If your practice is like mine, an increasing percentage of your patients have Medicare Advantage (MA), rather than traditional Medicare fee for service (FFS). If you are like me, you have been frustrated with the inability to get their Medicare “Advantage” plan to pay for treatments that Medicare covers (like cellular products). But not being able to provide certain types of care is not the worst of it.
The worst of the problems I have with Medicare Advantage plans is that I have patients who tell me that they can’t undergo things like a debridement or a compression bandage because their co-pay is too high and they can’t afford it. If a patient can’t afford the basic interventions that are needed to treat their wound, then I am wasting time and resources to see them at all.
One of my most challenging patients is a retired RN with 30 years of Hospital Nursing experience who has also worked in the insurance industry. She has several really serious, chronic medical conditions that have left her completely wheelchair-bound. Unfortunately, she gets recurrent, painful leg ulcers. She understands how insurance authorization works, but she also understands wound care. At nearly every visit, she told me a tale of frustration with her Medicare Advantage insurance plan, including the impact on her out-of-pocket expenses. I thought that it would be enlightening to have someone with her credibility provide a detailed explanation of the challenges she has faced as a chronically ill person with Medicare Advantage. I am not foolish enough to think that anyone at CMS will listen, but it could serve as a warning to other patients.
I hope Patricia will blog whenever she has another tale of the Medicare Disadvantaged.
Tales of the Medicare Disadvantaged
I became eligible for Medicare before age 65 due to a disability. Since traditional Medicare fee for service (FFS) covers 80% of healthcare costs, I tried to get a Medicare Supplement Plan to cover the other 20%. However, since I was under age 65, these private supplemental insurance plans could charge me any rate they wanted to charge. The best price I was given for a Medicare SUPPLEMENT was $900 per month, which of course, I could not afford being disabled and retired. That’s why I choose a Medicare Advantage (MA) plan initially.
The MA plan sounded like a really good deal. The premium was $15 per month and there was no deductible for medications. Initially I thought the plan was great until I needed a cellular product (“semi-synthetic skin”) for a wound on my ankle. The Medicare Advantage plan would not authorize any cellular product because they said they are considered experimental. They also do not pay for compression garments, even for patients with an open venous ulcer.
However, when I called CMS to ask if they covered cellular products, they said they do, and that they pay for a compression garment for the leg which has the wound. Per Medicare – The Medicare Advantage Plans are supposed to cover what Medicare covers, but clearly they do not. Medicare Advantage Plans do offer exercise programs, a hearing examination and sometimes hearing aids, dental and vision benefits, but they did not offer the treatments that I needed.
Although the monthly premiums for MA are low, they don’t tell you how much you will pay in copays and out of pocket expenses for the things they don’t cover. Last year in 2020 (not including Pharmacy Cost ), I paid $4,000 in copays over a 10 month period, most of which was to handle a recurrent and hard to heal wound on my ankle. When you divide that by 10 months that’s $400 per month. Folks that is entirely too much money.
Let’s talk about that $4,000 that I paid in copays with my Advantage plan (which does not include the Medicare Premium):
- A Hospital Inpatient stay was $1680, and that had to be paid prior to discharge
- An MRI copay was $300 as an outpatient
- Copays for doctors and wound care treatments must be paid at the visit
I am on a limited budget. When I initially started the Advantage plan, I was not as sick as I am now. I thought I’d just see my doctors for checkups and if that had been the case, that would have worked great. Medicare Advantage works great as long as you are not sick.
This year, now that I am 65, I have the choice of staying on a Medicare Advantage plan or changing to traditional FFS Medicare. You can see why I changed to traditional Medicare FFS. My Medicare Supplement is costing me $127.40 (it does go up 3% to 5% annually after 3 years to a max of $287). That is still a lot cheaper than an Advantage Plan with the copays and out of pocket, and this means I am better able to budget my money.
As an aside, I could have chosen the Medicare “Plan F,” although they are no longer taking members, because my Medicare was assigned to me before 2020. The upside of that plan is that there would be no deductible of $198. However, I did not choose Plan F because premium increases are based on amount of usage of the plan. Insurance companies want a balance of younger Medicare patients (or at least patients who are not as sick) in their mixture, to keep cost down. If plan F is closed – no younger health members can get on the plan – and the plans may charge the higher premium.
The Medicare Advantage Plans do sound great. They tell you that you get Dental, Hearing, Eye Benefits as well as Exercise programs, rides to doctors’ offices, and free meals. But look at the fine print. In the long run, if you are a “user” of healthcare, the costs begin to add up. You may find, as I did, that it is cheaper and more budget-friendly to have traditional Medicare FFS and buy a supplement plan.
Patricia Han, RN
Former Medicare Advantage beneficiary
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Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
I have found in my home health setting that the supplies needed for wound care are covered (if the wound and supplies meet the criteria in the LCD) but the vendor i use limits which ones I can actually get stating “that isn’t covered” (meaning the reimbursement and their contracts dont cover their costs and profit margin) and so i then just go somewhere else. There are too many DME’s out there to limit our patients. We use all effort to try and get the products needed. In summary though, we pretty much abhor managed care now!