What is Medicare Advantage?

Medicare Advantage (MA) plans have been heavily marketed for the past year or so. LCSWs have had many questions about what the difference is between MA plans and traditional Medicare. This summary of those differences may be helpful in understanding what mental health coverage patients have in these plans and how MA plans may affect coverage overall.

MA plans, known as Part C plans, are overseen by commercial insurers, i.e., United, Aetna, Cigna, BCBS, etc. The general goal of these plans is to improve profits; this is not different from the other plans that commercial insurers offer. Traditional Medicare, a public plan with Federal oversight, has an interest in keeping costs down balanced with an interest in giving the elderly and disabled reasonable health care. 

Some Medicare Advantage plans inappropriately delay and deny critical care; have low premiums but then charge exorbitant copays that prevent people from getting care; have limited networks and few providers available; and may have networks with poor quality providers.  Additionally, MA plans do not have the Medigap component that traditional Medicare offers to cover the “gap” that Medicare does not allow for certain conditions, including mental health treatment.

There is little doubt that the for-profit MA plans will put the needs of their shareholders first. Most Medicare-eligible beneficiaries are drawn to the low premiums and do not read the fine print about the limitations of MA plans. This may happen when there is a health crisis and the limitations on what care is covered by which paneled clinicians becomes suddenly clear.

According to the Psychotherapy Action Network, “Medicare Advantage (Part C) plans have been demonstrably disadvantageous to people who are sicker. If you have Part C and wait until you are sick to shift over to a Traditional Medicare plan, you may not be able to get a Medigap policy to cover copays and coinsurance, or that premium may be much higher.” 

How do the MA plans affect mental health treatment coverage? For acute or short-term treatment, the lower premiums may be an advantage. The advantage will disappear in an MA plan if a beneficiary needs long-term psychotherapy. The cost of copays may be so high that the total cost of treatment may be much more expensive. Further, beneficiaries cannot purchase a Medigap policy (which covers co-pays) if MA is their primary insurance.

There are many articles on what can be done to prevent the “bait-and-switch” approach of MA plans, from lawsuits against commercial insurers to advocating for a single payer health care plan. For now, the best option in the view of CSWA, is to think carefully about the pros and cons of MA plans and traditional Medicare before choosing MA plans. Please contact me if you have any other questions about MA plans.

Laura Groshong, LICSW, Director, Policy and Practice  
lwgroshong@clinicalsocialworkassociation.org