Don’t Be ‘Haunted’ By Your Medicare Open Enrollment Decision!

Welcome to October - the month when Halloween decorations go up, temperatures go down, and Medicare beneficiaries must decide what coverage they will need in the coming year. If the thought of choosing a Medicare plan gives you the creepy-crawlies, you’re not alone! There are many aspects to consider, including medical services covered, deductibles, premiums, and out-of-pocket costs.

Medicare Open Enrollment runs from October 15th to December 7th every year. During this period, Medicare beneficiaries can choose to enroll in traditional Medicare (Parts A and B) or Medicare Advantage, can switch between Medicare Advantage plans, and can enroll in Part D prescription coverage.

The following information should help you navigate this monster mash of Medicare choices – and avoid some of the more terrifying aspects of privatized Medicare Advantage plans:

The Spectre of Prior Authorization

Medicare Advantage plans usually require healthcare providers to get prior authorization before treating a patient. This is not only a time-consuming task for providers and their staff, but this prior authorization can delay care by up to 72 hours for emergency services and up to a week for standard services.

Even worse, about 7% of prior authorization requests – more than 3.4 million every year – are denied by Medicare Advantage insurers, according to recent research published in the Journal of the American Medical Association. An earlier study by the Centers for Medicare and Medicaid Services (CMMS) found that Medicare Advantage providers were rejecting nearly 20% of claims for medically-necessary services that would have been covered under traditional Medicare.

Avoid the Ghastly Ritual of Medical Underwriting

When you first become eligible for Medicare at age 65 (or when you activate Medicare Part B for the first time), you have a six-month “guaranteed issue” window to apply for Medicare supplemental coverage. Also known as Medigap coverage, these supplemental plans cover the portion of healthcare costs that traditional Medicare does not cover. These plans can be vital for seniors who need major surgeries, extended hospital stays, skilled nursing facilities, or hospice care. However, you cannot buy a Medigap plan if you are enrolled in Medicare Advantage.

If you miss the six-month guaranteed issue window, you will likely need to undergo medical underwriting in order to apply for Medigap coverage. This means you will need to fill out an extensive questionnaire detailing all of your recent health conditions, and may be denied Medigap coverage altogether if the carrier deems you too much of a risk to insure. Even if you are deemed eligible for Medigap coverage after undergoing medical underwriting, you may face exorbitantly high monthly premiums that could have been avoided had you chosen traditional Medicare and a Medigap plan in your initial 6-month enrollment period.

Beware: Medicare Advantage Contracts are Vanishing Like Ghosts

In recent years, hospitals and health systems across the country have chosen to end their contracts with Medicare Advantage plans, often citing slow payments from insurers and the hassles of prior authorization. At least 26 regional health systems are planning to cut ties with Medicare Advantage plans in the new year, which will put these health systems’ services out-of-network for current planholders. This number may well increase in the next few months as more regional hospitals and health systems choose to drop Medicare Advantage.

The Rattling Chains of Limited Healthcare Networks

The declining number of health systems accepting Medicare Advantage plans only adds to the existing difficulty Medicare Advantage beneficiaries experience in finding in-network providers. According to KFF Research, the average Medicare Advantage network only includes 46% of physicians in the county, and about a third of Medicare Advantage enrollees are on narrow-network plans that include less than 30% of doctors in their county. By contrast, a whopping 98% of medical providers nationwide accept traditional Medicare.

Coverage For The Whole Skeleton

Unfortunately, traditional Medicare – like most private and employer-sponsored health insurance plans – does not cover dental care. This is why healthcare activists often refer to teeth as luxury bones. Many Medicare Advantage plans take advantage of this gap in traditional Medicare by including dental coverage as part of their plans. However, traditional Medicare enrollees still have the option of enrolling in private dental plans - including extremely affordable plans through labor unions and organizations such as AARP.

The Monster of Medicare Privatization

Since its inception, Medicare Advantage has been an experiment in the privatization of one of our country’s largest and most successful public goods - traditional Medicare. This experiment has proven to be quite profitable for private insurers, who have overcharged the federal government more than $612 billion since 2007 – including more than $83 billion this year alone – into plans that spend roughly 9% less on patient care than traditional Medicare spends for comparable beneficiaries.

Furthermore, Medicare Advantage insurers routinely upcode the health conditions of new enrollees – making them appear sicker than they are in order to extract maximum premium payments from the federal government – even if the beneficiary is not seeking treatment for these conditions. All in all, the overhead costs of Medicare Advantage plans are 14%, compared with 2% for traditional Medicare, undermining the entire founding premise that a corporate-managed system would be more efficient and cost-effective than government-run Medicare.

Trick or Treat(ment)

The bottom line is that traditional Medicare (Parts A & B) and Medicare Advantage (Part C) have two fundamentally different missions. Traditional Medicare aims to provide health coverage and increased financial security for older Americans. The primary goal of Medicare Advantage insurers is to maximize profit – even if that means worse health outcomes for beneficiaries. Medicare beneficiaries should keep this fundamental difference in mind as they make their enrollment choices this fall.

Traditional Medicare is far from perfect, of course, and we in the Arlington Medicare For All Coalition welcome efforts by Senator Bernie Sanders and others to expand traditional Medicare to include dental, vision, hearing and mental care. We also want to see this coverage expanded to all age groups, covering the entire country with national, improved Medicare For All. Please visit https://linktr.ee/ArlingtonM4A to learn more about our campaign for a Medicare For All Resolution here in Arlington County.