It is that time of the year again. The big insurance companies are flooding the airwaves with advertisements urging seniors to take advantage of all of the wonderful extra benefits they can receive, if they only sign up for the company’s Medicare Advantage plan. And who doesn’t want free, extra benefits? Be careful, if you are considering joining a Medicare Advantage plan. There is a reason these companies can afford to offer extra benefits.

There are lots of complaints about Medicare Advantage plans. They are owned and operated by the largest health insurance companies. They have used questionable practices to get Medicare to pay them more for the care they provide to their plan members. The most common method is for the plan to identify new medical diagnoses for their members, since Medicare pays the plan more for accepting sicker patients. According to reports, doctors have been pressured to find additional diagnoses, or they have been offered rewards for finding additional diagnoses. Some report having been assigned quotas. Some of these additional diagnoses have bordered on fraud. For example, some plan members have been diagnosed with cataracts, after having already undergone cataract surgery. Cataracts cannot come back after surgery, so this diagnosis cannot be accurate. Other plan members have been assigned medical diagnoses that are similarly impossible from a medical standpoint.
Most Medicare Advantage plans do offer benefits not available under Traditional Medicare, but they do so at a price. In Traditional Medicare, you can see any doctor who is willing to accept Medicare patients. If that doctor wants to provide you with a treatment or to perform a procedure, you can be pretty sure Medicare will pay for it, so long as it is not experimental. Medicare Advantage? Not so much.
From the perspective of the patient, the most significant ways Medicare Advantage plans make money is by requiring plan members to see only certain doctors, and by requiring prior authorization to see specialists or to have most procedures. There have been many complaints about the requirement for prior authorization and that it has been routinely used to deny members necessary medical treatment. If the member does not appeal, or does not win the appeal, the member does not get the necessary treatment. Recent Congressional reports have asserted that the rate of prior authorization denials has been increasing and that some companies are using artificial intelligence, instead of an actual health care provider, to make decisions on requests for prior authorization. Every time a plan successfully refuses a request for prior authorization, it gets to keep the money it would have had to spend to pay for that treatment.
Another thing to consider before enrolling in a Medicare Advantage plan is that the plans change on a regular basis. The plan you sign up for today may not be the plan you have next year or the year after. Sometimes your plan may be discontinued entirely. At other times, the benefits it offers may be reduced or changed dramatically. Sometimes a plan may continue to be offered, but not to people who live in your area. Sometimes the plan changes the doctors you are allowed to see and you may have to choose a new doctor, even though you really liked your old doctor. It is not exactly bait and switch, but it can feel like it.
Even though you have the right during the open enrollment period (October 15 to December 7, 2024) to leave your Medicare Advantage plan and to return to Traditional Medicare, as a practical matter, you may find yourself stuck in the Medicare Advantage universe because you cannot afford to purchase a Medicare Supplement plan to cover those charges for which Medicare will not pay, such as co-pays or deductibles. If you elect Traditional Medicare when you first become eligible, the companies offering Medicare Supplement plans cannot consider your health status when deciding what premium to charge you. If, however, you are applying for coverage after you have been in a Medicare Advantage plan, the companies can charge you more, if by now you have medical conditions which make you a poorer risk. You may not be able to afford a Medicare Supplement plan and be forced to remain in Medicare Advantage.
All this means that there is a lot to think about when choosing between Traditional Medicare and Medicare Advantage. Don’t let the offer of extra benefits keep you from making a good analysis of the risks and benefits of Medicare Advantage. Also remember that, however good Medicare Advantage looks today, it may look very different to you as you age and your health changes. The decision you make today can have significant effects years from now.
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