October 31

Statement from the Center for Medicare Advocacy on Trump Administration’s ACA Actions

October 13, 2017 – WASHINGTON, DC

Like others who care about the well-being and health care of all Americans, the Center for Medicare Advocacy is dismayed by the Trump Administration’s actions to undermine the Affordable Care Act (ACA).

Following a pattern of sabotaging the ACA – including reducing the ACA enrollment period and gutting funding for both advertising and personal enrollment assistance – President Trump is doubling down on creating chaos. His most recent actions will dramatically increase individual premiums and out-of-pocket costs, while also encouraging people to spend their money on all-but-worthless plans. He is working to dismantle whatever he can of the ACA, regardless of the harm it will cause for millions of families.

Yesterday’s Executive Order would return us to the days when millions of Americans lacked valuable health insurance and consumer protections. The president’s Order would allow the sale of junk plans, sold across state lines, to cherry-pick younger, healthier people. These so-called insurance plans could turn away people with pre-existing conditions, impose lifetime and annual limits, charge older people more and increase out-of-pocket costs.

While Americans were still reeling from yesterday’s action, the White House announced last night that, starting next month, it will no longer fund the cost-sharing reduction subsidies (CSRs) that help lower income people afford valuable ACA health coverage. This decision will lead to increased premiums for millions of individuals. In fact, the Congressional Budget Office (CBO) estimates these actions will increase health insurance costs by 20% in 2018 and up to 25% in 2020. These misguided steps could also increase Medicare costs as people will come onto the program without having had adequate health coverage and care.

Judith Stein, Executive Director of the Center for Medicare Advocacy, states “Congress tried but failed to repeal the Affordable Care Act because of the repeated, overwhelming outcry from the public and virtually every segment of the health care world. The vast majority of Americans want the ACA refined, not repealed. The Administration is ignoring the clearly expressed will of the people with actions that gratuitously harm American families. We urge decision-makers to pursue bipartisan efforts to improve the ACA and advance access to quality coverage and care for all Americans.”

Judith Stein
Executive Director/Attorney
Center for Medicare Advocacy, Inc.

October 30


Why is CMS issuing new Medicare cards and new Medicare numbers?

The law requires the Centers for Medicare & Medicaid Services (CMS) to remove Social Security
numbers (SSNs) from all Medicare cards by April 2019. A new unique Medicare number will replace
the current Health Insurance Claim Number (HICN) on the new Medicare cards. We’re taking this
step to protect people with Medicare from fraudulent use of Social Security numbers, which can lead
to identity theft and illegal use of Medicare benefits.

When will CMS mail the new cards to people with Medicare?

We’ll begin mailing new cards in April 2018 and will meet the statutory deadline for replacing all Medicare cards by April 2019. Your patients who are new to the Medicare program starting in April 2018 and later will only have a card with the new Medicare number.

What do I need to be ready for the change?

Your systems and business processes must be ready to accept the new Medicare number (which we call the Medicare Beneficiary Identifier or MBI in official guidance) by April 2018 for transactions,
such as billing, claim status, eligibility status, and interactions, with our Medicare Administrative
Contractor (MAC) contact centers. There will be a transition period when you can use either the HICN or the MBI to exchange data and information with us.

The transition period will start April 1, 2018, and run through December 31, 2019. However, your systems must be ready to accept the new MBI by April 1, 2018. It’s especially important that you’re ready for people who are new to Medicare in April 2018 and later because they’ll only get a card with the MBI.

How will the MBI look?

The MBI format is still 11 characters long, contains numbers and uppercase letters, and is unique to
each person with Medicare. It will be clearly different from the HICN.

How many characters will the MBI have?

The MBI has 11 characters, like the Health Insurance Claim Number (HICN), which can have up to 11.

Will the MBI’s characters have any meaning?

Each MBI is randomly generated. This makes MBIs different than HICNs, which are based on the
Social Security Numbers (SSNs) of people with Medicare. The MBI’s characters are “non-intelligent”
so they don’t have any hidden or special meaning.

What kinds of characters will be used in the MBI?

MBIs are numbers and upper-case letters. We’ll use numbers 0-9 and all letters from A to Z, except
for S, L, O, I, B, and Z. This will help the characters be easier to read.

How will the MBI look on the new card?
The MBI will contain letters and numbers. Here’s an example: 1EG4-TE5-MK73
● The MBI’s 2nd, 5th, 8th, and 9th characters will always be a letter.
● Characters 1, 4, 7, 10, and 11 will always be a number.
● The 3rd and 6th characters will be a letter or a number.
● The dashes aren’t used as part of the MBI. They won’t be entered into computer systems or used
in file formats.

Who will get a new MBI?

Each person with Medicare will get their own randomly-generated MBI. Spouses or dependents who
may have had similar HICNs will each get their own different MBI.

What about Medicare Advantage and Prescription Drug plans?

Medicare Advantage and Prescription Drug plans will continue to assign and use their own identifiers
on their health insurance cards. For patients in these plans, continue to ask for and use the plans’
health insurance cards.

How do I use the MBI?
You’ll use the MBI the same way you use the HICN today. During the transition period, on all transactions, you can use either the HICN or the MBI in the same field where you’ve always put the HICN. You don’t need to say whether you’re using a HICN or MBI because our systems will be able to tell which you’ve used. You cannot submit both numbers on the same transaction. Once the transition period ends, you must use the MBI in the same field where you previously submitted the HICN.

What about Medicare crossover claims?

We are working closely with other payers, State Medicaid Agencies, and supplemental insurers to
make sure the crossover claims process will still work like it does now. During the transition period,
we’ll process and transmit Medicare crossover claims to other health insurance organizations with
either the HICN or MBI.

Do I need to protect the MBI?

The MBI is confidential just like the HICN so you’ll have to protect it as Personally Identifiable
Information and use it only for Medicare-related business.

What happens after the transition period ends?
On January 1, 2020, even for dates of services prior to this date, you must use MBIs for all transactions; there are a few exceptions when you can use either the HICN or MBI:

● Appeals
– You can use either the HICN or MBI for claim appeals and related forms.
● Claim status query
– You can use HICNs or MBIs to check the status of a claim (276 transactions) if the earliest date of service on the claim is before January 1, 2020. If you are checking the status of a claim with a date of service on or after January 1, 2020, you must use the MBI.
● Span-date claims
– You can use the HICN for 11X-Inpatient Hospital, 32X-Home Health, and 41X-Religious Non-Medical Health Care Institution claims if the “From Date” is before the end of the transition period (December 31, 2019). You can submit claims received between April 1, 2018, and December 31, 2019, using the HICN or the MBI. If a patient starts getting services in an inpatient hospital, home health, or religious non-medical health care institution before December 31, 2019, but stops getting those services after December 31, 2019, you may submit a claim using either the HICN or the MBI, even if you submit it after December 31, 2019.
● Home Health Claims and Requests for Anticipated Payments (RAPs)
– You can use MBIs or HICNs on home health claims and RAPs with a “From Date” before January 1, 2020. Because you submit home health claims for a 60-day payment episode, there may be times when an
episode ends after the transition period on December 31, 2019. If the “From Date” on the RAP
or the final claim date is before December 31, 2019, you may submit either the HICN or the MBI.
But, you must submit the MBI for RAPs and final claims when the “From Date” is on or after
January 1, 2020.

When will CMS share information with the public about the new Medicare card design and the
mailing schedule?

We will share information about the new card design in September 2017. The gender and signature
line will be removed from the new cards. There will be geographical waves of successive mailings.
Mailing everyone a new card will take some time. To protect people with Medicare from scams
associated with sharing the mailing schedule, targeted local outreach will occur, including outreach to
health care providers, before cards are due to arrive in a geographical area.

Where can I get more information?

Visit our New Medicare Card Home and Provider webpages for the latest details about the transition
at: www.cms.gov/Medicare/New-Medicare-Card

October 27

Elderly Hospital Patients Arrive Sick, Often Leave Disabled

AN FRANCISCO — Janet Prochazka was active and outspoken, living by herself and working as a special education tutor. Then, in March, a bad fall landed her in the hospital.

Doctors cared for her wounds and treated her pneumonia. But Prochazka, 75, didn’t sleep or eat well at Zuckerberg San Francisco General Hospital and Trauma Center. She became confused and agitated and ultimately contracted a serious stomach infection. After more than three weeks in the hospital and three more in a rehabilitation facility, she emerged far weaker than before, shaky and unable to think clearly.

She had to stop working and wasn’t able to drive for months. And now, she’s considering a move to Maine to be closer to relatives for support.

“It’s a big, big change,” said her stepdaughter, Kitty Gilbert, soon after Prochazka returned home. “I am hopeful that she will regain a lot of what she lost, but I am not sure.”

Many elderly patients like Prochazka deteriorate mentally or physically in the hospital, even if they recover from the original illness or injury that brought them there. About one-third of patients over 70 years old and more than half of patients over 85 leave the hospital more disabled than when they arrived, research shows.

As a result, many seniors are unable to care for themselves after discharge and need assistance with daily activities such as bathing, dressing or even walking.

“The older you are, the worse the hospital is for you,” said Ken Covinsky, a physician and researcher at the University of California, San Francisco division of geriatrics. “A lot of the stuff we do in medicine does more harm than good. And sometimes with the care of older people, less is more.”

Hospital staff often fail to feed older patients properly, get them out of bed enough or control their pain adequately. Providers frequently restrict their movements by tethering them to beds with oxygen tanks and IV poles. Doctors subject them to unnecessary procedures and prescribe redundant or potentially harmful medications. And caregivers deprive them of sleep by placing them in noisy wards or checking vital signs at all hours of the night.

Interrupted sleep, unappetizing food and days in bed may be merely annoying for younger patients, but they can cause lasting damage to older ones. Elderly patients are far different than their younger counterparts — so much so that some hospitals are treating some of them in separate medical units.

San Francisco General is one of them. Its Acute Care for Elders (ACE) ward, which opened in 2007, has special accommodations and a team of providers to address the unique needs of older patients. They focus less on the original diagnosis and more on how to get patients back home, living as independently as possible.

Early on, the staff tests patients’ memories and assesses how well they can walk and care for themselves at home. Then they give patients practice doing things for themselves as much as possible throughout their stay. They remove catheters and IVs, and encourage patients to get out of bed and eat in a communal dining area.

“Bed rest is really, really bad,” said the medical director of the ACE unit, Edgar Pierluissi. “It sets off an explosive chain of events that are very detrimental to people’s health.”

Such units are still rare — there are only about 200 around the country. And even where they exist, not every senior is admitted, in part because space is limited.

Prochazka went to the emergency room first, then intensive care. She was transferred to ACE about a week later. The staff weaned her off some of her medications and got her up and walking. They also limited the disorienting nighttime checks. Prochazka said she got “the first good night of sleep I have had.”

But for her, the move might have been too late.

“She will not leave here where she started,” Pierluissi said several days before Prochazka was discharged. “She is going to be weaker and unable to do the things you really need to do to live independently.”

Not A Priority

How hospitals handle the old — and very old — is a pressing problem. Elderly patients are a growing clientele for hospitals, a trend that will only accelerate as baby boomers age. Patients over 65 already make up more than one-third of all discharges, according to the federal government, and nearly 13 million seniors are hospitalized each year. And they stay longer than younger patients.

Many seniors are already suspended precariously between independent living and reliance on others. They are weakened by multiple chronic diseases and medications.

One bad hospitalization can tip them over the edge, and they may never recover, said Melissa Mattison, chief of the hospital medicine unit at Massachusetts General Hospital.

“It is like putting Humpty Dumpty back together again,” said Mattison, who wrote a 2013 report detailing the risks elderly patients face in the hospital.

Yet the unique needs of older patients are not a priority for most hospitals, Covinsky said. Doctors and other hospital staff focus so intensely on treating injuries or acute illnesses — like pneumonia or an exacerbation of heart disease — that they can overlook nearly all other aspects of caring for the patients, he noted.

In addition, hospitals face few consequences if elderly patients become more impaired or less functional during their stays. The federal government penalizes hospitals when patients fall, get preventable infections or return to the hospital within 30 days of their discharge. But hospitals aren’t held accountable if patients lose their memories or their ability to walk. As a result, most don’t measure those things.

“If you don’t measure it, you can’t fix it,” Covinsky said.

Improving care for older patients requires an investment that hospital administrators are not always willing to make, experts said. Some argue, however, that the investment pays off — not just for older people but for hospitals themselves as well as for a country intent on controlling health care spending.

Though research on the financial impact of problematic hospital care for the elderly has been limited, a 2010 report by the Department of Health and Human Services’ Office of Inspector General found that more than a quarter of hospitalized Medicare beneficiaries had suffered an “adverse event,” or harm as a result of medical care.

Those events, such as bed sores or oxygen deficiency, cost Medicare about $4.4 billion annually, according to the report. Physicians who reviewed the incidents determined that 44 percent could have been prevented.

In addition to outright mistakes, poor or inadequate treatment in hospitals leads to needless medical spending on extended hospital visits, readmissions, in-home caregivers and nursing home care. Nursing home stays cost about $85,000 a year. And the average hospital stay for an elderly person is $12,000, according to the Agency for Healthcare Research and Quality.

“If you don’t feed a patient, if you don’t mobilize a patient, you have just made it far more likely they will go to a skilled nursing [facility], and that’s expensive,” said Robert Palmer, director of the geriatrics and gerontology center at Eastern Virginia Medical School and one of the brains behind the idea of ACE units.

ACE units have been shown to reduce hospital-inflicted disabilities in older patients, decrease lengths of stay and reduce the number of patients discharged to nursing homes. In one 2012 Health Affairs study, Palmer and other researchers found that hospital units for the elderly saved about $1,000 per patient visit.

A Different Life

After coming home, Prochazka said she felt weak. It took weeks of walking her labradoodle, Gino, to regain strength.

Her stepdaughter, Gilbert, said Prochazka has started to improve. “We knew she was getting better when she was getting ornery,” she said.

But Prochazka, who is highly educated, still has some short-term memory loss, Gilbert said.

Prochazka knows that her life after hospitalization is different than before — she will have to depend more on others. It’s not an easy adjustment, she said.

“I have been somebody who has always been both mentally and physically active,” she said. “Before I fell … I was respected for what I have and what I did and all of a sudden, I’m not.”

She said her time at San Francisco General was frustrating. Getting the infection just as she was starting to recover was especially hard, she said. “I felt like I had been dealt a blow I really didn’t need.”

For other patients, being admitted proactively to the special geriatric unit can stave off such precipitous declines.

Rosenda Esquivel, 80, spent 18 days at San Francisco General, much of it in the unit, this spring. She suffered no noticeable setbacks, physical or mental, during her time in the hospital, according to Annelie Nilsson, a clinical nurse specialist in the unit.

Esquivel, an animated woman who used to work as a home caregiver, was admitted with intense arthritic pain and, while hospitalized, underwent a procedure to address an abnormal heartbeat.

Soon after her arrival, Pierluissi, the ACE unit medical director, speaking to Esquivel in her native Spanish, sought to determine how independent she was at home. He learned that a friend helped take care of her but that she took pride in cooking and cleaning for herself.

The doctor noticed that Esquivel needed help to get up from a chair but that she could get around with a walker. Her memory, though, wasn’t too strong. A few minutes after hearing three words — “honesty,” “baseball” and “flower” — she could only recall one of them.

Pierluissi came up with a plan for her time in the hospital: Get Esquivel’s pain under control. Make sure she walks three or four times a day. Arrange for her to have a caregiver at home to remind her to take her diabetes and blood pressure medications.

Then, release her as fast as possible.

“The less time she spends here, the better,” Pierluissi said.

This story was reported while its author, Anna Gorman, participated in a fellowship supported by New America Media, the Gerontological Society of America and The Commonwealth Fund.

October 26

I.R.S. Says It Will Reject Tax Returns That Lack Health Insurance Disclosure

Despite President Trump’s pronouncements, not only is Obamacare not dead, there are signs that his administration is keeping it alive.

In the latest signal that the Affordable Care Act is still law, the Internal Revenue Service said this week that it is taking steps to enforce the most controversial provision: the tax penalty people face if they refuse to obtain health insurance.

Next year, for the first time, the I.R.S. will reject your tax return when filed electronically if you do not complete the information required about whether you have coverage, including whether you are exempt from the so-called individual mandate or will pay the penalty. If you file your tax return on paper, the agency said it could suspend processing of the return and delay any refund you might be owed.

The agency’s new guidance for tax professionals seems to contradict Mr. Trump’s first executive order, on Inauguration Day, which broadly instructed various agencies to scale back the regulatory reach of the federal health care law.

As part of his promise to overturn the law, the executive order hinted that the new administration could stop enforcing the mandate that people have insurance or pay a tax penalty, which proponents have long argued is critical to the law’s success by requiring young and healthy people to enroll.

The I.R.S.’s guidance makes it clear that taxpayers cannot simply ignore the Affordable Care Act. While the penalty applies only to people without insurance, all taxpayers are required to say whether they have coverage.

Legal experts say the I.R.S. has been clear that the law was in effect, despite repeated efforts by Mr. Trump and Republican lawmakers to repeal it. Congress would have to specifically repeal the mandate, they say, even if the administration has significant leeway over how aggressively it enforces it.

“This guidance should put to rest speculation that the I.R.S. is no longer enforcing the individual mandate and improve compliance,” wrote Timothy Jost, an emeritus law professor at Washington and Lee University in a recent analysis.

But there has been substantial confusion among taxpayers and insurers. Many insurance companies raised their rates for next year’s plans because they were worried the administration would essentially stop penalizing people who refused to buy coverage, leading to fewer enrollments, said Sabrina Corlette, a research professor at Georgetown University.

People may have also mistakenly believed they did not have to comply with the law’s reporting requirements. The new guidance suggests taxpayers will now face a sharp reminder that they need to provide this information, when they go to file a return electronically or submit the appropriate paperwork to get any refund they are due.

Under the law, an individual who does not have insurance can face a penalty of $695 a year for an individual, up to a maximum of $2,085 for a family or 2.5 percent of your adjusted gross income, whichever is higher. People are exempt from the penalty if they have too little income or if the lowest-priced coverage available costs them more than 8.16 percent of their household income.

The I.R.S. had initially held off rejecting returns because the law was new, but then it delayed its plans to assess the effect of the executive order, said Nicole M. Elliott, a tax lawyer for Holland & Knight and a former I.R.S. official involved in putting into effect the Affordable Care Act.

“It is curious, given the executive order,” Ms. Elliott said. “It’s a little unclear where the agencies are going and how heavy-handed they will be in enforcing it.”

In evaluating its stance, the agency may have decided the requirement eases the burden on taxpayers by making it clear they need not worry if they have insurance or are exempt from the penalty, she said.

But the I.R.S. may still decide not to actively enforce the mandate, Ms. Elliott added. While the agency is taking steps to be sure it collects all the information necessary to levy the penalty, it could also take a very lenient view of how aggressively it goes after anyone who does not sign up. “It’s dangerous to read too much into this,” she said.

The White House declined to comment.

The I.R.S.’s decision to actively prepare to enforce the mandate only adds to the uncertainty about where the president stands about the future of the law. Just this month, he issued a second executive order aimed at allowing the sale of skimpier plans to both individuals and small businesses, the same day he announced he would abruptly stop funding subsidies for low-income individuals. He has abruptly switched positions on a new bipartisan proposal aimed at providing short-term stability to the insurance marketplaces under the law.

The proposed bill, drafted by Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington, would restore the government subsidies called cost-sharing reductions for two years. While the draft legislation is unlikely to reduce insurance premium prices for 2018, it could serve to reassure jittery insurance companies that the law has a future beyond next year. On Friday, a group of health plans, hospitals and doctors, as well as the U.S. Chamber of Commerce, came out in support of the proposal.

The I.R.S. action does make it easier to see who should be buying coverage under the law, said Gary Claxton, an executive with the Kaiser Family Foundation. “This was the best way to enforce the mandate,” he said.

But much still depends on what happens next. As part of the second executive order he issued, Mr. Trump seemed to raise the possibility that the A.C.A. market could be further disrupted by the introduction of new plans that would not have to comply with the law. These plans, short-term policies sold to individuals and association plans sold to employers, would be much cheaper and offer far less coverage. If those plans were widely available, younger and healthier individuals and groups could buy them, causing turmoil on the exchanges and soaring prices for A.C.A. plans.

“That would be a bigger deal than this,” Mr. Claxton said.
Correction: October 24, 2017

An article on Saturday about tax penalties associated with the Affordable Care Act misstated the exemption for the cost of coverage. People are exempt if the lowest-priced coverage available costs more than 8.16 percent of their household income, not 2.5 percent of their adjusted gross income.

A version of this article appears in print on October 21, 2017, on Page A14 of the New York edition with the headline: I.R.S. to Reject Tax Returns Out of Step With Care Act

Written By: Reed Abelson in The New York Times

October 25

Medicare Vs. Medicare Advantage: How To Choose

As health insurers struggle with shifting government policies and considerable uncertainty, one market remains remarkably stable: Medicare Advantage plans.

That’s good news for seniors as they select coverage for the year ahead during Medicare’s annual open enrollment period (this year running from Oct. 15 to Dec. 7).

For 2018, 2,317 Medicare Advantage plans will be available across the country, “the most we’ve seen since 2009,” said Gretchen Jacobson, associate director of the Kaiser Family Foundation’s program on Medicare policy. (Kaiser Health News is an editorially independent program of the foundation.)

Medicare Advantage is an alternative to traditional Medicare. Run by private insurance companies, the plans — mostly health maintenance organizations (HMOs) and preferred provider organizations (PPOs) — are expected to serve a record 20.4 million people next year, or slightly more than one-third of Medicare’s 59 million members.

On average, seniors will have a choice of 21 plans, though in some counties and large metropolitan areas at least 40 plans will be accessible, Jacobson said. Availability tends to be far more restricted in rural locations.

While a few insurers are entering or exiting the Medicare Advantage market, most established players are remaining in place. Eight insurers dominate the market: UnitedHealthcare, Humana, Anthem, plans affiliated with Blue Cross and Blue Shield, Kaiser Permanente, Aetna, Cigna and WellCare. (Kaiser Health News is unaffiliated with Kaiser Permanente.)

Despite Medicare Advantage plans’ increasing popularity, several features — notably, the costs that older adults face in these plans and the extent to which members’ choice of doctors and hospitals is restricted — remain poorly understood.

Here are some essential facts to consider:

The Basics

Medicare Advantage plans must provide the same benefits offered through traditional Medicare (services from hospitals, physicians, home health care agencies, laboratories, medical equipment companies and rehabilitation facilities, among others). Nearly 90 percent of plans also supply drug coverage.

In 2018, 68 percent of plans offered will be HMOs, while 27 percent will be PPOs, Jacobson said. The remainder are small, specialized plans that are expected to have relatively few members. In general, HMOs require members to seek care from a specific network of hospital and doctors while PPOs allow members to obtain care from providers outside the network, at a significantly higher cost.

Pros And Cons

The Center for Medicare Advocacy recently summarized the pros and cons of Medicare Advantage plans. On the plus side, it cited:

Little paperwork. (Plan members don’t have to submit claims, in most cases.)
An emphasis on preventive care.
Extra benefits, such as vision care, dental care and hearing exams, that aren’t offered under traditional Medicare.
An all-in-one approach to coverage. (Notably, members typically don’t have to purchase supplemental Medigap coverage or a standalone drug plan.)
Cost controls, including a cap on out-of-pocket costs for physician and hospital services (Medicare Part A and B benefits).

On the negative side, it cited:

Access is limited to hospitals and doctors within plan networks. (Traditional Medicare allows seniors to go to whichever doctor or hospital they want.)
Techniques to manage medical care that can erect barriers to accessing care (for example, getting prior approval from a primary care doctor before seeing a specialist).
Financial incentives to limit services. (Medicare Advantage plans receive a set per-member-per-month fee from the government and risk losing money if medical expenses exceed payments.)
Limits on care members can get when traveling. (Generally, only emergency care and urgent care is covered.)
The potential for higher costs for specific services in some circumstances. (Some plans charge more than traditional Medicare for a short hospital stay, home health care or medical equipment such as oxygen, for instance.)
Lack of flexibility. Once someone enrolls in Medicare Advantage, they’re locked in for the year. There are two exceptions: a special disenrollment period from Jan. 1 to Feb. 14 (anyone who leaves during this time must go back to traditional Medicare) and a chance to make changes during open enrollment (shifting to a different plan or going back to traditional Medicare are options at this point).

Medigap Implications

Choosing a Medicare Advantage plan has implications for the future as well as the present. Notably, if someone enrolls in a Medicare Advantage plan when she first joins Medicare and stays with a plan for at least a year, she may not qualify for supplemental Medigap coverage if she wants to join traditional Medicare at a later date.

Medigap policies cover charges such as deductibles, coinsurance and copayments that seniors with Medicare coverage are expected to pay out-of-pocket. People who join Medicare for the first time are guaranteed access to Medigap policies, no matter what their health status is, only for a limited time. Afterward, they can be denied coverage based on their health in most states.

Parsing Costs

There’s a widespread perception that Medicare Advantage plans cost less than traditional Medicare. But actual costs depend on an individual’s circumstances and aren’t always easy to calculate.

Seniors often first consider what they’ll pay in monthly premiums. This year, the average monthly premium for Medicare Advantage plans is $30, almost $2 below last year’s. But nearly half of Medicare members are enrolled in plans that don’t charge a monthly premium — so-called zero premium plans. (Seniors also need to pay Medicare Part B premiums, although some Medicare Advantage plans cover some or all of that charge.)

To get a full picture of plan costs, which can vary annually, seniors should look beyond premiums to drug expenses (including which drugs are covered by their plan, at what level and with what restrictions); deductibles (plans can charge deductibles for both medical services and drugs); what plans charge for hospital care (some have daily copayments for the first week or so); and coinsurance rates for services such as home health care or skilled nursing care, experts said.

“It’s really critical that folks dig deep and find out about all possible costs they may incur in a plan before they sign up for it,” said Chris Reeg, director of Ohio’s Senior Health Insurance Information Program. (Every state has a program of this kind; find one near you at https://www.shiptacenter.org.)

“Part of the equation has to be what you’ll have to pay if you need lots of care,” said David Lipschutz, senior policy attorney at the Center for Medicare Advocacy “In our experience, that’s often more than people expected.”

Since 2011, Medicare Advantage plans have limited members’ annual out-of-pocket costs to no more than $6,700 — a form of financial protection. There is no similar limit in traditional Medicare. Yet, protection isn’t complete since out-of-pocket limits don’t apply to drug costs, which can be considerable. (In PPOs, a cap of $10,000 limits costs for services received from out-of-network providers as well.)

Plans have discretion in setting out-of-pocket limits. In 2018, 43 percent of plans will have out-of-pocket limits exceeding $6,000; 31 percent will set limits between $4,000 and $6,000; 20 percent will have limits between $3,000 and $4,000; and 6 percent will set limits beneath $3,000, according to a new Avalere Health analysis.

Information about Medicare Advantage plans’ deductibles, copayments and coinsurances rates for medical services as well as coverage details for the medications you’re taking can be found at Medicare’s plan finder.

Finding A Doctor

One way that Medicare Advantage plans try to control costs and coordinate care is by working with a limited group of physicians and hospitals. But reliable information about these networks is hard to find and published directories often contain mistaken or out-of-date information.

“It’s not easy to determine who’s in-network for a Medicare Advantage plan,” said Fred Riccardi, director of client services at the Medicare Rights Center. “This information isn’t on Medicare’s website and there’s no one, streamlined way to search for information about provider networks across plans.” His advice to consumers: Call all your doctors to ask if they’re participating in a plan you’re considering. (Make sure you have your plan number when you do, because a single company may offer multiple plans in your market.)

Making matters even more difficult: Plans can drop physicians or hospitals from their networks during the year, leaving members without access to trusted sources of care.

A new report discloses data about the size of Medicare Advantage plans’ physician networks for the first time. It finds that, on average, Medicare Advantage HMOs included 42 percent of physicians in a county in their networks while PPOs included 57 percent. Altogether, 35 percent of Medicare Advantage members are in plans with narrow physician networks, which tend to be the cheapest plans.

Although this data highlights the choices that seniors have with regard to physicians, it doesn’t speak to the wait time they may encounter in accessing care, Jacobson said, adding that, to her knowledge, this kind of information about Medicare Advantage plans is not publicly available.

Written By: Judith Graham via Kaiser Health News