Medicare Advantage plan denials
There's an article in today's NY Times (April 28) about how Medicare Advantage plans frequently deny needed care. We and people we know have certainly run into this. https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html
Quoting from the report:
"In its review of 430 denials in June 2019, the inspector general’s office said that it had found repeated examples of care denials for medical services that coding experts and doctors reviewing the cases determined were medically necessary and should be covered.
Based on its finding that about 13 percent of the requests denied should have been covered under Medicare, the investigators estimated as many as 85,000 beneficiary requests for prior authorization of medical care were potentially improperly denied in 2019.
Advantage plans also refused to pay legitimate claims, according to the report. About 18 percent of payments were denied despite meeting Medicare coverage rules, an estimated 1.5 million payments for all of 2019. In some cases, plans ignored prior authorizations or other documentation necessary to support the payment.
These denials may delay or even prevent a Medicare Advantage beneficiary from getting needed care, said Rosemary Bartholomew, who led the team that worked on the report. Only a tiny fraction of patients or providers try to appeal these decisions, she said."
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For if you try to get it later it will cost significantly more, and Medigap insurers can then refuse you altogether.
Also, Advantage plans are local: if you move you'll need to get a new plan or revert to Original Medicare.
note that you can always revert to Original Medicare from an Advantage plan, however. It's just that if you want Medigap to go with that it will be costly (or potentially unavailable) if you're now a poor risk.
I have a couple of other comments/questions myself now that I've slept on what I wrote:
no. 1: I noted above that many if not most of the comments on the New York Times article seem to believe that Advantage Plans are too untrustworthy/too many denials, etc. and these comments recommend Original Medicare combined with a Medigap (aka Supplement Plan) as your best choice. But others on this forum and elsewhere have weighed in stating that these latter plans are too expensive for many if not most seniors, perhaps averaging about an extra $300 a month (rough estimate there). People who read the New York Times regularly enough to comment on the article may be in an upper income bracket, so yes, this may be the best choice for them. I live in a Senior Retirement residence and I do have to say that most of the residents I've met have an Advantage Plan.
no.2: As for this comment above: "note that you can always revert to Original Medicare from an Advantage plan, however. It's just that if you want Medigap to go with that it will be costly (or potentially unavailable) if you're now a poor risk."
My question: can anyone elaborate on a "poor risk" means, with some examples?
Thanks!
My question: can anyone elaborate on a "poor risk" means, with some examples?"
When you apply for a Medicare Supplement at the time you sign up for Medicare, there is no "medical underwriting". Everyone pays the same premium.
If you switch to a Medicare Advantage plan and drop Original Medicare and then want to switch back, the Insurance Company providing the supplemental policy submits your health history for Medical Underwriting. So if you've developed diabetes or cancer, your premiums will be sky high.
So I did the research for Mom. She had traditional Medicare. She also had PADD a State prescription plan. I did not like Medicare Advantages then and still don't. I knew exactly what my Mom needed, Medigap because she already had her prescription plan. This was way back but I kept her within what the employer allowed 1200 a yr for the suppliment. The other $200 towards a dental plan. I did not get vision because it really did not cover much for the cost. And since her glass prescription didn't change that often, the money she would put out on Vision, would pay for a pair of new glasses when she needed them. Medigap is goid for people who travel. It goes from state to state. As said Medicaid Advantages don't.
I had a friend who needed surgery and a Medicare surgeon was within walking distance from her house. She had switched to a MA. They have a network of doctors you must use. The one MA wanted her to use was clear across the city. When open enrollment came around she switched back to traditional Medicare with a supplimental. I have said my daughter, ran a unit in a hospital, called me to make sure I did not have an MA. They were not paying her for bandages that Medicare does which they are suppose to. It was costing her patients out of pocket expenses.
Take note that MA commercials have changed, they are calling themselves Part C. Used to be "get your Medicare additional advantages you are not getting now" It was false advertising. Not saying that MA may work for some but for me, I rather pay out of pocket than have to be part of a network.
https://www.aarp.org/health/medicare-insurance/info-2018/services-not-covered.html?cmp=EMC-DSM-NLC-OTH-WBLTR-1309502-1597905-6393373-NA-052822-Webletter-MS1-8Things_MEDICARE-BTN-MCTRL-HealthHygiene&encparam=4kDGzelnd%2fs1Dhf2Mj4PAq3C5%2bTwJ7aq%2f0ZUv%2bzsv60%3d
But the kicker is that if you go with traditional Medicare, you have to buy a Plan D drug plan. It will fry your mind trying to figure out which drug plan to go with, so give yourself plenty of time to game through each plan with your list of drugs.
I have traditional Medicare and the AARP United Healthcare Supplemental and the AARP United Healthcare Plan D. The drug coverage does not make me happy. I often use Good Rx instead.
One more thing. The other day I found out there is such a thing as Medicare-Medicaid. Some people might want to look into that.
My final word -- Universal Healthcare. I won't live to see it but I'd like younger Americans not have to go through this malarkey.