Is Medicare Advantage a Good Choice for Amputees?

Medicare Advantage has been in the news a lot lately. And not in a good way.

Early this year, a disability rights group denounced the deceptive marketing of Medicare Advantage plans, which for-profit insurers offer as a cost-saving alternative to traditional, government-run Medicare. That came on the heels of a shocking report from the Medicare Payment Advisory Commission (MedPAC, a nonpartisan Congressional oversight agency) showing that Medicare Advantage insurers overcharged taxpayers by $124 billion between 2008 and 2023. Meanwhile, the American Hospital Association urged MedPAC to scrutinize Medicare Advantage plans’ sky-high rates of delayed and denied healthcare.

It all led medical professor and patient advocate Cheryl Kunis to start mocking Medicare Advantage as “Medicarelessness.

That’s not to say traditional Medicare is perfect. If it were, we wouldn’t have seen such a stampede toward Medicare Advantage, which has captured roughly 50 percent of the market since its enactment in 2003. And, to be fair, Medicare Advantage offers some clear benefits compared to standard Medicare, including cheaper premiums, annual out-of-pocket expense caps, and options for dental, vision, and prescription medicine coverage.

But consumers increasingly are finding that you get what you pay for. And Medicare Advantage’s lower costs frequently translate into lower convenience and lower standards of care—especially for people with ongoing, complex healthcare needs.

Before you choose Medicare Advantage over standard, government-run Medicare, be sure to consider some of the downsides that have been flagged by people with disabilities:

1. Limited provider options

Many Medicare Advantage plans only cover in-network healthcare providers, and the networks are often quite narrow. If you have great relationships with your prosthetist, PT, mental health counselor, and other clinicians, it might be difficult to find a single Medicare Advantage plan that includes all of them in-network.

2. Referral requirements

Medicare Advantage plans routinely require a physician’s referral or insurance authorization before seeing a specialist. If you want to see a dermatologist for a skin problem, you’ll have to vist your primary care physician first, delaying your care by days or weeks. And if your plan calls for prior insurance authorization, the wait may stretch into months.

3. Denied care

A federal audit found that, in 2019, Medicare Advantage insurers denied authorization requests and payment claims about 15 percent more often than government-run Medicare. A study by the Kaiser Family Foundation found that Medicare Advantage care denials tripled between 2020 and 2022.

4. Medical necessity

As a general rule, government-run Medicare has more generous interpretations of what’s “medically necessary” (and therefore covered) than Medicare Advantage plans. If you require a high-end prosthesis that provides more than basic function, your might be advised to stick with regular Medicare.

5. Misleading marketing

Disability rights advocates in Connecticut complained about Medicare Advantage advertisements implying that the plans were part of the regular Medicare system, rather than separate, for-profit alternatives to the government program. Others stated that confusing, vague, or outright false information induced them to chose an Advantage plan.

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