Medicare vs. Advantage Medicare

By Dr. Ronald S. Dubin

Guest Columnist

Quick! What are the most annoying repetitive non-political commercials currently being played on TV? For me it is those stupid condescending commercials for Medicare Advantage plans by Humana and other health insurance companies.

For those over the age of 65, many of us will be eligible for Medicare Insurance. Just before you qualify for this, before your 65 birthday, you will begin to receive tons of promotional letters, emails and magazines from all the private insurance companies who contract with the Federal Government to sell you their brand of senior healthcare called Advantage Medicare. Their TV ads inundate you around the clock on how easy it is to qualify, the "wonderful" and all inclusive "products" you can get at one "affordable" low price. Several of the TV commercials last longer than the usual 60 seconds.

Study these ads, tape them and replay them. Note what they tell you and review what they don't. The alternative to these Medicare Advantage plans is straight Medicare or commonly called Medicare. Both plans are funded by the federal government, however, Medicare is the federal government's program for seniors while the Advantage plans directly contracts with the government and administers their own plans, regulations, and what is or is not covered. Their contract pays the same per person they insure. Their hidden motives are to insure as many people as they can and then deny as many services as possible to increase their profit margins. This is problem number one! Deny, deny and more denials. Limit the services they provide as well as limiting the number of physicians that are accepted in their plans or pay them less to limit the number of physicians. More on this later.

Just before you turn 65, you will start to receive voluminous emails, letters, pamphlets, phone calls and the like from Advantage plans. The TV commercials themselves will dominate your attention while watching TV. Guess what? Medicare will send you nothing, naught, zero. So off the bat looking at the advertising alone, which program appears the most attractive? I'm not sure about you but anything overpromoted and overpromising and under transparencies are programs I tend to run away from.

The next concern I have and again not told to you in their promotional material are the limited number of provider networks and the requirement that the Advantage plans stay within their network of providers. And guess what, these plans negotiate their fees to the providers and try to get the best deal they can from the practices in the network. Many of the best providers won't accept these arrangements. Most providers and medical groups in the US do accept Medicare. Medicare is a fee-for-service and the payment to providers is variable based upon the location of the country and cost of living expenses. There are usually no prior approvals authorization requirements under Medicare where the Advantage plans do have this.

Want your hip replaced for arthritis? Medicare will allow it without any prior authorization. With the Advantage plans, they might or might not accept you having the surgery and will depend on many requirements which are too varied to discuss in this article. In other comparisons between Medicare and Medicare Advantage plans:

Referrals: Referrals by your primary care providers to specialists can be complex in Advantage care plans depending on the need for the referral and the specialist involvement in your plan. With Medicare, seeing a specialist is as simple as a phone call by your provider (or you if the specialist does not require a referral).

Complexity: Medicare is straight forward. Most all procedures are covered, they identify the payment structure to the providers and again no pre-approval is necessary. Each Advantage plan is different and their rules can be confusing making it harder to understand their benefits. This is especially true when those people who are applying for it are senior citizens.

Out-of-State care: Medicare is everywhere. Every hospital in the US accepts this. Most providers everywhere accept it. When you travel out-of-state you might find it difficult to get your Advantage to pay for anything except true emergencies which are usually covered.

Major problem with Medicare Advantage Plans: Excessive prior authorization, denial rates, and slow payments from insurers, limited providers, higher copayments, difficulty with referral.

Major problems with Straight Medicare are the costs with additional plans: Part A provides inpatient/hospital coverage. Plan B covers outpatient and physician office visits. Both Plan A and B are typically covered in Medicare. The following plans are optional and associated with additional costs. Plan C is the plan that refers to Medicare Advantage (discussed above). Plan D covers prescription drug benefits. Plan G covers coinsurance for hospital costs and physician office expenses associated with Plan A and Plan B. It also covers hospice care, three pints of blood and skilled nursing coinsurance. So to use Medicare and have full coverage, you must pay for the additional plans which, for some people, might be out of their price range.

Limited Provider Networks: Many Advantage plans require members to use a network of doctors and hospitals. If you go outside this network, you may face higher costs or no coverage at all.

Prior Authorization Requirements: Some services and treatments may require prior authorization, which can delay access to necessary care.

Higher Out-of-Pocket Costs: Although some Advantage plans often have lower premiums than Original Medicare, they may have higher deductibles, copayments, and coinsurance for certain services.

Coverage Limitations: While MA plans may offer additional benefits (like dental or vision), they may also have more restrictions on services compared to Original Medicare.

Plan Changes: MA plans can change their benefits, premiums, and networks annually, which might lead to unexpected costs or the need to switch plans

Complexity: The variety of Advantage plans and their specific rules can be confusing, making it harder for beneficiaries to understand their coverage and options.

Travel Limitations: If you travel frequently or live in multiple locations throughout the year, you might find it challenging to get care covered outside your home area.

Referral Requirements: Some MA plans require referrals to see specialists, which can add another layer of complexity and delay in receiving care.

Complexity: The variety of MA plans and their specific rules can be confusing, making it harder for beneficiaries to understand their coverage and options.

Travel Limitations: If you travel frequently or live in multiple locations throughout the year, you might find it challenging to get care covered outside your home area.

Referral Requirements: Some Advantage plans require referrals to see specialists, which can add another layer of complexity and delay in receiving care. Medicare

So, deciding on what plans to choose, either Medicare Advantage or straight Medicare, you must decide which is the best plan for you and your family and what you can afford. Judge carefully because you have a lot riding on it. Most people will be senior citizens approaching the age of 65 knowing that as you age, you will be depending more from the healthcare juggernaut. My belief is that straight Medicare is a better plan for my wife and I mostly to be able to choose my own doctor and for better protections as we travel more during our retirement years. For others, this might not be that important and the better comprehensive care associated with the Medicare Advantage plans at a cheaper cost might be the road best traveled.

Ronald S. Dubin, M.D.

President, Kentucky Orthopedic Clinic

Middlesboro – Corbin, Kentucky

[email protected]

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