During open enrollment season, seniors in most parts of the U.S. will have dozens of Medicare Advantage plans to choose from. And while an increasing number of Medicare-eligible Americans are signing up for these private insurer plans, hospital advocates say the plans are threatening both patient care and the bottom line.
“Many of the providers are struggling with Medicare Advantage,” said Stephen Love, the president and CEO of the Dallas-Fort Worth Hospital Council. “The provider side is very concerned.”
Once President-elect Donald Trump takes office for his second term, he could further expand Medicare Advantage, which would exacerbate hospitals’ concerns.
People who are Medicare-eligible — mostly seniors — can choose a Medicare Advantage plan instead of traditional Medicare coverage. Medicare Advantage plans are operated by private insurers such as UnitedHealthcare and Humana. Seniors may opt for the private plans because they often have lower monthly costs and they may provide added benefits such as gym memberships or dental care.
These types of plans have been on the scene for decades, but enrollment has more than doubled in the past 10 years. A total of 33 million people opted to enroll in Medicare Advantage plans for this year, according to data from KFF Health News. That means 54% of people who are eligible for Medicare are enrolled in a Medicare Advantage plan.
Texas as a whole is slightly ahead of the national trend, with 58% of Medicare-eligible residents enrolled in a private plan, according to the KFF Health News data.
Under Trump, health experts say the privatization of Medicare might be accelerated. The Heritage Foundation’s Project 2025 agenda calls for Medicare Advantage to become the default enrollment option for America’s seniors. Trump has publicly distanced himself from Project 2025, but some of the architects of the conservative policy served in Trump’s first-term administration. The president-elect has promoted Medicare Advantage plans in the past.
Medical providers across the country say many Medicare Advantage plans are denying claims for care, requiring pre-approval before care is provided and slow-rolling payments to hospitals.
Denied claims and required pre-approvals can delay patient care, Love said. All three issues can stress medical providers’ finances.
“It can affect their cash flow and it can be significant,” Love said.
In some cases, hospital systems have decided it isn’t worth it to deal with Medicare Advantage plans, and have stopped accepting particular plans. There have been a couple of examples of Texas hospitals dropping these plans, although the exact reason isn’t always clear.
Earlier this year, Memorial Hermann Health System in Houston ended its agreement with Humana’s Medicare Advantage plans, Houston Public Radio reported.
The health system’s vice president of managed care, Michelle Lindsley, said in a statement that agreements with insurers require “mutual trust, transparency and respect.”
“In absence of this necessary foundation, we must make decisions we feel are best for our patients, our workforce, and ultimately the viability of our organization so we might continue serving the Greater Houston community for many years to come,” the statement said.
Southwestern Health Resources — which is affiliated with Texas Health Resources and UT Southwestern Medical Center — decided earlier this year to end its Medicare Advantage plan, known as Care N’ Care.
“Updated Medicare Advantage (MA) requirements, as well as increasing market pressures, resulted in an untenable environment for smaller MA plans like Care N’ Care,” says a statement on the Care N’ Care website.
Across the board, Love said, hospitals in the Dallas-Fort Worth association have expressed dissatisfaction with some Medicare Advantage plans, but haven’t necessarily talked about dropping the plans.
Carrie Williams, spokesperson for the Texas Hospital Association, said the organization doesn’t get involved in providers’ decisions to drop or retain Medicare Advantage plans. And while she didn’t comment on whether Texas hospitals are backing away from the plans, she said the association has been flagging issues with Medicare Advantage plans for years.
The problems with some of the plans are “simply not sustainable,” she said in an email statement.
“We can see that hospitals far and wide are dropping, or considering dropping, Medicare Advantage plans,” Williams said in the statement. “Excessive delays and denials are stressful for patients and stressful for hospitals, and these problems need to be addressed.”
It isn’t just hospitals who have raised concerns.
The U.S. Department of Health and Human Services’ Office of the Inspector General noted in a 2022 report that some Medicare Advantage plans were denying care that likely would’ve been covered by traditional Medicare, including MRIs and inpatient rehabilitation. Another 2022 report from the U.S. Office of Government Accountability found people in their last year of life disenrolled from Medicare Advantage plans at a high rate, indicating potential issues with the care provided under the plans.
The National Association of Insurance Commissioners, which represents state insurance departments across the country, wrote in a September letter that medical providers have been dropping the private plans and leaving patients in a lurch.
“Beneficiaries are faced with either paying the increased out-of-network costs or rescheduling their necessary medical services with another provider who may not have prompt availability,” the letter said. “A delay in access to medically necessary services is likely to result in harm.”
The association wrote that affected patients are contacting their state insurance departments and asking for help. Since Medicare and Medicare Advantage plans are overseen by the federal government and not by state governments, the state offices are unable to help.
In the letter, the association asked the federal Centers for Medicare & Medicaid Services to step in and offer guidance to residents on what happens if their medical provider drops their Medicare Advantage plan.
