MEDICARE ADVANTAGE PLAN? YOU BETTER BE HEALTHY!

Dr. Richard Feldman is a family physician who served as the State Health Commissioner of Indiana from 1997 to 2001. His career, however, was mostly spent as the director of the Family Medicine residency program at Franciscan St. Francis Hospital in Indianapolis for nearly 38 years. He is an author, speaker, and thought leader for the medical profession, and is an authority on current healthcare policy. 

It would follow, then, that Dr. Feldman would write an opinion essay published in the Daily Journal, the newspaper for the citizens of Johnson County, Indiana, that was based on a personal issue experienced by his wife. The subject of his opinion piece was Medicare Advantage Plans (MAPs), and how they appear to be a good deal when oftentimes they are not. His premise for the article was a warning to patients to be wary of hidden problems with these plans, and to know what you’re getting in to.

Personally, I think MAPs are a good deal if you’re a healthy person. If you’re not, and use the healthcare system a lot, restrictions imposed by MAPs will be limiting and costly for you. Traditional Medicare consists of Part A (hospital costs), Part B (medical services costs-doctors, lab, preventive), and Part D (prescription drug costs). A separate option is Part C, the name given to Medicare Advantage Plans.

MAPs usually have lower premiums. They cover everything Parts A and B cover plus pharmacy costs, vision, hearing, dental, and gym memberships. Sounds enticing, doesn’t it? Unfortunately, they impose significant limitations. Co-pays and higher deductibles are the first difference. My traditional plan has no co-pay, and the deductible is paid by my Part B supplement. Thus, I have no out-of-pocket expenses. MAPs have both. 

The second difference is access to care. MAPs have provider networks meaning you can only go to doctors in the plan network. That includes primary care doctors and specialists. Your current doctor may not be in the network so you must change doctors to avoid out-of-pocket expense. You are also restricted to going to hospitals, clinics, pharmacies, and specialists within the network. If you go elsewhere, the bill is on you. 

Thirdly, you must receive prior authorization (approval) for any special test, procedure, costly medication, rehab facility, skilled nursing home, or long-term acute care hospital. That means your MAP will pay for that MRI only if a third-party consulting doctor or nurse finds that there is justification for it to be done. If not approved and you still have it done, the cost is on you. If you have a hip replacement and need physical therapy at a rehab center, your admission has to be approved by your MAP. If it’s not approved, you pay. 

Dr. Feldman’s wife was insured through a MAP. She had a major orthopedic procedure and was told it may take a year to fully recover. Her surgeon recommended a rehab facility/ nursing home, and she was sent to the facility. Her MAP denied payment. So she was stuck with “several thousand dollars for the nursing home and physical therapy.” The MAP judged her “to be doing so well with post op physical therapy in the hospital, that she did not qualify for facility-based rehabilitation.” The nursing home therapist told Dr. Feldman that MAPs deny payment regardless of whether you’re doing well or not. 

Dr. Feldman’s overall analysis of MAPs reveals that it is common for services to be denied that are most often covered by traditional Medicare. He describes the authorization process as “out-of-control,” and that Congress is considering legislation to correct the problem. 

Dr. G’s Opinion: I agree with Dr. Feldman completely. Medicare Advantage plans are meant for healthy people on few, or no, medications, who do not have any chronic disease (diabetes, heart disease, COPD, etc.). Network restrictions and denials are not a problem because they don’t have any disease than requires a major procedure to correct. They use their gym membership and see the dentist and eye doctor at least annually. But these patients are in the minority. Most people have some diagnosis that requires annual monitoring or periodic treatment for flare-ups.

My personal situation is such that I have traditional Medicare. I pay a higher premium to avoid co-pays and denials. I can go to any doctor, hospital, pharmacy, or clinic that I want. If I’m hospitalized and need post-hospitalization therapy of any type, my care is covered—100%. In 2023, I had such an incident—6-day hospitalization followed by 44 days in a rehab center. I had zero out-of-pocket expense for that—ZERO. I’ve had over 20 MOHS skin cancer surgeries at no cost to me. My wife has had two cardiac ablations, again, with no cost to us. 

“Be wary of Medicare Advantage Plans,” says Dr. Richard Feldman. Pay a little extra to get a little more in a traditional Parts A, B, and D program. Premiums will be a bit more, but you’ll have no hassles and your care will be covered. 

Reference: Feldman R. “Be Wary of Medicare Advantage Plans” The Daily Journal 2024 November 14.