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  • Writer's pictureRaye Elaine, BCPA

Open Enrollment - Be Aware of limitations with Medicare Advantage Plans

It is that confusing time of year that all health insurance plans are required to allow you to change your health plan. Many of you who have Medicare may be contemplating Medicare Advantage Plans such as Kaiser, United Health or Humana, plus many others.

I encourage you to be exceptionally cautious when considering these plans. In my experience as a Healthcare Advocate, these plans look good on the surface, all services in one place, lower premiums. This can be a good arrangement if you are not very sick and only use the doctor occasionally. However, if you get very sick or have an unusual illness or symptoms, you are stuck within that system and cannot go to outside specialists such as UCSF or Stanford, as that requires a referral from the MA plan which is exceptionally hard and often impossible to get.

I have had patients that have been critically ill and desperately needed specialty help which was not available with Kaiser or other plans and were refused referrals to specialty hospitals or physicians. They were then forced to pay out of pocket in order to get the care they really needed.

They also create roadblocks that make it hard to even get referrals within their system. With Kaiser, you cannot go to any other department without a referral from your Primary Care physician.

"Private companies participating in MA are paid a fixed amount per enrollee, an amount which is adjusted based on the “risk” of the individual (that is, the state of their overall health and any conditions which may require care). By restricting care through pre-authorizations, referral requirements, and limited networks" (Physicians for a National Healthplan, Oct 2023)

With a "traditional" Medicare plan you have Medicare which pays 80% and you can purchase an additional supplemental plan that will cover the other 20%. While the premiums may seem higher, you will be able to go to any doctor you want often without a referral without any additional cost to you. Most physicians accept Medicare.

Within California there is a wonderful agency called HICAP that offers FREE counseling and support for choosing a plan based on your specific needs. I encourage you to reach out and set-up an appointment with them:

HICAP (the Health Insurance Counseling & Advocacy Program) provides free and objective information and counseling about Medicare. Volunteer counselors can help you understand your specific rights and health care options. HICAP also offers free educational presentations to groups of Medicare beneficiaries, their families and/or providers on a variety of Medicare and other health insurance related topics.

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