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Senior
advocates routinely advise Medicare participants to
scrutinize their options during the federal health care
plan’s open enrollment period, which runs through Dec.
15, but this year the warnings are taking on some added
urgency.
While
Medicare officials highlight reduced premiums among
Medicare Advantage plans, a recent audit of the Centers
for Medicare & Medicaid Services found “widespread
and persistent performance problems related to the
denial of care and payment,” among the plans,
according to the report of the Department of Health and
Human Services inspector general. The office reviewed
claims denials from 2014 to 2016.
Medicare
rights groups, meanwhile, have accused CMS of bias in
its 2019 Medicare & You Handbook, saying the annual
program guide inaccurately describes portions of the
program in an effort to persuade individuals to select
Medicare Advantage plans instead of traditional Medicare
coverage. Advantage plans are an all-in-one alternative
run by private insurers. They can offer lower premiums
and wider coverage for things like vision and dental
care, but there are tradeoffs, experts say.
“This
decision is difficult enough,” said David Lipschutz,
senior policy attorney for the Center for Medicare
Advocacy. “You don’t need (CMS) promoting one over
the other.”
Difficult,
indeed. Beyond a dizzying menu of options in many local
markets, seniors also need to factor a guess about their
future medical needs into the equation. That’s because
just four states offer unconditional rights to switch
back to Medigap supplemental policies with traditional
Medicare, said Gretchen Jacobson, associate director of
the Kaiser Family Foundation’s Program on Medicare
Policy.
“There
are tradeoffs between Medicare Advantage and traditional
Medicare,” she said. “Advantage plans do use prior
authorizations and more restrictions on getting care
than people would face in traditional Medicare, but all
Advantage plans have limits on out of pocket spending
and often provide benefits not traditionally covered by
Medicare.”
Complicating
matters even more, she said, is the fact that depending
on seniors’ individual health issues, a traditional
Medicare and Medigap combination could be cheaper than
the Advantage alternative, even while offering more
robust coverage. On the other hand, Medigap premiums
generally have been rising faster than Advantage plan
premiums.
So, how
to choose?
When
counseling Florida seniors on their Medicare options,
longtime volunteer Janet Mills typically begins by
asking if they are snowbirds and need highly portable
medical care, and how important it is to keep their
current doctors.
“A lot
of people just don’t want to leave their doctors,”
said Mills, a volunteer coordinator with Serving Health
Insurance Needs of Elders, a grant-funded program run
through Florida’s Department of Elder Affairs.
Traditional
Medicare and Medigap policies are less restrictive on
both of those fronts, Mills said.
Carolyn
McClanahan, a financial adviser and former physician,
agreed.
She
evaluates the overall quality of the provider network in
a given Advantage plan to help clients through the
tyranny of choice. If it’s strong and clients don’t
particularly need highly portable coverage, she then
drills down on a client’s overall health to help
predict future usage needs.
Kaiser’s
Jacobson gave an example of when costs might be
counterintuitive.
“People
who are looking at a lot of care may spend less money
with traditional Medicare and a Medigap plan with access
to their preferred providers” rather than an Advantage
plan, even with the Advantage plan’s out-of-pocket
maximums, she said.
“If
you’re in a Medicare Advantage plan with a maximum out
of pocket of $6,700 versus a Medigap plan that covers
all your cost sharing with a monthly premium of (around)
$200 a month, you can see how you’d come out ahead”
with the Medigap plan, she said. “Whereas, a healthier
person with a Medicare Advantage plan may be just
fine.”
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