JustCare

Category: Medicaid

  • Medicare for all would save $600 billion a year in administrative costs

    Medicare for all would save $600 billion a year in administrative costs

    A new paper by Steffie Woolhandler et al. in the Annals of Medicine exposes our health care system’s grave inefficiencies. It finds that the US currently spends more than $800 billion a year on administrative costs. Medicare for All would eliminate almost three-quarters of these costs and save more than $600 billion a year.

    The vast majority of Medicare for All’s savings would come from doing away with almost all provider-rate negotiations and bureaucratic headaches that come with having commercial health insurance. Today, literally thousands of health insurers must establish their own payment rates and their own set of rules for covering particular services. On top of that, the overwhelming majority of health insurers make a significant profit.

    In 2017, the US spent about one in three health care dollars (34.2 percent) on health care administration, $812 billion. In dollar terms, administrative costs added more than $2,497 to health care spending per person. Compared to Canada, which spent $551 per person on health care administration, the US spent almost five times more. Administrative functions represented just 17 percent of Canada’s health care spending.

    Administrative expenses in the US break down as follows: Insurers’ overhead accounts for $844 of per capita spending as compared to $146 in Canada. Hospital administration accounts for $933 of per capita spending as compared to $196 in Canada. Administrative costs for physicians adds still more to costs in the US.

    The cost of US health care administration has risen by 3.2 percentage points over an 18-year period. Administration had been 31 percent of health care spending in 1999. Three-quarters of the increase in administrative costs stems from high overhead in commercial Medicare and Medicaid managed-care plans.

    Commercial Medicare and Medicaid health insurance plans have far higher administrative costs than the public traditional Medicare program. Medicare Advantage plans, for example, spend about 12% of their premiums on health care administration, easily $1,155 per person more than traditional Medicare. Traditional Medicare spends under two percent on overhead.

    Medicare for All would drive down US administrative costs dramatically. If per person administrative costs in the US were at Canada’s level, $551 a person rather than $2,497, the US would save more than $600 billion a year.

    Here’s more from Just Care:

  • Free local resources to help older adults

    Free local resources to help older adults

    If you’re looking for free local resources to help older adults, your local Area Agency on Aging is a great place to begin. Area Agencies on Aging (AAAs) develop, coordinate and deliver aging services throughout the country. They serve people over 60 at every income level. In fact, they help more than eight million people a year with long-term care choices, transportation options, benefits information and caregiver issues. You can find them in almost every community.

    Most Area Agencies on Aging are also Aging and Disability Resource Centers (ADRCs). ADRCs provide a hub for information on long-term services and supports to help older adults, their caregivers and families; they work to ensure that older adults are better able to live alone in their homes for as long as possible. They are government agencies that work to meet people’s long-term care needs.

    To contact your local Area Agency on Aging for free local resources for older adults or simply to understand available benefits, call the Eldercare Locator 800.677.1116. The Eldercare Locator is a program of the Administration on Community Living. You can also visit the website at www.eldercare.gov.

    LeadingAge, an association of 6,000 community-based non-profit organizations in the U.S., offers another great resource. It has developed on online tool to help you locate non-profit agencies, agencies that “put people before profits,” that provide services and living facilities for older adults.

    By entering a zip code or city, LeadingAge’s Aging Services Directory will let you know about non-profit resources in the community. You can choose from a list of 18 resources, including nursing, transportation, home-delivered meals and dementia care. You can also learn about retirement communities, assisted living, and subsidized housing.

    And, if you need help navigating Medicare, you should contact your State Health Insurance Assistance Program or SHIP.  For the number of the SHIP in your area, click here. Or, for free help, call the Medicare Rights Center national hotline at 800-333-4114.  For other free and low-cost services for older adults, check out Just Care’s Get Help page.

    Here’s more from Just Care:

  • Programs that lower your costs if you have Medicare

    Programs that lower your costs if you have Medicare

    Medicare only covers about half of a typical person’s health care costs. So, even with Medicare, many people struggle to afford premiums, deductibles and other out-of-pockets health care costs. Some people qualify for Medicare, which fills most of the gaps in Medicare. But, if you do not qualify for Medicaid, there are other programs that lower your health care costs.

    1. Medicare Savings Programs. Depending on your income, Medicare Savings Programs, administered by Medicaid, help pay for Medicare premiums and coinsurance, even if you don’t qualify for Medicaid. There are three programs, Qualified Medicare Beneficiary (QMB), Specified-Low Income Medicare Beneficiary (SLMB) and Qualified Individual (QI). Income and asset limits, and how they are counted, are listed below for 2018, but vary somewhat by state. You should apply through your local Medicaid office.
      • Qualified Medicare Beneficiary (QMB)—100 percent of federal poverty level (FPL) + $20
        • Income limit monthly depends upon where you live but is around
          • $1,061 for individuals
          • $1,430 for couples
        • Asset limit
          • Individuals: $7,730
          • Couples: $11,600
      • Specified Low-income Medicare Beneficiary (SLMB)—120 percent of FPL + $20
        • Income limit monthly depends upon where you live but is around
          • $1,260 for individuals
          • $1,711 for couples
        • Asset limit
          • Individuals: $7,730
          • Couples: $11,600
      • Qualifying Individual (QI)—135 percent of FPL +$20
        • Income limit monthly depends upon where you live but is around
          • $1,428 for individuals
          • $1,923 for couples
        • Asset limit
          • Individuals: $7,730
          • Couples: $11,600

      No matter what state you live in, the first $20 of your income and the first $65 of your monthly wages are not counted as income. In addition, half of your monthly wages, after the first $65 is not counted, nor are food stamps. Some of your assets are also not counted, including your primary home, if you own it, your car, your wedding and engagement rings, a burial plot and $1,500 in burial funds, your life insurance with a cash value less than $1,500, and your furniture, household and personal items. Your bank accounts, stocks and bonds are counted.

      Tip: If your income is low but too high to qualify you for Medicaid, it is worth looking into whether you qualify for any of these programs. According to MACPAC, an independent agency that advises Congress on Medicaid policy, less than a half the people over 65 who qualify for the Qualified Medicare Beneficiary program (48%) are enrolled. And, an even smaller share of people over 65 who qualify for the Specified Low-Income Medicare Beneficiary program (28%) are enrolled. About one in seven people over 65 (15%) who qualify for the QI program are enrolled.

    2. Extra Help with Medicare Part D prescription drug coverage: You may qualify for Extra Help, a program administered by Medicaid, which pays for some or all of the cost of your drug coverage. The amount of help with cost-sharing depends on the level of your income and assets. In 2018, you may qualify if you have up to $18,735 in yearly income ($25,365 for a married couple) and up to $14,390 in assets  ($28,720 for a married couple). With Extra Help your drug costs are no more than $3.40 for each generic/$8.50 for each brand-name covered drug. And, depending upon your income, you may pay only part of your Medicare drug plan premiums and deductibles. You get Extra Help automatically if you have Medicaid or a Medicare Savings Program or receive Supplemental Security Income benefits. You can apply for Extra Help online here. (Some states have State Pharmaceutical Assistance Programs that provide even more assistance.)
    3. Federally Qualified Health Centers (FQHCs) and other programs run by the Human Resources and Services Administration: FQHCs are located across the country and provide a wide range of services to underserved populations and areas on a sliding-feed scale. They might waive the Medicare deductible and coinsurance, depending upon your income.
    4. Hill-Burton programs offer free or reduced care at Hill-Burton facilities in 38 states. Hill-Burton does not cover services fully covered by Medicare or Medicaid. Eligibility depends on your family size and income.
    5. Veterans’ Administration: If you are a vet, the Veterans’ Administration (VA) offers low-cost services and prescription drugs directly. And, you can have VA coverage as well as Medicare.

    Keep in mind that you may be eligible for Medicaid based on your income after paying for some health care costs. To contact your state Medicaid office, click here.

    Here’s more from Just Care:

  • Evidence suggests privatized Medicaid long-term care may put people at serious risk

    Evidence suggests privatized Medicaid long-term care may put people at serious risk

    The US health insurance system has become increasingly privatized. One big trend is in the Medicaid program. More than two dozen states have contracted with for-profit health insurance companies to deliver home and community-based services to people with Medicaid, crowding out mission-driven non-profit providers. The available evidence suggests that privatized Medicaid long-term care may put people at serious risk.

    Researchers at the Claude Pepper Center express concern both for people with Medicaid and for taxpayers. These large commercial insurers need to drive profits. And, in the health care space, they can do so relatively easily by delaying and denying people needed care. What’s happening to health care access, quality and costs for people with Medicaid needing long-term services and supports in states that have moved to for-profit Medicaid long-term care?

    Today, more than 1.7 million people with Medicaid are in managed long-term care (MLTC) programs operated by for-profit companies or private equity firms. There is precious little evidence to suggest that these programs are more efficient or deliver better care than the non-profits which had been delivering LTC services. There is simply a mindset among some policymakers that for-profit competition is the better model.

    What do we know? AARP has assessed states with the best LTC programs for people with Medicaid. And, the states which rely most heavily on for-profit long-term care (MLTC) rank at the bottom. Two studies conducted in Texas, which has extremely high MLTC enrollment, found poor quality and a system in need of major intervention. Access to network doctors was inadequate. And, the state has little if any ability to monitor or assess performance by the for-profit insurers.

    The federal government, in partnership with powerful corporations who wield undue influence in Congress and in the states, has pushed this move away from the non-profit model of LTC and towards the for-profit model. The GAO has investigated and found serious cause for concern and a lack of needed oversight. The Centers for Medicare and Medicaid Services (CMS) is doing little to ensure appropriate oversight.

    According to AARP, Washington, Oregon, Vermont, Minnesota, Arkansas, Wisconsin and Colorado have the best long-term care programs. None are MLTC. These states should resist a move to for-profit managed long-term care.

    Here’s more from Just Care:

  • Four things to know if your income is low and you have Medicare

    Four things to know if your income is low and you have Medicare

    Today, more than 11.4 million older adults and people with disabilities are enrolled in both Medicare and Medicaid.  Almost three out of four of them (72 percent) are eligible for full Medicaid benefits, the remaining 28 percent are enrolled in a Medicare Savings Program. While Medicare is an earned health care benefit for people over 65 and with disabilities, Medicaid is a means-based benefit for people with limited incomes and savings. Medicare and Medicaid work together to provide a more comprehensive set of benefits for people with low incomes.

    1. Medicaid picks up many health care costs that Medicare does not cover: Depending upon your income and assets, along with which state you live in, you might qualify for full Medicaid benefits in addition to Medicare. Medicaid would be your secondary insurance, paying after Medicare.  It generally covers the gaps in Medicare, including the Part B premium, the Part D drug premium, deductibles and coinsurance. It sometimes covers routine dental care and travel to and from the doctor’s office and some long-term care. No matter where you live, if you meet state-specific criteria, you will have coverage for nursing home care.  Depending which state you live in, and your care needs, you might also be eligible for home or community-based care.  In addition, there are several Medicaid/Medicare demonstration projects underway testing new ways to deliver home care for people with Medicare, in one project with the help of therapists, nurses and handymen.
    2. Your state Medicaid office or SHIP program can help you know whether you qualify for full Medicaid or other low-income assistance.  Even if your income or assets are over the limit, many states have what are called “spend-down” programs that allow you to qualify for Medicaid after you have spent some of your own money for health care.  You should know that if you own a home, Medicaid does not count it as an asset. To contact your state Medicaid office, click here and to learn about free and low-cost resources, including the State Health Insurance Programs (SHIP), click here.
    3. Some states enroll people with Medicaid and Medicare in commercial managed care plans: But, no matter what state you live in, you have the right to disenroll and switch to traditional Medicare if you’d like. Contact your state Medicaid office to learn about options in your state.
    4. Even if your income or assets are too high to qualify for full Medicaid benefits, Medicare Savings Programs, (administered by state Medicaid programs), may cover some of the gaps in Medicare. In 2013, 8.8 million people were enrolled in a Medicare Savings Program. Four different Medicare Savings Programs fill different Medicare coverage gaps, depending upon your income and assets. To learn more about these programs and which health care costs they pick up, click here.

    In addition to Medicaid and Medicare Savings Programs, there are thousands of government and charitable programs that provide free and low-cost services across the country.

    Here’s more from Just Care:

  • People with Medicare and Medicaid in Special Needs Plans at extra risk

    People with Medicare and Medicaid in Special Needs Plans at extra risk

    A paper in Health Affairs by Marc A. Cohen et al. explains that people with Medicare and Medicaid, “dual-eligibles,” enrolled in commercial Medicare Special Needs Plans, a type of Medicare Advantage plan, are now at extra risk. A new guideline by the Center for Medicare and Medicaid Services (CMS) severely restricts their right to disenroll from these plans. Yet, the data show that dual-eligibles with complex conditions may need to leave Special Needs Plans in order to get appropriate care.

    Dual-eligibles with complex conditions have been disenrolling at high rates from Special Needs Plans. And, it’s likely it’s because they are not getting the care they need. It’s hard to believe that dual-eligibles are jumping at the chance to leave their SNPs if they are getting the care they need. Changing health plans is never fun, always involves time and energy, and usually also stress and frustration.

    Keeping enrollees who choose to leave SNPs from disenrolling is not in these enrollees’ best interests. As of January 1, 2019, however, dual-eligibles may not leave their Special Needs Plan any month of the year, a protection they have always had. They must remain in their SNPs for at least three months, except during the Medicare Advantage Open Enrollment Period, between January and March of each year. Many states limit the disenrollment rights of dual-eligibles even further.

    The new guideline from the Centers for Medicare and Medicaid Services (CMS) supports the financial interests of Special Needs Plans (SNPs) that fail to provide good care to their enrollees. Cohen et al. explain that there is a high correlation between enrollees with complex conditions disenrolling from SNPs and low-quality SNPs. Another recent study showed high rates of disenrollment from Medicare Advantage plans for dual-eligibles with complex conditions.

    The new policy compromises the health of low income older adults and people with disabilities. It gives SNPs the ability to count on additional Medicare and Medicaid income that they previously had not been able to count on, even when they deliver poor care. Supporters of the new policy claim that it gives enrollees more time to adjust to the SNPs. Of course, if the SNPs are not serving their needs, it’s unclear why forcing enrollees to remain in the SNPs is helpful to them.

    To determine whether disenrollment from SNPs was associated with poor SNP performance, the paper’s authors looked at SNP quality measures. They found that the SNPs with poor performance were far more likely to see high disenrollment rates. Unfortunately, dissatisfied enrollees will no longer be able to leave as quickly as they had been able to.

    Here’s more from Just Care:

  • What’s a Medicare Special Needs Plan?

    What’s a Medicare Special Needs Plan?

    Medicare offers commercial health insurance coverage to help people with special needs through Medicare Special Needs Plans. The commercial health plans are a type of Medicare Advantage plan, which are only available in certain areas to certain people. If you qualify, should you join?

    Each Special Needs Plan (SNP) contracts with the Centers for Medicare and Medicaid Services to meet the needs of people with particular conditions. If you enroll in a Medicare SNP, you will only be covered for care from doctors and hospitals in its network.

    Who can enroll in a Medicare Special Needs Plan? A Medicare Special Needs Plan (SNP) is exclusively for people who have particular disabling conditions that the health plan is designed to address, people with both Medicare and Medicaid, “dual-eligibles,” and nursing home residents or other people who need an institutional level of care.

    What are your costs in a Medicare Special Needs Plan? As with all Medicare Advantage plans, your costs will vary depending upon the SNP you join and the care you use. However, if you are enrolled in Medicaid as well as Medicare, you should have no out-of-pocket costs so long as you use network providers. Each SNP sets premiums, copays and deductibles differently. All SNPs must provide Medicare Part D drug coverage, but each may cover a different array of drugs and set different copays. 

    What are your additional benefits in a Medicare Special Needs Plan? SNPs should offer care management and care coordination services to help you better manage your conditions. But, each one is different. If you are considering one of these plans, you should make sure you understand what additional benefits will be available to you, your out-of-pocket costs, and any restrictions on your access to care. For example, are you required to get a referral from a primary care doctor in order to see a specialist?

    Before enrolling in a Medicare Special Needs Plan, make sure you know the tradeoffs between enrolling in that plan and enrolling in traditional Medicare, which covers your care from most doctors and hospitals anywhere in the U.S. Click here to learn key differences between traditional Medicare and Medicare Advantage plans.

    If you are unhappy with your SNP, you have the right to disenroll. However, beginning in January 2019, you can no longer disenroll any month. As a general rule, you must remain in the plan for at least three months. Exception: You may disenroll at any time during the Medicare Advantage Open Enrollment Period, between January and March 31 of each year.

    Two recent studies reveal that people enrolled in Medicare Advantage plans, including Special Needs Plans, tend to disenroll at high rates and enroll in traditional Medicare when they develop complex conditions.

    Here’s more from Just Care:

  • People with serious health needs more likely to disenroll from Medicare Advantage plans

    People with serious health needs more likely to disenroll from Medicare Advantage plans

    A new study by David Meyers, Brown University School of Public Health, et al., of people enrolled in Medicare Advantage plans, published in JAMA Internal Medicine, shows that people with high health care needs disenroll from these commercial Medicare health plans into traditional Medicare at higher rates than people in better health. Their findings suggest that commercial health plans, overall, are not in business to meet the needs of people with complex conditions.

    Medicare Advantage plans have financial incentives to attract healthy members and steer less healthy members out of their plans. The federal government pays these plans a fixed rate per member. The less care each member receives, the more money the health plan gets to keep.

    The study’s authors find that rates of disenrollment from Medicare Advantage plans increase after people experience a serious health condition. The Government Accountability Office also has studied this issue and found that a high proportion of people disenroll from Medicare Advantage plans when they have serious health care needs.

    We have little clue how poorly the people with complex conditions who remain in their Medicare Advantage plans fare. Some evidence is concerning. In May 2018, Just Care reported on another study showing that enrollees in Medicare Advantage plans are more likely to end up in poorer quality skilled nursing facilities than people in traditional Medicare. More recently, a judge in Northern California found that UnitedHealth illegally denied necessary care to tens of thousands of enrollees with mental health needs.

    Poor treatment by commercial health plans of people with costly conditions is one reason why proponents of Medicare for All support improving and expanding Medicare to everyone. Medicare for all would fill gaps in traditional Medicare coverage, eliminating premiums, deductibles and coinsurance and adding vision, hearing, dental and long-term care. Medicare for All would also end commercial health insurance, including Medicare Advantage plans, which drive up costs and differ dramatically from traditional Medicare.

    The study’s authors looked at data of 13.9 million people enrolled in Medicare Advantage plans over a two-year period. They found a disenrollment rate of 4.6 percent for people with high needs as compared to a disenrollment rate of 3.3 percent for people without high needs. They infer from the data that Medicare Advantage plans are less likely to meet the preferences of people with complex conditions than people with fewer health care needs.

    The authors’ findings confirm what we already know. People with complex conditions are often hard-pressed to see the doctors they want to see and get the care they need when enrolled in a commercial Medicare Advantage plan.

    Of course, not all Medicare Advantage plans are alike. The study’s authors suggest that the ones with low star ratings are likely less well-equipped to meet the needs of people with costly conditions. But, the Medicare Advantage plans with five-star ratings could be ones that are engaged in wrongful delays and denials of care; the five-star ratings do not say enough about a plan’s performance to rely upon.

    The authors do not disclose the names of the Medicare Advantage plans with the disproportional disenrollment among enrollees needing costly care. Generally, Medicare Advantage plans only allow researchers to use their data on the condition that the researchers not call out particular health plans; in some cases, the researchers do not know which data belongs to which health plans. Keeping this information confidential is a particular disservice to the public.

    The authors categorized people as having a high health need if they have two or more “complex chronic conditions such as heart failure, chronic obstructive pulmonary disorder, and depression” or “six or more chronic conditions.”  They also looked at dual-eligibles–people with Medicare and Medicaid.

    Dual-eligibles with costly health needs disenrolled from Medicare Advantage plans to traditional Medicare at higher rates than others. But, the authors did not explore whether this is because others may not be able to buy the supplemental coverage they need to fill coverage gaps if they switch to traditional Medicare. The ability to buy supplemental coverage is not guaranteed in many states, except when people initially enroll in Medicare at 65.

    If you support Medicare for All, please tell your members of Congress. Please sign this petition.

    Here’s more from Just Care:

  • Medicaid coverage of home and community-based care

    Medicaid coverage of home and community-based care

    If you would like to remain in your home as long as possible–sometimes called “aging in place“–Medicare will be of only limited help. Medicare pays for only a small amount of home care in situations where it would be difficult for you to leave home on your own and you require skilled nursing or therapy services. That said, Medicaid can be of enormous help if you qualify.

    No matter where you live, if you qualify, Medicaid covers home and community-based services (HCBS). These services include coverage to fill gaps in Medicare and to allow you to remain in your home or a community-based setting, such as an assisted living facility. Medicaid provides services that Medicare will not cover. (Medicare always pays first if it covers the service.) How much care you get and the types of care you get depend upon the state you live in.

    Medicaid services that Medicare does not cover include:

    • Personal care, such as cooking or grocery-shopping
    • Homemaker services, such as cleaning
    • Home modifications
    • Help with chores
    • Case management
    • Adult day care

    Medicaid services that Medicare also covers, include:

    How can you qualify for Medicaid HCBS? You should plan ahead and understand the rules in your state. You may be able to move some of your assets into a trust to help you qualify or spend down your income and assets if they are above the Medicaid eligibility threshold, depending upon where you live. You also may be able to set aside some money for your spouse, if you are married, to bring down your assets. If you own your home, you need to understand how the value of your home will affect your Medicaid eligibility.

    Of course, you will need to meet your state’s eligibility requirements for Medicaid home and community-based services, which generally means that you need nursing home level care. Also, keep in mind that your state may have a limit on the number of people for whom it provides home and community-based services. If so, you may be put on a waiting list.

    Contact your local Medicaid office or Area Agency on Aging to learn more.

    Here’s more from Just Care:

  • Medicare changing nursing home incentives to deter poor care

    Medicare changing nursing home incentives to deter poor care

    Kaiser Health News reports on a ghastly phenomenon that appears all too common for people with Medicare in some nursing homes. To increase their revenues, nursing homes create conditions that lead residents to be rehospitalized. Medicare is now changing its nursing home payment policies to try to align nursing home financial incentives to deter poor care.

    KHN describes one case in which a nursing home literally dropped a resident, causing a hip fracture, and creating a reason to move the resident to a nursing home. That led to a lawsuit from the patient’s family and a settlement of $1.4 million by Richmond Pines Healthcare and Rehabilitation Center in North Carolina.

    All too frequently patients are discharged from hospital to a nursing home and return to hospital in less than a month. One in five Medicare patients are back in hospital after discharge in less than 30 days. And, in many cases, the rehospitalization was preventable–dehydration, medication errors, infections. Keep in mind that Medicare Advantage plans tend to steer people to poorer quality nursing homes than traditional Medicare.

    Unfortunately, Medicare payment policies give nursing homes a financial incentive to transfer patients back to hospital. While it may be good for the nursing homes’ bottom line, taxpayers and patients pay more in these cases.

    Medicare already financially penalizes hospitals with high readmission rates as a way to rein in costs and protect patients. Its policy has reduced the rate of readmissions more than 10 percent, from 12.4 percent to 10.8 percent over five years.

    Medicare is now about to penalize nursing homes for high transfer rates back to hospitals. Today nursing homes with patients who have both Medicare and Medicaid benefit when a patient is rehospitalized because it often triggers a fresh Medicare nursing home care payment for 100 days, which is higher than the Medicaid rate.

    Take care when someone you love is being transferred from hospital to nursing home. Often changes in medication regimens and other treatment protocols are misunderstood or not properly communicated. Moreover, choose hospitals and nursing homes carefully.  Some hospitals and nursing homes are better than others, and it is worth understanding which are the good ones. Medicare’s star ratings do not tell you enough. But, for sure, check out a hospital’s readmission rates and a nursing home’s rehospitalization rates, which can vary significantly.

    Here’s more from Just Care: