Medicare Advantage Is Under Fire. What It Means for Your Health—and Wallet

Medicare Advantage Is Under Fire. What It Means for Your Health—and Wallet.

Insurers may cut back on benefits as their profits get squeezed. Why a Medicare/Medigap plan could be a better deal for consumers.

Marcia Mantell won’t be eligible for Medicare for a few years yet. But she’s sure of one thing: Pitchmen like William Shatner won’t be luring her into a Medicare Advantage plan.

“You are nickel-and-dimed to death,” says Mantell, 62, a retirement consultant in Plymouth, Mass. Out-of-pocket costs can add up quickly in the plans, she says. And once you’re in, it’s tough to go back to traditional Medicare. “It sounds on TV like you can switch whenever you want. You can’t. It’s a 30-year decision.”

No one has a crystal ball to see how their health will hold up through retirement. But concerns are mounting about Medicare Advantage, also known as Part C—the insurance plans that manage Medicare coverage for more than 30 million people. Some big players in Advantage —notably Humana —are reporting sharply higher costs and lower profits, causing their stocks to fall. If the trends continue, it could translate to ancillary benefit cuts and more denials of services.

Other pressures on Advantage are mounting. Some large hospital chains and medical providers have dropped Advantage plans, citing low payments and administrative hassles. The federal government is scrutinizing Advantage plans over insurance industry practices that are driving up costs. The Biden administration has also taken aim at Advantage marketing—featuring the likes of Shatner and football legend Joe Namath in TV ads—saying it may be misleading consumers.

4 Responses

  1. Medicare is now forcing my aging mother, who isn’t in very good health, to pick a new pain med out of their junk options because hers isn’t on their formulary anymore. So far, they’ve tried to give her one that no pharmacy in our area carries and doesn’t know if they can even get due to “limited supply”, a well known addiction treatment med that would almost certainly be dangerous for her to take due to her health issues, or another one that didn’t provide adequate, lasting relief due to her ultrarapid metabolizer status. But because she’s been on what she’s currently taking for over a decade and was put on it under the care of a former provider who seemingly didn’t document the meds she’s already tried very well, they have denied the Request for Reconsideration and the appeal to the denial. She doesn’t even have Advantage and it’s still a dumpster fire. My mother-in-law has Advantage and they’ve denied the only med that she was able to find, after a long period of trials, that controls her seizures. I am just about convinced that they’re culling the population, so to speak. It’s absolutely ridiculous.

    • Medicare is forcing her to chose a new med, Doesn’t matter if she has Medicare-D or Medicare-C, they are both provided by a for-profit insurance company. Congress just gives those plans so much $$$/pt/month to take care of what the pt needs. you may want to look into Request an Administrative Law Judge (ALJ) Hearing You do not need any attorney and it costs you nothing except your time. >50% of pt who do this, gets whatever they are seeking to be covered -APPROVED.

      • Yes, I actually spent all of last evening looking over her options. She isn’t in any shape to do all of this on her own, so I’m looking at pretty much every angle for her. I did note an ALJ hearing was an option and I do think we should absolutely give that one a go. It’s her doctor who kind of seems to have thrown hands in the air and determined it was best to “try” her on all of the suggested medications. The one I am DEEPLY concerned about, due to mom’s health issues, is that one of the “suggested” formulary meds is Methadone. I certainly hope her doctor doesn’t think she should try that one, and will take the time to put together evidence that it would almost certainly harm her health (being the phrasing they like to use) as opposed to being of any benefit to her. I apologize, I would have responded sooner, but I didn’t receive notification of a reply even though I had it turned on. Thanks for the input, Steve. I do greatly appreciate it.

        • actually Methadone can be a very good pain med. However, it takes a experienced prescriber to do it safely. First EKG/ECG be ran to rule out any cardiac issues are present.Initial dosing should be titrated up very slowly and EKG/ECG should be ran, and then ECG/ECK ran twice 6 months apart and then ran annually.

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