番茄社区

Physicians and their practice staffs approach this time of year with dread. It's inevitable that some patients will show up for appointments expecting their Medicare Advantage plan coverage is the same as it was last year, that their doctor is still in network, and that they'll pay zero or a very low co-pay.

But many will be surprised when they're told, "We're sorry. There has been a change."

That change could be that their doctor is no longer in their MA network, either because the plan changed contracts, the doctor's practice withdrew, or the patient -- sometimes without knowing it -- is now enrolled in a different plan.

Or it could be that the doctor is still in network, but certain non-Medicare covered services offered last year, such as coveted "extra benefits" -- for example, routine podiatry -- are no longer covered.

Or their co-pays have risen, some by $15, others $55.

Deadline: March 31

Between now and March 31, MA enrollees can change plans. So it's important for patients and caregivers to check the plan's fine print, including whether prescription drugs are still in the plan formulary, and whether the drug prices have changed. The allows one to compare MA plans.

While the plans should notify beneficiaries of upcoming changes, those notices may have been missed, or were forgotten.

It's particularly important to check benefits this year because many MA plans -- in response to that are expected to from Medicare -- are that will result.

Some plans may have already started cutting. There may be higher co-pays for Medicare services or new limits on "extra benefits," like transportation or home-delivered meals.

Doctors Should Check, Too

Perhaps the task of regularly checking benefit changes shouldn't fall just on beneficiaries and their families.

Martin Serota, MD, an internist who practiced for 25 years in California, said that doctors have a role to play. Even though it's more work, it's a good idea for practices to verify coverage before the beginning of each plan year, during re-enrollment periods, and especially before the patient comes in for an appointment, he said.

Certainly re-check plan benefits when the patient arrives, he said. "If you wait until the patient has taken time off or made arrangements to come in, and you have to tell them they're no longer covered for that service, it's too late."

"Yes, it's a lot of work for the practice but otherwise, they may not find out the patient wasn't covered -- or should have paid a much higher co-pay -- when the claim comes back several months later. That can be frustrating and awkward for both the patient and the practice," he said.

He suggested that practices post notice of plan changes in exam rooms.

James Grisolia, MD, a neurologist in San Diego, said that at the start of every year, "we meet patients and their families who are blindsided by insurance changes they don't understand. All of a sudden, they went from Medicare or a commercial PPO to an HMO product and have no blessed idea that they need permission from the PCP office to see a longstanding consultant, whether cardiologist or neurologist or podiatrist."

"The disappointments and snafus are slowly filtering in," Grisolia said.

Sticker Shock

Some plans have reduced many benefits in 2024.

Among 10 plans serving one California county, there are dozens of reduced benefits, noted one counselor for the Health Insurance Counseling and Advocacy Program (HICAP), a federally-funded, unbiased service that helps beneficiaries make informed plan choices. Some 2024 plans now charge $45 more for an emergency department visit or have reduced by half the number of covered acupuncture and chiropractic visits. Ambulatory surgical service co-pays rose 39% in one plan.

A plan offering a quarterly credit for over-the-counter products reduced the amount from $50 to $30. A co-pay for ambulance transport went from $100 to $140. The same plan is paying $50 less for eyewear.

Sophie Exdell, program manager for the San Diego HICAP, said a lot of surprised and upset patients have called the program since January 1.

A major issue, she said, is access to the desired physician. A new plan didn't have the same doctor or medical group in network, or extra benefits like dental or hearing coverage were no longer offered. Exdell said a common problem is that enrollees didn't see that the plan's drug formulary had changed, and now their prescriptions are a lot more expensive.

A 2022 found that nearly half of MA beneficiaries reviewed their plan offerings each year during the re-enrollment period, and even fewer compare their plans with other offerings, or compare prices of their prescription drugs.

Too Many Choices

Older beneficiaries are the least likely to check, perhaps because plan options are so numerous, the report suggested. Now, according to a Medicare Payment Advisory Commission , the average number of choices has increased from 27 in 2020 to 43 this year.

It's confusing, because there are so many ways benefits can change, said David Lipschutz, an attorney for the non-profit Center for Medicare Advocacy. While the plans are required to give an annual notice of changes, "most people don't read that and make the assumption that things are going to stay the same."

"Plans can change their networks, their formularies, their cost sharing, their prior authorization rules. Every year, the plan makes business decisions about what they provide and who they contract with," he said.

Of course, knowing exactly what kind of specialists one will need in advance of a diagnosis requires a crystal ball. KFF's program director for Medicare policy, Tricia Neuman, author of that 2022 KFF report, acknowledged consumers have to check network status for all of their providers, including specialists and hospitals.

The task "is easier said than done and takes some legwork," she said. It also isn't foolproof.

"Provider directories are sometimes out of date, may be riddled with errors, and may list physicians who are not taking new patients," she said.

It's often the case that an MA plan enrollee with a complex diagnosis discovers they need more intense services from research and teaching hospital systems, which often aren't in MA plan networks. From now until March 31, they can switch to traditional Medicare, and purchase a a separate Part D drug plan for prescriptions.

But that can be expensive. Traditional Medicare only covers 80% of costs and hospitalization episode has a co-pay of $1,632, which they have to pay. They can try to purchase a Medicare supplemental plan, which requires a separate monthly premium, to pick up those costs. But patients with common pre-existing conditions such as cancer or heart failure or a recent hospitalization may be rejected in 46 states.

Comment