Why Medicare Advantage Plans May Fall Short

Why Medicare Advantage Plans May Fall Short

Why Medicare Advantage Plans May Fall Short, For many older Americans, Medicare Advantage plans can work just fine. A JAMA study found that Advantage members often receive more preventive care than those on traditional Medicare. Advantage plans compete not only on cost but also on the quality of care, says Dr. Kenton Johnston, an associate professor of health management and policy at Saint Louis University and a co-author of the study.

But if you have chronic illnesses or major health care needs, you should think twice before purchasing Medicare Advantage, due to prior authorization requirements and the need to use network providers, says Melinda Caughill, co-founder of 65 Incorporated, a company that provides guidance on Medicare enrollment to financial advisors and individuals.

“If you need to see multiple specialists and have to get referrals for each appointment or fight to override coverage denials, it can be really challenging,” says Caughill.

Steven Feld, 65, a retiree in South Pasadena, Florida, struggled to get coverage for an injection to treat his arthritic knee. The treatment, a prefilled injection given in a doctor’s office, is considered a medical device by the FDA, for which the plan twice denied coverage. “When I was in my employer group plan, there was no problem getting the shot covered,” says Feld, who joined his Medicare Advantage plan in May. 

After nearly three months, the plan approved an alternative brand of injection. And Feld intends to stick with its Advantage plan, which includes the best doctors in its network, as well as a fitness plan. “The premiums are much lower than the group insurance I had,” says Feld.

According to a recent Kaiser study,  if you get seriously ill, you could end up paying higher costs in a Medicare Advantage plan than in Original Medicare. Analyzing plan cost data, researchers found that for five-day hospital admissions for pneumonia, half or more of Advantage beneficiaries would face higher costs than traditional Medicare (assuming there was no complimentary coverage). 

“People with Medicare Advantage often don’t realize they can pay more out of pocket for services until they reach the plan limit,” says David Lipschutz, associate director of the Center for Medicare Advocacy, a nonprofit group profit.

For those who live in rural areas, where there are fewer doctors and hospitals, the Advantage plan’s limited networks can be a barrier to getting the care they need. According to a recent Health Affairs study, people who live in rural areas are almost twice as likely to drop an Advantage plan for Original Medicare as those who live in urban or suburban areas.

“The results suggest that people may be dissatisfied with their health care due to difficulty getting to doctors’ offices and making appointments,” says study co-author David Meyers, Ph.D., assistant professor of health services, policy and practice. at Brown University.