Open Enrollment ends on Dec. 7! Download the free guide to help weigh coverage options. 

Coverage Experiences Vary for Original Medicare and Medicare Advantage Enrollees

A recent survey from the Commonwealth Fund asked people with Original Medicare (OM) and Medicare Advantage (MA) about their experiences with access to benefits, services, providers, care coordination, and satisfaction.

The key findings include:

Care Delays and Affordability

Larger shares of beneficiaries in MA plans experienced care delays due to prior authorization restrictions (22% vs. 13%) and couldn’t afford care because of copayments or deductibles (12% vs. 7%).

Among those reporting difficulties, about one-third in both MA plans (33%) and OM (32%) said the problem occurred when trying to access primary care. Smaller shares said the challenge occurred when trying to get surgery (13% for MA plans and 15% for OM), physical therapy or rehabilitative care (13% for both), or cardiology care (13% vs. 10%). About one in six beneficiaries said they were told to go to urgent care because their provider had no appointments available (16% vs. 18%).

Health Assessments and Care Coordination

Nearly three-quarters of both OM and MA enrollees said they coordinate their own care. About 62% of people in MA plans and 27% of people with OM said they were asked to undergo a health assessment. Most people with MA had assessments done at home (53%), compared to 13% of OM enrollees. Regardless of coverage pathway, few beneficiaries said the assessment impacted their care plan or led to more services.

As the Commonwealth Fund notes, Medicare “uses information collected from health assessments to adjust payments to MA plans to account for plan enrollees’ health status and expected health care utilization.” As a result, MA plans have a financial incentive to conduct and maximize these reviews. Some abuse this system by assigning “paper-only” diagnoses—coding for conditions that are unsupported by the enrollee’s medical record and do not result in additional treatment. This allows the plan to receive extra money without providing extra care and contributes to the growing problem of MA overpayment.

Supplemental Benefits

Supplemental benefits are items or services available to MA enrollees but not to people with OM. This may include some dental, vision, or hearing care as well as perks like gym memberships. Restrictions on the use of these benefits, as well as coverage details, vary across plans.

Seven in 10 MA enrollees (69%) said they used some of their plan’s supplemental benefits in the past year. Four in 10 reported accessing dental or vision benefits, or an allowance for over-the-counter medications. Among those who did not use any supplemental benefits in the past year, 63% said they did not need to do so. Others faced barriers: 24% did not know what benefits their plan offered, and 15% said the benefits were either hard to use or unaffordable.

Inadequate data and transparency have long made it difficult to evaluate supplemental benefit use and value, including whether they are working well for MA enrollees. Despite this opacity, they remain appealing. A separate Commonwealth Fund survey found that in 2022, 24% of those who chose MA did so because of these “extras.”

At Medicare Rights, these survey results echo what we hear from callers to our national helpline, especially issues accessing care within MA. Addressing these and other systemic challenges­—including by holding plans accountable and paying them accurately—will only become more urgent as MA enrollment and costs grow. We continue to urge policymakers to act without delay to curb the burden of prior authorization and inappropriate denials of carestreamline cumbersome appeals processesimprove data and transparency, reduce MA overpayments, and standardize and improve supplemental benefits, including by expanding such benefits to people with OM.

Read the Commonwealth Fund survey findings, What Do Medicare Beneficiaries Value About Their Coverage?

Check out the Medicare Rights Center’s Medicare Advantage 101 policy series for more about The Beneficiary Experience with MA Enrollment and Access to Care and Payments to Medicare Advantage: The Methodology

The Latest
Most Read

Add Medicare to Your Inbox

Sign up to receive Medicare news, policy developments, and other useful updates from the Medicare Rights.