Medicare What's Buzzing

Don’t be seduced by Medicare Advantage bells and whistles

Written by Diane Archer

As you’re thinking about your Medicare options this Fall, don’t be seduced by new bells and whistles available from some Medicare Advantage plans. Congress is allowing these corporate health plans, which contract with the federal government to provide Medicare benefits, to spend money on health-related services that otherwise would be spent on medical services. The question is to what extent these health plans are stinting on the delivery of medical care in order to provide the bells and whistles.

A story in Forbes by Howard Gleckman indicates that some corporate Medicare plans will offer modest new benefits, including additional home care services, adult day programs, transportation services and home-modification services. These services will be attractive to some people with Medicare. They could help people with chronic conditions who have difficulty living independently in their homes. If you need these supports, the PACE program, which works with traditional Medicare, is another option to explore.

Traditional Medicare does not cover these non-medical services. Rather, it covers all medically reasonable and necessary medical care you need. You can see virtually any doctor or use virtually any hospital anywhere in the United States. If you have supplemental insurance, which fills virtually all coverage gaps, such as Medigap, retiree coverage or Medicaid, your out-of-pocket costs are minimal. With Medicare Advantage, your out-of-pocket costs can be as high as $6,700 a year for in-network services alone and unlimited for out-of-network care if you’re in an HMO.

The corporate Medicare plans do not explain how they can afford to pay for the additional non-medical services they offer. They are not receiving extra money to do so. However, for the last several years, federal audits suggest that they have overcharged the government tens of billions a year for their services. Those overpayments may be one way they fund the non-medical services, though the government is trying to get that money back. They also may be charging higher copays for people who need care. There is no data on copay amounts these plans charge their members for different services.

Federal reports also show that these corporate health plans are not reporting accurately or completely the Medicare-covered services they are delivering their members, as they are required to do by law. That should give people who consider joining these plans pause. It’s reasonable to believe that they are stinting on the delivery of the medically necessary services they are supposed to be covering.

Given the data, it’s particularly fair to be concerned that if you join a Medicare Advantage plan, you might be denied the care or coverage your treating physicians believe you need. A report from the Office of the Inspector General reveals that these corporate health plans engage in widespread inappropriate delays and denials of care. Since the government has yet to advise people of which corporate plans to beware of, you take a gamble when you join one of them.

Here’s more from Just Care:


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