Roadblock to Medical Care? Medicare Advantage Plans

What is described in this article is exactly what happened to my cousin, a retired RN, last month in Texas. After an auto accident in March, and a bout of pneumonia, she had used 26 days of her 30 day "rehab" allotment according to her Advantage Plan. In April she was found unresponsive at home and was hospitalized again by ambulance.

It took 5 days for the hospital to get permission to conduct all the diagnostics to prove it she had a stroke and not just a recurrence of pneumonia. Her Advantage plan was only going to allow 4 days of rehab in spite of the new diagnosis and in-hospital therapy already showing progress. The insurance carrier insisted they were "powerless to change this Medicare rule" but gave the family 3 days to find a place for her. The kids didn't know what to do and were about to place her in palliative care as suggested by the hospital social worker who told them "this happens all the time." No suggestion of an appeal was made.

Her sisters and I, realizing she was also a Vietnam era Veteran, insisted they contact the VA. Today she is receiving full rehab (PT & OT) services through them, and will soon get a small financial supplement to her Social Security that will improve her life. As a result she is regaining her mobility and independence so she will be able to be in a residential Assisted Living facility instead of skilled care.

This story has a happy ending, but is another example of unwarranted denial of care, and a family with no idea they could appeal. All communications between the family and the Advantage plan were by phone or relayed by hospital staff.

Just a side note - in this electronic era, we have found that the documents regarding patient rights (like the right to appeal) are frequently presented to patient and family to sign at admission, and paper copies are not always provided. I am sure that in those stressful moments, it never occurs to people to ask for a hard copy.

I think Medicare advantage plans was a terrible policy decision. They started under George Bush who also promoted privatizing Medicare. Medicare sends more money to insurers per person for these plans than it actually spends on individuals who choose traditional Medicare. The worse part is that when the law that established Medicare advantage plans the law did not change the eligibility for for Medicare supplemental plans. That means after the open enrollment period which is only 6 months a person has to qualify for the plans through full health underwriting.

I was talking about Medicare with my oncologist because I will turn 65 in January. He says that Medicare, traditional, allows doctor to be doctors. If the procedure is covered by Medicare it doesn't require prior approval. Medicare Advantage plans are great money makers for insurance companies when they are able to keep cost down. It's an example of corporate welfare in my opinion and a poor use of tax payer dollars

I have been keeping informed about these occurrences for some time. I like complaints with medicare and any state regulatory entities. 9 times out 10 the resolution was in my favor. I will be 64 in October by the time open enrollment starts. Still evaluating whether to switch to just medicare. My plan is to be on a medigap policy in October 2025. The power medicare advantage plans have is scary. My plan no longer handles my prescription meds. Only on 3 but I pay for them myself using Scriptco.

Any input advice appreciated. Open enrollment coming up. I will be 64 in 13 days. This post is spot on. I have been following MA plans horrors.Do I switch to straight medicare,? Can't get supplement for another year.

I'm unsure what you mean when you say "Do I switch to straight medicare,? "
As far as I know, unless you have End Stage Renal failure, and maybe a few other diseases, you cannot sign up for Medicare until the month when you turn 65. For you that would be October 2025.

Here is what I suggest - find an INDEPENDENT - not tied to one company - insurance agent who specializes in Medicare or Health insurance. Start looking now, reading and asking questions of friends, neighbors and family members. Then, next year about 6 months ahead of your birthday, sit down with that person and find out what your options are, and the costs for each one.

In the mean time figure out what you need in an insurance policy
1) whether you have specific doctors you want to continue seeing,
2) whether you travel or plan to and will need coverage while away from home,
3) whether you have conditions that may worsen with age and require surgery or expensive care
4) what you can afford to pay for premiums and copays.
Sometimes the "zero premium" policies end up costing far more than one with a monthly premium. For example, if you need a joint replacement followed by a short rehab stay and then PT - if there is a $1000 hospital copy, then $50 copays each for physical 12 therapy sessions, and $200/day copays for a week in rehab, your out-of-pocket expenses for that one procedure are $3000. But if theses costs are all (or mostly) covered by a policy that costs $250 per month and gives you good coverage the rest of the year, you are way ahead.
My friend showed this calculation to a group of seniors in our winter community and they were amazed.
Do you live in/near a town or city where you can find a good agent?

Already on medicare and social security. SSDI. Thank you

I appreciate your input. I have taken all these steps. Yes I have found an independent agent - called her twice so far. Medicare Advantage are going to cut benefits for 2025. I have already called some of my providers to make sure they take medicare assignment. I have had ongoing issues for over 3 years with medicare advantage denying care delaying care giving me wrong info. Long ago I stopped trying to work it out with them. I just file complaints with Medicare and other regulatory agencies. My medicare advantage plan no longer handles my prescriptions. I only take 3 but one is lamotrigine for seizure prophylaxis. I have been seizure free 10 1/2 years. Literally their actions can cause death.

Straight Medicare is the best( imo). I am living proof, any of my friends or family that have advantage plans have problems. To me it’s simple there is no “free-lunch”! When other plans offer things “better than Medicare” other things have to be cut/minimized.

@mdk1960 Since you will be turning 65 next year you will likely be inundated with mailings from a number of companies that sell supplemental plans such as United Health Care, Omaha of Nebraska to name a few. I certainly was.

By “straight” Medicare I’m wondering if you mean Original or Traditional Medicare? That’s where you sign up for Parts A and B, choose a supplemental plan to “fill in the gap” after your Part B pays 80% of your outpatient bills, and then also choose Part D which is your prescription plan.

I chose Original Medicare. I have Part A (no cost to any of us), Part B (we do pay for this $174.70 per month) although this amount can be higher depending on your income as filed with the IRS), Part G (I chose Transamerica Insurance and I pay $165 per month) and Part D (I chose WellCare, I do not have a premium). With all of this I can go anywhere I choose in the U.S. that takes Medicare. I do not need pre-authorization as no private insurance companies are involved. This is why I chose Original Medicare because I did not want to be in a provider network that limited where I go for my medical care.

On occasion I pay for a lab test (a blood test) that Medicare does not cover. At times my co-pay for my prescriptions has been over $100 which irks me but that’s the way the drug companies work.

Can you switch to Original Medicare? I don’t know the answer to that. It is very confusing. I do know that when a person first enrolls in Medicare at age 65 one cannot be refused any health care plan, including the Supplemental Plans based on prior diagnoses. If a person chooses a Medicare Advantage Plan at age 65 and then later wants to switch to Original Medicare with a Supplement I believe the insurance companies can deny based on prior health history. But you should get more clarification on that by carefully reading the policy descriptions for the Supplemental Plans.

What’s Medicare Supplemental Insurance?
— https://www.medicare.gov/health-drug-plans/medigap

Does this help?

Thank you so much. Yes by straight medicare I meant medicare A and B or original medicare. I am considering changing to original medicare only during upcoming open enrollment. I had 2 issues today with my humana medicare advantage plan. One is resolved but I still liked a complaint with medicare. The other was I charged for my annual mammogram by the imaging company. It is $0 . A preventive service. I called humana it was escalated to claims and supervisor. Supposedly they will call the company. But I document everything and follow up. I appreciate the details you provided about your supplement. I have to wait a year for the supplement so I avoid underwriting but my medicare advantage is so difficult now and for 2025 they offer less benefits and charge more. I called my father who has Aetna medicare advantage plus the info for 2025. I was shocked and worried but have seen this coming for at least 6 months. Aetna raised the patient costs co pays etc. When you see a doctor do you think your care is better with medicare a and b and your supplement?