In 2016 Richard Timmins went to a free informational session to find out how to use Medicare coverage.
“I have listened to the insurance agent and in the end, he advertised Medicare Advantage,” Timmins declares. The agent spoke of less costly and more comprehensive coverage provided through the Medicare Advantage plans, which are funded in large part by the federal government but managed privately-owned insurance firms.
For Timmins who has a 76th birthday, it was logical to join the club. It was a great decision for a short time.
Three years later, however the patient noticed a lesions on the earlobe of his right.
“I have an extended family history of Melanoma. So I was paying attention to it and contemplating that,” Timmins says of the growth that doctors later identified as malignant melanomas. “It began to expand and began to become quite painful.”
Timmins was able to discover that enrolling in an Premera Blue Red Medicare Advantage plan could mean the existence of a small network of doctors, as well as the requirement for approval, or preapproval by the insurer prior to receiving treatment. The experience, he says, made getting care more difficult, and now he wants to switch back to traditional, government-administered Medicare.
However, he isn’t. He’s not alone.
“I have no control over my own medical needs,” he says, noting that he is now advising his friends to not join private health insurance. “I believe that people don’t understand the concept behind Medicare Advantage. about.”
The number of people who enroll of Medicare Advantage plans has grown significantly over the last few years, and has attracted over 50% of people who are eligible mostly those aged who are over 65, by offering affordable premiums and perks such as vision and dental insurance. As the private plan take a bigger share of Medicare pie of patients has risen to 30.8 million, they as are the concerns regarding insurance companies’ aggressive marketing tactics and false claims about coverage.
Participants, such as Timmins who join as they are healthy may become in a bind as they age and become sicker.
“It’s one of those benefits that could be a hit with people at the start due to their low no premiums, and also in the event that they’re receiving some of these additional benefits, like dental, vision sort of stuff,” says Christine Huberty as an expert in lead benefits who is also the supervising attorneys of the Greater Wisconsin Agency on Aging Resources.
“But the moment they really have to utilize it for the bigger problems,” Huberty says, “that’s the time people begin to think that ‘Oh it’s not going to do anything for me. ‘”
Medicare offers private insurers an annual fixed amount for each Medicare Advantage enrollee. Medicare often offers bonuses that insurers may offer additional benefits. Huberty states that these benefits serve as a motivator to “get individuals to sign up for the program” however, plans later “restrict access to many benefits and cover the most important things.”
David Meyers, assistant professor of health practices, policies and services within the Brown University School of Public Health studied the last period of about a decade in Medicare Advantage enrollment. He discovered that around 50 percent of beneficiaries (both urban and rural quit their plan by the time they reached the end the five-year period. A majority of enrollees shifted to a different Medicare Advantage plan, rather than traditional Medicare.
According to the research, Meyers as well as his colleagues suggest that switching plans might be a positive indicator of a marketplace that is free however, it could also be a sign of “unmeasured discontent” about Medicare Advantage.
“The issue is that after you’re enrolled into Medicare Advantage, if you have several chronic diseases and want to quit Medicare Advantage, even if Medicare Advantage isn’t meeting your requirements, you may not be able to go back to regular Medicare,” Meyers says.
Traditional Medicare isn’t cheap enough for people who have switched to Medicare Advantage. adds. In traditional Medicare participants pay a monthly fee and, when they reach a deductible, usually in instances are required to cover 20 percent of the cost for every nonhospital item or service they require. There’s no limit on the amount an enrollee is required to pay in the 20% coinsurance, when they use many services, Meyers says.
To reduce the amount they pay out-of-pocket, Medicare enrollees usually opt for additional insurance plans, like employee coverage, or an individual Medigap policy. If they’re low-income, Medicaid may provide that insurance supplementary insurance.
However, Meyers says, there’s an issue: While those who first enroll in traditional Medicare are guaranteed to be eligible for an Medigap policy, without having to base pricing on their medical records, Medigap insurers may decline coverage for beneficiaries who are transferring to Medicare Advantage plans or base their rates upon medical subwriting.
Four states including Connecticut, Maine, Massachusetts and New York — prohibit insurers from refusing the benefits of a Medigap policy if the person who is enrolled is suffering from preexisting medical conditions, such as heart disease or diabetes.
Paul Ginsburg is a former commissioner of the Medicare Payment Advisory Commission commonly referred to as MedPAC. It’s a legislative branch organization which provides advice to Congress about its Medicare program. He says that the inability of Medicare Advantage enrollees to change from Medicare Advantage or traditional Medicare in open enrollment time is “a serious issue in the system- it should not be this way.”
The federal government provides particular enrollment periods each year to switch plans. During Medicare’s open enrollment period, from Oct. 15 to Dec. 7, enrollees can switch out of their private plans to traditional, government-administered Medicare.
Medicare Advantage members can change plans or move to traditional Medicare in a different open enrollment period that runs starting from January. 1 through March 31.
“There are many people who say, “Hey I’d like to come back, but I’m not able to receive Medigap in the future or I’ll need pay much more in the future,'” says Ginsburg, who is currently an associate Professor of Health Policy of the University of Southern California.
Timmins has been one them. Timmins is a retired veterinarian who lives in a community of rural people situated on Whidbey Island, just north of Seattle. It’s a beautiful, rugged area that is a favorite to rent second houses, hikes, and the arts. However, it’s also isolated.
Although it’s generally harder to locate doctors in remote regions, Timmins says he believes that his Premera Blue Cross plan made difficult to obtain treatment for a variety of reasons, such as the difficulties of finding and getting to consult with specialists.
About half of Medicare Advantage plan directories included incorrect information about the providers that were offered, as per the most recent federal audit. In 2024, all new or expanded Medicare Advantage programs must prove conformance with federal network requirements otherwise, their application could be rejected.
Amanda Lansford, a Premera Blue Cross spokesperson, has declined to discuss Timmins the situation. She claims the plan is in compliance with federal requirements regarding network adequacy in addition to the standards for travel time and distance “to ensure that members aren’t being burdened by unnecessary costs when seeking treatment.”
Traditional Medicare permits beneficiaries to visit almost every doctor or hospital within the U.S., and in the majority of cases, enrollees don’t require authorization to access services.
Timmins who just completed immunotherapy, does not think he’s accepted for the Medigap policy “because of my health condition.” If the chance came up to enroll in it, Timmins says, it is likely to be expensive.
At present, Timmins said, he will continue to use the Medicare Advantage program.
“I’m getting older. More things are going to occur.”
There’s also the possibility, Timmins says, that his cancer might resurface “I’m conscious of my own mortality.”
KFF Health News, formerly named Kaiser Health News (KHN) is a newsroom in the nation which produces in-depth news on health-related issues. It’s one of the primary operating programs of KFF — an non-profit source for research on health policies as well as polling and journalism.
9(MDEwMjQ0ODM1MDEzNDk4MTEzNjU3NTRhYg004))
Transcript:
MARYLOUISE KELLY HOSPIT:
You might have seen lots of advertisements for Medicare Advantage plans.
(SOUNDBITE of RECORDING OF ARCHIVED)
Unidentified NARRATOR: 2024 Medicare Advantage plans are currently available to everyone who is who is on Medicare is able to call to check whether they qualify for Medicare Advantage plan is available…
KELLY The KELLY Medicare Advantage programs are private insurance plans that Americans who are 65 or older may select as an alternative to traditional Medicare. Many Americans are taking advantage of the plans. It’s an open enrollment period starting now and running through March. But, as Sarah Jane Tribble with our partner KFF Health News reports, certain people don’t like enrolling into the program only to find it difficult to leave.
SARAH JANE Tribble: In 2016 when Richard Timmins first signed up for Medicare and Medicare Advantage, he attended an informational seminar for free hosted by an insurance representative.
Richard Timmins: In essence the way he was a proponent of Medicare Advantage. He simply said look, it’s more costly. It’s more comprehensive in its coverage.
TRIBBLE The reason for this is that for Timmins the decision made economic sense to enroll in Medicare Advantage in lieu of conventional Medicare which was a great idea for a short time. He then noticed one small bump on the inside part of his left ear.
Timmins: I have an ancestral background of melanoma. I was focused on that and thinking about it.
TRIBBLE: It took his time to locate the right specialist within the Medicare Advantage network, and getting his paperwork in order was a bit confusing.
Timmins: It was beginning to to increase in size and eventually get quite painful.
TRIBBLE Timmins: By the time Timmins finally met with an oncologist, the tumor was now the size of one dime. The earlobe on his right needed for removal. He believes getting treatment using conventional Medicare could have been more efficient and less complicated as well. David Meyers at Brown University School of Public Health believes it’s likely to be right.
DAVID MEYERS: You are able to consult any physician you wish. There are fewer kinds of limitations on healthcare. You can enjoy a greater degree of freedom when you use the traditional Medicare.
Tribble: Timmins wants to switch, but there’s an drawback.
TIMMINS: Would you reconsider traditional Medicare If it weren’t expensive? Absolutely.
TRIBBLE The traditional Medicare premiums are about $170 per month. While Medicare Advantage plans are still required to have to pay for that cost however, their monthly costs is often lower. This is because those who enroll in the plan do not have to pay for additional prescription insurance. Also, they don’t need to purchase additional insurance, which is usually referred to as Medigap. The need for supplemental insurance comes due to the fact that unlike Medicare Advantage plans the traditional Medicare doesn’t have a limit on the cost of out-of-pocket. However, Timmins may not be eligible for an Medigap policy in the future. This is David Lipschutz, associate director of the Center for Medicare Advocacy.
DAVID Lipschutz: Medigap is one of the insurance types which can deny you coverage due to preexisting health conditions, in the event that you sign up during specific specified times.
TRIBBLE: This time is usually the time you sign up to Medicare. However, since Timmins was enrolled in an Medicare Advantage plan rather than traditional Medicare and is suffering from a preexisting medical problem, he might be denied Medigap coverage or be paid a higher price for it. The law in the United States generally prevents insurance companies from refusing those with existing medical health conditions, Medigap is an exception. Lipschutz again.
LIPSSCHUTZ: It’s much more simple to join and stay in the Medicare Advantage policy, however it’s much harder to exit and sign up for an Medigap plan, based on the location you’re in.
There are only four states that need Medigap insurance companies to cover applicants of all ages and health. However, Timmins is a resident of Washington state and is not one of the four states. He would like people to know.
Timmins: You may get scammed if you’re on Medicare Advantage. The benefit kind of vanishes when you require the benefits.
TRIBBLE Then, Timmins worries. There’s a possibility that his cancer may return and he’ll be a victim in Medicare Advantage if it does. He’s trying to focus on what he can do to prevent.
TIMMINS: I know I’m vegetarian. I don’t drink. I don’t smoke. I try to active as often as I can.
He TRIBBLES: He knows it’s not enough.
KELLY The name it was Sarah Jane Tribble with our partner, KFF Health News.
(SOUNDBITE of MAHALIA SONG “LETTER To U R EX”) Transcript supplied by NPR Copyright NPR.
