An article in Forbes Magazine released last week sums it up wisely: “Older Americans say they feel trapped in Medicare Advantage Plans.” Medicare Advantage plans, also called “MA” or “Part C,” are a heavily advertised class of privatized Medicare-type insurance plans. The government pays a private insurance company a lump sum they have allocated to your care, and the insurance company provides the insurance coverage that Medicare otherwise would. That insurance company can charge additional premiums, and limit you to their provider network, but they can and normally do incorporate additional benefits, such as prescription drug coverage, dental, and vision.

Medicare Advantage plans are attractive because of their ease and similarity to employee coverage that adults are familiar with. You get once card, and you use that for everything. However, as Medicare recipients age and their medical needs grow, they are often subjected to the flip side of what seemed like a good value: Denials of expensive surgeries or treatment residents, and denial or early disapproval of rehabilitation coverage following a hospital stay or surgery. Where Medicare typically defers to medical providers and rehabilitation specialists on what procedures are needed and how long rehabilitation services continue to be appropriate, private insurance companies actively look for reasons to deny or terminate coverage of professionally recommended services. That, and specialized care (or sometimes not so specialized) can be denied in practice due to bottlenecks in any company’s approved provider network.

While Medicare open enrollment ended over a month ago, Medicare open disenrollment extends from January 1 to March 31. During this time, any MedicareAdvantage participant has the right to cancel their private insurance plan, as well as purchase a Part D drug plan and/or Medicare Supplement to go with their new, traditional Medicare coverage. In light of that, here are some things to consider when choosing whether to stay with your Medicare Advantage Plan:

Will I have significant medical bills, or need expensive treatment this year?

In general, seniors who expect to incur significant costs or major treatments/procedures this year should consider dropping to “straight” Medicare. In the case of significant treatments, there is the risk of denial by your private insurer. Additionally, opting out of MA means you can opt IN to a Medicare Supplement, such as Medigap F or G plans, which can help you to limit your exposure to high coinsurances and hospital copays.

Am I at risk of needing nursing home rehabilitation this year?

There are a number of reasons why seniors may anticipate needing rehab care. Fundamentally, older seniors (80+) can lose muscle tone rapidly if disrupted from their usual mobility, meaning any hospitalization for any reason is likely to require some rehab care, and the risk of illness requiring hospitalization at some point is quite high. Similarly, younger seniors with degenerative conditions, frailer health, or significant osteoporosis are likewise at a general high risk of needing hospital care followed by rehab. Medicare coverage is very straightforward; MA coverage can be unpredictable, can limit the facilities you can be discharged to, and try to force you out soon. And as noted above, the copays are the copays, because you are not* on a Medicare Supplement.

Anticipating major knee, hip, or foot surgery could likewise qualify for consideration, but if you are otherwise able-bodied and in good health, and able to afford your copays, you may rightly decide that the convenience of your coverage outweighs the potential cost or slightly early discharge of your procedure and rehabilitation. Particularly in a situation where your procedure and follow-up care can be pre-approved, the risk is somewhat lower.

* This article does not cover retiree plans, but [1] individuals may purchase MA coverage and also have supplemental coverage as a benefit from a past employer, union, or that of a spouse, and [2] some retirees are provided MA plans or similar private coverage as a benefit of retirement. If this is provided for free, or with subsidized cost sharing, or both, these significantly affect the economics of whether opting out is the best move.

Do I require behavioral health treatment…?

A major trend in private insurers in recent years – one which applies to employee plans and Medicare plans in equal measure – is the lack of sufficient in-network mental health service providers to meet the needs of the insurance companies’ clients. That means both a limited network of approved providers for those with existing care, and an utter lack of access for new patients. So whether you simply benefit from talk therapy, or if you have a more serious condition that requires physician monitoring (as roughly 1 in 11 Americans do), it is important to compare what is available in-network to what may be available under straight Medicare. This is particularly important for new enrollees who may face issues getting existing, trusted providers paid.

…Or any other specialized care?

While this is an especially challenging problem with mental health coverage, you may face a similar predicament if you have a condition requiring highly specialized care. MA participants are not likely to have an issue finding an orthopedist or GI doctor, but if you need treatment from a less common specialty for a less common chronic condition, you should surely check whether any existing provider is in network, and if not, if there are other local providers who will continue your care. If the answer to either of those questions is no, you may consider disenrolling from your MA plan to keep the doctors you have.

The above questions are only the most prominent ones that you should consider if you are still enrolled in a Medicare Advantage plan and think it may not be right for you. Additionally, home care and other long-term care expenses are addressed differently and bear differently on insurance recommendations.  If you have complex, potentially expensive needs that warrant further analysis, or want to know how long-term care costs relate to the Medicare-MedicareAdvantage system, feel free to call Attorney Rosenberg at 203-871-3830 for a senior care planning consultation.

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