Saturday Soapbox: Look closely at the details before enrolling in a Medicare Advantage plan

Medicare enrollment is underway.

I am not a Medicare insurance agent, but I have firsthand experience with family members who used both original Medicare and Medicare Advantage plans. After long hospital stays, both needed nursing care. One family member with original Medicare received care for the full 100 days without a problem.

Another family member, covered by an advantage plan, received nursing home coverage for 14 days before being told, with two days' notice, that coverage had ended. She then faced an immediate bill of $26,000 to remain in the nursing home because she was unable to get out of bed.

We appealed and lost at first, though we were allowed another appeal.

The nursing home was not helpful in providing the documentation needed. It took the medical power of attorney to obtain records from the hospital and other medical providers. We managed to compile the material just within the 45 days allowed for the appeal. The file was about 100 pages long. We ultimately won the appeal.

I do not believe that would have been possible without a nurse in the family who understood how to work through the barriers to getting the information.

I urge caution when choosing whether to enroll in a plan. Although original Medicare and Medicare Advantage both cover medically necessary procedures and care, Advantage plans use different criteria and definitions for what counts as medically necessary. They may also limit which providers you can use and where the coverage applies.

It is wise to check rejection rates for claims and coverage decisions.

Advantage plans often require pre-approval for many medical procedures. After doing some research, I was surprised to find that some companies have claim and pre-approval rejection rates in the 30% range.

There is no magic here. Advantage plans are run by private companies operating for profit. Original Medicare and Advantage plans both involve private health providers.

While Advantage plans may offer lower premiums and extra features designed to attract buyers, I would encourage people to consider original Medicare with a Medicare supplement.

Original Medicare has no geographic limit within the United States, allows you to choose any provider or doctor who accepts Medicare patients, and uses a broader definition of what is medically necessary.

I am saying this not as an insurance agent, but as a consumer who has experienced both options.

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