Medicare open enrollment has begun, and Montana medical providers want seniors to understand the tradeoffs that come with Medicare Advantage plans run by private insurance companies.
Austin Amestoy: Election season is over, which means Montanans are getting a welcome reprieve from political ads and phone calls. But Montana seniors are likely being bombarded with ad campaigns for enrollment in Medicare Advantage plans. Montana Public Radio’s Health Care Reporter Aaron Bolton is here to talk about these private Medicare plans, and the pros and cons for those shopping around this year.
Hey Aaron.
Aaron Bolton: Hey Austin.
What is Medicare Advantage?
AA: Can you explain what Medicare Advantage is for those that don’t know, and why people turn to these plans?
AB: Under traditional Medicare, you’re on the hook for a portion of your health care costs. You can get a “Medigap” plan, which picks up that tab. But that can cost $200 per month in Montana, according to KFF, a nonpartisan research group. A lot of people can’t afford that.
Medicare Advantage plans are run by private insurance companies. People turn to Medicare Advantage because it offers cheap premiums and bundles care under one plan. Many seniors will have seen ads like this one:
[Medicare Advantage ad]: In this one simple call they offered to enroll me in a plan that includes rides to medical appointments, private home aids, doctors and nurses visits by telephone and even home-delivered meals.
Provider networks could limit what doctors you see
AA: If I’m a senior on a fixed income, getting all my care bundled for a low or $0 premium sounds great. But I suspect since you’re here talking about these plans, there’s more to it?
AB: There is. Under traditional Medicare, you can basically go to any provider you want. But Advantage plans run their own network. They may only include in-state providers or may have sporadic coverage in certain areas of the state.
AA: So if someone got one of these plans, there’s no guarantee it will cover the doctor they already have?
AB: Right. If you need specialty care, these plans may advertise that coverage, but you may find out that they don’t have an in-network provider near you.
AA: So, if a senior is looking at getting one of these plans it sounds like it’s worth getting a sense of, not only what is covered by these plans, but where those providers are.
Prior authorization process can by delayed and dangerous
AB: Yes. And another thing providers are warning people about are prior authorizations. That’s when the insurance company needs to review care the doctor says a patient needs, before it agrees to pay.
Bob Olsen, President of the Montana Hospital Association, says patients on Medicare Advantage plans run into that issue a lot.
"The feeling among the hospital community, the physician community, is that they’re being asked to authorize so many items that are initially denied; and then through various appeals processes, they end up approved.”
AB: Even if care is eventually approved, Olsen says the appeals process delays care.
The American Medical Association surveyed providers about this issue. Dr. Bruce Scott is the president.
“What's really bad is that it’s harming patients. Twenty-five percent of physicians say that their patients have suffered serious adverse events, hospitalizations, disability or even death, because of delays from insurance companies’ prior authorization,” Scott says.
AA: So, if the medical community is saying this is causing such a problem, is there anything being done about it?
AB: The Biden Administration passed regulations earlier this year that will require insurance companies to make their prior authorization rules more transparent and may speed up the process. But those rules don’t go into effect until 2027.
It can be hard to switch back to traditional Medicare
AA: Ok, there are issues with patients having fewer choices and issues with getting care approved. Are patients trying to move away from Medicare Advantage?
AB: Yes, but switching back to traditional Medicare has drawbacks.
Remember, under traditional Medicare, patients can be on the hook for 20% of their care. You can get a Medigap plan, which covers that. During your first year of eligibility, those plans can’t deny you or charge you a crazy high premium because you have a pre-existing condition.
Say you go for that cheaper Medicare Advantage plan. If you get sick and want to switch back because of the other issues we’ve already talked about, Medigap plans can deny you or charge you a really big premium.
Some people can wind up trapped in their Medicare Advantage plan because they can’t afford the out-of-pocket costs and also can’t afford or get a medigap plan.
Know what you're signing up for
Here’s Dr. Bruce Scott with the American Medical Association again:
“Every day in my office, I see patients who, when they find out the rules, they're like, ‘I didn’t understand that, I didn't know that.' And that’s so sad. This is a vulnerable population, and they need to be helped to clearly understand what it is that they’re signing up for.”
AA: So where can seniors in Montana turn for help when considering their options?
AB: Montana does have a State Health Insurance Assistance Program, which can help you shop for Medicare coverage and provide all the info you need to know for free. Medicare open enrollment runs through Dec. 7.
