Understanding the Details of Medicare Advantage Plans
Millions of seniors will weigh rates, benefits, and network options while choosing a new Medicare Advantage plan, which will be open until December 7.
(“Medicare Plans Free’ Dental, Vision, Hearing Benefits Come at a Cost,” Oct. 27). Many consumers are unaware that certain health plans contain inconvenient restrictions that restrict access to vital services. For example, across all of Aetna’s health plans, including Medicare Advantage, prior authorization for cataract procedures is now required. Thousands of Americans covered by Aetna have had their vision-restoring procedures postponed or cancelled as insurance company employees decide who gets to see better and who has to wait for their cataract to worsen before insurance can pay cataract surgery.
The Improving Seniors’ Timely Access to Care Act, which has 239 co-sponsors in the House and was just introduced in the Senate, is aiming to establish guardrails on prior authorization misuse in Medicare Advantage.
Meanwhile, seniors should be aware of prior authorization requirements in Medicare Advantage plans and encourage insurance representatives to be forthright about roadblocks that could result in care delays or denials.
Your recent article on Medicare Advantage programmes was informative, yet it overlooked key details.
Traditional Medicare coverage contains a well-defined set of benefits, as well as coverage rules and regulations. Unfavorable coverage decisions might be challenged. The procedure for filing an appeal is carefully specified. Which Medicare Advantage plan is best to cover services not covered by regular Medicare and “more”? The issue is that there is no way to verify whether or not such assertions are true. Furthermore, coverage under such plans is conditional and at the plan’s discretion. There is no standardised way to appeal a denial of care. The appeal is directed at the proposal as a whole. There is no way to overturn an adverse coverage decision, and because there is no external review mechanism that can overturn the plans’ choices, the plans tend to uphold their adverse decisions on appeal.
Few independent providers have the financial means to appeal adverse coverage decisions made by the large health insurance firms that manage Medicare Advantage plans. I’m a service provider. If a commercial health plan refuses to resolve a coverage disagreement, I can file a complaint with the Texas Department of Insurance. The Medicare Advantage Plans are not under TDI’s control.
I contacted the Centers for Medicare & Medicaid Services and others to find out who has jurisdiction over adverse coverage decisions made by Medicare Advantage plans. There have been no responses!
“Caveat emptor,” I say to everybody turning 65. Unfortunately, the public does not have access to all of the information they require to make informed decisions.
— Dr. Ed Davis,
How Covid Was Able to Take Over Hospitals
I can speak to the facts provided in Christina Jewett’s essay concerning hospital “safety” and how it pertains to the retired pharmacist who died of covid-19 as a former registered nurse at a hospital in southwest Florida. (“Patients Went Into the Hospital for Care. After Testing Positive There for Covid, Some Never Came Out,” Nov. 4).
My views and personal experiences in the hospital during the early stages of this infection were exactly as she described, with one exception that may be of interest. For suspected and/or positive cases, our med-surg unit became an overflow unit. What isn’t mentioned (but is true) is that when our negative-pressure rooms (of which there were only two on our level) were full, patients were moved into conventional rooms with the door shut.
Although this appears to be a “good” concept on the surface, I instantly recognised a flaw in management’s solution: the room doors had a 1- to 2-inch gap underneath them. There were no masks on the patients in those rooms. This suggests that the patients’ infected respirations were escaping from their rooms and into the hallways, as is intuitively clear. Additionally, this “air” has the potential to spread into other patients’ rooms, infecting them with covid-19. Needless to say, we had a couple of infected nurses on our floor before long.
Many, many hospitals “reacted” in this manner during the early days of the pandemic, in my opinion. I wasn’t working at this hospital long enough into the pandemic to see where or how patients who were suspicious or positive for the virus were assigned rooms when researchers established that transmission was airborne rather than droplet-based, as had been assumed at the time.
Finally, as a nurse, I am aware of a number of other nurses in Florida who have declined to be vaccinated early, midway, or late in the pandemic. I completely believe that these nurses and other “holdout” staff, like the man mentioned in the storey, could have “spread the infection without knowledge” to their patients. There is no doubt in my view that the retired pharmacist was carried and infected by a “carrier” (presumably unsymptomatic and unvaccinated). It’s a fantastic narrative, and it’s well-written.
— Janet M. Konikow, Fort Myers, Florida
On Oral Health and the Role of a Dental Hygienist
Licensed Illinois dental hygienists who also have public health dental hygienist (PHDH) certification were featured in a recent KHN piece.
(“Hygienists Brace for Pitched Battles With Dentists in Fights Over Practice Laws,” Oct. 19).The Illinois Dental Hygienists’ Association (IDHA) has worked hard to pass legislation that will allow persons who reside in skilled nursing institutions and other constrained settings to get affordable direct preventative oral health services. “I just don’t feel someone with a two-year associate’s degree is medically prepared to correct your health,” Dave Marsh, a lobbyist for the Illinois State Dental Society (ISDS), was cited as saying.
The IDHA would like to inform ISDS that a registered nurse’s entry-level degree is also a two-year associate’s degree. Is this to say that registered nurses are unqualified to care for the elderly as well? Certainly not! This is yet another example of how ISDS continues to fight licenced dental hygienists and limit their ability to practise to the fullest extent possible.
Dentists in Illinois argue they can’t afford to treat those who have state-funded dental insurance, are uninsured, or are destitute. They also don’t want dental hygienists to look after them. Why? ISDS demonstrates the strength of lobbying groups in altering regulations on where health professionals can practise and who retains the profits, as the article clearly states. And who is the one who suffers? The state’s most vulnerable residents.
The Illinois State Dental Society further alleges that developing the PHDH curriculum required years after the Illinois Dental Practice Act was changed to allow direct preventative treatment by a public health dental hygienist. The fact that legislation was tangled up in the administrative rules process from 2015 to 2019 was conveniently overlooked. Within nine months of completing this procedure, the hygienists’ association established, implemented, and graduated the first class of PHDHs.
The article correctly mentions that Illinois lags behind a number of other states. In fact, 38 other states allow dental hygienists to work with patients unattended. The article also correctly claims that the Illinois State Dental Society is politically wealthy and influential. This enables them to give generously to legislators.
The Illinois Dental Hygienists’ Association would like to thank KHN for exposing the truth that the Illinois State Dental Society is motivated by profits and control rather than providing access to care. Now that lawmakers understand ISDS’ genuine motivations for restricting Illinois dental hygienists’ scope of practise, they may approve legislation to ensure that all Illinois residents have access to the oral health care they need, want, and deserve.