By Kate Ashford | NerdWallet
Slightly greater than half of Medicare-eligible individuals are enrolled in Medicare Advantage — however hospitals across the nation have been dropping Medicare Advantage plans as a consequence of points with prior authorizations and denials. Hospitals and well being techniques in at the very least 11 states introduced in 2023 that they’d be out-of-network for some or all Medicare Advantage plans in 2024, in accordance with reporting from Becker’s Hospital Review, a medical business commerce journal.
“It’s a real problem for people,” says Katy Votava, who holds a doctorate in well being economics and nursing and is president and founding father of Goodcare, a consulting agency centered on the economics of well being care. “This has always been a problem, but it’s getting worse. It’s not only the reimbursement rates, but the approvals have become so onerous for providers to deal with.”
Why are hospitals dropping Medicare Advantage?
Among different issues, Medicare Advantage plans require sufferers to get prior authorization for extra companies than Original Medicare. Prior authorizations require time on the a part of a medical supplier, and the requests aren’t all the time profitable.
“It’s not like you get paid more to compensate for the fact that you spent all this doctor time jumping through hoops,” says Melinda Caughill, co-founder and CEO of 65 Incorporated, which presents steerage on Medicare. “Essentially, it is a huge money loser for medical practices.”
Nilsa Cruz, an administrator and affected person advocate at a rheumatology apply in Milwaukee, remembers spending two hours attempting to succeed in an insurance coverage consultant to advocate for a affected person. “Many of the critical administrative and clinical functions have been outsourced by these plans,” she says.
Medicare Advantage corporations say prior authorization has advantages, however they’ve taken steps to ease the burden on suppliers and sufferers. UnitedHealthcare, as an illustration, introduced final 12 months that it could remove virtually 20% of its prior authorizations. “Prior authorizations help ensure member safety and lower the total cost of care, but we understand they can be a pain point for providers and members,” mentioned Dr. Anne Docimo, chief medical officer of UnitedHealthcare, in a press launch.
Hospitals are additionally annoyed by administrative delays and denials for care. In October 2023, St. Charles Health System in Oregon introduced it could be dropping three Medicare Advantage suppliers in 2024. “We care deeply about our patients and the care they receive, which is why we are unwilling to continue with the status quo with Medicare Advantage plans that result in restrictions to patient care, longer hospital stays and administrative burdens for providers,” mentioned Dr. Mark Hallett, chief medical officer for St. Charles, in a press launch.
It doesn’t make medical sense for suppliers to have to return to insurance coverage corporations a number of instances, Votava says. “The cost of doing that — which is, by the way, extremely wasteful — it doesn’t gain anybody good care.”
How huge a difficulty is it?
If your most well-liked hospital stops accepting your Medicare Advantage plan, you may need to make a change. Tens of hundreds of Medicare Advantage beneficiaries in California, as an illustration, needed to scramble to change their insurance coverage or their suppliers when well being care system Scripps Health introduced that two of its medical teams would not take Medicare Advantage in 2024.
“Scripps tried to negotiate with private insurers for reimbursements that would cover our costs but was unsuccessful,” mentioned Scripps spokesperson Janice Collins in an e-mail.
If your hospital system drops your plan and there isn’t one other Medicare Advantage plan that works for you, chances are you’ll be in a predicament: You can change again to Original Medicare throughout sure enrollment intervals, however chances are you’ll not be capable to get an inexpensive Medicare Supplement Insurance, or Medigap, plan.
Except in a couple of states, Medigap is “guaranteed issue” — that means an insurance coverage firm should give you a plan and never cost you extra for pre-existing well being circumstances — just for six months that begin if you’re at the very least 65 and signed up for Medicare Part B.
Medigap covers lots of the out-of-pocket prices that include Original Medicare. Without Medigap, Original Medicare may be expensive. “For Original Medicare to work most effectively, you need a Medigap policy,” Caughill says.
What can sufferers do?
Although Medicare’s fall open enrollment interval has ended, Medicare Advantage open enrollment runs from Jan. 1 to March 31 every year. During that point, Medicare Advantage enrollees can change plans or return to Original Medicare.
If you’re outdoors of an open enrollment window, you may be capable to make the most of a 5-star particular enrollment interval, which lets you change out of your present Medicare Advantage plan to a 5-star plan in your space. You can do that as soon as between Dec. 8 and Nov. 30 of the next 12 months. “That hinges on whether you have access to a 5-star plan,” says Meredith Freed, senior coverage supervisor for the Program on Medicare Policy for KFF, a well being coverage assume tank.
Do your analysis earlier than leaping to a different plan, although. “If you’re considering switching because you’re concerned about having access to a specific provider or hospital, I would suggest calling [the provider] to make sure they’re in-network for any plan you’re considering,” Freed says.
If you’re outdoors of open enrollment and also you don’t qualify for a particular enrollment interval, you’ll have to attend for the following open enrollment interval to vary plans — except you progress, which Caughill calls the “nuclear option.”
“When you move, you have a Medicare do-over,” Caughill says. “You just have to move out of your Medicare Advantage plan’s service area.” Not solely can you modify Medicare Advantage plans should you transfer, however you’ve gotten one other probability to enroll in Original Medicare and a Medigap plan with assured challenge rights.
The caveat: You do have to truly transfer — not simply fake you’ve moved. “Don’t commit insurance fraud,” Caughill says.
This article was written with the assist of a journalism fellowship from the Gerontological Society of America, the Journalists Network on Generations and the Silver Century Foundation.
The article What to Do if Your Hospital Drops Your Medicare Advantage Plan initially appeared on NerdWallet.
Source: www.bostonherald.com”