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 The So-Called Medicare Advantage Plan 

The So-Called Medicare Advantage Plan

By Judith S. Parnes, L.C.S.W., C.M.C

Medicare Advantage Plans are health plan options that are a component of Medicare and were created along with the Medicare drug benefit as a result of the 2003 Medicare Modernization Act. If you join one of these plans, you generally receive all your Medicare-covered health care through that plan, which can include prescription drug coverage.  Under the Medicare Advantage Program, the Centers for Medicare and Medicaid services approves private companies to offer programs to Medicare enrollees as an alternative to the original Medicare coverage with deductibles, sometimes called Medicare part C. The premiums or costs of services (co-pays) can be lower in a Medicare Advantage Plan because it provides all traditional Part A (hospital) and part B (medical) coverage without needing to purchase a supplemental “Medigap” policy.  This does then appear to be an “advantage”.  

However, the privatization of the Medicare Advantage Plan has caused much confusion as well as a lack of available information in regards to the right to appeal claims, lengthy delays in the process, and sometimes the necessity of using an experienced advocate to navigate the process.  The volatility of a Medicare drug benefit available only through private insurance companies translates into fluctuating plan premiums, drug prices, formularies, and utilization management restrictions. And,  most enrolled in the Medicare Advantage Plan are locked into the specific option they choose for one year, regardless if they realize they made a mistake.

 Studies show that patients under Medicare Advantage have been denied further days of care, which seems to be based entirely on avoiding any more expense to the companies and not on the medical needs of the patient.  According to a recent survey, almost all nursing facilities and home care providers that were questioned indicated that they were advising their patients to go back to original Medicare where beneficiaries would receive more treatment. This certainly is our recommendation as well when assisting clients and their families. Understanding eldercare needs and insurance coverage typically does not become an issue until the “insurance” is needed. It is unfortunate that it is not until that time that most people become more educated.

For now, enlisting outside assistance to clarify various options may be extremely helpful.  Comprehensive elder care agencies can offer helpful information that can help you and your loved ones select the most appropriate plan that can best cover your needs.

 

Judith S. Parnes, L.C.S.W., C.M.C., Gerontologist And Elder Care Consultant is Executive Director Of Elder Life Management, Inc., Ocean, NJ.  They provide quality elder care planning and management services to older adults and their families. Please visit www.elderlifemanagement.org or call (732) 493-8080 for more information.