Who Are Medicare Advantage Plans Bad For
Medicare Advantage plans may not be a good fit for you if you have chronic or serious health conditions because they can require expensive copays.
Even if youre healthy now, you should consider your risk for health issues that may require frequent doctor visits and hospitalization in the future. These costs could be much higher under a Medicare Advantage plan.
Since Medicare Advantage plans have provider networks that limit which doctors and other providers you can see, they are not a good choice if you want the option of choosing your own doctor or if you travel or live part of the year in another part of the country.
It can also be difficult and expensive to switch from a Medicare Advantage plan to Original Medicare with Medigap coverage if you later decide thats a better option for you.
Plans Change Throughout The Year
Medicare changes occur pretty much every year. Most changes are centered around out-of-pocket costs deductibles, premiums, coinsurance, and copays. But there are also coverage changes, such as Medicare recently adding chiropractor services to its list of Part B benefits.
Advantage plans also get to switch things up every year. Common changes include:
- Ancillary benefits
- Out-of-pocket costs
- Changes to the drug formulary
- Providers leaving and entering the plan’s network
You get the Annual Notice of Change in the fall , which outlines any changes coming to your plan next year.
It is imperative that you take the time to review the documents your insurer sends. The ANOC and other notifications contain vital information about your plan. And you don’t qualify for a Special Enrollment Period just because you didn’t read the notice that your plan no longer covers one of your medications.
The ANOC is timed to arrive before the Annual Enrollment Period . It gives you ample opportunity to compare your coverage options and any changes to your plan. Annual Enrollment begins on October 15 and lasts through December 7.
Medicare Advantage Has Its Own Network Of Doctors And Hospitals
When you have original Medicare, you can go anywhere in the country that accepts Medicare and your medical services will be covered by your chosen plan. However, that is not how Medicare Advantage works.
Medicare Advantage Plans have their own networks of doctors, hospitals and other healthcare service providers. Only providers within the network will be covered. If you go outside the network, then you will have to pay full price for the bill out of your own pocket.
Be sure to ask your doctors and other care providers if they are part of the Medicare Advantage plan network that you are considering. If not, you may be better off opting for original Medicare or a Medicare Supplement plan. Original Medicare and Medicare Supplements give you access to hundreds of thousands of doctors, hospitals and specialists, nationwide. The only drawback to these options is a higher out of pocket cost or a higher monthly cost .
Sadly, many people are unable to get the care they need from the doctors that they know and trust just because they failed to check and see if their doctors were in the network. This can be prevented by working with an agent who can confirm what plans and networks all of your doctors accept.
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Medicare Advantage Plans Coverage For Some Services And Procedures May Require Doctors Referral And Plan Authorizations
Medicare Advantage plans try to prevent the misuse or overuse of health care through various means. This might include prior authorization for hospital stays, home health care, medical equipment, and certain complicated procedures. Medicare Advantage plans often also require your primary care doctors referral to see specialists before they will pay for services.
Medicare Advantage Plans Have Smaller Networks
Most MA plans have provider networks you have to stay within. You can go out-of-network to find a doctor, but you may have to pay significantly more than if you stayed in your network.
You may even go to your favorite doctor and get turned away because your doctor isnt in your plans coverage network.
Many people dont realize that MA plans have networks when they enroll, and that may be why Medicare Advantage plans are bad according to some people.
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Plans Change Every Year
The Centers for Medicare and Medicaid Services allows plan providers to set their own rules regarding plan costs and networks. Most plans encounter some changes every year. You might find a plan that works great for you now, but the coverage details or costs could change the following year. This is why it is important for Medicare beneficiaries to compare plans each year during the Medicare Advantage plan selection period. Many enrollees simply sign up for an Advantage plan and stay on it for years without comparing other plans. This can lead to you being enrolled in a plan that is not the best fit since these plans change almost every year.
Are Medicare Advantage Plans Worth It
Medicare Advantage plans are certainly worth the zero-dollar premium however, its your choice to decide if the coverage is right. The value of an Advantage plan depends on your location, healthcare needs, budget, and preferences.
Some healthy people live in prime Medicare Advantage areas, and they prefer to pay as they go. But at the same time, people do leave Medicare Advantage plans for good reasons.
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Seiu Aetna Medicare Advantage And The Attack On Traditional Medicare
Corporate Crime Reporter, February 13, 2021
Carolyn Adessa worked for fifteen years as an art therapist for the Bronx Lebanon Hospital Center.
When she retired in 2010, she went on traditional Medicare.
But sometime in 2014 or 2015 her union, SEIU 1199, without her consent, switched her out of traditional Medicare.
This came at a time when Adessa was battling stage four lymphoma at Memorial Sloan Kettering Cancer Center in New York City.
I was treating this cancer at Sloan Kettering when the union, without my knowledge or approval, switched me out of Medicare, Adessa said. This resulted in an incredible amount of stress, and hours on the telephone, in an attempt to have my enrollment in basic Medicare restored. I was sick as a dog. I was going to work every day. Apparently they had sent me a letter saying they were going to take me out of traditional Medicare unless I opted out. And I missed the letter. Suddenly, my bills werent being paid. I had to contact my Congressman to get it back.
I continue to be outraged by the fact that Medicare would allow any entity to disenroll people from the federal Medicare program under any circumstance, Adessa said.
Then in November 2020, the union came after her again.
Does the union get paid by Aetna for doing this?
Then why dont the retirees get to choose between traditional Medicare and the Aetna Medicare Advantage plan?
The union could not provide an answer.
Again, the union could not provide an answer.
Why Is Medicare Advantage So Bad
Have you been considering Medicare Advantage? If you asked at your doctors office or at the local hospital you may have been told that Medicare Advantage is not as good as original Medicare. Perhaps you may have even heard this from friends too.
Medicare Advantage isnt necessarily bad. However there are some good reasons why some people do not like it.
Care providers may not like Medicare Advantage as much because they dont appreciate the burden of extra paperwork that sometimes comes with referrals and preauthorizations required by Medicare Advantage.They also have to ensure the doctors they refer you to are in network and covered.
For the patient, Medicare Advantage can be a good thing, if they fully understand how it works. Many people dont like Medicare Advantage because it isnt what they thought it would be. This is why it is so important to have someone in your corner when you are making these decisions.
A Medicare insurance broker can help you understand all of your healthcare plan options. The best part is, it doesnt cost you anything. You can get all of the professional insight and advice that you need to make the best decision.
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Additional Costs For Coverage
Original Medicare charges a premium, deductible, and coinsurance for both parts A and B, plus any Part D or Medigap costs.
Medicare Advantage plans often consolidate these costs, but you may notice additional fees. For example, many Medicare Advantage plans include drug deductibles and specialist visit copays.
Medicare Advantage Plans May Actually Cost Less
Even though you may still owe the Part B monthly premium, you could end up paying less overall if you have Medicare Advantage.
Your cost-sharing may also be less with a MA plan. If you only have Original Medicare, you will owe 20 percent of covered services, and Original Medicare will pay 80 percent of approved costs.
To illustrate what this looks like, lets say you see your doctor because you have the flu. Your doctor charges Medicare $100. Medicare approves the charge and you owe $20.
Many MA plans have copays of $10 or less for doctors appointments. That $10 savings for one doctors visit may not seem like much, but it adds up over time.
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What About The Medicare Advantage Give Back Benefit
Some Medicare Advantage plans can offer plan participants a return on their monthly Medicare Part B premiums thanks to the give-back benefit. The benefit is received through Social Security for beneficiaries with a give-back plan. Direct payments are not permitted.
Medicare Part B premium reduction is the precise phrase for the benefit. The insurance company covers a portion or all of your premium when you join one of these plans. There is a section labeled Part B Premium Buy-Down in the evidence of coverage document that the plan is required to give. This is where youll find the percentage of your Part B premium that the plan paid.
Giving-back plans are getting more popular, although they are still not widely available. Aetna, Cigna, and Humana are among the largest providers of these plans. The amount of money given back ranges from $.10 to the full amount of the normal Part B premium.
Why Medicare Advantage Plans Are Bad For You
But Why Medicare Advantage Plans Are Bad Part Two of the Problem: Most plans automatically include some doctor visits, usually at very low costs. If you have a specialty and/or emergency doctor that is covered by your primary plan, then you will not pay anything extra for that coverage. On the other hand, if you do not have a primary doctor who is covered, and instead rely on an emergency room or a clinically relevant physician whom your doctor has to refer you to, then you are out of luck. In these circumstances, your best bet is to enroll in a Medicare Advantage Plan. Also, keep in mind that most plans will only cover doctors who accept Medicare, so you need to be sure that the doctor you see is on the approved list.
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No Plans Are Really Free
When you hear that a Medicare Advantage plan has no monthly premium, you might assume that the plan is free. That is certainly not the case! Even though you might not be required to pay a monthly premium for the plan, there are many costs associated with these plans that make them anything but free. Since these plans utilize a fee-for-service model, you will find that these plans have many out-of-pocket expenses associated with them. Each time you visit the doctor, you will be charged a copay. If you receive certain treatments, you are generally responsible for a 20% coinsurance amount.
You might even find some Advantage plans that offer a Medicare Part B give-back benefit. This means that the plan will pay a portion or all of your Medicare Part B premium. However, remember the old saying, There is no such thing as a free lunch. When you begin to explore all the plan details, you will find that the items you have to pay for on the back end might outweigh the price of the premium.
What Is The Best Medicare Advantage Plan
If youve read this far, youre probably wondering which Medicare Advantage plan is the best. Is it Humana, AARP, Aetna, Blue Cross Blue Shield, Cigna, Wellcare, or Kaiser?
Its easy to answer the question, What is the best Medicare supplement insurance plan? Its Plan F. It offers the most coverage.
We wish the answer was as clear-cut with Medicare Advantage, but its not. Heres why.
When you combine all of the standard Medicare Advantage plans, employer plans, and Special Needs Plans, there are literally over 70,000 plan options. Its a truly staggering number.
The good news is that all of those plans are organized across nearly 2,800 U.S. counties. Why? Because most plans use local provider networks, making county boundaries the most logical way to organize private health insurance.
To find the best private health plan for you, use our Plan Finder tool. It will show you all of the plans in your area, their 5-star rating, premiums, copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service…., and extra benefits, too. If you have both Medicare and Medicaid, use the SNP Plan Finder. Plus, every plan page has a free PDF document you can download with basic cost and coverage information.
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Cap On How Much You’ll Pay For Covered Services
Unlike traditional Medicare, Medicare Advantage plans have out-of-pocket limits that cannot be more than $7,500 a year for beneficiaries who access care through plan networks. This is especially good for those who have ongoing medical conditions because if you have Parts A and B alone, you won’t have a cap on your medical spending.
Going outside of the network is allowed under many Medicare Advantage preferred provider plans, though medical costs are higher than they are when staying within the plan network. The highest out-of-pocket maximum for health care spending both inside and outside of networks is $11,300 annually.
Switching Back To Original Medicare
While you can save money with a Medicare Advantage Plan when you are healthy, if you get sick in the middle of the year, you are stuck with whatever costs you incur until you can switch plans during the next open season for Medicare. At that time, you can switch to an Original Medicare plan with Medigap. If you do, keep in mind that Medigap may charge you a higher rate than if you had enrolled when you first qualified for Medicare.
Most Medigap policies are issue-age rated policies or attained-age rated policies. This means that when you sign up later in life, you will pay more per month than if you had started with the Medigap policy at age 65. You may be able to find a policy that has no age rating, but those are rare.
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The Pros And Cons Of Medicare Advantage
These popular plans may carry hidden risks. Heres what to know.
If youre one of the 63 million Americans enrolled in Medicare, youre probably being deluged by marketing pitches for Medicare Advantage plans, which offer managed care with low or zero premiums.
Medicares fall open enrollment season starts Oct. 15 and runs through Dec. 7, when you can switch your coverage between Original Medicare and Medicare Advantage, change Medicare Advantage plans, or make changes to your prescription drug plan.
All that marketing seems to be working. Recently, 42 percent of Medicare beneficiaries were enrolled in Advantage plans, up from 31 percent in 2016, according to data from the Kaiser Family Foundation. Those numbers include 50 percent of Black and 54 percent of Hispanic enrollees vs. 36 percent of whites in 2018. By 2025, half of Americans are expected to be in Advantage plans.
Its easy to see the appeal of Advantage. Original Medicare doesnt cover all your medical expenses, while Advantage plans have cost-sharing requirements but then cap your out-of-pocket costs. Plus, you have low premiums and the simplicity of all-in-one coverage.
But there can be hidden risks to Advantage plans, especially for those with major health issues.
Some people in Medicare Advantage end up paying unexpectedly high costs when they become ill or find their network lacks the providers they need, says Tricia Neuman, senior vice president at Kaiser.
The Formula For Higher Profits: Score Patients As Sicker Than They Are
Much of the debate centers on the complex method used to pay the health plans.
In original Medicare, medical providers bill for each service they provide. By contrast, Medicare Advantage plans are paid using a coding formula called a “risk score” that pays higher rates for sicker patients and less for those in good health.
That means the more serious medical conditions the plans diagnose the more money they get â sometimes thousands of dollars more per patient over the course of a year with little monitoring by CMS to make sure the higher fees are justified. According to whistleblower complaints calling out this practice of upcoding, three of the conditions frequently given a higher risk score by Medicare Advantage plans include cases of diabetes with complications, major depression and congestive heart failure.
Congress recognized the problem in 2005 and directed CMS to set an annual “coding intensity adjustment” to reduce Medicare Advantage risk scores and keep them more in line with original Medicare.
But since 2018, CMS has set the coding adjustment at 5.9%, the minimum amount required by law. Boccuti said that adjustment is “too low,” adding that health plans “are inventing new ways to increase their enrollees’ risk scores, which gain them higher monthly payments from Medicare.”
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