Fighting Against Medicare Advantage

Filed in Delaware, National by on November 17, 2023

Guest post by Representative John Kowalko (25th District, retired)

Over the past year and a half, I have dedicated much of my energy to exposing the fraudulent and dishonest Medicare Advantage Plans for what they are.

This issue has now become the focal point of thousands of ads on television promoting the private insurance industry’s attempts to continue draining billions of dollars of Medicare funding from the system into the insurers’ coffers.

During these commercials, these grifters deliberately omit the realities of harm to the program and the patients who subscribe to it. The truth is that in many if not most situations these plans restrict health care access, restrict, and often deny necessary tests, treatments, pharmaceuticals, and doctors. There are often insurmountable hurdles imbedded in these Medicare Advantage (Disadvantage) plans.

Scores of emails that I’ve received and testimonials that have been documented record the horror stories that many Medicare Advantage enrollees have experienced.

Make no mistake about it. All Medicare Advantage plans displace those who enroll from the government program of Medicare. All Medicare Advantage plans are “privatization” of Medicare and are administered and run by private health care insurers who enjoy immense profits at the expense of those enrolled in their plans.

While we, at RISE, continue to focus our attention on the immediate problem of Governor Carney’s appointees trying to mandate a Highmark Medicare Advantage for all State retirees with no other options, we intend to continue our efforts to displace Medicare Advantage plans as an option nationally.

In Delaware the Governor’s appointees, Claire DeMatteis, Cerron Cade and Rick Geisenberger have lied and deliberately spread misinformation about the Highmark-crafted Medicare Advantage plan. They have lied about the timing of contracts that were allegedly signed and they have tried to perpetuate the falsehood that Highmark’s Medicare Advantage program is not only equal to but better than the existing Medicare supplement plan known as Medicfill that retirees currently enjoy. Their efforts to cheat retirees out of their contractually earned benefits and renege on Delaware’s promises to those retirees should and must be exposed.

The reality that these plans were contrived and conceived in secret meetings outside the public’s view and then presented as a fait accompli demonstrates a serious dishonesty and callous disregard for state retirees. Only the lawsuit filed by RISE enabled a stay of the mandate and a reconsideration of a Medicare Supplement as the retirees’ option. Now the Delaware Legislature must act on behalf of the State employees, teachers, University of Delaware and Police and others to keep those promises made to all of those who have diligently and faithfully served all Delawareans’ best interests over the years.

Medicare Advantage plans will cost retirees money, health care access, and in some cases their lives, needlessly lost.

This Administration tried to impose a Medicare Advantage program on its employees that has over 2,000 impediments to health care access that are not in the current Medicfill supplement program. These include limiting access to your current doctor, specialists, necessary tests, treatments, and pharmaceuticals. These preauthorization requirements and denials of treatments would directly impact the health and well-being of thousands of retirees in Delaware.

This is not some exercise in histrionics or unsubstantiated conjecture. You can see for yourselves by viewing the Highmark Medicare Advantage contract with Delaware, allegedly signed September 28, 2022, at this link.

To date, RISE, hundreds of volunteers, and attorneys retained by RISE at significant expense have managed to ferret out the lies and misinformation presented by this Administration and secured a court ordered temporary stay to this mandate, but it will take more money and a definitive effort by the legislature to secure the promises made to its retirees.

Contributions to the legal fund may be sent to RISE Delaware, PO Box 7262, Newark DE 19714.

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  1. Denial of treatment is a scandal in and of itself. It’s insurance companies saying ‘no’ over and over again until people either give up, prevail eventually, or die while waiting. It’s part of the cruel calculus of the industry–pocket as much money as you can, provide as little service as you can get away with.

  2. Alby says:

    For those unfamiliar with the issues surrounding Medicare Advantage, this will give you some background.

    The concerning part: Money that should go into Medicare to keep the program solvent is instead going to insurance companies.

    https://www.dailykos.com/stories/2023/11/16/2206209/-What-s-Wrong-with-Medicare?pm_campaign=front_page&pm_source=trending&pm_medium=web

  3. paul says:

    Why do we permit private insurers to use Medicare in the names of their insurance products at all? It muddies the waters in the minds of consumers, especially as many programs supplant Medicare benefits, often denying the services that Medicare would have paid. It is unconscionable that private companies are permitted to abuse language in the ways they are.

  4. Here is pretty much EVERYTHING YOU NEED TO KNOW about Medicare Advantage and how it’s marketed:

    https://www.kff.org/report-section/how-health-insurers-and-brokers-are-marketing-medicare-report/

  5. Yet more. This one with a literal money quote:

    https://minnesotareformer.com/2023/11/03/medicare-advantage-is-a-money-grab-by-big-insurers/

    ““Medicare Advantage” is the misleading name given to the privatized portion of Medicare — the portion in which tax dollars are funneled through insurance companies so they can take 15% off the top to pay for administrative costs and profit before sending the other 85% to doctors and hospitals with strings attached. The traditional Medicare program — the unprivatized portion – does not funnel money through insurance companies; it pays doctors and hospitals directly, and it devotes around 2% of its expenditures to administrative costs. Today half of all Medicare beneficiaries are insured by insurance companies and the other half are insured by traditional Medicare.”

    ‘15% off the top to pay for administrative costs and profit.’ Need I say more?

  6. Andrew C says:

    Again, the thing that irks me the most with these plans — as I see them every day, working in billing and coding in a doctor’s office — is the very obvious grift. The plans ask more from Medicare for sicker, more medication-dependent, disabled patients with many chronic conditions. They’re given a risk-value score that estimates their total cost for the insurer, and the government pays out per month. The estimates are ridiculously high and laughable if ever examined, but that means the insurer is pocketing billions every year from over-billing CMS.

    In the last five years, the companies are even outsourcing the jobs of verifying these diagnosis codes — generally how they determine the “value” of a patient — to the very offices that treat them. In other words, me. I do this work. They essentially pay our office in incentives, literally checks in the mail, to confirm or deny diagnosis codes for their enrolled patients. Just pointing and clicking in a website can earn us as much as $100 a pop for a single diagnosis.

    So the problem is that our office has already started to become semi-dependent on these bonuses, which combined with other incentives for reporting compliant patients (blood pressure, diabetic A1c labs, routine screenings, filling prescriptions, etc.) results in tens of thousands of extra dollars from these Advantage Plans. We can never pull out now. Combined with the fact that probably most enrollees are on plans that are free or nearly-free, and increasingly are now the required plan for retiree benefits from other states and pension plans (the nearby Kraft/Heinz plant in Dover, for example), it makes me feel stuck.

  7. Karen Peterson says:

    Rep. Kowalko deserves credit for “sounding the alarm” on Medicare Advantage. He, County Councilwoman Lisa Diller, and Connie Merlet founded “RISE Delaware” as a vehicle to fight the State of Delaware in its attempts to take away our retiree healthcare benefits. It has been a real David and Goliath battle but thanks to our lawsuit and thousands of hours of volunteer work (and donations) by retirees, we won. Now, it’s time for the legislature to do its job and codify the results of our efforts.

    Sen. Karen Peterson (ret.)

    • Michael says:

      Karen, as you know some of us are doing our best to resolve this injustice. Thank you for all your
      research, insight and support! Michael