JustCare

Tag: Medicare Advantage

  • Medicare Advantage inappropriate denials of care abound

    Medicare Advantage inappropriate denials of care abound

    Just as with restaurants, automobiles and homes, Medicare Advantage plans vary from awful to excellent. But, unlike with restaurants, automobiles and homes, you can’t choose a Medicare Advantage plan knowing it will meet you needs. It’s a total crapshoot. Inappropriate denials of care abound.

    Beware. And take a hard look at your Medicare Advantage plan, if you’re in one. Choosing the wrong Medicare Advantage plan could kill you. A report from a few years ago revealed that if the Centers for Medicare and Medicaid Services cancelled contracts with the five percent of worst performing Medicare Advantage plans, it would save tens of thousands of lives a year!

    To ensure you have access to the care you need when you develop a serious condition or suffer a bad injury, consider switching to traditional Medicare, the government administered program that covers your care from most physicians and hospitals anywhere in the US. You have until the end of March to switch. But, unless you have Medicaid, you will need to be sure you can buy supplemental coverage to fill gaps in traditional Medicare.

    If you stay in a Medicare Advantage plan, be prepared to fight your insurer when you need costly care. CMS not only does not cancel contracts of insurers with high rates of inappropriate denials, it doesn’t tell you which are the worst-performing Medicare Advantage plans.

    Do not assume that a Medicare Advantage plan with a five star rating will meet your needs. The ratings do not factor in inadequate networks or inappropriate denial rates, much less mortality rates. And, while CMS has worked to improve those ratings, the insurers have successfully sued to prevent changes to the ratings. For reasons yet unknown, the Trump administration just dropped a Biden administration appeal of one of those lawsuits.

    If you stay in Medicare Advantage, consider denial rates. The latest report from the Kaiser Family Foundation reveals that CVS and Centene have the highest prior authorization denial rates in 2023. On average, MA plans denied 6.4 percent of prior authorization requests, which might sound reasonable. But, MA insurers use prior authorization predominantly for costly services, which only a small fraction of their enrollees need.

    Centene’s denial rate was 13.6 percent in 2023. CVS Health’s was 11 percent. Typically, denials are overturned 80 percent of the time when appealed. When people appealed Centene’s denials, they prevailed 93.6 percent of the time. Unfortunately, only about 10 percent of coverage denials are appealed.

    Here’s more from Just Care:

  • Medicare Advantage dental, vision and hearing benefits offer little value

    Medicare Advantage dental, vision and hearing benefits offer little value

     

    Medicare Advantage plans advertise their “extra” benefits as a way to lure in new enrollees. But, new research published in JAMA Network finds that Medicare Advantage dental, vision and hearing benefits offer little value to enrollees. Enrollees have no better access to dental, vision and hearing benefits than people in traditional Medicare.

    The most recent MedPAC data show that the federal government is spending 22 percent more per Medicare Advantage enrollee than for enrollees in traditional Medicare. The data are increasingly also showing that, notwithstanding the estimated $83 billion more the insurers offering Medicare Advantage received from the federal government in 2024, Medicare Advantage enrollees get fewer benefits than people in traditional Medicare.

    For the most part, insurers offering Medicare Advantage only cover care for their enrollees from a restricted network of physicians and hospitals. In rural communities, people have to travel long distances to see a doctor or get treated at a hospital because their local providers are not in their Medicare Advantage plan network. And, the specialists qualified to treat certain conditions are also often not in-network.

    Moreover, Medicare Advantage insurers often inappropriately delay and deny care to their enrollees, particularly when they have complex and costly conditions. The insurers’ financial incentive is to withhold care because the government pays them upfront regardless of the amount of money they spend on care. The less care they cover the more money they get to keep.

    A team at Mass General Brigham looked at whether the “extra” benefits Medicare Advantage insurers offer add value. Insurers misleadingly claim that they give their enrollees more than traditional Medicare in the form of extra benefits. But, that is not true in fact.

    Insurers often deny Medicare Advantage enrollees coverage for treatments that traditional Medicare covers. And, while insurers technically offer enrollees additional benefits, too often, enrollees are not aware of these benefits or the out-of-pocket costs present a barrier to care. The researchers found that fewer than six in ten enrollees knew their Medicare Advantage plan covered these “extra” benefits.

    Between 2017 and 2021, people in traditional Medicare and Medicare Advantage spent about the same amount for dental, vision and hearing services, notwithstanding that Medicare Advantage plans claim to offer these benefits and traditional Medicare does not.  They also received about the same number of services. There is no reason to be paying Medicare Advantage insurers more per enrollee than the government spends in traditional Medicare.

    “Medicare Advantage plans receive more money per beneficiary than traditional Medicare plans, but our findings add to the evidence that this increased cost is not justified,” said first author Christopher L. Cai, MD. At best, people in Medicare Advantage are getting a discount of less than 10 percent on vision, hearing and dental treatment. Out-of-pocket costs are high, even with the benefits, and the panel of covered providers is narrow.

    “Supplemental benefits are a major draw to Medicare Advantage, but our findings show that people enrolled in Medicare Advantage have no better access to extra services than people in traditional Medicare, and that much of the cost comes out of their own pockets,” according to senior author Lisa Simon, MD, DMD, assistant professor in the Division of General and Internal Medicine at Brigham and Women’s Hospital. “Older adults and people with disabilities deserve better from Medicare.”

    Here’s more from Just Care:

  • Medicare Advantage insurers are killing rural hospitals and communities

    Medicare Advantage insurers are killing rural hospitals and communities

    Write-Off Warrior, a research and advocacy firm that supports rural health systems, just released “Preyed On: How Insurance Corporations are Bleeding Rural Hospitals and Communities to Death.” The report documents the many harmful behaviors of large insurance corporations responsible for endangering the health of rural America. The report also highlights the far-reaching consequences for our country if Congress fails to address insurer behaviors driving rural health disparities.

    Rural Americans represent about 20 percent of the US population. They tend to suffer more from chronic conditions than other Americans. But, they struggle more to get the care they need than other Americans and their plight is worsening.

    The authors surveyed 41 rural hospitals in 15 states across the US and found that the biggest problems they faced were burdensome insurer prior authorization procedures, insurers’ second-guessing of treating physicians, and insurers’ long delays and denials of provider payments. Moreover, insurers take advantage of rural hospitals’ weak bargaining power to negotiate excessively low rates or to keep these hospitals from being in-network. Rural hospitals are foundering.

    Medicare Advantage insurers are the biggest threat to rural hospitals and communities, according to 31 of 41 hospital execs surveyed. These corporate insurers have undermined the hospitals’ financial stability. These insurers have led rural hospitals to end important mental health and rehab services. And, these insurers are leading many rural hospitals to shut down altogether.

    While the top six Medicare Advantage insurers profited to the tune of $41.7 billion in 2023 alone, Medicare Advantage enrollees continue to face rising costs, notwithstanding these insurer practices. They also are often forced to travel long distances for care. Congress must recognize that Medicare Advantage does not work for rural Americans and reform the system.

    Until Congress reforms the Medicare Advantage program to meet the needs of rural Americans, insurers will profit more at the expense of rural communities. Nearly 200 rural hospitals have closed in the last 2o years. And, more than 700 are at serious risk. These hospital closures put rural America on life support.

    Without vibrant rural communities and good rural health, critical food and energy production, vital to the entire country, are at risk of failing.

    Here’s more from Just Care:

  • 2025: Take advantage of the Medicare Advantage Open Enrollment Period

    2025: Take advantage of the Medicare Advantage Open Enrollment Period

    If you’re in a Medicare Advantage plan, you should seriously consider taking advantage of the Medicare Advantage open enrollment period between January 1 and March 31 that allows you to switch to Traditional Medicare (government-administered insurance coverage) or to a different Medicare Advantage plan. This right to switch out of your Medicare Advantage plan is a critical consumer protection.

    Many people do not realize that there are few guarantees with Medicare Advantage. Between the time you sign up for a plan and the beginning of the new year, both the drugs and providers the plan covers could have changed significantly. So be sure to check. Moreover, you never know what illness you might be diagnosed with and whether your Medicare Advantage plan will cover the treatments your physicians recommend or deny them. And, most of the time, you will be faced with what could be harmful delays as a result of prior authorization requirements.

    I’ve written at length about all the reasons not to enroll in a Medicare Advantage plan, especially if you have Medicaid or can afford the supplemental coverage that you need in Traditional Medicare to limit your out-of-pocket costs. Upfront costs in Medicare Advantage are lower than those in Traditional Medicare with supplemental coverage. But, if you get sick and need care–the reason you have health insurance–your out-of-pocket costs are likely to be a lot higher in Medicare Advantage than in Traditional Medicare.

    Moreover, in a Medicare Advantage plan, you are at risk of not getting the care you need if you are diagnosed with a costly condition. The Office of the Inspector General has twice reported widespread delays and denials of care and coverage in most Medicare Advantage plans. Also, access to care is much simpler in Traditional Medicare than in Medicare Advantage.

    In Traditional Medicare, your treating physicians decide the care you need without an insurance company second-guessing your doctor and profiting every time it denies you care. And, there are no prior authorization requirements, requiring you to wait before your care will be covered. Furthermore, you are covered for care from almost all providers anywhere in the US, whereas in Medicare Advantage, your insurer generally will only cover your care from a limited set of providers. And, in Traditional Medicare, with supplemental coverage, your costs are predictable and often very little.

    Medicare Advantage HMOs restrict your coverage to the doctors and hospitals in their networks. You can go out of network for some coverage only if you’re in a PPO. But, even in a PPO, coverage tends to be limited and unpredictable. Driving your costs up further and/or endangering your health, Medicare Advantage plans usually impose prior authorization requirements before they will cover costly care. And, they inappropriately deny care, particularly to people with costly conditions–people needing rehab care, people with cancer and people with other complex care needs.

    The Centers for Medicare and Medicaid Services, which oversees Medicare, should be protecting you from bad actor Medicare Advantage plans, but it cannot. It does not have the capability, the money, or the power to oversee the 4,000 Medicare Advantage plans, much less to hold them to account for their bad acts.

    You should also bear in mind that you can’t count on the providers in Medicare Advantage directories actually being willing to see you. Multiple reports reveal “ghost” networks in some Medicare Advantage plans. As well, I’ve reported many times in Just Care on hospitals terminating their Medicare Advantage contracts, leaving Medicare Advantage plan enrollees scrambling to find alternative care or forced to drive long distances for inpatient services.

    N.B. If you want to switch to Traditional Medicare, note that you will need supplemental coverage (Medigap) to protect you from high out-of-pocket costs. Traditional Medicare does not have an out-of-pocket  limit. If you don’t have Medicaid or coverage from a former employer, make sure you can buy it in the individual market. In most states, insurers selling Medicare supplemental coverage are not required to sell you a policy, with some exceptions, including when you first enroll in Medicare at age 65 or later.

    Here’s more from Just Care:

  • UnitedHealth physicans help boost insurers’ Medicare payments

    UnitedHealth physicans help boost insurers’ Medicare payments

    UnitedHealth now employs or contracts with about 10 percent of the physicians in the US. It’s one way UnitedHealth maximizes Medicare Advantage profits, report Anna Wilde Mathews, Christopher Weaver and Tom McGinty for the Wall Street Journal. UnitedHealth incentivizes its physicians to include additional diagnoses codes on Medicare Advantage patient records, which enables UnitedHealth to receive higher Medicare payments.

    UnitedHealth advises its physicians to check their Medicare Advantage patients for certain diagnoses. So, in Eugene, Oregon, one physician explained that before he could move from one patient to another, he must enter into a software system whether his patient had any of a list of diagnoses. In many cases, the diagnoses had nothing to do with the patient, such as hyperaldosteronism, which is a hormone condition related to high blood pressure.

    Rather than ensuring their doctors focus on treating Medicare Advantage patients for the conditions these patients are reporting, UnitedHealth is focused on having its doctors document as many conditions as possible that will increase the company’s Medicare payments.

    UnitedHealth does nothing to ensure its doctors document additional conditions for their patients in traditional Medicare. That’s not surprising.  Because of the way Medicare pays insurers in Medicare Advantage, adding diagnoses codes to traditional Medicare patient records would hurt UnitedHealth financially.

    The Wall Street Journal found that patients leaving traditional Medicare for Medicare Advantage in the three years ending 2022 had many more diagnoses in their medical records once they were in Medicare Advantage. Their “sickness scores” typically increased 55 percent. To put it succinctly, once in Medicare Advantage, from a sickness perspective, patients effectively had HIV and breast cancer.

    While UnitedHealth does more than other insurers to raise sickness scores for its Medicare Advantage patients, other insurers raised scores by 30 percent for new patients in Medicare Advantage. There is no evidence whatsoever that entering more diagnoses into Medicare Advantage enrollees’ medical records benefits patients in any way. In fact, UnitedHealth doctors do not use the company’s diagnoses software for patients outside of Medicare Advantage.

    By the Wall Street Journal’s calculations, United’s Medicare Advantage enrollees who saw UnitedHealth physicians had such high sickness scores that UnitedHealth benefited financially to the tune of $4.6 billion over three years.

    This insurer gaming of the Medicare payment system must end. Among other things, it is gouging taxpayers, depleting the Medicare Trust Fund, and driving up Medicare Part B premiums.

    Here’s more from Just Care:

  • Is Mehmet Oz fit to run Medicare agency?

    Is Mehmet Oz fit to run Medicare agency?

    Last month, Senator Elizabeth Warren, along with six other Democratic Senators, sent a letter to Dr. Mehmet Oz, whom President-elect Donald Trump has named as Administrator-Designate, Centers for Medicare & Medicaid Services (CMS), regarding Dr. Oz’s call for the elimination of traditional Medicare and his lack of qualifications for the CMS Administrator position. If Dr. Oz becomes head of CMS will we be playing with fire?

    Dr. Oz has substantial investments in corporate health insurance companies. He has said that he wants everyone with Medicare in a Medicare Advantage plan, even though Medicare Advantage does not work for large swaths of the population. (People in rural communities who are in Medicare Advantage plans often must travel tens of miles to receive hospital care because their Medicare Advantage plans won’t pay their local hospitals appropriately. People with cancer in Medicare Advantage plans can’t see physicians at cancers centers of excellence because they are all out of network. People who travel and need care in multiple parts of the US can’t get the in-network coverage they need in Medicare Advantage. Amputees and other people needing rehab services too often can only get that care covered if they are in traditional Medicare.)

    Dr. Oz also either does not appear to appreciate or does not care that traditional Medicare is far more cost effective than Medicare Advantage. He either does not know or does not care that Medicare is overpaying corporate health insurers operating Medicare Advantage plans tens of billions of dollars each year.

    MedPAC projects that these insurers will overcharge CMS $83 billion relative to traditional Medicare in 2024 alone. To maximize profits, private insurers make their MA enrollees appear sicker than they actually are. The HHS Office of the Inspector General finds that insurers engage in constant inappropriate delays and denials of needed care and force physicians and hospitals to jump through hoops to deliver needed care. Dr. Oz does not seem to know about or ignores these abuses.

    Dr. Oz also has a financial conflict of interest. He owns more than $550,000 of stock in UnitedHealth, which is under Justice Department investigation for antitrust abuses. But, his desire to eliminate traditional Medicare would double revenue for UnitedHealth to nearly $300 billion.

    Senators Warren, Wyden, Cardin, Merkley, Durbin and Blumenthal ask Dr. Oz for answers to a series of questions by December 23, 2024:

    1. Does he continue to believe traditional Medicare should be eliminated and, if so, why?
    2. Will he commit to protecting Medicare, not privatizing it or cutting benefits?
    3. Does he understand why Medicare Advantage is highly dysfunctional and, if not, what does he think about the upcoding and widespread delays and denials of needed care?
    4. Will he sell off all investments in health insurance companies in order to ensure he has no financial conflicts of interest if he is confirmed as CMS Administrator?

    Here’s more from Just Care:

  • New physician survey finds prior authorization harms cancer patients

    New physician survey finds prior authorization harms cancer patients

    Here’s yet another reason to opt for traditional Medicare over insurer-run Medicare Advantage plans. A new survey by the American Society for Radiation Oncology (ASTRO) finds that insurers’ use of prior authorization can harm cancer patients, reports Renal+Urology News. Prior authorization also makes it hard for oncologists to do their job.

    Your insurance plan should provide good coverage for you today and in the future, whatever your health care needs. Sadly, as we get older, it becomes increasingly likely we will be diagnosed with cancer or some other serious health conditions. So, it’s not wise to gamble with your health insurance.

    According to the 754 oncologists surveyed in the last few months, in more than nine and out ten (92 percent) instances, prior authorization means that patients don’t get care as quickly as they otherwise could. Consequently, about one in ten patients end up forgoing treatment. Some patients end up in the ER or the hospital. Some end up with disabilities, which can be permanent. And, seven percent of respondents said that their patients died.

    More than half of patient radiation oncology services require prior authorization, even though insurers approve them more than seven in ten times initially. On appeal, nearly three quarters of denials are approved.

    Nearly six in ten (58 percent) physicians surveyed said that prior authorization kept them from being able to follow treatment protocols. More than eight in ten (82 percent) said that in some cases they ended up providing their patients with less good treatment as a result of prior authorization.

    Not only can prior authorization seriously harm patients’ primary treatment, it can also prevent them from or pose a significant barrier to their receiving treatment for side effects. For example, they might not be able to get pain or antinausea medicines.

    According to respondents, insurers are ramping up prior authorization requirements, not easing them. A typical delay is at least five days. It also requires more administrative staff.

    Howard M. Sandler, MD, chair of the ASTRO board of directors, sums up the survey findings: “These survey findings confirm what radiation oncologists witness daily: prior authorization policies are failing people with cancer, causing avoidable delays that are dangerous and, in too many cases, deadly.”

    Here’s more from Just Care: 

  • Humana could be penalized over misleading provider directories 

    Humana could be penalized over misleading provider directories 

    Keith Ellison, Minnesota’s attorney general, is trying to hold Humana accountable for misrepresenting the in-network providers in its Medicare Advantage plans, reports Rylee Wilson for Becker’s. It could be the first time that any state has acted to protect their older and disabled residents from misleading Medicare Advantage information. And, it’s about time.

    For more than a decade, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, has reported that insurers mislead older adults and people with disabilities through inaccurate provider directories. But, CMS has never done anything to correct the problem, much less penalize insurers for misleading their enrollees.

    In Minnesota, Ellison says that people considering joining a Humana Medicare Advantage plan are misled to believe that Humana will cover their care from Essentia Health, Avera Health, North Memorial Health and Sanford Health in 2025. But, all have said that they are leaving the Humana Medicare Advantage network at the end of this year.

    In addition to correcting all misinformation in its provider directories as quickly as possible, Ellison wants Humana to detail which Medicare Advantage out-of-network providers it incorrectly listed as in-network this annual open enrollment season. He also wants Humana to protect enrollees who joined based on this misinformation. He argues that Humana should cover their care from these providers.

    According to the Minnesota Star-Tribune, UnitedHealthcare also misleads people with Medicare about the providers in its network.

    Over the last several months, many health systems have ended their contracts with Medicare Advantage insurers. These health systems not only cite huge administrative burdens they face with MA insurers but also large numbers of inappropriate denials of care.

    If you enrolled in a Medicare Advantage plan because you cannot afford traditional Medicare, contact your Senators and representative in Congress. Urge them to add an out-of-pocket cap to traditional Medicare so that it is a meaningful choice for everyone with Medicare, not only a luxury for the wealthy. Only traditional Medicare covers your care from most doctors and hospitals anywhere in the country without requiring prior authorization or otherwise inappropriately delaying or denying medically necessary care.

    Here’s more from Just Care:

  • Turning 65? When to enroll in Medicare

    Turning 65? When to enroll in Medicare

    Turning 65 is fraught for all kinds of reasons, one of which is that you will need to consider whether you should enroll in Medicare. Here’s what I just explained to a friend.

    Should you enroll in Medicare at 65? If you’re not actively working or you do not have health insurance coverage through your job or your spouse’s current job, you will need to enroll in Medicare when you turn 65. And, if you have insurance through your job or through your spouse’s job but the employer has fewer than 20 employees, you also should enroll in Medicare at 65. If you do not, you will pay a penalty for each year you delay enrolling.

    You can enroll before your 65th birthday. You can and should enroll in the three months before your 65th birthday to ensure you are covered on the first day of your birthday month. Contact your Social Security office to enroll. You do not have to sign up for Social Security at that time. In fact, if you can afford to delay taking Social Security, you should, in order to earn larger benefits down the road.

    What choices do you need to make? You need to choose between traditional Medicare, which you should get automatically (but you should confirm) and a Medicare Advantage plan. Traditional Medicare gives you coverage for care from almost all doctors and hospitals across the US, without administrative barriers to care like prior authorization. You pay for supplemental coverage, sometimes called Medigap, to fill coverage gaps–about $2,500 a year for a comprehensive policy–but then you have few out-of-pocket costs; almost all your care is covered in full.

    Medicare Advantage restricts your access to care to its network of providers and has administrative barriers to care such as prior authorization requirements, which can cause undue delays. Medicare Advantage plans also have been found to engage in widespread and persistent inappropriate denials of care and coverage. But, Medicare Advantage plans have an out-of-pocket cap so they save you money if you do not need a lot of care.  If you do, you could spend as much as $9,350 out of pocket in 2025 for in-network care alone. You cannot buy supplemental coverage to cover these costs. If you opt for Medicare Advantage, you will need to choose your Medicare Advantage plan carefully. Do not trust an insurance agent or broker to help you because they generally work on commission. You can compare options online here. You can call your State Health Insurance Assistance Program for free guidance.

    N.B. If you opt for Medicare Advantage when you first enroll in Medicare, you could be locked in. You can always enroll in traditional Medicare, but you might not be able to buy supplemental coverage. It will depend upon where you live. Your federally guaranteed right to Medicare supplemental coverage, sometimes called Medigap, ends one year after you first enrolled in a Medicare Advantage plan, with some limited exceptions. Only four states–NY, CT, ME and MA–require Medicare supplemental insurers to sell you coverage after your initial enrollment period.

    How about prescription drug coverage? With traditional Medicare, you will need to enroll in a Medicare Part D prescription drug plan. You can compare your options online. With Medicare Advantage, prescription drug coverage is almost always included. If you go with a Medicare Advantage plan, to save money, you should choose a Medicare Advantage plan that covers the drugs that you use at the lowest cost. That said, the drugs these plans cover and your out-of-pocket costs can change at any time. Moreover, it can sometimes be cheaper to get your drugs through Costco or another pharmacy. 

    Here’s more from Just Care:

  • What will Dr. Oz do as head of Medicare agency?

    What will Dr. Oz do as head of Medicare agency?

    President-elect Donald Trump has nominated Mehmet Oz to be the next head of the Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare and Medicaid, reports the New York Times. The choice of Dr. Oz, a TV celebrity with no government or management experience is in keeping with Trump’s other picks for big government roles. The open question is what will Dr. Oz do as head of CMS?

    If the past is any indicator, Dr. Oz will put in place plans to eliminate the public traditional Medicare program. It would be a huge mistake and arguably not doable, given that Medicare Advantage doesn’t work for some people in some parts of the country and works poorly for people with serious conditions and people with low incomes in many parts of the country. Wealthy Americans who understand the health risks of a Medicare Advantage plan avoid it at all costs.

    Traditional Medicare covers your care from virtually any physician or hospital in the country, without delay or forcing you to go through prior authorization hoops. When you need costly care, as most of us will at some point, Medicare protects you and ensures you are able to get the care you need. Medicare Advantage, in sharp contrast, works well when you’re healthy and tends to delay and deny care inappropriately when you most need care. So, people in Medicare Advantage take a huge risk.

    Back when he ran against John Fetterman for a US Senate seat in 2022, Oz made clear that, unlike his opponent, he does not support “free health care for everyone.”  Oz advocates for Medicare Advantage for All, a health care system that gives full control over our healthcare to big private insurers and will ration care based on ability to pay.

    Oz has suggested a 20 percent payroll tax to cover the costs of his Medicare Advantage for All plan. It would be a huge windfall for the biggest corporate health insurers. It would also be a huge windfall for Oz, as he and his wife are reported to have millions of dollars invested in the health care industry.

    Senator Patty Murray of Washington State expressed deep concern about Dr. Oz’s nomination: “Even putting aside the raft of alarming pseudoscience Dr. Oz has previously endorsed, it is deeply disappointing to see someone with zero qualifications being announced to head up such a critical agency.”

    Here’s more from Just Care: