Elder in Bad Health? Medicare Advantage May Not Be an Advantage


Medicare open enrollment ends on December 7th and many people are reviewing their options. About 40% of seniors in California are on a Medicare Advantage plan such as Kaiser, Blue Shield or United HealthCare. These plans are terrific for people over 65 who are healthy. But, if your senior suffers from conditions such as dementia, stroke or seems to be ending up in rehab a lot, consider getting him/her back into original Medicare.

Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are an “all in one” alternative to Original Medicare. They are offered by private companies approved by Medicare. If you join a Medicare Advantage Plan, you still have Medicare. These "bundled" plans include Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), and usually Medicare drug coverage (Part D). With Original Medicare, you can go to any doctor or facility that accepts Medicare. Medicare Advantage plans have fixed networks of doctors and hospitals. Your plan will have rules about whether or not you can get care outside your network.

I spend my days working with seniors and their families to help them find assisted living, often hearing from them when a calamity has occurred that has required hospitalization. It is what happens after hospitalization that makes me, and my colleagues hesitate whenever we hear someone is on an Advantage plan.

No doubt Medicare Advantage appears less expensive than original Medicare plans. Like any HMO type policy, the managed care aspect of all Advantage plans allows the insurer to actively manage costs, which results in a seeming advantage to these policies. But “Medicare Advantage is, in the opinion of most Health Plan Advisors, an oxymoron. Better to be called a ‘dis-advantage’ plan. It is a marketing program of the insurance agencies,” says Medicare specialist, Barry Sikov, who owns Belair Insurance in Los Angeles.

My own personal beef with Medicare Advantage centers on two issues that you may not think about when you are making your initial choice but becomes very important when your elderly loved one ages and requires more services:

1. Poor in-network skilled nursing facilities

2. Lack of mobile services


Let’s take an example.

Your mom has dementia and has fallen or gotten a Urinary Tract Infection (UTI), two common situations. She is now in the hospital, gotten weak, and is being discharged to a skilled nursing (SNF) for further recuperative care. With an Advantage plan, your loved one must go to one of the skilled nursing facilities that are contracted with the medical group that your doctors are in.

Frequently, clients will call me to go over the choices of SNFs that the hospital has given them, and it is a dismaying list, to say the least. Medicare publishes a ranking of nursing homes and rates them based on health inspections, staffing and quality of resident care using a scale of one to five stars. Here is the link: https://www.medicare.gov/care-compare/.

The SNFs generally recommended by the Advantage plans usually have ratings between one and three stars, with low staffing levels being a primary deficiency leading to health citations for lack of proper care and supervision. With original Medicare, your loved one still will receive a recommended list from the hospital, but I’ve found there to be a wider range of higher ranked (three to five stars) facilities to choose from and more responsiveness to personal preferences.

Mobile services are another consideration. Let us once again consider the elder with dementia who has fallen. It is tough to get that person to her doctor’s appointments. Mobile medical services are a trend in Los Angeles geriatric care servicing most of the assisted living facilities in Los Angeles, many also providing service bedside in an individual’s home.

Mobile medical services offer everything from house call doctors, to phlebotomists for blood work, mobile x-ray technicians, visiting nurses, even mobile dental services. Most of these services are covered by original Medicare Part B. With Medicare Part C, the Advantage plans, these services are out-of-network and therefore not available. Mobile medical providers specializing in geriatrics include Access Healthcare Associates and HouseCall MD. Many of my clients may still take their loved one out to an appointment to see a specialist but for the day-to-day types of services needed, switching to mobile doctors and technicians has been a godsend.

During this open enrollment period, take the time to review what types of services your elder is using and whether his/her Advantage plan is the best fit. Plan for the future when he/she may be less mobile or otherwise in decline and think about how you want to provide care.

Your friends at Assisted Living Locators are happy to help you think through a care plan for your aging parent. Please feel free to reach out at 310-853-8282.