As you might know, the federal government is moving towards a “capitated” payment model for everyone with Medicare, paying insurers, private equity, and other intermediaries a flat fee for each enrollee and handing over to them the power to decide when to cover enrollees’ care and what care to cover. These intermediaries might have your best interests at heart, but they also might be focused on maximizing their profits and not your care needs. Your primary care doctor should be able to help you understand whether you are getting the care you need.
If you’re in a Medicare Advantage plan, you signed up for coverage that an insurance company oversees. Some Medicare Advantage plans do a better job than others of ensuring you get the care you need. Others inappropriately delay and deny care a lot of the time.
If you’re in traditional Medicare, an insurance company or private equity intermediary might be overseeing your coverage and you might not know it. Until 2021, that was never the case. You should find out whether there is an intermediary, sometimes called a Direct Contracting Entity or DCE. It is possible that this intermediary will try to inappropriately delay or deny your care through its preferred network of providers. You should know that, even if you are in a DCE, you have still have easy access to the doctors and hospitals of your choice and coverage of all medically necessary care through traditional Medicare outside that network.
To help you decide whether your primary care doctor will provide you with the care you need or whether you are better off disenrolling from your Medicare Advantage plan or switching primary care doctors and opting out of your DCE, find out the answers to these questions.
1. Is your primary care doctor employed or working under contract for an insurance company or a private equity firm?
- If you are in a Medicare Advantage plan, the answer is always yes.
- If you are in traditional Medicare, the answer could be yes or no. You should be able to find out the answer by calling 1-800-MEDICARE or by calling your primary care doctor’s office. If the answer is no, you are not in a Direct Contracting Entity and no one should be interfering with the care you receive. If the answer is yes, the federal government likely involuntarily enrolled you in a Direct Contracting Entity, and you have the right to opt out.
2. Is anyone directing your primary care doctor as to how to handle your care? How is it affecting the care your primary care doctor delivers?
- Is your primary care doctor unable to spend adequate time with you?
- Is your primary care doctor being directed to refer you only to lesser quality doctors and hospitals?
- Is your primary care doctor ever prevented from getting you the care the doctor thinks you need?
If the answer to any of these questions is yes, you might want to consider finding a new primary care doctor and opting out of your DCE or Medicare Advantage plan. Tip: If you are in traditional Medicare, you always have the freedom to use whatever doctors and hospitals you would like, regardless of what your primary care doctor recommends. And, so long as you have supplemental coverage–Medigap, retiree coverage from a former employer, or Medicaid, virtually all your costs will be covered.
If you are in traditional Medicare and your primary care doctor suggests you either drop your Medicare supplemental coverage or move to a Medicare Advantage plan, ask why and beware.
- Dropping your supplemental coverage if you are in traditional Medicare or moving to a Medicare Advantage plan will prevent you from being able to get care wherever you’d like because your out-of-pocket costs could be very high.
- Moving to a Medicare Advantage plan restricts your choice of health care providers and often limits your ability to get care at centers of excellence and from the best specialists. Your annual out-of-pocket costs could be as much as $7,550 for in-network medical and hospital care alone.
- Whether you drop your supplemental coverage and remain in traditional Medicare or switch to Medicare Advantage, you very well may never be able to get supplemental coverage again. Your right to buy supplemental coverage is extremely limited.
If you have questions, please email info@justcareusa.org.
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