Original Medicare or Medicare Advantage Plans? Which is Better If You have A-Fib?

An A-Fib.com reader emailed me that he has A-Fib and is turning 65. He has to decide whether to sign up for Original Medicare or a Medicare Advantage plan. (Open Enrollment is between October and December each year). This decision will affect how much he pays for coverage, what services he gets, what doctors he can use, and his overall quality of care.

Medicare coverage options is a complicated business. I’m not qualified to give you advice. My intent is to point out areas of interest to A-Fib patients. Remember these comments are only my opinion.

Choice of Doctors?

Which is better if you have A-Fib?

With the Medicare Advantage plans, your choice of doctors is limited. Usually you can only use doctors in the plan’s network. This may be fine for a primary care doctor or family doctor.

What if you need a specialist? To see a specialist, you’ll need a referral from your primary care doctor. These referrals are often hard to obtain. You also need prior approval for most services.

Choice of Electrophysiologists (EPs)?

If you have A-Fib, your choice of EPs in Medicare Advantage plans is severely limited. All too often Medicare Advantage plan administrators seem more motivated to reduce your choices.

In one instance, I found only a single EP listed as available for someone I was trying to advise.

Referrals Out of Network. And it’s nearly impossible to get a referral to an industry leader, no matter how good a doctor is or how great a reputation they have. The administrators make it incredibly difficult. And there is usually no appeal.

Not All EPS Are Equal. Most EPs in Medicare Advantage plans would not be considered world beaters (i.e., best in their field). Though most of my experience with Advantage Plans is anecdotal, I’ve never seen an EP industry leader listed in these types of plans.

Not all EPs are equal. Some are low volume operators with high complication rates. You want to avoid these types of EPs at all costs.

When You Need the Best: If your A-Fib is difficult to treat or you have comorbidities (i.e., hypertension, obesity, diabetes) that complicate your treatment, your choice of EP is vital. You need an EP with a track record in successfully treating difficult A-Fib cases.

Shameful: I know of one person who was diagnosed with A-Fib under a Medicare Advantage plan. She was never told about Electrophysiologists who are specialists in arrhythmias, and she was never told about treatments like catheter ablation. This is all despite her facility having well-respected EPs and an active catheter ablation lab. The staff knew but didn’t discuss it with her.

In the end, she had to visit our website to learn about Electrophysiologists and catheter ablation options.

Medicare Gives You Real Choices

Compared to Medicare Advantage plans, with Original Medicare you can use any doctor or hospital that takes Medicare, anywhere in the US.

This is really important if you have A-Fib. You want to be able to go to the best EP you can find.

Fees or Fines for Seeing an EP in Medicare Advantage Plans

Another factor to be considered in Medicare Advantage plans is you pay a fee or fine for every time, for example, when you see an EP. One person told me his fee was $45.00 for one visit to an EP. Those fines or fees can add up pretty fast, especially when you have comorbidities and see multiple doctors for specialized tests.

In contrast, Original Medicare covers routine doctors’ visits. They send payment to the doctor, and the doctor cannot charge the person more than the plan allows. (Check your coverage before making any coverage decision.)

Be Prepared to Fight Advantage Plan Administrators

Having to interact with a Medicare Advantage plan administrator can be a very frustrating experience. Knowing you’re not being taken care of properly can be very depressing.

You often have to be very assertive and fight them ‘tooth and nail’ to get the care and treatment you need. It can take weeks, months, even years until you finally see the right doctors and receive the treatment you need.

Medicare: More Choices and Better for Psychological Health

The bottom line for most A-Fib patients is that Original Medicare not only gives you more choices but is also better for your psychological health. Also, with Original Medicare if you disagree with a coverage or payment decision, you have the right to appeal. (See Your Medicare Benefits booklet.)

Under Original Medicare, it’s tremendously liberating to know you can go to any doctor or facility you want. The last thing you want in your life is some bureaucrat dictating to you what treatments or doctors you can access.

Though obviously many personal and individual factors may influence your choice of Medicare plans, in general, Original Medicare is probably a better choice for many patients with A-Fib.

Medicare coverage options is a complicated business. To learn more, see the downloadable booklet, Your Medicare Benefits.

Are My Comments Too Negative?

Your choice of health coverage is a tricky subject. People tend to email me when they have negative experiences. So, my anecdotally-based comments may be more negative than warranted. There are many different Medicare Advantage plans. Some may be better than others.

If anyone has any clinical studies on this subject or more positive experiences, please let me know.

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