The Kaiser Family Foundation just released a report on Medicare Advantage facts and figures for 2022. The report shows no additional premiums for most people in Medicare Advantage (MA), the private health insurance option for people with Medicare. But, it comes on the heels of reports from the US Department of Health and Human Services’ Office of the Inspector General, Government Accountability Office and MedPac detailing key failings with Medicare Advantage that drive up Medicare spending and threaten the health and well-being of enrollees.
There’s reason that people enroll in MA. Sixty-nine percent of people with Medicare Advantage get the Medicare Part D prescription drug benefit at no additional cost to them. They are in 0 premium Medicare Advantage plans. But, the more important question is: Are they covered for the care they need when they need it? Or, do they pay more for their care than they would in traditional Medicare with supplemental coverage, and do they pay more for their drugs when they need them than people in traditional Medicare who pay a separate premium for Medicare Part D coverage?
While there’s no denying that Medicare Advantage has lower upfront costs than traditional Medicare, there’s also no denying that they too often inappropriately delay and deny care. In other words, join a Medicare Advantage plan and you might go without needed care or have to pay out-of-pocket for the full cost of that care. We don’t even know which Medicare Advantage plans are the worst offenders, so there’s no way to avoid them. Do not be misled by the government’s star ratings.
Even for services that Medicare Advantage plans cover, maximum out-of-pocket costs can be twice or even three times as much as you would spend for care in traditional Medicare with supplemental coverage. Medicare Advantage plans have an out-of-pocket limit in 2022 that averages $4,972 for HMOs and $9,245 for PPOs. And, Kaiser reports that if you need seven days or more of hospital care, you are more likely to incur higher out-of-pocket costs in a Medicare Advantage plan than in traditional Medicare.
Most Medicare Advantage plans require you to get their prior authorization before they will cover a wide range of services that your doctor might say you need. Indeed, virtually all specialty services and medical equipment require prior authorization in most Medicare Advantage plans. Prior authorizations are a way for Medicare Advantage plans to keep utilization down and can lead to inappropriate delays and denials of care and coverage, as the Office of the Inspector General has found.
Notwithstanding the restrictions in access to care in Medicare Advantage, people often opt for this coverage because they offer additional benefits and low upfront costs. For example, you might be able to get some vision, hearing and dental coverage if you can afford the copay and use their network providers. But, Medicare Advantage plans have never disclosed medical service usage data for these additional benefits, and it appears that enrollees who join because of these benefits often do not get them because of high out-of-pocket costs.
The government has done a poor job of collecting information on use of medical services and out-of-pocket spending in Medicare Advantage. Until we have meaningful data that is publicly reported, anyone who joins a Medicare Advantage plan is taking a gamble with their health and well-being should they develop a serious condition.
Here’s more from Just Care:
- Government watchdog agencies tell Congress Medicare Advantage inappropriately restricts access to care and needs fixing
- Well-kept secrets of Medicare Advantage plans
- Four things to think about when choosing between traditional Medicare and Medicare Advantage plans
- If you want easy health care access and good quality care, you probably want traditional Medicare
- Senate Finance Chair looks into deceptive Medicare Advantage marketing practices
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