Are Medicare Advantage Plans Bad?

Are Medicare Advantage plans bad? Many people don’t UNDERSTAND MAPD plans. No premium, dental and vision come with a price. What’s not to love? How do I find the BEST Medicare plan? The one that is right for me?

GA Medicare expert Bob Vineyard explains

If Medicare Advantage plans are bad why do they dominate some areas? Why do so many people buy into the Advantage plan sales pitch? Good benefits, low OOP (out of pocket), decent networks.

It all sounds so good.

Still there ARE limits on access to health care. Policyholders can’t go anywhere they want. Networks do change from year to year. Over half the Georgia Advantage plans are HMO, the balance are PPO. Understand the difference!

“Your” doctor(s) may be in network this year but not next.

Are Medicare Advantage plans bad?
Are Medicare Advantage Plans Bad?

Medicare Advantage Limited Access to Health Care

Some folks have medical conditions that require specialized care and there may be only a handful of Medicare Advantage providers in your area that offer that kind of treatment. There are patients who have a level of trust with their provider that cannot bridge saving $$$ to follow the path allowed by the HMO.

Chronic care is one area where the doctor-patient relationship is invaluable. I have insulin dependent diabetics including those with pumps. They have no desire to find another endo just because their insurance carrier and doc part ways.

The choice of plans is not JUST dollars and cents. Too many agents either ignore this aspect or don’t understand it. How Medicare Advantage plans are sold, what you are told and what is omitted, can make an impact on your buying decision.

I Was Told All Doctors Accept This Plan

When I talk with prospective clients I always talk about access to care. I can’t recall a single time when they were pitched an MA plan and they said “Oh yeah, the agent/carrier mentioned that but I don’t think it will be a problem”.

More often than not they had no idea how managed care plans work. For that matter, neither does the doctor’s office. When a patient mentions they will be going on Medicare they are usually told “No problem, we take Medicare”. Sometimes they will add “But we DON’T take Aetna (Humana, Cigna . . . whomever).”

Original Medicare offers unfettered access to care anywhere in the country. This includes specialty centers like Mayo, Sloan-Kettering, MD Anderson, etc.

The same cannot be said about MA plans.

Prior Authorization? What is That?

There is also the prior authorization issue. Something shared by almost every managed care plan, but NOT by traditional Medicare.

80 percent of Medicare Advantage enrollees are in plans that require prior authorization for at least one Medicare-covered service

Prior Authorization in Medicare Advantage Plans: How Often Is It Used?

How Prior Authorization Can Impede Access to Care in Medicare Advantage – Medicare Rights Blog

This goes hand in glove with claim denials. The problem is so big the OIG is investigating MA claim rejections.

The study found that 82% of the wrongful denials arose from appeals by providers for payment for services already rendered. While that is not surprising in a third-party payor system, what is surprising is the failure of insurer trade association AHIP to treat it as a significant issue.
Most medicare advantage denials really are wrong – And the biggest victims are the providers: A just-released report by the Office of Inspector General of the U. S. Department of Health & Human Services shows that most coverage denials from insurers and plans in the Medicare Advantage program were flat-out wrong.
Becker Hospital Review

If someone is in the middle of a major claim the LAST THING they need or want is to fight their insurance carrier over treatment plan or claim payments.

I Get Calls From People Who Have Advantage Plans

I get calls all throughout the year from people who have MA plans and they want to change. The two biggest complaints are:

I can’t afford them
They won’t pay my claims

Can’t afford does not mean the premium is too high. It means they cannot afford to pay for care.

The second issue, about claim denial, is addressed above.

Are MA plans evil or wrong for everyone?

No, but most people don’t understand what they have until it is too late to do anything about it. When you are faced with denial of care or big medical bills what is the worst time in the world to find out your insurance isn’t working.

Do I like Medicare Advantage plans?

Nope. Wouldn’t have one.

Do I SELL only Medigap?

No, I don’t SELL anything but I do explain how the plans work and offer prospective clients a choice.

Most people who find me already know they want original Medicare and a Medigap plan. The only thing I have to do at that time is SHOW them how I can help more than some bozo in a call center. Or the home office rep that is telling you how great their plans are and last week they were asking if you wanted fries with your order.

In addition to informing people about how Medicare works . . . and access to care . . . and prior authorization . . . and claim denials . . . I also talk about Part D.

We Have Videos

I have several videos about Medicare Part D including one that specifically addresses drug plan deductibles. Quite a few agents either don’t understand the deductible or know how to explain it.

Of course the easy thing is to only sell a plan that does not have a deductible. It doesn’t matter that the beneficiary will not only pay higher premiums but will also pay more for their Rx with a no deductible PDP. It was just easier to sell than taking the time to educate your client about drug plans.

I also show them how to save money, and sometimes avoid the donut hole, by purchasing some of their med’s outside the plan.

It would be so much easier if all I did was sell the PERCEIVED benefits of $0 premium plans, the lowest premium Medigap plan and only Part D without a deductible.

But then I would be like all the other 99 agents out there who are calling incessantly or knocking on their door to sell anything for a buck.

Stealing a line from the late Lee Iacocca, “If you can find a better plan than traditional Medicare and a supplement plan, BUY IT”.

#MedicareAdvantagePriorAuthorization #ManagedCareNetworks

Answers to Common Medicare Questions

I have answers to your most common Medicare questions. Here are just a few examples of questions asked by people just like you who are turning 65.

  • How do I know which Medicare plan is right for me?
  • When should I enroll in Medicare?
  • Should I have the same plan as my spouse?
  • How much does Medicare cost?
  • Does Medicare cover (fill in the blank)?

Many of your questions can be answered by copying this into your Google search bar – site: 

Why is Medicare so confusing?

Why is Medicare Confusing?

Parts, plans, gaps, deductibles, copay’s, coinsurance . . .

It doesn’t take much before your head is swimming. Where do you go for answers  . . . but without the sales pitch?

Answers to Common Medicare Questions

Below are links that correspond to the questions shown above.


You have Medicare Questions.

I have answers.

Give me a call. I would love to help. (404) 252-5859

Medicare Open Enrollment 2019

Medicare 2019 Open Enrollment starts on October 15th and ends on December the 7th. Who is affected? How do you decide what to keep and what to change? Where can you get answers to your questions?Medicare Open Enrollment 2018

Don’t get distracted by the hype.

During this open enrollment many will want to offer advice but how do you know their opinions are useful? Can you really get solid, unbiased advice or are you at the mercy of scoundrels?

Let’s set the record straight and give you some guidelines about what you need to know and how to sort out good advice from bad.

Five Medicare Open Enrollment Tips You MUST Know

Medicare Open Enrollment 2019 – A Journey with a Purpose

Let’s start with the basics of Medicare 2019 open enrollment. One area that creates more confusion than anything else is changing Medicare supplement plans.

You can change your Medigap plan any time of the year. The annual enrollment period does not include Medicare supplement plans. Only Medicare Advantage and Part D drug plans are included in open enrollment.

There is generally only one time when you can buy a Medigap plan without answering health questions. For most folks that is when they turn 65 and enroll in Medicare for the first time. Once you have been enrolled in Medicare Part B for 6 months you can change plans as long as you pass through underwriting.

If you have questions about your ability to change plans, give us a call. In less than 5 minutes you can learn if you are healthy enough to be approved or not. We will also be glad to quote Medicare supplement rates over the phone and email you a Medigap rate report like this one.

If you can change your supplement plan at any time of the year, what do I need to know about Medicare Open Enrollment 2018?

Medicare open enrollment allows you to change your Part D prescription drug plan, or your Medicare Advantage plan. Neither require medical underwriting with one exception. If you are currently in renal failure you cannot change Advantage plans.

At Georgia Medicare Plans our focus is strictly on finding the best Medigap coverage that fits your needs and budget. We also offer detailed advice on Part D and will guide you through the enrollment process.

We do not offer Medicare Advantage plans but we will refer you to an associate if you are convinced Advantage plans are right for you.


Medicare Drug Plans are Confusing

The most difficult part of my work is helping clients find the right drug plan that delivers the best value. Let’s look at how I handled a review for a new client.

Bill currently takes two different medications to control his cholesterol, Ezetimibe and Xarelto. While was covered under a group health insurance plan his Xarelto copay was $0. That goes away once he is covered by Part D.

Bill likes to take charge of things and his own review of drug plans led him to believe his best option was a plan with a monthly premium of $55.

I felt he could do better.

Both of these drugs are expensive. Ezetimibe has a retail price of $300 for a 30 day supply; Xarelto is $400.

2019 update – Ezetimibe is currently $12 with a GoodRx discount. 


Avoiding the Donut Hole

My analisys indicates he will enter the donut hole by the 4th month and his out of pocket drug costs will exceed $350 per month.

My suggestion was to drop Ezetimibe from his drug plan evaluation and purchase outside of Part D using GoodRx. His copay would be about the same as his drug plan but by removing the drug from the formulary calculation he is able to delay entering the donut hole to month 7 vs. the 4th month.

Can he avoid the donut hole completely?

As it turns out he can.

He can buy Ezetimibe through Blue Sky and lower his costs even more than using GoodRx. Before he enters the donut hole his Xarelto copay is $46. Once in the donut hole his copay more than triples. Copay’s for all drugs, not just the expensive ones, increases while in the donut hole. He can avoid the donut hole completely by purchasing his meds (except Ezetimibe) through the drug plan and then buying Xarelto from Blue Sky right before entering the donut hole.

Combining these suggestions he can choose a drug plan with a $22 monthly premium vs the $55 plan he would have picked on his own. Bill saves over $500 in prescription drug costs.


Medicare Drug Plans – Who is Advising You?

Where can you go for help and advice for drug plans during Medicare open enrollment 2018? Let’s run down the list.

  • You can do it on your own
  • You can call 1-800-MEDICARE
  • Ask a friend what they have
  • Choose the same plan you spouse has
  • Talk to a volunteer at Georgia Cares
  • Search online
  • Ask an insurance agent
  • Talk with your hair stylist

Obviously there are many choices but whatever route you take during Medicare open enrollment 2018 make sure you consider all of the following.

  • Start with the Medicare plan finder even if you are going to ask for advice
  • Next, record your Drug List ID number and Password Date for future reference
  • Be sure to consider lower cost generics where possible
  • Make sure you are including the lowest cost participating pharmacy’s*
  • Check generic pricing using GoodRx
  • Also check pricing at a Canadian pharmacy such as Blue Sky
  • Include star ratings in your evaluation
  • Don’t just assume the plan that worked well this year is your best choice for 2018
  • If you use an agent, make sure they are looking at ALL available plans, not just the one that compensates them
  • If you use 1-800-MEDICARE ask if they have suggestions on ways to save by purchasing drugs outside of Part D
  • Sometimes free advice is worth what you paid for it

*In 2017 Walgreen’s often has the lowest prices for medications. If your evaluations for this year did not include Walgeen’s as an option you probably never saw the lowest priced drug plans. Low price pharmacy’s change every year. Make sure you don’t make the same mistake for 2018.


Look for Medicare Supplement Premium Savings

At Georgia Medicare Plans we do things other agents fail to do. If an agent fails to offer you a free Medigap rate report are they showing you the best options for you or only the plans that pay them the most money?

Every prospective client receives this report for the plan(s) they are considering. Just ask. It’s that simple. We email your report  for review. Take time to study the report and form your questions. We are happy to help.

You have entered the “No Selling Zone”. Most of all, there is no pressure to buy but we do hope to earn your business. Call or email with questions, when you turn 65 or during the Medicare Open Enrollment 2019 dates.


#MedicareOpenEnrollment #MedicarePartD #GeorgiaMedicareSupplementRates #Turning65