The Kaiser Family Foundation lays out what Medicare Advantage plans–the health plans administered by corporate health insurers–are doing for their Medicare members in 2024. The Medicare Advantage plans disclose limited data on their performance. They are all too likely to be inappropriately delaying and denying care for anyone with a complex and costly condition because that’s one way they can maximize profits.
The insurers offering Medicare Advantage plans receive, on average, $2,329 more per enrollee than the government spends on enrollees in Traditional Medicare as a result of a defective payment system. With this money, they can offer an out-of-pocket cap and other appealing-sounding benefits to members. But, they pocket much of this money to benefit their shareholders, and people in Medicare Advantage often struggle to get the Medicare benefits to which they are entitled.
People in Medicare Advantage, unlike in Traditional Medicare, frequently cannot get the care they want from the physicians they know and trust. In Traditional Medicare, they are covered for reasonable and necessary services from most doctors and hospitals anywhere in the country. In an HMO, they can’t get care outside their community generally; moreover, they often need approval for costly and complex services from their Medicare Advantage plans before they will be covered.
It’s concerning that there’s so little data reflecting what the Medicare Advantage plans are doing with the money the government gives them. We don’t know what MA plans spend and don’t spend on care, or how often they deny costly services. We don’t know how many hoops each MA plan puts people through or the extent to which each MA plan discriminates against different subpopulations of people with Medicare.
We do know that 99 percent of people in Medicare Advantage plans must get prior authorization before they can get certain services. Generally, skilled nursing and rehab care, Part B drugs, inpatient hospital stays and psychiatric services all require prior authorization.
As Medicare Advantage insurers have learned to game the Medicare payment system–largely by relying on physicians and nurses to add diagnosis codes to patient records, even when they are not treating patients for these conditions–the insurers have been able to offer a little bit more in the way of supplemental benefits to their members. People often join Medicare Advantage plans for these benefits. But, it’s unclear how many people actually receive these benefits; the data is unavailable. And, it’s equally unclear what basic Medicare benefits they give up–as a result of inappropriate denials of care–in exchange for these supplemental benefits.
To be more specific, it’s unclear how valuable a Medicare Advantage plan’s dental benefit is. It’s not standardized. So, depending upon the Medicare Advantage plan, it could only cover care from a small number of dentists or only cover a small fraction of the total cost of dental services or only cover a cleaning. Copays can be high.
People in Medicare Advantage have an out-of-pocket limit on their costs, if their Medicare Advantage plan is willing to cover the care their treating physicians say they need. The limit averages $4,882 for people in HMOs and $8,707 for people in PPOs. Traditional Medicare limits people’s costs to 20 percent of its approved amount with no ceiling.
Here’s more from Just Care:
- Bi-partisan group of Senators call for better Medicare Advantage data to protect enrollees
- 19 Leaders Support CMS Medicare Advantage Proposed Payment Changes using data from United Health Group’s Study
- Medicare Advantage: Combating fraud is a challenge because there’s no data on denied claims
- Medicare Advantage plans fail to release data required for oversight
- Data show Medicare Advantage covers less nursing, rehab, home health care
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