If you’re in a Medicare Advantage plan, you should seriously consider taking advantage of the Medicare Advantage open enrollment period between January 1 and March 31 that allows you to switch to Traditional Medicare (government-administered insurance coverage) or to a different Medicare Advantage plan. This right to switch out of your Medicare Advantage plan is a critical consumer protection. And, there’s always good reason to switch.
There are few guarantees with Medicare Advantage and no telling whether the plan you’re enrolled in will cover the care you need when you need it. Here’s why: Between the time you sign up for a plan and the beginning of the new year, both the drugs and providers the plan covers could have changed significantly. So be sure to check.
Even if all is as expected with your Medicare Advantage plan, keep in mind that the four and five-star plans could have high denial rates. The star-ratings are a farce. You never know what injury might befall you or illness you might be diagnosed with and whether your Medicare Advantage plan will cover the treatments your physicians recommend or deny them.
Too often, you will be faced with what could be harmful delays as a result of prior authorization requirements. They also inappropriately deny care, particularly to people with costly conditions–people needing rehab care, people with cancer and people with other complex care needs. The Office of the Inspector General has twice reported widespread delays and denials of care and coverage in most Medicare Advantage plans. Access to care is much simpler in Traditional Medicare than in Medicare Advantage.
I’ve written at length about all the reasons not to enroll in a Medicare Advantage plan, especially if you have Medicaid or can afford the supplemental coverage that you need in Traditional Medicare to limit your out-of-pocket costs. Yes, upfront costs in Medicare Advantage are lower than those in Traditional Medicare with supplemental coverage. But, if you get sick and need care–the reason you have health insurance–your out-of-pocket costs are likely to be a lot higher in Medicare Advantage than in Traditional Medicare.
In Traditional Medicare, your treating physicians decide the care you need without an insurance company second-guessing your doctor and profiting every time it denies you care. And, there are few prior authorization requirements, requiring you to wait before your care will be covered. Furthermore, you are covered for care from almost all providers anywhere in the US, whereas in Medicare Advantage, your insurer generally will only cover your care from a limited set of providers. And, in Traditional Medicare, with supplemental coverage, your costs are predictable and often very little.
Medicare Advantage HMOs restrict your coverage to the doctors and hospitals in their networks. You can go out of network for some coverage only if you’re in a PPO. But, even in a PPO, coverage tends to be limited and unpredictable. Driving your costs up further and/or endangering your health, Medicare Advantage plans usually impose prior authorization requirements before they will cover costly care.
The Centers for Medicare and Medicaid Services, which oversees Medicare, should be protecting you from bad actor Medicare Advantage plans, but it cannot. It does not have the capability, the money, or the power to oversee the more than 3,000 Medicare Advantage plans, much less to hold them to account for their bad acts.
You should also bear in mind that you can’t count on the providers in Medicare Advantage directories actually being willing to see you. Multiple reports reveal “ghost” networks in some Medicare Advantage plans. As well, I’ve reported many times in Just Care on hospitals terminating their Medicare Advantage contracts, leaving Medicare Advantage plan enrollees scrambling to find alternative care or forced to drive long distances for inpatient services.
N.B. If you want to switch to Traditional Medicare, note that you will want supplemental coverage (Medigap) to protect you from high out-of-pocket costs. Traditional Medicare does not have an out-of-pocket limit. If you don’t have Medicaid or coverage from a former employer, make sure you can buy Medigap in the individual market. In most states, insurers selling Medicare supplemental coverage are not required to sell you a policy, with some exceptions, including when you first enroll in Medicare at age 65 or later.
Here’s more from Just Care:
- Medicare Advantage networks can be narrow and harmful
- Senate investigation shows high Medicare Advantage denial rates for costly care
- To increase Medicare Advantage profits, insurers slash benefits and pull out of some markets
- Traditional Medicare v. Medicare Advantage? Different as night and day
- Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
