Tag: Traditional Medicare

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 or to a different Medicare Advantage plan. This opportunity for to switch out of your Medicare Advantage plan is an important consumer protection. Medicare Advantage plans could have changed their provider networks or drug coverage between the fall Medicare Advantage Open Enrollment Period and now.

I’ve written at length about all the reasons to avoid enrolling 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 less 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, 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, nor is there a restricted network. You are covered for care from the vast majority of physicians and hospitals in the US. 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 impose prior authorization requirements before they will cover your 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 more than 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. Memorial Hermann in Houston, Texas is the most recent hospital system to do so, ending its Medicare Advantage contract with Humana.

Here’s more from Just Care:
January 9, 2024
2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
The Annual Medicare Open Enrollment period begins October 15 and ends December 7. If you have Medicare, you are likely to see endless ads and receive lots of mail from an assortment of insurers chomping at the bit to get you to sign up with one of their Medicare Advantage plans. That’s how they rake in the big bucks, tens of billions of dollars a year. Unfortunately, our government does a poor job of helping you to understand differences between traditional Medicare, which is administered by the Centers for Medicare and Medicaid Services (CMS), and Medicare Advantage plans, which are administered by corporate health insurers that contract with the government. And, you can’t trust the corporate health insurers or their sales agents to tell you what you need to know.

There are five basic differences between Traditional Medicare and Medicare Advantage that you need to understand.

1. Coverage:

Traditional Medicare. With traditional Medicare, you are covered for the medicallyreasonable and necessary care your providers believe you need. An insurance company is not second-guessing your doctors.

Medicare Advantage. Medicare Advantage plans are supposed to cover the same benefits as traditional Medicare, but they cover significantly fewer, as has been documented over and over again. They often engage in widespread inappropriate delays and denials of care and generally require you to get approval before they will pay for most costly services. That’s how they maximize profits. If you think you might get sick or need costly health care at some point, even if you don’t need it now, think twice before signing up with a Medicare Advantage plan. No one provides you with the information you need to know to distinguish the good Medicare Advantage actors from the bad ones. And, there appear to be a lot of bad ones.

2. Health care providers:

Traditional Medicare. With traditional Medicare, you can see almost all doctors and use virtually all hospitals anywhere in the United States. Almost all take Medicare and more than 90 percent “take assignment,” accept Medicare’s approved charge as payment in full. The most they can charge is 15 percent above that amount.

Medicare Advantage. With Medicare Advantage, your care is generally only covered when you use “in-network” providers. They can be few and far between and are often only located in your community. If you travel or spend time away from your primary residence, a Medicare Advantage plan usually will not cover your care, except in emergencies, Also, you might find that the providers in their directories are not taking new patients or have left the network. So, if you are thinking of joining a Medicare Advantage plan or are in one now, talk to any of the doctors you know you want to continue seeing to confirm that you will still be able to have your care covered when you see them. Keep in mind that a lot of the Medicare Advantage plans have lower quality providers in their networks and might not have a cancer center of excellence as part of their network.

3. Costs:

Traditional Medicare. With traditional Medicare you must pay your Part B monthly premium. You are generally liable for a hospital deductible and 20 percent of the cost of your medical care, unless you have supplemental coverage, either Medigap, which you buy in the individual market, Medicaid, or retiree coverage from a former employer. If you have supplemental coverage, most if not all of your costs will be covered. Traditional Medicare does not have an out-of-pocket maximum.

Medicare Advantage. With Medicare Advantage, you pay your Medicare Part B premium and you might have no additional premium, but your out-of-pocket costs can be sky high. You cannot buy supplemental coverage to pick up your out-of-pocket costs. Your costs turn on the Medicare Advantage plan you choose, the care you need, and what the Medicare Advantage plan charges you for your care. You generally will have to pay a copay when you are hospitalized or need medical services. Your out-of-pocket costs can be over $8,000 for in-network care alone if you need costly care. But, each Medicare Advantage plan has its own out-of-pocket maximum. If you go out-of-network for your care, you will be liable for the full cost of your care, unless you are in a PPO (preferred provider organization), in which case you generally will be liable for 40 percent of the cost.

4. Drugs:

Traditional Medicare. With traditional Medicare, you will need to buy Medicare Part D prescription drug coverage if you want drug coverage. That typically costs about $55.50 a month.

Medicare Advantage. With Medicare Advantage, your drug coverage is usually included in your plan’s monthly premium.

Whether you’re in traditional Medicare or a Medicare Advantage plan, be sure to look at differences in your drug costs among Medicare Part D drug plans. And, keep in mind that it is possible, even likely, that you might spend less getting some of the drugs you take from Costco or another mail-order pharmacy than paying the copay for them through your Part D plan. Part D plans can have higher copays than the total cost of the drug from a low-cost pharmacy.

5. Quality:

Traditional Medicare. If you want control over the quality of your health care providers, you probably want to be in Traditional Medicare, where you choose the providers you see.

Medicare Advantage. In a Medicare Advantage plan, the plan restricts your access to providers. And, even when you see a provider you want to see, the Medicare Advantage plan might not let your physician or hospital provide the care that they think is best for you. For example, if your doctor thinks you need 50 days of inpatient rehab therapy, your Medicare Advantage plan still might decide you only need 10 and will only cover 10 days.

Bottom line: With traditional Medicare, your doctors and hospitals have every incentive to provide you with all the care they think you need and traditional Medicare will cover it. Medicare Advantage plans receive a fixed amount from the government to cover your care regardless of how much they spend on your care. Consequently, they have an incentive to withhold needed care and to incentivize their physicians to limit the care they provide you. The less money a Medicare Advantage plan spends on your care, the more money the Medicare Advantage plan has for its shareholders. Since there’s no good data to distinguish the good Medicare Advantage actors from the bad ones, you are gambling with your health and well-being when you enroll in a Medicare Advantage plan. To learn more, read this blog post by Diane Archer and Theodore Marmor on the fundamental difference between traditional Medicare and private insurance.

Here’s more from Just Care:
October 11, 2023
Traditional Medicare’s fee for service payment system contains costs better than other payment models
Since establishment through the Affordable Care Act, the Center for Medicare & Medicaid Innovation (CMMI) has been testing new ways to deliver and pay for care in Medicare, Medicaid and the Children’s Health Insurance Program, with the goal of reducing spending and improving care quality. A new report from the Congressional Budget Office (CBO) indicates that, over the last ten years, CMMI’s pilot programs cost more than Traditional Medicare with a fee for service payment system.

CBO looked at evaluations of 49 CMMI delivery and payment models, alternatives to Traditional Medicare’s fee-for-service payment system, and found that Medicare spending is up $5.4 billion between 2011 and 2020. At the time Congress created CMMI, lawmakers believed that CMMI would save the government money in its first decade. They believed a $7.5 billion investment in new models would result in $10.3 billion less spending.

In this next decade, CBO projects $1.3 billion in net additional spending as a result of CMMI’s pilot programs rather than the $77.5 billion in net savings originally projected. Based on this information and, even more so, what we know about some of the models CMMI is testing, it’s not clear that CMMI is offering the value people hoped it would.

It’s no surprise that CMMI’s alternative payment models are costing more than Traditional Medicare’s fee for service payment system. The big models all rely on multiple third-party intermediaries to oversee care. These intermediaries drive up administrative costs and are often profit-making entities, such as private equity firms, or large non-profit systems.

What’s worrisome is that some of the CMMI payment models, such as the ACO REACH model, incentivize companies to withhold needed care in order to maximize profits. That’s a recipe both for driving up Medicare spending and for endangering the health and well-being of older adults and people with disabilities.

Here’s more from Just Care:
October 9, 2023
Medicare should increase physician pay to ensure good access to care
The Medicare Payment Advisory Commission’s (MedPAC’s) most recent report to Congress recommends that Medicare increase physician pay in traditional Medicare. Its recommendation came in the context of recognizing good access to care for people in traditional Medicare–as good as or better than people who are privately insured–but inflationary pressures on physician practices. MedPAC does not address the rates Medicare Advantage plans–corporate health plans offering Medicare benefits–pay physicians.

MedPAC recommends that traditional Medicare increase physician pay by 1.45 percent. It also recommends an increase in pay of 15 percent to primary care physicians who serve dual-eligibles–people with both Medicare and Medicaid. And, MedPAC recommends a 5 percent increase in pay for other physicians serving people in traditional Medicare with low incomes.

Not surprisingly, the American Medical Association supports these recommendations and wants them to be even higher. The AMA argues that physician pay in traditional Medicare has not gone up at the same rate as the cost of practicing medicine. AMA says with inflation adjustment, physician pay in Medicare has dropped 26 percent in the last 22 years. Physicians in small practices, in rural communities, and serving low-income populations are most hurt.

In addition, MedPAC recommends moving more Medicare support to safety-net hospitals. And, MedPAC believes that Medicare should not be paying different amounts for the same service depending upon where the service is provided.

Medicare Advantage plans can set their own physician rates; they also can piggyback off of traditional Medicare rates. Given access to care issues in Medicare Advantage plans, particularly access to high quality specialists, it would be helpful to know whether Medicare Advantage plans are paying in-network specialists at the same rate as traditional Medicare today or at a lower rate. To ensure access to care in Medicare Advantage, while delivering cost-effective care, Medicare Advantage plans should be paying the Medicare rate for specialty care.

Six years ago, Medicare Advantage plans paid physicians somewhat less than traditional Medicare. In 2017, “MA paid 96.9% of what traditional Medicare paid for a mid-level office visit, 91.3% of what traditional Medicare paid for a cataract removal in an ambulatory surgery center and 102.3% of what traditional Medicare paid for a complex evaluation and management of a patient in the emergency department. Laboratory services and durable medical equipment saw much lower MA rates, including only 67.4% for a walker and 75.8% for a complete blood cell count.” It’s not clear whether Medicare Advantage provider rates have come down further since then. People in Medicare Advantage plans should be concerned about their ability to access good quality providers if they have come down further.

Here’s more from Just Care:
March 20, 2023
The choice between traditional Medicare and Medicare Advantage: It’s a sham

If all things were equal, the choice between traditional Medicare and Medicare Advantage is easier than you think, as I wrote in a previous post. But as one reader commented, there’s more to it than I could include in that post.

Here’s part two, explaining why about half of all people with Medicare are now enrolled in the privatized Medicare option: Medicare Advantage.

Traditional Medicare’s upfront costs are high

Traditional Medicare does not have an out-of-pocket cap. Unless people have supplemental coverage to pick up their out-of-pocket costs, their upfront costs in traditional Medicare are high. They easily could spend $3,000 on supplemental coverage and Part D prescription drug coverage. And, that’s on top of their Medicare Part B premium.

Millions of people cannot afford supplemental coverage; the typical person with Medicare has an annual income of less than $30,000. So, people with lower incomes are more likely to enroll in Medicare Advantage, which has an out-of-pocket limit and few, if any, upfront costs. Not surprisingly, wealthier individuals are more likely to enroll in traditional Medicare.

In truth: You’ll spend less out of pocket in traditional Medicare with supplemental coverage than in Medicare Advantage when you need costly care and have direct access to the care you want. Cost will not be an obstacle to care as it can be in Medicare Advantage.

To save money, employers and unions steer retirees into Medicare Advantage

Increasingly, companies and unions offering retiree benefits contract with Medicare Advantage plans to cover their retirees’ care. The Medicare Advantage plans are willing and able to offer companies and unions special benefits to enroll their retirees, better than what they offer people in the individual market, because the Medicare Advantage plans profit morethrough these contracts than in the individual market. And companies and unions save money on the cost of supplemental coverage.

In truth: Millions of people with retiree benefits lose their easy access to care, choice of doctors and hospitals, and coverage anywhere in the U.S. without their consent.

Medicare Advantage marketing misleads people about their benefits

Medicare Advantage plans use taxpayer dollars to promote their benefits and to claim they are better than traditional Medicare. A lot of the marketing is misleading about the benefits people will get in Medicare Advantage. The government does not use taxpayer dollars to promote traditional Medicare, let alone to explain why it is better than Medicare Advantage.

In truth: No one should trust the Medicare Advantage TV ads or mailers.

Sales agents steer millions of people into Medicare Advantage

Sales agent commissions for enrolling people in Medicare Advantage are significantly higher than commissions for enrolling people in traditional Medicare. As a result, sales agents have a financial incentive to steer people into Medicare Advantage.

In truth: No one should trust sales agents; they should use independent, unbiased advisers, such as State Health Insurance Assistance Programs.

People aren’t told that a Medicare Advantage plan might not meet their needs

The government suggests that people can pick the Medicare Advantage plan that’s right for them. But, the government does not make data available about key differences among Medicare Advantage plans on Medicare Compare or anywhere else. For example, people don’t know about rates of denial, disenrollment or mortality in different Medicare Advantage plans. Moreover, people do not know what their future needs will be and how the Medicare Advantage plan they choose will meet them.

The Centers for Medicare and Medicaid Services’ “Medicare & You” handbook does not warn people that some Medicare Advantage plans engage in widespread and persistent inappropriate delays and denials of care, let alone which ones. Medicare’s five-star rating system of Medicare Advantage plans is largely a farce.

In truth: People, who elect Medicare Advantage must gamble on whether they will get the care they need.

Medicare Advantage plans generally cover fewer services than traditional Medicare

While in theory, Medicare Advantage plans should cover people for the same medically reasonable and necessary services traditional Medicare covers, in practice they do not.

People generally don’t know about high rates of inappropriate delays and denials of benefits in some Medicare Advantage plans, let alone which plans have the highest such rates. They also do not know which Medicare Advantage plans have high voluntary disenrollment rates, particularly for people with costly conditions or high mortality rates.

In truth: Medicare Advantage plans profit from delaying and denying care, and the government does not have the tools or resources to hold them accountable when they are bad actors.

Additional benefits in Medicare Advantage might not be valuable

Medicare Advantage plans market their dental and vision benefits, gym memberships and other freebies not available in traditional Medicare. There’s almost no data on the value of these benefits or to show who is able to use these benefits and whether out-of-pocket costs or limited access make them less beneficial than they appear.

In truth: Enrollees often can’t take advantage of these additional benefits; they can come with high out-of-pocket costs and limited provider networks.

Medicare Advantage costs can be an obstacle to care

There’s little information about typical out-of-pocket costs in Medicare Advantage plans, let alone typical out-of-pocket costs for people with different health conditions, such as diabetes or cancer. The Medicare Advantage plans do not make this information available. The government’s “Medicare & You” handbook does not include information on out-of-pocket limits in Medicare Advantage, which can be as high as $8,300 for in-network care alone this year, and significantly more for out-of-network care.

In truth: Medicare Advantage plans impose financial barriers to care that lead some people – particularly those with low incomes and people of color — to skip or delay care when they get sick.

Medicare Advantage prior authorization rules and networks can be an obstacle to care

People do not know what care they will need down the road and whether their Medicare Advantage plan has specialists and specialty hospitals in its network to meet those needs. People often face obstacles such as prior authorization from their MA plans when they need critical care.

In truth: Medicare Advantage plans impose administrative barriers to care that keep some people from getting the care they need.

Traditional Medicare is not always an option once people enroll in Medicare Advantage

People are told that they can switch Medicare Advantage plans and switch to traditional Medicare each year during the Annual Open Enrollment Period. But most people don’t know that, except in Maine, Massachusetts, Connecticut and New York, they have no right to buy supplemental coverage that fills gaps in traditional Medicare after they first enroll in Medicare, with limited exceptions. They also don’t know that companies selling supplemental coverage generally can charge them much higher rates based on their health status if they switch out of Medicare Advantage.

In truth: People are often locked into Medicare Advantage once they enroll.

March 8, 2023
Case study: Medicare Advantage delays, denials and consequences
Rick Timmins, a retiree in Washington State, reports the delays and denials he has faced trying to get care while enrolled in a Medicare Advantage plan in Washington State. The costs of these delays and denials have been substantial and the consequences severe. What’s worse is that he is locked in to Medicare Advantage, no longer able to switch to Traditional Medicare.

Many people join Medicare Advantage when they turn 65 in order to save money on the supplemental coverage that is needed to protect themselves financially in Traditional Medicare. They also often save money on prescription drug coverage, which usually is included with Medicare Advantage. What people often don’t realize is that once they’ve been in a Medicare Advantage plan for more than a year, they have no right to buy Medicare supplemental coverage if they want to switch to Traditional Medicare, except in Connecticut, Massachusetts, Maine and New York.

Rick Timmins had a rapidly growing painful lump in his ear. But, his Medicare Advantage plan made him wait five months before it authorized him to see a dermatologist. And, when the dermatologist referred him to a surgeon, the Medicare Advantage plan made him wait an additional two months.

Timmins made countless calls to his Medicare Advantage plan to try to speed up the approval process. But, he could not get a straight answer as to why the prior authorization was taking so long. Customer service could not even find his prior authorization request.

As it turned out, his Medicare Advantage plan had subcontracted the prior authorization to Optum, another company, without telling him. When he finally learned that this is what had happened, his Medicare Advantage plan could not provide him with Optum’s contact information.

The Medicare Advantage plan’s website provided inaccurate information about his claims and out-of-pocket costs. He paid $6,570 out of pocket although his out-of-pocket costs were supposed to be capped at $6,500. And, the MA plan’s customer service staff could not explain the frequent claims denials for services he received at the cancer center or his financial liability.

As a result of all these delays, Timmins’ lump, which turned out to be cancerous, grew larger and became a more aggressive tumor. He needed extensive surgery and immunotherapy over the course of a year to treat the cancer. All this additional treatment cost him more physically, financially and emotionally. He had a longer and painful recovery from a partial amputation of his ear and exploratory surgery in his neck.

Timmins would like to switch to Traditional Medicare, but he can’t. Insurers offering supplemental coverage to fill gaps in Traditional Medicare will not sell him a policy. And, he does not have a right to it. He is locked in to Medicare Advantage for the rest of his life.

Here’s more from Just Care:
January 24, 2023
It’s Medicare Open Enrollment: To save money and avoid big risks, check out your options
The Medicare Annual Open Enrollment Period is underway through December 7. You could save a lot of money and headache if you check out your options. Most people don’t tend to switch Medicare drug plans or Medicare Advantage plans and many don’t even look to see how their benefits are changing next year, according to the latest research. To avoid big risks and beware of bad actors, check out this post. Here are a few additional tips:

If you have Medicare directly from the government and supplemental coverage that fills gaps, little is changing except your Medicare prescription drug plan options. Even if you have a Medicare prescription drug plan that’s meeting your needs, keep in mind that everything about it can change in 2023.

If you have a Medicare Advantage plan from a health insurance company, check to see how your provider network, out-of-pocket costs and additional benefits are changing and compare your options. You might want to switch to a different Medicare Advantage plan to save money. Some might have lower out-of-pocket maximums, and some might offer you better prescription drug coverage than others. You also might want to switch to traditional Medicare.

With traditional Medicare, you will need to pay for prescription drug coverage and supplemental coverage separately, but the total cost of that coverage could be far less than your out-of-pocket costs in a Medicare Advantage plan, and you will have coverage from most doctors and hospitals throughout the US.

As important as it is to look at all your options each open enrollment season, one recent survey found that most people with Medicare don’t switch plans from one year to the next. In fact, 45 percent don’t look at their options during the Open Enrollment Period. Four in ten people in Medicare Advantage plans don’t know how their benefits will change in 2023.

To be clear, there is a lot you can’t know about your future health care needs as well as differences among Medicare Advantage options, including your out-of-pocket costs if you are diagnosed with a serious health condition, the specialists your Medicare Advantage plan will cover and your plan’s denial rates. Traditional Medicare offers more predictable coverage and easier access to care from the physicians and hospitals you want to use.

Here’s more from Just Care:
November 8, 2022
Data show Medicare Advantage covers less nursing, rehab, home health care
The Kaiser Family Foundation just released a new study looking at more than 60 past studies of Medicare Advantage. The takeaway is familiar: People with few health care needs fare well in Medicare Advantage. People with costly and complex health care needs receive less post-acute care: they get less nursing, rehab and home health care, often from lower quality providers, in Medicare Advantage. When deciding whether to enroll in Medicare Advantage, keep in mind that health insurance should meet your unforeseeable health care needs down the road.

The 62 studies, conducted since 2016, focused on people’s experiences affording health care, using health care and getting quality care in traditional Medicare and Medicare Advantage. The authors found that people in Medicare Advantage were less likely than traditional Medicare enrollees not only to use post-acute services but to get treatment in hospitals, skilled nursing facilities, and home health agencies which have the highest quality ratings. The study could not determine whether less use of post-acute care jeopardized health outcomes of study participants.

We already know from the HHS Office of the Inspector General that Medicare Advantage plans use prior authorization requirements for post-acute services that inappropriately delay and deny care their enrollees need. These “widespread” inappropriate delays and denials likely contribute to why MA enrollees use fewer of these services than people in traditional Medicare, which has no prior authorization requirements for these services. It’s also likely why people with costly conditions tend to disenroll from Medicare Advantage plans at higher rates than other people.

The data also show that people in Medicare Advantage often forgo care in order to avoid going into medical debt and/or having no money to pay for food and rent. Copays and deductibles can be high in Medicare Advantage plans, particularly for post-acute care. People in traditional Medicare, particularly those with supplemental coverage, experience fewer cost-related problems.

Medicare Advantage plans do not appear to do a better job of keeping enrollees healthy than traditional Medicare, based on the available data. Satisfaction rates with both care and wait times is similar in traditional Medicare and Medicare Advantage.

Here’s more from Just Care:
September 20, 2022
Medicare Advantage benefits: Appearances v. reality
The Commonwealth Fund’s latest report on Medicare Advantage “benefit design” provides what I would call the standard take, highlighting Medicare Advantage’s out-of-pocket cap and “additional benefits,” as if those are the most important differences. It also assumes that what you see with Medicare Advantage is what you get rather than explaining that appearances belie reality with Medicare Advantage.

The report questions some of the lack of detail available about Medicare Advantage additional benefits. But, the report overlooks the biggest point about Medicare Advantage plan benefits–they tend to be withheld, delayed and denied a lot more than people might imagine.

People with Medicare (and everyone else) should be able to assume that the health plan they enroll in will cover all the medical treatments that they need. But, each Medicare Advantage plan has different prior authorization and specialty referral requirements, provider networks, and out-of-pocket costs. Each also has different proprietary rules for when they will pay for particular treatments and different rates of inappropriate delays and denials of care. All of these elements are part of the “benefit” package and can mean the difference between getting needed care and being forced to forgo it.

Medicare Advantage plans often rely on proprietary algorithms to determine whether care is covered. They always make their own decisions about medical necessity that lead to their spending nearly 25 percent less on medical and hospital care than traditional Medicare. Medicare Advantage plans cover fewer services and fewer costly services than traditional Medicare. The Office of the Inspector General has found that Medicare Advantage plans engage in widespread inappropriate delays and denials of care and coverage.

You can’t know what you need to know about a Medicare Advantage plan’s benefits before you enroll. The consequence: You can’t meaningfully distinguish among Medicare Advantage plans and you take a huge risk when you enroll. The Commonwealth Fund’s experts warn that people know little about the extra benefits Medicare Advantage plans offer–who gets them, how frequently, where, and at what cost to them. Putting aside additional benefits, people know little about the standard benefits Medicare Advantage plans cover–who gets them, when, how frequently, where, and at what cost to them. For example, Medicare Advantage plans must cover physical therapy, but they decide–with no meaningful oversight– when it is warranted, how often an enrollee will get treatment, from whom and the copay.

The Fund highlights that nine in ten Medicare Advantage plans offer dental, vision and/or hearing benefits. But, it does not explain that narrow provider networks and high out-of-pocket costs keep a large number of people from taking advantage of these benefits. Rather, it says that Medicare Advantage “may have more limited provider networks or prior-authorization requirements for some services” as if this is simply a possibility when it fact it is the norm.

On the issue of costs, the report explains that lack of standardization of costs in Medicare Advantage keeps people from knowing what their costs will be in different Medicare Advantage plans. The majority of people in Medicare Advantage plans are in HMOs, which have no out-of-pocket cap for out-of-network care, an issue which the report omits; and, out-of-pocket costs are a barrier to care for many low- and middle-income enrollees.

Also of note and overlooked in the report: The cost of supplemental coverage in traditional Medicare, which has no out-of-pocket cap, tends to be far lower than the out-of-pocket cap for in-network care in Medicare Advantage. Moreover, we do not know typical out-of-pocket costs in Medicare Advantage because no independent reliable data is available.

For sure, costs in Medicare Advantage can be very high for people whose medically necessary care is wrongly denied or not available in-network, potentially keeping people from getting needed care. For example, many Medicare Advantage plans do not have centers of excellence in-network that people may want to use for complex conditions. If enrolless can’t afford to pay out of pocket, they can be forced to forgo medically necessary care.

Here’s more from Just Care:
April 7, 2022
Questions for your primary care doctor if you have Medicare
As you might know, the federal government is moving towards a “capitated” payment model for everyone with Medicare, paying insurers, private equity, and other intermediaries a flat fee for each enrollee and handing over to them the power to decide when to cover enrollees’ care and what care to cover. These intermediaries might have your best interests at heart, but they also might be focused on maximizing their profits and not your care needs. Your primary care doctor should be able to help you understand whether you are getting the care you need.

If you’re in a Medicare Advantage plan, you signed up for coverage that an insurance company oversees. Some Medicare Advantage plans do a better job than others of ensuring you get the care you need. Others inappropriately delay and deny care a lot of the time.

If you’re in traditional Medicare, an insurance company or private equity intermediary might be overseeing your coverage and you might not know it. Until 2021, that was never the case. You should find out whether there is an intermediary, sometimes called a Direct Contracting Entity or DCE. It is possible that this intermediary will try to inappropriately delay or deny your care through its preferred network of providers. You should know that, even if you are in a DCE, you have still have easy access to the doctors and hospitals of your choice and coverage of all medically necessary care through traditional Medicare outside that network.

To help you decide whether your primary care doctor will provide you with the care you need or whether you are better off disenrolling from your Medicare Advantage plan or switching primary care doctors and opting out of your DCE, find out the answers to these questions.

1. Is your primary care doctor employed or working under contract for an insurance company or a private equity firm?
- If you are in a Medicare Advantage plan, the answer is always yes.
- If you are in traditional Medicare, the answer could be yes or no. You should be able to find out the answer by calling 1-800-MEDICARE or by calling your primary care doctor’s office. If the answer is no, you are not in a Direct Contracting Entity and no one should be interfering with the care you receive. If the answer is yes, the federal government likely involuntarily enrolled you in a Direct Contracting Entity, and you have the right to opt out.
2. Is anyone directing your primary care doctor as to how to handle your care? How is it affecting the care your primary care doctor delivers?
- Is your primary care doctor unable to spend adequate time with you?
- Is your primary care doctor being directed to refer you only to lesser quality doctors and hospitals?
- Is your primary care doctor ever prevented from getting you the care the doctor thinks you need?
If the answer to any of these questions is yes, you might want to consider finding a new primary care doctor and opting out of your DCE or Medicare Advantage plan. Tip: If you are in traditional Medicare, you always have the freedom to use whatever doctors and hospitals you would like, regardless of what your primary care doctor recommends. And, so long as you have supplemental coverage–Medigap, retiree coverage from a former employer, or Medicaid, virtually all your costs will be covered.

If you are in traditional Medicare and your primary care doctor suggests you either drop your Medicare supplemental coverage or move to a Medicare Advantage plan, ask why and beware.
- Dropping your supplemental coverage if you are in traditional Medicare or moving to a Medicare Advantage plan will prevent you from being able to get care wherever you’d like because your out-of-pocket costs could be very high.
- Moving to a Medicare Advantage plan restricts your choice of health care providers and often limits your ability to get care at centers of excellence and from the best specialists. Your annual out-of-pocket costs could be as much as $7,550 for in-network medical and hospital care alone.
- Whether you drop your supplemental coverage and remain in traditional Medicare or switch to Medicare Advantage, you very well may never be able to get supplemental coverage again. Your right to buy supplemental coverage is extremely limited.
If you have questions, please email [email protected].

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