Be wary of the complex pros and cons of Medicare Advantage plans during open enrollment through Dec. 1, columnist advises

Community Health News Service

Along with crunchy leaves and pumpkins, fall brings a slew of advertising for insurance plans that fill the gaps in Medicare coverage.

Misleading and confusing messages continue to reach beneficiaries and those nearing Medicare age. To take myself as an example, I’ve received an invitation to a Medicare Advantage plan informational meeting. I’ve gotten a solicitation from my physician’s medical group offering a “zero-cost, no obligation way to review coverage” online or over the phone. The “review” is likely to bring a sales pitch for a plan.

A mailer from another plan offered “a friendly, money-saving Medicare Advantage Plan” that seemed to promise the moon: savings of up to $2,380 a year, maximum dental coverage of $1,500, and a $750 hearing aid allowance, a drop in the proverbial bucket considering the average cost of two hearing aids is about $4,500. One seller seemed to think I was on both Medicare and Medicaid and pitched a “special needs plan.” Since I wasn’t a candidate for such an arrangement, was the insurer trying to get in the door to sell a regular Medicare Advantage plan?

Too many people fall for those kinds of pitches during Medicare’s open enrollment period, which runs through Dec. 1. Shopping to cover the gaps in Medicare is a task no one should take lightly. The stakes are too high.

Medicare is a fine program, but it was never meant to cover everything. It’s based on the old Blue Cross model of insurance common in the 1960s, where the company paid 80 percent of the medical bill and the patient paid 20 percent. An industry selling “Medigap” policies sprang up to cover the 20 percent, and deceptive sales practices plagued the business for years.

Congress ended that and standardized the coverage into 10 plans (now 11, including a high-deductible option) that give people a broad choice for covering what Medicare does not pay. If people bought Plan F or Plan C as their supplemental insurance, they were pretty much covered for most illnesses.

Beginning next year, however, new Medicare beneficiaries – those who turn 65 on or after Jan. 1, 2020 – won’t be allowed to buy Plan F or C. Congress wants more beneficiaries in Medicare Advantage plans, so it eliminated the option to buy the most comprehensive plans. Lawmakers wanted seniors to pay more for their care.

They can still buy Plan G, which offers the same protection as F except that it doesn’t cover the Medicare Part B deductible, which is $183 next year. People already on Medicare can still buy Plans F or C.

The goal is to push more people into Medicare Advantage plans, a private alternative that is a step toward privatizing the entire program. To move the process along, the government has overpaid insurers to provide the care, which enables them to offer inducements to join. About one-third of Medicare beneficiaries have moved to MA plans, so that strategy seems to be successful.

But does it come at a cost?

Serious questions have arisen about the overpayments the government has made using taxpayer dollars– overpayments that allow plans to offer gym memberships and even Apple watches, as monitoring devices, to new enrollees as one plan is doing. In September six Democratic senators wrote to the Centers for Medicare and Medicaid Services, noting that taxpayers have overpaid Medicare Advantage plans more than $30 billion over the last three years and that CMS has “taken little to no action to correct” the overbilling and overpayments.

Even more troubling, the letter also says that several other government agencies such as the Office of the Inspector General in the Department for Health and Human Services have raised “serious concerns” about Advantage plans that fail to meet needs of older adults and those with disabilities.

The letter raises questions about the kind of care beneficiaries are actually receiving, and notes that Medicare’s own audits have found “widespread and persistent Medicare Advantage performance problems related to denials of care and payment” that “threaten the health and safety of their members.”

Those are government watchdogs raising a red flag about problems getting care when you’re really sick and need good insurance.

Medicare Advantage plan advisers note that traditional Medicare does not put a limit on the amount a beneficiary must pay out of pocket each year, while Advantage plans do – $6,700 for in-network providers and $10,000 for those out of network. They usually don’t mention that a good Medigap policy will cover those amounts, but the premiums may be higher than for an MA plan heavily subsidized by the government.

The trade-off becomes what it does with all insurance: Pay now in the form of higher premiums, or pay later in the form of higher expenses if the worst happens. Insurers seldom mention that tough trade-off when they host those informational meetings for Medicare shoppers.