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

Medicare Things You Don’t Know

Medicare things you don’t know (but wish you did). Questions you never asked because no one told you. And you will pay dearly if you are not prepared.

There are things about Medicare that will trip you up when you least expect it. Not so much with Original Medicare, but there are things about Advantage plans no one mentioned. Medicare things you don’t know. Stuff like access to care and prior authorization.

Medicare Stuff About Advantage Plans

You may think you understand Advantage plans but my guess is there are things in this video that will shock you.

Almost everyone LOVES their Advantage plan until they have to use it. I get calls all year long from folks who say they can’t afford their Medicare plan and want a supplement.

Most GA Medicare Advantage premiums are $0. If they can’t afford their plan there’s a good chance they are incurring hundreds or even thousands of dollars out of pocket for claims.

I have a friend that has been bragging about his plan ever since he went on Medicare. He thought I was foolish for paying “all that money” every month for a Medigap plan.

A few years ago a cancer diagnosis was a shock. His provider had grant money to pay for his treatment so his out of pocket was minimal.

Now the Cancer is Back

Gary is learning things about Medicare he did not know. Such as prior authorization.

Before he can have a test ordered by his doctor, the carrier must APPROVE the test. It’s all about the money.

His oncologist wants him to have proton therapy but his plan will only pay for a less expensive protocol. Dollars drive many medical decisions when an insurance carrier controls your benefits.

Proton Therapy – It Helps Only a Few at a Wildly Extravagant Cost MedPage Today

All he wants to do is get well but his Advantage plan is running interference. His carrier is interested in saving money. THEIR money. Not his.

It’s all about the dollars. Just another Medicare thing he did not know.

What is Prior Authorization?

According to the Kaiser Foundation “80 percent of Medicare Advantage enrollees are in plans that require prior authorization for at least one Medicare-covered service“.https://www.kff.org/medicare/issue-brief/prior-authorization-in-medicare-advantage-plans-how-often-is-it-used/

Prior authorization is more frequently imposed for HIGHER COST services.

Reading further . . .

A potentially overlooked consideration is access to covered services; specifically, how prior authorization may affect beneficiaries’ access to covered services.

Medicare Advantage plans can require enrollees to get approval from the plan prior to receiving a service, and if approval is not granted, then the plan generally does not cover the cost of the service.

On the other hand, Original Medicare does not require prior authorization for most services.

There are probably many things about Medicare Advantage plans you did not know. Limited access to care because of prior authorization requirements is probably just one of them.

#MedicarePriorAuthorization #MedicareAdvantage #GAMedicareExpert