Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds

[Sgent]

Source: NY Times

Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.

The investigators urged Medicare officials to strengthen oversight of these private insurance plans, which provide benefits to 28 million older Americans, and called for increased enforcement against plans with a pattern of inappropriate denials.

Advantage plans have become an increasingly popular option among older Americans, offering privatized versions of Medicare that are frequently less expensive and provide a wider array of benefits than the traditional government-run program offers.



The industry’s main trade group claims people choose Medicare Advantage because “it delivers better services, better access to care and better value.” But federal investigators say there is troubling evidence that plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care.



Read more: https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html

[Deminpenn]

1. Private insurance companies are in the business of making money

They don't make money, in their model that's the difference between premiums+gov't reimbursement and expenses, if they pay for expensive care and procedures.

[ashredux]

2. Stick with Medicare....there is no private plan that is cheaper and better...

Their ads are VERY misleading

[Bengus81]

31. These are Medicare supplement plans unless I'm reading this wrong

Medicare should have kept up over the decades and lowered that 20% deductible or do away with it altogether. The ACA is cheaper than Medicare when you factor in a supplement plan but your have no choice after you turn 65. You have to go on Medicare.

[ashredux]

33. I read it as Medicare Advantage, it was a way the Right tried to "Privatize" Medicare

Often those on an Advantage plan end up paying more in the long run.

“But federal investigators say there is troubling evidence that plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care. “

[progree]

34. Medicare Advantage is entirely different from Medicare Supplement aka Medigap plans

Two ways to go:

(1). The original Medicare route:

-Start out with Medicare Parts A and B. Part B covers 80% of qualified claims, the insured person has to cover the other 20%. Also, Part A (Hospital coverage) has limitations.

-Optionally, add a Medicare Supplement Plan (aka Medigap) to improve coverage, e.g. take care of the 20% that Part B doesn't cover and better hospital coverage. Optionally, but extremely very strongly recommended. Without one, just that 20% that Part B doesn't cover can (and does) sink many elderly persons financially.

-One must still pay the Part B premium on top of the Supplement premium.

-The government insures the part A and B, while Supplement plans are always sold by private health insurance companies. So this route is partially privatized, unless one is a riverboat gambler and tries to get by with just Part A and B alone.

(2). The Medicare Advantage (M.A.) route:

- Roughly equivalent to original Medicare with a Supplement plan. Is essentially handing over original Medicare to a private insurance company which insures it all. Aka fully privatized Medicare

- But one must adhere to provider networks or pay much more for out-of-network care.

- One must still pay the Part B premium along with the M.A. premium

- Often, has some extras like some dental and vision coverage (unlike Supplement plans that rarely do)

- Is more heavily subsidized by the government than (1) above, that's why its usually cheaper. When they suck enough people into M.A., then the subsidies will almost certainly be less generous.

===============================================

I decided on the original plus Supplement route (1) above, because I hate networks with a passion. Plus I read about how people like M.A. because it all costs less than (1), until one gets seriously and/or chronically ill, then many try to switch to (1), but Supplement plans can charge sick people more or deny them coverage completely (they can't if someone starts out with Supplement and signs up within a few months window of when they are first eligible for Medicare, like I did). Some switch anyway.

Complicated.

[Grasswire2]

52. the good part of Medigap plans....

the benefits are standardized. You know exactly what you are getting.

Advantage plans are crafted by private carrier companies. They may or may not be completely transparent in descriptions, and so you can't easily compare one carrier's plan to another.

The very best coverage was Medigap plan F, but IIRC that was discontinued some time ago.

[aocommunalpunch]

3. Car insurance ads pull this shit and it drives me crazy

Everybody’s designed to save you money, allegedly. Who the fuck cares when you’re stuck in a torrent in the middle of the night after a hit and run from a drunk and when you call the insurance agency they tell you it’s a you problem when it comes to finding a tow.

The model is take your money and fight me for what you pay for. Fuck these bloodsuckers. Take the private insurance out of the goddamned equation. They are not here to help and if their fucking tagline is all about saving you money up front, caveat fucking emptor, I guess.

[Ferrets are Cool]

7. I understand what you are saying, however, Progressive has been very good to us.

They have never balked at any claims I've made. Of course, everyone's circumstances are different.

[FakeNoose]

25. I have AAA membership plus their auto insurance policy

I must say that AAA has always been prompt whenever I've called for a problem. Once or twice I had a dead battery, once it was a flat tire, couple times I needed a tow.

I believe it's AAA membership service (not the car insurance co.) that responds to most of these types of emergency calls. However I've had no serious accidents for a very long time.

[gab13by13]

4. I can't stand Joe Namath and the Dyn-O-Myte guy

shilling for Medicare Advantage.

Why is Medicare Advantage being pushed so hard?

Advantage plans are heavily advertised because of how they are funded. These plans' premiums are low or nonexistent because Medicare pays the carrier whenever someone enrolls. It benefits insurance companies to encourage enrollment in Advantage plans because of the money they receive from Medicare.

Beware, many plans limit choices of doctors, and when sick, co-pays can be expensive. There are also lifetime penalties in some plans.

Bottom line, MA plans are hurting Medicare.

MA is nothing more than private insurance eating into Medicare funds.

[keithbvadu2]

23. I think Joe Namath has had more tv exposure time in the ads than as a football star.

[RussBLib]

30. and they never call it "Medicare Advantage"

it's a DISadvantage, of course. They shill and push, emphasizing you can put MONEY in your pocket!! Yeah, short-term. Then you get screwed when you have an expensive claim.

Call now, the call is FREE!!!!! As if no one has free long-distance anymore? They prey on the confused and ill-informed. It's sickening.

Yeah, capitalism!

[Bengus81]

32. The premiums are low?

Most are in the $150-200 per month range on top of what is taken out of SS for your regular Medicare payment.

[DuaneT]

39. Are you speaking of Medicare supplements or Advantage?

[DuaneT]

41. What are the lifetime penalties in some plans you speak of?

[PdamnedQ]

5. Medicare Advantage Plans suck "literally"

Companies like Humana and United Healthcare get every penny allotted to Medicare recipients when they sign up.

However, the truth is most people never use anywhere near the funds that Medicare sets aside for each individual, and the fact is many seniors only have one or two serious health issues - just before they leave us for good, but the insurance companies get all of the money that seniors are allotted every year after they turn 65.

Medicare Advantage Plans suck money away from the Medicare system. That's why the Bush Administration thought they were so cool.

Republicans love a slick con, especially if it keeps poor people poor, and them in power.

[Delphinus]

8. Good to know.

I'm turning 65 in a year and a few so need to start researching what I have to do pretty soon.

[gab13by13]

12. Check out Medi-Gap, it's better than MA.

[INdemo]

16. I had friends that had the Med Advantage and it cost them their

life saving for co-pay for cancer treatments.

I have a supplement plan G and once the Part B deductible is paid everything is then covered 100%. Yes, I do have a premium but over the years the return has outweighed the Premiums.

[Delphinus]

27. Was there a seminar

or a person you sat down with to decide upon the best avenue?

[INdemo]

35. My Brother had a supplement policy and told me about the plans

then I called several companies direct and talked to their sales staff. I bought what has proven to be the best deal that I've had for 12 years now. I'm not sure that a person can get a sales person direct anymore. Most companies will now refer a potential customer to assigned agents.
The one issue is that the premium will rise each year according to age being a year older but its not very much, percentage wise.

[Casady1]

40. I have done all the work

All supplemental plans are the same. They are government mandated. AARP pushed United and Blue cross is the most expensive. The least expensive is Mutual of Omaha and they give you a 12% discount for being married. You have to choose a a separate RX plan and the medicare site will guide you to the one for you. Dental is separate as is optical. AARP dental is decent and it is $75 per month andt it is the only plan that covers implants (it is delta dental).

Your cost will be as follows

Medicare- $170 to more(means tested) and it goes by your last year's earnings.
Mutual of Omaha is $112 per month
Dental is $75
RX is about $20.

You are immediately accepted into medicare. If you go to Advantage and you get sick and want to go back to original medicare the insurance companies now have the right to underwrite you( you are screwed)

Last year my wife had 3 operations and one included a 25 day stay in the hospital. Her bills were $800,000.

I paid $205 total with the supplemental and I did not have to fight the insurance companies one time.

[Delphinus]

46. Bless you!

Thank you for sharing your important facts.

And Wow! $800k with only having to pay $205 more.

[Casady1]

47. and not once

fighting with the insurance companies. Once I had a chance to get out of that racket I did.

[DuaneT]

42. It was Clinton that originally got the ball rolling on Medicare Advantage and Bush with the Medicare

act of 2003 expanded to include Part D, prescription drugs.

[Skittles]

51. you get it

essentially if you are for privatization of Medicare, MA is for you

[twodogsbarking]

6. Like a mass of tangled fishing line and they are telling us how to cast.

[The Jungle 1]

9. Fought with insurance companies for years.

It took Blue Cross two years to pay for my child's birth. That has been the pattern for 45 years. Just don't pay and a percentage of people will just pay themselves. Fight over everything. Private healthcare insurance sucks. They only care about profit. Thanks Nixon.
I couldn't wait to join Medicare. The Advantage plans are desperately trying to destroy Medicare.

[Fritz Walter]

20. Same here!

After working 39 years for a single-employer, they laid me off three years before I became eligible for Medicare. Had to shop at the “marketplace” for coverage, and went with Florida Blew. By the time I did fully retire, the monthly premium — for crappy, single coverage with high deductible and co-pays — cost almost $900/month. Had to take a part-time job and do gig-work just to pay that premium.

My Advantage plan is infinitely better. I found a retiree health exchange that helps me choose/renew every year. Strongly recommend others explore and utilize such an exchange for their needs.

And it’d be a cold day in hell before I’d ever switch back to BC/BS!!

[leftyladyfrommo]

28. Before I got on Medicare my premiums were about $400

a month with a $4,000 deductible and lousy coverage.

My Humana Advantage Plus has been wonderful compared to what I had before. Ot doesn't cost me anything to see my doctor or Urgent Care.

$400 was an awful lot for me at the time.

[kellytore]

10. Never get a Medicare Advantage plan if you travel frequently.

I know someone who lives in Georgia and while vacationing in Montana they needed medical care and had trouble finding a doctor who took their plan. With Medicare Part B that would not have been a problem.

[Ohioboy]

14. One of the main reasons I never got an Advantage plan

[Emile]

38. No kidding! Usually when you are travelling it's an emergency. You don't have time

to make sure the doctors, clinics, hospitals, etc are in network. I have heard horror stories where retired people have lost everything just because of an accident. Even the big insurers are not always in network everywhere.

[DuaneT]

44. A doctor or hospital does not have to be in network if it is a bonifide emergency.

[Emile]

45. Okay. . .

[Sgent]

59. While true

what you say is an emergency and what your insurance company agrees is an emergency can be very different. They probably won't argue about an ER visit too much, but they might argue about whether you needed your broken hip actually fixed before traveling back home.

[paleotn]

11. Of course they were. It's a private, for profit industry.

It's in THEIR best interests to deny as much as they can possibly get away with. That's all gravy on top of the actuarial models.

Private medical insurance.....Is inherently inefficient, incentivizes the WRONG behaviors and is thus morally reprehensible. I don't know how people in that industry live with themselves.

[Ohioboy]

13. I like how certain supplemental plans are designed to make you pay more than if you paid yourself

For example, those supplemental vision plans where they'll cover an annual exam and half a pair of glasses at the price of two exams and a full pair of specs. They count on people not doing the math.

[Lonestarblue]

15. Original Medicare needs to add vision and dental coverage and also get rid of the Advantage plans.

I’m disappointed that the Biden appointees are continuing Trump’s money-skimming plan for eventually privatizing all of Medicare to put the insurance companies in charge of whether we get the healthcare we need.

And it’s long past time to lower the age for Medicare.

[Wuddles440]

18. Exactly!

Part C administrative costs are approximately 10 times that of Parts A and B. It's purely designed to enhance the profits of private insurers while draining the resources of the Medicare Trust Funds.

[Raven123]

17. MediGap is the way to go.

My mother transitioned from an Advantage to Medicare Plan F (no longer available), and a Part D drug plan. It was very good. Less hassle and confusion.

[leftyladyfrommo]

29. My experience has been that Medigap is great but a

lot more expensive.

[Skittles]

50. yes, it costs more to get actual care

it costs less if your treatment can be denied

[leftyladyfrommo]

53. I get actual care. I have never been refused anything.

I turn down stuff because I don't want to be bothered with it.

[Skittles]

55. read the original article

it's becoming a real problem with MA plans

[murielm99]

56. My husband and I have Plan F.

We are grandfathered in. Every year, we go to the senior center to work with a person from the Illinois Department of Aging. They help us with Plan D. They help us compare plans and find the one that is best for each of us, depending on the meds we take.

We could get the best deal at Walmart, but I refuse to walk into the place. Our local pharmacy was the next best choice. The pharmacist there is very helpful so that is where we get our meds.

[panfluteman]

19. I Am Now Experiencing This First Hand.

After returning from Mexico, and at the start of this year, I switched to a Medicare Advantage Plan, and since then, trying to find care has been a total nightmare. Everything, all the contact info, that could be gotten wrong about the personal physician I selected - even his gender - and his given name is Mohamed - they got wrong, and now I am fighting coverage bills. Geez, the bozos at my Medicare Advantage plan would even flunk out of third grade history class! Many times I wish I had stayed in Mexico, where I could get access to healthcare fairly cheaply for my relatively modest healthcare needs, just by going down to a local pharmacy, where they had consulting physicians on staff. And my Spanish was perfectly adequate for the occasion. As I age - this coming Tuesday will be my seventieth birthday - my metabolism, which was never very fast or strong to begin with - is slowing down, with increasing blood sugar problems. The sedentariness of the COVID lockdown didn't help either. Anyway, I have been managing my blood sugar problems with diet, exercise and, very importantly, medicinal herbs, up until now, but it's getting to be more and more of an uphill battle, with increasing blood sugar spikes and signs and symptoms of high blood sugar when I forget to take my herbs. The big question is: can I find care in time? I am now urgently trying to find care with a new primary care provider before my 70th birthday, while I am making major changes in my diet and regimen to stay on top of things. Stay tuned!

[Casady1]

43. I have done all the work

All supplemental plans are the same. They are government mandated. AARP pushed United and Blue cross is the most expensive. The least expensive is Mutual of Omaha and they give you a 12% discount for being married. You have to choose a a separate RX plan and the medicare site will guide you to the one for you. Dental is separate as is optical. AARP dental is decent and it is $75 per month andt it is the only plan that covers implants (it is delta dental).

Your cost will be as follows

Medicare- $170 to more(means tested) and it goes by your last year's earnings.
Mutual of Omaha is $112 per month
Dental is $75
RX is about $20.

You are immediately accepted into medicare. If you go to Advantage and you get sick and want to go back to original medicare the insurance companies now have the right to underwrite you( you are screwed)

Last year my wife had 3 operations and one included a 25 day stay in the hospital. Her bills were $800,000.

I paid $205 total with the supplemental and I did not have to fight the insurance companies one time.

[Midnight Writer]

21. Got a friend struggling with this now. His local doctor is on the plan, but

in order to get a (covered) blood test, he has to travel to a different facility 50 miles away, since the local lab is not on the plan. And apparently there are no local anesthesiologists on the plan, so if he has a procedure he'll have to pay that out of pocket.

[Emile]

58. Wow a 100 mile roundtrip just to do a blood test. My doctor is a vampire

and orders a blood test two to four times a year.

[dalton99a]

22. Kick

Kurt Pauker, an 87-year-old Holocaust survivor in Indianapolis who has kidney and heart conditions that complicate his care, is enrolled in a Medicare Advantage plan sold by Humana.

In spite of recommendations from Mr. Pauker’s doctors, his family said, Humana has repeatedly denied authorization for inpatient rehabilitation after hospitalization, saying at times he was too healthy and at times too ill to benefit.

Last March, after undergoing hip surgery, Mr. Pauker was again told that he did not qualify for inpatient rehab but would be sent back to a skilled nursing center to recover, his family said.

During his previous stay at a skilled nursing center, he received little in the way of physical or occupational therapy, the family said. He has so far lost his appeals, and relatives have chosen to pay for care privately while continuing to pursue his case.

People “should know what they’re giving up,” said David B. Honig, a health care lawyer and Mr. Pauker’s son-in-law. People signing up for Medicare Advantage are surrendering their right to have a doctor determine what is medically necessary, he said, rather than have the insurer decide.

[keithbvadu2]

24. After reading up on it, MA is more of a HMO and it was less risky to pay the Part B for better cover

https://www.democraticunderground.com/100216622964

Katie Porter leads letter urging Biden not to dump more money into Medicare Advantage

After reading up on it, MA is more of a HMO and it was less risky to pay the Part B for better coverage.

[FakeNoose]

26. "Medicare Advantage" is converting seniors from their gov't Medicare coverage into a private plan

It's tricking them into another plan that is not Medicare.

I don't believe they should be allowed to use the name Medicare because it has confused people. It's all mirrors and tricky marketing, I call it "weasel words."

[moose65]

54. I agree

There’s too much confusion because they have the word “Medicare” in the name. People think these are original Medicare plans. A cousin of mine posted something on Facebook about “all those Medicare commercials.” I jumped right in and explained that those are NOT commercials for Medicare - they are commercials for private insurance plans.

Medicare Advantage providers have been over paid for years. The Affordable Care Act tried to reduce payments to them - remember when Romney went around claiming that the ACA took billions from Medicare to pay for Obamacare? That’s what he was talking about. Truth is, Medicare pays a set amount per person to those in Medicare Advantage plans, and it goes to those private insurance companies. If they have to pay out less in claims, then they get to keep the rest as profit. That’s why they try to draw in healthier people, so they can make money off them.

Those plans ought to be illegal.

[Emile]

57. +1.

[cstanleytech]

36. I have been rather lucky then with my Humana plan as they so far have yet to deny anything.

Of course the most I have had was to get 3 discs replaced in my neck and that was done with no hassle.
Only downside is that their dental plan is less than stellar as it does not offer any coverage for things like bridges or basic implants which would be nice to have nor does it offer even a discount for paying out of pocket.

[Samrob]

37. I tried to warn so many about this. Only two people I know out of dozens believed me. nt

[Skittles]

49. NO SHIT

that's how they make their money, along with scamming the government