Should I switch my aunt's current health insurance to an Advantage plan?

This is from a friend of mine who is a director/social worker for a Hospice/Palliative Care Organization. She posts this on her personal page almost every year during open enrollment time.

PSA: PLEASE, PLEASE, PLEASE do NOT change from traditional Medicare (your red, white, and blue card), to a Medicare Replacement Plan, i.e. Aetna, BCBS, Cigna, Humana Advantage. These plans REPLACE your Medicare benefits and offer you less benefits, which is why they cost less. Secondary supplement insurance is different, and these companies provide good coverage for that. Switching to a replacement plan means losing your Medicare benefits to a managed insurance plan where an insurance rep dictates your care and NOT your doctor.

You've likely already heard enough against Medicare Advantage plans, but I'll add on: A Medicare Advantage plan helped to kill my older sister.

She had a blood sugar drop in her sleep, which placed her in a coma for five weeks. After that, it was a two-year nightmare until her passing this past April at age 75. Again and again, doctors told me that if my sister had had Original Medicare, she would have received the proper treatments in a facility equipped to deal with brain-injured patients--if a doctor recommends a certain course of treatment, Original Medicare pays for it. This will seem a waste to anyone concerned with the high cost of healthcare, but when you need that care, it's very, very urgent.

After she began to wake up from her coma, her doctors recommended complex care in a long-term acute care hospital. But Anthem absolutely refused; appeals went nowhere. No skilled nursing facility would accept her because her CARE WAS TOO COMPLEX. After an additional month in the hospital (time when she could have been in the L-TACH), one SNF finally took her. There, she was treated like any other stroke or dementia patient, with no specialized care for brain injury. I struggled to patchwork together appropriate care myself, but the SNF staff said that I could not take her elsewhere for private-pay outpatient rehab, because then the insurance company would no longer pay for her 100 days in the SNF (which they stopped paying for at around 60 days anyway--we had to switch to private-pay at $400/day).

At that stage, her care was too complex for us to take on at home, so I was at the facility nearly every day to ensure she got the meager 30 minutes of physical rehab/30 minutes of speech therapy that they provided (instead of the three collective hours of guaranteed rehab that a facility specializing in brain injury would provide). If I wasn't there, many days she wouldn't receive the 30 minutes, because the injury left her oppositional to treatment--another thing a specialized facility is trained to deal with. In a SNF, if a patient says no, PTs/STs are off to the next resident in about 30 seconds.

The first few months of treatment after a brain injury are critical, and I simply could not get her the care she needed in that window. She improved a bit, but the SNF was not staffed to watch her, so 7 months in she fell and broke her hip at a time when we weren't there, leading to more hospital stays. It was a long, slow, heart-wrenching decline after that. We brought her home after rehab failed for the broken hip--by then it was too late.

Now, I realize that I should have used my sister's funds to try paying, at least for a few weeks, for the $2,000/day specialized rehab facility. But at the time, that amount just seemed so astronomical to consider--$400/day seemed awful enough. She had saved quite a bit, but at that time, I was not sure how long she would live or how much money she would need.

As my sister's court-appointed guardian, I was met with such "so-sad, too-bad" indifference from Anthem at every turn. Now, I'm left wondering "what if" every day, and I'm still reeling from the two-year ordeal in which I lost my sister slowly. It's just about unbearable.

To anyone who reads this: Medicare Advantage plans are only an "advantage" if you stay relatively healthy and require only straightforward care until you one day die of uncomplicated causes. If you ever need complex care, your chosen insurance company that oversees your Advantage Plan will refuse necessary care at every turn and simply bide its time waiting for you to die.

The irony: Between all the substandard care that Anthem DID pay for, they probably paid at least 3x more for my sister's care than they would have if they had just paid for the more effective doctor-recommended care and rehab she needed in the first place. But if other patients die more quickly, the money all balances out in their favor in the end. Yay for them.

I don't do Medicare advantage for my mom and husband. I like having the freedom to go to any doctor or hospital of my choice.

Medicare Advantage plans have one goal, to make money for the insurance companies. I agree with Sophia54. They’re probably great when you’re relatively healthy. But God forbid anyone get a rare brain disease like my dad got, they would be s**t out of luck. There are only a few specialists in the country that deal with such things, and my dad was in and out of icu’s for months. I believe my mom would be bankrupt now if she had Medicare Advantage. What she DID have was a good secondary insurance to cover the 20% Medicare doesn’t cover.

I’m going to expand on Barbs post: How Medicare Advantage plans work ideally & best is for every single provider (physicians, clinics, hospitals, therapists, etc) and every single ancillary service (lab, specialty testing, etc) is 100% in their network. Again everything ever billable IN NETWORK. If not, it’s out of network and significant copay….. could be very significant like 25% of a non negotiated rate…. Serious costs

You need to - absolutely must - find out if the Advantage Plan she’s being switched to is designed to work for long term care facilities and if the NH Auntie is in specifically is in this Advantage Plans system. The DON at the NH can answer this.

If the AP knows she is in a NH, it may not actually be an traditional Advantage plan but a MCO aka Managed Care Organization that is being run through an Advantage Plan via a narrow group of insurers. That is happening in some States for how medical care is done in NH. Texas does this.

I know this is confusing so hang with me on this and some of this may be stuff you already know, if so I apologize: Advantage Plans are a spin off from Original MediCARE & was done under the guise of giving consumers more choice. But have evolved to be basically health insurance companies supported by the feds via CMS / Centers for Medicare & Medicare to run the AP’s. It’s been to the point on some Adv Plan that if federal subsidy wasn’t happening to the extent it has been that they couldn’t make the big profits. For the States, as so many are “duals” (on MediCARE & Medicaid), the States end up with higher bills as well in all this too, So what has happened to bring cost containment more in line is that the Feds & States have been pushing MCO / Managed Care Organizations to happen when feasible. And for those in NH as they are a captive audience, having them go onto a MCO makes sense to be done. The AP insurers in some areas have partnered to do MCOs and use their existing in-network for it & get their doc to be Nh medical directors w a lot of telemed. So…. Again clearly find out if the AP works for the MD, therapists, etc at her NH and that the hospital/ clinics the NH refer to out of this NH are in network for the AP as well. AP should have on-line a list of everything in network.

HOWEVER
if your Aunt is new to the NH and is still thinking she’s keeping all her old doctors, the reality of how medical care is done in a NH either wasn’t discussed with her, her POA and you OR somebody dropped the ball on discussing this with you all. If y’all are thinking she’s going to keep her old docs, that is not going to happen. She may, like may, be able to do a visit or two, but it cannot work long term as the MD who is the medical director at the Nh will be the one to determine her health care needs, write script for meds, set up schedules, determine if a run to the ER is needed, etc.. It’s really hard to have outside MD consult happening over time in a NH u less this is a pricey private pay NH. Some accommodations can be done for pre-existing but gets unwieldy. So the need for her health insurance to cover that type of care goes always and replaced by something that works for how healthcare in a long term care facility is done.
This can be hard for some elderly to accept.

My daughter managed a Wound care Unit. She had a hard time getting MA to pay for A&B services. Yes, they are suppose to cover parts A & B but they try not. So then you are on the phone arguing with them that the service is covered. Not me.

Ugh. I don't like Advantrage Plans at all. Terrible idea. They are much more likely than Regular Supplemental Plans to limit what services or care they will cover and what they do cover has to go through their specific network.

If you can afford to keep regular Medicare and a regular Medicare Suppemental plan, that is a much better and more flexible option.

Old Dude is right, specifically if your Aunt has a list of her own doctors she wants to keep - or thinks she can keep. I went on Original Medicare in 2021, enrolling in original Parts A & B, and then bought separate plans for Vision and Dental care. I also enrolled in a Supplemental Plan to pay what Medicare approves, but does not pay, and a Part D Plan for prescription medicine. I did all that because I have a lot of health conditions that my primary care doctor manages, and I wanted to keep my other doctors that I’ve been seeing, some for at least 20-30 years, some not that long. Back when I was working, I always kept health insurance plans that let me see “any doctor, any hospital, any lab - anytime”. Usually Blue Cross/Blue Shield. When I was initially looking at Medicare Plans, I just assumed my doctors might belong to some Medicare Advantage Plans, since they are overwhelmingly “pushed” at seniors everywhere we look. “Managed Care”. Wrong! None of them were Advantage Plan doctors. So, I enrolled in Original Medicare with a Supplemental Plan to pay what Medicare approves but does not direct pay. My doctors bill Medicare, and then balances are sent to my Supplemental Plan to pay. I seldom have any out-of-pocket medical costs to pay myself. Medicare Part D for my Prescriptions is another story. That one can be expensive, depending on what “phase of the plan” I’m in during a given year. I check with my doctors to see if a medicine is necessary, or if there is a less expensive alternative, before filling them. When he can, my PCP gives me samples. I also buy 90-day supplies of my maintenance medicines. I plan to move some of those maintenance meds (those that never vary in strength) to my plans Mail Order Pharmacy so they cost me even less. As of now, I intend to stay in my home for as long as I can, before moving to Senior Housing/Assisted Living. Perhaps at that point, I’ll consider a Medicare Advantage Plan. My Primary Care will be retiring at some point, along with a few of the others. I’m looking at stairlifts now to retrofit my split foyer house while I’m still mobil.

Please talk to a SHIP counselor.
SHIP stands for Senior Health Insurance Program.
The counselors are not beholden to any company so they will review what plans are available for a person, look at medications, and other factors and will make recommendations.
Do a Search for "SHIP counselors near me"

If you change plans and you don't like the new plan, it is my understanding that you will not be able to get the old plan back. If you/your aunt are satisfied with the current plan, I wouldn't change...but that's just me.