The promotional video for the new Medicare Plan Finder says it was designed to make it easier to learn about and compare coverage options. However, to make an informed decision, one needs to know how a plan would work. For Medicare Advantage plans, coverage rules (specifically, what to do in order for the plan to pay) are important.
There are two coverage rules of concern.
1. Plans can require a referral from the member’s primary physician to see another physician or healthcare provider. Most HMO (health maintenance organization) plans have this requirement but it’s starting to appear in a few PPO (preferred provider organization) plans. Without a referral, the beneficiary either won’t be able see that provider or will pay out-of-pocket for the visit.
2. A plan can require a physician to obtain approval from an insurance plan to prescribe a healthcare service, treatment plan, or a piece of medical equipment. This prior authorization process can lead to a limitation on services or a complete denial of the order, meaning the care won’t happen unless the person pays for it privately.
These coverage rules can shift “who’s in charge” of the member’s care and treatment from a physician to the insurance plan. This is something that people must know about up front, before making a decision.
The current or Legacy Plan Finder clearly identifies referral and authorization requirements (through little purple and turquois circles) by each service under the Health Benefits tab so the coverage rules are very visible.
That is not the case with the new Plan Finder for three reasons.
- You can view all the details about health benefits for only one plan at a time. The plan comparison page does not list all benefits. To check all the details of a plan, it would be necessary to print the pages or flip back and forth between computer screens.
- You must click on “Limits apply” next to each specific service or benefit to learn whether the plan requires a physician referral or “advanced plan approval.“ That could be 20-30 or more clicks to learn about all of one plan’s rules.
- And the most questionable reason, the “limits apply” links do not appear for PPO plans in the new Plan Finder. I compared plan information in the Legacy and new Plan Finders for four zip codes. The Legacy Plan Finder displays authorization requirements for many PPO plans and referral requirements for a couple. In the new Plan Finder, there are no “limits apply” for those same plans. It’s doubtful that the plans changed their coverage rules so why did this information vanish?
With the new Plan Finder, it’s easier to see monthly premiums and there’s an expanded section of additional benefits. Based on those items, Medicare Advantage plans look very attractive. However, the details must reveal all important information, especially coverage rules, that can have an impact on beneficiaries’ plan decisions.
For more information, see “Check Out Coverage Rules Before Buying A Medicare Advantage Plan.”