So, whose fault is this? Majority of Medicare Advantage enrollees don't fully understand their plan

[Duaine]

However, only 44% of MA enrollees say they fully understand their plan, with 68% saying certain details have caused confusion. Dental coverage was the most reported area of confusion, followed by out-of-pocket costs, transportation to medical appointments, caregiver support services, home health services and vision and hearing coverage. At least 20% of beneficiaries said they didn’t understand one or more of these plan elements.

Other respondents believed a lack of familiarity with the plan (56%) caused confusion, while some (44%) believed there was inadequate communication and education about benefits offered. More than 1 in 4 beneficiaries reported paying out-of-pocket costs for services they believed were covered by their plan, while 1 in 10 said they thought were overbilled for their MA plan.

https://www.fiercehealthcare.com/pa...ceHealthcareWeekly&oly_enc_id=7676I6111445A4B

 

[somarco]

Who is to blame? There is enough to go around and you don't have to look too far.

Health insurance is more complicated than perhaps any other insurance product. Too many moving parts.

Networks. Prior authorization. Hidden providers. PARE claims. Reimbursement surprises.

Having worked the under 65 market for many years I can tell you this. Most folks with health insurance, individual or group, have no idea how their plan works. Much of the blame is due to under utilization . . . they are generally healthy and rarely use their plan except for primary care. Hospitalizations, other than for maternity, are rare so they have little or no exposure to what happens with a major claim.

That changes when they turn 65. Many of those folks will see major health changes in the next 5 years after turning 65.

All of a sudden they have to learn how to find new providers that will accept their plan. They are faced with delays and denials of claims . . . often due to prior authorization. They panic when they get an initial "this is not a bill" notification from a provider and the charges are thousands of dollars.

I recently experienced that for outpatient surgery on my wife. Outpatient surgery facility charge, $19,681 . . . Medicare paid $0.

That will open your eyes!

Turns out the hospital used the wrong HCPCS codes when filing with Medicare. The code said she had cosmetic surgery which was denied. Digging further, I discovered the CORRECT code was off by one digit. I contacted the hospital, they refiled the claim with the correct code and the claim was paid in full.

Granted, this is OM not MA, and SHOULD have been more cut and dry but the same coding error in an MA plan would have resulted in the same denial . . . and much more red tape to get the claim paid.

Agents assume that, just because someone has had a managed care plan for years there is no reason to explain how the MA plan works. Agents pitch BENEFITS and fail to explain how to use the plan and what to expect with out of the ordinary claims.

Many seniors approaching 65 have postponed diagnostic testing and treatment due to high deductibles with their ACA or EGH coverage. Cataract surgery is a common affliction that is postponed in the belief they will pay less when they are on Medicare. I see similar situations where joint replacement is needed and again, has been postponed.

In addition to increased utilization by the senior, a decline in mental acuity should be factored in as well as hearing loss. The senior is expected to use a product where they have no point of reference based on their past health. Today's MA plan is like a Swiss army knife. Unless you understand what the plan actually does, and how to access all the features, you will be completely lost.

Even those that did use their prior coverage not only were healthier but also had larger networks and more providers willing to take their plan. MA is, in many ways, not the same as what they had before and when their health changes they see the underbelly of managed care.

Many of these problems could be alleviated if agents did a better job of explaining how the product works and less time pitching all the "free" benefits.

 

[somarco]

Other things many agents overlook is this. About 70% of the T65 crowd has never had to buy health insurance and coverage under an EGH plan usually comes with subsidized premiums.

So they have no point of reference in how much health insurance, and health care, actually costs.

They have changed jobs and health insurance multiple times and never had to answer health questions. Between that and all the Obama talking about how the "insurance companies will no longer be able to discriminate against you because of your health" they can't imagine a world where you have to QUALIFY based on your health to get a plan.

They were also told if you like your doctor you can keep your doctor but of course that was another lie. So they should have no problem adjusting to MAPD where docs tell them they don't take plan X or Y.

 

[yorkriver1]

Other things many agents overlook is this. About 70% of the T65 crowd has never had to buy health insurance and coverage under an EGH plan usually comes with subsidized premiums.

So they have no point of reference in how much health insurance, and health care, actually costs.

They have changed jobs and health insurance multiple times and never had to answer health questions. Between that and all the Obama talking about how the "insurance companies will no longer be able to discriminate against you because of your health" they can't imagine a world where you have to QUALIFY based on your health to get a plan.

They were also told if you like your doctor you can keep your doctor but of course that was another lie. So they should have no problem adjusting to MAPD where docs tell them they don't take plan X or Y.

How many clients have forgotten they have a $0 deductible on lower tier Rx, then call about why all of a sudden am I being charged this huge amount? "Hey, I thought I had a $0 deductible?" It varies based on plan deductible--granted a number of MAPD's have lower or no deductible on higher tiers vs stand alone PDP's, where it is more likely to happen.
I am learning to be very careful with my T65's who sign up 2nd half of the year. The deductible I reminded them about is forgotten the following year, when it shows up 4,6,9 months later. Hasn't happened a lot, but enough. 2-3 times in the past few years.
PS, when helping ACA clients coming off group there is the same issue you describe, Bob. I have had a couple of them who just couldn't get it together to pay once a month, maybe even less than their group plan, but no responsibility to pay attention.

 

[somarco]

How many clients have forgotten they have a $0 deductible on lower tier Rx, then call about why all of a sudden am I being charged this huge amount? "Hey, I thought I had a $0 deductible?" It varies based on plan deductible--granted a number of MAPD's have lower or no deductible on higher tiers vs stand alone PDP's, where it is more likely to happen.
I am learning to be very careful with my T65's who sign up 2nd half of the year. The deductible I reminded them about is forgotten the following year, when it shows up 4,6,9 months later. Hasn't happened a lot, but enough. 2-3 times in the past few years.
PS, when helping ACA clients coming off group there is the same issue you describe, Bob. I have had a couple of them who just couldn't get it together to pay once a month, maybe even less than their group plan, but no responsibility to pay attention.

I am generally a bit more forgiving with clients than I am with agents. Our clients are 65+ and some may have cognitive challenges . . . plus we do this every day and they don't.

Part D is the most confusing portion of Medicare and it is understandable that seniors will not understand things or forget what you told them. But many agents believe they understand all things relating to managed care . . . networks, prior authorization, step therapy, copay vs coinsurance . . . and really don't need to be educated on how PPO and HMO plans work.

Most of my clients coming off Obamacare think OM + Medigap is a windfall. I can't recall when I talked to someone who had a full subsidy ACA plan and is shocked at premiums, deductibles and copay's. A new client I just picked up is paying $1100 per month (single coverage) for a plan with a $5k deductible. He can't wait to cancel his plan.

Many coming off group plans are also happy but a few that worked for companies that paid all the premium sometimes have reluctance and say they may try the MAPD for a year and then decide. I remind them if they miss the 12 month anniversary they may have to go through underwriting to which they ask "What's that"