It is that time of year again for seniors 65 years old or older to decide if they want to enroll in Original Medicare or select a Medicare Advantage Plan such as Amerivantage, Humana Gold, or United Health Care’s AARP Choice Plan. The enrollment window is October 15 – December 7, 2023. A Medicare Advantage Plan is Part C Medicare and is a replacement for Original Medicare, not a supplement. There has been much information in the past year regarding the Medicare Advantage Plans, which is troubling and concerning.
Last year, the Office of Inspector General (OIG) published a report on a study that was conducted in June 2019, which raised concerns about Medicare Advantage (MA) Plans delaying or denying access to services even though requests met Medicare coverage rules. OIG analyzed a random sample of 250 prior authorization denials and 250 payment denials issued by 15 of the largest Medicare Advantage insurers between June 1 and June 7, 2019. From that sample, the analysts predicted likely denial rates that fit within Medicare’s requirements. OIG found that 87% of prior authorization denials in MA plans would have been approved within Medicare coverage requirements, as did 82% of denied payment requests. These claims would not have been an issue if the patient had been enrolled in Original Medicare.
In addition to those disturbing results, we have observed negative impacts on patient care caused by MA Plans to Floyd County residents. One patient had to pay out-of-pocket for routine lab services received when being treated by a Lockney doctor because the MA Plan wanted him to go to a reference lab in Lubbock. Other recent examples include denials for inpatient hospitalization where outpatient treatment was not effective, denials for diagnostic tests that could have provided an earlier diagnosis of cancer, and denial of swing bed days. These results have caused Congress to implement additional rules guiding MA plans and attempting to control their deceptive marketing practices. Unfortunately, these rules will not go into effect until 2024.
Our experience has been that patients who choose an MA Plan may have care denied or delayed, and these patients experience higher out-of-pocket costs for their care when they are sick. In addition, many specialists are not in network with MA Plans, so access to care is limited. NBC News has a detailed, powerful story describing the financial problems that Medicare Advantage plans are causing for rural hospitals and people who live in rural communities.
“Because the plans routinely deny coverage for necessary care, they are threatening the existence of struggling rural hospitals nationwide, CEOs of facilities in six states told NBC News. While the number of older Americans who rely on Medicare Advantage in rural areas continues to rise, these denials force the hospitals to eat the increasing costs of care, causing some to close operations and leave residents without access to treatment.”
Seniors paid into Medicare all their lives so they could have access to healthcare benefits as they get older. Services offered through Original Medicare require fewer pre-approvals and result in fewer restrictions than MA Plans. While Medicare Advantage Plans may offer certain perks not available through Original Medicare, they also funnel significant profits back to private insurance companies that operate these plans. MA Plans have an incentive not to spend money on healthcare because they keep the extra dollars paid to them by the Federal Government.
We want to be clear to our community: WJ Mangold Memorial Hospital and the Cogdell Clinics favor Original Medicare. If you can afford it, a supplement with Original Medicare is the best coverage possible. If you select an MA plan, you cannot buy a supplement to cover the out-of-pocket costs. Don’t be swayed by all of the advertising, phone calls, and salespeople insurance companies use to try and convince you to select an MA Plan (Part C). The truth is that Original Medicare is the preferred choice and recommended by your local hospital and doctors.
If you have any questions, please contact Saundra Rendon at 652-3373, ext. 300, Almadena Rendon at ext. 207, or talk to your physician. Thank you for being so supportive of WJ Mangold and your local healthcare providers.
(Vince DiFranco is CEO of W.J. Mangold Memorial Hospital in Lockney, TX)
