Category: Medicare

Why doesn’t the federal government regulate assisted living facilities?
The Senate Special Committee on Aging is looking into quality and cost issues in Assisted Living Facilities, reports Jordan Rau for KFF Health News. But, the federal government does not regulate these facilities, even though it pays for them in some cases for people with Medicaid. It’s not likely that Congress will enact legislation to regulate them.

More than 800,000 Americans live in an Assisted Living Facility (ALF) today. ALF residents include people who can’t bathe themselves or feed themselves. People with dementia. People unable to walk unassisted.

The cost of living in an ALF is prohibitive for most Americans, typically around $4,500 a month, way more than the typical Social Security check. In cases where residents need substantial amounts of care, the cost can be $10,000 a month. Some facilities impose additional charges for basic services. One ALF charges $93 a month simply to order medications for its residents.

Medicare does not cover ALFs. And, only 20 percent of ALFs accept Medicaid patients. But, one argument for federal oversight of ALFs is that the federal government spends more than $10 billion dollars on these ALF residents.

What services do people get for their money in an ALF? They should get assistance with activities of daily living. However, staffing levels in ALFs are too often low and workers can be poorly trained.

Today, it’s up to each state to regulate ALFs. Given that few states have the will, the skill, the power and the resources to oversee these facilities, many patients in these facilities are not getting quality care.

Monitoring of ALFs is inconsistent across states. And, data is hard to secure if you want to understand how different ALFs operate. Federal oversight is needed to protect ALF residents across the US.

Richard Molloy, who runs the Long Term Care Community Coalition, explains that “too many [long term care facilities] take in or retain residents for whom they are unable to provide safe care and dignified living conditions. Too many residents and families are at risk for financial exploitation and even fraud.”

Here’s more from Just Care:
January 30, 2024
Choose your hospice provider carefully
Hospice care has grown in popularity for people with terminal conditions who seek comfort care rather than curative treatment. But, now, more than ever, you need to choose your hospice provider carefully. Ava Kofman continues to write for Pro Publica on how profiteers have taken over hospice in the US, at huge financial cost to the Medicare program and huge risk to patients at the end of life.

As a result in significant part of Kofman’s earlier reporting, described in this Just Care post, the Centers for Medicare and Medicaid Services (CMS) conducted more hospice inspections. But, CMS continues to certify new hospices, even in California, where the state has banned new hospice licenses because of mounting hospice fraud.

It appears that CMS does not have the ability or desire to close down hospices engaging in fraud. After visits to 7,000 hospices, CMS stopped just 46 of them from billing the government for their services. The travesty: The 46 hospices were nonoperational.

CMS claims that it’s up to the states to stop the proliferation of hospices. CMS appears to be unwilling or unable to prevent even fraudulent or unneeded hospices from receiving certifications to deliver the hospice benefit to people with Medicare.

Arizona, California, Nevada and Texas have seen a huge spike in the number of its hospice providers. CMS showed marginal concern at best about fraudulent bills from these hospices and the lack of need for additional hospices in these states. CMS said it would look at their bills more closely.

California attempted to put a moratorium on new hospices in its state, with little success. Its auditors detected “a large-scale, targeted effort to defraud Medicare.” Hospice providers charged Medicare for patients who were not terminally ill and sometimes for patients who were fictitious.

Notwithstanding California’s good oversight, CMS is allowing these hospice providers to bill Medicare for their “services.” CMS claims to need “evidence of sanctions” against a hospice in order to block a hospice from the Medicare program.

In California, people enrolled in hospice fraudulently—people who are not terminally ill or who do not want hospice—are reportedly at risk of not getting needed care. Medicare covers hospice services only for patients who agree not to receive curative care for their conditions. That said, they should be able to get care for any condition unrelated to a terminal condition. Moreover, they are also always able to opt out of hospice to get curative care.

In one case, a nursing home resident with dementia was fraudulently enrolled in hospice by a doctor she did not know. Medicare paid the hospice $7,500. But, the patient lost her ability to have her pacemaker checked and to receive physical therapy. CMS is now investigating.

Here’s more from Just Care:
January 30, 2024
Take advantage of the Medicare Advantage Open Enrollment period
If you’re in a Medicare Advantage plan, you should seriously consider taking advantage of the Medicare Advantage open enrollment period between January 1 and March 31 that allows you to switch to Traditional Medicare or to a different Medicare Advantage plan. This opportunity for to switch out of your Medicare Advantage plan is an important consumer protection. Medicare Advantage plans could have changed their provider networks or drug coverage between the fall Medicare Advantage Open Enrollment Period and now.

I’ve written at length about all the reasons to avoid enrolling in a Medicare Advantage plan, especially if you have Medicaid or can afford the supplemental coverage that you need in Traditional Medicare to limit your out-of-pocket costs. Upfront costs in Medicare Advantage are less than those in Traditional Medicare with supplemental coverage. But, if you get sick and need care–the reason you have health insurance–your out-of-pocket costs are likely to be a lot higher in Medicare Advantage than in Traditional Medicare.

Moreover, access to care is much simpler in Traditional Medicare than in Medicare Advantage. In Traditional Medicare, your treating physicians decide the care you need without an insurance company second-guessing your doctor and profiting every time it denies you care. And, there are no prior authorization requirements, nor is there a restricted network. You are covered for care from the vast majority of physicians and hospitals in the US. With supplemental coverage, your costs are predictable and often very little.

Medicare Advantage HMOs restrict your coverage to the doctors and hospitals in their networks. You can go out of network for some coverage only if you’re in a PPO. But, even in a PPO, coverage tends to be limited and unpredictable. Driving your costs up further and/or endangering your health, Medicare Advantage plans impose prior authorization requirements before they will cover your care. And, they inappropriately deny care, particularly to people with costly conditions–people needing rehab care, people with cancer and people with other complex care needs.

The Centers for Medicare and Medicaid Services, which oversees Medicare, should be protecting you from bad actor Medicare Advantage plans, but it cannot. It does not have the capability, the money, or the power to oversee the more than 4,000 Medicare Advantage plans, much less to hold them to account for their bad acts.

You should also bear in mind that you can’t count on the providers in Medicare Advantage directories actually being willing to see you. Multiple reports reveal “ghost” networks in some Medicare Advantage plans. As well, I’ve reported many times in Just Care on hospitals terminating their Medicare Advantage contracts, leaving Medicare Advantage plan enrollees scrambling to find alternative care or forced to drive long distances for inpatient services. Memorial Hermann in Houston, Texas is the most recent hospital system to do so, ending its Medicare Advantage contract with Humana.

Here’s more from Just Care:
January 9, 2024
Critical home care is no longer affordable for most people and too often not available
Caring for an older person with multiple needs can take a toll physically, emotionally and financially. Reed Abelson reports for The New York Times on how reliable home care is hard to come by and not affordable over the long-term.

Frank Lee, the husband of one woman with dementia, was tending to his wife morning, noon and night. He ended up putting her in a respite program at an assisted living facility so he could take a short break. While he was away, she fractured her sacrum. Mr. Lee was at a loss to find home health aides he could trust, the plight of many older couples.

Eight million older adults suffer from dementia or need help with at least two activities of daily living, such as bathing and toileting. Only a small fraction of them–one million–have paid help outside a nursing home. Three million have no help.

Our federal government does little to help people who need home health aides. Medicare only covers very limited home health health care and, then, only for people who are homebound and who need skilled nursing on an intermittent basis or skilled therapy. People with dementia don’t usually fit these criteria. If you don’t have Medicaid, you are generally out of luck in terms of government assistance and, even with Medicaid, there are often waitlists for home care.

Most older adults are cared for by family, not professionals. They cannot afford $27 an hour, the going rate for a home care aide. Paying for fulltime home care usually means expenses of tens of thousands of dollars a year. Usually it is the older adult’s spouse or daughter who takes on the role of caregiver.

People who can afford to pay for a caregiver often cannot find one with the skills to take care of their loved ones. They are often forced to hire untrained caregivers. Paid caregivers in the US rarely earn a living wage; they often can’t count on fulltime work. And, they tend not to get health insurance benefits. It’s no wonder that there is a shortage of paid caregivers; they can get better jobs for the money.

What to do? Plan ahead. Talk to your loved ones about likely long-term care needs. Even if you have limited resources, it is better to be prepared. Most people do not have these conversations. Families are often unprepared. Many families cannot save enough to offset the cost of long-term care. But, if you plan ahead, you could qualify for Medicaid.

Keep in mind that long-term care needs can be extensive. Sometimes, two people are needed just to move someone from one place to another. Without assistance, simple tasks become huge burdens.

Mr. Lee wonders “What’s the end game look like?” Is it right that he should watch his wife, who is already severely demented and unable to take care of herself or speak, deteriorate further? “As she disintegrates, I disintegrate.” When people are terminally ill–six months or less of life–Medicare covers hospice care, which covers some home care. But, good luck getting it if you’re in a Medicare Advantage plan. And, even in traditional Medicare, finding an agency that will provide hospice care can sometimes be challenging.

Here’s more from Just Care:
December 5, 2023
Seven questions you should be asking this Medicare Open Enrollment period
During this Medicare Open Enrollment period, ask yourself these seven questions. And, please know that you can always call the Medicare Rights Center at 1-800-333-4114 or your SHIP (State Health Insurance assistance Program) for free, unbiased advice on any of your Medicare questions.
1. Q. What’s the biggest difference between traditional Medicare and a Medicare Advantage plan? To ensure you have good coverage for both current and unforeseeable health needs, you should enroll in traditional Medicare. In traditional Medicare, you and your doctor decide the care you need, with no prior approval. And, you have easy access to care from almost all doctors and hospitals in the United States with no incentive to stint on your care. In a Medicare Advantage plan, a corporate insurance company decides when you get care, often requiring you to get its approval first. Medicare Advantage plans also restrict access to physicians and too often second-guess your treating physicians, denying you needed care inappropriately. The less care the Medicare Advantage plan provides, the more the insurance company profits. You will pay more upfront in traditional Medicare if you don’t have Medicaid and need to buy supplemental coverage, but you are likely to spend a lot less out of pocket when you need costly care. Regardless of whether you stay in traditional Medicare or enroll in Medicare Advantage, you still need to pay your Part B premium.
2. Q. Should I trust an insurance agent’s advice about my Medicare options? No. Unfortunately, insurance agents are paid more to steer you away from traditional Medicare and into a Medicare Advantage plan, even if it does not meet your needs. While some insurance agents might be good, you can’t know whom to trust. Keep in mind that while Medicare Advantage plans tell you that they offer you extra benefits, you still need to pay your Part B premium, and extra benefits are often very limited and come with high out-of-pocket costs; be aware that many Medicare Advantage plans won’t cover as much necessary medical and hospital care as traditional Medicare. For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a State Health Insurance Assistance Program (SHIP).
3. Q. Why can’t I rely on my friends or the government’s star-rating system to pick a good Medicare Advantage plan? Unlike traditional Medicare, which gives you easy access to the physicians and hospitals you use from everywhere in the US and allows for continuity of care, you can’t count on a Medicare Advantage plan to cover your care from the health care providers listed in their network or to cover the medically necessary care that traditional Medicare covers. Even if your friends say they are happy with their Medicare Advantage plan right now, they are gambling with their health care. The government’s five-star rating system does not consider that some Medicare Advantage plans engage in widespread inappropriate delays and denials of care, and other Medicare Advantage plans engage in different bad acts that can endanger your health. So, while you should never sign up for a Medicare Advantage plan with a one, two or three-star rating, Medicare Advantage plans with four and five-star ratings can have very high denial and delay rates.
4. Q. If I’m enrolled in a Medicare Advantage plan, can I count on seeing the physicians listed in the network and lower costs? Unfortunately, provider networks in Medicare Advantage plans can change at any time and your out-of-pocket costs can be as high as $8,300 this year for in-network care alone. You can study the MA plan literature, and you can know your total out-of-pocket costs for in-network care. But, you cannot know whether the MA plan will refuse to cover the care you need or delay needed care for an extended period. This year alone, dozens of health systems have canceled their Medicare Advantage contracts, further restricting access to care for their patients in MA, because MA plans make it hard for them to give people needed care.
5. Q. Doesn’t the government make sure that Medicare Advantage plans deliver the same benefits as traditional Medicare? No. The government cannot protect you from Medicare Advantage bad actors. The insurers offering Medicare Advantage plans can decide you don’t need care when you clearly do, and there’s no one stopping them; they are largely unaccountable for their bad acts. In the last few years there have been multiple government and independent reports on insurance company bad acts in Medicare Advantage plans.
6. Q. If I join a Medicare Advantage plan, can I disenroll and switch to traditional Medicare? You can switch to traditional Medicare each annual open enrollment period. However, depending upon your situation, where you live, your income, your age and more, you might not be able to get supplemental coverage to pick up your out-of-pocket costs and protect you from high costs. What’s worse, you could incur thousands of dollars in out-of-pocket costs in Medicare Advantage.
7. Q. If I have traditional Medicare and Medicaid, what should I do? If you have both Medicare and Medicaid, traditional Medicare covers virtually all your out-of-pocket costs. You will get much easier access to physicians and inpatient services in traditional Medicare than in a Medicare Advantage plan if you need costly health care services or have a complex condition.
For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a State Health Insurance Assistance Program (SHIP).

Here’s more from Just Care:
November 9, 2023
Medicare Advantage plans are not addressing loneliness among their enrollees
Loneliness is prevalent amount older adults in Medicare Advantage plans, reports Alexa Mikhail for Fortune. Most older adults no longer work and have few outlets for social interaction. The government is not addressing their lack of social stimulation. Their Medicare Advantage plans, government health plans administered by corporate health insurers, which are paid to manage their enrollees’ health, should be helping to address their enrollees’ loneliness.

A survey of 28,000 older adults in Medicare Advantage plans finds that more than half of them (three in five) are lonely or extremely lonely. Family are often not near by. Friends are often not around. As a rule, their Medicare Advantage plans do not help them. Consequently, older adults who suffer from loneliness are at greater risk for a range of health issues, including dementia, depression and anxiety.

What can isolated adults do in an emergency? One in five older adults have no one to turn to in an emergency. Two in five struggle to find social support. Medicare Advantage plans do not make it their business to foster social interaction among their enrollees, even though it’s an important way to promote their well-being.

Many older adults struggle mentally and physically as a result of social isolation. They need help taking their medicines and remodeling their homes, but they can’t get help. They don’t have easy and safe access to a bathroom, shower, kitchen and bedroom. They can’t get to their doctors’ appointments. It’s not clear that any Medicare Advantage plans are helping to ensure these basic needs are met or even to minimize enrollees’ risk of falling, even though these corporate health plans are receiving some $140 billion in overpayments each year from the government.

Half of older adults have annual incomes under $30,000 and deteriorating health. Loneliness means that they are as much as three times more likely to end up in an emergency room than people who have family or other social companions around to help.

If Medicare Advantage plans were putting enrollees’ needs ahead of their profits, they would be promoting social engagement among their enrollees and otherwise spending money on their enrollees in meaningful ways.

Here’s more from Just Care:
November 8, 2023
2024: Access to Medicare mental health services is expanding
Even with Medicare, it can be hard to see mental health providers. Tens of thousands of mental health providers will not take Medicare because of its low payment rates and, on top of that, for people in Medicare Advantage plans, a lot of administrative burdens. But, beginning in January 2024, Medicare will cover mental health care from marriage and family therapists, mental health counselors, and drug addiction specialists, increasing the pool of mental health providers available for people with Medicare to see, reports Judith Graham for The Washington Post.

To date, Medicare has only covered care from psychiatrists, psychologists, psychiatric nurses and licensed clinical social workers. They are a small group, and nearly half of psychiatrists and more than half of psychologists, 124,000 mental health providers, have opted out of Medicare. In addition, many Medicare Advantage plans do not contract with adequate numbers of mental health providers, according to a recent report from the Kaiser Family Foundation and a recent Senate Finance Committee survey.

People in Medicare Advantage plans can struggle to access mental health services as well as a wide range of other services, particularly costly ones such as rehab therapy and nursing home care. Even if they can find a mental health provider who will see them in network, Medicare Advantage enrollees generally need approval from their Medicare Advantage plans before their mental health care will be covered. And, that approval can be hard to come by.

Inability to get Medicare-covered mental health care has been a huge issue for the more than 15 million people with Medicare who have a mental health condition. Aa many as 7,500 of them do not receive mental health treatment today. The wait for a therapist who accepts Medicare can be six months.

Medicare’s expansion of mental health services to marriage and family therapists and mental health counselors should mean that people will have less trouble finding a mental health provider who takes Medicare, at least if they are enrolled in Traditional Medicare. An additional 400,000 mental health providers are eligible to see patients with Medicare. In particular, people with Medicare in rural areas should have better access to mental health services.

However, a lot turns on the payment rates Medicare sets for these providers. If Medicare’s approved rate is not fair, these providers may refuse to see Medicare patients. And, if Medicare Advantage plans engage in inappropriate denials and delays of care or refuse to pay mental health provider bills, as they too often do, these mental health providers will refuse to contract with them. Often older adults needing mental health services also have multiple chronic conditions. Providing treatment for them is not as simple as caring for younger adults.

Medicare will also cover as much as 19 hours a week of outpatient mental health care for people most in need of outpatient mental health services–people with severe mental illness and people in need of substance use disorder care. Medicare will also enable some people to get mental health treatment in their homes through an expansion of mobile crisis services.

Since the Covid pandemic began, people with Medicare can receive mental health services through telehealth, on the phone or through a computer. Medicare pays providers the same rates for telehealth services as for in-office appointments.

Graham raises the question of whether Medicare will ever have mental health parity as is required for private insurance plans. Given so many other issues with Medicare mental health coverage, it’s not clear how much difference it would make, beyond an important symbolic one. But, at least it would eliminate Medicare’s 190-day lifetime limit on psychiatric hospital care. Medicare has no lifetime coverage limit on hospital care.

Here’s more from Just Care:
November 1, 2023
2024: Medicare Part D coverage and costs
Whether you are enrolled in traditional Medicare or a Medicare Advantage plan, Medicare covers the prescription drugs you get from the pharmacy under Medicare Part D. The vast majority of people with Medicare, 50.5 million in 2023, are enrolled in a Part D drug plan. Here’s what you need to know about Medicare Part D coverage and costs in 2024 and why you should take a close look at your options for next year during this annual open enrollment period.

Don’t assume that your current Part D drug plan will cover your drugs in 2024, even if it does in 2023. Rather, assume that your costs will go up a lot if you didn’t check which Part D plan was likely to save you the most money based on your drug needs, during the Medicare open enrollment period (October 15-December 7). Each year, these Part D private insurance plans can change dramatically. Kaiser Family Foundation offers key facts about Part D plans in 2023.

As a general rule, close to three in four people enrolled in traditional Medicare and a Part D plan will pay higher costs the following year, if they do not look at their options and switch plans.

In 2024, there are 709 prescription drug plans available nationally, according to the Kaiser Family Foundation. If you are in traditional Medicare, you will be able to choose from among 15 to 24 Part D plans in your state. 16 national Part D prescription drug plans, with monthly premiums ranging from $6 to $111. The average premium is $43.

Premiums: Premiums are typically higher for Part D plans offering enhanced benefits, lower cost-sharing and/or low or no deductibles. Standard Part D plans have a base monthly premium in 2024 of $34.70, but it could be higher or lower depending upon multiple factors. Part D “enhanced” plans that charge no or a low deductible have a base monthly premium of $55.50 in 2024.

If your annual income is $103,000 or higher, you pay a supplemental premium of between $12.90 and $81 a month.

Standard deductible: The standard and highest possible deductible—the amount you must pay before your coverage begins—is $545, up from $505 in 2023.

If you have traditional Medicare: You typically will be able to choose among 24 Part D drug plans. Depending upon the state you live in, your options range between 19 and 28.

If you are in a Medicare Advantage plan: You typically will have a choice of around 35 Part D drug plans.

Cost-sharing: For non-preferred brand-name drugs, coinsurance could be as high as 40-50 percent and as low as $0 for preferred generics, depending upon the Part D plan you choose. You also are likely to pay 15-25 percent coinsurance for preferred brand drugs.

Typically you’ll pay about $1 for preferred generics and $5 for generics. You’ll pay around $44 copay for preferred brands, 45 percent coinsurance for non-preferred drugs, and 25 percent coinsurance for specialty drugs.

Maximum out-of-pocket: The most you will pay out of pocket for drugs you purchase through Part D is $3,300 in 2024, even though the out-of-pocket spending limit is rising to $8,000 or $12,447 in total drug costs). But the $8,000 includes the value of the manufacturer discount on the price of brand-name drugs during the coverage gap phase of the benefit. If you only use brand-name drugs, you will only have to pay around $3,300 out of pocket.

Also, keep in mind that in 2025, your maximum out-of-pocket cost for drugs covered through Part D will be $2,000 because of the Inflation Reduction Act.

Costs in each coverage phase: After you have paid your deductible, you are in the initial coverage phase, where you generally will pay around 25 percent of the cost of both brand-name and generic drugs until your drug costs total $5,030. You will then be in the coverage gap phase, where you will be responsible for about 25 percent of the cost of your drugs. Once your out-of-pocket drug costs, including the deductible, but not your Part D premium, total $8,000 in the coverage gap phase (in fact, around $3,300 plus manufacturer discounts,) you will be in the catastrophic coverage phase. At that point, you will pay nothing more for your covered drugs.

If you qualify for a low-income subsidy (LIS) or Extra Help: You will have lower out-of-pocket costs, depending upon the Part D plan you choose and the drugs you use. You should pay $4.50 for each generic drug that is covered and $11.20 for each brand-name covered drug. Around 13 million people with Medicare qualify for extra help with their prescription drug costs. There are 198 Part D drug plans for which you will not pay a premium. You can also choose a “non-benchmark” plan and pay a portion of the monthly premium.

You should get Extra Help automatically if you have full Medicaid benefits or are receiving SSI benefits. If not, you can apply for Extra Help through the Social Security Administration. To qualify, generally, an individual’s countable income needs to be below $21,870 and your assets need to be below $16,600.

If you need insulin: The Inflation Reduction Act limits your monthly copayment to no more than $35 in all phases of Part D coverage. However, that limit applies only to insulin in a plan’s formulary, not all insulin products.

If you need a vaccine: Vaccine costs are covered in full for vaccines that are on the Part D formulary.

Here’s more from Just Care:
October 24, 2023
What are your Medicare premiums in 2024?
Medicare only covers about half of a typical person’s health care costs. People with Medicare generally pay a monthly Medicare Part B premium, more than 20 percent of their medical and inpatient costs out of pocket (or through Medigap or Medicaid,) as well as most 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 2024. Here’s what you need to know.

Part B premiums in 2024:
In 2024, people whose modified adjusted gross income from two years ago as reported on their federal tax return is $103,000 or less pay a monthly Part B premium of $174.70, an increase of $9.80.

People with incomes above $103,000–about eight percent of the Medicare population–pay a Medicare Part B premium of:
- $244.60 a month, if their income is above $103,000 and no more than $129,000.
- $349.40 a month, if their income is above $129,000 and no more than $161,000.
- $454.20 a month, if their income is above $161,000 and no more than $193,000.
- $559 a month, if their income is above $193,000 and less than $500,000.
- $594 a month, if their income is $500,000 or more.
For couples with combined incomes of $386,000 or less two years ago, filing a joint tax return, the premium amount doubles. Couples filing jointly with annual incomes above $386,000 and less than $750,000 each pay a $559 monthly premium. And, couples with annual incomes of $750,000 and above each pay a $594 monthly premium. Visit this CMS web site for your Part B premium amount if you are filing separate returns.

Medicare Part B annual deductible: $240, an increase of $14 from the annual deductible of $226 in 2023.

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 2024 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 coverage.
- The Medicare Part A premium, if you or a spouse has at least 30 quarters of coverage, is $278 a month, the same as in 2023; if you don’t have at least 30 quarters, the premium is $505 a month, a $1 decrease from 2023.
- The Medicare Part A inpatient hospital deductible is $1,632, in 2024 an increase of $32 from 2023, and coinsurance for hospitalizations after day 60 is $408 a day in a benefit period; coinsurance for lifetime reserve days is $816 a day.
- The Medicare Part A daily coinsurance for skilled nursing facility stays after day 20 is $204, an increase of $4.00 from $200 in 2023.
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.

Here’s more from Just Care:
October 17, 2023
2023: Five things to think about when choosing between traditional Medicare and a Medicare Advantage plan
The Annual Medicare Open Enrollment period begins October 15 and ends December 7. If you have Medicare, you are likely to see endless ads and receive lots of mail from an assortment of insurers chomping at the bit to get you to sign up with one of their Medicare Advantage plans. That’s how they rake in the big bucks, tens of billions of dollars a year. Unfortunately, our government does a poor job of helping you to understand differences between traditional Medicare, which is administered by the Centers for Medicare and Medicaid Services (CMS), and Medicare Advantage plans, which are administered by corporate health insurers that contract with the government. And, you can’t trust the corporate health insurers or their sales agents to tell you what you need to know.

There are five basic differences between Traditional Medicare and Medicare Advantage that you need to understand.

1. Coverage:

Traditional Medicare. With traditional Medicare, you are covered for the medicallyreasonable and necessary care your providers believe you need. An insurance company is not second-guessing your doctors.

Medicare Advantage. Medicare Advantage plans are supposed to cover the same benefits as traditional Medicare, but they cover significantly fewer, as has been documented over and over again. They often engage in widespread inappropriate delays and denials of care and generally require you to get approval before they will pay for most costly services. That’s how they maximize profits. If you think you might get sick or need costly health care at some point, even if you don’t need it now, think twice before signing up with a Medicare Advantage plan. No one provides you with the information you need to know to distinguish the good Medicare Advantage actors from the bad ones. And, there appear to be a lot of bad ones.

2. Health care providers:

Traditional Medicare. With traditional Medicare, you can see almost all doctors and use virtually all hospitals anywhere in the United States. Almost all take Medicare and more than 90 percent “take assignment,” accept Medicare’s approved charge as payment in full. The most they can charge is 15 percent above that amount.

Medicare Advantage. With Medicare Advantage, your care is generally only covered when you use “in-network” providers. They can be few and far between and are often only located in your community. If you travel or spend time away from your primary residence, a Medicare Advantage plan usually will not cover your care, except in emergencies, Also, you might find that the providers in their directories are not taking new patients or have left the network. So, if you are thinking of joining a Medicare Advantage plan or are in one now, talk to any of the doctors you know you want to continue seeing to confirm that you will still be able to have your care covered when you see them. Keep in mind that a lot of the Medicare Advantage plans have lower quality providers in their networks and might not have a cancer center of excellence as part of their network.

3. Costs:

Traditional Medicare. With traditional Medicare you must pay your Part B monthly premium. You are generally liable for a hospital deductible and 20 percent of the cost of your medical care, unless you have supplemental coverage, either Medigap, which you buy in the individual market, Medicaid, or retiree coverage from a former employer. If you have supplemental coverage, most if not all of your costs will be covered. Traditional Medicare does not have an out-of-pocket maximum.

Medicare Advantage. With Medicare Advantage, you pay your Medicare Part B premium and you might have no additional premium, but your out-of-pocket costs can be sky high. You cannot buy supplemental coverage to pick up your out-of-pocket costs. Your costs turn on the Medicare Advantage plan you choose, the care you need, and what the Medicare Advantage plan charges you for your care. You generally will have to pay a copay when you are hospitalized or need medical services. Your out-of-pocket costs can be over $8,000 for in-network care alone if you need costly care. But, each Medicare Advantage plan has its own out-of-pocket maximum. If you go out-of-network for your care, you will be liable for the full cost of your care, unless you are in a PPO (preferred provider organization), in which case you generally will be liable for 40 percent of the cost.

4. Drugs:

Traditional Medicare. With traditional Medicare, you will need to buy Medicare Part D prescription drug coverage if you want drug coverage. That typically costs about $55.50 a month.

Medicare Advantage. With Medicare Advantage, your drug coverage is usually included in your plan’s monthly premium.

Whether you’re in traditional Medicare or a Medicare Advantage plan, be sure to look at differences in your drug costs among Medicare Part D drug plans. And, keep in mind that it is possible, even likely, that you might spend less getting some of the drugs you take from Costco or another mail-order pharmacy than paying the copay for them through your Part D plan. Part D plans can have higher copays than the total cost of the drug from a low-cost pharmacy.

5. Quality:

Traditional Medicare. If you want control over the quality of your health care providers, you probably want to be in Traditional Medicare, where you choose the providers you see.

Medicare Advantage. In a Medicare Advantage plan, the plan restricts your access to providers. And, even when you see a provider you want to see, the Medicare Advantage plan might not let your physician or hospital provide the care that they think is best for you. For example, if your doctor thinks you need 50 days of inpatient rehab therapy, your Medicare Advantage plan still might decide you only need 10 and will only cover 10 days.

Bottom line: With traditional Medicare, your doctors and hospitals have every incentive to provide you with all the care they think you need and traditional Medicare will cover it. Medicare Advantage plans receive a fixed amount from the government to cover your care regardless of how much they spend on your care. Consequently, they have an incentive to withhold needed care and to incentivize their physicians to limit the care they provide you. The less money a Medicare Advantage plan spends on your care, the more money the Medicare Advantage plan has for its shareholders. Since there’s no good data to distinguish the good Medicare Advantage actors from the bad ones, you are gambling with your health and well-being when you enroll in a Medicare Advantage plan. To learn more, read this blog post by Diane Archer and Theodore Marmor on the fundamental difference between traditional Medicare and private insurance.

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October 11, 2023