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

Last week, the Social Security Administration announced that there will be a 2% cost-of-living adjustment (COLA) to Social Security benefits in 2018. However, some people with Medicare will not see the full two percent increase in their monthly benefits. Those who paid less than the standard $134 Part B premium in 2017 had lower costs because they were protected by the hold harmless provision.

This provision prevents an individual’s Social Security benefit from going down from one year to the next as a result of Medicare premium increases. Many people were held harmless in 2016 and 2017 because the COLAs for those years (0% and 0.3%) were not large enough to cover the full amount of the increased Part B premium ($134). For these individuals, the Part B premium increased the same amount as the increase in their Social Security benefit. The average premium for individuals protected by hold harmless in 2017 is $109.

In 2018, the two percent COLA is likely to be enough to cover the difference between a person’s previous premium and the standard Part B premium, which is expected to stay at around $134 per month. In this case, the hold harmless provision will not affect premiums and most people will pay the standard premium. If a person’s benefit does not increase enough for them to pay the $134 without their Social Security benefit decreasing, the hold harmless provision will limit the Part B premium increase to the amount their Social Security benefit increased.

Here is an example of how this will work for someone whose Social Security award in 2017 is $1,300 a month. If someone with Medicare pays the average $109 Part B premium in 2017, their check is $1,191 after the premium is deducted. In 2018, their benefit will increase by $26 to $1,326, and their premium will increase by $25 to $134. Their Social Security check, after the premium deduction, will be $1,192.

People who paid $134 for Part B in 2017 (including people who were new to Medicare in 2017) will have the same 2% increase to their Social Security benefits, but no increase in Part B premiums if the 2018 premium stays the same. These individuals will see an increase to their Social Security check after the premium is deducted.

Everyone should look at their Social Security statement for personalized information about their benefit and premium amounts.

Once the Part B premium for 2018 is announced, we will update the hold harmless page on Medicare Interactive with more details about how the COLA and the Part B premium affect Social Security benefits for people with Medicare in 2018.

Written By: Emily Whicheloe

Massachusetts’ highest court rules that the Stored Communications Act does not prohibit an email provider from disclosing the contents of a decedent’s email account to the decedent’s personal representatives. Ajemian v. Yahoo!, Inc., (Mass., No. SJC-12237, Oct. 16, 2017).

John Ajemian had a Yahoo email account that he used as his primary email. After he died, his personal representatives sought access to the email account. Yahoo declined to provide access without a court order.

Mr. Ajemian’s estate sued Yahoo, seeking a declaratory judgment that it was entitled to access the emails in the account. Yahoo filed a motion for summary judgment, arguing that the federal Stored Communications Act (SCA), which prohibits unauthorized third parties from accessing communications stored by service providers, prevented it from disclosing the emails. The trial court judge agreed, and the estate appealed.

The Massachusetts Supreme Judicial Court reverses, holding that the SCA does not prohibit the estate from accessing Mr. Ajemian’s emails. According to the court, the SCA “permits Yahoo to divulge the contents of the e-mail account where, as here, the personal representatives lawfully consent to disclosure on the decedent’s behalf.”

For the full text of this decision, go to: https://www.mass.gov/files/documents/2017/10/16/12237.pdf

Washington, DC – The Medicare Rights Center and the Center for Medicare Advocacy sent a letter to Senate leadership today in opposition to the recently unveiled “Graham-Cassidy” bill. The letter voices both organizations’ deep concerns that the Graham-Cassidy bill, like its predecessors, would take away access to affordable health care for millions of Americans, especially older adults and people with disabilities. The bill is particularly destructive to the Medicaid program and puts long-term care and services, including nursing home care and the ability for people to stay in their homes, at risk through damaging per-capita caps. The letter urges the Senate to instead pursue bipartisan solutions to strengthen the Affordable Care Act (ACA), Medicaid, and Medicare through an open and transparent process.

“This plan, like those before it, makes no attempt to enhance health care access or affordability for American families,” said Joe Baker, president of the Medicare Rights Center. “Instead, it creates chaos, permanently damages Medicaid, eliminates protections for people with pre-existing conditions, and strips coverage from millions of Americans. This is not the path forward.”

“It’s awful to have to fight for health care—yet again,” said Judith Stein, executive director of the Center for Medicare Advocacy, “but we’re ready. We are appalled the Senate is trying to take away coverage, without public input or a complete Congressional Budget Office score. Americans want to know what the Graham-Cassidy bill would do to their families’ health care coverage. We won’t give up the fight for continued access to the ACA, Medicaid, Medicare, and quality health care.”

To Read the Letter Click Here

Contact:

Center for Medicare Advocacy – Matthew Shepard: 860-456-7790, mshepard@MedicareAdvocacy.org
Medicare Rights Center – Mitchell Clark: 212-204-6286, mclark@medicarerights.org

If the Trump administration’s sabotage of the Affordable Care Act (e.g., threatening to cut-off cost sharing reduction payments, reducing outreach funding by 90 percent, cutting navigator grants by more than 40 percent) is any guide, Medicaid faces a rocky road in the coming months and years.

After Congress failed in its legislative attempts to dismantle Medicaid by capping its funding, the immediate threats to Medicaid lie with the administration as it considers approving waivers submitted by states pursuant to Section 1115 of the Social Security Act. While some of the waivers coming from the states are indeed proposing innovative approaches to improve Medicaid, some states are seeking waivers to impose harmful cuts and restrictions.

Medicaid operates as a federal-state partnership; the federal government provides states with generous funding, but states must adhere to the provisions of the federal Medicaid statute and regulations. Section 1115 of the Social Security Act, however, allows the Secretary of HHS to waive some requirements of the Medicaid Act so that states can test novel approaches to improving medical assistance for low-income people. To be approved, a waiver must:

implement an “experimental, pilot, or demonstration” project;
be limited to the subset of Medicaid provisions in one specific section (42 U.S.C. Sec. 1396a);
be likely to promote Medicaid’s objectives; and
be limited to the extent and period needed to carry out the experiment.

Over the years, courts have enforced these legal limits to the scope of Section 1115 waivers. For example, courts have noted that Section 1115 was not enacted to enable states to save money or to evade federal requirements but rather to test out new ideas and ways of addressing the problems of public benefit recipients.

The administration’s initial HHS Secretary Tom Price signaled a willingness to allow states to dramatically reshape and limit their Medicaid programs using section 1115. We expect his successor will continue on this path. Indeed, the Administration seems on the brink of approving waivers whose main outcomes will be to reduce Medicaid enrollment (thus increasing the numbers of the uninsured) and to unwind the achievement – 30 years in the making – of tying Medicaid coverage to income rather than paternalistic notions of who are the “worthy poor.” The current crop of waiver requests would roll back this progress by conditioning Medicaid (i.e., access to medically necessary health care) on such things as work requirements, drug testing, unaffordable premiums, and high copayments for even emergency use of an emergency department. Several states’ waiver applications (including Ark., Ind., Ky., Maine, Texas, Utah, Wis.) contain some or all of these harmful cutbacks yet the Administration is likely to approve them in whole or in part as early as this month.

These approvals will be problematic. None of them is designed to improve the Medicaid program. Those states that even bother to state a hypothesis focus on saving money rather than improving access.

All this raises some potential legal problems. As noted, section 1115 waivers must be experimental projects that are consistent with the objectives of the Medicaid Act. The stated purpose of Medicaid is to furnish medical assistance and long-term care (such as nursing home care) to low-income individuals.

Instead, the proposals now under consideration are harmful. Take work requirements: In the 50-plus years of Medicaid’s existence and through both Republican and Democratic administrations, HHS has never approved a waiver permitting a mandatory work requirement for Medicaid applicants or enrollees. HHS has always denied these requests, recognizing they reduce access to care. For example, HHS denied work requirement requests from Ariz., Ark., Ind., and N.H. concluding that such requirements are not consistent with Medicaid’s purposes. Lessons from work requirements in TANF reinforce this conclusion. The purpose of Medicaid has not changed, only the administration has changed. Given the limits imposed by section 1115, serious legal questions arise as to whether the HHS secretary has authority to allow a state to impose work requirements.

Mandatory drug testing is also impermissible. Receipt of Medicaid can assist an individual with a substance-use disorder get the treatment needed to stop using drugs and, of course, also provides access to other medically necessary services that the individual needs. Requirements for drug testing that cause people to lose access to care thus conflict Medicaid’s stated purpose.

Notwithstanding this administration’s desire to allow states to restructure their Medicaid programs, Section 1115 does not give the secretary unfettered discretion. The secretary cannot ignore the underlying requirements of the Medicaid Act and has only limited authority to approve Medicaid waivers. If the secretary acts beyond the scope of Section 1115, the approval will be without statutory authorization, and the courts will need to step in.

Courtesy of Mara Youdelman and Jane Perkins on October 12, 2017