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By Carla Anderson
Medicare Insurance Center Contributor
Enrollment in Medicare Advantage plans has grown significantly since the mid-2000s. The first part of the growth spurt is generally attributed to higher reimbursement rates from the government, which in turn has enabled the plans to offer more supplemental benefits to attract Medicare beneficiaries.
While reimbursement rates were cut by the 2010 Affordable Care Act, beneficiaries continue to enroll in Medicare Advantage plans. Insurance companies warn that premium increases and dropping enrollment are coming, while HHS projects an 11 percent increase in enrollment and slightly higher premiums for 2013.
According to the Kaiser Family Foundation, 13.1 million Medicare beneficiaries were enrolled in Medicare Advantage plans in 2012. That’s about 25 percent of all people covered by Medicare.
Medicare Advantage – or Medicare Part C as it is also known – is an alternative to Original or “traditional” Medicare. Medicare Advantage covers Medicare Part A (hospitalization) and Medicare Part B (outpatient services) – everything that Original Medicare covers – through private insurance companies rather than the federal government.
The only exception is hospice care, which is covered by Medicare Part A even for those enrolled in Medicare Advantage plans. Medicare Advantage plans may also offer supplemental benefits like vision or dental coverage, and most include prescription drug coverage.
While more people are choosing Medicare Advantage plans, not all are pleased with their choices. A 2012 study by The Commonwealth Fund reported that 15 percent of Medicare Advantage enrollees rated their insurance fair or poor, as compared to six percent of beneficiaries enrolled in traditional Medicare.
Provider access problems – Provider access problems include a variety of situations. The vast majority of Medicare Advantage plans are HMOs or PPOs, meaning they use a network of doctors and other providers. In some instances, beneficiaries may not be aware of the network requirement before enrolling in the plan. A particular doctor may drop out of the plan’s network, so subsequent visits to that doctor would no longer be covered or be covered at a different rate. A beneficiary may be diagnosed with a new condition and want to see a new provider who is not part of the plan’s network.
Sales and marketing abuses – Each year, thousands of Medicare beneficiaries file complaints about insurance sales agents. According to a 2010 report by the Health and Humans Services Office of the Inspector General, some agents were found to provide misleading information, use high-pressure sales tactics, and sign beneficiaries up for plans without consent.
Coverage denials for medical care or prescription drugs – Claims may be appropriately or inappropriately denied. The plan may not believe a procedure or treatment is medically necessary, requiring justification from the provider. In some cases, beneficiaries may have misunderstood the plan documents that spell out what is and is not covered. Sometimes, a claim is denied due to a mistake – such as being submitted without all necessary details or a coding error (meaning the plan thinks a different procedure was performed instead of the actual one).
High costs – Beneficiaries may be dismayed by a hike in premium cost from one year to the next or by high cost-sharing (deductibles, copays or coinsurance).
If you’re unhappy with your Medicare Advantage plan, you can make a change at certain times during the year.
Remember, despite the issues listed above, 85 percent of people enrolled in Medicare Advantage plans are satisfied with their plans. By doing your homework, odds are good you can find a plan that’s a better fit for you and join the ranks of satisfied customers.
You can switch to a different Medicare Advantage plan during annual open enrollment. The exact dates for the open enrollment period have varied from year to year; the open enrollment period for 2013 ran from Oct. 15 to Dec. 7, 2012. The dates are widely published each year well in advance of the open enrollment period. Visit medicare.gov or call 1-800-MEDICARE (1‑800‑633‑4227). TTY users can call 1‑877‑486‑2048. If you sign up during the open enrollment period, your coverage with a Medicare Advantage plan will be effective Jan. 1.
You may also be able to switch plans at other times for certain special situations – for example, if you move to an area not covered by your current plan or you become eligible for other coverage. Visit Medicare.gov to read about Special Enrollment Periods and 5-Star Enrollment.
If you wish to leave your Medicare Advantage plan and return to Original Medicare, you can do so during the Medicare Advantage Disenrollment Period. The disenrollment period runs from Jan. 1 to Feb. 14 each year. As Original Medicare does not cover prescription drugs, you also have until Feb. 14 to join a prescription drug plan.
If you go back to Original Medicare during the Medicare Advantage Disenrollment Period, your coverage will be effective the first day of the next month. So, if you leave your plan on Feb. 10, your Original Medicare coverage will begin March 1.
Posted January 16, 2013
Editor's Note: Opinions expressed on these pages are those of the individual author(s) and do not necessarily reflect the views of the management or ownership of healthinsurance.org.
If you wish to leave your Medicare Advantage plan and sign up for Original Medicare, you can do so during the Medicare Advantage Disenrollment Period. The disenrollment period runs from Jan. 1 to Feb. 14 each year. As Original Medicare does not cover prescription drugs, you also have until Feb. 14 to join a prescription drug plan.
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