Medicare Advantage plans are referred to in the Federal Registry by CMS as “Part C – Medicare Replacement Plans.” Medicare Advantage plans are NOT Medicare nor are they a supplement to Medicare benefits. If you have Medicare Advantage, you have given up your Medicare benefits to an insurance company. In turn, they agree to manage your healthcare such that they remain a profitable company.
If Medicare provides your primary insurance coverage, your doctor will decide which treatments are medically necessary and then you and your doctor together will decide the appropriate course of treatment for you. However, if you have Medicare Advantage, the doctor recommends a treatment plan, but the insurance company decides if the treatment is appropriate, or too expensive — not your doctor.
Shortcomings of Medicare Advantage plans include:
- Restrictive Networks
- Co-payments to providers, including daily charges for hospital stay
- Significant out-of-pocket expenses
- Pre-certification for procedures or admission
- Insurance Company decides which tests and procedures are approved
- Caps on additional benefits offered such as dental, vision, etc.
One tool Medicare Advantage plans use to ration healthcare is requiring prior-authorizations for most procedures and admissions, and they deny coverage all the time! Additionally, the prior-authorization process takes so long that the patient is left suffering while waiting for unnecessary approvals after the doctor has already ordered the procedure. Medicare does not require these prior-authorizations.
Additionally, Medicare Advantage plans routinely ration healthcare relating to post-acute care. Even if your doctor orders a stay in a Skilled Nursing Facility (SNF), Long Term Acute Care Hospital (LTACH), or Inpatient Rehab Facility (IRF), the insurance company will decide if you qualify for this level of service or if you should be released on home health or even hospice. Though the authorizing statute states that Medicare Advantage plans must cover the same services which Medicare covers, they continually deny coverage for post-acute care!
In summary, If you have Medicare Advantage coverage, you are in a less-desirable class of patients. Whether you are in a doctor’s office or hospital, the staff will have much more to do to deliver the care you deserve compared to Traditional Medicare. The doctor will have to work harder and take longer to provide the care you need than if you were on Traditional Medicare. In essence, you have become a second-class patient by having, let’s be frank, crappy insurance which requires healthcare providers to work harder to get paid less.