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Don't be fooled: What New Jersey residents need to know about Medicare Advantage

Originally published in the Bergen Record.

Don't be fooled: What New Jersey residents need to know about Medicare Advantage

By Congressman Bill Pascrell, Jr.

This year, the Affordable Care Act celebrated its 13th birthday amid enormous successes. Thanks to the landmark law, 40 million Americans now have health care coverage. 

And because of the ACA, Americans have an enrollment window to seek out plans to find their best personal fit. However, navigating that window is critical to accessing this coveted benefit.

Similarly, the Open Enrollment period annually allows Medicare beneficiaries aged 65 and older to compare options and pick a plan that provides the best coverage for their needs. The choice you make determines which doctors you can see, how much you pay out-of-pocket, and if you might experience administrative barriers to care, like requirements for prior approval.

Each year, nearly two million New Jerseyans and 65 million Americans use the open enrollment window to find health coverage that works for them. Accurate, complete and unbiased information is essential to making the right choice.

Yet, in these pages, Humana recently offered slanted information about the Medicare Advantage program that was essentially an advertisement masquerading as an op-ed.

But misleading information about American health care is not isolated. Through deceitful TV marketing and thinly veiled advertising campaigns, Medicare Advantage plans often fail to present the full picture to New Jerseyans, leaving many of them, and especially our seniors, confused about their options.

Medicare Advantage versus Medicare

The Medicare Advantage program is different than traditional Medicare, and it is important for consumers to understand those differences.

Private insurers score billions in profit off the taxpayer-funded Medicare Advantage program annually. To illustrate, in 2021, Medicare Advantage plans made a profit of over $1,700 per enrollee.

The goal of insurance companies here is maximizing their profits by enrolling as many beneficiaries as possible — not watching out for the best interests of Americans.

This lack of transparency is particularly important given that the U.S. Department of Justice, Office of Inspector General, and other watchdogs have found rampant overbilling of Medicare and outright fraud throughout the Medicare Advantage market.

These insurance plans often fail to even mention fundamental plan information, using aggressive marketing and advertising tactics that are confusing and sometimes predatory.

This is why the Biden administration requires more transparency and is cracking down on how these plans are advertised to ensure Medicare beneficiaries aren’t getting scammed when making their enrollment decisions.

If you are searching for a new plan, make sure you have honest information at your fingertips before making any decisions. Weighing tradeoffs between plans is highly personal, and it is vital to use the best information available from trustworthy sources.

For assistance, State Health Insurance Assistance Programs — or SHIPs — provide local Medicare counseling. The Medicare Rights Center also has resources designed to help beneficiaries, families, and caregivers understand plan differences.

Another helpful free resource is the Center for Medicare Advocacy, which has educational materials geared toward consumers. You or your loved one can compare plans, benefits, and costs by visiting Call toll-free any time: 1-800-MEDICARE (800-633-4227), or 1-877-486-2048.

Things to consider before using Medicare Advantage

Additionally, here are a few of the issues Americans should consider before utilizing Medicare Advantage:

Provider networks: In traditional Medicare, beneficiaries can see any provider that accepts Medicare nationally, which most do. In Medicare Advantage, insurance companies often limit access to only in-network providers, and networks can change each year. There is no guarantee you can keep your doctor and if you or your loved one gets seriously sick and you want to see a particular specialist outside of your network, you may face enormous out-of-pocket costs.

Bureaucratic barriers to care: Plans increasingly use administrative roadblocks that delay or deny needed care. For example, private insurance plans may require your provider to obtain prior approval before providing certain care to you. In 2021, plans subjected more than 35 million treatments to prior authorization procedures.

Supplemental benefits: Many Medicare Advantage plans offer supplemental benefits, or services offered that traditional Medicare does not, including dental, vision, hearing, and transportation benefits. Sounds great, right? What plans don’t tell you upfront is that access is often unclear, limited, or outright denied. Before enrolling, it is difficult to figure out what the actual benefits are and what providers you can see to get these benefits. Be wary.

Prescription drugs: It is important to check every year to ensure that your prescription drugs remain covered and at what cost, regardless of whether you choose traditional Medicare or a private insurance plan.

Medigap, or supplemental coverage: Switching between traditional Medicare and Medicare Advantage is not a two-way street. In traditional Medicare, Medigap plans (often called “supplemental” plans) help cover and reduce out-of-pocket spending. If you switch to a Medicare Advantage plan, in most states, you lose your right to Medigap without getting charged extra — and you can be denied a Medigap policy if you want to switch back to traditional Medicare. Choose carefully.

We will fight misleading information

Back in Washington, I will keep fighting to stand up to any insurers who offer misleading information.

We must increase transparency in Medicare Advantage and hold plans accountable that seek to exploit our parents, grandparents and the American taxpayer.

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