pays may apply in other situations.”
In addition, noted Omdahl, “start digging into the evidence of coverage and you will see that Medicare Advantage is pay-as-you go: fifty dollars to see a specialist, four hundred dollars a day for five or six days of hospitalization. So you are writing checks, and that’s what people don’t realize. They think ‘zero premium’ means it’s free, which it’s not.”
Savage said that due to the Medicare program’s rules, Medicare Advantage enrollees could wind up paying out of pocket as much as $7,500 a year more than $11,000 a year if you use out-of-network health care providers.
“These plans work best if you don’t get sick,” she said. “Once you need to see a lot of specialists, then you start paying.”
Omdahl said that before signing up for a Medicare Advantage plan, understand that anytime you want care other than an emergency, the plan has to approve it.
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You Can Use The Healthcare Providers Of Your Choice
Patients with Original Medicare can use any healthcare provided thats approved by Medicare to accept Medicare payments. This is both good and bad.
While most primary care physicians and specialists are approved by Medicare, not all accept new Medicare patients. And, not all doctors accept Medicare-assignment, which requires them to take payment Medicare establishes for each healthcare service. Many doctors and specialists who dont accept Medicare-assigned will see patients for an additional 15 percent fee, which is billed to the patient as Part B Excess ChargesA Medicare Part B excess charge is the difference between a health care providers actual charge and Medicares approved amount for payment…..
How Do You Know If Your Medicare Advantage Plan Limits You To Network Doctors
Not every Medicare Advantage plan requires you to use doctors in its provider network, but many of them do. Some Medicare Advantage plans let you go outside the plan network, but might charge you a higher coinsurance amount or copayment.
Some types of Medicare Advantage plans that might have provider networks are listed below. Check your plan information to see details and rules about coverage, including whether you need to use only doctors who accept your Medicare Advantage plan.
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Reason : Free Plans Are Not Really Free
This is true.
The real issue here is peoples misunderstanding of how Medicare Advantage plans work. Specifically, many people dont understand copayments and coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. …. So, if you are wondering, how can Medicare Advantage plans be free?, they arent. Far from it.
Just like Original Medicare , Medicare Advantage is a cost-sharing system. With Original Medicare beneficiaries pay about 20 percent of the cost for all Medicare-approved services and Medicare pays 80 percent. With a Medicare Advantage plan, you also pay about 20 percent of your costs, but there is an annual cap that limits your out-of-pocket costs, which solves one of the biggest problems with Medicare Parts A and B.
NOTE: The annual maximum out-of-pocket limit thats built into all Medicare Advantage plans is a major advantage. For those beneficiaries with chronic health conditions, who cannot get a Medicare supplement, the annual MOOP keeps them out of bankruptcy from excessive medical bills.
Limited Network Of Doctors
Network restrictions are a common reason why beneficiaries leave their Medicare Advantage plans. Going out of network could mean high fees. Even with a Preferred Provider Organization plan, youll pay more to see doctors that arent in-network.
But, Medigap beneficiaries can visit any physician that accepts Medicare. Although, if you dont mind limitations to doctors and hospitals, an Advantage plan may work for you.
Yet, its essential to keep in mind that the doctors can leave the network anytime, and plans change annually. So, a policy may be superior coverage for one year, but unsuitable for the next.
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Why Should I Choose Medicare Advantage
Medicare Advantage covers some of the gaps of Original Medicare and usually offers a $0 premium through a private company. It can be an affordable option for patients who are not currently sick or in need of intense medical care. If a patient’s situation worsens, it might be difficult or expensive to switch plans.
Find Medicare Advantage Plans Available In Your Area
Your best bet is to give us a call. Were a great resource for helping you find the right Medicare Advantage Plan.
We have MA agents in 38 states who can sell plans from most major carriers. Contact Medicare Plan Finder to discuss your Medicare options.
There is never any obligation to buy, and all of the information is free. You can also give us a call at 1-855-783-1189 .
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Why Medicare Advantage Is Not The Best Choice For Most
Originally Printed in the Pope County Tribune, October 14, 2019 Content updated October 29, 2021
Residents eligible for Medicare have already been inundated with marketing and advertising about Medicare Advantage plans. Thats because the open enrollment period for Medicare for seniors begins Tuesday, Oct. 15, and runs through December 7.
There may be confusion about whether or not to sign up for the traditional Medicare plan with a Medigap policy or choose a Medicare Advantage plan. And there are some pitfalls that many Medicare Advantage enrollees dont find out about until they get sick.
The marketing effort pushing the Medicare Advantage plans show the plans are adding some benefits not typically covered by Medicare. But, those added benefits should be carefully considered, since some Medicare Advantage plans, which are privately run versions of the governments Medicare, can restrict access to a network of doctors or hospitals, cause delays in procedures and limit care, it was recently reported in the Star Tribune. Traditional Medicare doesnt do that.
Edit 10/29/21: As you are probably aware from a Medicare notice sent in October 2021 to most Medicare age residents in Pope County, Humana is no longer offering Advantage plans in Pope and 11 other counties in MN for 2022. Patients with those plans need to switch or theyll have costly charges for being out-of-network!)
Medicare Providers And Original Medicare
Original Medicare is made up of Medicare Part A and Medicare Part B .
- Participating Medicare providers agree to accept Medicare payment, called assignment. This means the provider accepts Medicare payment and will charge only up to the amount that Medicare allows for services.
- Non-participating Medicare providers can choose to accept or not accept Medicare assignment for individual services.
- A doctor who doesnt accept Medicare assignment may be legally allowed to charge more for a service than the Medicare-approved amount. In this case, the Medicare provider may be allowed to charge you an excess charge. An excess charge may be up 15% more than what Medicare allows for certain services.
- Providers who have opted out of Medicare do not accept Medicare assignment at all and will not bill Medicare for your care. Unless you have other insurance, you will be responsible for the entire bill.
If you decide to receive your coverage through Original Medicare, you can choose any doctor or hospital who accepts Medicare payments, and Medicare will typically pay its portion for covered services. You dont need referral authorizations to see specialists. Medicare providers will handle the paperwork of filing claims with Medicare on your behalf.
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Pitfalls Of Medicare Advantage Plans
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A Medicare Advantage Plan, also called a Part C or an MA Plan, may sound enticing. It combines Medicare Part A , Medicare Part B , and usually Medicare Part D into one plan. These plans cover all Medicare services, and some offer extra coverage for vision, hearing, and dental. They are offered by private companies approved by Medicare.
Still, while many offer low premiumssometimes as low as $0 per monththe devil is in the details. You will find that many plans unexpectedly won’t cover certain expenses when you get sickresulting in unforeseen out-of-pocket costs for youand what they pay can differ depending upon your overall health. Here’s a look at some of the disadvantages of Medicare Advantage Plans.
Coverage Doesnt Travel With You
If you like to travel, an Advantage plan is not a good deal for you. Unlike a Medicare Supplement insurance policy, your coverage will not travel with you.
An Advantage plan is likely not the right choice for someone with multiple and/or chronic health problems. Signing up for an Advantage plan when you have several or serious health problems could result in you paying for a lot out-of-pocket.
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When You Can Enroll In A Medicare Advantage Plan
Most people are eligible to enroll in Original Medicare during their Initial Enrollment Period . The IEP is a 7-month window that lasts from three months before your 65th birthday, includes your birthday month and ends three months after. During that time, you can also enroll in an MA plan.
If you dont enroll in MA during your IEP, you can select a MA plan during Medicares Annual Enrollment Period . It takes place every October 15 through December 7.
Some special circumstances may also allow you to enroll during other times of the year.
What You Can Do
Obviously, you cannot strong-arm your healthcare provider to accept Medicare. While you could pay out of pocket for your care or ask for a discount, it makes more financial sense to find a pracitioner who does take Medicare. The Medicare website provides a list of enrolled healthcare providers. If you have a Medicare Advantage plan, the insurance company will provide you with a directory of participating healthcare providers in its network.
Just because a practitioner accepts Medicare does not mean they will take you on as a patient. Because of the financial reasons listed above, some medical practices only accept a certain number of Medicare patients. Call ahead to find out if their office is accepting new Medicare patients.
Other people may turn to urgent care centers, also referred to as a “walk-in clinics”, “stand-alone clinics”, or a “doc-in-a-box” to get care. There are more than 8,000 of these clinics in the United States, and the majority of these centers do take Medicare patients.
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More Physicians No Longer Seeing Medicare Patients
The federal health program that serves seniors and individuals with disabilities is losing doctors wholl see its patients.
- The Centers for Medicare and Medicaid Services says the number of doctors wholl take Medicare patients is falling.
- A combination of constant battles over reimbursement rates, red tape and payment below what services actually cost has simmered for a long time.
- Medicare now faces the same tell-tale signs of trouble as Medicaid, the low-income health program. One-third of primary care doctors wont take new patients on Medicaid.
- While the number of Medicare decliners remains relatively small, the trend is growing. If it continues, that could make it more difficult for seniors to get timely treatment.
More doctors are reducing their dependence on Medicare. Theyve done this in several ways. At the same time, the Medicare population is growing because of the retirement of baby boomers now and over the next couple of decades.
The number of doctors not accepting Medicare has more than doubled since 2009. Some 9,539 doctors dropped out of Medicare practice in 2012. Thats risen dramatically from 3,700 in 2009.
While 685,000 doctors take Medicare patients, their frustration factor has grown.
All Of Your Major Healthcare Expenses Are Covered Up
Both Original Medicare and Medicare Advantage cover the beneficiarys major medical costs. At its core, and from the very beginning, thats what Medicare was designed to do. More specifically, Medicare was designed to pay about 80 percent of a beneficiarys major medical costs, both inpatient and outpatient. However, the introduction of Medicare Advantage in 2003 muddied the waters in terms of how coverage is provided.
With Original Medicare, a patients costs are clear. Medicare pays 80 percent and the patient pays the remaining 20 percent of all covered services. If the beneficiaryA person who has health care insurance through the Medicare or Medicaid programs…. wants additional coverage, to isolate themselves from the 20 percent gap, they simply buy a Medigap plan .
The combination of Original Medicare and a Medigap plan takes all of the risks of hospitalization costs and high medical costs away from the Medicare beneficiary and shifts it to insurance. And it does it all for one manageable cost that is predictable.
Why wouldnt everyone want this?
However, and this is the third point, Medicare dictates to the Medicare supplement insurance industry that any new Medicare beneficiary, whos getting their benefits by turning age 65, has a narrow window of time to enroll in the Medigap plan of their choice without questions. This is the beneficiarys guaranteed-issue right.
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Medicare Advantage Is Managed Care
We know that CMS pays private insurance companies a monthly fee for each individual they insure. Thatâs how these private companies can offer extra benefits and even $0 premium in many cases.
However, another way MA plans can offer more benefits for $0 premium is because itâs managed care. With MA plans, youâll often see procedures or treatments being declined in favor of less-expensive treatment alternatives.
Dr. Jacob D. Sams, MD, a board-certified orthopedic surgeon at explains that Medicare Advantage plans often require a pre-approval process thatâs difficult and time-consuming.
Dr. Sams has also had MA plans change his treatment plans â even if itâs not in line with his recommendations.
For example, one of his patients was ready for a hip replacement. That patientâs Advantage plan denied the surgery and instead suggested several more weeks of therapy.
PBS explains that the federal governmentâs preference for MA plans started during the Obama Administration, and according to Philip Moeller, PBS contributor, it was âdriven by the desire to limit health-care expenses and improve the health of Medicare enrollees at the same time.â
Managed care seemed like the best way to meet those money-saving goals. MA plans were the obvious way to do it because they had the necessary management tools in place.