Tag: #Medicare

Update – Medicare Advantage – No No

Medicare Advantage (MA) has received mixed reviews after 25 years of implementation. While it may benefit employers, unions, and states with retiree obligations, it has raised concerns for seniors, doctors, and the government. Seniors may receive worse care under MA compared to traditional Medicare, doctors face cumbersome prior authorizations, and the federal government spends more on MA per capita than traditional Medicare. Additionally, several major insurance companies offering MA plans are involved in lawsuits.

Medicare Advantage began life as a brilliant idea: a public-private partnership to keep older people healthier and reduce costs.

At the time in 1992, both President George H.W. Bush and his challenger, Bill Clinton, supported it. An editorial in The New York Times declared, “The debate over health care reform is over. Managed competition has won.” What finally emerged in 1997 — Medicare Choice, now known as Medicare Advantage — was hailed as a win-win-win for patients, providers, and payers.

Twenty-five years later, a different consensus is clear: Medicare Advantage (MA) is a failure for seniors, who receive worse care than they do under traditional Medicare; for doctors, who must negotiate costly and dangerous prior authorizations for their patients; and for the federal government, which spends more per capita on MA than on traditional Medicare. Further, eight of the ten largest insurance companies offering Medicare Advantage plans are currently defendants in False Claims Act lawsuits brought by whistleblowers or the Department of Justice.

But it’s been a winner for employers, unions, and states that have pension and health care obligations to their retirees. They push hard to get people off traditional Medicare and onto MA plans. That’s because retiree benefits often include supplemental or Medigap policies that former employers pay for, while Medicare Advantage plans are almost entirely paid for by the federal government. Medicare Advantage plans are also winners for the private insurance companies that offer and administer them. Their gross margins are typically two to three times greater than other insurance plans.

DO NOT CHOOSE MEDICARE ADVANTAGE

Evidence of Coverage (EOC) | Medicare

What is it?

If you’re in a Medicare Plan, your plan will send you an “Evidence of Coverage” (EOC) each year, usually in the fall. The EOC gives you details about what the plan covers, how much you pay, and more.

When should I get it?

September

Who sends it?

Your plan

What should I do if I get this notice?

  • Review any changes to decide whether the plan will continue to meet your needs in the next year. 
  • If you don’t get this important document, contact your plan.

Benefits Provided by Medicare Advantage

Medicare Advantage, also known as Part C, is offered by private insurance companies. It was introduced in the 1980s to provide competition and choice. Seniors may find that these private plans offer convenience, a wider range of benefits, and lower out-of-pocket costs than Original Medicare. More than 3,100 Medicare Advantage plans are available nationwide as of 2020, with the average beneficiary being able to choose from 28 different plans.

CONS of Medicare Advantage

  • You are always responsible for copayments and coinsurances, and sometimes even for deductibles. Therefore, the cost could be quite high. There is an out-of-pocket limit – $8,300/year.
  • Your choice of doctors/hospitals is limited by the provider network within a specific geographic area. Members are required to pay an increased cost, sometimes up to the full price, for services outside the provider network.
  • Medicare providers may not always accept Medicare Advantage plans so your choices may be limited. Some doctors and hospitals do not participate in any Medicare Advantage plans and others only in a selected few.
  • Many plans require referrals for specialists and other services.
  • Medicare Advantage plans may change every year. Such changes may affect your premium, deductibles, copayments/coinsurances, and the scope of extra services.

Understanding #Medicare Parts A, B, C & D

Do you really need to know the details of what Parts A, B, C, and D stand for? Doesn’t Medicare just pay its share of your bills and that’s it? Well, not entirely. Medicare’s architecture is more than a tad weird, but each of its building blocks determines the coverage you get and what you pay.

Besides that, however, is the simple fact that making sense of Medicare is difficult unless you understand what Parts A, B, C, and D actually mean.

Part A

Medicare Part A is usually described as hospital insurance — a term originally coined to distinguish it from medical insurance (Part B). But the phrase is misleading. “Hospital insurance” sounds as though Part A covers your entire bill if you’re admitted to a hospital, but it doesn’t work that way. The services you receive from doctors, surgeons, or anesthetists while you’re in the hospital are billed separately and are covered under Part B. And you don’t even have to be hospitalized to get services under Part A, because some are provided in settings outside the hospital or even in your own home.

A more accurate way to think of Part A is as coverage primarily for nursing care. It helps pay for the following:

  • The services of professional nurses when you’re admitted to a hospital or a skilled nursing facility (such as a nursing home or rehab center) for short-term stays or when you qualify for home health services or hospice care in your own home
  • A semiprivate room in the hospital or nursing facility
  • All meals provided directly by the hospital or nursing facility
  • Other services provided directly by the hospital or nursing facility, including lab tests, prescription drugs, medical appliances and supplies, and rehabilitation therapy
  • All services provided by a home health agency if you qualify for continuing care at home
  • All services provided by a hospice program if you choose to stop treatment for a terminal illness

The vast majority of people in Medicare are eligible for Part A services without paying any premiums for it. That’s because Part A is essentially paid for in advance by the Medicare payroll taxes that you or your spouse contributed from every paycheck while working.

But, of course, Part A services themselves aren’t free. You still pay deductibles and co-payments for specific services.

Part B

Many people in Medicare never need to go into the hospital, but almost everybody sees a doctor or needs diagnostic screenings and lab tests sooner or later. That’s where Part B — known as medical insurance — comes in. The wide range of services it covers includes the following:

  • Approved medical and surgical services from any doctor who accepts Medicare patients, whether those services are provided in a doctor’s office, in a hospital, in a long-term-care facility, or at home
  • Diagnostic and lab tests done outside hospitals and nursing facilities
  • Preventive services such as flu shots, mammograms, screenings for depression and diabetes, and so on, many of which are free
  • Some medical equipment and supplies (for example, wheelchairs, walkers, oxygen, diabetic supplies, and units of blood)
  • Some outpatient hospital treatment received in an emergency room, clinic, or ambulatory surgical unit
  • Some inpatient care in cases where patients are placed under observation in the hospital instead of being formally admitted
  • Inpatient prescription drugs given in a hospital or doctor’s office, usually by injection (such as chemotherapy drugs for cancer)
  • Some coverage for physical, occupational, and speech therapies
  • Outpatient mental health care
  • Second opinions for non-emergency surgery in some circumstances
  • Approved home health services not covered by Part A
  • Ambulance or air rescue service in circumstances where any other kind of transportation would endanger the patient’s health
  • Free counseling to help curb obesity, smoking, or alcohol abuse

You must pay a monthly premium to receive Part B services unless your income is low enough to qualify you for assistance from your state. Most people pay the standard Part B premium, which is determined each year by a formula set by law ($144.60 in 2020). If your income is over a certain level, however, you’re required to pay more.

You also pay a share of the cost of most Part B services. In traditional Medicare, this amount is almost always 20 percent of the Medicare-approved cost. Medicare Advantage health plans charge different amounts — usually flat dollar co-pays for each service.

Part C

The coverage provided by Part A and Part B together form what is known as traditional or original Medicare — so named because that was the extent of the program’s coverage when it began back in 1966. It’s also called fee-for-service Medicare because each provider — whether it’s a doctor, hospital, laboratory, medical equipment supplier, or whatever — is paid a fee for each service.

But these days Medicare also offers an alternative to the traditional program: a range of health plans that mainly provide managed care through health maintenance organizations (HMOs) or preferred provider organizations (PPOs). These plans are run by private insurance companies, which decide each year whether to stay in the program. Medicare pays each plan a fixed fee for everyone who joins that plan, regardless of how much or little health care a person actually uses. This health plan program is called Medicare Advantage or Medicare Part C.

Medicare Advantage plans must, by law, cover exactly the same services under Part A and Part B as traditional Medicare does. (So, if you need a knee replacement, for example, the procedure is covered — regardless of whether you’re enrolled in a Medicare Advantage plan or in the traditional program.) But the plans may also offer extra benefits that traditional Medicare doesn’t cover — such as routine vision, hearing, and dental care. Most plans include Part D prescription drug coverage as part of their benefits package.

Still, being enrolled in one of these plans is a very different experience from using the traditional Medicare program. Your out-of-pocket costs are different, and so are your choices of doctors and other providers.

Part D

Part D is insurance for outpatient prescription drugs — meaning medications you take yourself instead of having them administered in a hospital or doctor’s office. Medicare’s drug benefit was only added to the program in 2006, a full 40 years after Medicare began. Since then, it has saved huge amounts of money for millions of people and allowed many to get the meds they need for the first time.

Part D is a complicated benefit that takes a lot of getting used to. Here are just some of the peculiar ways it differs from other drug coverage you may have used in the past:

  • Coverage goes through four distinct phases during a calendar year, and in each phase the same drug can cost a different amount.
  • To get coverage, you must select just one private plan that provides Part D drugs out of many plans (at least 15) that are available to you.
  • Different plans cover different sets of drugs, and no plan covers all drugs.
  • Plans set their own co-pays for each drug, and these amounts can vary enormously, even for the same drug.
  • Plans may require you or your doctor to ask permission before they cover certain drugs or to try a less-expensive version before they cover the one you were prescribed.
  • Plans are allowed to change their costs and benefits or to withdraw from Medicare entirely each calendar year.

Source:  Patricia Barry

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