You’ve probably heard me say this before, but I’ll say it again: The less corporate health insurers spend on your care, the more of your premium dollars they can keep. What’s worse is that states and the federal government generally do not begin to have the resources to protect Americans from health plans that inappropriately refuse to cover needed care. Not surprisingly, there’s a new report out from the Urban Institute finding that the federal government’s star-rating system for Medicare Advantage plans neither promotes quality nor helps people distinguish effectively among their Medicare health plans choices.
In other words, if you’re in a Medicare Advantage plan or thinking about enrolling in one, keep in mind that the insurance companies offering these plans have both a financial incentive to inappropriately delay and deny your care and the ability to do so with near impunity.
The Health and Humans Services’ Office of the Inspector General has now issued two reports finding that many Medicare Advantage plans engage in inappropriate delays and denials of care and coverage. The federal government, through the Centers for Medicare and Medicaid Services (CMS), is charged with overseeing these health plans and helping you make an informed choice among them. But, it is not disclosing important information you need to make an informed choice.
What should you do to avoid unnecessary delays and denials of care and coverage? If you can afford traditional Medicare, you should not face barriers to care or inappropriate delays and denials of coverage. There is no corporate health insurer coming between you and your doctors. But, if you don’t have Medicaid or supplemental retiree insurance to fill gaps in your Medicare coverage, you will need to buy “Medigap” supplemental coverage.
If you opt for a Medicare Advantage plan to save the cost of supplemental insurance, keep in mind that a health plan with a five star rating may inappropriately delay or deny your care. Here’s why, according to the Urban Institute’s latest report:
- The rating system is based on an overall assessment of several Medicare Advantage plans an individual corporate health insurer offers. So, if one of those plans is terrible, it could still get a four or five-star rating if others of the plans are deemed to offer good care.
- The Centers for Medicare and Medicaid Services (CMS) does not take account of certain deficiencies with Medicare Advantage plans in its star ratings, including rates of inappropriate delays and denials of care and coverage.
- CMS inflates its scores, giving high star ratings too often.
- CMS does not focus its star-rating measures on whether Medicare Advantage plans meet the needs of people with costly and complex conditions. Because health insurance is about protecting people from unforeseen health problems, this is a serious flaw.
Keep in mind that insurance should be about covering your unforeseen health care needs. if you get sick and need costly care, your out-of- pocket costs in a Medicare Advantage plan can be as high as $8,300 for in-network care, this year alone.
Advocates are working hard to get CMS to publish delay and denial rates of individual Medicare Advantage plans. Some plans, we are told, have problematically high denial rates. For sure, those health plans should be avoided and the government should have a duty to, at the very least, let you know about them, as well as to penalize them heavily. If Medicare Advantage plan are jeopardizing the health and well-being of their enrollees, the government should be canceling their contracts.
Here’s more from Just Care:
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