What are the Problems With Medicare Advantage Plans?

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For services not covered under traditional Medicare, a patient has several choices. One of the most popular is to receive benefits through a managed-care plan called Medicare Advantage, which is offered through various insurance providers. These policies are generally less expensive than Medicare plus a Medigap supplemental policy. Definite problems have surfaced with the Medicare Advantage plans, though. State departments of insurance monitor the managed-care plans for their populations, and dissatisfactions can be reported to them.

Limiting Health Care Providers

The Health Maintenance Organization is the least expensive but most restrictive type of Medicare Advantage plan. HMO members may receive care only from the HMO's network of doctors, except in emergencies that occur while out of the member's area. If a plan member uses a provider outside the network, the plan will pay nothing. And since the member has left traditional Medicare, that program will not contribute to the bill either.

Blocking Referrals or Discharging Early

Although many senior citizens need specialist care, HMOs encourage the member's primary care physician, who is paid less than a specialist by the plan, to take care of most medical problems. At the least, the patient must be referred to a specialist by the primary doctor, and the physician must get approval from the plan before making the referral. Another frequent complaint about Medicare Advantage plans is that doctors are pressured to limit the length of hospital stays for their patients who are enrolled in the plans.

Dropping of Providers or Geographic Coverage

Instability is a risk whenever signing up with a managed-care plan. Doctors are sometimes dropped because the plan thinks they are making too many referrals, or the physicians decide to end their contracts with the plan because of the restrictions to their practice of medicine. Medicare Advantage plans also have a history of dropping coverage in entire states or geographic areas with little notice.

Rate Hikes

The government does not regulate the premiums and co-payments charged by Medicare Advantage plans. They are subject to change at any time. Raising co-payments for specific services, like prescription drugs, or suddenly charging a premium for the first time are common practices, as is cutting back on coverage or restricting access to certain medications.

Joining A Different Plan After Being Dropped

You may join another managed-care plan covering your county if the new plan has not reached a preapproved membership limit. However, you may do this only during a "Special Election Period" each year between Oct. 1 and Dec. 31.