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Trauma Center

Bryan Health does more Medicare procedures than any other hospital in the state, according to data from Dexur.

Senior advocates routinely advise Medicare participants to scrutinize their options during the federal health care plan’s open enrollment period, which runs through Dec. 15, but this year the warnings are taking on some added urgency.

While Medicare officials highlight reduced premiums among Medicare Advantage plans, a recent audit of the Centers for Medicare & Medicaid Services found “widespread and persistent performance problems related to the denial of care and payment,” among the plans, according to the report of the Department of Health and Human Services inspector general. The office reviewed claims denials from 2014 to 2016.

Medicare rights groups, meanwhile, have accused CMS of bias in its 2019 Medicare & You Handbook, saying the annual program guide inaccurately describes portions of the program in an effort to persuade individuals to select Medicare Advantage plans instead of traditional Medicare coverage. Advantage plans are an all-in-one alternative run by private insurers. They can offer lower premiums and wider coverage for things like vision and dental care, but there are tradeoffs, experts say.

“This decision is difficult enough,” said David Lipschutz, senior policy attorney for the Center for Medicare Advocacy. “You don’t need (CMS) promoting one over the other.”

Difficult, indeed. Beyond a dizzying menu of options in many local markets, seniors also need to factor a guess about their future medical needs into the equation. That’s because just four states offer unconditional rights to switch back to Medigap supplemental policies with traditional Medicare, said Gretchen Jacobson, associate director of the Kaiser Family Foundation’s Program on Medicare Policy.

“There are tradeoffs between Medicare Advantage and traditional Medicare,” she said. “Advantage plans do use prior authorizations and more restrictions on getting care than people would face in traditional Medicare, but all Advantage plans have limits on out of pocket spending and often provide benefits not traditionally covered by Medicare.”

Complicating matters even more, she said, is the fact that depending on seniors’ individual health issues, a traditional Medicare and Medigap combination could be cheaper than the Advantage alternative, even while offering more robust coverage. On the other hand, Medigap premiums generally have been rising faster than Advantage plan premiums.

So, how to choose?

When counseling Florida seniors on their Medicare options, longtime volunteer Janet Mills typically begins by asking if they are snowbirds and need highly portable medical care, and how important it is to keep their current doctors.

“A lot of people just don’t want to leave their doctors,” said Mills, a volunteer coordinator with Serving Health Insurance Needs of Elders, a grant-funded program run through Florida’s Department of Elder Affairs.

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Traditional Medicare and Medigap policies are less restrictive on both of those fronts, Mills said.

Carolyn McClanahan, a financial adviser and former physician, agreed.

She evaluates the overall quality of the provider network in a given Advantage plan to help clients through the tyranny of choice. If it’s strong and clients don’t particularly need highly portable coverage, she then drills down on a client’s overall health to help predict future usage needs.

Kaiser’s Jacobson gave an example of when costs might be counterintuitive.

“People who are looking at a lot of care may spend less money with traditional Medicare and a Medigap plan with access to their preferred providers” rather than an Advantage plan, even with the Advantage plan’s out-of-pocket maximums, she said.

“If you’re in a Medicare Advantage plan with a maximum out of pocket of $6,700 versus a Medigap plan that covers all your cost sharing with a monthly premium of (around) $200 a month, you can see how you’d come out ahead” with the Medigap plan, she said. “Whereas, a healthier person with a Medicare Advantage plan may be just fine.”

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