Medicare Your Coverage Options

Congress should level the playing field between traditional Medicare and Medicare Advantage

Written by Diane Archer

To protect people with Medicare and give them meaningful choice, Congress needs to level the playing field between traditional Medicare and Medicare Advantage. Unless traditional Medicare and Medicare Advantage offer the same benefits under the same terms, people cannot make a meaningful choice between them or protect themselves from Medicare Advantage plans that may threaten their health and safety.

In a previous post, I compiled information from the Office of the Inspector General (OIG), the Government Accountability Office (GAO) and the Centers for Medicare and Medicaid Services (CMS) revealing that some Medicare Advantage plans are threatening the health and safety of their members. But, we do not know specifically which Medicare Advantage plans remain a danger for people with Medicare. All we know is that CMS may award five-star ratings to ones it has found to jeopardize people’s health and safety, and MedPac currently finds these star ratings not trustworthy.

Yet, many people who want to leave their Medicare Advantage plans for traditional Medicare may not have that choice. A new Health Affairs paper by David Meyers et al., Brown University School of Public Health, reveals that people who want to leave their Medicare Advantage plan for traditional Medicare may not be able to buy supplemental coverage, Medigap, to fill coverage gaps. Because, unlike Medicare Advantage, traditional Medicare does not have an out-of-pocket cap, supplemental coverage is critical to protect people’s health and financial well-being.

The paper explains that people with higher health care needs are more likely to want to leave their Medicare Advantage plans. But, these same people are the ones least likely to be able to switch to traditional Medicare because it lacks a catastrophic cap and there is no guarantee they can buy supplemental coverage.

There are some federal protections that guarantee people the right to buy Medigap when they first enroll in Medicare and within one year of enrolling in a Medicare Advantage plan. But, other than during those times, in all but eight states, insurance companies selling Medigap coverage that fills gaps in Medicare can refuse to sell people this coverage or hike up premiums to the point that they are unaffordable.

The information from the Office of the Inspector General (OIG), the Government Accountability Office (GAO) and the Centers for Medicare and Medicaid Services (CMS) on the health and safety risk of Medicare Advantage plans is likely the tip of the iceberg. They have also found that more CMS oversight and audits of these plans is needed. Moreover, it appears that CMS has not been able to get Medicare Advantage plans to comply with federal regulations over several years.

To protect people with Medicare enrolled in Medicare Advantage, Congress should  take immediate action. It should impose a cap on out-of-pocket costs in traditional Medicare as well as ensure that Medigap plans are all community-rated and guaranteed issue.

Here’s more from Just Care:

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5 Comments

  • Which “eight states, insurance companies selling Medigap coverage that fills gaps in Medicare can refuse to sell people this coverage or hike up premiums to the point that they are unaffordable?”.

    • Alaska, Minnesota, Vermont, and Washington all require Medigap policies to be community-rated. Connecticut, Maine, Massachusetts, and New York have both community rating and guaranteed issue.

      • So what you are saying is that if I decided to go on regular Medicare..I
        Might not be able to buy gap-insurance for Medicare? I live in the state of Florida…does this mean I am dumed?? Would appreciate an answer
        As I wa thinking of going on Traditional Medicare! Thanks

        • You should check with your state health insurance assistance program. If you are going on Traditional Medicare for the first time at 65 or later, you have a right to buy Medigap at the time you enroll in Medicare. If you have been in a Medicare Advantage plan, you need to check whether you can get Medigap insurance in your state. Even if your state does not guarantee you that right, some Medigap companies still might offer you insurance.

  • I started out on Traditional Medicare with a supplement. Then the practice where my doctor worked joined a Medicare Advantage program and sent a rep around to sign me up. The specialty providers they advertised never signed up with the program and I ended up paying out of pocket for services that should have been covered (i.e. a CT Scan). After a year of fighting, I switched back to Traditional Medicare but had an extremely difficult to find Medigap coverage because I had a preexisting condition (diabetes, diabetic neuropathy).
    In addition, I had two friends die of cancer in the last year who were on Medicare Advantage. One asked her doctor about a breast lump for three years before he agreed to see if it was cancer. It was at the Stage III level and had already metastasized.

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