How to deepen your reporting on Medicare Advantage

By Cheryl Clark

Here’s an under-reported story that’s important for 22 million people in the United States: One in three Americans over age 65 are enrolling in Medicare Advantage plans rather than traditional Medicare. It’s a ratio that’s been growing every year.

These days the ads on Facebook and TV networks seem to come every 15 minutes, advertising a wonderful array of services that Medicare Advantage, or Part C plans, provide for low or no monthly cost. “Call now,” says one spot that features football great Joe Namath. “It’s free.”

Doctor appointments, hearing, vision, prescription drugs, rides to medical facilities, private home aid, doctors’ and nurses’ visits by telephone, and even home-delivered meals.

All at no additional cost.

But as I reported in a recent story for MedPage Today, there’s another side of the story that the ads — and often insurance brokers and plans themselves — don’t mention. It’s that once you get into one of these plans and become ill and unhappy with services or your selection of providers, you may not be able to get out without incurring a lot more expense. The only time you can get out and transfer to traditional Medicare with a Medigap plan, without being subjected to Medigap denials for any medical conditions, is if you enroll at age 65.

After that age, you probably will be asked to answer a medical questionnaire disclosing any care you’ve previously received for any diseases and conditions, plus list any drugs that you’ve taken in the last several years. Health insurance counselors familiar with this issue say that Medigap plans have many exclusions, with even a diagnosis of diabetes or prediabetes becoming a potential grounds for rejection.

Here’s what David Lipschutz, an attorney for the Center for Medicare Advocacy, said in one of my interviews with him.

“There is a trial period for 12 months if you enroll in Medicare Advantage when you’re first eligible for Medicare, but if you choose to get out within a year, you do have a right to purchase a Medigap plan. But most people, if they’re aware of that right at all, believe that that right exists indefinitely.”

It doesn’t.

During that one-year “trial period,” you have 63 days from your date of disenrollment to get into a Medigap plan without medical underwriting, which means they can reject you if they don’t like a particular condition you claim or charge you a prohibitively high amount for your monthly premium.

So choosing a Medicare Advantage plan over traditional Medicare with a Medigap plan and Part D for prescription drugs can end up being penny wise and pound foolish.

Medigap plans pick up the 20-percent co-pays of all your Part B outpatient expenses, which include anything from emergency room care, physician services in and out of the hospital, imaging, lab work, ambulatory surgery, durable medical equipment like wheelchairs, rehabilitation care, physical therapy and other cost-sharing charges.

The is an issue that has been under-reported. It’s also a marvelous opportunity for journalists to learn about the complexities of a Medicare system that over the years has slowly — and now many say not so slowly — been shifting Medicare beneficiaries to commercial plans with biased promotions.

In case you’re starting to get lost:

Traditional Medicare is divided into three parts. Part A, B and D. A is generally hospital coverage, with Part B typically paying outpatient care, including emergency room trips, or durable medical equipment such as wheelchairs. Part D is drug coverage.
Part C, sold by commercial insurance companies like UnitedHealthcare or Blue Cross Blue Shield, combines A, B and D in one package of benefits paid for by Medicare directly to insurance companies with a capitated monthly rate. Most of these plans are managed-care plans.

Part C plans may include lots of extra benefits, such as gym memberships, dental care or transportation to medical appointments. But most of these plans include a very big catch: enrollees have to stay in the plan’s network, which can and do exclude many favored providers and health systems. They also may cap benefits at a certain point, thus requiring much higher co-pays.

Why would Medicare Advantage enrollees ever want out of such plans? In my conversations with several acquaintances and friends, including a few doctors, these plans are wonderful when you’re healthy and have little need for care. But once someone requires specialty care they have to contend with prior authorization requirements, long waits for appointments, and most of all, narrow networks that can exclude the best specialists you may want to see.

I’d been hearing stories from friends who regretted their decision to enroll in Medicare Advantage plans once they had received a diagnosis of cancer or heart disease that made then ineligible to transfer to traditional Medicare with a Medigap plan. Most of them have become resigned to staying in Medicare Advantage and enduring the waits and requirements for prior authorization.

So how can you as a journalist report this story?

First, contact your state’s State Health Insurance Assistance Program, which may go by another name such as HICAP, the Health Insurance Counseling & Advocacy Program, which can answer your questions without bias.
Check the Medicare.gov plan finder tool to learn what Medicare Advantage plans in your area disclose.
Contact some Medicare coverage brokers. If they are not getting inordinately high commissions from one provider, can possibly provide examples.
Ask older people in your neighborhood or friends and colleagues what their parents’ have obtained for Medicare coverage and about their experiences. Elder law and senior counseling services may be helpful as well.
Talk with leaders of local cancer or diabetes advocacy groups. Their clients may have stories about difficulties obtaining specialty services because they’re not in the person’s MA plan’s network.

Note that four states have rules allowing Medicare Advantage enrollees who disenroll to buy Medigap plans without underwriting. They are Connecticut, Maine, Massachusetts and New York. Research those laws and find out what situations prompted them to make exceptions.

You also can write about how confusing Medicare.gov is on the topic:

The newly revised Medicare Plan Finder tool does not explain that if you choose a Medicare Advantage plan and later decide to switch to traditional Medicare with a Medigap plan, you may not be able to do so. Nor does another Medicare.gov website, “Join, switch, or drop a Medicare Advantage plan.”
A third Medicare.gov website, “When can I buy Medigap?” is more specific, explaining in the third section that after six months, “there’s no guarantee that an insurance company will sell you a Medigap policy if you don’t meet the medical underwriting requirements…” Meaning, if you get sick.
A fourth Medicare source, a brochure on the whole Medigap system, provides more detailed information but the best part of it is this chart which you can find here.

The challenge of transferring from one Medigap plan to another is a whole other topic. In general you can’t do this without undergoing underwriting, although California has a “birthday rule” that allows Californians a 61-day window to transfer to another Medigap plan regardless of their health, but only if they are already in a Medigap plan.

It’s a complicated topic, but such an important one. Medicare Advantage plans offer a huge array of services, but remember that health care needs when one turns 65, and for a few years thereafter can be a lot different years later if the person develops an illness or chronic condition.

As always, I’m interested to hear your thoughts and questions.

Sources

David Lipschutz at the Center for Medicare Advocacy: dlipschutz@medicareadvocacy.org
Bonnie Burns at California Health Advocates: bburns@cahealthadvocates.org