JustCare

Tag: Network

  • 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:

  • Medicare Advantage networks can be narrow and harmful

    Medicare Advantage networks can be narrow and harmful

    If you’re in a Medicare Advantage plan or thinking of joining one, you should worry about two things: Whether you will get the Medicare benefits you are entitled to when you need costly care and whether you’ll be able to use the doctors and hospitals you want to use. Cheryl Clark reports for MedPage Today on a recent Medicare Payment Advisory Commission (MedPAC) meeting in which commissioners criticized the Medicare Advantage networks as ever-changing and often too narrow and harmful to enrollees.

    You can’t trust Medicare Advantage (MA) provider directories to list in-network providers accurately. A lot of the time, the listed physicians and hospitals are not, in fact, in network. They’ve left the network. Or, they leave the network midyear. It can hurt enrollees, who lose continuity of care and must scramble to find new providers.

    When you buy health insurance, you should be thinking not simply about now but about what could happen to you in the future. Literally anything. A car accident, a fall on ice, a cancer diagnosis, a stroke. You might be away from home. Will your care be covered the way you want it to be in a Medicare Advantage plan? What will you pay out of pocket?

    Here are some of problems you can face in any Medicare Advantage plan when it comes to getting a provider to deliver care. These problems don’t exist in traditional Medicare, the government-administered program that covers your care from almost any physician or hospital in the US:

    1. The Medicare Advantage plan can leave the Medicare program at the end of any year. And, many have done so in the last couple of years.
    2. Physicians and hospitals can leave the Medicare Advantage network. Your care is not covered if you keep seeing these providers. You can pay out of your own pocket to see them or you need to find new providers.
    3. In-network physicians might not be willing to see you. They might have too many patients already.
    4. Cancer centers of excellence and specialists you need to see might not be in-network.

    The Medicare Advantage network directories are very often out of date and inaccurate. Moreover, government oversight to ensure the adequacy of Medicare Advantage plan networks leaves a lot to be desired. Plans know that they can offer inadequate networks without accountability. The government has never penalized a Medicare Advantage plan for offering an inadequate network.

    There’s little good about Medicare Advantage networks in practice, though in theory they should help ensure you are getting good coordinated care. Unfortunately, the insurance companies offering Medicare Advantage make more money keeping you from getting good costly care. So, except for some of the nonprofit Medicare Advantage plans, Medicare Advantage insurers’ incentive is to delay and deny you care from good quality physicians and hospitals when you need them.

    Here’s more from Just Care:

  • 24 health systems drop their Medicare Advantage contracts

    24 health systems drop their Medicare Advantage contracts

    When Congress passed legislation allowing corporate health insurers to offer Medicare benefits, our representatives may not have appreciated that the new law would effectively be increasing shareholder value for the biggest health insurers and putting millions of vulnerable older adults and people with disabilities at risk of not getting needed care. They likely did not imagine that Medicare Advantage insurers would inappropriately underpay hospitals, nursing homes, home health agencies and rehabilitation facilities, harming them financially or, worse still, forcing them to close their doors. Jakob Emerson reports for Beckers on how 24 health systems across the country are dropping their Medicare Advantage contracts because they are not able to deliver Medicare Advantage enrollees the care they need and because insurers are not paying them appropriately.

    In all likelihood, the corporate health insurers offering Medicare Advantage likely did not start off engaging in the bad acts many of them currently engage in, including using prior authorization processes excessively, delaying and denying care inappropriately, and failing to pay physicians and hospitals adequately. Nor were they overcharging the government excessively at the outset. But, today, more than six in ten provider CFOs say that the obstacles to care and payment are only getting worse.

    Beckers now lists 24 health systems that are ending their Medicare Advantage contracts, some with all Medicare Advantage insurers. Other health systems are cancelling contracts with UnitedHealthcare and/or Humana, two of the largest Medicare Advantage insurers. The list is not comprehensive. So, if you’re in a Medicare Advantage plan now, check to see whether you will be able to continue to use the doctors and hospitals you want to use or whether they are no longer in the provider network.

    In California, Scripps Health ended all its Medicare Advantage contracts for its integrated medical groups this year.

    In Delaware, ChristianaCare cancelled its contract with Humana’s Medicare Advantage plans as of Jan. 1.

    In Illinois, Blessing Health is only continuing its contracts with BCBS, UnitedHealthcare, Molina and Total Retiree Advantage.

    In Indiana, Powers Health (formerly Community Healthcare System) cancelled their contracts with Humana and Aetna’s Medicare Advantage plans on June 1.

    In Kansas, LMH Health is cancelling contracts with Aetna and Humana Medicare Advantage in 2025.

    In Kentucky, Baptist Health cancelled its contract with UnitedHealthcare Medicare Advantage and Centene’s WellCare this year.

    In Maine, Northern Light Health is cancelling its Medicare Advantage contract with Humana beginning October 1.

    In Michigan, MyMichigan Health is cancelling its Aetna Medicare Advantage contract in 2025.

    In Minnesota, HealthPartners is cancelling its contract with UnitedHealthcare Medicare Advantage plans in 2025. Essentia Health is cancelling its contracts with UnitedHealthcare and Humana Medicare Advantage in 2025.

    In Missouri, Cameron (Mo.) Regional Medical Center cancelled its Aetna and Humana Medicare Advantage contracts this year.

    In Nebraska, Kimball (Neb.) Health Services is cancelling all its Medicare Advantage contracts in 2025.

    In Nevada, Carson Tahoe Health is cancelling its contract with UnitedHealthcare Medicare Advantage in 2025.

    In New York, Med Health System cancelled its contract with Humana Medicare Advantage on July 1.

    In North Carolina, ECU Health cancelled its Humana’s Medicare Advantage plans in January.

    In Ohio, Aultman Health System hospitals are cancelling their contracts with Humana Medicare Advantage in 2025. Genesis Healthcare System cancelled contracts with Anthem BCBS and Humana Medicare Advantage plans in January.

    In Oklahoma, Comanche County Memorial Hospital cancelled its contract with UnitedHealthcare Medicare Advantage plans on May 1.

    In Oregon, Samaritan Health Services‘ hospitals cancelled its contracts with UnitedHealthcare’s Medicare Advantage plans on Jan. 9. They are cancelling contracts for physicians and provider services on Nov. 1. St. Charles Health System cancelled its contracts with Humana Medicare Advantage and Centene MA.

    In Pennsylvania, WellSpan Health ended its Humana Medicare Advantage and UnitedHealthcare Medicare Advantage plans on Jan. 1. It still accepts some UnitedHealthcare D-SNP plans.

    In South Dakota, Sanford Health is cancelling its Humana Medicare Advantage in Minnesota in 2025. Brookings (S.D.) Health System cancelled all its Medicare Advantage contracts this year.

    In Texas, Memorial Hermann Health System ended its contract with Humana Medicare Advantage on Jan. 1.

    Here’s more from Just Care:

  • Medicare Advantage plans continue to endanger hospitals and patients

    Medicare Advantage plans continue to endanger hospitals and patients

    Jakob Emerson reports for BeckersHospital on the plight of hospitals dealing with Medicare Advantage plans. The insurers offering Medicare Advantage plans often try to maximize profits by denying payments to hospitals inappropriately. Or, they refuse to pay for patient inpatient stays and downgrade them to outpatients stays, which cost less. In short, Medicare Advantage plans continue to endanger hospitals and patients.

    Patients are beginning to feel the unhappy consequences of insurer misbehavior towards hospitals. In some cases, Medicare Advantage plans are denying patients needed care or forcing them to jump through multiple hoops in order to get critical care. Hospitals are cancelling their Medicare Advantage contracts, leaving patients to scramble to find other network providers. This year alone, at least 17 hospital systems have cancelled or will cancel their Medicare Advantage contracts.

    More than half the Medicare population is now enrolled in a Medicare Advantage plan, so hospitals tend to need the Medicare Advantage business. At the same time, they face financial risks when they contract with the insurers offering Medicare Advantage plans. S&P Global’s new report finds hospitals extremely vulnerable to Medicare Advantage bad acts.

    The risks to hospitals is only growing, as the insurers in Medicare Advantage are wildly overpaid. It is more than likely that Congress and the administration will do more to eliminate these overpayments. When that happens, the hospitals will likely face even more challenges getting paid appropriately by Medicare Advantage insurers.

    Another deep concern with Medicare Advantage is that there’s no counting on insurers to stay in business from one year to the next. Three big insurers, Centene, Aetna and Humana are saying they are pulling out of some of the Medicare Advantage markets in 2o25. The government and Medicare Advantage enrollees cannot rely on insurers to continue offering Medicare Advantage plans.

    If they continue in business, there’s also no counting on insurers to keep their Medicare Advantage provider networks, cost-sharing and additional benefits. Insurers can narrow their provider networks, increase cost-sharing, and eliminate additional benefits. Everything can change.

    “[W]e expect insurers to prioritize margin over membership, and we expect large insurers will use their scale and market clout to limit provider rate increases over what will prove to be a challenging contract negotiation season,” reports S&P Global.

    Here’s more from Just Care:

  • More hospitals are dropping Medicare Advantage

    More hospitals are dropping Medicare Advantage

    Jakob Emerson reports for Becker’s Hospital Review that at least 17 large hospital systems are dropping their Medicare Advantage contracts this year. As we’ve seen over the last couple of years, hospitals are making clear that Medicare Advantage enrollees risk not getting needed care in a timely manner, if at all. In addition, with hospitals refusing to be part of Medicare Advantage networks, Medicare Advantage enrollees are struggling to access hospital services.

    More than 30 million older adults and people with disabilities are now enrolled in Medicare Advantage plans. The insurers offering Medicare Advantage plans mislead them to believe that they will get all the benefits of Medicare and more, as they should, in Medicare Advantage. But, report after report shows that Medicare Advantage enrollees face huge obstacles to care when they most need it. They face bureaucratic prior authorization hurdles when they have cancer, or need rehab or skilled nursing services as well as other costly treatments. Their Medicare Advantage plans too often deny them critical care.

    Hospital systems offer several reasons why they are ending their Medicare Advantage contracts. The biggest reason, by far, is that Medicare Advantage plans deny care excessively through their prior authorization processes. And, when patients get care, Medicare Advantage plans too often do not reimburse the hospitals for the care they get.

    A recent survey of 135 health system CFOs by the Healthcare Financial Management Association found that 16 percent intend to end contracts with at least one Medicare Advantage plan in the next two years. Nearly half of them reported that they are considering cancelling their Medicare Advantage contracts. Sixty-two percent said that it had become increasingly more difficult to get the Medicare Advantage plans to pay for the care the hospitals provide.

    UnitedHealth and Humana are the two insurers with the largest share of Medicare Advantage enrollees. They appear to be among the worst offenders when it comes to prior authorization abuses and denied payments from the hospital systems’ perspective.

    In Canton, Ohio Aultman Health System is ending its hospital and physician contracts with Humana Medicare Advantage. Med Health System in Albany, New York, Power Health in Munster, Indiana, Memorial Hermann Health System in Houston, Texas, WellSpan Health  in York, Pennsylvania, Christiana Care in Newark, Delaware, EcuHealth in Greenville, North Carolina, and Genesis Healthcare System in Zanesville, Ohio either have cancelled or will cancel their Humana Medicare Advantage contracts this year.

    Comanche County Memorial Hospital in Lawton, Oklahoma is ending its UnitedHealthcare Medicare Advantage contract as is Samaritan Health Services in Carvallis, Oregon and Health Partners in Bloomington, Minnesota.

    Powers Health and MyMichigan Health are cancelling their Aetna Medicare Advantage contracts.

    Genesis Healthcare System also dropped its Anthem BCBS Medicare Advantage contract.

    Here’s more from Just Care:

  • New report shows Medicare Advantage might not save you money

    New report shows Medicare Advantage might not save you money

    Many people say they enroll in Medicare Advantage–Medicare coverage through private health insurers- thinking it is a lower cost alternative to Traditional Medicare. Certainly, the Medicare Advantage plans want you to think that. But, a new report in the Annals of Internal Medicine by Sungchul Park, Amal Trivedi, and David Meyers  shows that people in Medicare Advantage face about the same costs as people in Traditional Medicare; overall, the difference in spending is a wash!!!

    The researchers looked at costs for people in Traditional Medicare as compared to costs of people who switched from Traditional Medicare to Medicare Advantage. They found that “[d]ifferences in financial outcomes between beneficiaries who switched from TM to MA and those who stayed with TM were small. Differences in financial burden ranged across outcomes and did not have a consistent pattern.” The findings are particularly significant because people too often assume they will save money in Medicare Advantage and fail to appreciate the challenges they could face getting the care they need from the physicians and hospitals they want to use in Medicare Advantage.

    To be clear, there’s no question that if you need few or no health care services, you will have few if any costs in a Medicare Advantage plan. But, you would have few if any costs in Traditional Medicare as well if you did not buy supplemental coverage. The question you should consider when deciding whether to enroll in a Medicare Advantage plan is whether you are willing to trade the cost of supplemental coverage in Traditional Medicare to pick up your out-of-pocket costs for a serious gamble as to whether you will be able to get the care you need at a price you can afford in a Medicare Advantage plan.

    There are four big issues facing people in Medicare Advantage that people in Traditional Medicare do not face.

    1. Even though you are supposed to get the same benefits in Medicare Advantage as in Traditional Medicare, Medicare Advantage plans often inappropriately delay and deny care, forcing you to get prior authorization before receiving services and, sometimes, challenge denials of care your treating physicians say you need. In some cases, your only choice is to pay out of pocket for the full cost of those services.
    2. Traditional Medicare covers your care from almost any physician or hospital you want to use. Medicare Advantage plans restrict your access to physicians and hospitals, sometimes not covering care in cancer centers of excellence or from top specialists. In some cases, your only choice is to pay out of pocket for the full cost of services from the physicians or hospitals you want to use.
    3. Traditional Medicare covers your care anywhere in the United States. So, if you are traveling or have a second home or want to receive your care away from home and near a friend or family member, Traditional Medicare will cover it. But, if you are in a Medicare Advantage HMO, it will only cover your care out of your area if it is an emergency. And, if you are in a Medicare Advantage PPO, it will only cover at best 60 percent of the cost of your care out of your area, except in emergencies.
    4. Some Medicare Advantage plans might meet your needs and others might not. But, the data is not available to let you know which ones are better than others. You should avoid all Medicare Advantage plans that are not five stars, but five star plans could still have high denial, high delay and high mortality rates.

    Here’s more from Just Care:

  • Issues with network adequacy and prior authorization in Medicare Advantage persist

    Issues with network adequacy and prior authorization in Medicare Advantage persist

    MedPAC, the Medicare Payment Advisory Commission, just released a report focused in part on Medicare Advantage network adequacy and prior authorization issues. People enrolled in Medicare Advantage plans can find it challenging both to find health care providers who meet their health care needs and to get covered for the care their treating physician says they need. The Centers for Medicare and Medicaid Services (CMS) has taken some steps to address these issues, but there’s more to be done.

    Many hospitals and physician specialists say that some Medicare Advantage plans endanger patient health and well-being as a result of inadequate networks and non-evidence-based prior authorization requirements. In particular, many Medicare Advantage do not have cancer centers of excellence or mental health specialits in their networks. And, CMS only studies network adequacy at the “contract” level, meaning that it looks at an insurers’ entire network in an area, not at the networks of each individual Medicare Advantage plan the insurer offers.

    MedPAC explains in its report that in 2021, MA plans required prior authorization in 37.5 million instance, about 1.5 determinations for each enrollee. In the vast majority of cases, the MA plan covered the service. MedPAC does not address the consequences of delays in getting these determinations on patient health.

    In nearly two million cases–about five percent of the time–the MA plan denied coverage for the service requested. But, different MA plans had very different denial rates. Some denied coverage three percent of the time and some 12 percent of the time. Unfortunately, as of now, no one know which are denying 12 percent and which are denying 3 percent of requests, preventing individuals from distinguishing meaningfully among Medicare Advantage plans.

    The insurers offering Medicare Advantage profit significantly from denials. Most of the time, they are not appealed. Only 11 percent of denials are appealed, even though 80 percent of the time they are reversed on appeal.

    For sure, prior authorization costs hospitals and physicians a lot of time and money. To what extent is it keeping patients from getting necessary care or delaying critical care or creating a serious health risk?

    Even a small proportion of prior authorization denials amounts to a large number of denials. The vast majority are not challenged, often to the detriment of patients. The Office of Inspector General’s audits suggests that a large proportion of those denials should have been approved.

    Here’s more from Just Care:

  • If Medicare Advantage can’t offer adequate provider networks and accurate directories, why are they in business?  

    If Medicare Advantage can’t offer adequate provider networks and accurate directories, why are they in business?  

    People who need health care in Medicare Advantage too often find that the provider directories they rely on when choosing a Medicare Advantage plan are inaccurate. The Senate Finance Committee is looking to address the problem, and the American Medical Association is cheering it on. The fixes are a step forward but should go a lot further. If Medicare Advantage can’t offer adequate provider networks and accurate directories, why are they in business?

    For the last 20 years, insurers have been able to make their Medicare Advantage provider network directories look far more robust than they actually are, misleading enrollees. The Centers for Medicare and Medicaid Services, CMS, does not begin to have the resources to oversee network adequacy in the more than 4,000 Medicare Advantage plans, let alone protect enrollees when CMS identifies networks that are inadequate. So, insurers have every incentive to have narrow networks and to mislead enrollees.

    The MA plans must know who’s in their network since they pay these providers. There’s no excuse for inaccurate directories. Moreover, the insurers should not be allowed to deceive people by offering different plans with different networks that people cannot distinguish or discriminate against people with low incomes or communities of color by offering them poorer networks than others.

    What’s wrong in the network directories? A lot. The directories often fail to explain where enrollees can see in-network physicians (yes, the same physician can be in-network at one location and out-of-network at another,) or they claim physicians are in-network when they are not; and, if providers are in-network, the directories often don’t indicate that they are not taking new patients. It would be easy to fix the problem with one national government directory that imposed penalties on insurers who did not maintain accurate or complete information. One directory would also make it far easier for people to comparison shop for a Medicare Advantage plan.

    CMS proposed a national provider directory a couple of years ago, but it has not gone anywhere to date.

    But, the insurers oppose a system that would actually help people make informed choices of Medicare Advantage plans. Many in Congress appear to be right there with the insurers. Senator Ron Wyden, who chairs the Senate Finance Committee is trying to end provider directory errors and protect enrollees. Mike Crapo, the ranking Republican on the Committee, claims he is as well. But, what are they doing?

    The Finance Committee approved “The Better Mental Health Care, Lower-Cost Drugs, and Extenders Act of 2023,” legislation. Some of it is now law. The bill requires Medicare Advantage plans to have accurate and updated provider directories. Though Medicare Advantage plans always have been required to have accurate in-network information, the bill would require more verification. The bill would also protect Medicare Advantage enrollees from the costs of inaccurate directories if they had to pay for out-of-network care when they were led to believe care was in-network. Beginning in 2026, enrollees would only be responsible for the in-network copay.

    Here’s more from Just Care:

  • Seven questions you should be asking this Medicare Open Enrollment period

    Seven questions you should be asking this Medicare Open Enrollment period

    During this Medicare Open Enrollment period, ask yourself these seven questions. And, 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.

    1. Q. What’s the biggest difference between traditional Medicare and a Medicare Advantage plan? To ensure you have good coverage for both current and unforeseeable health needs, you should enroll in traditional Medicare. 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 doctors 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.
    2. Q. Should I trust an insurance agent’s advice about my Medicare options? No. Unfortunately, insurance agents are paid more to 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. Keep in mind that while Medicare Advantage plans tell you that they offer you extra benefits, you still need to pay your Part B premium, and extra benefits are often very limited and come with high out-of-pocket costs; be aware that many Medicare Advantage plans won’t cover as much necessary medical and hospital care as traditional Medicare. 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).
    3. Q. Why can’t I rely on my friends or the government’s star-rating system to pick a good Medicare Advantage plan? 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 or to cover the medically necessary care that traditional Medicare covers. Even if your friends say they are happy with their Medicare Advantage plan right now, they are gambling with their health care. 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.
    4. Q. If I’m enrolled in a Medicare Advantage plan, can I count on seeing the physicians listed in the network and lower costs? Unfortunately, provider networks in Medicare Advantage plans can change at any time and your out-of-pocket costs can be as high as $8,300 this year for in-network care alone. You can study the MA plan literature, and you can know your total out-of-pocket costs for in-network care. But, you cannot know whether the MA plan will refuse to cover the care you need or delay needed care for an extended period. This year alone, 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.
    5. Q. Doesn’t the government make sure that Medicare Advantage plans deliver the same benefits as traditional Medicare? No. 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.
    6. Q. If I join a Medicare Advantage plan, can I 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 high costs. What’s worse, you could incur thousands of dollars in out-of-pocket costs in Medicare Advantage.
    7. Q. If I have traditional Medicare and Medicaid, what should I do? 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).

    Here’s more from Just Care:

  • Underpayments lead hospitals and specialists to cancel Medicare Advantage contracts

    Underpayments lead hospitals and specialists to cancel Medicare Advantage contracts

    Ken Alltucker reports for USA Today on how insurers offering Medicare Advantage plans are underpaying hospitals and specialists. Consequently, these health care providers are dropping their Medicare Advantage contracts. It’s hard to see how this persisting issue can be solved given the corporate health insurers’ ability to use their own proprietary claims processing software, which makes oversight near impossible.

    Since Medicare Advantage plans legally must cover the same benefits as Traditional Medicare, they should be required to to use the same claims processing software as Traditional Medicare to ensure they do. They should also be required to pay hospitals and specialists the same rates as Traditional Medicare.

    Traditional Medicare rates are significantly lower than commercial insurance rates because, unlike Medicare, which uses its enormous leverage to set fair rates with providers, commercial health insurers are generally unwilling or unable to negotiate low rates for people under 65. But, Congress allow Medicare Advantage insurers to pay providers even lower rates than Traditional Medicare. So, the insurers sometimes will only pay lower rates; consequently, they can keep top quality providers out of their networks and increase their profits. Narrow networks keep people with costly conditions from enrolling or remaining in a Medicare Advantage plan.

    The USA Today story feeds off of other stories in Becker’s Hospital, MedPage Today and Kaiser Health News, documenting the financial problems and patient safety concerns that hospitals are dealing with because Medicare Advantage plans are undermining their ability to provide good patient care and underpaying them. When these hospitals cancel their Medicare Advantage contracts, tens of thousands of patients face major care disruptions.

    The patient care disruptions mean that patients need to find new doctors and hospitals or pay out of network to continue to get care from the same providers. The Centers for Medicare and Medicaid Services, which oversees Medicare, can step in to help patients when there are “significant network changes,” but it is not clear how often or whether it ever does.

    It’s likely that the disputes that USA Today documents are the tip of the iceberg. Even when Medicare Advantage plans agree to pay decent rates to hospitals, they can and do often refuse to pay the hospitals and other care providers what they owe them, cutting payments by as much as 30 percent. Hospitals then report losing tens of millions of dollars in revenue, while the insurers run away with the store. Moreover, hospitals also report inability to provide timely and necessary care to their patients in Medicare Advantage plans.

    The Medicare Advantage payment system is defective. The government pays the insurers upfront regardless of how much they spend on care. The government is not even able to monitor how much the Medicare Advantage plans spend on care effectively, in order to ensure enrollees are getting the benefits to which they are entitled. Not surprisingly, the Office of the Inspector General has found widespread and persistent failure on the part of the health insurers to pay for medically necessary care they should be paying for and that Traditional Medicare covers. That’s one way that the insurers profit.

    St. Charles Health system in Oregon tried and failed to resolve its disputes with insurers offering Medicare Advantage. As a result, it is cancelling contracts with Humana, HealthNet and WellCare. Its chief clinical officer said that unless it cancelled these contracts, their physicians would face restrictions on “patient care, longer hospital stays and administrative burdens.”

    Here’s more from Just Care: