The Commonwealth Fund’s latest report on Medicare Advantage “benefit design” provides what I would call the standard take, highlighting Medicare Advantage’s out-of-pocket cap and “additional benefits,” as if those are the most important differences. It also assumes that what you see with Medicare Advantage is what you get rather than explaining that appearances belie reality with Medicare Advantage.
The report questions some of the lack of detail available about Medicare Advantage additional benefits. But, the report overlooks the biggest point about Medicare Advantage plan benefits–they tend to be withheld, delayed and denied a lot more than people might imagine.
People with Medicare (and everyone else) should be able to assume that the health plan they enroll in will cover all the medical treatments that they need. But, each Medicare Advantage plan has different prior authorization and specialty referral requirements, provider networks, and out-of-pocket costs. Each also has different proprietary rules for when they will pay for particular treatments and different rates of inappropriate delays and denials of care. All of these elements are part of the “benefit” package and can mean the difference between getting needed care and being forced to forgo it.
Medicare Advantage plans often rely on proprietary algorithms to determine whether care is covered. They always make their own decisions about medical necessity that lead to their spending nearly 25 percent less on medical and hospital care than traditional Medicare. Medicare Advantage plans cover fewer services and fewer costly services than traditional Medicare. The Office of the Inspector General has found that Medicare Advantage plans engage in widespread inappropriate delays and denials of care and coverage.
You can’t know what you need to know about a Medicare Advantage plan’s benefits before you enroll. The consequence: You can’t meaningfully distinguish among Medicare Advantage plans and you take a huge risk when you enroll. The Commonwealth Fund’s experts warn that people know little about the extra benefits Medicare Advantage plans offer–who gets them, how frequently, where, and at what cost to them. Putting aside additional benefits, people know little about the standard benefits Medicare Advantage plans cover–who gets them, when, how frequently, where, and at what cost to them. For example, Medicare Advantage plans must cover physical therapy, but they decide–with no meaningful oversight– when it is warranted, how often an enrollee will get treatment, from whom and the copay.
The Fund highlights that nine in ten Medicare Advantage plans offer dental, vision and/or hearing benefits. But, it does not explain that narrow provider networks and high out-of-pocket costs keep a large number of people from taking advantage of these benefits. Rather, it says that Medicare Advantage “may have more limited provider networks or prior-authorization requirements for some services” as if this is simply a possibility when it fact it is the norm.
On the issue of costs, the report explains that lack of standardization of costs in Medicare Advantage keeps people from knowing what their costs will be in different Medicare Advantage plans. The majority of people in Medicare Advantage plans are in HMOs, which have no out-of-pocket cap for out-of-network care, an issue which the report omits; and, out-of-pocket costs are a barrier to care for many low- and middle-income enrollees.
Also of note and overlooked in the report: The cost of supplemental coverage in traditional Medicare, which has no out-of-pocket cap, tends to be far lower than the out-of-pocket cap for in-network care in Medicare Advantage. Moreover, we do not know typical out-of-pocket costs in Medicare Advantage because no independent reliable data is available.
For sure, costs in Medicare Advantage can be very high for people whose medically necessary care is wrongly denied or not available in-network, potentially keeping people from getting needed care. For example, many Medicare Advantage plans do not have centers of excellence in-network that people may want to use for complex conditions. If enrolless can’t afford to pay out of pocket, they can be forced to forgo medically necessary care.
Here’s more from Just Care:
- Four things to think about when choosing between traditional Medicare and Medicare Advantage plans
- Costs in Medicare Advantage present barrier to care
- How prior authorization requirements in Medicare Advantage could threaten your health
- Well-kept secrets of Medicare Advantage plans
- People with serious health needs more likely to disenroll from Medicare Advantage plans