Medicare Your Coverage Options

Don’t rely on Medicare Advantage plans to cover care from doctors you can trust

Written by Diane Archer

There is not a lot of good information available to help you choose a doctor, whether the doctor is a primary care doctor or a specialist. Yet, particularly when you’re ill or injured, it is important to be able to count on good primary care doctors and specialists. Unfortunately, you cannot rely on Medicare Advantage plans–commercial health plans that contract with the federal government to provide Medicare benefits–to cover care from doctors you can trust, let alone from the doctors you want to see.

A recent Pro Publica report highlights how a Medicare Advantage plan had a neurosurgeon in its network who was critically harming and sometimes killing his patients. Lesson learned: It is a mistake to assume that Medicare Advantage plans ensure the quality of the doctors with whom they contract to provide in-network care.

It is also a mistake to assume that Medicare Advantage plans offer you the choice of doctors you want to see. A Kaiser Family Foundation report found that more than one in three Medicare Advantage plans offer narrow networks, meaning less choice of doctors and hospitals. They typically include fewer than half of all doctors in a region.

Medicare Advantage plans also typically cover care at only half the hospitals in their area, according to the Kaiser Family Foundation. What’s particularly troubling is that they too often do not cover care at centers of excellence. Even when there is a national cancer institute in the area, more than 40 percent of Medicare Advantage plans do not cover care delivered in that specialty hospital.

Fewer than one in four Medicare Advantage plans offer broad networks, covering care in 70 percent of area hospitals.

It’s critical to do your homework before deciding to join a Medicare Advantage plan. Traditional Medicare may require higher upfront costs than Medicare Advantage plans–particularly for people who need to buy supplemental coverage. But, traditional Medicare offers coverage from a wide range of doctors and hospitals throughout the country; and, you do not need a referral from a primary care doctor to see a specialist. Moreover, with supplemental coverage, you generally have no or small out-of-pocket costs for covered services. Out-of-pocket costs for in-network care in a Medicare Advantage plan can easily reach $6,700 a year for people with costly conditions. And, the sky’s the limit on your out-of-pocket costs if you use out-of-network care.

No matter which Medicare plan you are enrolled in, be sure to choose your doctors carefully, a challenging task. Keep in mind that hospitals may employ surgeons who are not fit to be practicing medicine. They may not report surgeons who they know to be hurting their patients. And, these doctors may do serious harm.

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3 Comments

  • Several years ago my primary care doctor’s group signed up with a Medicare Advantage Plan and tried to get all their patients signed up. I was hesitant but finally decided to try it. They gave me a list of all the specialties that were covered. I called one of the listed dermatologists and was told (very rudely) that they never agreed to join the plan and weren’t taking any Medicare patients. Next I fell and needed a CT scan but there were no participating CT scan places so I had to pay a lot upfront. After a year of trying to get the treatments that I needed I decided to rejoin traditional Medicare and buy a supplement. By then I was accused of having pre-existing conditions and all but one of the supplemental companies in my area refused to cover me.

  • There you go again Diane, bashing Medicare Advantage plans. You apparently are one of the lucky ones who can afford a Medicare Supplement plan. How about offering good advice to those of us who can’t?

    • Works as long as you don’t need medical attention. I’ve had two friends with Medicare Advantage die this year. The first had a lump for three years and the doctor said it wasn’t important. Then she was diagnosed with Stage Three breast cancer that had metastasized. She died in February. The second death was a man who had been told his prostate markers weren’t anything to worry about. Until a new doctor discovered the cancer had metastasized. He died this week.

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