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:
- 2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
- Need a shrink? Your Medicare Advantage plan might not think so
- Underpayments lead hospitals and specialists to cancel Medicare Advantage contracts
- For-profit hospitals urge CMS to hold Medicare Advantage plans to account for wrongful denials
- AHA warns Medicare oversight agency about dangers of Medicare Advantage
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