Getting out is a lot
harder than getting in
by Cheryl Clark, Contributing Writer, MedPage Today December 03, 2019
Like many of the 22
million seniors now enrolled in Medicare Advantage (MA) plans, Tom
Mills belatedly discovered its dirty little secret.
Also called Part C, these plans can cover a
broad array of health services at low cost -- that is, until one gets sick, at
which point out-of-pocket costs can soar. But once in an MA plan, getting out
can be even less affordable.
After Mills underwent a mitral valve repair
and suffered a mild stroke with no lasting effects, the San Diego resident's
plan now charges him hundreds of dollars in monthly copays for drugs and other
medical services. He had to pay $295 a night for his hospital stay.
But there was a much bigger shock. Mills, 71,
learned that switching out of his MA plan will incur exorbitantly higher costs
the next time he needs a serious medical intervention. If he moves to
traditional Medicare and a prescription plan, he still needs a supplemental
Medigap plan to pick up his 20% copays and deductibles.
Though the retired environmental geologist is
training for his 57th half marathon, he now has a pre-existing condition.
Medigap plans in all but four
states can and do reject people like him or require prohibitively
higher premiums. Diabetes, heart disease, or even a knee replacement can be
criteria for exclusion.
A health insurance broker told him no
supplemental plan would cover him, and he'd be wasting his time if he applied.
No one told him about this side of MA when he
enrolled at age 65. "You hear the pros, but nobody lists the cons."
In the run-up to the Dec. 7 deadline to sign
up for Medicare coverage, broadcast ads like one with Joe
Namath tout Medicare Advantage's array of services: dental, vision,
hearing, gym membership, rides to medical appointments, doctor and nurse visits
by phone, and even meal delivery and home aid. "Get what you deserve ...
at no additional cost," Namath says. "Call now -- it's free."
But some advocacy groups, including the
American Medical Association (AMA), are pushing to mandate tighter plan rules
and disclosure, with lists of network specialists. The AMA
recently approved a resolution calling on the Centers for Medicare
& Medicaid Services and other stakeholders, including the senior citizens'
lobby AARP, to make the process of choosing Medicare plans less confusing and
more transparent.
A similar AMA resolution in 2018 declared that
"seniors are lured to these advantage plans by misinformation and
confusing sales techniques," and that plan inadequacies result in
"delay in nursing home placement for some members," produce
"poor service for some members ... due to difficulties with physical
therapy and rehab services. The number of days approved (for payment) has
tended to be too short and the extent of rehab services too limited."
Kevin Burke, MD, and Deepak Azad, MD, primary
care doctors in Indiana, are members of the delegation that sponsored both
resolutions.
"If your health is good, maybe these
plans represent value for some patients, like providing gym memberships,"
Burke said. "But that can change in the blink of an eye ... with a stroke
or an accident or some acute medical condition and they need a rehabilitation
stay." Then, services are restricted so much that "they can't recover
adequately from the stroke, or they bankrupt themselves staying another month
to get a good recovery."
Then they're eligible for Medicaid, which pays
doctors much less.
Bonnie Burns, training and policy specialist
consultant for California Health Advocates, said, "The thing that docs
should focus on is that people are spending down the resources they have as a
result of healthcare costs, and so people who are in an MA plan where they're
paying out of pocket for various costs, they're spending down but in the
process of spending down, that means more and more people showing up on the
Medicaid rolls in that age group. Lots of doctors don't take Medicaid for
obvious reasons."
Burke and Azad think Medicare should not let
people with serious health risks buy MA plans in the first place. And some
critics say MA across the board is basically a scam.
'Confusing' Tools
Medicare.gov websites aren't always clear
about the process of transferring out of MA to traditional Medicare with a
Medigap plan, but the general bottom line is that getting accepted by a Medigap
plan is guaranteed only within the first 12 months after enrolling in Medicare
at age 65.
MA plans, which are managed by private
insurers, can be very complex, with the potential for substantial out-of-pocket
costs when beneficiaries get sick played down. Medigap policies, which pay for
many expenses not covered in basic Medicare, may cost more in monthly premiums
up front, but once one is enrolled, premiums are set solely through
"community rating" and beneficiaries' age. New-onset health issues do
not lead to premium increases.
The catch is that if one initially enrolls in
an MA plan and then decides to switch out more than a year later, Medigap
insurers will take into account the individual's pre-existing conditions, and
may decline coverage or demand high premiums.
The newly revised Medicare Plan Finder tool
does not explain this possibility. Nor does another CMS website,
"Join, switch, or drop a Medicare Advantage plan."
A third Medicare.gov website,
"When can I buy Medigap?" is more specific, explaining in the third
section that "there's no guarantee that an insurance company will sell you
a Medigap policy if you don't meet the medical underwriting requirements,"
meaning the Medigap issuer's stance on pre-existing conditions.
Yet another
Medicare publication does explain that if beneficiaries enroll in a
Medicare Advantage plan at age 65 and want to get out, they must do so within 1
year, and then they have another 63 days from the disenrollment date to buy a
Medigap plan without risk of coverage denial or being subject to underwriting.
But many of these documents are full of terms
unfamiliar to ordinary laypeople, Burns pointed out. "Networks and
copayments and formularies and uncovered costs and appeals and who knows about
that stuff? That doesn't happen until you get sick. No one understands their
insurance coverage until they have to use it."
Other Complaints
Besides MA's lack of transparency on costs,
critics also cite problems with insurers' provider networks. The AMA
wants CMS to make sure networks are adequate and list physicians,
their specialties and subspecialties, and how many actually cared for plan
members the prior year.
AMA spokesman Robert Mills (no relation to Tom
Mills) referenced a Kaiser Family Foundation report
that found 35% of plans studied were served by a "narrow" physician
network, meaning that fewer than 30% of the physicians in that county were
contracted.
"Plans may purposefully understaff
specialties to avoid attracting enrollees with expensive pre-existing
conditions like cancer and mental illness," he said.
David Lipschutz, an attorney with the Center
for Medicare Advocacy in Washington, D.C., also hears about limitations.
"It's a common scenario," he said. "Often you have to jump
through certain hoops or over certain barriers to access care, or it's subject to
prior authorization."
His colleague, attorney Toby Edelman, has
heard beneficiaries complain about plans that have two nursing homes in their
network. "There are 50 in your area, but they have two and these are not
the best."
At California's Health Insurance Counseling and
Advocacy Program, San Diego manager David Weil hears horror stories
too. "If they answer yes [on a questionnaire] to something the company
doesn't like, the company won't sell them a policy. Almost anything can be on
their list."
Why do people want to switch? Weil described
it as a "funnel effect, the feeling that you have to squeeze through an
ever-closing hole in order to get services ... Or you have to wait eight weeks to
see a specialist. People get fed up with that."
Last month, veteran consumer advocate Ralph
Nader blasted MA plans as nothing more than a way to enrich health
insurers at seniors' expense. Calling the plans "Medicare
Disadvantage" and a "corporate trap," Nader took the AARP, which
offers its brand of Medicare Advantage through UnitedHealthcare, to task for
being asleep on the issue, and in conflict because it gets a 4.95% commission.
AARP spokesman Gregory Phillips responded:
"AARP supports increasing access through guaranteed issue to Medigap
coverage, in addition to eliminating medical underwriting and age rating, to ensure
that older Americans will get the coverage they need when they need it
most."
And he agreed that many beneficiaries may not
be aware that plans "may terminate their relationship with Medicare in any
given year; change the premiums, cost-sharing charges, or benefits from year to
year (including drug coverage); and drop physicians from their networks during
the year."
"Beneficiaries may also not be aware that
if they want to voluntarily leave an MA plan and return to traditional
fee-for-service Medicare, they may be subject to medical underwriting for a
Medicare supplement (Medigap) policy. This underwriting may result in their
being refused a policy or being required to pay higher rates."
But Phillips defended AARP's participation in
MA, saying it provides information on both MA and traditional Medicare plans.
last
updated 12.03.2019
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