Sick Patients switching to traditional Medicare near end of life

[FIREd_2015]

"...A Wall Street Journal analysis of Medicare data found a pattern of Medicare Advantage’s sickest patients dropping their privately run coverage just as their health needs soared. Many, like Greene, made the switch after running into problems getting their care covered...As recipients get sicker, though, they may have more difficulty accessing services than people with traditional Medicare. That’s because the insurers actively manage the care, including requiring patients to get approval for certain services...the inspector general that oversees the Medicare agency analyzed a sample of Medicare Advantage denials and found that 13% of them actually met Medicare coverage rules and likely would have been approved if the patients had been enrolled in government Medicare...

https://www.wsj.com/health/healthcare/medicare-private-plans-insurers-389af1a0?st=Xr2ScX&reflink=desktopwebshare_permalink

 

[Spock]

"BuT MeDiCaRE AdVaNtaGe iS tHe SaMe aS MeDiCaRe"

 

[Tadpole]

Death doesn't wait for approval but waiting until someone dies to process authorizations does save a lot of money.

 

[Rianne]

Read that article yesterday. There's only a few states you can change without medical underwriting. We have the birthday rule in IL but we have to stay with our insurance co and would probably move to plan N from plan G if it gets too expensive. Thanks to the many posts on this forum and advice from others, we didn't even think about choosing MA.

 

[athena53]

I saw that, too. I've never been a fan of Medicare Advantage and neither has my friend who answers calls from Medicare beneficiaries as a government contractor- and yet I think nearly half the people on Medicare choose Advantage plans. They're attracted by low premiums and "window dressing", as we used to call it in the insurance business, such as some "free money" for groceries, gym memberships and a little dental and vision coverage. It's also sold aggressively. Just two days ago I saw a commercial in which a wife was pitching Advantage plans to her husband because of all the freebies. (I'm spared most because I watch only commercial-free streaming at home.)

Really rotten that the Advantage insurers attract members but then make life difficult for them when they need them and they're thrown back into the traditional Medicare pool- if they can afford the premums.

 

[aja8888]

Not a great article, very little discussion about medical underwriting requirements in order to switch out of MA to traditional Medicare. Very difficult (or impossible) if you have certain pre existing conditions. The people who buy MA plans have choices and can shop all options.

My friend who sells Humana medical plans (all types) says 9 out of 10 people who inquire about MA plans ask the question (first one) "what do I get for free?"

 

[MichaelB]

I didn’t see the article mention MediGap or Medicare Supplemental plans. It also didn’t address what happens with drug coverage, which is included in many (most?) MA plans.

 

[Jerry1]

I didn’t see the article mention MediGap or Medicare Supplemental plans. It also didn’t address what happens with drug coverage, which is included in many (most?) MA plans.

I didn’t see the article either, but I’m confused about some of the above statements. Does Part A or B have medical underwriting if you leave to an advantage plan and then come back? I thought that was only for the gap coverage. I’m guessing the pharmacy wouldn’t be an issue since you did have credible coverage with the advantage plan. I assume if you’re really sick and given that is underwritten, you probably couldn’t even get gap coverage.

 

[aja8888]

I didn’t see the article either, but I’m confused about some of the above statements. Does Part A or B have medical underwriting if you leave to an advantage plan and then come back? I thought that was only for the gap coverage. I’m guessing the pharmacy wouldn’t be an issue since you did have credible coverage with the advantage plan. I assume if you’re really sick and given that is underwritten, you probably couldn’t even get gap coverage.

In many states if you have an MA plan (coverage by an insurance company for A, B and D), you will have to pass medical underwriting to go back to traditional Medicare. If you get lucky and pass, and get back on traditional Medicare, you can then buy a Medigap (supplemental) policy to cover the 20% of costs Medicare will not cover, and you can also buy a Part D plan for medications.

 

[MichaelB]

I didn’t see the article either, but I’m confused about some of the above statements. Does Part A or B have medical underwriting if you leave to an advantage plan and then come back? I thought that was only for the gap coverage. I’m guessing the pharmacy wouldn’t be an issue since you did have credible coverage with the advantage plan. I assume if you’re really sick and given that is underwritten, you probably couldn’t even get gap coverage.

You don’t need underwriting to go from MA to traditional Medicare. You do need underwriting to enroll in a MediGap plan after being in MA (with a few exceptions that don’t apply here).

 

[Koolau]

When I first went on medicare, my Megcorp-supplied broker sorta "talked" me out of MA, by detailing the advantages and disadvantages. At first MA sounded kinda good, but it was clear the broker was warning me of the issues that can make it a "trap" (my words.) I was in pretty good health at the time and MA would have saved me money (at the time.) I'm so glad I didn't fall for it but YMMV.

 

[aja8888]

You don’t need underwriting to go from MA to traditional Medicare. You do need underwriting to enroll in a MediGap plan after being in MA (with a few exceptions that don’t apply here).

Correct, Michael, brain fart on my part. Yes, you can get back on Medicare from an MA plan, but then will be faced paying the 20% Medicare doesn't cover unless you qualify for a Medigap policy. (I must be getting brain dead)

 

[ncbill]

IIRC, those doing so were either in a state where they didn't need to pass underwriting to switch to Medigap.

Or they were on or going onto Medicaid.

 

[Chuckanut]

You don’t need underwriting to go from MA to traditional Medicare. You do need underwriting to enroll in a MediGap plan after being in MA (with a few exceptions that don’t apply here).

And without Medigap one could be liable for filling in some VERY big gaps.

 

[Texas Proud]

Read that article yesterday. There's only a few states you can change without medical underwriting. We have the birthday rule in IL but we have to stay with our insurance co and would probably move to plan N from plan G if it gets too expensive. Thanks to the many posts on this forum and advice from others, we didn't even think about choosing MA.

You can always go back to regular Medicare... you just cannot always get on a supplement plan... which means you pay the 20%...

 

[MBSC]

I didn’t see the article mention MediGap or Medicare Supplemental plans. It also didn’t address what happens with drug coverage, which is included in many (most?) MA plans.

Most are dual-eligible (Medicaid). Others live in states like NY where Medigap plans are guaranteed issue. Being in a nursing home creates a federal Special Enrollment Period (SEP) to switch from MA to OM + PDP.

From the article:

The Journal’s analysis found that people in the last year of life who had access to that type of additional coverage—either Medicaid or Medigap policies—dropped out of Medicare Advantage at far higher rates... At Healthfirst, an insurer in New York, where state law makes Medigap policies far more accessible, 12% of members near the end of life left for traditional Medicare...At Molina Healthcare, an insurer focused on patients with both Medicare and Medicaid, 16% of members quit their plan in the last year of life, the highest rate in the country among large insurers. Both insurers pointed to the large share of their Medicare members who are also enrolled in Medicaid.

Special Enrollment Periods

You change where you live.
I live in ...a nursing home.
What can I do?
* Drop your Medicare Advantage Plan and return to Original Medicare.
* Join a Medicare Advantage Plan or Medicare drug plan.
* Switch from your current plan to another Medicare Advantage Plan or Medicare drug plan.
* Drop your Medicare prescription drug coverage.

When?
Your chance to join, switch, or drop coverage lasts as long as you live in the facility and for 2 full months after the month you move out of the facility.

Special Enrollment Periods

You can make changes to your Medicare Advantage and Medicare drug coverage when certain events happen in your life, like if you move or you lose other coverage.

www.medicare.gov

 

[savory]

We didn’t do my homework when we signed up for Advantage. We will be signing up for plan N this week. We live in a state where we will need to go through underwriting.

We have no ‘yes’ answers on the online survey concerning health issues so I am hopeful we will not have any problems getting back in. It will cost much more as we may have made money this year with Advantage since our premium was zero and they kept giving us money. But the limitation of selecting a preferred health care provider is not worth the savings to us. We are fortunate to be able to have the finances to make that decision however.

 

[jazz4cash]

"BuT MeDiCaRE AdVaNtaGe iS tHe SaMe aS MeDiCaRe"

Serious question. What does it mean when upper and lower case are intermixed this way?

 

[walkinwood]

I am surprised by how many of my acquaintances who can afford Medigap plans instead opted for Medicare advantage.
It makes me question my decision to get a Medigap plan when I'm eligible next year, but then I read articles like this one and believe I'm making the right decision. We do not live in a state that allows a change from MA to Medigap without underwriting.

 

[Rianne]

If you live in one of these states you can change from MA to Medigap G without medical underwriting. It looks like the WSJ article was focused on NY.

States that generally allow moving from Medicare Advantage to a Medigap G plan without medical underwriting include: Connecticut, Maine, Massachusetts, New York, Oregon, Washington, as these states often have "guaranteed issue" provisions allowing policyholders to switch Medigap plans without undergoing medical underwriting, depending on their specific state regulations; some states may also have a "birthday rule" allowing switching around one's birthday each year without underwriting.

 

[Sunset]

And without Medigap one could be liable for filling in some VERY big gaps.

Yes,

But think of all the money the insurance companies save ...

 

[Sunset]

I am surprised by how many of my acquaintances who can afford Medigap plans instead opted for Medicare advantage.
It makes me question my decision to get a Medigap plan when I'm eligible next year, but then I read articles like this one and believe I'm making the right decision. We do not live in a state that allows a change from MA to Medigap without underwriting.

Everyone loves a deal.. and MA sounds like a deal in the beginning.

For us, we can get MA for FREE, from employer, instead we pay for regular Medicare + Sup, an extra expense of ~$3,500 each.

Are we stupid or smart, ask in 25 yrs and I'll have an answer.

 

[flyoverstate]

I will have to choose my Medicare in one year. I already know people who chose Medicare Advantage and are regretting it. For example, one of those people started having neck pain and finger numbness consistent with a bulging or burst disc in their neck. Their provider gave them an appointment NINE weeks out. They literally had to fight at multiple levels to get a specialist exam, which showed that there indeed is a bulging disc, but instead of a discectomy, they are ordering injections and physical therapy. They are at their wits end with the pain and lack of sleep. If they switch back to regular Medicare, they will not be able to get a Medigap policy, and will be on the hook for 20% of a very expensive operation.

 

[Rickt]

I signed up for PLAN G just yesterday. Coverage starts in January, 2025.
I'm Glad I listened to your advice (members of E-R.org) and chose Medigap Insurance instead of Medicare DisAdvantage Insurance policy.

 

[Irishgirlyc58]

I started a thread a few weeks ago about changing from my employer sponsored MA plan to medicare/gap. The MA plan is costly-with the employer contributing less than 10% of the cost but money wasn't the driving reason I thought about and am now leaving the MA plan. I was paying for what someone else referred to as "window dressing". When you dig down into these plans the majority of the plan is covering exactly what Medicare covers. The rest is more "perks" you might use someday but probably you won't. I just didn't see the value and was concerned about being stuck in the MA plan.
I can tell you from talking to people I used to work with (I live in a small town and most of us live and worked here) people have no idea that these MA plans are mostly covering Medicare approved services. Very little is over and above Medicare. But they think it is the MA plan covering.
I guess those years I spent as an analyst early in my career are serving me well!