JustCare

Category: Medicare

  • Older people’s annual drug costs average $26,000

    Older people’s annual drug costs average $26,000

    A new AARP Public Policy Institute report reveals that drug prices have been increasing significantly over the last 10 years, way higher than overall inflation. Indeed, double-digit retail price increases have been the norm, contributing to higher health insurance premiums, deductibles and copays. Today, older people’s annual drug costs average $26,000, most of which is covered by insurance. Will Trump honor his campaign pledge to rein in drug prices? In the meantime, how can you keep your out-of-pocket drug costs down?

    In 2015, the average increase in the price of 268 brand-name prescription drugs heavily used by people with Medicare was 15.5 percent as compared with the rate of inflation, which was 0.1 percent. What does this mean from a cost perspective?

    Older adults take 4.5 prescription drugs on average for their chronic conditions. In 2015, the average annual cost of one brand-name drug to treat a chronic condition was $5,800. This means that average annual drug costs for the typical older adult total $26,000–$1,850 more than the median yearly income for older people with Medicare. And, in 2014, 576,000 Americans had annual drug bills over $50,000.

    A majority of people with Medicare have prescription drug coverage that pays for most of the cost of the drugs they need. But, out-of-pocket costs in the form of premiums, deductibles and copays can still be high.

    To keep your costs down:

    House Speaker Ryan and the Republican leadership are looking to take the money the federal government currently spends on Medicare and use it to pay for tax cuts for the wealthy over the next ten years. If they succeed, people with Medicare will be forced to spend a lot more out of pocket for their drugs or go without them. If you believe the government should keep its hands off Medicare, please sign this petition.

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  • Check your medical bills before paying them

    Check your medical bills before paying them

    All it takes is a visit to the doctor and a few tests or pretty much any visit to the hospital and you’re very likely to see a large number of medical bills. They just seem to keep rolling in, even when you’re relatively healthy. Expert advice is to check your medical bills before paying them–carefully–as they may be wrong.

    All kinds of factors can cause errors, including simple human data inputting mistakes or miscoding by health care providers. So much information is collected and reported that it’s inevitable that there will be mistakes.

    So, check to make sure that your medical bills are for services you actually received. If you’re not sure, call your doctor to find out. And, make sure you understand your health insurer’s deductibles and copays. They can change from one year to the next.

    Beware of surprise medical bills, bills you don’t expect from doctors who are not in your insurer’s network. Too often, people get care from out-of-network doctors who are working in an in-network hospital. If you get a surprise medical bill, here’s how to protect yourself and contest it.

    And, if your insurer denies coverage, you should appeal. If you have Medicare, it’s easy, costs you nothing, and you have a high likelihood of winning and getting Medicare to pay. With traditional Medicare, all you need do is return the Medicare summary notice to Medicare, circle the denial and fill out the section at the bottom of the MSN for the Medicare insurance carrier to review the denial. For more information, read this post from Just Care on how to fight back and appeal if your health plan denies coverage.

    If you have Medicare, State Health Insurance assistance Programs, SHIPs, provide free counseling to help advise you on your medical bills. You can find the number for your state’s SHIP online or by calling  800-677-1116. You can also contact the Medicare Rights Center, which provides free Medicare counseling services, at 1-800-333-4114. For information on other free and low-cost services, visit the Just Care Get Help page.

    Here’s more from Just Care:

  • What’s the Medicare premium in 2017?

    What’s the Medicare premium in 2017?

    The monthly Medicare Part B premium in 2017 technically is $134.00, up 10 percent from this year, for people with incomes of $85,000 or less. It’s a big increase, but half as much as the Trustees suggested it might be. More importantly, because Social Security benefits are barely increasing, the vast majority of people with Medicare are seeing a far smaller premium increase.

    In late June, in the Medicare Trustees’ annual report to Congress on Medicare’s financial state, the Trustees projected as much as a 20 percent increase in Medicare premiums for some people because of rapidly rising health care costs. However, about 70 percent of people with Medicare are seeing a premium increase of $4.00 a month from last year’s premium of $105. That’s because of a “hold harmless” provision in the Social Security Act that protects most people with Medicare from paying more in Medicare premiums than the increase in their Social Security monthly benefits.

    Since Social Security benefits are barely increasing in 2017, up just 0.3 percent or about $4.00 a month, Medicare monthly premiums can only increase that much for the majority of people with Medicare. But, about three in ten people with incomes of $85,000 or less will pay the full $134.00 monthly premium. They include people not receiving Social Security benefits, people enrolling in Part B for the first time in 2017 and people with Medicare and Medicaid, whose state Medicaid agencies will pay the higher premium.

    The Part B premium is a lot more for people with incomes over $85,000. People whose modified adjusted gross income from two years ago as reported on their federal tax return–about six percent of the Medicare population–will pay:

    • $187.50 a month, if their income is above $85,000 and no more than $107,000.
    • $267.90 a month, if their income is above $107,000 and no more than $160,000
    • $348.30 a month, if their income is above $160,000 and no more than $214,000
    • $428.60 a month, if their income is above $214,000

    To arrive at the premium amount for married people filing a joint tax return, double the income.

    The Part B annual deductible is $183.00, a $17 increase from 2016.

    People with incomes up to 135 percent of the federal poverty level, ($1,357 in monthly income for an individual and $1,823 for a couple in 2016) are eligible for help paying their premiums through Medicaid or a Medicare Savings Program.

    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.

    Right now, Congressman Paul Ryan and others in Congress are considering Medicare reforms that would privatize Medicare and turn it into a voucher program; it would drive up costs for people with Medicare significantly. Right now, people with Medicare typically spend about $5,000 out of pocket for care that Medicare does not cover, and people with costly conditions spend about $10,000. If you oppose such reforms, please sign this Social Security Works petition.

  • New and innovative home and community-based services for older adults

    New and innovative home and community-based services for older adults

    According to a new report from the Commonwealth Fund, 12 million older adults with Medicare have mild or serious physical or cognitive impairments (PCI) but millions cannot afford home and community supports and often end up in nursing homes. More than one in three of them have incomes below twice the federal poverty level but do not qualify for Medicaid. Fortunately, there are several new and innovative home and community-based services administered by the Centers for Medicare and Medicaid Services (CMS) to help older adults remain in their homes and communities, and the report proposes some new ones.

    CMS programs that provide home and community-based care include Independence at Home, Hospital at Home, PACE–which you can read about on Just Care here—Community Aging in Place, Advancing Better Living for Elderly (CAPABLE)–which you can read more about on Just Care here–and Maximizing Independence for Persons with Dementia (MIND) at home. While all these programs are relatively small and may not be available in your community, if you are looking for home and community-based care for yourself or someone you love, it’s worth seeing whether these programs can help.

    Older adults with serious physical or cognitive impairments, such as dementia, have a high likelihood of having multiple chronic conditions. Nearly two thirds of those living in the community have three or more chronic conditions. Virtually all of them have at least one chronic condition.

    Programs that offer community and home-based supports can improve the quality of life of older adults with PCI, helping them maintain their independence and keeping them out of nursing homes. So, the Commonwealth Fund is proposing two additional cost-effective options for providing home and community-based services for older adults who do not qualify for Medicaid.  These programs are designed to delay nursing home admissions, so they could save CMS substantial money.

    1. Medicare Help at Home would offer supplemental home and community-based care. People with Medicare could elect this benefit on turning 65. Older adults with PCI would be able to receive 20 hours a week of personal care services at home or the cash equivalent, $400 a week, for other care services. Older adults would contribute anywhere from 5 to 50 percent of the cost based on their income. A combination of income-related premiums, an extra monthly premium of $42 and a small payroll contribution from employees and employers of 0.4 percent would cover the cost. And, it could save Medicaid $1.6 billion over 14 years.
    2. Medicaid Community First Choice, a program that provides supports for people with incomes up to 150 percent of the federal poverty level available in nine states, could be made available to all people with Medicare with incomes up to 200 percent of the federal poverty level who are eligible for nursing home care. It would cost $16,224 per person a year. But, costs would be offset by fewer nursing home placements, which cost $80,000 per person a year.

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  • Medicare and Veterans’ benefits: Vets can have both

    Medicare and Veterans’ benefits: Vets can have both

    If you’re a Vet and also have Medicare, you may be entitled to health care benefits through both Medicare and the Veterans Administration (V.A.). Many would say that the V.A. offers some of the best care in the U.S. through its network of more than 1,400 care facilities, including hospitals and clinics. And, Medicare offers coverage from most doctors and hospitals anywhere in America. So, there’s value in having both. When you’re deciding whether to get your health benefits from the Veterans Administration or through Medicare, here are four things you should know.

    1. V.A. and Medicare benefits work independently of one another. You can’t use your Medicare benefits at a V.A. hospital.  And, you can’t use your V.A. benefits at a non-V.A. hospital.
    2. All Vets are eligible for V.A. health benefits, so long as you served in active military service for 24 continuous months or the full term  for which you were called to active duty, and you were not discharged or released under dishonorable conditions. You can apply by phone at 1-877-222-VETS (8387), Mon-Fri between 8 am and 8 pm, EST or online here.
    3. It’s generally also wise to enroll in Medicare Part B when you become eligible, even if you have V.A. benefits.  Medicare Part B will give you coverage for care from doctors and hospitals outside the V.A. system.  If you do not enroll in Part B when you are first eligible, you can enroll later. But, if you delay enrolling, you will likely have to pay a premium penalty for late enrollment.
    4. Depending upon your service as a Vet, your V.A. benefits may include coverage for hearing aids and over-the-counter drugs that Medicare does not cover.  The V.A. also covers care from doctors and hospitals in the V.A. system. And if you get your prescription drugs from the V.A., your cost generally should be far lower than anywhere else.

     

  • Turning 65? Make sure you’re not involuntary enrolled in a Medicare Advantage plan

    Turning 65? Make sure you’re not involuntary enrolled in a Medicare Advantage plan

    An increasing number of people first going on Medicare are being involuntarily enrolled in Medicare Advantage plans when they turn 65. The Centers for Medicare and Medicaid Services, CMS, has given their health insurers the right to enroll them in the insurers’ Medicare Advantage plans–commercial insurance plans that offer Medicare benefits under special conditions–without their permission. If you’re turning 65, make sure you’re not involuntary enrolled in a Medicare Advantage plan.

    To date, CMS already has approved proposals from 27 insurance companies to “seamlessly enroll” their Medicaid and commercial members in their Medicare Advantage plans once they become eligible for Medicare. Aetna, UnitedHealth Group, Health First, Anthem and Blue Cross Blue Shield of Michigan are among the companies with permission. For the full list, click here.

    These insurers have permission from CMS to enroll their members who become eligible for Medicare in their Medicare Advantage plans without signed authorization from their members. These enrollments should be described as “troubling,” not “seamless.” The insurers’ Medicare Advantage plans generally have different doctor and hospital networks and different cost structures from the pre-Medicare health plans they offer members.

    This automatic and troubling Medicare Advantage enrollment undermines people’s choice and jeopardizes their continuity of care, leaving them at significant financial and health risk. Indeed, traditional Medicare is the only choice that maximizes the likelihood of that continuity of care.

    People who turn 65 should be able to assume they are enrolled in traditional Medicare, which has been the case. Historically, people who don’t affirmatively choose to enroll in a Medicare Advantage plan by signing up with one are enrolled in traditional Medicare. If they are enrolled in a Medicare Advantage plan without their knowledge, it can wreak havoc on their lives.

    When people believe they are enrolled in traditional Medicare–and they are not–they will use whichever doctors and hospitals they please. Since these providers are likely not in the Medicare Advantage plan’s network into which they have been involuntarily enrolled, they can get hit with huge out-of-network charges.

    CMS does not notify the people who are involuntarily enrolled in their health plans’ Medicare Advantage plans that they are no longer in traditional Medicare. CMS relies on the insurers to notify their members. But, people may not read mail from their insurers once they’ve signed up for Medicare. Instead, they may assume they are enrolled in traditional Medicare, seek care, and rack up huge costs from out-of-network providers.

    By allowing the insurers to automatically involuntarily enroll people in their Medicare Advantage plans, CMS is working against the interests of people with Medicare; it is disregarding its own advice to people choosing a Medicare plan to compare their options carefully. People are only protected if they receive and read the required health plan notification informing them of their automatic enrollment and their right to opt out within 60 days.

    Enrollment in a Medicare Advantage plan must be voluntary. So, if you or anyone you know is enrolled in Medicare Advantage plan involuntarily and unknowingly racks up bills from out-of-network doctors and hospitals, call your local State Health Insurance Assistance Program or SHIP for assistance disenrolling.

  • 8.3 million people benefit from both Medicare and Medicaid

    8.3 million people benefit from both Medicare and Medicaid

    Medicaid is a joint federal and state public health insurance program for 70 million vulnerable people in the United States, funded in large part by the federal government and in some part by each state. Today, 8.3 million people benefit from both Medicare and Medicaid, 4.6 million older adults and about 3.7 million people with disabilities. People with Medicare and Medicaid are sometimes called “dual-eligibles.”

    Medicaid covers about 15 percent of people with Medicare. Medicaid is a cost-effective program delivering a broad benefit package to older adults at about 20 percent less cost than private insurance. That said, a June 2015 Kaiser Family Foundation survey shows that Medicaid offers similar access to care as private insurance.

    People with both Medicare and Medicaid have lower incomes and fewer assets than people who do not qualify for Medicaid. More than 85 percent of them have annual incomes below about $16,500. Even if your income or assets put you above the Medicaid eligibility 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. 

    States must provide a minimum set of Medicaid benefits and have flexibility in terms of offering additional benefits. People with Medicare and Medicaid generally have low out-of-pocket costs. Medicaid helps cover Medicare premiums and out-of-pocket costs. And, as or more importantly, Medicaid also pays for some key services that Medicare does not cover, including community-based long-term services and supports, and nursing home care. And, it covers a wide range of behavioral health services.

    About one-third of Medicaid’s budget goes to paying for long-term services and supports. More than half of Medicaid spending on long-term services and supports is for care at home or in the community. The Program for All-inclusive Care for the Elderly or PACE is a  Medicare-Medicaid program. At the same time, Medicaid covers 64 percent of all nursing home residents.

    Click here to find out if you qualify for Medicaid. Many states allow you to apply on online. Click here to apply. And, click here to contact your state for application and renewal information. And, for simple health and retirement advice you can trust, subscribe to our weekly Just Care feed.

  • For-profit PACE programs: Cause for worry?

    For-profit PACE programs: Cause for worry?

    Sarah Varney reports for Kaiser Health News that the for-profit sector will now be providing a program for all-inclusive care for the elderly (PACE). Click here to learn about PACE on Just Care. Until recently run exclusively by non-profit organizations and paid for by Medicare and Medicaid, PACE has provided valuable services. But it has reached only a small fraction of older adults. Are for-profit PACE programs cause for worry or can they reach more adults and deliver as good results as non-profit PACE programs?

    Last year, Congress changed the law governing PACE to permit for-profit companies to run PACE programs. The alleged goal is to reach more people. And, now private equity firms are funding companies to deliver for-profit PACE programs, reaching many more people.

    PACE is intended to help older adults age in place through comprehensive medical and social supports. Medicare and Medicaid pay for the services because they can save money on people in PACE who remain at home, do not need nursing home care and are not as likely to be hospitalized. But, only 40,000 people were enrolled in the program at the beginning of 2016.

    With for-profits in the picture, more people will receive PACE services. And, that could have great value to patients who want to remain at home, as most do, and still be able to socialize and enjoy the services available in their communities. Without PACE, many would remain isolated and homebound, jeopardizing their health and well-being and putting them at increased risk of an early death.

    PACE programs provide key services many older adults would not otherwise be able to afford or access. People may get comprehensive rehabilitation services. They also generally receive critical dental care that Medicare does not pay for outside the PACE setting. Dental care helps prevent infections that can land a person in the hospital. It also helps to ensure good nutrition.

    And, PACE programs also help patients with basic services at home, such as housecleaning and laundering.

    The question remains whether the for-profit sector will deliver the value that non-profit PACE programs have delivered. When for-profit companies began delivering hospice services, the U.S. Office of the Inspector General found that they were treating patients with less costly conditions, avoiding patients who would cost them more money, and they were holding back on services people needed.

    The for-profit programs are paid a flat fee and lose money if PACE enrollees spend too much time in hospital or visit the emergency room frequently. So, for-profit PACE programs may try to avoid patients more likely to use these services, like the for-profit hospice agencies, avoiding patients who would cost them more money. To save money, they may also be more inclined to deliver care through telehealth rather than transporting patients to facilities, failing to recognize the negative health consequences of social isolation and the value of socialization.

    Here’s more from Just Care:

  • Insurers denying some costly treatments patients need

    Insurers denying some costly treatments patients need

    Bob Tedeschi reports in Stat news on a growing trend by health insurers to deny some costly treatments doctors say patients need and require them to try less costly treatments first. It’s called “step therapy.” The goal of keeping health care costs down is reasonable, but the consequences for some patients can be serious. (Note: If you’d like your insurer to cover whatever reasonable and necessary care your doctor recommends, sign up for traditional Medicare if you’re eligible.)

    Step therapy at its best is arguably a good thing. There is no reason for patients to get newer treatments that are more expensive when older less costly treatments are available. But, step therapy presents a serious problem when insurers use it as a way to save money even if the older less costly treatments are not working. And, insurers are becoming “more aggressive” about making patients wait long periods before insurers will cover more costly treatments.

    In some cases, doctors know that their patients need particular treatments because they have tried other treatments that have not worked. Yet, that will not stop some insurers from requiring step therapy. As a result, many states have enacted legislation to block insurers from making patients try treatments that their doctors know won’t work.

    To be clear, no one is suggesting that insurers should pay for more expensive treatments when less expensive treatments work. However, insurers should not be requiring patients to try treatments when there are risks to so doing. For example, when patients switch insurers mid-treatment, the new insurer might require their doctors to drop their current course of treatment and retry treatments that have already failed.

    What is to be done? More transparency about insurer practices is critical, including how they define whether a treatment has failed. And, insurers should not be allowed to require patients to retry treatments that have already been determined to fail. Speedy appeals of insurer denials are also needed, especially when people’s lives and well-being are hanging in the balance.

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  • Value-based insurance design coming to Medicare

    Value-based insurance design coming to Medicare

    In January 2017, the Centers for Medicare and Medicaid Services, CMS, will launch a new initiative for some older adults and people with disabilities enrolled in Medicare Advantage plans. People in some states with certain chronic conditions will be able to choose a Medicare Advantage plan–a commercial insurance plan that contracts with the government to offer Medicare benefits–that has “value-based insurance design,” with the goal of providing them better care at lower cost. How good the care will be is still a big question mark.

    Just to say it, the vast majority of people with Medicare are enrolled in traditional Medicare because it gives them easy access to care and predictable costs almost anywhere in the country. Medicare Advantage plans appear less costly, but they generally come with very little choice of doctors and hospitals and high out-of-pocket costs, particularly for people with costly and complex conditions. While there is a limit of $6850 on out-of-pocket costs in 2016, on top of that you usually must pay the full cost of your care, or a large chunk of the cost, if you use doctors or hospitals outside the health plan’s network. And, your copays and deductibles may not be included in the out-of-pocket limit.

    Medicare Advantage health plans are supposed to provide the same benefits as traditional Medicare, but they often have a narrower view than traditional Medicare of when those benefits are reasonable and necessary, further limiting people’s access to care. The Medicare Advantage Value-Based Insurance Design Model (VBID), launching in 2017 is intended to benefit people with diabetes, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), past stroke, hypertension, coronary artery disease, mood disorders, rheumatoid arthritis (starting in 2018) and dementia (starting in 2018).

    How does VBID work? The goal is to make out-of-pocket costs for people with these chronic conditions low enough to encourage them to take advantage of Medicare Advantage plan “high-value clinical services” that help manage and improve their care.  CMS is encouraging plans to help members with these chronic conditions. Health plans have the flexibility to lower their members’ out-of-pocket costs if they use particular doctors, services or disease management programs; health plans can also offer extra benefits to meet their needs.

    Historically, Medicare Advantage plans have tried to avoid enrolling members with costly and complex conditions in order to maximize their profits, so presumably CMS is giving them a financial incentive to participate in this pilot. That said, CMS says that another goal of this pilot is to reduce Medicare spending.

    Medicare Advantage plans in seven states–Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee–may be able to test the VBID model. CMS will announce in September which plans will be offering VBID.  In January, 2018, CMS will expand the model to three more states–Alabama, Michigan, and Texas.

    Here’s more from Just Care: