The night before his scheduled cataract surgery last November, Bob Miller's eye doctor informed him the operation would be delayed because his insurer refused to pay.
Miller's Aetna Medicare plan covered a surgery just a few weeks before on his right eye. Without the surgery on his left eye, the 73-year-old residential painting contractor couldn't drive at night. Halos appeared to ring the headlights of oncoming cars. Roadside signs were difficult to read.
"I was anxious," said Miller, who lives in Columbus, Ohio. "Having a surgery canceled the night before due to their whim was troubling."
Miller is among more than 28 million older adults enrolled in Medicare plans administered by private insurance companies rather than the federal government. Signups among older Americans in these private plans, known as Medicare Advantage, more than doubled since 2007 and are expected to surpass government-run Medicare next year, according to an analysis by Kaiser Family Foundation.
From mid-October through Dec. 15, adults 65 and older can select 2023 Medicare Advantage plans or traditional, government-run Medicare. Experts say it's an important decision older adults should assess for care and coverage options and expenses.
Older Americans who sign up for private plans are enticed by lower monthly premiums and extra benefits not covered by traditional Medicare such as vision, dental, hearing and gym memberships. Private plans also cap out-of-pocket expenses at $8,300 for 2023 coverage while traditional Medicare does not unless a person purchases supplemental coverage.
But similar to private health insurance Americans get through the workplace, these plans use tools to control spending. Plans limit the network of doctors and hospitals that people can visit and often require a primary-care doctor's referral before visiting a specialist such as a cancer doctor.
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And for patients like Miller, private Medicare plans might require people to get prior authorization before undergoing certain procedures, filling prescriptions or visiting medical facilities. Traditional Medicare does not require prior authorization for any medical service.
The American Academy of Ophthalmology estimates 10,000 to 20,000 Aetna beneficiaries had cataract surgery delayed in July alone.
Miller was denied during a one-year period in which Aetna had a "national precertification" for cataract surgery. The insurer dropped the program this summer after collecting data and feedback from the medical community.
"Aetna is committed to promoting evidence-based medicine as we regularly evaluate and update our transparent clinical policies and processes to help our members receive the right care at the right time," the company said in a statement.
Miller eventually was able to get cataract surgery on his left eye after waiting several weeks. Alice Epitropoulos, the ophthalmologist who performed the cataract procedures on Miller, said it's frustrating some patients get needed care delayed or denied.
"Prior authorization policy when levelled in such a heavy-handed and irrational way is an undeniable power grab by insurers to really put profits over patients," Epitropoulos said.
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Despite the delay in getting his second cataract surgery, Miller said he's been satisfied with his private Medicare coverage.
Based on the guidance of his health insurance broker, he evaluates plans every year during Medicare's enrollment period for him and his wife and switches if one has a better mix of benefits, prescription drug coverage and network of doctors. He has changed plans four consecutive years, and he has no plans to switch to government-run Medicare because one surgery was delayed.
Other than his delayed cataract surgery, "I've not had any problems with any doctor, any procedure of any kind," Miller said.
Other surveys show that both Medicare Advantage and traditional Medicare plans are popular with older adults.
A Kaiser Family Foundation review of 62 studies found private Medicare and traditional Medicare beneficiaries had similar rates of satisfaction with their care. The private plans scored higher on factors such as use of preventive services, while traditional Medicare did better among those getting care at highest-rated cancer hospitals, skilled nursing facilities and home health agencies.
The review also found people on traditional Medicare who purchased supplemental insurance coverage had fewer problems with medical costs than those with private Medicare plans.
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In July, the private online health insurance marketplace eHealth.com conducted a survey of 2,519 Medicare beneficiaries that found 95% were worried about how inflation would impact health costs. Other analysts project inflation will not significantly impact health costs until 2023 or later.
Meanwhile, traditional Medicare's Part B monthly premiums will drop to $164.90 next year from $170.10 this year, in part because the costs from the Alzheimer's drug Aduhelm have not materialized after the Centers for Medicare and Medicaid Services restricted coverage to those enrolled in studies.
Fran Soistman, CEO of eHealth, expects more cost-conscious consumers who are on fixed incomes and pay for a supplemental plan might have trouble paying for extra coverage with inflation reaching its highest rate in four decades.
"Those who have been dealing with high gas prices, food prices and inflation in all other elements of their lives may not be able to afford that monthly premium," Soistman said.
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Medicare marketing generates complaints
Commonwealth Fund commissioned a survey this spring and summer of 1,605 adults enrolled in traditional or private Medicare. Of those who selected a private plan, 24% named additional benefits, 20% cited out-of-pocket cost limits and 15% followed the advice of someone they trusted.
"There are a lot of options people have and an immense amount of information to wade through," said Gretchen Jacobson, Commonwealth Fund's vice president of Medicare.
Jacobson said nearly one-third of people who choose a Medicare plan rely on the advice of a broker to evaluate options. Yet not all consumers are aware brokers and insurance agents typically receive a commission from insurance companies whose plans they sell, and brokers "typically don't offer all plans," Jacobson said.
The Commonwealth Fund survey found only 6% of respondents relied on marketing as a source of information when selecting a plan. However, about 12% of Black survey respondents said advertisements helped them make a selection, more than double the rate of white people.
A report released last Thursday by Democrats on the Senate Finance Commission found the number of complaints involving the marketing of private Medicare plans more than doubled from 2020 to 2021. Mail ads, robocalls and telemarketers and television ads all generated complaints.
Some examples include mailers that appeared to be official government documents, ads that use Medicare in the company's name or branding, marketing plans to people with dementia, or switching plans without a person's consent.
The Senate Finance Committee report recommended Medicare recipients should be aware of potential scams and take steps to avoid them during enrollment. Consumers enrolled in a new plan that doesn't work for them should call 1-800-MEDICARE for help, the report said.
"It is unacceptable for this magnitude of fraudsters and scam artists to be running amok in Medicare and I will be working closely with CMS to ensure this dramatic increase in marketing complaints is addressed," said Senate Finance Committee Chair Ron Wyden, D-Oregon.
Ken Alltucker is on Twitter as @kalltucker or can be emailed at email@example.com.
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This article originally appeared on USA TODAY: Private Medicare plans entice consumer enrollment despite limitations