Yves here. The advertising deluge for Medicare Advantage plans serves to legitimate an inferior product. It is bad enough that Medicare Advantage is intended to create a two-tier Medicare system, one with pretty good coverage for those who subscribe to traditional, as in government-run Medicare, and gappy, even threadbare, Medicare Advantage plans for everyone else. It is bad enough that this second-tier coverage often looks deceptively attractive to particularly budget-strained older Americans, who may feel they cannot afford traditional Medicare premiums and opt for no-fee Medicare Advantage plans. Even worse, it is clear as a matter of policy that Federal officials support the privatization of Medicare, as in shifting more and more Americans onto crappy Medicare Advantage regardless of whether they are needy enough for that to be the less bad of bad choices.
By Sarah Jane Tribble, KFF Health News Chief Rural Health Correspondent, who previously covered health care for Cleveland’s NPR and PBS affiliate and spent more than a decade as a staff writer for newspapers across the country. Originally published at KFF Health News
In 2016, Richard Timmins went to a free informational seminar to learn more about Medicare coverage.
“I listened to the insurance agent and, basically, he really promoted Medicare Advantage,” Timmins said. The agent described less expensive and broader coverage offered by the plans, which are funded largely by the government but administered by private insurance companies.
For Timmins, who is now 76, it made economic sense then to sign up. And his decision was great, for a while.
Then, three years ago, he noticed a lesion on his right earlobe.
“I have a family history of melanoma. And so, I was kind of tuned in to that and thinking about that,” Timmins said of the growth, which doctors later diagnosed as malignant melanoma. “It started to grow and started to become rather painful.”
Timmins, though, discovered that his enrollment in a Premera Blue Cross Medicare Advantage plan would mean a limited network of doctors and the potential need for preapproval, or prior authorization, from the insurer before getting care. The experience, he said, made getting care more difficult, and now he wants to switch back to traditional, government-administered Medicare.
But he can’t. And he’s not alone.
“I have very little control over my actual medical care,” he said, adding that he now advises friends not to sign up for the private plans. “I think that people are not understanding what Medicare Advantage is all about.”
Enrollment in Medicare Advantage plans has grown substantially in the past few decades, enticing more than half of all eligible people, primarily those 65 or older, with low premium costs and perks like dental and vision insurance. And as the private plans’ share of the Medicare patient pie has ballooned to 30.8 million people, so too have concerns about the insurers’ aggressive sales tactics and misleading coverage claims.
Enrollees, like Timmins, who sign on when they are healthy can find themselves trapped as they grow older and sicker.
“It’s one of those things that people might like them on the front end because of their low to zero premiums and if they are getting a couple of these extra benefits — the vision, dental, that kind of thing,” said Christine Huberty, a lead benefit specialist supervising attorney for the Greater Wisconsin Agency on Aging Resources.
“But it’s when they actually need to use it for these bigger issues,” Huberty said, “that’s when people realize, ‘Oh no, this isn’t going to help me at all.’”
Medicare pays private insurers a fixed amount per Medicare Advantage enrollee and in many cases also pays out bonuses, which the insurers can use to provide supplemental benefits. Huberty said those extra benefits work as an incentive to “get people to join the plan” but that the plans then “restrict the access to so many services and coverage for the bigger stuff.”
David Meyers, assistant professor of health services, policy, and practice at the Brown University School of Public Health, analyzed a decade of Medicare Advantage enrollment and found that about 50% of beneficiaries — rural and urban — left their contract by the end of five years. Most of those enrollees switched to another Medicare Advantage plan rather than traditional Medicare.
In the study, Meyers and his co-authors muse that switching plans could be a positive sign of a free marketplace but that it could also signal “unmeasured discontent” with Medicare Advantage.
“The problem is that once you get into Medicare Advantage, if you have a couple of chronic conditions and you want to leave Medicare Advantage, even if Medicare Advantage isn’t meeting your needs, you might not have any ability to switch back to traditional Medicare,” Meyers said.
Traditional Medicare can be too expensive for beneficiaries switching back from Medicare Advantage, he said. In traditional Medicare, enrollees pay a monthly premium and, after reaching a deductible, in most cases are expected to pay 20% of the cost of each nonhospital service or item they use. And there is no limit on how much an enrollee may have to pay as part of that 20% coinsurance if they end up using a lot of care, Meyers said.
To limit what they spend out-of-pocket, traditional Medicare enrollees typically sign up for supplemental insurance, such as employer coverage or a private Medigap policy. If they are low-income, Medicaid may provide that supplemental coverage.
But, Meyers said, there’s a catch: While beneficiaries who enrolled first in traditional Medicare are guaranteed to qualify for a Medigap policy without pricing based on their medical history, Medigap insurers can deny coverage to beneficiaries transferring from Medicare Advantage plans or base their prices on medical underwriting.
Only four states — Connecticut, Maine, Massachusetts, and New York — prohibit insurers from denying a Medigap policy if the enrollee has preexisting conditions such as diabetes or heart disease.
Paul Ginsburg is a former commissioner on the Medicare Payment Advisory Commission, also known as MedPAC. It’s a legislative branch agency that advises Congress on the Medicare program. He said the inability of enrollees to easily switch between Medicare Advantage and traditional Medicare during open enrollment periods is “a real concern in our system; it shouldn’t be that way.”
The federal government offers specific enrollment periods every year for switching plans. During Medicare’s open enrollment period, from Oct. 15 to Dec. 7, enrollees can switch out of their private plans to traditional, government-administered Medicare.
Medicare Advantage enrollees can also switch plans or transfer to traditional Medicare during another open enrollment period, from Jan. 1 to March 31.
“There are a lot of people that say, ‘Hey, I’d love to come back, but I can’t get Medigap anymore, or I’ll have to just pay a lot more,’” said Ginsburg, who is now a professor of health policy at the University of Southern California.
Timmins is one of those people. The retired veterinarian lives in a rural community on Whidbey Island just north of Seattle. It’s a rugged, idyllic landscape and a popular place for second homes, hiking, and the arts. But it’s also a bit remote.
While it’s typically harder to find doctors in rural areas, Timmins said he believes his Premera Blue Cross plan made it more challenging to get care for a variety of reasons, including the difficulty of finding and getting in to see specialists.
Nearly half of Medicare Advantage plan directories contained inaccurate information on what providers were available, according to the most recent federal review. Beginning in 2024, new or expanding Medicare Advantage plans must demonstrate compliance with federal network expectations or their applications could be denied.
Amanda Lansford, a Premera Blue Cross spokesperson, declined to comment on Timmins’ case. She said the plan meets federal network adequacy requirements as well as travel time and distance standards “to ensure members are not experiencing undue burdens when seeking care.”
Traditional Medicare allows beneficiaries to go to nearly any doctor or hospital in the U.S., and in most cases enrollees do not need approval to get services.
Timmins, who recently finished immunotherapy, said he doesn’t think he would be approved for a Medigap policy, “because of my health issue.” And if he were to get into one, Timmins said, it would likely be too expensive.
For now, Timmins said, he is staying with his Medicare Advantage plan.
“I’m getting older. More stuff is going to happen.”
There is also a chance, Timmins said, that his cancer could resurface: “I’m very aware of my mortality.”
60 comments
Comments are closed.
This is an under-reported and under-investigated issue … the medigap insurance barrier. It differs from state to state. Here’s my experience: I recently moved from NYS to another state and was surprised at what I had to go through to get the same medigap coverage in the new state. There was a long health screen questionnaire and investigation before I was accepted for the same exact policy coverage in the new state. It was fortunate for me that I had a history of good health. Otherwise, might have been refused. Before moving, I had no idea there would be this barrier. Not only people in Medicare Advantage could be trapped but people who move across state lines could also be.
If I understand you correctly, if you’re planning on moving to another state after retiring, you should really move before you turn 65. Of course, most people can’t move until they retire, and people don’t get “full” SS benefits until they turn 66 or 67 (depending on when the were born), and they don’t get really full benefits until 70.
Just trying to wrap my head around this. If the city where you live and work might have severe problems in maybe 20 years (that might be too optimistic for New Orleans and Miami), and you’re too old too easily start a new career somewhere, you may well have planned on moving as soon as you retire. You can move in state with no problems for your medigap policy, but you could have problems moving to another state. I don’t think there’s a safe part of Fla. for Miami (or Tampa or Jacksonville) residents to move to, and I seriously doubt that there’s any part of Northern LA that most New Orleanians would want to move to.
At 62, I knew that I had some homework to do over the next 3 years, but it sounds like there might not be any point to it if I’m planning on moving to another state at some point between 67-70. With a preexisting condition, it sounds like my options will be to stay in Louisiana with Medigap coverage or saddle myself with Medicare Advantage if I plan on moving. Or, am I missing something?
Wasn’t trying to make it about me, but I imagine similar situations are pretty common. They really are trying to push us into Medicare Advantage.
Once again, I would like to thank NC for steering me far, far, and did I mention f-a-r away from Medicare Advantage. My attitude is overflowing right now. It really is.
Thank you! If I could hug you through my computer screen, I would!
Me too. Thanks!
Whoops! I forgot to call that attitude by name. It’s the attitude of gratitude!
Again, thank you, NC!
I’m what’s called a SHIBA or SHIP Advisor – trained volunteer who offers Medicare advice to people without taking any position pro or con on which plan to choose. Advice from someone with no dog in the hunt, so to speak. To show how unbelievably horrible our medical system is, last week a 68 year old woman came in needing serious dental work, and (mistakenly) thinking SHIBA could sell her such insurance, recommended to us by Washington’s DSHS (Medicaid) service, who should have known better. This woman’s income was as follows – 900 a month from Social Security and another 800 from her work at a local school, part time. She made little enough money to have DSHS or the government cover her Part B premium costs of 174 a month, but too much to get full Medicaid coverage. As an advisor I could only tell her that she either needed to try to find some kind of charity medical help (which is nearly impossible to find) or quit her little school job such that she qualified for full Medicaid, to get the dental work done.
Here is a single elderly woman who makes 1700 a month and somehow lives on that, extremely marginally, facing a circumstance where either she delays the dental work in order to keep earning that 800 a month, or she quits her job to get the dental work covered.
I can’t tell you how many people I see like this lady – usually female, 65 and older, making less than 2,500 a month, and often less than 2,000 a month, barely making ends meet, yet making too much to qualify for important medical coverage. It is absolutely terrifying. Almost to a person these people are thoughtful, smart, do not see themselves as victims, often very well educated, and cheerful about the terrible choices they face (or cannot face because they are in that terrible place between Medicaid help and enough income to survive. I don’t know where they find the courage.
And yes, for people like these, the no premium Advantage Plan, or the “cash back” Advantage Plan, is hard to resist, that is until they get sick…..
Well, I’m 74 and I make so little that I do qualify for that important medical coverage, which is, of course, medicaid. Traditional medicaid which doesn’t cover much in the way of dentistry. Which is my current problem.
I haven’t fallen for the Medicare DisAdvantage business.
perfect name for it – tried to talk a friend out of doing it but those ‘freebees’ like dental and eye were sugar plums to him and he raved about the money he got for some things he purchases at the drugstore – and lower rate – what made me think of him was the initial story about the melanoma, which my friend also had removed from his ear, when he had Medicare – hope it doesn’t come back for him – and BS about trying to change back to Medicare is a horror – Medicare was wonderful for me when i had my aortic valve replaced, looking at how much was covered was jaw-dropping – during the recent sign-up period i was bombarded by text messages to sign up for the DisAdvantage –
I’ve had some personal experience lately with the advantages of remaining on traditional Medicare.
I’ve been having some problems with my lower digestive track for a while. My skepticism about the American medical industry, Covid and family issues kept me from seeing anyone about this. I don’t have a primary care physician, nor have I had one since I’ve been married. My spouse always had a gyn-ob and for the last 20 years, an ophthalmologist for glaucoma, and the kids had pediatricians when they were young, but I’ve done without a PCP for 50 years with the result that up until a few months ago, I was medication free.
Back in the fall, my son talked me into a colonoscopy, and he set up everything at the hospital (not Cleveland Clinic) where he had interned as a music therapist. This is a teaching hospital, and the one I would have chosen myself. The first appointment was about what I expected: an inexperienced resident and a cold head resident, but when the colonoscopy was performed, things changed. I had a tumor obvious even to me as I watched the screen, and I wasn’t far from being blocked. The GI doc who conducted the colonoscopy called a surgeon who immediately scheduled an appointment with me. Her empathy was striking especially when she personally escorted me to the bathroom after she conducted an exam. She brought in a radiation oncologist and a medical oncologist who scheduled a bunch of exams in preparation for radiation and chemo.
Then the surgeon requested a PSA for a suspicious looking prostate that came back sky high. That meant a prostate biopsy which revealed a twofer bringing on more scans and two more oncologists for the prostate. Now I’m set for five radiation sessions aimed at both the prostate and rectum followed by chemo for the rectal cancer and anti-hormone treatment for the prostate. Both cancers have spread, but each to only one place, and these doctors, who did their training at Mass General, Sloan Kettering, Duke, Washingon University and Johns Hopkins, have a can-do spirit that’s quite a contrast to my Murphy’s Law view of the universe.
At no point has it been necessary to wait for insurance company approval. At no point have I been restricted from receiving care from a doctor “not on the network.” I have no doubt that if I had been a Medicare Advantage patient, I would not have had access to this level of care.
Thanks for sharing your experience, and best wishes for your ongoing treatment. May you continue to be pleasantly surprised with decent care.
Henry Moon Pie: All the best to you during these many treatments. I’m glad that I detect your constitutional equanimity. You have much to deal with in the next few weeks. I’m looking forward to posts from you.
Sending good thoughts, Henry Moon Pie! Stay positive as it can impact things.
Be careful with going radio first and chemo second. Radio destroys tissue and therefore makes any resection harder to work in long term, or may require greater excision margins, in order for any reconnecting work to stay sealed. This is more to do with colon site. On prostate I suppose it’s just a matter of removing everything but on colon you have to think of it functioning for some more years, without any anastomotic leaks. Good luck!!
Sorry just another point, I do know where in the rectum your problem is, but check to make sure it is a TME procedure they are proposing (long and expensive and requiring an extremely skilled surgeon). This allows for extremely low possible reconnecting thus avoiding the permanent stoma bag which you will get with APR (cheap and cheerful, everyone can do it straight out of college), and never removing all the nasty stuff thus ensuring palliative ending.
I am not a doctor just speaking from experience.
I will second Dandyandy. Radiation can be very problematic and maybe should go last — in both prostate and colin cancers. I have seen a lot of suffering from radiation.
Surgery, then chemo and last radiation.
So sorry for your diagnosis. My wife’s experience with *fortunately* breast cancer 1b, mastectomy 2x and radiation under traditional Medicare and supplement has been as positive as it could be. Even before Medicare Disadvantage became a big issue here at NC, we heard too many horror stories to consider it. We had unimaginable problems under Obamacare for our schizophrenic son, denial after denial. Fortunately he is now doing well as “officially” disabled with his own traditional Medicare and supplement.
Please keep your comments coming, as your spirits allow!
My heart goes out to you, gentle sir!
Many thanks for the kind thoughts, encouragement and advice. It’s been a time of conflicting currents for me. I had more or less resigned myself to a near-term end. After all, I’ve had my three score and ten. Moreover, it’s not lost on me how massive the carbon footprint must be for all these scans and treatment. Does it make sense for a 70 year-old to use up that much of the carbon budget? But then it occurred to me how people in my position would give just about anything to have the help of doctors like I have who demonstrate not only brilliance but also compassion. With the family push and these doctors’ can-do commitment to help, it seemed to me that the non-ado way of proceeding was to go with the flow, at least up to the point where the misery index gets too high.
Re: reconnect, the surgeon conducted her own exam to see if there would be enough healthy tissue to do a reconnect. It’s close, but doable she says, but after living with the concern that I’d be blocked any day, I’m just glad to have a reliable exit system with my Anus 2.0. I would like to avoid a catheter to deal with the prostate’s reaction to all this attention. It got notably worse after Friday when the prostate radiation oncologist described how she was going to zap it. Do prostates have ears?
wish you the best – a close friend who was an ER nurse for most of his life saw a rapid increase in his PSA from one annual physical to the next and knowing that prostate cancer ran in the males in his family he elected to have a robot-assisted radical prostatectomy (RARP) at the Univ of Mich hospital – he was discharged after 24 hours and cross-country skiing four weeks later, but he was very active before the surgery and in good shape to begin with – he said no to radio & chemo – like me, he is 74 and had it done 6 years ago – whichever path you choose i wish you the best outcome, and you have a wonderful son that loves and cares for you –
Many state/public employees with retirement health care are begin routed into Medicare Advantage. North Carolina advertises its Humana MA program as 90/10 (“equivalent”) with no spouse premiums vs a Medicare 70/30 option with monthly spouse premiums of several hundred dollars. Virtually everyone chooses MA in retirement.
It is also becoming very very clear that physician’s practices are being bought up by expanding health networks, as here in Washington State you see Polyclinic growing to buy more and more doctor networks ( and the degree of hedge funds behind them I have no idea, but….) and THEN if you look a bit further you discover that the overall owner of Polyclinic is a Health Plan (!!!) now renamed Optum or something like that… (https://www.fiercehealthcare.com/payer/seattle-based-polyclinic-absorbed-by-unitedhealth-s-optumcare) ….which is now nakedly promoting its Medicare Advantage plans to possible customers, over traditional Medicare…..How this is even legally possible remains a complete mystery to me….
Optum is owned by Unitedhealth. https://www.unitedhealthgroup.com/people-and-businesses/businesses/optum.html
Matt Stoller and others have written about how UnitedHealth has moved into the care business after Obamacare and has made a series of acquisitions of practices (usually just below the limit that requires federal approval). They bought one of the largest such groups in Massachusetts (Atrius Health)
I’ve used this NC state retiree program for a year without issue, including to ER for possible heart attack that i paid $65 for a complete workup and $40 for detailed followup vascular imaging and consult. Have been able to select any Duke or UNC Dr unconstrained, and just had broad genetic testing done at Duke Cancer because of family history that was covered completely. My spouse just had a colonoscopy also for $40. She will be Medicare eligible in 12 months, when current $650/mo to cover her drops to $4+medicare B w/ Humana covering D with of course no coverage for higher tier drugs on their reasonably stable formulary. I use the silver sneakers gym membership in AZ and NC, great for the weekly HIT I do that I always felt ripped off about when paying a large monthly fee for what amounted to 3 hr/month gym time. So far we are medication free, but yes the prospects of higher tier drug expense always looms.
And when she is Medicare eligible we will certainly reassess whether Medicare+Medigap makes sense compared to Humana or whoever NC shifts to as Boomheist downthread suggests. Certainly the current Humana vision and dental parts at extra expense are not good value IMO.
And i’ll add that my 35 yr PCP in NC retired 2 yrs ago and it took that time searching to find a replacement taking new patients in an area crawling with Drs but all specialists. Finally found one, who promptly went on maternity leave. Thousands of retirees are moving here, i guess they think that PCPs are abundant.
WakeMed, in the Raleigh area, is one relatively large local provider that didn’t sign a contract with the state’s Humana MA program last year. So they are “out of network” now. Didn’t affect me but suspect many are looking for new providers or ways to move back to the 70/30 + Medicare option.
Hopefully, it will be easier for state retirees to move from MA back to the 70/30 + Medicare plan if MA turns out too good to be true.
The idea that a for-profit private company can promise you lower co-pays and more coverage at lower premiums than the government, as long as you are healthy, is ridiculous.
Yes but notice what happened to the guy in the story. He was pitched on Medicare Advantage. Thought it sounded so great he didn’t bother comparing it to Medicare. And the ads on old people TV are nonstop.
Of course, my criticism is of the concept of Medicare disadvantage itself, not of the people who had to choose it.
Understood.
Totally agree about the ads but we cannot discount for a second the appeal of “zero premium” MA plans which include drug coverage, and vision, dental -such as they are – and gym memberships – to anyone who is income restrained (think, everyone in that cohort that cannot come up with, say, 400 dollars in unexpected new costs or is one paycheck away from under the underpass). When choosing a plan such people are of course looking for any way to to minimize out of pocket monthly costs, and further costs at the other end, such as co-pays or so called Out of Pocket Maximums,( which for MA plans are in the 5,000 to 8,000 range), while seen, are discounted or by financial necessity ignored when signing up.
One consideration for such people, if they can find $ 60-75 a month here in Washington state, and probably similarly in other states, is to stay on Traditional Medicare or go on Traditional Medicare now before March 31st if they have just enrolled (ie within six months of their Medicare enrollment period) and buy a Part D plan for 10 to 25 a month and then to buy a high decuctible Medigap Plan for 50 a month, which has a 2770 annual deductible, as compared to buying as Part G Medigap plan for 150 to 250 a month depending where you live (which has no such deductible.) Worst case you might pay 600 for the plan premiums and 2770 for the deductible (which remember is the 20 percent portion of bills so you’d need to incur over 11,000 in bills that year); best case you are out of pocket only 600 dollars if you have a good year. And once you have any Medigap, you can switch from high deductible to a full version pretty much any time here in Washington, so if you know for example you are going to face big medical bills in six months, say as knee replacement, you can upgrade now to a full plans in time.
The comments about being under Traditional Medicare and then struggling to change Medigap plans one state to another are troubling if true, as most of these plans are by definition national- and I’d love to hear more about that circumstance. You are supposed to be able to change around among the various Medigap Plans if you have Medigap of any kind WITHOUT underwriting tests. Remember Traditional medicare is national in scope, covering any US doctor anywhere in the US, and so are the Medigap plans.
One other comment is if you ARE a longer term MA customer, ie beyond the six month no questions asked Medigap enrollment, it may be if your Medicare Advantage company also offers Medigap plans to those on Traditonal Medicare maybe because they know your medical history they may be more likely to cover you without penalty. Maybe. Worth asking…..
With the *as long as you are healthy caveat* it’s not rediculous at all. Of course it defeats the whole purpose of insurance
>And the ads on old people TV are nonstop.
Understatement of the month! Not only are MA commercials nonstop, they are qualitatively the most obnoxious and counterproductive ads I’ve ever seen. I Do Not Understand why these ripoff artists are allowed to use the Medicare name in promoting this garbage. Fortunately my wife’s employer (we are both retired) provides us with excellent Medigap, visual, and dental insurance through the State of California.
Calls to my old people’s flip-phone were non-stop until Dec. 7. You can’t block them. They seem to have an endless battery of phone numbers to maintain the barrage. Soon you get know the area codes (202 and 505 big time) and block them immediately, but they kept coming. I’m marking Oct. 15 on my calendar.
This article shows why “Medicare For All” is a bad idea, because if it were ever implemented it would be “Medicare Advantage For All”. We need National Health Care For All. What we don’t need are third party insurers who add zero value to receiving health care.
I’m not old enough for Medicare, but if and when the time comes, I am better informed so as to not fall victim to the ubiquitous scams, snake-oil, rip-offs etc that we call “US health care”. Thank you NC for being on top of this, it’s like a full-time job just to keep track of the shenanigans.
Two years ago I was working in my yard and had a deer tick infect me with Lyme disease.
I had premium health insurance through a company that is also the largest Medicare Advantage provider in my state.
Having had bad experiences with the healthcare system, I diagnosed myself (easy– deer tick and target rash were visible), found the proper solution for it (30 days on amoxicillin), and went to a doc-in-the-box near where I live.
The ‘doctor’ agreed that it was Lyme Disease, but threatened that I either have a blood test or she would not give me a prescription for the antibiotics.
As I was becoming too sick to stand up, the insurance company refused to pay for the prescription. After most of an hour on the phone with the pharmacist, the insurance company said that 1) yes, I was insured with them and 2) yes, they were obligated to pay for the prescription but 3) they just weren’t going to. No further reason was given.
They added that I could appeal the decision by driving several hours from where I live to appeal to an ‘arbitration panel’ consisting of lawyers working for the insurance company. I was so sick that I forked over the full prescription price and spent the next week in bed.
The doc-in-a-box called to tell me that the blood test had come back negative. Of course it did. It was an antibody test that had a false negative rate of 75% in the first 21 days after infection with Lyme disease.
The doctor didn’t know this. She didn’t appear to know what an antibody test is. She knew nothing about the 21 days and false negatives. As it turns out, she is absolutely typical. The Cleveland Clinic claims that there are no false negatives from the antibody test even though I was able to find conclusive evidence about them from a reliable source in ten seconds.
Since then, I simply assumed that I had gotten Long Covid from an asymptomatic infection. For two years I’ve barely been able to get out of bed and my memory has been that of a much older person.
As it turns out, there is such a thing as “long’ Lyme disease with the exact symptoms that I have been experiencing.
Two weeks ago I started antibiotics for an unrelated infection. Toward the end of the course I started feeling better than I have in years.
Having been a runner for most of my adult life, I am now able to run consistently again.
However, and this is my point, I would have been much, much, better off without the insurance, without the doctor, and without the doc-in-a-box staff.
My experience is what Medicare Advantage participants can expect in my state.
I’m not speculating here. The complaint roster for this provider has over eight-hundred complaints about the insurer simply refusing to pay claims. Many of those whose claims were denied died while waiting for ‘arbitration.’
>And the ads on old people TV are nonstop.
Our long-time PCP practice was sold a couple of years ago. The practice became part of an accountable care organization (ACO).
When I went to the doctor’s office for a visit, there were Medicare Advantage posters in the waiting room.
I feel more like a customer than a patient.
I would also like to point out that the limited networks, denial of payments, problems with referrals are also experienced by people on Obamacare plans.
–antidlc (still stuck in Obamacare hell while helping out a family member)
Romney/Obama “care” is just a giant subsidy for the insurance parasites -it’s a scam as usual. The US is the only OECD country that lacks a comprehensive health care system. The US spends at least 18% of GDP on “health care” – the most of any country, yet has some of the worst health outcomes. In some cases the US has the worst health outcomes in the whole OECD.. The US is the only (perhaps now New Zealand) that allows BigPharma ads on TV, doctor’s offices etc.
The US health extortion system makes the Mafia look good by comparison. At least the Mafia is honest about it: “nothing personal, strictly business, just pay us the f-in money!”
I recently signed up for Medicare and when presented the *opportunity* of an Advantage plan, had an immediate thought along the lines of advantage for whom?
Being distrustful by nature, it only required me to dedicate two spare gray cells to figuring out the answer. Thing is, most people are both stupid and greedy and lack the ability to figure out who is getting screwed when the deal seems too good to be true.
However, what especially sucks is the government is in cahoots with the insurance companies in allowing the process to be like a diode, a one-way gate to perdition. So once they figure it out, it’s too late and they’re screwed.
Who is really to blame? Not the companies because they’re doing what companies do, so you may as well get angry at a snake for being a snake. Nope, it’s those on the take, as usual – Congress (both parties). Or does anyone labor under the belief these things happen to our citizens by accident?
Could it be the French were onto something in the application of Dr. Guillotine’s invention to their leadership class beginning September 5th of 1793? Or as Shakespeare’s most famous line in Henry the VI line expresses, “The first thing we do, let’s kill all the lawyers”.
Me? I don’t know the answer because I’m a non-violent person but it seems the vote is being subjugated from the will of the people to those who rule us. And thus, we the people are simply being ignored.
Case in point; recently in Ohio the citizens voted to allow abortion, the state government decided to ignore them. And in FL, smoking pot won on the ballot but the legislature has ignored them by making it difficult. Ditto NY.
So today’s angry citizenry seems to have good cause for their feelings, and with these Advantage plans, they screw over the ones with the greatest proclivity to vote. Me? I’m thinking one day, they may find themselves voted out of office in a wholesale fashion, e.g. vote them all out!
Couldn’t happen to a nicer bunch.
Political bribery is legal in America. And when they voted out they get jobs as lobbyists.
Companies doing what they do = Congress doing what it does.
The newest wrinkle I’ve seen is the ‘extras’ that are only available to Advantage plans. There is a grocery cash benefit and the Silver Sneakers exercise program that are under Medicare but only available to those in Advantage plans. A friend of mine thinks these are both great benefits (they are), but that Medicare only provides them to those with Advantage plans is not good. My friend thinks his plan is great because of these modest benefits, but he hasn’t had any serious medical issues yet.
Thanks for your comment. DIdn’t know that the Silver Sneakers plan was under Medicare but only available to Disadvantage members. That figures! Every year my good friend resolves to get away from the Disadvantage plan but his complaints are “no silver sneakers”, “Medicap is way too expensive”. He works out daily and keep away from doctors, pharma drugs and hospitals. He’s very healthy and practices yoga and is a vegetarian. He says to me that the annual wellness visit is a joke and most PCP’s don’t know how to diagnose a problem. I tend to agree with his views. I wonder why Medicare forces one to choose a drug plan when opting for Original Medicare + Medigap?
Not true about Silver Sneakers. I have Medigap G and the plan includes Silver Sneakers.
Often what isn’t stated in these articles is how Medicare Advantage (MA) impacts providers. As someone who works for a small non-profit stand alone Skilled Nursing Facility (SNF) on the outskirts of Chicago, where patients are admitted for rehabilitative therapy services, the difference between MA and traditional Medicare can be startling. While the care of the patient is the same, the additional bureaucratic work around MA is what makes it a huge disadvantage. While both Medicare and MA need to meet 3 midnight rule to be admitted to a SNF, MA will also need additional pre-authorization in order for the patient to start their rehab. While your admission team can utilize on-line portals such as Navi-Health that work on behalf of MA plans to obtain pre-auth, often they will need to spend time on the phone wasting up to an hour getting through. In addition, since the pre-auth requires specific diagnoses codes, a typical clerical office worker would not have the knowledge how to answer certain questions if the MA rep follows up, thus someone at the level of a nurse or equivalent usually performs these tasks (which include scanning, faxing, emailing hospital medical records) wasting their talent instead of caring for patients. This pre-authorization of course does not guarantee payment from MA plan. Then every few days after the patient is admitted, the process of re-certifying their care by forwarding medical records continues until the MA sends a letter that the patient according to them no longer meets skill care. Each facility usually has contracts with specific MA insurances in order to be in-network to admit patients. If you don’t sign a contract (meaning you are out-of-network), you might be perceived as a non-preferred provider if the local hospital is looking to discharge their patients which might negatively impact your census. Each contract specifies a reimbursement rate which is always much lower than what traditional Medicare pays. Our daily gross Medicare reimbursement is around $600/day. Depending how the contract is structured (most of the time a facility does not have much leverage to negotiate a more favorable rate, basically you either take it or leave it) it will vary between tiered rates for example $350/day for traditional care to $550/day for more advance care to a percent of charges such as 95% of Medicare reimbursement minus any other fees such as 2% sequestration. Therefore your MA reimbursement can range from 93% to 58% of what traditional Medicare pays. But, it doesn’t end here. Once the facility gets paid, the MA plan often will audit the payment. Sometimes they will even do an audit before the facility gets paid. Usually they will find something small in the medical records such as a lack of signature to deny a portion of the claim. Traditional Medicare does audits also, but very infrequently. Fortunately for us, our overall MA volume represent less than 10% of facility revenue, but as NC has been reporting for a while now, 51% of elderly are enrolled in MA and it is going to probably go higher. I can’t fathom how a stand alone non-profit SNF especially in a rural setting would be able to survive on majority of MA reimbursement. These facilities if they make 1% of net profit, consider it a good year. Many, if they are lucky and have endowment funds, usually tap into it in order to meet cashflow operational needs. Since Covid, a lot of SNFs have been suffering census issues which compound the problem. All in all, MA plans require you to use more resources for lesser gain. This is a recipe for disaster.
I have a Humana Advantage HMO, which has actually been OK. I simply could not afford Medigap and Medicare was also a stretch. The first year I had Humana, I needed a drug that cost $120,000 and expensive monthly bloodwork. They paid all but $8.00, with no problem. Later that year, I found I had an invasive breast cancer. They paid all but a $1000, and even sent me a supply of truly awful frozen dinners. I think where you live is the deciding factor. Philadelphia has so many poor folks, if they refused bad insurance or Medicaid, they would have no patients, and PA is fairly liberal.
Thank you. I absolutely hate articles like this one. I don’t see the point in stressing people out because they can’t afford the Cadillac and had to buy the Yugo so that they can at least get around.
In case no one’s noticed, it’s difficult to impossible to get a timely appointment with a PCP or specialist no matter how much money you’ve got to spend.
And the quality of “care” in this country is abysmal judging by statistics that rate population “health.” Life expectancy is declining. It’s time to consider the possibility that you’d be better off just avoiding the mess altogether.
Not to mention that even non-Medicare “insurance” in under-65s causes a tsunami of medical bankruptcies year after year and no one gives a good goddamn.
Constantly harping on how bad Medicare Advantage is is just whistling past the graveyard. The whole system is rotten to the core, predicated as it is on keeping people thinking they’re as sick as possible for as long as possible to maximize the profit per soul.
I think it’s obscene that seniors are incessantly harangued about spending their last dime to buy a “healthcare” plan that pays a provider, if they can find one, the MAX or they’ll be sorry. It’s abusive. Cut it out, please.
I agree completely!
We don’t watch TV so haven’t seen those ads, but during the open enrollment period We get a letter every other day urging us to enroll in different plans which are simply scams.
I am at something of a loss. I am 83. I have a Medicare Advantage policy, which, so far, has served me well. That includes eye operations on both eyes. The only things I paid for where three office visits with my opthalmologist — $25 each time for a totally of $75. One of my eyes required a special lens which cost me $1,200 plus $505 for operating costs. The operation was performed at Rex Hospital here in Raleigh, NC. (This hospital is part of the UNC Health Care system. I can go to any physician/specialist in the Duke, Rex, WakeMed and UNC systems of my choice) I realize that many people cannot afford those type costs. It was already a stretch for me. But it is considerably better than the alternative!!!! I have had a major operation on my spine after several cortisone treatments (9 if I remember over about 5 years) before I needed surgery. None of that cost me a dime. The same applies to my shoulder impingement for which I received shots a couple of times. They were ineffective and short-lived. The surgery and the shots did not cost a penny. So……I do not know if I have been lucky, but my MA plan has been of tremendous assistance over the years. Both my wife and I have had episodes of skin cancer. All treatment to date, removal, biopsy and treatment have also been without cost. So much as I empathize with those who are less fortunate, we have had the most satisfying success with our MA.
One possible exception may be Medicare Advantage plans that are effectively HMOs for the medical systems of teaching hospitals. My parents were in the HMO of the University of Alabama med school and they were basically rolled into its Medicare Advantage plan.
Having said that, the supposedly well-rated rheumatologist who was treating my father’s autoimmune disease gave him an experimental treatment (n=8!!!!) which greatly worsened his symptoms, to the degree he shot himself. He also aggressively discouraged my father from trying a different protocol using tetracycline (an extremely well tolerated medication) which had vastly more evidence, albeit from many underpowered studies (as in no formal controls, but it would not have been hard to create controls from the records of patients with the same disease at roughly the same point of disease progress). I did not realize until much later there was a procedure I could have used to complain to the hospital board and force a review,
What happened to your father is absolutely shocking. Doctor acting like a psychopath. I feel bad for you. Really, really bad.
The reason I went to an Advantage Plan years ago was that when I read the material, it seemed that some Advantage plans offered to limit “out of pocket” payments to several thousand dollars, whereas Medicare seemed to be saying they would pay 80% of my medical bills, but that 20% that I paid would have no upper limit. Given the distinct possibility that the basic charges for treating a serious illness or accident seem to have no upper limit, I thought the Advantage plan was the better bet, the alternative being possibly catastrophic financially if I had bad luck and the black swans came for me. This is assuming that the Advantage plan actually pays what they claim to pay, a theory upon which this and similar articles cast a good deal of doubt. I have no idea how I can establish truth in this area, since we live in a polity where lying is a normal way of conducting business and discussing policy. My legislators are all good social democrats and will assure me they are fighting for my and others’ interests, and we see the result of this fighting.
I’d like to point out that my beloved Michigan Wolverines didn’t fight for the national championship of football. They won it. Big difference.
GO BLUE!!!
Recently 61 US senators pledged their support for Medicare Advantage. Among them is democratic senator John Fetterman from my state of Pennsylvania. These senators made the point that MA offers high quality affordable care to for their constituents. The support is bipartisan.
https://bettermedicarealliance.org/news/bipartisan-majority-of-senators-urge-support-for-medicare-advantage/
Yes, we have the best Congress money can buy.
These senators made the point that MA offers access to high quality affordable care to for their constituents.
There, fixed for ya!