JustCare

Category: Medicare

  • Insurers focus on Medicare Advantage Special Needs Plans to maximize profits

    Insurers focus on Medicare Advantage Special Needs Plans to maximize profits

    Laura Beerman writes for HealthLeaders about how Medicare Advantage insurers are making out like bandits from offering care to people in Medicare Advantage “Special Needs Plans” or SNPs. Insurers like the Medicare Advantage program because they profit more from Medicare Advantage plans than from other insurance they offer. Providing Medicare coverage to people who have both Medicare and Medicaid in D-SNPs is even more lucrative than providing Medicare coverage to people who have only Medicare.

    Medicare Advantage Special Needs Plans are intended to cover people with Medicare and Medicaid, people with chronic or disabling conditions, including people with diabetes, HIV/AIDS, and dementia, as well as people living in a nursing home or requiring nursing care at home. But, it is not clear that most of the SNPs actually provide people with good Medicare benefits from high quality providers. People eligible for SNPs should seriously consider traditional Medicare, which makes it easy to get care from the providers you want to see anywhere in the US. People with Medicare and Medicaid generally have no out-of-pocket costs in traditional Medicare.

    Insurers are getting an increasing number of SNP enrollees. The number of SNP enrollees has doubled in the last five years. Insurers are also offering more SNP plans. Insurers make twice the profits from SNPs covering people with Medicare and Medicaid than they do from people without Medicaid in Medicare Advantage plans.

    It’s not clear whether people in SNPs understand what they are giving up when they opt for a SNP instead of traditional Medicare. People with Medicare and Medicaid in SNPs tend to be especially vulnerable, in poor health and living on small incomes, struggling to make ends meet. They also often struggle to keep their Medicaid eligibility.

    The Biden administration made it a little harder for the Medicare Advantage insurers to run away with as many taxpayer dollars as they’d like. As a result of some reforms that rein in Medicare Advantage payments a little, the Medicare Advantage market is changing somewhat. Insurers want big profits. So, some insurers have ended some Medicare Advantage plans that are less profitable.

    More than half of people in D-SNPs (people with Medicare and Medicaid) are in either a UnitedHealth Medicare Advantage plan or a Humana Medicare Advantage plan.

    Here’s more from Just Care:

  • Insurers end agent commissions for certain Medicare Advantage plans

    Insurers end agent commissions for certain Medicare Advantage plans

    CVS and Elevance appear to believe that some of their Medicare Advantage plans are less profitable than others. To maximize profits, they have ended commissions to insurance agents for certain Medicare Advantage plans, reports Allison Bell for ThinkAdvisor. Bottom line, if you live in a state where insurer agents don’t have a financial incentives to steer you to those Medicare Advantage plans, you have even more reason not to trust an insurance agent to help you choose a Medicare Advantage plan. Get free unbiased advice from your state health insurance assistance program.

    It seems that the less profitable Medicare Advantage plans are in California, Connecticut, New York and Texas. What does that mean for consumers? Most likely, insurance agents will not advise them to sign up for certain Medicare Advantage plans even though those plans could be better options for them. Of course, one never knows.

    Right now, during the Medicare Open Enrollment Period, people are choosing between traditional Medicare and Medicare Advantage plans. If you can afford traditional Medicare’s upfront costs–the cost of Medicare supplemental coverage–or you have Medicaid or retiree coverage, enroll in traditional Medicare to ensure you will be covered for the care you need from the physicians and hospitals you trust, in a timely manner. If you cannot afford the cost of supplemental coverage and you need costly care, you will be taking a gamble choosing a Medicare Advantage plan.

    Most people with Medicare can still choose a Medicare Advantage plan that does not charge a monthly premium. And most will also have coverage for some dental benefits. But, beware. With Medicare Advantage plans, you don’t pay upfront, but as soon as you get sick and need complex care, you often pay big time–they might not cover your care, they might not cover the cancer center of excellence you want to use, they might delay your care even though you need it urgently, and they might charge high out-of-pocket costs.

    The dental benefit offered in Medicare Advantage is often very limited. It can be hard to find a dentist near you who will accept coverage. You will still likely have high out-of-pocket costs.

    No matter what you do, if you are in a Medicare Advantage plan and not switching to traditional Medicare, look very carefully at changes to your current plan and other options. You won’t be able to see whether a Medicare Advantage plan has high rates of prior authorization or high denial and mortality rates, unfortunately. That’s what you really need to know.

    Also, keep in mind that the five-star Medicare Advantage plans are usually better than the 1, 2, 3 and 4-star plans on some metrics, but they can still have high denial rates and high mortality rates. You just can’t know.

    Some good news on the prescription drug front. Your Part D drug coverage, whether through a stand-alone plan if you have traditional Medicare or through a Medicare Advantage plan, will have a $2,000 out-of-pocket limit in 2025. Unfortunately, your premiums and deductibles might go up and the list of drugs covered could shrink. Take a hard look at your options on Medicare Compare, the government’s web site comparing your options.

    Centene’s WellCare division seems to have decided that its Part D drug plans are not profitable enough any longer so it has stopped paying brokers commissions to steer people to those plans.

    For free unbiased help making a Medicare choice, call your state health insurance assistance program or the Medicare Rights Center at 1-800-333-4114.

    Here’s more from Just Care:

  • Lower income Medicare cancer patients less likely to get optimal care

    Lower income Medicare cancer patients less likely to get optimal care

    A new study of Medicare cancer patients published in the Journal of Clinical Oncology finds that patients with lower incomes who receive a Medicare Part D Low-Income Subsidy (LIS) through the Extra Help program, are less likely to get optimal care, reports Medscape. These lower income individuals too often do not get systemic cancer therapy as compared to individuals with higher incomes not in the LIS program. People in the LIS program are more likely to get treatment that is not recommended.

    The goal of the Medicare Low-Income Subsidy or Extra Help program is to promote health equity. However, many people with low incomes who qualify for the program either do not know it exists or face too many barriers applying for it. As a result, around half of all people eligible are not enrolled in it.

    To qualify for Extra Help, you must apply through your state Medicaid office. However, you will be automatically enrolled if you have Medicaid, receive Supplemental Security Income benefits or are enrolled in a Medicare Savings Program.

    This new observational study of cancer patients suggests that those who are enrolled in the LIS program still face financial barriers to care that prevent them from getting the systemic cancer treatment they need. The LIS program helps offset the cost of oral prescription drugs under Medicare Part D for people with incomes up to 150 percent of the federal poverty level. The LIS program does not help offset the costs of drugs administered by physicians under Medicare Part B.

    However, many people in the LIS program also qualify for a Medicare Savings Program. There are a few programs to help with Medicare Part A and Part B out-of-pocket costs, depending upon your income. Some pay the deductibles and coinsurance. To apply, contact your state Medicaid office.

    Also, as of January 1, 2023, a new Medicare prescription drug law could help offset coinsurance costs for some drugs and biologicals under Medicare Part B.

    Of the group studied, more than 40 percent did not receive systemic therapy for their cancer. Those who did not receive systemic therapy were more likely to be among those in the LIS program. Moreover, of those who did receive systemic therapy, those in the LIS program were more likely to receive inferior care.

    The study authors posit that the inferior care for the LIS cohort stems from financial barriers.

    Here’s more from Just Care:

  • What happens to Medicare if Trump wins?

    What happens to Medicare if Trump wins?

    Older adults and people with disabilities have no warning to avoid enrolling in Medicare Advantage plans–plans run by corporate health insurers–that likely will deny them care. And, they have no good protections. If Donald Trump becomes President again, everyone could be forced into a Medicare Advantage plan, reports Jessica Glenza for The Guardian.

    Today, traditional Medicare, the government-administered alternative to Medicare Advantage, has become a luxury for the wealthy. People enroll in Medicare Advantage because the upfront costs are lower. And, they are then locked in. They can’t switch to traditional Medicare because it lacks an out-of-pocket cap, and they can’t afford supplemental insurance to protect themselves against catastrophic costs.

    Problems abound in Medicare Advantage for people who get sick and need costly care. Millions of people in Medicare Advantage struggle to figure out how they are going to stay with their treating physicians because their Medicare Advantage plan is leaving their area or their physicians are leaving their Medicare Advantage plan networks. Or, they wonder how they will travel tens of miles to get the care they need because their local hospital is no longer in-network. Or, they struggle to deal with Medicare Advantage denials of care their treating physicians says they need.

    Joe Namath and William Shatner might tell you how much they like Medicare Advantage, but dollars to donuts, they are in traditional Medicare. Traditional Medicare is a luxury for the wealthy because it actually covers the care you need from the physicians and hospitals you want to use.

    Trump and his supporters in Congress want to privatize Medicare and end traditional Medicare. They want you to believe that you will have all the choices you need in Medicare Advantage. The fact is that you will have a bunch of meaningless choices because you won’t be guaranteed the choice of a Medicare Advantage plan that will meet your needs if you are in an accident or are diagnosed with cancer or heart disease. Only traditional Medicare guarantees you coverage for all your needs.

    The ten big insurers offering Medicare Advantage have been charged with fraud many times. In 2022, eight of them were defending themselves in court.

    While Medicare Advantage plans might not meet your needs, they meet the needs of the biggest health insurers, who are able to profit wildly. Nearly half of United Healthcare’s total revenue came from Medicare Advantage. But, Medicare Advantage enrollees represent only 15 percent of all its enrollees, according to Accountable.US.

    Trump and his supporters in Congress appear to prefer a Medicare program in which health insurers have the financial incentive to stint on care and profit wildly at taxpayer expense, to a more cost-effective world in which people can get the care they need and the government is in charge.

    Here’s more from Just Care:

  • New OIG report finds taxpayers pay billions extra for Medicare Advantage insurers’ in-home visits

    New OIG report finds taxpayers pay billions extra for Medicare Advantage insurers’ in-home visits

    For years, government agencies and independent experts have reported that Medicare Advantage insurers game the Medicare payment system to generate billions of dollars in extra revenue from the government. A new report from the Office of the Inspector General focuses on how insurers use home visits as a way to add diagnoses to enrollee medical records and increase their Medicare reimbursements.

    The government pays Medicare Advantage insurers a flat upfront amount for each enrollee. The amount is based on what the government spends in traditional Medicare. But, the government increases that amount for “sicker” patients–patients with more diagnosis codes.

    So, insurers do what they can to increase the amount they get from the government; they “upcode” or add diagnosis codes to enrollee records. They engage nurses to visit enrollees at home and identify more diagnoses for these enrollees. The home visits could be value-added if the insurers provided care tailored to these diagnoses. But, the OIG reports that Medicare Advantage insurers generally simply bill the government more for these enrollees. They do not conduct follow-up visits or deliver other services related to the added diagnoses.

    On average, the insurers generate an extra $1,869 from each home visit. In fiscal year 2023, these visits translated into $3.73 billion for UnitedHealth alone. Not surprisingly, UnitedHealth contends that the home visits add value to the care they provide.

    What additional diagnoses did the nurses who conducted home visits tend to find? They found vascular disease, depression, morbid obesity, chronic obstructive pulmonary disease and rheumatoid arthritis most frequently. They also found enrollees with complications resulting from their diabetes.

    Now what? The Centers for Medicare and Medicaid Services (CMS), which administers Medicare, has never been successful at recouping the overpayments. But, it has ended payment to insurers for certain diagnosis codes that are commonly added during in-home visits and do not result in further treatment. It’s a start, but CMS clearly needs to do a lot more.

    Here’s more from Just Care:

  • Even with Medicare, older adults struggle to afford their care

    Even with Medicare, older adults struggle to afford their care

    Maggie Shaw writes in AJMC  about new findings reported in the Annals of Internal Medicine that many older adults struggle to pay the $1,600 Medicare Part A deductible. These findings corroborate a slew of earlier findings that cost is a barrier to care for people with Medicare, be they in traditional Medicare or Medicare Advantage.

    Most people in traditional Medicare have supplemental coverage to pick up those costs, either through Medigap, insurance they buy to fill coverage gaps, Medicaid, if their income is low, or retiree coverage from their jobs. How many people in Medicare Advantage can afford their care?

    Cost is a barrier to care for far too many people with Medicare, whether they are in traditional Medicare or Medicare Advantage. Traditional Medicare needs an out-of-pocket limit so that people who cannot get supplemental coverage still have financial protection. Usually, they sign up for Medicare Advantage, thinking they have protection because it does have an out-of-pocket cap.

    But, in Medicare Advantage, people are too often denied the care they need or forced to go through too many hoops to get their Medicare Advantage plan to cover their care. Moreover, when it is covered, they can have high out-of-pocket costs and they can’t get supplemental coverage to fill cost gaps. We have only a limited understanding of how often that leads Medicare Advantage enrollees to forego needed care.

    The AJMC study found that between a third and a half of all people with Medicare lack financial stability. Black and Hispanic adults with Medicare are particularly at risk financially; many do not have supplemental coverage. An NBER study a few years back found that even a $10 copay increase for prescription drugs under Medicare Part D led many to stop filling their prescriptions.

    The people most at risk in Medicare have incomes too high to qualify for Medicaid, up to 400 percent of the federal poverty level. Some of them qualify for Medicare Savings Programs that help with their costs. But, this help is not automatic and too often they do not apply for these programs. It’s a hassle.

    Instead, people with Medicare are left without needed care. The authors recommend that policymakers either make it easier for people with low incomes to qualify for help with their out-of-pocket costs or add an out-of-pocket maximum to Medicare.

    Here’s more from Just Care:
  • Senate investigation shows high Medicare Advantage denial rates for costly care

    Senate investigation shows high Medicare Advantage denial rates for costly care

    One thing’s for sure. If there’s a way for the UnitedHealth, Humana and CVS/Aetna to profit off of Medicare Advantage, they will find it. We know that they overcharge the government more than $2,300 a year per enrollee. A new Senate Permanent Committee on Investigations report finds that Medicare Advantage insurers also profit from denying rehab services, nursing services and other costly services at ever-increasing rates.

    The Senate Permanent Subcommittee on Investigations’ report warns that insurers “are using prior authorization to protect billions in profits while forcing vulnerable patients into impossible choices.”  Older adults and people with disabilities are getting hurt. What exactly are the insurers doing to manage their enrollees’ care?

    According to Senator Richard Blumenthal, who chairs the Subcommittee: “Insurance companies say that prior authorization is meant to prevent unnecessary medical services. But the Permanent Subcommittee on Investigations has obtained new data and internal documents from the largest Medicare Advantage insurers that discredit these contentions. In fact, despite alarm and criticism in recent years about abuses and excesses, insurers have continued to deny care to vulnerable seniors—simply to make more money. Our Subcommittee even found evidence of insurers expanding this practice in recent years.”

    How do the insurers get away with all these denials? The report does not explain how the insurers get away with all these denials. But, the answer is simple. They often deploy a proprietary “secret sauce” to determine whether they should cover costly care. Their sauce can take a very narrow view of what is medically necessary care. Consequently, amputees can be denied rehab services. Newly diagnosed leukemia patients can be forced to wait long periods before their urgently needed care is approved.

    Is there evidence that insurers are not using prior authorization to improve care? All we hear is that they use prior authorization to keep people from getting care and to increase their profits. The Senate report does not get into other findings that some prior authorization denials for costly services are overturned on appeal more than 75 percent of the time. But, most people don’t appeal their coverage denials. The vast majority end up going without needed care. No one is looking out for them.

    The Centers for Medicare and Medicaid Services does not begin to have the resources to oversee nearly 4,000 different Medicare Advantage plans. It also lacks the power to hold insurers to account for their bad acts in meaningful ways.

    How to fix prior authorization? More rules won’t fix prior authorization in Medicare Advantage. Congress needs to take prior authorization out of the hands of the profit-driven insurers and put it into the hands of an outside independent entity that applies medically sound prior authorization rules in a standardized way across all Medicare Advantage plans.

    Here’s more from Just Care:

  • To increase Medicare Advantage profits, insurers slash benefits and pull out of some markets

    To increase Medicare Advantage profits, insurers slash benefits and pull out of some markets

    October 15 marked the first day of open enrollment in Medicare Advantage (MA) plans — a time that will deliver chaos and confusion for many of the 34 million seniors who depend on these plans to pay their healthcare bills. It’s yet another reminder that Medicare wastes billions of dollars funneling public money to private companies that are primarily driven by profit-seeking.

    Last year, more MA members than expected used their benefits to get necessary medical care. One might assume that companies would expect beneficiaries to use health care services. But after years of making outsized profits, the insurance companies that own these plans are reacting to this by downsizing plans, cutting benefits, increasing copays, and raising prescription drug deductibles. In other words, Medicare Advantage beneficiaries are being penalized for using the health care that they pay for.

    Insurers Are Dropping Plans and Slashing Benefits

    Having spent decades luring enrollees and collecting premiums, two of the biggest health insurers in the MA marketplace, CVS and Humana, are scaling back, slashing benefits, and canceling plans with too many members who used their health benefits. They are closing less profitable health plans that serve half a million or more seniors, forcing them to sign up for other more expensive or less generous coverage. Humana is set to leave 13 markets around the country, affecting 560,000 beneficiaries or 10 percent of its plan members. The reason for exiting? The CFO herself, Susan Diamond, said the specific markets just aren’t profitable. CVS Chief Financial Officer Tom Cowhey sent a similar message at a conference last month: “Could we lose up to 10 percent of our existing Medicare members next year? That’s entirely possible. And that’s okay because we need to get this business back on track.”

    Medicare Advantage plans are being impacted all over the country. In Vermont, MVP and WellCare are dropping two MA plans in January 2025. This will affect 6,000 older Vermonters who will need to quickly choose new plans in the upcoming enrollment period. The MA plans cited spiking health care costs and lower Medicare reimbursements. WellCare, which is run by Centene Corp, pulled out of Alabama, Massachusetts, New Hampshire, New Mexico, and Rhode Island in addition to Vermont, leaving 40,000 people and 4 percent of MA beneficiaries without continued coverage past the enrollment period. In New Hampshire, multiple MA plans are shutting down, leaving tens of thousands beneficiaries scrambling. In Minnesota, nearly 60,000 people will face disruptions to their MA plans.

    Health systems and hospitals are also making the decision to cancel contracts due to excessive prior authorization denial rates and slow payments from insurers. Already 27 health systems have canceled their Medicare Advantage contracts this year. MA plans can be especially harmful to rural providers who already face financial hurdles, and may further struggle to continue providing care to their communities due to unreliable and low reimbursements from insurers.

    The MA companies are following a similar strategy when it comes to prescriptions. To weed out people who require expensive medications, insurance companies are raising copays on drugs, hoping members will seek more affordable coverage elsewhere. Roughly two-thirds of all 34 million Medicare Advantage enrollees are in plans where the drug deductibles will increase by 167 percent — or at least $200 next year.

    And all of this is in addition to the serious, well-documented problems with denials of care and coverage in Medicare Advantage that beneficiaries have experienced since the program started.

    Medicare vs. Privatized Medicare Advantage

    The purpose of insurance companies running Medicare Advantage plans is to make money, pure and simple. Seniors across the country rely on these plans — yet the record shows that insurers don’t value the quality and affordability of care, and don’t want beneficiaries to use the medical services they need. Beneficiaries are tossed aside because they live in an unprofitable market for their insurer or because they are actually using the insurance they signed up for to access services.

    The purpose of Medicare is different: Protecting American seniors by guaranteeing health coverage. Medicare Advantage funnels taxpayer money to predominantly large insurance companies like CVS-Aetna and UnitedHealthcare to manage what healthcare beneficiaries can access. This has cost significantly more than Traditional Medicare, transferring hundreds of billions of dollars in overpayments to large corporations who profit by getting more taxpayer money and spending less on coverage. Now that beneficiaries want to utilize the care they have been promised, these insurance giants are choosing to raise healthcare costs for American seniors.

    As we reach the open enrollment period from October 15 to December 7, beneficiaries should consider signing up for Traditional Medicare to ensure they get covered for the care they need from the doctors and hospitals they want to use, without administrative hurdles. In Traditional Medicare, seniors need not worry about insurance companies dropping or altering their plans or pushing higher costs on them and reducing access. Since the government does not require an out-of-pocket cap in Traditional Medicare — something that is necessary in MA plans — beneficiaries should consider getting a supplemental Medigap plan if they can afford it to get true comprehensive coverage.

    In most regions, the companies assure that there will still be Medicare Advantage plans available from other companies, or the same company. But what is to say MA plans do not use profit as their north star once again next year?

    When healthcare is a business, regular people lose.

    Here’s more from Just Care:

  • Getting public assistance? Beware of Medicare Advantage flex cards

    Getting public assistance? Beware of Medicare Advantage flex cards

    Maya Goldman reports for Axios on the risks of Medicare Advantage flex cards for people getting public assistance. The extra money people think they’re getting through a flex card could mean the end of your government housing or food benefits. UnitedHealth, Humana, CVS offer these cards to entice people to join their MA plans without warning people that the cards could mean the end of their public assistance, even if they don’t use them.

    How is it possible people can lose precious benefits? Government agencies can count flex cards as income. So, when people apply for Supplemental Security Income or rental assistance, adding the value of the flex cards to their income could disqualify them.

    Why are Medicare Advantage plans offering flex cards when they could be harmful to enrollees? It’s hard to imagine insurers are concerned with the risks of giving flex cards to disabled and low-income enrollees. They likely see the flex cards simply as a good hook to boost enrollment and profits.

    Some of the flex cards are specifically targeted to use on items such as groceries and electric bills. Each Medicare Advantage plan offers something different. But, the value of these cards can be significant, with an average value of nearly $1,000.

    People with Medicare and Medicaid could be far better off in traditional Medicare, with coverage from most providers in the US and without the prior authorization obstacles to care people face in Medicare Advantage. But, an extra several hundred dollars a year from a Medicare Advantage plan to offset grocery or utility costs is hard to pass up.

    Ideally, the Biden administration could direct agencies not to consider the flex cards as income, as more than 30 Democratic members of Congress have requested. But, regulations and statutory mandates for different agencies could get in the way of that. Alternatively, CMS should permit insurers to use the money in the flex cards for a different benefit, such as over-the-counter drugs, which would not be considered income.

    The Department of Housing and Urban Development (HUD) excludes most Medicare Advantage benefits from a person’s income when they apply for help. But, HUD is required by statute to count certain utility and rent benefits as income.

    One other concern: People can be misled about the flex cards. They can come with a bunch of limitations that prevent people from using them as they expected. Of course, the insurers profit more if people don’t use their flex cards.

    The insurers, for their part, have done nothing to address the serious issues their flex cards present for some of their most vulnerable enrollees.

    Here’s more from Just Care:

  • 2024: What to know this Medicare Open Enrollment Period

    2024: What to know this Medicare Open Enrollment Period

    During this Medicare Open Enrollment Period, here’s the most important thing you need to know: You gamble with your health if you are in the Medicare Advantage program. Your upfront costs are lower in Medicare Advantage than if you enroll in Traditional Medicare and need to buy Medicare supplemental coverage. But, you could pay a much bigger price in Medicare Advantage when you need costly care. Please know that you can always call the Medicare Rights Center at 1-800-333-4114 or your SHIP (State Health Insurance assistance Program) for free, unbiased advice on any of your Medicare questions.

    If you can afford it, choose Traditional Medicare over a Medicare Advantage plan. Enroll in Traditional Medicare to ensure you have good and speedy coverage when you need it. Most older adults will develop a serious condition at some point. In Traditional Medicare, you and your doctor decide the care you need, with no prior approval. And, you have easy access to care from almost all specialists and hospitals in the United States with no incentive to stint on your care. In a Medicare Advantage plan, a corporate insurance company decides when you get care, often requiring you to get its approval first. Medicare Advantage plans also restrict access to physicians and too often second-guess your treating physicians, denying you needed care inappropriately. The less care the Medicare Advantage plan provides, the more the insurance company profits. You will pay more upfront in Traditional Medicare if you don’t have Medicaid and need to buy supplemental coverage, but you are likely to spend a lot less out of pocket when you need costly care. Regardless of whether you stay in Traditional Medicare or enroll in Medicare Advantage, you still need to pay your Part B premium.

    Get advice from your SHIP about your Medicare options and not from an insurance agent. Unfortunately, most insurance agents are paid to give you biased advice and steer you away from Traditional Medicare and into a Medicare Advantage plan, even if it does not meet your needs. While some insurance agents might be good, you can’t know whom to trust. For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a State Health Insurance Assistance Program (SHIP).

    Assume you will get worse care in Medicare Advantage than Traditional Medicare. In Traditional Medicare you get all medically necessary care your doctor recommends without having to go through any hoops. Every Medicare Advantage plan is different, some good and some to avoid at all costs. But, there’s no good information to tell you which plans to avoid. Overall, in Medicare Advantage you are very likely to get less home care, less rehab care, less nursing care, less hospital care if you need it than in Traditional Medicare. Medicare Advantage plans must technically cover the same benefits as Traditional Medicare, but they tend to cover many fewer services, taking the view that care your doctors say you need is not medically necessary. They often overrule your treating physician or delay treatment when you most need care. Moreover, there’s mounting evidence that you will see lower quality physicians and might not get access to specialty hospitals in Medicare Advantage. Bottom line: You cannot know whether your MA plan will refuse to cover the care you need or delay needed care.

    Don’t rely on friends or the government’s star-rating system to pick a good Medicare Advantage plan. Even if your friends say they are happy with their Medicare Advantage plan right now, they are gambling with their health care in a Medicare Advantage plan. Everything can change at any time. Unlike Traditional Medicare, which gives you easy access to the physicians and hospitals you use from everywhere in the US and allows for continuity of care, you can’t count on a Medicare Advantage plan to cover your care from the health care providers listed in their network. Providers leave Medicare Advantage networks all the time. Moreover, you can’t count on getting ready access to the care your doctors say you need. If you are choosing among Medicare Advantage plans, choose a five-star plan. But keep in mind that the government’s five-star rating system does not consider that some Medicare Advantage plans engage in widespread inappropriate delays and denials of care, and other Medicare Advantage plans engage in different bad acts that can endanger your health. So, while you should never sign up for a Medicare Advantage plan with a one, two or three-star rating, Medicare Advantage plans with four and five-star ratings can have very high denial and delay rates.

    Don’t count on seeing the physicians listed in the Medicare Advantage network, much less the physicians you need to see if you develop a complex condition. Unfortunately, provider networks in Medicare Advantage plans are limited and can change at any time. This year, dozens of health systems have canceled their Medicare Advantage contracts, further restricting access to care for their patients in MA, because MA plans make it hard for them to give people needed care. Also, MA network directories are usually inaccurate.

    Know that the government can’t ensure that Medicare Advantage plans deliver the same benefits as Traditional Medicare. The government cannot protect you from Medicare Advantage bad actors. The insurers offering Medicare Advantage plans can decide you don’t need care when you clearly do, and there’s no one stopping them; they are largely unaccountable for their bad acts. In the last few years there have been multiple government and independent reports on insurance company bad acts in Medicare Advantage plans.

    If you’re dissatisfied with a Medicare Advantage plan, you can’t disenroll and switch to Traditional Medicare. You can switch to Traditional Medicare each annual open enrollment period. However, depending upon your situation, where you live, your income, your age and more, you might not be able to get supplemental coverage to pick up your out-of-pocket costs and protect you from financial risk. If you can, it might be very expensive. What’s worse, you could incur thousands of dollars in out-of-pocket costs in Medicare Advantage or be forced to forgo needed care.

    If you have Medicare and Medicaid, you should seriously consider Traditional Medicare. If you have both Medicare and Medicaid, Traditional Medicare covers virtually all your out-of-pocket costs. You will get much easier access to physicians and inpatient services in Traditional Medicare than in a Medicare Advantage plan if you need costly health care services or have a complex condition.

    For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a State Health Insurance Assistance Program (SHIP).