Medicare Advantage Plans Are Not What You Expected

If you want to enroll in a Medicare Advantage Plan, there are some things you should know. Medicare Advantage Plans are not what they seem, because Advantage Plans are funded by Medicare, and you cannot choose the plan you want (Medicare has to approve it); and you could get a different plan (one that Medicare approves), instead of the plan you wanted.  And once enrolled, you cannot use your Medicare card anymore, because you have to use the Advantage Plan insurance card instead!  

You should also know that once you enroll in an Advantage Plan, they will start calling you to make an appointment for a nurse to come to your home. They will want to do this every year, to diagnose you with new health conditions, and sign you up for services, so they can get more money from Medicare.

Although you still have the right to choose your own Primary Care Physician (PCP), as long as they are in the Advantage Plan network, you do not have the right to choose the nurse who will come to your home and diagnose you.  You have no choice!

The fact that Advantage Plans want to do house calls is not common knowledge. You have no way of knowing this in advance, because Advantage Plans do not reveal this information to the public, or on their websites. They only reveal the cost of each plan.

Once the Advantage Plan starts calling you, they will call every day, sometimes several times a day.  When you answer the phone, they start asking questions about your health, and want to send a nurse to your home to do a "health risk assessments," and sign you up for "in-home or community based services."

These assessments are invasive and controlling, and undermine the diagnoses of your own PCP.

If the Advantage Plan cannot reach you, they will leave messages on your answering system, using a recorded mechanical sounding voice.  These messages do not reveal the reason of the call. They just say to call them. Then they will send you pages of questionnaires in the mail.

They offer a $25 Walmart gift card if you do the in-home assessment, which seems to be a deceptive tactic, since you do not know what the exam will be like, or what they will ask, or why they want to do these visits. You also do not know why Walmart is giving away gift cards, or how are they reimbursed.

If you agree to these assessments, you need to know that Medicare Advantage Plans want to do in-home assessments because they can get more money from Medicare if you are diagnosed with more health conditions.

Medicare pays the Advantage Plans different rates for each person, based on their health conditions, and Medicare Advantage plans use a billing formula for each person called a "risk score."  So if the nurse or social worker makes an additional diagnosis and says you have more health risks, you will have a higher risk score, and Medicare will pay the insurance companies more money.  

Remember: if you have a higher risk score, that means Medicare will pay the Advantage Plan more money!

Advantage Plans hire nurses and social workers, and this costs money, also.  This is wasting money and costing Medicare billions of dollars each year if there are exaggerated risk scores, and duplicate diagnoses or unnecessary services.

Advantage Plans do not need to assess you in your home to find your health risks, because when you apply for health insurance or life insurance, the insurance company can get your medical file from the Medical Information Bureau (MIB).  The MIB does not have your medical records; they just have "codes" that represent your health conditions.  So, if the insurance company wants to know this information, they have to give you an "MIB Pre-Notice" letting you know that they will request this information from MIB.

If you have applied for any insurance (that is not from an employer) in the past seven years, the MIB should have your file.  You can get a copy of your file for free by calling the MIB: 1-866-692-6901.

If you agree to an in-home assessment, it will take about an hour.  They will do an exam, take your blood pressure, listen to your heart, ask about your medications and medical conditions, and assess you for your ability to bathe, cook, walk upstairs, and dress yourself, etc. 

If the nurse decides you need a home health care aide or physical therapy, they will want you to sign papers for these services. If you did not need a home health care aide before, why do you need one now?

If you have not answered their questions over the phone, they will ask them during the assessment.  They will ask about FORTY questions (most with two parts and some with six parts.)  This is a partial list of some of the questions they ask:

  • The language you speak
  • Your Primary Care Physician (PCP)
  • If you have a living will, advanced directive, or health care power of attorney
  • What type of care you discuss with your PCP
  • If your religious beliefs affect your medical decisions
  • The specialists you see
  • Your height and weight
  • If you have been diagnoses with a heart condition
  • If you have diabetes, high blood pressure, COPD or renal disease
  • What prescriptions you take
  • If you are you bi-polar or schizophrenic
  • If your medical condition prevents you from leaving the house
  • If your medical condition keeps you in bed all day
  • If you smoke
  • If you take drugs
  • If you need to cut down on your drinking
  • If you need help with daily activities or if you “can do it yourself”
  • If you use a wheelchair, hospital bed, walker, hearing aid…etc.

When they ask questions like these, especially about your health care power of attorney, it should make you wonder if the insurance company’s nurse can ask you to sign your health care power of attorney over to her, if you have not already chosen one. Or if the insurance company’s nurse or social worker can diagnose you with something your PCP has not diagnosed you with?

Afterwards, the nurse will want to sign you up for in-home and community based services, if you are diagnosed with new medical conditions! 

If the nurse wants to sign you up for in-home services, more people will provide care, and you will be rated as sicker with a higher "risk score," because you have more medical conditions.

So, it makes sense that you should question any new diagnosis and be allowed to have it confirmed by a second opinion doctor, since it is a subjective diagnosis!  But, the Advantage Plan might not pay for this.

You should also be allowed to ask your PCP to confirm the new diagnosis, but the Advantage Plan might not want to pay for this, either.

If the Advantage Plan will not pay for a second opinion, then there could be something suspect about these assessments.

If your new diagnosis is correct, does that mean you could be able to sue your PCP for not diagnosing you correctly?  And if the new diagnosis is not correct, does that mean you could be able to sue the insurance company for making an unnecessary and inflated diagnosis, and for care that you do not need?  These are questions that the Advantage Plans do not publish in their booklets.

When you turn 65, and think Medicare pays 80% of your medical bill, and an Advantage Plan helps with the additional remaining 20%, you are wrong.  There appears to be a hidden agenda to these Medicare Advantage Plans, because they will want to diagnose you in your home, independently of your own PCP; and make money from Medicare based on your "risk score;" and override your control of your own health care.

Jeanne Coppola

Jeanne Coppola is a lifelong resident of the Collinwood neighborhood, and is interested in art and writing. She has a Bachelor of Arts Degree from Cleveland State University. 

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Volume 10, Issue 10, Posted 8:10 AM, 10.14.2018