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Part D

Diabetes and Medicare Advantage

Differences between Original Medicare vs. Medicare Advantage

If I have diabetes, should I choose Original Medicare or Medicare Advantage?

The answer to this question depends on how important individualized care is to you.

Medicare Advantage plans are typically bundled, all-in-one plans that are made as a ‘one size fits all’, with a prescription drug plan included.

However, Original Medicare is set up for you to choose a supplement plan along with a prescription drug plan tailored to your individual needs.

The American Journal of Managed Care published a study pertaining to the difference in treatment of diabetes between Original Medicare and Medicare Advantage.

In the study, they concluded that in order to achieve savings, Medicare Advantage enrollees are more likely to be treated with cheaper medications, such as Metformin and Sulfonylureas, rather than receive costly, newer medications, compared to Original Medicare. This means Original Medicare affords you the opportunity to have the drugs that might best suit you.

In this video, we review the study and explain some of the differences between Original Medicare and Medicare Advantage. We also discuss why this decision is so important if you or someone you know has diabetes and are searching for the best plan.

If you would like help finding the best Medicare plan for you, please reach out. Our help is 100% FREE to you.

2021 Medicare and You Book

The 2021 Medicare & You Guidebook is available and you can download it here.

When downloading the digital version, it will open in your Acrobat document reader, or in your browser. A tip for finding what you want, instantly, is to hit the Control and F button at the same time on your keyboard. This will bring up the FIND feature in your reader. 

Then, type in a word or phrase you are looking for. The reader should show you how many instances of that word or phrase exist in the entire book and you can click the down arrow to move from the first to the second, and so on.

This is how we zero in on things such as the Special Election Periods, Trial Right scenarios, Guarantee Issue Periods, and more. 

The 2021 Medicare & You book is slightly less controversial than those in the past. CMS (Center for Medicare and Medicaid Services) has been leaning more and more toward promoting Medicare Advantage plans and this bias has started to come through in their Medicare guide book.

In 2018, the non-profit Medicare Rights Center, in a joint letter with the Center for Medicare Advocacy and Justice in Aging, wrote a letter to the Administrator of CMS urging corrections in the proposed guidebook for 2019. 

They stated, “First, in several places, the Handbook suggests that Medicare Advantage is the less expensive alternative for beneficiaries. This is an overstatement. There are many variables determining whether enrollment in a Medicare Advantage plan may be more or less expensive for any particular Medicare beneficiary…. The repeated suggestion that Medicare Advantage can save beneficiaries money does not fairly represent these realities.”

The letter went on to point out that various descriptions throughout the book give the false impression that the benefits of Original Medicare are the same as the benefits in Medicare Advantage.

When the guidebook was first read by many of our clients, they found it to be confusing, contradictory, and inaccurate to their experience with Medicare. This again points to the benefit of using an independent Medicare professional who can interpret the realities of Medicare and how it works in the real world. This only comes from experience.

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Medicare Advantage Investigation by OIG | Denials For Profit

Medicare Advantage Practics Draw Scrutiny from HHS


The Office of Inspector General (OIG) for the Department of Health and Human Services (HHS) has published the findings of an investigation into claims denials for members of Medicare Advantage Plans. The report concluded that there is a profit motive, stating specifically, “A central concern about the capitated payment model used in Medicare Advantage is the potential incentive for MAOs to inappropriately deny access to services and payment in an attempt to increase their profits.”

 

Medicare Advantage plans are becoming a popular choice for seniors as they enter Medicare years (65 year’s old) and often has a monthly premium of $0. The monthly premium is subsidized by the government’s payment to private insurance companies who then manage the care the senior receives. The incentive to closely scrutinize what is approved for care is what amounts the insurer’s profit – that is, the difference between the government’s monthly pay for the senior’s care, at a fixed rate, versus the actual cost of care provided.

 

Most seniors joining Medicare Advantage plans are aware that there are usually network limitations and restrictions on providers where they can seek treatment. This is the most recognized trade-off for a very low, or even zero monthly premium in comparison to original Medicare and a Medicare Supplement, which pays what Medicare does not pay, typically 20% of medical costs. Unlike original Medicare, however, the restrictions put in place on most Medicare Advantage plans go beyond merely agreeing to abide by a network of contracted providers and having co-payments when services are utilized.

 

The OIG study found that during 2014-2016, Medicare Advantage plans overturned 75% of their own preauthorization and payment denials, overturning approximately 216,000 denials each year. Even more, denials were overturned when the beneficiaries went further into the appeals process, beyond the first stage. The report states, “The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided.”

 

The alarming conclusion of this study points to the fact that only 1 percent of denials were appealed to the first level during the examined period. This means that 99% of denials to beneficiaries went unchallenged and those services were just not provided. When 75% of appeals were ultimately won by the beneficiary, it would appear that most beneficiaries are not aware of the success rate or the appeals process at all.

 

At the Senior Savings Network, seniors are shown the options available to them when they are joining Medicare. These options include original Medicare and a Supplement, which offers the freedom of choice to visit any doctor and any hospital that accepts Medicare; or a Medicare Advantage program with its inherently unique set of network and procedure conditions. The Medicare Supplement route means that the senior can travel from coast to coast, without restriction, and there are no significant deductibles, pre-authorization procedures, or maximum out of pocket concerns when seeking the care their chosen physician feels is best for them, as long as the procedure is deemed medically necessary by Medicare.

 

While the Medicare Advantage network can be searched to see if the beneficiary’s doctor is within the network, that network can still change during the plan year, as doctor and hospital contracts are not always calendar-year contracts and providers can choose to leave the networks. A provider leaving the Medicare Advantage plan in the middle of the plan year does not provide the beneficiary with a Special Election Period to change plans. In that scenario, the beneficiary must stay in the plan and simply choose a different plan-authorized doctor or hospital. A recent story from the Mississippi Clarion Ledger on October 29, 2018 “Hospitals Dropping Medicare Advantage agreements leaves patients in lurch” reported, “North Mississippi Health Services CEO Shane Spees recently told the Northeast Mississippi Daily Journal that only 4 percent of his company’s patients use Humana Medicare Advantage, but they account for 85 percent of payment denials for all payers.

 

The benefits within a Medicare Advantage plan, as announced at the beginning of the year are fixed for the duration of the calendar year, but not beyond that one-year period. This means that a member of a specific Medicare Advantage plan who signed up for a set premium (or no premium), after finding out that their favorite doctor is in the network might find that the next year the premium, co-payments, and provider networks have changed. This is announced in their “Annual Notice of Change” received by the members in October which outline what changes will happen to their program on the next January 1.

 

Conversely, with original Medicare and a Medicare Supplement plan, the benefits of the Supplement are guaranteed renewable. This means that the benefits are guaranteed not to change in the future as long as the premiums for that plan continue to be paid. This provides more certainty with regard to the future benefits of their chosen plan. While the monthly premiums can change, the benefits and freedom to choose any Medicare doctor or hospital from coast-t0-coast, does not.

 

In their audit, the OIG recommends that the Center for Medicare & Medicare Services (CMS) “enhance their oversight of Medicare Advantage contracts, including those with extremely high overturn rates and/or low appeal rates, and take corrective action as appropriate.” It was also recommended that CMS implement strategies to communicate with beneficiaries in a clearer way about the appeals process available to them. The Medicare Advantage appeals process can be quite daunting and has various layers of complexity.

See the video:

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