Medicare Advantage Plans - Are They Taking Advantage of Seniors?

The time has arrived for open enrollment for Medicare 2022. It began October 15 and will run through December 7. "Open enrollment", also known as Medicare's annual election period, permits plan enrollees to reevaluate their coverage – whether it’s Original Medicare with supplemental drug coverage or Medicare Advantage plans (MA) – and make changes or purchase new policies if they choose to do so.

During the Medicare open enrollment period, you can also:

  • Switch from Original Medicare to Medicare Advantage (as long as you’re enrolled in both Medicare Part A and Part B, and you live in the Medicare Advantage plan’s service area).

  • Switch from Medicare Advantage to Original Medicare (plus a Medicare Part D plan, and possibly a Medigap plan).

  • Switch from one Medicare Advantage plan to another.

  • Switch from one Medicare Part D prescription drug plan to another.

  • Enroll in a Medicare Part D plan if you didn’t enroll when you were first eligible for Medicare. If you haven’t maintained other creditable coverage, a late-enrollment penalty may apply.

Another piece of information for those individuals with end-stage renal disease is that prior to 2021, they were unable to enroll in Medicare Advantage plans unless there was a Medicare Special Needs plan available in their area for ESRD patients. But that changed as of this year, under the terms of the 21st Century Cures Act. People with ESRD gained the option to enroll in Medicare Advantage as of this year, and CMS expected more than 40,000 to do so. This can be particularly advantageous for beneficiaries with ESRD who are under age 65 and living in states that don’t guarantee access to Medigap plans for people under the age of 65.

What You Can't Do

The annual Medicare open enrollment period does not apply to Medigap plans, which are only guaranteed in most states during a beneficiary’s initial enrollment period or during limited special enrollment periods. If you didn’t enroll in Medicare when you were first eligible, you cannot use the fall open enrollment period to enroll. Instead, you’ll use the Medicare general enrollment period, which runs from January 1 to March 31.

There are limitations...

Medicare’s general enrollment period is for people who didn’t sign up for Medicare Part B when they were first eligible, and who don’t have access to a Medicare Part B special enrollment period. It’s also for people who have to pay a premium for Medicare Part A and didn’t enroll in Part A when they were first eligible.

If you enroll during the general enrollment period, your coverage will take effect on the first of July. Learn more about Medicare’s general enrollment period by clicking on the blue phrase.

The ABC's of Health Insurance

One last bit of information before we get into the main focus of this blog is understanding the differences are between the acronyms of health insurance and what type of plan may make sense for you.

  • Health Maintenance Organization (HMO) - HMOs are considered one of the least expensive types of health insurance. Its premiums are usually low, deductibles are affordable and co-pays are fixed. With HMO plans, you are required to choose doctors within the network, including specialty providers. If you need a specialist, a referral from your primary care doctor is required. These are a good choice if you are on a fixed income and in decent health.

  • Point of Service plan (POS) - This plan also requires referrals from your primary care doctor in order to see a specialist. A POS has higher premiums than an HMO but you are able to see providers outside of the network but you will be paying a higher co-pay. This plan works for those who may have a condition and require specialists who are not located within the area.

  • Exclusive Provider Organization (EPO) - This is a lesser-known plan but contains larger networks than HMOs. EPOs still only cover those within the network and they may or may not require referrals to specialists. Premiums may be higher than HMOs.

  • Preferred Provider Organization (PPO) - These plans are usually more expensive than HMOs and POSs but they allow you to see specialists without a referral. Copays and coinsurance for in-network providers are low and if you have a lot of health needs or know within the next year, your health will require more attention and you can afford higher premiums, a PPO is an excellent choice.

But Joe Namath Said...

With that out of the way, let's get back to the focus of this blog - Medicare Advantage plans (MA), also known as Medicare Part C, whose ads have been running ad nauseam since late August. What's important to know here is that these ads are not sponsored in any way by any government agency or Medicare itself, rather private insurers trying to sell a Part C policy and the promises being made on these commercials do not represent, as the late Paul Harvey would say, "the rest of the story." Let's explore this further.

"Over the past weekend, I was watching a documentary on the history channel when ad after ad featuring older celebrities and retired sports figures aired touting free benefits the may be available from Medicare Advantage plans," said Attorney RJ Connelly III, certified elder law attorney (CELA) who works with seniors and their families on health insurance and long term care concerns. "As with all things that seem too good to be true, it's important to view these commercials with that adage in mind, and listen very closely to the words that are being used." Attorney Connelly is certainly on the mark with that statement as the promises made may come with a price.

Get free things? Just don't get sick with an MA plan...

The website, MedPage Today, published a story about a San Diego man named Tom Mills who discovered one of the dirty little secrets about MA plans that offer low rates -- that is until you get sick. At that point, out-of-pocket costs soar, and even worse, getting out of one can be even more expensive.

After Mills underwent a mitral valve repair and suffered a mild stroke with no lasting effects, the San Diego resident's plan began charging him hundreds of dollars in monthly copays for drugs and other medical services. He also had to pay $295 a night for his hospital stay.

"You hear plenty of the pros, but none of these celebrity endorsers ever list the cons, which can be life altering for those on a fixed income." -- Attorney RJ Connelly III, CELA

But then came the biggest shock of all - Mills,71, - learned that if he switched out of his MA plan, he would incur exorbitantly higher costs the next time he needed a serious medical intervention. If he moved to traditional Medicare and a prescription plan, he still needed a supplemental Medigap plan to pick up his 20% copays and deductibles.

Though the retired environmental geologist was healthy enough at that point to train for marathons after his medical emergency, he was now carrying the baggage of a pre-existing condition, which can be a problem when seeking a Medigap plan and these plan providers, in all but four states, can and do reject people like him or require prohibitively higher premiums. Diabetes, heart disease, or even a knee replacement can be criteria for exclusion. A health insurance broker told him no supplemental plan would cover him, and he'd be wasting his time if he applied. No one told him about this side of MA plans when he enrolled at age 65.

Surprisingly high co-pays can result in sticker shock.

"So we see Joe Namath and others tout MA's array of services - free dental, vision, hearing, gym membership, rides to medical appointments, doctor and nurse visits by phone, and even meal delivery and home aid," stated Attorney Connelly. "You hear plenty of the pros, but none of these celebrity endorsers ever list the cons, which can be life-altering for those on a fixed income."

American Medical Association Concerns

The American Medical Association (AMA) has also called out these commercials as deceptive. They have lobbied for the government to mandate tighter plan rules and disclosure, with lists of network specialists being made available up front. Within the last year, the AMA approved a resolution calling on the Centers for Medicare & Medicaid Services and other stakeholders, including the senior citizens' lobby AARP, to make the process of choosing Medicare plans less confusing and more transparent.

"Seniors are lured to these [Medicare] advantage plans by misinformation and confusing sales techniques..." --- American Medical Association

A similar AMA resolution in 2018 declared that "seniors are lured to these [Medicare] advantage plans by misinformation and confusing sales techniques," and that plan inadequacies result in "delay in nursing home placement for some members," produce "poor service for some members ... due to difficulties with physical therapy and rehab services. The number of days approved (for payment) has tended to be too short and the extent of rehab services too limited."

Government Website Confusion websites aren't always clear either when it comes to the process of transferring out of Medicare Advantage plans to traditional Medicare with a Medigap plan, but the general bottom line is that getting accepted by a Medigap plan is guaranteed only within the first 12 months after enrolling in Medicare at age 65.

Some information on websites may be confusing.

MA plans, which are managed by private insurers, can be very complex, with the potential for substantial out-of-pocket costs when beneficiaries get sick not being explained very well, resulting in high co-pays. Medigap policies, which pay for many expenses not covered in basic Medicare, may cost more in monthly premiums upfront, but once a person is enrolled, premiums are set solely through "community rating" and beneficiaries' age. New-onset health issues do not lead to premium increases.

The catch is, as with the story on Mr. Mills earlier, that if one initially enrolls in an MA plan and then decides to switch out more than a year later, Medigap insurers will take into account the individual's pre-existing conditions, and may decline coverage or demand high premiums.

Other Complaints

Besides MA's lack of transparency on costs, critics also cite problems with insurers' provider networks. The AMA wants CMS to make sure physician networks are adequate and list physicians, their specialties and subspecialties, and how many actually cared for plan members the prior year. A Kaiser Family Foundation report that found 35% of plans studied were served by a "narrow" physician network, meaning that fewer than 30% of the physicians in that area were contracted.

"There is a very good reason for this, and it's financial," said Attorney Connelly. "Many plans appear to purposely understaff specialties and subspecialties to avoid expensive pre-existing conditions like cancer or those with mental illness. Those networks that do provide these services force patients to jump through hoops in order to receive care or secure prior authorizations. It's a common practice by them."

Ralph Nader

In 2020, veteran consumer advocate Ralph Nader blasted MA plans as nothing more than "a way to enrich health insurers at seniors' expense." Calling the plans "Medicare Disadvantage" and a "corporate trap," Nader took the AARP, which offers its brand of Medicare Advantage through UnitedHealthcare, to task for being asleep on the issue, and having a conflict of interest because it gets a 4.95% commission on each plan sold.

AARP spokesman Gregory Phillips responded to Nader's criticisms by saying, "AARP supports increasing access through guaranteed Medigap coverage, in addition to eliminating medical underwriting and age rating, to ensure that older Americans will get the coverage they need when they need it most."

"These networks that do provide these services force patients to jump through hoops in order to receive care or secure prior authorizations. It's a common practice by them." -- Attorney RJ Connelly III, CELA

Phillips agreed that many beneficiaries may not be aware that plans "may terminate their relationship with Medicare in any given year; change the premiums, cost-sharing charges, or benefits from year to year (including drug coverage); and drop physicians from their networks during the year. Beneficiaries may also not be aware that if they want to voluntarily leave an MA plan and return to traditional fee-for-service Medicare, they may be subject to medical underwriting for a Medicare supplement (Medigap) policy. This underwriting may result in their being refused a policy or being required to pay higher rates." But Phillips continued to defend AARP's participation in MA plans, saying it provided information on both MA and traditional Medicare plans to consumers.

Scams During Open Enrollment

What would any enrollment period be without scammers attempting to take advantage of seniors and those confused by the plethora of confusing and misleading advertising? A November 2nd report from WPRI - TV12 in Providence, Rhode Island, cited a warning from the Better Business Bureau (BBB) about scammers who "come out of the woodwork to try and trick people out of money and personal information," Paula Fleming from the BBB told WPRI. "A lot of people are left with a lot of questions on what [Medicare and ACA] involves and the process, and rightfully so, of course, scammers are taking advantage of this,” she stated.

According to Fleming, the majority of the unsolicited calls and messages reported involved the victim providing money or personal information directly to the scammer. Fleming provided WPRI with the following tips to avoid falling for a scam call during this open enrollment period:

  • Be cautious of any unsolicited messages or calls

  • Don’t accept promotional gifts for personal information

  • Protect your government-issued numbers

Connelly Law reached out to Kathleen Heren, the Rhode Island State Long Term Care Ombudsman for her thoughts on the scams that occur during the open enrollment period which target senior citizens.

Kathleen Heren

"Elders are such easy targets for these types of scams," said Ms. Heren. "It’s sad but they sometimes switch their Medicare plans legitimately and choose the wrong plan. They only realize when they try to use the plan and their benefit is not there. One of the Ombudsman in my office has already received 3 of these calls."

So just what is being done about this? "RI is very fortunate our Attorney General Peter Nerona makes elderly scams one of his priorities," continued Ms. Heren. "There are two individuals, Molly Cote and Michaelia Driscoll who for the past two years have spent countless hours training groups on these scams. They also work closely with law enforcement in investigating victims of elder scams. Sometimes elders are ashamed to report that they have fallen victim to these scams so the number of elders affected is most likely higher than we know."

"Elders...sometimes switch their Medicare plans legitimately and choose the wrong plan. They only realize it when they try to use the plan and the benefits are not there." --- Kathleen Heren, RI Long Term Care Ombudsman

Anyone who receives an unsolicited phone call regarding open enrollment is urged to hang up and instead visit or for official information.

For over-the-phone assistance with open enrollment or if you’re worried you’ve fallen victim to a scam, call 1-800-MEDICARE.

Statewide SHIP Assistance

We want to close out this blog with information about the State Health Insurance Assistance Program (SHIP). SHIP provides Medicare beneficiaries with information, counseling, and enrollment assistance. Its mission is to strengthen the capability of grantees to support a community-based, grassroots network of local SHIP offices that assist beneficiaries with their Medicare-related questions.

Consulting with SHIP counselors.

SHIPs present and distribute information to groups and individuals to inform them on Medicare benefits, coverage rules, written notices and forms, appeal rights and procedures, and more. They also provide free, in-depth, one-on-one insurance counseling and assistance to Medicare beneficiaries, their families, friends, and caregivers.

SHIPs assist people in obtaining coverage through options that include the Original Medicare program, Medicare Advantage (Part C) Plans, Medicare Prescription Drug (Part D) Plans, and programs designed to help people with limited incomes pay for their health care, such as Medicaid, the Medicare Savings Program, and the Low-Income Subsidy. They can help people compare Medicare Supplemental (Medigap) insurance policies and explain how these and other supplemental insurance options (e.g., insurance plans for retirees) work with Medicare.

These programs also provide information on long-term care insurance and, when needed, refer beneficiaries to agencies such as the Social Security Administration and local Medicaid offices for additional assistance. Many SHIP counselors are volunteers who are trained and certified to help navigate systems for older adults and some people with disabilities.

We at Connelly Law Offices encourage you to contact your local SHIP office and make an appointment if you have insurance questions. Click on the logo below to find the SHIP office in your state.

A Final Thought on Medicare Advantage Plans

"According to Federal law, whatever we see or hear in an advertisement must be truthful and not misleading. I spent some time the last few days closely watching several different commercials," stated Attorney Connelly. "Everything that was said about the cost and benefits was true, to the extent that it was said. But there was so much more left unstated or understated and unfortunately, that’s the important information you need in order to make a smart decision about your Medicare plan. Being an educated consumer is the best way to avoid making a wrong choice or being the victim of a scam. In our blog, we listed a number of resources that can help with this, and we encourage you to learn as much as you can prior to making your choice."

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