As a long-term care provider, what’s your favorite thing about Medicare Advantage? No three-day hospital stay. And not much else.
As a beneficiary of Medicare Advantage (MA), there are plenty of things to like, including low premiums, perks like gift cards and memberships, prescription coverage, etc. Over half of those eligible for Medicare are using the Advantage plans. As long as your 85-year-old mom stays healthy and doesn’t need care, Medicare Advantage is the way to go. But when she needs care in a hospital, home care, or skilled nursing facility, the landscape changes.
We all have stories about the MA patient who had two surgeries, was admitted to the SNF on Friday, and was cut by insurance on Tuesday, even before the follow-up appointment with the surgeon. Why does that keep happening? It happens because MA plans are not government plans; they’re for-profit HMOs that require prior authorization for anything and everything and require the patient to be seen in-network. No contract? No care.
I have recently seen some really appalling ads for MA plans. He’s quietly reading his newspaper with his coffee, and she enters screaming about how he’s settling for regular Medicare and not the Advantage plan they deserve.
Joe Namath, Jimmie “JJ” Walker, William Shatner, and other beloved and trusted celebrities are hawking plans that are never named in the ad, conspicuously and misleadingly displaying the Medicare logo and pounding an 800 number into the brain of the viewer until, as if by hypnosis, the viewer obeys and makes the call.
Those who call that number are led to believe they are calling a government line, but they’re calling a private company or insurance broker. Health and Human Services Secretary Xavier Becerra has called those ads “misleading marketing schemes by health insurance companies that offer Medicare Advantage plans,” and those ads will no longer be permitted after September 30, 2023.
The Senate has been investigating MA denials and has concluded that some private, for-profit insurances that call themselves “Advantage” plans inappropriately restrict beneficiary access to medically necessary services. The umbrella of “prior authorization” is just a means of justifying that restriction.
But on Aug. 10, 2023, United Healthcare announced they are cutting back the prior auth requirement, and Cigna and Aetna may be following (cautious celebrations and religious conversions may occur). The reduced prior auth requirement will not yet reach into the SNFs and will (so far) only affect radiology and some tests, but with the pressure applied by the government, it may soon become the Advantage that the beneficiaries deserve.
One group of physicians in San Diego has terminated their MA contracts, stating that health costs are rising, and reimbursement from those plans isn’t keeping up. The burden of prior authorization coupled with the reduced reimbursement makes accepting these often-inferior plans untenable.
I know from personal experience that I can’t convince someone who loves their MA HMO plan to accept Medicare as their personal savior. Medicare is more expensive, it requires a supplement, it requires Part D, it requires vision and dental, and is overall more trouble.
But given government investigations, the desperation of SNF residents whose insurance has cut their care because of a financial algorithm and not because their care is complete, and our personal experience, it is in everyone’s best interest to ensure the optimal healthcare for those we care for and our loved ones. Now that some of the MA plans are reducing or removing their prior auth requirements, we may actually see some improvement in healthcare and improved benefits.
Once the “Advantage” plans live up to their name, we will see improvement in all aspects of healthcare, better outcomes, and healthier lives.
Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD, is the regional director of therapy operations at Diversified Health Partners in Ohio.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
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