Medicare Advantage Plans Under Fire

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A Medicare Advantage plan is a one-stop shop alternative to original Medicare. Private insurance companies offer these plans. They contract with Medicare to provide Part A and Part B benefits. They sometimes also offer Part D, which are prescriptions.

But lately, these plans have been under fire by both the healthcare system and the federal government. There’s a demand for more oversight and accountability. Why are these plans being scrutinized? What problems does a Medicare Advantage plan have?

Medicare Advantage Plan Has Limitations

Medicare Advantage plans do not offer the same choices as a Medicare plus Medigap combination. Most plans have a network of doctors and health providers you must use.

The network is in your primary home area. This makes it inconvenient if you have a secondary home in another location. You might find that coverage is denied, or you'll have to pay extra. And that’s assuming a health care provider will take you.

If you need a psychiatrist in a Medicare Advantage plan, you might be out of luck. A Health Affairs study found that almost half of the counties reviewed didn’t have a Medicare Advantage-participating psychiatrist.

Medicare Advantage plans are particularly difficult for people in rural areas since there are even more limited choices.

Saving Money When Healthy

Medicare Advantage plans have out-of-pocket cost maximums—original Medicare does not. And most Medigap plans don’t have an out-of-pocket max either. For example, with Medigap, once you’ve met your Part B deductible, $226 in 2023, nothing more is owed for covered services.

Medicare Advantage plans do limit your annual out-of-pocket costs. This is called the maximum out-of-pocket (MOOP). Once this limit has been met you don’t pay for covered services.

In 2024, Medicare Advantage plan providers cannot set a MOOP any higher than $8,850. This is up from $8,300 in 2023. They can set lower MOOPs, but there’s a relationship between the plan’s price and the MOOP’s amount.

You may have a low premium, but it’s a risky approach to health care. And it can end up being expensive. The goal, if you have a Medicare Advantage plan, is to stay healthy.

Patient Care and AI

Medicare Advantage plans’ prior authorization often results in inappropriate delays or denials. Many Medicare Advantage plans use artificial intelligence (AI) to determine coverage in specific settings.

Under the guise of scientific rigor, insurers are using unregulated prediction AI to determine when they can plausibly terminate treatment. This generally affects older patients.

It has often delayed the treatment of seriously ill patients. These patients are not aware that AI has determined their care. Doctors have disputed many of the AI’s determinations.

Medicare Advantage insurers claim that the AI algorithm provides personalized care and better outcomes. But, many patient advocates disagree. Some AI recommendations fail to adjust for individual patient’s circumstances. There is also a conflict with basic rules on what Medicare plans must cover.

David Lipschutz, associate director of the Center for Medicare Advocacy, made a statement about AI. He said, “There’s no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care.”

A new industry has formed to predict several patient care aspects. They consist of:

• hours of therapy the patient needs
• types of doctors that patients might see
• when patients will be discharged from the hospital or rehab

This technology’s predictions have become integral to Medicare Advantage insurers. So much so that insurers have started acquiring makers of the most widely used tools.

Those insurers that have purchased these capabilities include:

• Elevance
• Cigna
• CVS Health
• Aetna

The biggest company using AI is United Health Group.

Hospitals Dropping Medicare Advantage

Medicare Advantage health coverage is provided to more than half the nation’s seniors. Despite this, some hospitals are dropping some or all of these private insurers’ plans.

Commonly cited reasons include excessive prior authorization rates, denial rates and slow payment. Chris Van Gorder, president and CEO of San Diego-based Scrips Health, said, “It’s become a game of delay, deny and not pay.”

Government Probes Medicare Advantage Insurers

Hearings were held in May 2023 by Congress questioning the country’s largest Medicare Advantage plans. The insurers were told they must abide by Medicare’s coverage rules and can’t rely on AI to deny care.

In a bipartisan effort, Congress asked United Health Group, Humana, and Aetna for internal documents to show how decisions were made to grant or deny access to health care. This included how AI was used.

Government Issues Request for Information

The Centers for Medicare & Medicaid Services (CMS) said that “Americans with Medicare who have managed care plans call Medicare Advantage should not feel like their health care is a black box.” The CMS is looking for transparency with MA plans.

The result is that the CMS has issued a request for information (RFI) from the public. The CMS wants to strengthen its data capabilities and guide policymaking with the information gathered from the RFI.

To participate, go to FederalRegister.gov.

Research Medicare Advantage Plans

For the moment, AI is being used with many Medicare Advantage plans. How long this will be the case may depend on Congress and the CMS.

In the meantime, do your due diligence. Go on the Medicare.gov website or call Medicare’s toll-free number (1-800-MEDICARE). You can also go to the Medicare Plan Finder to compare coverages and costs in your area.

Medicare Advantage plans can end up being expensive if you’re not healthy. Do the research.

The Epoch Times copyright © 2024. The views and opinions expressed are those of the authors. They are meant for general informational purposes only and should not be construed or interpreted as a recommendation or solicitation. The Epoch Times does not provide investment, tax, legal, financial planning, estate planning, or any other personal finance advice. The Epoch Times holds no liability for the accuracy or timeliness of the information provided.