Is Medicare there for those who need it?

Facts about Medicare Advantage plans you never saw in the TV ads

Annual enrollment is past; if you are a healthy senior and can take advantage of the “free” fitness membership some programs offer, then you will probably be happy with your Medicare Advantage program.

On the other hand, if you are a senior with some health problems, you may not be so happy. Even though you may not pay a monthly premium or pay a very low monthly premium, you will be hit with primary visit co-pays (up to 20% of the doctor’s fee), specialty visit co-pays (up to $30), four levels of co-pays for medications, and Hospital co-pays between $250 and $350 per day for the first four hospital days. There will also be restricted networks of hospitals and doctors, denials of service and, in some cases, denials of payment for a service that would have been paid for under traditional Medicare.

An investigation by the Inspector General of the Department of Health and Human Services in 2019 found repeated examples of care denials that coding experts and independent physician reviewers found were medically necessary. They estimated that 85,000 beneficiary requests for prior medical care authorization were potentially improperly denied in 2019. You may find that a denied whole-body MRI scan may cost you $2,499. However, you may be happy to know that Medicare has placed a limit on what a Medicare Advantage participant must pay “Out-Of-Pocket.” For 2023 this annual in-network limit is $8,300.

Where do the Medicare Advantage programs get their funds? In addition to premiums and co-pays, the Medicare Advantage program is paid by the Medicare Trust Fund about $1200 per month to “manage” and “provide” your care. Where does the Medicare Trust Fund get this money? It is funded by a payroll tax you pay every two weeks during your career.

Recognizing that some members in any Advantage program may be sicker than others, Medicare instituted a “Risk Adjustment” system based on multiple diagnoses in 2000. Since then, a whole industry has emerged to scan medical records, hire nurses for home visits and develop specific software programs; all to identify additional diagnoses to enhance payment.

Medicare has also implemented quality bonuses and a “Star” system to provide more money to the Medicare Advantage programs. This “Risk Adjustment” system has been fraught with documented fraud and abuse. In a federal audit in 2021, Humana was found to have overcharged Medicare $200 million. As noted in a recent NYT article, four of the five most prominent players in the Medicare Advantage business (UnitedHealth, Humana, Kaiser and Elevance) have faced federal lawsuits alleging that efforts to overdiagnose patients have crossed the line into fraud. The Federal Medicare Payment Advisory Commission’s 2022 report to Congress found that at least $12 billion in over-payments were made to Medicare Advantage plans in 2020 alone.

If you are upset by this abuse of your Medicare tax dollars, I suggest you call the U.S. Capital switchboard at 202-224-3121 to speak to or leave a message for either of our Senators and your Representative to voice your concern.

So, during your first year in your new Medicare Advantage program, you be the judge of actual cost and value to you. If it does not meet your medical needs, or your financial situation, know that during this first year, you can switch to traditional Medicare with supplemental insurance (Medi Gap) without penalty. You cannot be denied supplemental insurance, and there will be no underwriting.