The Risks of Medicare Advantage Plans

December 16, 2016
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When choosing where to get Medicare benefits, an increasing number of seniors are opting for the lower out-of-pocket costs of Medicare Advantage plans rather than private healthcare or the government-run Medicare. The Wall Street Journal reports that, while the lower costs may be enticing, it is important to weigh the risks associated with these plans.


Medicare Advantage plans offer seniors an alternative to private insurance and government-run Medicare. Typically run by health maintenance organizations, these plans offer seniors hospital and medical coverage, and sometimes prescription-drug coverage, dental care, or benefits such as gym memberships. The caveat to applying for one of these plans is that members will only see decreased costs for using in-network doctors and hospitals.


When researching whether a Medicare Advantage plan is right for you, it is important to research the size and composition of the hospital networks within the plan. However, the providers of these plans do not make researching easy. The network directories for many Medicare Advantage plans are often confusing, contain incorrect information, or are outdated. A report by the Henry J. Kaiser Family Foundation found one plan directory comprised of 600 pages without an index or table of contents.


The Kaiser Family Foundation report comprised data of over 409 Medicare Advantage plans to determine the scope of the networks. A plan including more than 70% of a county’s hospitals were defined as broad networks, between 30%-69% were defined as medium networks, and below 30% were narrow networks. The report indicated that only 23% of the studied Medicare Advantage plans had broad networks, 61% had medium, and 16% had narrow networks. However, the report found that some plans within the narrow network classification get good ratings from the Centers for Medicare and Medicaid based on other criteria.


The Congressional Budget Office reported that approximately 30% of the Medicare population enrolled in an Advantage plan in 2015. The number is expected to increase to 40% by the year 2025. While the plans offer additional benefits such as gym memberships and dental coverage, seniors should also consider the increased risk of significant expenses for out-of-network doctors. The Centers for Medicare and Medicaid Services (CMS) are attempting to address the concerns of many seniors.


CMS currently examines provider networks for the accuracy of listings, when they expand to new geographic areas. The agency also investigates complaints, changes of ownership, or termination of a large provider. In 2017, CMS plans to expand their regulation by requiring providers to provide their entire network for review before seeking to expand. Even with this regulation in place, it will be important for seniors to do their own research when choosing a right plan. However, due to the difficulty of predicting future specialty care, this research may be difficult for many seniors.


The Long Island-based elder care coordinators of Tully Law, PC recognize the stresses associated with navigating long-term care. Although Medicare generally does not cover costs of assistance with daily tasks, chronic and custodial needs, New York Medicaid is available to help pay for these services. The dedicated lawyers at Tully Law, PC are available to help you or your loved one plan and apply for New York Medicaid. Our office is conveniently located in Melville to assist New York City, Nassau and Suffolk County residents with their Medicaid planning and application needs. Contact us today at (631) 271-9804.

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