- Medicare Annual Enrollment Period Begins October 15: Look Before You Leap
- This Week in ACA Sabotage
- Breast Cancer Awareness Month
- International Day of Older Persons
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October 18, 2017
It’s that time of year when the leaves begin to change color, and all Medicare beneficiaries can change their coverage options. The Medicare Annual Election Period (AEP) runs from October 15 through December 7; coverage decisions will be effective January 1. This year, MA plans will be marketing a host of new low-cost promotions to entice individuals to join their plans. The Center for Medicare Advocacy urges beneficiaries to carefully weigh all their Medicare options.
Individuals should consider their own unique circumstances before choosing how to access Medicare benefits. They can choose traditional Medicare, or a private Medicare Advantage plan.
People with Medicare can obtain coverage through the traditional national Medicare program; most Medicare beneficiaries do. Those who choose traditional Medicare usually also have to select a Part D prescription drug plan and a Medigap supplemental insurance plan to help with Medicare out-of-pocket expenses. While enrollment can be complicated, and may cost more than private Medicare Advantage plans, there are also advantages to keep in mind. Most doctors, other health care providers, hospitals, and other institutions participate in traditional Medicare. People enrolled in traditional Medicare can access care from all of these providers and can obtain care anywhere in the United States.
About a third of all Medicare beneficiaries are enrolled in a Medicare Advantage plan. Medicare Advantage plans are private plans that may cost less and be easier to enroll in than traditional Medicare, but MA plans also limit enrollee’s choices of health care providers and the geographic area where care will be covered.
State Health Insurance Assistance Programs, (SHIPS) can help make these choices and arrangements. Find your state SHIP at https://www.shiptacenter.org.
The Center outlines advantages and disadvantages of enrolling in a Medicare Advantage (MA) plan below, and provides questions and responses that individuals should consider when making their Medicare choices.
Advantages of Choosing an MA Plan Option
- No claims. Generally, a beneficiary need not submit claims unless emergency or urgent care is received while outside the service area.
- Emphasis on preventive care. Preventive health care, including annual physical exams, as well as some health care screening services not covered under traditional Medicare, although preventive services benefits have expanded in traditional Medicare pursuant to the Affordable Care Act.
- Additional services. These services, which are not covered under traditional Medicare, often include some level of vision care, dental care, and hearing exams.
- No need for Medigap insurance. Managed care plans should provide beneficiaries with all or most of the benefits offered by a Medigap policy.
- Easier to budget health care expenses. Beneficiaries should know the amount of any premiums and copayments for doctor services in advance. In addition, unlike traditional Medicare, MA plans have beneficiary out-of-pocket spending caps.
Disadvantages to Choosing an MA Plan
- Plan terminations. Plans may decide to terminate services and make elections whether to participate in a given market annually.
- Limitations on receiving specialized care. Many plans require a beneficiary to have the prior approval of his or her primary care physician in order to see a specialist. Because of financial incentives and pressures from plan administrators, some primary care physicians resist making referrals. Also, many plans include a limited number of specialists and specialty healthcare institutions in their networks.
- Financial incentives to limit service. Plans receive a capitated rate per beneficiary member. The Center for Medicare Advocacy has heard from a number of providers who report that Medicare Advantage enrollees have shorter periods of covered hospital, skilled nursing facility, and home health care than Medicare beneficiaries in traditional Medicare receive. Waiting time may be longer, fewer tests may be performed, or services may be limited. Limiting services based on financial considerations may result in questionable quality of care.
- Requirement to use plan providers. In most plans, a beneficiary is not free to go to any physician or hospital he or she may choose. Beneficiaries are often “locked in” and must use the plan's providers and facilities or must pay higher premiums for the privilege of going outside the network. In other plans, a beneficiary must pay more to see “non-network” providers. In addition, plans can terminate providers from their networks mid-year, while a beneficiary’s corresponding rights to change plans mid-year are limited.
- Out-of-area care limitations. If a beneficiary lives outside the plan service area for more than a specified period of time, the plan may not sell a beneficiary a plan or may disenroll a beneficiary. Plans cover emergency and urgent care if a beneficiary is out of the service area for a brief time, but a beneficiary must return to the area for routine care. The plan may offer a separate option that covers out-of-area care, but the beneficiary will have to pay an additional premium.
- Limited Service locations. In most plans, there are limited locations where a beneficiary can receive care.
- Higher copayments and deductibles. Provided that services and costs are actuarially equivalent, some plans charge higher copayments and deductibles than traditional Medicare, including larger copayments for hospital, skilled nursing facility (SNF), and home health services, and for durable medical equipment (DME), including oxygen. This has been criticized as a way of cherry picking (e.g., forcing heavy care patients out of the managed care plan).
- Disenrollment. Most enrollees are locked in to their plan for most of the year. When an individual has a right to leave the plan, it can take up to 30 days to disenroll, or other rules may apply, and a beneficiary must continue to use the health plan during this time. Even after the disenrollment becomes effective, Medicare's computers may not be updated, and some traditional Medicare claims will be erroneously rejected.
Below, we reprise a 2016 CMA Alert about considerations that should be reviewed when making this year’s AEP Medicare choices:
1. Which providers/facilities will you want to use?
- How important is it to you to continue seeing them?
- Do they accept Medicare?
- What Medicare Advantage Plan networks do they participate in?
Response: Many people have providers (doctors, specialists, pharmacies, therapists, hospitals) they have gone to for years and they want to continue seeing. Others will want to be sure they will have access to any specialists and facilities they may need. Traditional Medicare will let you use the services of anyone who is a Medicare participating provider – which includes most providers. If you elect to join a Medicare Advantage plan, you usually have to see the contracted providers in their network or receive reduced or no coverage. If keeping your providers is important to you, make sure they are in the network of any Medicare Advantage plan you consider joining. If the providers you want or may need are not, or may not be, in the Medicare Advantage plan networks, you may wish to elect traditional Medicare.
2. Are you comfortable with your care choices being directed…
- By going through a primary care physician?
- By obtaining referrals to see specialists?
- By having to get prior authorization for some services?
Response: In traditional Medicare, there are no required “gatekeepers” to services. As long as the care is reasonable and necessary, you can go directly to the providers to receive Medicare-coverable services. In Medicare Advantage, you typically must go to the “gatekeeper” (usually a primary care provider) who will then determine if you need to be referred for additional care. If making your own decisions about your health care and provider choices is important to you, you may wish to choose traditional Medicare.
3. Do you travel outside your general home area?
- How often?
- How do you feel about having care access limited to emergency coverage and urgent care if you are outside your general home area?
Response: Traditional Medicare coverage is available in all U.S. States and Territories. Wherever you are in the U.S., you have access to Medicare-covered care. Medicare Advantage plans have networks that typically limit care to a small geographic area; if you need care outside that area, coverage from the plan will likely only be for emergency situations. To get more extensive care under Medicare Advantage, you will have to get yourself back to your plan network area. If you travel outside that area, you may prefer coverage through traditional Medicare.
4. What medications do you take?
- What Plan’s formularies include your medications?
- How much are the co-payments for your medications?
- Can you take generic medications?
Response: Whether you are considering traditional Medicare or Medicare Advantage, find out if your medications are covered by visiting the Part D or Medicare Advantage Prescription Drug Plan Finder at https://www.medicare.gov/find-a-plan/questions/home.aspx. Once you determine if your medications are covered and under what plans, it will give you more information to make your decision about which Part D plan or Medicare Advantage plan to choose.
5. Do you qualify for payment assistance or have access to other coverage through any of the following…
- Medicare Savings Program?
- Part D Low Income Subsidy?
- Employer/Military/Other Insurance?
- Medigap Plan?
Response: Contact the State Health Insurance Program (SHIP) in your state (https://www.shiptacenter.org/) to find out if you might qualify for financial assistance and to compare the options available to you for Medigap and Medicare Advantage plans. This information will give you a base by which to compare all the price options and then answer the remaining questions to determine which coverage options are best for you.
6. How important are limits on your annual maximum out-of-pocket costs?
Response: Traditional Medicare does not have an annual out-of-pocket cost maximum. If you can obtain cost-sharing assistance (as determined by question #1), you may have coverage to address this risk. Medicare Advantage Plans have annual out-of-pocket maximums for covered Parts A and B services (typically $6,200 in 2016). These out-of-pocket maximums do not include most prescriptions or costs for non-Parts A and B services (e.g. dental), so out-of-pocket costs on Medicare Advantage may actually run higher than the expected maximum.
7. What is the value for you of some coverage for other possible services?
(Examples: Dental, hearing and/or vision care, health club membership.)
Response: Medicare Advantage plans may offer some coverage for services that are not covered under traditional Medicare. Some of this “additional’ coverage is often limited to plan network “brand” items, or may only be of use to healthy beneficiaries, while some may be of more general use. This limited-dollar-value benefit should be weighed in consideration of all the major medical coverage that a beneficiary may require.
8. How do you weigh the convenience of staying with a coverage option for most of your care versus continual annual checking to ensure providers/coverage requirements are not changing?
Response: Coverage in the traditional Medicare program rarely changes. As long as your provider is participating in Medicare, you have access to the coverage. On the other hand, in Medicare Advantage, providers (doctors, specialists, pharmacies, therapists, hospitals) change annually, and even during the year, due to their individual contracts with the MA plan. Providers do not have to wait for open enrollment to terminate their contracts. You have more assurance of continuity of providers in traditional Medicare. So, what many consider as the “convenience” of Medicare Advantage’s one-stop-shopping at the outset (combining Parts A, B, and D), becomes less convenient as the right Medicare Advantage plan for you must be reviewed on a continuing basis.
9. How do you feel about a Medicare Advantage plan potentially having the ability to challenge your doctor’s determination that your care is reasonable and necessary?
Response: In traditional Medicare, your provider determines if your care is reasonable and necessary. In Medicare Advantage, the Medical Director of the plan, or the Utilization Review Team of the plan, can overrule the determination of your provider. The providers may give up some of their autonomy to be able to participate in the Medicare Advantage plan network. If you want your doctor to decide if your care is reasonable and necessary, you may want to choose traditional Medicare.
10. Will you be more likely to seek care if it is…
- Easily accessible (Almost all providers/suppliers are available)?
- Convenient (Coverage available for care in most geographic areas)?
- Lower cost?
Response: Remember that Medicare Advantage plans have networks of specific providers that are limited to certain geographic areas.
Review your responses to the information provided in this Alert, both financial and coverage related, to consider the best Medicare option to fit your needs and circumstances for next year.
Unfortunately, there are more reports of Affordable Care Act (ACA) sabotage by the Department of Health and Human Services (HHS). We’ve already seen the Administration announce plans to take healthcare.gov offline for significant periods of time during open enrollment, decimate the budget used for outreach and enrollment, cut the enrollment period in half, refuse to participate in enrollment events, and create uncertainty in the marketplace by not committing to paying cost-sharing reductions for the long term.
Now there are reports that HHS officials have told regional staff not to even meet with grassroots organizations about enrollment and that the Administration is looking to dismantle some ACA requirements.
For years, HHS and grassroots organizations have successfully collaborated to educate people about their health insurance options and help them enroll in a plan that meets their needs. This type of collaboration is more critical now than ever before, due to budget cuts to ACA Navigator organizations and the other acts of sabotage listed above. Once again, we urge the Administration to stop undermining the ACA. Protect the care of millions of Americans who need quality coverage.
During the month of October, we pause to remember the survivors, families, loved ones we’ve lost, and all others who have been touched by breast cancer. It is also a time to draw attention to the impact of the disease and the importance of early detection and treatment. According to the Susan G. Komen Breast Cancer Foundation, in 2017 there will be 252,710 new cases of invasive breast cancer and 40,610 breast cancer deaths. According to the Foundation, the two most common risk factors are being female and getting older. Given the prevalence of the disease and the risk factors, it is critical that women have access to quality health coverage and are able to get screening tests and treatment if diagnosed.
Fortunately for Medicare beneficiaries, Medicare covers screening mammograms, diagnostic mammograms, breast prostheses, chemotherapy, prescription drug coverage, person-centered care planning, inpatient hospital care, hospice care, and skilled nursing and home care. For those who need help with out-of-pocket or prescription drug costs, there are Medigap and Special Needs Plans, and the Low Income Subsidy.
The Affordable Care Act (ACA) also provides much needed support by eliminating annual lifetime caps on benefits, giving women access to mammograms, and ensuring that women can’t be denied because their disease is a pre-existing condition. For women without insurance, it is important to note that Marketplace open enrollment begins this year on November 1st and ends on December 15th. Get covered.
The Center for Medicare Advocacy will continue its more-than 30-year fight to ensure that women with chronic conditions like breast cancer have fair access to health care. Survivors, families, and the memories of those we’ve lost are worthy of no less.
Last week, Ben F. Belton, Chiplin Senior Fellow at the Center for Medicare Advocacy, participated in the 27th anniversary of the United Nations International Day of Older Persons (UNIDOP) in New York, NY. This year’s theme was “Stepping into the Future: Tapping the Talents and Participation of Older Persons.” The UNIDOP brought together NGOs, UN representatives, and leaders in aging from around the world to discuss how technology, entrepreneurship and civic engagement will impact global aging. The UNIDOP also formally launched the World Population Ageing 2017 – Highlights, a global report on key trends in population aging and living arrangements of older people. Another highlight was an interactive dialogue featuring representatives from the United States, Germany and Tanzania, on engaging older people in their communities.
As an organization that provides education, advocacy and assistance to help older people obtain fair access to health care, the Center for Medicare Advocacy is pleased to be part of the discussion. As stated in the United Nations Principles for Older Persons, “Older persons should have access to health care to help them to maintain or regain the optimum level of physical, mental and emotional well-being and to prevent or delay the onset of illness.”
We join the United Nations and leaders in aging in celebration of the contributions and resilience of older people around the world.