JustCare

Category: Medicare

  • Medicare prices for all?

    Medicare prices for all?

    It’s as yet unclear what the Trump administration and the Republican Congress will do to Medicare. The Heritage Foundation’s Project 2025, if adopted, would appear to let traditional Medicare wither on the vine and force new Medicare enrollees into Medicare Advantage. But, that’s a politically fraught agenda that would also drive up Medicare spending significantly, as Medicare Advantage costs a lot more than traditional Medicare.

    If Republicans are looking for ways to fund their massive tax cuts, they could address the massive overpayments in Medicare Advantage, which are projected to cost more than $1.4 trillion over the next decade. Republican Senators Cassidy, Blackburn and Braun all see the need for this reform. Taking some of the savings to put an out-of-pocket cap in traditional Medicare would help level the playing field between Medicare Advantage and traditional Medicare and promote competition–but strengthening traditional Medicare is likely a bridge too far for Republicans.

    If Republicans want to lower health care costs and raise wages for Americans, without hurting industry, they might consider Phil Longman’s proposal this week in the Washington Monthly–Medicare prices for all. The idea is simply to have employer-sponsored health plans pay providers Medicare prices–not the current average of 254 percent of Medicare. And, then, Longman would require corporations to share the savings with their workers in the form of higher salaries.

    Of course, hospitals and specialists would push back. But, the data suggests that they would suffer little as a result, according to Longman. Most hospitals are non-profit and could manage on Medicare rates.

    Medicare prices for all would neither raise taxes nor require people to give up their private insurance. It would simply eliminate predatory health care prices to the benefit of Americans. Is there a Republican in Congress who would support it?

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  • Congress extends Medicare telehealth coverage through March 31, 2025

    Congress extends Medicare telehealth coverage through March 31, 2025

    Shortly after the onset of the Covid pandemic, Medicare began covering telehealth services for all of its enrollees. It has been doing so ever since. Last week, Congress continued the Medicare telehealth program through the end of March 2025, reports Paula Span for the New York Times.

    Medicare’s telehealth coverage allows older adults and people with disabilities to see their doctors without ever leaving their homes. Consequently, a cancer patient with severe pain in Indianapolis can receive palliative care from a physician in Manhattan, and Medicare will cover it. Palliative care focuses on the comfort and quality of life of the patient.

  • Is Mehmet Oz fit to run Medicare agency?

    Is Mehmet Oz fit to run Medicare agency?

    Last month, Senator Elizabeth Warren, along with six other Democratic Senators, sent a letter to Dr. Mehmet Oz, whom President-elect Donald Trump has named as Administrator-Designate, Centers for Medicare & Medicaid Services (CMS), regarding Dr. Oz’s call for the elimination of traditional Medicare and his lack of qualifications for the CMS Administrator position. If Dr. Oz becomes head of CMS will we be playing with fire?

    Dr. Oz has substantial investments in corporate health insurance companies. He has said that he wants everyone with Medicare in a Medicare Advantage plan, even though Medicare Advantage does not work for large swaths of the population. (People in rural communities who are in Medicare Advantage plans often must travel tens of miles to receive hospital care because their Medicare Advantage plans won’t pay their local hospitals appropriately. People with cancer in Medicare Advantage plans can’t see physicians at cancers centers of excellence because they are all out of network. People who travel and need care in multiple parts of the US can’t get the in-network coverage they need in Medicare Advantage. Amputees and other people needing rehab services too often can only get that care covered if they are in traditional Medicare.)

    Dr. Oz also either does not appear to appreciate or does not care that traditional Medicare is far more cost effective than Medicare Advantage. He either does not know or does not care that Medicare is overpaying corporate health insurers operating Medicare Advantage plans tens of billions of dollars each year.

    MedPAC projects that these insurers will overcharge CMS $83 billion relative to traditional Medicare in 2024 alone. To maximize profits, private insurers make their MA enrollees appear sicker than they actually are. The HHS Office of the Inspector General finds that insurers engage in constant inappropriate delays and denials of needed care and force physicians and hospitals to jump through hoops to deliver needed care. Dr. Oz does not seem to know about or ignores these abuses.

    Dr. Oz also has a financial conflict of interest. He owns more than $550,000 of stock in UnitedHealth, which is under Justice Department investigation for antitrust abuses. But, his desire to eliminate traditional Medicare would double revenue for UnitedHealth to nearly $300 billion.

    Senators Warren, Wyden, Cardin, Merkley, Durbin and Blumenthal ask Dr. Oz for answers to a series of questions by December 23, 2024:

    1. Does he continue to believe traditional Medicare should be eliminated and, if so, why?
    2. Will he commit to protecting Medicare, not privatizing it or cutting benefits?
    3. Does he understand why Medicare Advantage is highly dysfunctional and, if not, what does he think about the upcoding and widespread delays and denials of needed care?
    4. Will he sell off all investments in health insurance companies in order to ensure he has no financial conflicts of interest if he is confirmed as CMS Administrator?

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  • New physician survey finds prior authorization harms cancer patients

    New physician survey finds prior authorization harms cancer patients

    Here’s yet another reason to opt for traditional Medicare over insurer-run Medicare Advantage plans. A new survey by the American Society for Radiation Oncology (ASTRO) finds that insurers’ use of prior authorization can harm cancer patients, reports Renal+Urology News. Prior authorization also makes it hard for oncologists to do their job.

    Your insurance plan should provide good coverage for you today and in the future, whatever your health care needs. Sadly, as we get older, it becomes increasingly likely we will be diagnosed with cancer or some other serious health conditions. So, it’s not wise to gamble with your health insurance.

    According to the 754 oncologists surveyed in the last few months, in more than nine and out ten (92 percent) instances, prior authorization means that patients don’t get care as quickly as they otherwise could. Consequently, about one in ten patients end up forgoing treatment. Some patients end up in the ER or the hospital. Some end up with disabilities, which can be permanent. And, seven percent of respondents said that their patients died.

    More than half of patient radiation oncology services require prior authorization, even though insurers approve them more than seven in ten times initially. On appeal, nearly three quarters of denials are approved.

    Nearly six in ten (58 percent) physicians surveyed said that prior authorization kept them from being able to follow treatment protocols. More than eight in ten (82 percent) said that in some cases they ended up providing their patients with less good treatment as a result of prior authorization.

    Not only can prior authorization seriously harm patients’ primary treatment, it can also prevent them from or pose a significant barrier to their receiving treatment for side effects. For example, they might not be able to get pain or antinausea medicines.

    According to respondents, insurers are ramping up prior authorization requirements, not easing them. A typical delay is at least five days. It also requires more administrative staff.

    Howard M. Sandler, MD, chair of the ASTRO board of directors, sums up the survey findings: “These survey findings confirm what radiation oncologists witness daily: prior authorization policies are failing people with cancer, causing avoidable delays that are dangerous and, in too many cases, deadly.”

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  • Proposed Medicare Advantage rule aims to limit bad insurer behavior

    Proposed Medicare Advantage rule aims to limit bad insurer behavior

    Last week, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, proposed a new rule intended to limit some of the many insurance company bad acts, reports Rebecca Pifer for HealthcareDive. Unfortunately, Medicare Advantage plans all too frequently inappropriately delay and deny people’s care notwithstanding CMS rules. To protect MA enrollees, the government should penalize insurers who violate their obligations severely enough to deter bad acts; without strict penalties, more rules are unlikely to be of much help.

    The CMS proposed rule strives to address five of the biggest concerns with Medicare Advantage. The Trump administration will have the power to decide which, if any, of these proposals will be finalized.

    • Insurers’ use of artificial intelligence to deny care without consideration of patient needs. The rule is designed to make transparent to MA enrollees their insurers’ coverage policies. Insurers sometimes use artificial intelligence to engage in across-the-board denials of care, even when care is urgently needed. The  MA insurers use AI particularly to deny care for people with costly and complex conditions, such as people with cancer and people needing rehabilitation services. New CMS data reveals that more than 80 percent of denials are overturned on appeal, but only four percent of people appeal. The proposed rule also would require insurers to notify enrollees about their appeal rights.
    • Insurers’ publication of inaccurate provider directories that misrepresent which physicians and hospitals are in network. The rule strives to ensure that the provider directories do not mislead enrollees as they are wont to do.
    • Insurers’ misleading marketing. The rule strives to protect enrollees from misleading marketing.
    • Insurers’ coverage of supplemental benefits. The rule aims to ensure that enrollees are fully aware of these benefits and their limitations.
    • Insurers’ reporting of how much money they spend on patient care rather than administration and profits. Insurers are legally required to spend at least 85 percent of the money they are paid to cover enrollees on patient care. But, many appear to find ways to spend a lot less.

    In addition, if finalized, the proposed rule would for the first time require Medicare to cover weight-loss drugs for people who are obese, even if they don’t have other health conditions.

    Here’s more from Just Care:

  • Humana could be penalized over misleading provider directories 

    Humana could be penalized over misleading provider directories 

    Keith Ellison, Minnesota’s attorney general, is trying to hold Humana accountable for misrepresenting the in-network providers in its Medicare Advantage plans, reports Rylee Wilson for Becker’s. It could be the first time that any state has acted to protect their older and disabled residents from misleading Medicare Advantage information. And, it’s about time.

    For more than a decade, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, has reported that insurers mislead older adults and people with disabilities through inaccurate provider directories. But, CMS has never done anything to correct the problem, much less penalize insurers for misleading their enrollees.

    In Minnesota, Ellison says that people considering joining a Humana Medicare Advantage plan are misled to believe that Humana will cover their care from Essentia Health, Avera Health, North Memorial Health and Sanford Health in 2025. But, all have said that they are leaving the Humana Medicare Advantage network at the end of this year.

    In addition to correcting all misinformation in its provider directories as quickly as possible, Ellison wants Humana to detail which Medicare Advantage out-of-network providers it incorrectly listed as in-network this annual open enrollment season. He also wants Humana to protect enrollees who joined based on this misinformation. He argues that Humana should cover their care from these providers.

    According to the Minnesota Star-Tribune, UnitedHealthcare also misleads people with Medicare about the providers in its network.

    Over the last several months, many health systems have ended their contracts with Medicare Advantage insurers. These health systems not only cite huge administrative burdens they face with MA insurers but also large numbers of inappropriate denials of care.

    If you enrolled in a Medicare Advantage plan because you cannot afford traditional Medicare, contact your Senators and representative in Congress. Urge them to add an out-of-pocket cap to traditional Medicare so that it is a meaningful choice for everyone with Medicare, not only a luxury for the wealthy. Only traditional Medicare covers your care from most doctors and hospitals anywhere in the country without requiring prior authorization or otherwise inappropriately delaying or denying medically necessary care.

    Here’s more from Just Care:

  • What will Dr. Oz do as head of Medicare agency?

    What will Dr. Oz do as head of Medicare agency?

    President-elect Donald Trump has nominated Mehmet Oz to be the next head of the Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare and Medicaid, reports the New York Times. The choice of Dr. Oz, a TV celebrity with no government or management experience is in keeping with Trump’s other picks for big government roles. The open question is what will Dr. Oz do as head of CMS?

    If the past is any indicator, Dr. Oz will put in place plans to eliminate the public traditional Medicare program. It would be a huge mistake and arguably not doable, given that Medicare Advantage doesn’t work for some people in some parts of the country and works poorly for people with serious conditions and people with low incomes in many parts of the country. Wealthy Americans who understand the health risks of a Medicare Advantage plan avoid it at all costs.

    Traditional Medicare covers your care from virtually any physician or hospital in the country, without delay or forcing you to go through prior authorization hoops. When you need costly care, as most of us will at some point, Medicare protects you and ensures you are able to get the care you need. Medicare Advantage, in sharp contrast, works well when you’re healthy and tends to delay and deny care inappropriately when you most need care. So, people in Medicare Advantage take a huge risk.

    Back when he ran against John Fetterman for a US Senate seat in 2022, Oz made clear that, unlike his opponent, he does not support “free health care for everyone.”  Oz advocates for Medicare Advantage for All, a health care system that gives full control over our healthcare to big private insurers and will ration care based on ability to pay.

    Oz has suggested a 20 percent payroll tax to cover the costs of his Medicare Advantage for All plan. It would be a huge windfall for the biggest corporate health insurers. It would also be a huge windfall for Oz, as he and his wife are reported to have millions of dollars invested in the health care industry.

    Senator Patty Murray of Washington State expressed deep concern about Dr. Oz’s nomination: “Even putting aside the raft of alarming pseudoscience Dr. Oz has previously endorsed, it is deeply disappointing to see someone with zero qualifications being announced to head up such a critical agency.”

    Here’s more from Just Care:
  • Insurer provider directories misleadingly include physicians who are out of network

    Insurer provider directories misleadingly include physicians who are out of network

    Max Blau reports for Pro Publica on how the big insurers provide their enrollees with misleading directories of in-network providers, but nothing is done to fix the problem. We are in the age of tech, when accurate directories should be quick and easy. Insurers should be held accountable if they cannot keep an accurate provider directory, but neither the states nor the federal government is willing to hold the insurers accountable.

    Blau explains that insurers are not penalized for inaccurate directories and that it takes old fashioned cold-calling to figure out how misleading a provider directory is. Misleading directories are helpful to insurers since they encourage people to enroll; and, yet, the insurers won’t cover care from the providers they list who are not in-network.

    For more than ten years, the federal government has reported large inaccuracies in Medicare Advantage provider directories. Do not assume they are anywhere near accurate and up to date. Providers in the network today can leave the network at any time, and many have been leaving Medicare Advantage plans over the last few years.

    New York State government staff called health care providers listed in insurance company directories to determine whether they were actually seeing patients. They wanted to know two key things about the supposedly in-network providers: Do you accept insurance? And are you seeing new patients?

    But, the New York State staffers found that lots of physicians who were listed in the provider directories no longer accepted the insurance or were not taking new patients. Some of the time, staff didn’t even get a call back. As it turned out, insurers’ enrollees could not get treatment from more than eight in ten mental health providers listed in directories whom staff reached out to.

    The New York State law provides for penalties on insurers who do not keep accurate provider directories. But, New York State rarely penalizes insurers and, when it does, the penalty is tiny. When it comes to provider directories, New York State insurer behavior is no different from insurer behavior in other states. Misleading directories are the norm in most states, including Arizona, California and Massachusetts.

    The US Senate Finance Committee staff undertook an investigation a year ago of Medicare Advantage provider directories, and Senate Finance staff also found extremely misleading provider directories. As in the states, the federal government rarely holds the Medicare Advantage insurers accountable.

    The consequences of inaccurate directories can be dire for patients who cannot find providers to treat their conditions. For the insurers, it’s more money in their pockets. If their enrollees can’t get care, the insurers keep more money and grow profits.

    Here’s more from Just Care:

  • Medicare Advantage networks can be narrow and harmful

    Medicare Advantage networks can be narrow and harmful

    If you’re in a Medicare Advantage plan or thinking of joining one, you should worry about two things: Whether you will get the Medicare benefits you are entitled to when you need costly care and whether you’ll be able to use the doctors and hospitals you want to use. Cheryl Clark reports for MedPage Today on a recent Medicare Payment Advisory Commission (MedPAC) meeting in which commissioners criticized the Medicare Advantage networks as ever-changing and often too narrow and harmful to enrollees.

    You can’t trust Medicare Advantage (MA) provider directories to list in-network providers accurately. A lot of the time, the listed physicians and hospitals are not, in fact, in network. They’ve left the network. Or, they leave the network midyear. It can hurt enrollees, who lose continuity of care and must scramble to find new providers.

    When you buy health insurance, you should be thinking not simply about now but about what could happen to you in the future. Literally anything. A car accident, a fall on ice, a cancer diagnosis, a stroke. You might be away from home. Will your care be covered the way you want it to be in a Medicare Advantage plan? What will you pay out of pocket?

    Here are some of problems you can face in any Medicare Advantage plan when it comes to getting a provider to deliver care. These problems don’t exist in traditional Medicare, the government-administered program that covers your care from almost any physician or hospital in the US:

    1. The Medicare Advantage plan can leave the Medicare program at the end of any year. And, many have done so in the last couple of years.
    2. Physicians and hospitals can leave the Medicare Advantage network. Your care is not covered if you keep seeing these providers. You can pay out of your own pocket to see them or you need to find new providers.
    3. In-network physicians might not be willing to see you. They might have too many patients already.
    4. Cancer centers of excellence and specialists you need to see might not be in-network.

    The Medicare Advantage network directories are very often out of date and inaccurate. Moreover, government oversight to ensure the adequacy of Medicare Advantage plan networks leaves a lot to be desired. Plans know that they can offer inadequate networks without accountability. The government has never penalized a Medicare Advantage plan for offering an inadequate network.

    There’s little good about Medicare Advantage networks in practice, though in theory they should help ensure you are getting good coordinated care. Unfortunately, the insurance companies offering Medicare Advantage make more money keeping you from getting good costly care. So, except for some of the nonprofit Medicare Advantage plans, Medicare Advantage insurers’ incentive is to delay and deny you care from good quality physicians and hospitals when you need them.

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  • What are your Medicare premiums in 2025?

    What are your Medicare premiums in 2025?

    Medicare only covers about half of a typical person’s health care costs. People with Medicare generally pay a monthly Medicare Part B premium, about 16 percent of their medical and inpatient costs out of pocket (or through supplemental coverage: Medigap, Medicaid or retiree insurance) as well as some or all of the cost of dental, vision, hearing and long-term care services. Medicare Part B premiums and other out-of-pocket costs are rising in 2025. Here’s what you need to know.

    Part B premiums in 2024:
    In 2025, people whose modified adjusted gross income from two years ago as reported on their federal tax return is $106,000 or less pay a monthly Part B premium of $185, an increase of $10.30.

    People with incomes above $106,000–about eight percent of the Medicare population–pay a Medicare Part B premium of:

    • $259 a month, if their income is above $106,000 and no more than $133,000.
    • $370 a month, if their income is above $133,000 and no more than $167,000.
    • $480.90 a month, if their income is above $167,000 and no more than $200,000.
    • $591.90 a month, if their income is above $200,000 and less than $500,000.
    • $628.90 a month, if their income is $500,000 or more.

    For couples with combined incomes of $400,000 or less two years ago, filing a joint tax return, the premium amount doubles. Couples filing jointly with annual incomes above $400,000 and less than $750,000 each pay a $591.90 monthly premium. And, couples with annual incomes of $750,000 and above each pay a $628.90 monthly premium. Visit this CMS web site for your Part B premium amount if you are filing separate returns.

    Medicare Part B annual deductible: $257, an increase of $17 from the annual deductible of $240 in 2024.

    For more than four decades, the Medicare Part B premium (medical insurance) was the same for everyone regardless of income, geography or health status, a quarter of the cost of Part B services. (Medicare Part A, hospital insurance, is premium-free if you have contributed into Social Security for at least 40 quarters.)  In 2007, wealthier people with Medicare began paying higher premiums.

    Here are 2025 Medicare Part A costs:

    • There is no Medicare Part A premium if you or your spouse are among the 99 percent of people with Medicare who have at least 40 quarters of Medicare-covered employment.
    • The Medicare Part A inpatient hospital deductible is $1,676, in 2025, and  coinsurance for hospitalizations after day 60 is $419 a day in a benefit period; coinsurance for lifetime reserve days is $838 a day.
    • The Medicare Part A daily coinsurance for skilled nursing facility stays after day 20 is $209.50.

    Extra Help paying your Medicare premiums and out-of-pocket costs: People with low incomes and assets have help paying these costs through Medicaid and the Medicare Savings Program. You should apply through your Medicaid office, if you think you might be eligible.

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