NOVEMBER 26, 2024
The Centers for Medicare & Medicaid Services announced Tuesday it is pursuing further limits on Medicare Advantage plans’ use of prior authorization and artificial intelligence as “barriers to care.”
Continue reading: https://www.mcknights.com/news/breaking-cms-proposes-more-medicare-advantage-guardrails
*NOTE FROM ANDY ORLIKOFF, OWNER/BROKER AMERICAN INSURANCE BENEFITS*
As an independent broker, I am frequently approached by insurers to promote Advantage plans. These plans are enticed with high commission levels that are significantly more lucrative than compensation for Medigap plans. However, I have consistently declined to offer Advantage plans due to their potential negative impact on consumers.
I regularly receive calls from individuals who have purchased Advantage plans and subsequently expressed a desire to switch to Medigap because they have encountered various drawbacks. Regrettably, in many cases, I am unable to accommodate their requests because they no longer qualify for coverage due to medical conditions.
It is important to note that Open Enrollment is exclusively for Advantage plans. Medigap coverage is guaranteed for six months before and after an individual’s 65th birthday. After this period, individuals must qualify for coverage based on their health status. There are specific circumstances that may qualify for a special enrollment, such as when the Advantage plan is no longer offered in the individual’s service area.
To avoid being misled by agents and brokers who prioritize their income over your interests, I encourage you to educate yourself about Medigap plans. Please do not hesitate to contact us for further information. Our conversations are completely free of charge.
Andy Orlikoff
American Insurance Benefits
Surprise, Arizona
623-742-3878
www.azhealth.us
Janna Herron
Hospitals and insurance giants are clashing over wildly popular Medicare Advantage plans as both sides try to protect their profits. Many seniors enrolled in these plans are caught in the crosshairs.
More hospitals and healthcare providers are terminating agreements with insurers that provide these private-sector alternatives to Medicare, citing too many denials, delays, and refusals to pay for care that government-run health insurance would typically cover. The fracas is deepening this year as the federal government issues new guidance on how the plans can be run, posing a major new threat to a profit engine for some of the country’s largest insurance companies.
“We call these knife fights in the industry and I think we’re seeing more and more,” Whit Mayo, an analyst with Leerink Partners, told Yahoo Finance. “And is this something that these insurers are going, ‘OK, this could become a bigger problem for our bottom line.’”
Seniors also have a lot at stake. If more hospitals ditch these plans, seniors who rely on that coverage will be forced to pay higher costs or may even be kept from seeing the doctor of their choice. Many have little recourse if they face these challenges.
“It stinks,” Mayo said. “You’re putting consumers in the middle of these negotiations and they really value being able to know if they’re facing out-of-network costs if they do see a provider that’s not within their network. So the emotional strain that this takes on the people caught in the middle is the worst.”
This year, 33 million Americans have MA plans, representing just over half of Medicare-eligible individuals, according to research from Chartis. They are offered by giant companies like UnitedHealthcare, which is owned by UnitedHealth Group (UNH), as well as Humana (HUM) and CVS/Aetna (CVS).
These MA plans have only grown in popularity since the program’s inception, with enrollment outpacing that of traditional Medicare in the last six years. Two big allures of these plans are their perks and cost.
MA plans provide benefits traditional Medicare doesn’t offer, such as dental and vision coverage and a grocery allowance. Many also offer a low or $0 monthly premium. That’s cheaper than Medicare’s $174.70 monthly premium and any supplemental coverage seniors who choose Medicare often buy.
“MA plans are very well compensated. With that extra money, MA plans are able to offer services that Medicare doesn’t offer,” David Lipschutz, the associate director for the Center for Medicare Advocacy, told Yahoo Finance. “The deck is heavily stacked in favor of MA enrollment.”
Of course, there’s a tradeoff. Depending on the MA plan, enrollees have to go to a network of providers who have contract agreements with the insurer. If an enrollee goes out of network, they either must pay higher costs for the care or may not be allowed to see that provider at all.
The consequences of that tradeoff came to a head in 2022 as MA insurers began denying more coverage for necessary care just as seniors who had delayed elective procedures flooded back into hospitals that were already struggling with major labor shortages.
The practice has infuriated healthcare providers.
“This practice does cost substantial amounts of time and money, but more importantly, it’s not right for our patients who are often caught in the middle or receive coverage that is different than that offered to patients enrolled in traditional Medicare,” wrote a spokesperson for Louisville, Ky.-based Baptist Health Medical Group, which last year terminated its MA agreement with Humana.
Some hospitals move forward with care without prior authorization because it’s an emergency and the appeals process takes too much time.
“There are patients out there that can’t wait. The delay of a cardiac procedure or cancer procedure could be life-threatening,” said Chris Van Gorder, the president and CEO of San Diego-based Scripps Health.
And when the hospital files a claim, “They deny it saying, ‘We didn’t approve it,’” Van Gorder said.
Many healthcare providers are losing money as a result.
Scripps Health lost $75 million last year from its MA-insured patients, Van Gorder said. Scripps Clinic and Scripps Coastal, the medical groups that have exclusive medical service contracts with Scripps Health, tried to renegotiate with MA insurers to reach acceptable terms, but that ultimately wasn’t successful.
The medical groups then withdrew from their MA HMO agreements with UnitedHealthcare, Anthem Blue Cross, Blue Shield of California, Health Net of California, SCAN Health Plan, UnitedHealthcare of California, and Alignment Health last year.
“The last thing in the world I wanted to do is cancel a contract for 32,000 patients. I’m in the business of delivering healthcare, not canceling healthcare,” Van Gorder said. “We just can’t afford it financially.”
In the last 18 months, more than a dozen other healthcare and hospital systems nationwide have dropped out of MA plan networks, many of them citing denial-of-care issues.
“I think we are sadly the vanguard of what is going to be some pretty confrontational contract negotiations between payers and hospitals in the next few years,” Van Gorder said. “I think this is going to get ugly.”
UnitedHealthcare told Yahoo Finance that “each year, we successfully renegotiate the vast majority of our contracts with providers. Our goal is to be a good steward of the resources available to cover our members’ cost of care by ensuring they are charged fair, sustainable prices for the services they need.”
Humana and Centene did not respond to requests for comment.
Still, the tumult also has gotten the attention of the Centers for Medicare & Medicaid Services, which recently put out new rules on processing prior authorizations, patient risk coding, and other reporting and transparency requirements designed to address some of the medical providers’ concerns.
It also adds more pressure on insurers by making it harder to deny claims, potentially forcing insurers to cut back on the perks their MA plans offer.
“The industry is engulfed in just a historically high level of controversies right now. It’s a very tough environment for the plans,” Mayo said. “And I think we’re going to see a sector that’s going to really pull back on benefits.”
In the meantime, seniors who need healthcare are stuck in the middle.
Seniors can opt for a different MA plan or original Medicare during the Medicare Advantage open enrollment period from Jan. 1 to March 31 — and they have been. Plan swapping was up in January and February, Mayo said, based on monthly data from the CMS.
Still, switching to traditional Medicare is no panacea, either. While seniors will have no problem getting Medicare, they may find it harder to get a Medigap policy, a supplemental policy that covers the 20% of costs that Medicare does not cover for medical care.
When a senior first signs up for Medicare at age 65, Medigap policies — which are provided by many of the insurers that offer MA plans — cannot deny or charge a higher premium based on preexisting conditions.
But insurers can deny or charge more for preexisting conditions when someone wants to switch to traditional Medicare down the road. That’s why seniors may choose another MA plan instead, one that could be dumped later by their medical provider.
“That is a danger each and every year,” Lipschutz said. “People don’t have much recourse if their doctor leaves the network.”
Janna Herron is a Senior Columnist at Yahoo Finance. Follow her on Twitter.
Vladimir Supica
In a recent TikTok video, a nurse has issued a PSA to her viewers, advising against enrolling in Medicare Advantage plans.
The video, posted by Christy (@christyprn) on Nov. 21, has amassed over 128,900 views, sparking a lively debate among commenters about the pros and cons of these private health insurance alternatives.
In the video, Christy recounts encountering a billboard on her way home: “I saw a big billboard that said, ‘Enroll in a Medicare Advantage plan, and you’ll get a free gym membership!’ and it reminded me to give you guys your yearly reminder to not enroll in a Medicare Advantage health insurance plan.”
She explains, “When those Medicare health insurance plans are managed by the government, that is just called Medicare or some of us call it traditional Medicare. However, a while back, the government started allowing private insurance companies to distribute these plans as well. These are called Medicare Advantage plans.”
Christy goes on to express her reservations about these private insurance plans, citing concerns that they may deny crucial healthcare services that traditional Medicare would cover, “A lot of health care workers really don’t like these Medicare Advantage plans because they tend to deny a lot of really important care that traditional Medicare would have covered,” she claims.
However, while emphasizing the need for careful consideration, the TikToker gives out a disclaimer: “There may be some instances where a Medicare Advantage Plan offers some additional benefit that might be more beneficial to a patient than traditional Medicare.”
Since it was posted, the video has sparked a lively debate in the comments section, with healthcare workers and viewers sharing their experiences and opinions.
Some echoed Christy’s concerns, with one commenter saying, “I work in outpatient care, and the Medicare advantage plans are the worst. We can’t get anything covered.”
“Thank you, say it louder. Advantage plan are thieves,” a second added.
“RN here. Amen sister. It will bankrupt them,” a third wrote.
However, others disagreed, recounting their positive experiences with their plans.
“My father was on different Medicare Advantage plans here in NC. They worked out great for him. No extra monthly cost and more docs to choose from,” one such commenter wrote.
“Medicare Advantage has worked great [for] me. My Dr’s med group totally has their act together,” a second claimed.
“No doctors in my area accept regular Medicare. I can only use it at urgent care clinics,” a third commenter remarked.
The Daily Dot has reached out to Christy via TikTok comment.
For a true Medicare supplement/Medigap, contact [www.azhealth.us](www.azhealth.us).
As you approach age 65, you’ll have some decisions to make about medical coverage. On one hand, you can enroll in Medicare. But you may be tempted to choose another option instead: a Medicare Advantage (MA) plan instead. If you’ve seen the advertisements for MA plans, you might think they’re more cost-effective and comprehensive than Medicare. But according to Keith Armbrecht, Founder of Medicare education company, Medicare on Video, that’s not necessarily true.
“I would never choose a Medicare advantage plan,” he says in a YouTube video entitled “Why Medicare Advantage Is The Worst Choice For Seniors.”
Here’s why he’s not a fan of these plans.
Medicare Advantage plans are alternative insurance plans to Medicare, and they’re offered by Medicare-approved private companies. These plans are sometimes called “Part C” or “MA,” and they include Medicare Part A (hospital insurance) and Part B (medical insurance).
Those interested in MA have more than 40 different plans to choose from. The main
reasons to explore them include:
That being said, there are a few downsides to Medicare Advantage plans. Here are some important things to consider before locking into an MA plan.
If you opt for an MA plan, your choice of doctors can be limited and you’re likely to face obstacles in getting approved for procedures or seeing specialists. “The primary reason I would absolutely choose original Medicare and would never choose Medicare Advantage is because I want control over what I do,” says Armbrecht. With an MA plan, he warns, you can face wait times of “weeks, even months,” to get referrals or have procedures authorized.
You’re typically limited to doctors in the plan network and service area, as well,
according to the government’s Medicare website.
The Medicare Advantage plan industry has a history of deceptive practices. In 2022, the Majority Staff of the U.S. Senate Committee on Finance found that Medicare beneficiaries were being inundated with aggressive marketing tactics, false and misleading information and overall predatory marketing from MA providers. According to the report, deceptive Medicare Advantage marketing practices are, “widespread, not isolated events.”
According to a 2022 review from the New York Times, four out of five of the largest MA providers (UnitedHealth, Humana, Elevance and Kaiser) have faced federal lawsuits for fraud and at least eight providers overbilled, according to the U.S. Department of Health and Human Services Office of the Inspector General.
Multiple studies have shown MA plans have a pattern of denying claims that should be covered.
A 2022 review from the Inspector General’s office found that MAs denied 13% of prior authorization requests that met Medicare coverage rules. Essentially, these claims would have been approved under original Medicare. The most commonly denied requests were imaging services, stays in post-acute facilities and injections.
“Medicare is probably the only government program that does exactly what it’s supposed to do and does it very well,” says Armbrecht. In other words, original Medicare is likely your best choice. If you’re nearing 65 and considering your options, you can visit Medicare.Gov for accurate and up-to-date information so you can make the right decision for your health insurance needs.
