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Reasons Why Medicare Advantage Plans are Bad

by Dustin Cortright

Since the beginning of this year, Medicare Advantage plans will cover supplemental non-skilled home benefits as well as daily maintenance. It will be a first time that it’s allowed that service is eligible as a supplemental benefit and covers daily maintenance. According to the Agency, the aim is to provide more alternatives for seniors, as well as, lower premiums in their Medicare health and drug plans. This will mean the world to patients as their specific needs will be addressed and there will be new flexibilities for Medicare Advantage plans which will be able to offer new health-related benefits.

Managed care refers to solutions whose goal is to reduce the costs for health care while providing better services for patients. This strategy discourages providers from promoting preventive medicine and doing unessential services. It includes provider networks with providers who agree to specific standards and costs. Managed care means that each patient under its care gets a paid health plan. Hence, the plan makes money only if the caring for a patient requires less money than the fixed fee. However, if there is more money required, the plan loses money but has an investment which limits costs.

Nevertheless, when the costs of Medicare started increasing, Congress considered managed care as a possible solution. Therefore, there was a contract between managed care plans and the Medicare program, which became known as Medicare Advantage. Medicare Advantage provides services for all Medicare beneficiaries who choose the managed care option. So, the managed care plan gets a fixed monthly fee and thus, provides services to every Medicare beneficiary under its care.

Every person who decided to be covered by a Medicare Advantage plan receives all the coverage like under original Medicare, as well as, coverage for services and products, such as custodial care and prescription drugs, which aren’t usually covered by original Medicare. This might sound like a perfect thing, but it only sounds like that.

Why Medicare Advantage Plans Are Bad?

Managed care plans limit their costs by offering a list or network of selected health care providers their patients can choose from. The patients are allowed to use these network providers with whom the plan has special rates. Hence, if you choose to use a provider who is not in the network, neither the plan or Medicare will cover the cost. So, if your doctor is a member of the network not, no one guarantees that they will continue so, especially if they start to cost the plan too much.

The plans also limit costs with the fact that all your care needs to be carried out by a primary care physician. This means that it’s the doctor who will decide whether you need a specialist, which is only done when there is an absolute necessity, while you can’t make an appointment yourself. Nevertheless, Medicare Advantage plans are required to allow patients with serious health issues or women who need health care screening to see specialists without referrals from their primary care physicians.

Likewise, in order to get certain medical services, the plan administrators have to approve your primary care physician’s plan. Hence, if they don’t agree that your procedure is medically necessary, they might refuse to pay for it. These plans seem to reduce costs by being very restrictive, such as shortening the time their patients stay in a hospital.

It has been suggested that there are many cons of the Medicare Advantage plans over original Medicare. Hence, patients enrolled in a Medicare Advantage plan are more likely to experience issues getting emergency or urgent care, end up in a lower quality nursing home, and have problems getting continuity of care than patients with traditional Medicare. In fact, a recent study concluded that Medicare Advantage plans are probably having a huge influence in nursing home selection for their beneficiaries.

Medicare Advantage plans often cover only medications which are part of the list known as “formulary”, while you will have to pay for the rest. However, it also happens that if a medication is on the list now it might be removed later.

Another possible downside of the plan it the extent of its service area. Hence, if you travel a lot, you might face a lack of access to health providers.

In a nutshell, before you decide whether a Medicare Advantage plan is a good idea for you, talk with your physician. There are many aspects you need to consider, such as whether the plan allows treatments, referring to specialists, and whether if often overrules the doctor. Before enrolling in the plan, make sure to review your Medicare plan, especially during October 15 – December 7, which is known as an open enrollment period.

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