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Why Do People Leave Medicare Advantage for Original Medicare?

This week, researchers released an analysis of patterns in Medicare showing that people with high needs—like significant chronic illness—and people with both Medicare and Medicaid coverage choose to leave their Medicare Advantage (MA) plans more often than people without similar health issues or Medicaid coverage. The researchers sought to discover why these patterns exist and what the implications might be for MA going forward.

While most people with Medicare get their coverage from Original Medicare, some choose Medicare Advantage plans instead. MA plans are private health plans that are paid a fixed amount per person to provide all of the same benefits as Original Medicare. They can also offer some additional benefits, like limited dental and vision coverage, and have an out-of-pocket cap on beneficiary expenses. However, MA plans also have different coverage rules, like requiring enrollees to remain in-network for services. People with Original Medicare can choose any doctor that accepts Medicare. People with MA must choose from the list of doctors that contract with the MA plan. Similarly, though MA plans must cover the same health services as Original Medicare, people with MA may have to pay more for certain services or take additional steps to obtain needed care.  For example, an MA plan may require a referrals to see a specialist or require providers to request prior authorization before some services are covered.

In studying the patterns around MA enrollment and disenrollment, researchers found that people with Medicare who have complex medical needs or Medicaid coverage are far more likely to leave MA for Original Medicare than beneficiaries who are not covered by Medicaid or who are in better health. Importantly, though high-quality MA plans saw fewer people dropping out in favor of Original Medicare in general, disenrollment rates remained high among both people with complex needs and those with Medicaid eligibility. According to the researchers, this suggests that some aspect of MA plans, especially lower quality plans, may be unattractive to sicker enrollees, and to people with fewer financial resources.

The researchers suggest that these unattractive qualities might be the limited networks MA plans offer, driving sicker beneficiaries into Original Medicare where they have a wider choice of doctors. They also suggest that more should be done to ensure that people with complex conditions or Medicaid eligibility get the coverage and care they need within MA.

Choosing between MA and Original Medicare can be a complicated decision, and if mismanaged, beneficiaries may end up in coverage that is not the best fit for their unique circumstances. We urge the Administration and Congress to do more to empower people with Medicare to make informed, timely, optimal coverage choices, and to ensure they get the care they need regardless of the coverage pathway they select.

Read the research analysis (requires paid subscription).

Read more about the research.

Read more about Medicare Advantage plans.

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