Is Medicare Advantage Too Good to Be True?

Article originally featured on HME News

In November, at the height of open enrollment season, U.S. Rehab’s Dan Fedor warned complex rehab providers about the Medicare Advantage plans that were being promoted by celebrities in TV commercials.

The first thing providers need to know about these plans: what they’re promising Medicare beneficiaries.

“A lot of (MA plans) are trying to lure (beneficiaries) from traditional Medicare to their MA plan,” said Fedor, director of reimbursement and education for U.S. Rehab, during a Nov. 12 webcast. “They often state there are additional benefits that they give the patients, and we all wonder, how can they provide all these benefits at these lower costs? They sometimes say no out-of-pocket-costs at all. You start thinking, it seems too good to be true.”

Open enrollment started on Oct. 15 and ran through Dec. 7, with CMS touting the average monthly premium for MA plans expected to decrease 11% to $21 in 2021.

One reason MA plans are able to tout lower premiums is because they’re not providing the same services or timely and accurate reimbursement as Medicare – the second thing providers need to know about these plans, Fedor says.

“Providers have to go through hoops and hurdles to receive payment for services,” he said.

While MA plans often say they “follow” Medicare, they’re not required to follow the traditional Medicare’s fee schedules or rules, Fedor says. That may mean, for example, they don’t have a purchase option on complex rehab power wheelchairs, just a rental option.

“While they’re required to offer the same coverage criteria,” he said, “they’re actually not required to follow the same way they process claims.”

The third thing providers need to know about MA plans: Beneficiaries aren’t necessarily locked into them, Fedor says.

“If they get in a situation where they can’t access what they need, they can switch back (to traditional Medicare) until Feb. 14 for any reason,” he said.