Medicare Advantage: Is The Name Accurate—or Misleading?
History of Medicare Advantage
Medicare started in 1965 and started paying for dialysis and transplant in 1973. At that time, patients were enrolled in Original Medicare with the U.S. government as the payer. Medicare Advantage plans, also called MA plans or Medicare Part C, were first offered in 1997. People on dialysis were excluded from these MA plans—out of concern that the focus on containing costs by managing care might leave those on dialysis vulnerable, with limited access to essential specialist care and treatment.
The Medicare Modernization Act of 2006 extended MA plans to include three types of special needs plans (SNPs):
D-SNPs for people who had both Medicare and Medicaid
I-SNPs for those with Medicare would in nursing homes or psychiatric facilities
C-SNPs for those with any of 15 chronic conditions, including ESRD
SNP coverage started in 2006, and dialysis patients could join a C-SNP if one served the area where they lived. For years, few C-SNPs accepted dialysis patients. The nonprofit Medicare Rights Center that helps people with Medicare has a short video about MA plans.
Medicare Advantage and ESRD
The 21st Century Cures Act passed in 2020 opened the flood gates for those with ESRD to enroll in MA plans starting in 2021. CMS required all MA plans to accept any dialysis patient who applied. During open enrollment that year, more than 40,000 ESRD patients switched to an MA plan: enrollment of ESRD patients in MA plans grew from 22.7% to 30.3%.1
Each year, ads for MA plans flood the airwaves and print media, especially during the Annual Election Period from October 15-December 7, when people can choose health (MA) and Part D drug plans and during the MA Open Enrollment Period from January 1 through March 31, when people can switch MA plans or switch back to Original Medicare. MA plan ads use “celebrities” who encourage people to choose an MA plan, and often show the government issued Medicare card and tell people to call a number that is not the Medicare number. Seniors have complained that these ads are confusing. They warn people to enroll before they lose out on extra benefits in MA plans that may be more limited than what people are led to believe.
While MA plans must cover all services Original Medicare covers and MA plans can offer extra services, e.g., vision, dental, and hearing, they can also limit where someone can get care and may require referrals and prior authorization, and can make their members jump through hoops to get coverage. CMS requires MA plans to have sufficient providers of other types within time and distance limits of members’ homes—but it no longer requires MA plans to have sufficient dialysis clinics within time and distance limits of members who are on dialysis.1 So, patients may have to travel long distances to get the type of dialysis they want or even to get dialysis at all.
Medicare Advantage Complaints
CMS has received many complaints about confusing and misleading advertising and coverage denials. A 2022 Office of the Inspector General report describing results from an investigation of 15 MA plans in 2019 found that 13% of MA plans’ prior authorization denials and 18% of MA plans’ payment denials were for Medicare covered services.2 These kinds of denials delay access to care putting patients’ health at risk.
I was curious about the experience of dialysis patients and social workers with MA plans, so I posted a message to social workers in my CNSW chapter area, to the NKF’s CNSW listserv, and to members of the Home Dialysis Central Facebook group. Below are responses I received.
The Good:
“My husband has been on an Advantage plan since before he started dialysis. It has worked very well for him. He meets the out of pocket maximum around April, and pays nothing else the remainder of the year. The OOP max changes from year to year, but it has only gone down the last 3 years. And there are no premiums. He was in the hospital 3 times early this year and met the OOP very quickly…this year the OOP max is $3500. We would probably pay that much for premiums with a traditional plan. He has had no difficulties getting coverage.”
Spouse of Home Dialysis Patient
The Bad:
“From my patient experience, multiple MA plans offer dental, food vouchers, transportation assistance, and other benefits that draw patients to enroll. However, the caveat is once patients enroll in the plan, the transportation assistance is usually short-term like six trips, which wasn’t explained in advance. The vouchers are limited as well. Let’s not forget, the promised 100% coverage later results to 90% or a little lower. All of these factors upset the patients once the patients realize they’re not provided promised services.”
Dialysis Social Worker
“I can’t tell you all the times I’ve had a patient ask me if the ads they’ve seen about Medicare Advantage are legit, if they should consider an MA plan, etc. I’ve had patients change over to a MA plan only to find out that not everything they needed to be covered still was. These have mostly been in-center patients.”
Dialysis Social Worker
“The things I’ve heard the most are:
Sometimes Part D is better coverage than the MA plan drug coverage.
Most MA plans only cover dialysis at 80%, leaving the patient with 20% coinsurance to pay until they meet their out of pocket maximum.
Plans may not be available where they live, especially rural areas although that seems to be getting better.
We’ve had some patients revert back to original Medicare.”
Former Dialysis Social Worker
“I believe that (hospital name) that operates the 2 dialysis centers has withdrawn from all Medicare Advantage plans. I read about it on some article online, talking about the issues with MA…slow payments; arduous authorizations; denials, etc.”
Former Dialysis Social Worker
“I’ve just always been told never to choose one. If you have straight up medicare and a supplement, medicare has strict rules about coverage. But the advantage plans are run by private companies who can choose what to cover and need to make a profit.”
Home Dialysis Patient
“Wouldn’t have one if you paid me! I was a financial counselor for a hospital for many years and had to fight hard to get payment for the patients that chose these plans.”
Home Dialysis Patient
“When my husband was receiving proton beam therapy for prostate cancer, we met people who were paying out of pocket for their treatment because their Medicare Advantage plan wouldn’t cover it. Medicare paid 80 percent, and our gap insurance paid the other 20.”
“We had one first 2 years of dialysis not an issue he was approved for transplant from plan and we didn’t have an issue. we are moving so felt safer switching to regular plan.”
Home Dialysis Care Partner
“AKF got me an MA plan that is wonderful, no deductible on anything and 100% coverage, but it comes with part D for prescription coverage, and basically covers nothing. I got a free 30 day (drug name) card given to me, and it says it’s good for Medicare recipients, but pharmacy said it’s rejected because I have part D. I have a tough time getting meds that aren’t part of the dialysis bundle. (Drug) is $400 a month and I can’t get it. I’ve applied for free programs and can’t get approved.”
Home Dialysis Patient
“Straight Medicare is the way to go if you have chronic medical issues. The Advantage plans are basically bartering your medical care away. With straight Medicare you can go to any doctor you choose, and pre-authorization is not required. I get turned down for nothing, because I don’t even have to apply. Now there are some things that Medicare doesn’t cover period, no matter what type of Medicare you have. They’re not giving you a facelift, ya know? But medical care—yeah, it’s covered.
And Almost every doctor on the planet accepts it. Major players like the Mayo Clinic won’t even accept Advantage plans. They’re not an advantage for the patient or the hospital. They’re an advantage to the insurance company, because they limit your health to save them money. Why do you think there are so many? They’re all insurance companies fighting for a piece of the pie and they want to make money off of you. They’re even giving flex cards now.. money you can use for anything and it doesn’t take a rocket scientist to figure out that they can’t get their little monthly premium that you pay for Medicare, and pay for your medical care and then still give you cash back to buy other things…so how they doing it? By stinting on your medical care. You get less care, period. The money has gone into flex cards.
Advantage plans are for the very healthy, that person who goes to the doctor once every eight years. If you have chronic illness, you better have straight Medicare and a supplement. Covered 100%, never post a penny for medical care. That’s the way to go.”
Home Dialysis Patient
“It’s such a scam – all about the insurance companies making a buck, and slick marketing, making you think that free hearing aids, dental and vision make up for good health care. IMHO no one on dialysis should be in a MA.”
Home Dialysis Patient
“I don’t see the advantage when most of them were charging ME more for copays than I paid when my visit was with straight Medicare. The ‘mother may I’ system doesn’t work when you have chronic illnesses and most of your doctors are specialists.”
Home Dialysis Patient
The Ugly:
“My PD patient was just given Medicare (effective 1/1/24) and he picked up a MA (effective 5/1/24) plan but it does not go retro. As a result, he has no secondary coverage for the first 4 months of the year.”
Dialysis Social Worker
“Rehab stays are difficult to be approved. Transplant drug approval can be difficult, as multiple PAs are sent back and forth while the patient is without.”
Transplant Social Worker
“Humana has HMO plans with very limited networks because providers do not like (the) contract and it can be hard for those patients to get care. We’ve had issues with discharging after transplant when patients with MA plans need a lower level of care but are not ready to go home yet. It is not just Humana though. I have heard patients express frustrations about how none of their providers are in-network with their plan. They may still be able to see those providers, but their cost is significantly higher. I have also heard patients state that some providers refuse to see them with OON (out of network) benefits, but that is usually because there are no OON benefits for that MA plan.
“Transplant is unique when it comes to contracting. Most big payers (Aetna, Cigna, BCBS, Humana, UHC) have their own transplant center of excellence network and require or strongly steer insured to use those transplant providers. This applies to the Medicare Advantage plans. Smaller payers and third party administrators (TPAs) usually pay the Transplant Centers of Excellence networks to access their network. For example, a TPA (name) might access the Aetna National Institute of Excellence for transplant contracting. So, while the Medicare Advantage plans have to cover transplant since Medicare does, they can deny it at an out-of-network provider or make it cost the patient a lot more due to the out-of-network benefits.
For those who cannot get enrolled into a Medigap and do not have group health or full Medicaid, the Medicare Advantage plans can be beneficial and their best option to be fully insured for transplant because they have out-of-pocket maximums. MA plans are enticing because they come with ‘extra benefits’ like grocery debit cards but those benefits come and go and depend on funding from the government. The plans usually offer dental and vision coverage. MA plans also have network restrictions and patients will have fewer options where they can go for various services. We’ve had issues with trying to discharge to skilled nursing, rehab, or home health for patients with MA HMO plans because there are no providers that contract with their plan. We’ve had many patients contacted by agents via phone or at their doorstep who were convinced to switch to a plan without fully understanding the difference. Patients have reported to me they were told ‘nothing will change with your coverage and you’ll have added benefits.’
| Medicare Advantage Pros | Medicare Advantage Cons |
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Transplant Financial Counselor
Filing a Complaint about an MA or Part D Plan
Medicare has information on filing a complaint along with a link to the form on its website, and recommends contacting the plan to file a complaint. The MA plan’s card and website has information about the steps to file a complaint.
Conclusion
Choosing a Medicare health or drug plan is complicated. As the saying goes, buyer beware. It’s important to take time and research the options. However, people on dialysis may not have the time or the energy to read the fine print. If a patient needs help, consider suggesting that they contact their State Health Insurance Assistance Program (SHIP). To locate a specific SHIP click here. SHIPs receive federal dollars to help people choose the best plan to meet their individual needs. SHIP staff and volunteers receive CMS training. SHIP personnel provide unbiased one-on-one help and are not paid based on what plan they help someone enroll in. On the other hand, agents and brokers get compensation (and sometimes bonuses or even vacations) from MA plans when they enroll a new person in an MA plan or renew their enrollment. CMS changes for 20253 may limit the incentives agents and brokers have had to steer people into MA plans, but only time will tell whether those changes will help to rein in practices that put the agent/broker’s financial gain over Medicare beneficiaries’ needs and whether there will be fewer complaints.
Avalere. ESRD Enrollment in Medicare Advantage Now Exceeds 30%. October 20, 2023. https://avalere.com/insights/esrd-enrollment-in-ma-now-exceeds-30-percent-of-all-dialysis-patients↩︎
United States Office of the Inspector General. Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care. https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf↩︎
Centers for Medicare & Medicaid Services. Contract Year 2025 Medicare Advantage and Part D Final Rule (CMS-4205-F). April 4, 2024. https://www.cms.gov/newsroom/fact-sheets/contract-year-2025-medicare-advantage-and-part-d-final-rule-cms-4205-f↩︎
Comments
Julie Williams
Jun 20, 2024 9:30 PM
Another fun fact - Many of these MA plans will not cover immunizations given by your dialysis unit, they require you to go to your PCP.
To put it in plain terms - the Medicare ESRD PPS is based on COST so when the MA plans claim that they will contract with your dialysis unit for the MEDICARE rate, you are basically contracting for 80% of the Medicare rate. The 2024 ESRD PPS bundled payment is $271.02 (which is much less in the midwest and rural areas like Arkansas and Missouri after they reduce it be the geographic wage index) and then your dialysis unit gets paid 80% but they are unable to get your Medicaid, coinsurance, patient payments, etc. for the MOOP your patient signed up for. The hard fact is - you are essentially GIVING the patient that amount in FREE MEDICAL CARE.
$271.02 is the COST of providing dialysis and this is based on the costs from 2 years ago, it does not even reflect the current higher costs, post COVID. As the % of MA plans grows (currently > 45% in the midwest), it is sickening when you calculate that you are now trying to provide care when you are getting 80% of the Medicare rate for 45% of your patients. The MA plans have figured out how to essentially make your dialysis unit pay for your MOOP. So they win all the way around which is why they TARGET the dialysis and CKD population. CMS is not allowed to "interfere" with the MA Plans management and there is no oversight of these despicable practices.
It is truly evil and our patients are paying the price.