Every year in the fall, people eligible for Medicare are given options on how to use their Medicare benefits. Medicare, as most people know is the government program that you have paid into all your life and helps pay health care benefits to people over the age of 65. The program has seen rising costs over the last several decades because of increased technology and the rising number of people entering the over 65 age bracket. Medicare has now created a program called Medicare Advantage that allows private insurance to take control of your Medicare dollars. This way Medicare pays them to care for you, which helps them control costs and have less financial risk. We now have 3 main categories of Medicare to choose from: Original Medicare, Medicare Advantage HMO, or Medicare Advantage PPO.

Medicare No Longer Means One Thing

Original Medicare covers 80% of the services provided by doctors that participate in their plan. Most patients choose to keep Medicare as their primary insurance and then purchase a supplemental insurance plan to cover the 20% out of pocket costs. Most doctors in this country (Dr. Amundsen included) are Medicare providers but most are not Medicare Advantage or Managed Care providers.

Medicare Advantage HMO plans turn your Original Medicare into an HMO (Health Maintenance Organization) that has limited contracted providers and restricts care. The HMO usually pays doctors significantly less to see you so they are required to see more patients per day to make the same income. This generally means: less time with your doctor and more waiting. To make this work, the panel of available doctors is significantly restricted and requires referrals to see a specialist. We are also seeing some procedures being delayed or not covered. 

Medicare Advantage PPO plan, also referred to as “Managed Care Plan” is also misleading. In the explanation given by Medicare, this is a PPO that you can see any doctor, in or out-of-network – you will still get benefits although there will be a difference in coverage. What they do NOT explain is that if the provider is not in contract with this plan then Medicare will deny coverage and the patient will be responsible for the cost. There is no clear way to know if your provider is able to bill on your behalf unless you call your doctor’s office and ask them directly. 

Private Insurance’s Role with Medicare Advantage Plans

With Medicare Advantage plans many patients choose a private HMO or PPO insurance to become their primary health plan instead. Unfortunately, seniors are often misinformed about their doctors’ participation when they sign up for one of the private plans and the insurance does not cover everything that Medicare can. We have seen an increase in medical claims being denied and then sadly, having to mail the bill to our patients because we are not apart of Medicare Advantage Plans.

Dr. Amundsen’s Thoughts

We have noticed an increase in the number of patients changing from Original Medicare to a Medicare Advantage Plan. We have also noticed that these patient’s coverage has decreased and their patient responsibility costs have increased. For our patients, either Advantage Plan has denied all procedures and office visits – leaving the entire amount billable to the patient. Our concern is growing as our patients are being surprised by extra cost when they thought they had made a wise insurance decision. Choosing an insurance is terribly confusing and it’s hard to know who to trust and what to do.

Our opinion is that the Medicare information is misleading. Patients think they have choices, but for our patients – it has taken away coverage and makes the patient think about compromising their medical treatments because of cost! Clearly the best option, if you can afford it, is to participate in Original Medicare with a supplement and not Medicare Advantage or Managed Care Plans. Don’t take the word of the insurance salesperson or the insurance carrier. We strongly recommend that you call all of your doctors directly before you sign up for a Medicare Advantage Plan to see if they are a participant. We hope you find this information useful for how to choose your Medicare coverage.