In 2016, Richard Timmins went to a free informational seminar to learn more about Medicare coverage.
“I listened to the insurance agent and, basically, he really promoted Medicare Advantage,” Timmins said. The agent described less expensive and broader coverage offered by the plans, which are funded largely by the government but administered by private insurance companies.
For Timmins, who is now 76, it made economic sense then to sign up. And his decision was great, for a while.
Then, three years ago, he noticed a lesion on his right earlobe.
“I have a family history of melanoma. And so, I was kind of tuned in to that and thinking about that,” Timmins said of the growth, which doctors later diagnosed as malignant melanoma. “It started to grow and started to become rather painful.”
Timmins, though, discovered that his enrollment in a Premera Blue Cross Medicare Advantage plan would mean a limited network of doctors and the potential need for preapproval, or prior authorization, from the insurer before getting care. The experience, he said, made getting care more difficult, and now he wants to switch back to traditional, government-administered Medicare.
But he can’t. And he’s not alone.
“I have very little control over my actual medical care,” he said, adding that he now advises friends not to sign up for the private plans. “I think that people are not understanding what Medicare Advantage is all about.”
Enrollment in Medicare Advantage plans has grown substantially in the past few decades, enticing more than half of all eligible people, primarily those 65 or older, with low premium costs and perks like dental and vision insurance. And as the private plans’ share of the Medicare patient pie has ballooned to 30.8 million people, so too have concerns about the insurers’ aggressive sales tactics and misleading coverage claims.
Enrollees, like Timmins, who sign on when they are healthy can find themselves trapped as they grow older and sicker.
“It’s one of those things that people might like them on the front end because of their low to zero premiums and if they are getting a couple of these extra benefits — the vision, dental, that kind of thing,” said Christine Huberty, a lead benefit specialist supervising attorney for the Greater Wisconsin Agency on Aging Resources.
“But it’s when they actually need to use it for these bigger issues,” Huberty said, “that’s when people realize, ‘Oh no, this isn’t going to help me at all.’”
Medicare pays private insurers a fixed amount per Medicare Advantage enrollee and in many cases also pays out bonuses, which the insurers can use to provide supplemental benefits. Huberty said those extra benefits work as an incentive to “get people to join the plan” but that the plans then “restrict the access to so many services and coverage for the bigger stuff.”
David Meyers, assistant professor of health services, policy, and practice at the Brown University School of Public Health, analyzed a decade of Medicare Advantage enrollment and found that about 50% of beneficiaries — rural and urban — left their contract by the end of five years. Most of those enrollees switched to another Medicare Advantage plan rather than traditional Medicare.
In the study, Meyers and his co-authors muse that switching plans could be a positive sign of a free marketplace but that it could also signal “unmeasured discontent” with Medicare Advantage.
“The problem is that once you get into Medicare Advantage, if you have a couple of chronic conditions and you want to leave Medicare Advantage, even if Medicare Advantage isn’t meeting your needs, you might not have any ability to switch back to traditional Medicare,” Meyers said.
Traditional Medicare can be too expensive for beneficiaries switching back from Medicare Advantage, he said. In traditional Medicare, enrollees pay a monthly premium and, after reaching a deductible, in most cases are expected to pay 20% of the cost of each nonhospital service or item they use. And there is no limit on how much an enrollee may have to pay as part of that 20% coinsurance if they end up using a lot of care, Meyers said.
To limit what they spend out-of-pocket, traditional Medicare enrollees typically sign up for supplemental insurance, such as employer coverage or a private Medigap policy. If they are low-income, Medicaid may provide that supplemental coverage.
But, Meyers said, there’s a catch: While beneficiaries who enrolled first in traditional Medicare are guaranteed to qualify for a Medigap policy without pricing based on their medical history, Medigap insurers can deny coverage to beneficiaries transferring from Medicare Advantage plans or base their prices on medical underwriting.
Only four states — Connecticut, Maine, Massachusetts, and New York — prohibit insurers from denying a Medigap policy if the enrollee has preexisting conditions such as diabetes or heart disease.
Paul Ginsburg is a former commissioner on the Medicare Payment Advisory Commission, also known as MedPAC. It’s a legislative branch agency that advises Congress on the Medicare program. He said the inability of enrollees to easily switch between Medicare Advantage and traditional Medicare during open enrollment periods is “a real concern in our system; it shouldn’t be that way.”
The federal government offers specific enrollment periods every year for switching plans. During Medicare’s open enrollment period, from Oct. 15 to Dec. 7, enrollees can switch out of their private plans to traditional, government-administered Medicare.
Medicare Advantage enrollees can also switch plans or transfer to traditional Medicare during another open enrollment period, from Jan. 1 to March 31.
“There are a lot of people that say, ‘Hey, I’d love to come back, but I can’t get Medigap anymore, or I’ll have to just pay a lot more,’” said Ginsburg, who is now a professor of health policy at the University of Southern California.
Timmins is one of those people. The retired veterinarian lives in a rural community on Whidbey Island just north of Seattle. It’s a rugged, idyllic landscape and a popular place for second homes, hiking, and the arts. But it’s also a bit remote.
While it’s typically harder to find doctors in rural areas, Timmins said he believes his Premera Blue Cross plan made it more challenging to get care for a variety of reasons, including the difficulty of finding and getting in to see specialists.
Nearly half of Medicare Advantage plan directories contained inaccurate information on what providers were available, according to the most recent federal review. Beginning in 2024, new or expanding Medicare Advantage plans must demonstrate compliance with federal network expectations or their applications could be denied.
Amanda Lansford, a Premera Blue Cross spokesperson, declined to comment on Timmins’ case. She said the plan meets federal network adequacy requirements as well as travel time and distance standards “to ensure members are not experiencing undue burdens when seeking care.”
Traditional Medicare allows beneficiaries to go to nearly any doctor or hospital in the U.S., and in most cases enrollees do not need approval to get services.
Timmins, who recently finished immunotherapy, said he doesn’t think he would be approved for a Medigap policy, “because of my health issue.” And if he were to get into one, Timmins said, it would likely be too expensive.
For now, Timmins said, he is staying with his Medicare Advantage plan.
“I’m getting older. More stuff is going to happen.”
There is also a chance, Timmins said, that his cancer could resurface: “I’m very aware of my mortality.”
Medicare Advantage? More like Medicare Disadvantage.
This flood of money is fattening the bottom line of the health insurance giants even as they’re increasing pressure on the Medicare Hospital Insurance Trust Fund, which is projected to run out of funds in 2026. And Congress is loath to crack down, thanks to the combined power of health insurance lobbying and the program’s popularity with cash-strapped seniors.
Meanwhile, it’s not like seniors are getting better care for the money the federal government is spending — in fact, it can be worse. A research brief posted on the National Bureau of Economic Research website found picking the right plan could literally be a matter of life or death.
So why do people sign up? Traditional Medicare is not simple. It’s a complicated stew of different parts — for hospitalization, for doctors and for prescriptions. Seniors might feel they have to purchase supplemental coverage known as Medigap, which helps cover the co-pays and deductibles that Medicare does not cover.
Many Medicare Advantage plans eliminate or significantly reduce these out-of-pocket costs, as long as beneficiaries stay within their approved network. The private policies also frequently offer vision and dental coverage, not to mention gym memberships, something not on offer in Medicare itself.
Medicare Advantage defenders are quick to point out that surveys show their enrollees are more likely to receive such preventive health and wellness services as monitoring of high blood pressure than those with the traditional program. But it’s usually when someone gets seriously ill that Medicare Advantage’s weaknesses become clear.
What would be best would be to fix Medicare, to make it more generous to enrollees and less generous to insurers. That’s unlikely to happen. But we can at least insist on calling it out for what it is: Try Medicare Disadvantage.
The Truth About Those Medicare Advantage TV Commercials
Why the ‘Friends Talk Money’ podcast hosts say the ‘free’ policy come-ons can be misleading
Now that it’s Medicare Open Enrollment season through Dec. 7, if you’re 65 or older and eligible for Medicare, or a loved one is, you’ll want to know the answer.
“We’re going to give you a Turkey on Thanksgiving! They promise so much.”
My “Friends Talk Money” podcast co-hosts and I just looked into the popular Medicare Advantage plans (also called Medicare Part C plans) for our latest episode, speaking with Medicare maven Diane Omdahl, of the 65Incorporated.com site. These plans, now chosen by 42% of Medicare beneficiaries, are sold by private health insurers, as opposed to the alternative Original Medicare program offered by the federal government.
The commercials, said “Friends Talk Money” co-host Terry Savage, a syndicated personal finance columnist and author and Medicare expert, promote their one-stop shopping and potential money savings.
What the Medicare Advantage Commercials Say
Savage noted the ads often say: “Let us do everything! And we’re going to give you hearing [coverage] and we’re going to give you dental and we’re going to pick you up and drive you to your doctor’s appointments. We’re going to give you a turkey on Thanksgiving! They promise so much.”
Omdahl told listeners: “Based on the commercials that are on television every day, people see something they think is going to be more cost effective and then they opt for that [Medicare Advantage] coverage without really knowing what they’re getting into.”
She’s right. A recent survey by the Kaiser Family Foundation found that seven in 10 Medicare beneficiaries didn’t compare coverage options during the most recent Open Enrollment period. And in a MedicareAdvantage.com survey of over 1,000 beneficiaries, three out of four called Medicare “confusing and difficult to understand.”
According to the Kaiser Family Foundation, the average Medicare beneficiary has a choice of 54 Medicare plans, there are 766 Medicare Part D prescription drug plans and a record 3,834 Medicare Advantage plans will be available in 2022 (up 8% from 2021).
Here’s the bottom line from Omdahl and the “Friends Talk Money” hosts: Some of what you hear on those Medicare Advantage TV ads is true, but the fine print shows that “free” isn’t really “free.” When the commercials say “zero premium, zero deductible and zero co-pay,” that’s not the whole story.
Despite Medicare, Health Costs Are Painful for Americans 65+ | Money & Policy
How high out-of-pocket health costs are causing them financial pain
Before I explain the truth about Medicare Advantage’s costs and coverage, it may help to provide a little context about Open Enrollment and Medicare Advantage plans. (Buckle up: Medicare Open Enrollment rules are complicated.)
During annual Open Enrollment, Medicare enrollees can switch from Original Medicare to Medicare Advantage or the other way around; switch from one Medicare Advantage plan to another and enroll in a Medicare Part D prescription drug plan in certain instances.
There’s also a Medicare Advantage Open Enrollment period, from Jan. 1 through March 31, when you can switch your Advantage plan to a different one or switch back to Original Medicare and sign up for a Part D plan.
The Fine Print of Medicare Advantage Plans
Medicare Advantage plans, usually bundled with prescription drug coverage, typically require you to use health care providers in their network. The policies limit your annual out-of-pocket costs for covered services.
“They think ‘zero premium’ means it’s free, which it’s not.”
“People need to go beyond the commercials” to understand the fine print of Medicare Advantage plans, Omdahl said. “There are indeed zero-premium Advantage plans and many of the plans do not have any [annual out-of-pocket] deductibles. But the zero co-pay is misleading. Zero co-pay is for your primary doctor; depending on where you live, co-pays may apply in other situations.”
In addition, noted Omdahl, “start digging into the evidence of coverage and you will see that Medicare Advantage is pay-as-you go: fifty dollars to see a specialist, four hundred dollars a day for five or six days of hospitalization. So you are writing checks, and that’s what people don’t realize. They think ‘zero premium’ means it’s free, which it’s not.”
Savage said that due to the Medicare program’s rules, Medicare Advantage enrollees could wind up paying out of pocket as much as $7,500 a year; more than $11,000 a year if you use out-of-network health care providers.
“These plans work best if you don’t get sick,” she said. “Once you need to see a lot of specialists, then you start paying.”
Omdahl said that before signing up for a Medicare Advantage plan, understand that anytime you want care other than an emergency, the plan has to approve it.
“If you need physical therapy, for instance, the plan has to approve the request for the service and then they’ll usually say the person gets three visits or five visits or whatever. So, they are controlling the utilization of services of the members,” she explained.
Savage said if you’re in a Medicare Advantage plan and want to switch back to traditional Medicare for 2022, you could run into a problem. “If you have become ill, there’s a medical underwriting [a health care provider must check you out before you’re granted coverage] and in most states they can turn you down for the most comprehensive Medicare supplement [Medigap] plan.”
Think Before You Switch
So, Savage advised, “think very carefully before you switch out of traditional Medicare, which lets you see just about any doctor or go to any hospital.”
I noted a recent study by the nonprofit health care research group The Commonwealth Fund that looked at Medicare Advantage plans and traditional Medicare. Overwhelming majorities of Medicare beneficiaries in both traditional Medicare and Medicare Advantage were satisfied with their care.
The researchers discovered that the Advantage plans didn’t substantially improve beneficiaries’ health care experiences compared to traditional Medicare, but did offer somewhat more care management. That means of those with a health condition, a larger share of Medicare Advantage enrollees in the study said that a health care professional had given them clear instructions about symptoms to monitor and had discussed their priorities in caring for the condition.
Indian pharmaceutical company Marksans Pharma Limited is recalling metformin hydrochloride extended-release tablets because their levels of NDMA, a “probable human carcinogen,” were higher than the acceptable daily intake limit of 96 nanograms per day, according to a recall published this week by the US Food and Drug Administration (FDA).
Metformin tablets are used to treat type 2 diabetes and are designed to lower glucose levels.
The recall applies to metformin tablets between 500 mg and 750 mg, sold under the brand name Time-Cap Labs, Inc.
The recall expands an earlier recall of the same product from this summer. But it’s just one of several metformin products that have been found to contain NDMA in the last year. Seven other pharmaceutical companies have issued recalls for metformin hydrochloride extended-release tablets due to their carcinogenic contents.
The FDA is still investigating where NDMA comes from and how it ends up in metformin products. Most levels found in medications are generally low and fall within the FDA’s accepted daily intake, but recently recalled medications exceed that. Marksans Pharma Limited, India, however, did not reveal how much NDMA its recalled products contained.
The recall applies to the following products, which can be identified by their National Drug Code numbers listed below (National Drug Codes can be used to search and identify products online through the FDA). The tablets are either embossed with 101 or 102 on one side and are plain on the other.
Metformin Hydrochloride Extended-Release Tablets, USP 500mg:
90 counts: 49483-623-09
100 counts: 49483-623-01
500 counts: 49483-623-50
1000 counts: 49483-623-10
Metformin Hydrochloride Extended-Release Tablets, USP 750mg:
100 counts: 49483-624-01
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The American Association for Medicare Supplement Insurance just completed its 2020 Medigap Cost Comparison for those turning 65, and it reveals an important finding that has real significance for insurance agents marketing Med Supps.
“With Medigap Plan F no longer available for new enrollees, we compared Plan G that we expect will become 2020’s No. 1-selling option,” says AAMSI Director Jesse Slome.
Here’s what they found: A 65-year-old man in Manhattan buying Medicare Supplement insurance (Plan G) could pay as little as $268 a month or as much as $476 a month. A 65-year-old woman shopping for Medigap Plan G in Dallas could find coverage for $99 or $381 (monthly).
The Association’s 2020 Price Comparison examined costs for Medicare Plan G costs for Top 10 U.S. Metro Areas. The chart shows the increase in costs for both men and women who will be first applying at age 65. No one Medicare insurance company was consistently the lowest cost for Plan G. No one company was the highest. In fact, for the 20 Zip Codes, the survey found 13 different Medicare insurance companies had either the lowest or the highest prices.
To get the most competitive rate in your area click this link for a free quote: https://mic-financial.com/get-a-quote
- Certain costs are adjusted yearly by the government and can affect premiums, deductibles and other cost-sharing aspects of Medicare.
- Even though each change doesn’t necessarily involve huge dollar amounts, they can add up and should be factored into your monthly health-care spending.
- Beneficiaries with limited income might qualify for Medicaid or other programs that cover Medicare expenses, while higher-income beneficiaries pay more for some parts of coverage.
The maze that is Medicare includes some higher costs for 2020 that beneficiaries might want to factor into their health-care budgets.
For the program’s 61 million beneficiaries — most of whom are 65 or older — certain costs are adjusted by the government from year to year and can affect premiums, deductibles and other cost-sharing aspects of Medicare. While each of the changes don’t necessarily involve huge dollar amounts, experts say it’s important to plan for how any increases will affect your household spending.
“For someone on a fixed income, all of those little changes really add up,” said Elizabeth Gavino, founder of Lewin & Gavino in New York and an independent broker and general agent for Medicare plans.
Basic Medicare consists of Part A (hospital coverage) and Part B (outpatient care). About a third of beneficiaries choose to get those benefits delivered through an Advantage Plan, which are offered by private insurers.
Those plans typically also include Part D prescription drug coverage, as well as extras such as dental or vision. They also limit what you pay out of pocket for Parts A and B services.
Other beneficiaries stick with basic Medicare and pair it with a standalone Part D prescription drug plan. About 30% of them also purchase a supplement plan — aka “Medigap” — which picks up some of the costs that come with basic Medicare, such as coinsurance or copays
And then, there are those in-between.
“We’ve got a subset of people who aren’t eligible for Medicaid or other types of assistance, but they fall into a category where every penny counts,” Gavino said.
Here are costs that have changed for 2020.
Parts A & B
Most Medicare beneficiaries pay no premium for Part A because they (or their spouse) have enough of a work history — at least 10 years — of paying into the system through payroll taxes to qualify for it premium-free.
If you don’t meet the minimum requirement, though, monthly premiums could be as much as $458 a month, depending on whether you’ve paid any taxes into the Medicare system at all. That maximum is up from $437 in 2019.
And, regardless of whether you pay a premium, there are cost-sharing aspects that go with Part A.
For those who don’t have additional coverage beyond basic Medicare, the amount you’d pay when admitted to the hospital will be $1,408 next year, up from $1,364 in 2019. That covers the first 60 days of Medicare-covered inpatient hospital care in a benefit period.
For the 61st through 90th days of a hospitalization, beneficiaries will pay $352 per day, up from $341 in 2019, and then $704 per day for 60 “lifetime reserve” days, up from $682 this year.
Meanwhile, for Part B, the standard premium in 2020 will be $144.60 monthly, up $9.10 from $135.50 in 2019.
Some recipients won’t pay the full standard premium due to a “hold harmless” provision that prevents their Part B premiums from rising more than their Social Security cost-of-living adjustment, or COLA.
Others, however, will pay more than the standard due to income-adjusted surcharges (see tables below).
Keep in mind that the government uses your tax return from two years earlier to determine whether you’ll pay those monthly adjustments. So for 2020, it would be your 2018 return. To request a reduction in that income-related amount due to a life-changing event such as retirement, the Social Security Administration has a form you can fill out.
The annual deductible for Part B will rise to $198, up from $185 in 2019. Once you meet that deductible, you typically pay 20% of covered services. Keep in mind that beneficiaries in Advantage Plans might pay a different amount through copays, and Medigap policies either fully or partially cover that coinsurance.
Also, while Advantage Plan premiums vary among plans — the average for 2020 is $23, down from about $27 this year — any monthly charge would be on top of your Part B premium. And, some of those options either have no monthly charge or will pay your Part B premium.
(If you don’t like your Advantage Plan, you can switch or drop it in the first three months of the year.)
How much you pay for drug coverage depends partly on the plan you choose, along with your income.
The average monthly premium for a standalone drug plan in 2020 will be $30, according to the Centers for Medicare and Medicaid Services, down from $32.50 in 2019. As with Part B premiums, higher earners pay extra (see chart below).
Those surcharges were adjusted slightly downward: for example, individuals with income above $500,000 (again, based on 2018 tax returns) will pay $76.40 extra each month, vs. $77.40 in 2019.
Be aware that those charges are not tacked on to your plan premium — they either come out of your Social Security check or you get a bill.
Also, while not everyone pays a deductible for Part D coverage — some plans don’t have one — the maximum it can be is $435 in 2020, up from $415 in 2019.
For people with high prescription costs, be aware that the amount that Part D enrollees pay out of pocket before qualifying for “catastrophic coverage” will jump to $6,350 in 2020 from $5,100 this year. In that phase of coverage, your share of prescription costs drops.
Remember, though, there are no out-of-pocket limits when it comes to Part D coverage. Sometimes, you can find medicines at a cheaper cost than through your plan, such as with a free drug-discount card or program, such as GoodRx or Blink Health, Gavino said.
However, she said, if you go this route instead of through your insurance, your plan won’t count the medicine’s cost and your copay toward your deductible or other calculations it uses to determine your share.
Medicare’s Fall Open Enrollment Period (OEP) is a busy time for beneficiaries and those who help them evaluate their health care and prescription drug coverage options. From October 15 to December 7 each year, people with Medicare can make changes to their coverage, such as switching Part D prescription drug plans, or switching between Original Medicare and Medicare Advantage. This annual decision-making process can be complex, and several changes this year are making it even more so.
First, people with Medicare must compare more plans than ever before. A new analysis from the Kaiser Family Foundation (KFF) finds the average Medicare beneficiary will have a choice of 28 prescription drug plans (PDPs) in 2020, a 29% increase from just three years ago. And these decisions aren’t getting any easier, as plan premiums continue to vary widely. Among the 20 PDPs available nationwide, average premiums range from $13 to $83 per month.
Second, an unprecedented number of beneficiaries are facing premium increases if they don’t change plans by December 7. According to KFF, two-thirds of Part D enrollees without low-income subsidies—9 million enrollees—will see their monthly premium increase in 2020 if they maintain current coverage. This is largely due to plan changes and consolidations. For example, Humana recently consolidated two of its PDPs (Humana Walmart Rx and Humana Enhanced) into one new plan, Humana Premier Rx, which will carry a $57 monthly premium in 2020. As a result, unless they switch plans, 1.9 million enrollees without low-income subsidies in the Humana Walmart Rx Plan—the third most popular PDP in 2019—will see their monthly premium double in 2020, from $28 to $57.
Third, for this year’s OEP, the Centers for Medicare & Medicaid Services (CMS) redesigned the Medicare Plan Finder (MPF) tool on which millions rely for accurate plan information. Medicare Rights appreciates CMS’s work to modernize MPF; many of the changes are significant improvements. However, we remain concerned that this well-intended revamp may further complicate the plan comparison process for some looking to make plan changes this fall. Specifically, that issues with the new tool’s roll out, content, and functionality could cause beneficiaries to make sub-optimal coverage decisions for 2020, errors they may not discover until well into next year. A recent Health Affairs article underscores this concern, noting that many of the MPF revisions will make the tool more user-friendly—while others may undermine plan selection efforts, including by steering beneficiaries away from lower-cost options.
To mitigate these potential hardships and improve MPF ongoingly, Medicare Rights is working with CMS and other stakeholders to address problems with the tool; we applaud the agency’s responsiveness in quickly adopting many of our initial recommendations. We are also urging CMS to take steps to prevent beneficiaries from experiencing any MPF-related enrollment complications in 2020. We look forward to continuing to work to strengthen this important resource in ways that empower people with Medicare to make informed decisions about their care.
Additionally, amid these trends and changes, Medicare Rights is helping people with Medicare weigh their options. Read more about the services and resources we provide during Fall Open Enrollment, including Medicare Plan Finder appointments, and call our National Consumer Helpline (800-333-4114) today with any questions. We also offer a free, downloadable Fall Open Enrollment guide to connect beneficiaries with accurate, unbiased Medicare information, as well as this online resource to help people get started with the new MPF.