‘While Medicare Advantage plans are required to cover everything covered by original Medicare, they aren’t required to cover them in the same way or for the same price.’

Ed Reed/Mayoral Photography Office.

Mayor Bill de Blasio in July announced an agreement with the Municipal Labor Committee to implement the NYC Medicare Advantage Plus Program for city retirees.

New York’s municipal retirees prevailed in New York State Supreme court on Tuesday when Judge Lyle Frank delayed the implementation of the mayor’s plan to shift them from traditional Medicare to privately-managed Medicare Advantage.

Here’s why. Medicare Advantage, also known as Medicare Part C, is not Medicare. It’s private insurance masquerading as Medicare for those who are eligible. For all practical purposes, it’s indistinguishable from the employment-based health insurance many had before retirement and it’s provided by the same insurance companies i.e., United Healthcare, Blue Cross/Blue Shield, Aetna, Humana, Cigna, and in this case, Emblem Health and Empire Blue Cross Blue Shield. Like those plans, monthly premiums are paid to the insurer. And while some Medicare Advantage plans don’t have a premium, as with any private plan, it’s the insurer that controls coverage and increasingly, medical decisions.

The unholy union of Medicare and private insurance is perplexing, often misleading, and filled with mind-numbing language; its financing even more so. No wonder so many municipal employees are confused. It confuses some of the most dedicated policy experts; mere mortals haven’t got a prayer.

A form of this public/private partnership dates all the way back to Medicare’s beginnings, but Medicare Advantage as we now know it goes back to the Clinton administration. It allows Medicare (a federal, taxpayer-funded program) to contract with private, for-profit health insurance companies that are paid an annual fee for each Medicare beneficiary they sign up. The sicker the beneficiary, which is almost a given in this demographic, the higher the fee. As recent investigations have demonstrated, fraud is not uncommon in Medicare Advantage plans.

This multi-billion-dollar insurance quagmire, which includes the pharmaceutical industry because distribution is controlled by the same companies, defines what passes for a healthcare system in the United States. The insurance industry wants you to believe that you’re better off buying their insurance rather than sticking with the federally-administered traditional Medicare. The industry is most certainly better off; profits are through the roof. The beneficiaries and the taxpayers, not so much, despite what their celebrity fronts tell you.

While Medicare Advantage plans are required to cover everything covered by original Medicare, they aren’t required to cover them in the same way or for the same price.

A Medicare Advantage customer can’t use the government-issued red, white, and blue Medicare card when going to the hospital or doctor. Instead, an ID card from the insurance company is required. Customers are confined to a network of doctors, hospitals, and non-hospital treatment facilities. That’s far fewer providers and facilities than accept traditional Medicare. And networks exist to cut costs and increase insurance company profits, which they do very well.

When a Medicare Advantage customer is asked about their insurance when calling for a healthcare appointment, many assume they have Medicare, and tell that to the doctor’s office. But many also get a nasty surprise, sometimes months later, once they arrive for care and discover the doctor is not in network.

What’s more, doctors move in and out of networks all the time so there’s no guarantee that someone in your network today will be there next week. Stability is important in healthcare and even more so the older one gets. Studies indicate that more and more doctors are opting out of Medicare Advantage plans completely because the reimbursement rate is so low and the paperwork to wring it out takes up too many staff hours.

In addition, Medicare Part D, often included in Medicare Advantage or available as a stand-alone component with traditional Medicare, limits drug coverage to the company’s formulary. And there are better, often cheaper ways to get the drugs your doctor prescribes.

Medicare Advantage for New York’s municipal employees is nothing but a gift to Big Insurance and Big Pharma; they don’t need it and our municipal employees deserve better.

Toni L. Kamins is a journalist and the creator and publisher of the Medicare Reporter on Substack.

9 thoughts on “Opinion: Medicare Advantage is a Disadvantage for New York’s Municipal Retirees

  1. And to think my union is In a partnership to provide us with this substandard health insurance…….none of my doctors or local health agencies take this plan! However, my union rep told me they did…out and out lie!

  2. You will be at a real disadvantage holding a Medicare Advantage plan if you are looking at nursing home care and frequent tests. Traditional Medicare does not have the extra layer of approval called the insurance company. Also, if you ever require frequent testing like an MRI even with strong doctor recommendation expect delays and denials. I don’t think the people in charge of making these insurance decisions understand what they are selling. It often looks fine on paper but never in practice. I’m helping a family member with health insurance issues and traditional Medicare is often the way to go if you have frequent medical needs. If you never see a doctor then it doesn’t matter.

  3. I chose to pay the extortion to keep Medicare. It’s better than being robbed every time I need healthcare.

    That’s the choice: Pay the extortion or get robbed regularly.

  4. This push to remove Municipal retirees from traditional Medicare and steer them into privately managed Medicare Advantage plans is deeply unfair. As presently designed, the plan requires that the retirees are automatically enrolled in the Medicare Advantage Plans. They have to “opt out” of the Advantage Plan to remain in the traditional Medicare system. The retirees thought that when they retired, the insurance choices they had made were a contract with the City. The process to opt out is confusing and the ramifications are unclear. Many of these retirees are elderly and/or have serious medical conditions. Medicare should be the default option. This is no way to treat people who spent years serving the City.

  5. I am concerned with the retirees being forced into Medicare Advantage. It is much lees than what they have now. I help people across the country make the right Medicare choices.
    I have a video on why I would never choose Medicare Advantage:
    I also have a video on the best Medicare option in New York:
    I hope the retirees get real help from someone that has their interest in mind.

    • I understand all Medicare Advantage Plans are not the same. I am a NYC retiree and am due to be switched to the NYC Medicare Advantage Plus plan on April 1st. The network of physicians and hospitals is large and nationwide. The biggest issue I have with it are the pre authorizations. If you are familiar with this plan I would appreciate any insight you have. Thank you.

  6. The Medicare Advantage Plan is unfair to retirees who are not represented by a union. The plan does not have prescription coverage and in order to comply with the requirement for part D, retirees are forced to take out the emblem rider at $125.00 per month. This is an unnecessary burden on fixed income retirees as there are stand alone plans available for a fraction of the cost. (My Caremark plan is $12.90)
    While union retirees get there prescriptions through their unions, non union(management) have to take on this rider. WHY?

  7. I have Aetna PPO Plan I received a new card with a new ID number I called Aetna and was told I am in the Medicare Advantage Plan despite “opting out “ twice. Aetna said I will continue to receive the same benefits for now. Medicare Advantage like it or not!!

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