The Little-Known Pitfalls of Medicare Advantage Plans

Doctor and patient

Author Wendell Potter’s mother had a Medicare Advantage (MA) plan, with premiums that increased significantly over the years. Despite the increasing premiums, she didn’t feel she had any real motivation to disenroll. This was until she broke her hip and required skilled care in a nursing facility. After a few days, the nursing home administrator told her that if she stayed there, she would have to pay for everything out of her own pocket. How could this happen when she has a plan that she thought should cover this sort of thing?

In Ms. Potter’s situation, a utilization review nurse at her MA plan, who had never seen or examined her, decided that the care she was receiving was no longer “medically necessary.” This was when Ms. Potter discovered that there are no commonly used criteria as to what constitutes medical necessity, and that insurers have wide discretion in determining what they will pay for and when they will stop paying for services like skilled nursing care by decreeing it “custodial.”

Also known as Part C, Medicare Advantage plans are HMOs or PPOs that provide both basic Medicare Part B coverage and many of the benefits offered by supplementary Medigap insurance policies.  But Medicare beneficiaries’ premiums for an Advantage plan plus Medicare Part B coverage are roughly half, on average, of the premiums for a Medigap policy plus Part B.

Similar to Ms. Potter, nearly 18 million people are currently enrolled in Medicare Advantage Plans. Many baby boomers are enticed by them, as many of them offer $0 premiums, but what most people don’t realize is that there can be enormous unexpected out-of-pocket expenses when you get sick. These are some of the other pitfalls that people may not know about MA plans:

● Care can actually end up costing more, to the patient and the federal budget, than it would under original Medicare, particularly if one suffers from a very serious medical problem.

● Some private plans are not financially stable and may suddenly cease coverage. This happened in Florida in 2014 when a popular MA plan called Physicians United Plan was declared insolvent.

● One may have difficulty getting emergency or urgent care due to rationing.

● The plans only cover certain doctors, often drop providers without cause, breaking the continuity of care

● Members have to follow plan rules to get covered care.

● There are always restrictions when choosing doctors, hospitals and other providers, which is another form of rationing that keeps profits up for the insurance company but may limit patient choice.

● It can be difficult to get care away from home, because you are out of the HMO’s coverage area.

● The extra benefits offered can turn out to be less than promised.

● Plans that include coverage for Part D prescription drug costs may ration certain high-cost medications.

● Access to National Cancer Institute (NCI) cancer centers is limited.

● It can be difficult to ascertain whether certain specialty care facilities affiliated with a hospital listed in an Advantage plan network, such as heart, rehabilitation, or women’s care centers, are covered as part of a plan’s provider network.

● HMOs tend to have narrower hospital networks than preferred provider organizations, or PPOs.

So, be sure to shop very carefully if you are thinking of using a Medicare Advantage plan. Remember to read the fine print, and get a comprehensive list of all co-pays and deductibles before choosing one. Also, be sure to find out if all your doctors accept the plan and all the medications you take (if it’s a plan that also wraps in Part D prescription drug coverage) will be covered. If the plan doesn’t cover your current physicians, be sure that its doctors are acceptable to you and are taking new patients covered by the plan.

It is important to understand that neither Medicare nor Medicare Advantage plans ever pay one penny for long-term care. Medicare only pays for medical care delivered by doctors and hospitals, and in certain cases short-term rehabilitation which might take place in a nursing home. Medicare covers, at most, 100 days of short-term rehabilitation (20 days in full and 80 days in part), and does not cover help with activities of daily living, such as eating, bathing, dressing, and toile ring — long-term care that the aged can need for years.

Medicaid Planning for Long-Term Care

What if you or a loved one needs long-term nursing home care in the future? Long-term care in our area costs $10,000 to $14,000 a month. To protect your hard-earned assets from these catastrophic costs, the best time to create your own long-term care strategy is NOW.

If you have not done Long-Term Care Planning, Estate Planning, or Incapacity Planning, you should call us as soon as possible to make an appointment for an initial consultation:

Fairfax Elder Law: 703-691-1888
Fredericksburg Elder Law: 540-479-1435
Rockville Elder Law: 301-519-8041
DC Elder Law: 202-587-2797

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About Evan H Farr, CELA, CAP

Evan H. Farr is a 4-time Best-Selling author in the field of Elder Law and Estate Planning. In addition to being one of approximately 500 Certified Elder Law Attorneys in the Country, Evan is one of approximately 100 members of the Council of Advanced Practitioners of the National Academy of Elder Law Attorneys and is a Charter Member of the Academy of Special Needs Planners.