JustCare

Category: Medicare

  • If you need long-term care services, how will you get them?

    If you need long-term care services, how will you get them?

    The majority of older adults will need long-term care services at some point. But, caregiving costs for older adults are super high, stemming from significant labor and facility costs, along with high demand. If you need long-term care services, how will you get them?

    More and more people are looking for adult day care, assisted living facility care and nursing home care. For many of them, relying on volunteer caregivers, such as friends and family, is not possible. But, the cost of paid care is prohibitive, swallowing up years of savings quicly. Caregiving costs increased more than 20 percent between 2012 and 2019 and continue to rise.

    Medicare does not pay for long-term care services. At best, Medicare will cover 100 days in a rehab facility or nursing home for people who need daily skilled nursing or therapy services. And, most Medicare Advantage plans inappropriately deny coverage for rehab and nursing care beyond a few days.

    But, a stay in a rehab or nursing facility can cost thousands of dollars if you have to pay out-of-pocket. The average cost of a nursing home stay is now more than $9,000 a month. The average cost of a stay in an assisted living facility is more than $4,500 a month.

    Caregiving costs are a lot higher in some states than others. In Massachusetts, average costs for a nursing home stay can be more than $15,000 a month. An assisted living facility stay can cost well over $8,000 a month.

    More than four in five households with someone over 65 need some type of care. Almost a quarter of them have significant care needs, including round the clock care. Almost two in five need help, though not round the clock. Only about one in five of them need minimal care, such as help getting groceries and cooking.

    Here’s more from Just Care:

  • People with both Medicare and Medicaid can get Traditional Medicare at little cost

    People with both Medicare and Medicaid can get Traditional Medicare at little cost

    More than 12 million Americans with Medicare also have Medicaid. These “dual-eligibles” typically have few out-of-pocket health care costs, whether they are in Traditional Medicare or a Medicare Advantage plan. Still, the Kaiser Family Foundation reports that half of them choose a Medicare Advantage plan, even though Medicare Advantage restricts their access to health care providers and imposes other barriers to care.

    People with Medicare and Medicaid, “dual-eligibles,” can get coverage through Traditional Medicare, with Medicaid picking up deductibles and coinsurance costs, through standard Medicare Advantage plans, or through Medicare Advantage plans designed specifically for dual-eligibles. Because there is so much we don’t know about Medicare Advantage plans, including denial rates and wait times for coverage, much less how quality differs among these plans, dual-eligibles should be better off in Traditional Medicare, where it is far easier to get care than in a Medicare Advantage plan.

    In the ideal world, health systems would do a good job of coordinating people’s care. But, that’s not the world we live in. Still, a lot of people with Medicare and Medicaid opt for a Medicare Advantage plan. Misleading ads and sales agents can be convincing.

    About half of dual-eligibles are enrolled in corporate-run Medicare Advantage plans when they would likely have easier access to care in Traditional Medicare. Traditional Medicare covers your care from almost all health care providers in the US without prior authorization requirements. Black, Hispanic and Asian/Pacific Islanders are more likely to sign up for Medicare Advantage plans than non-Hispanic White people.

    About three in ten dual eligibles are enrolled in Medicare Advantage Special Needs Plans or SNPs, which are corporate health plans intended to coordinate their care and to work well with Medicaid in their states. But, it’s not clear how well these plans work. In fact, the Office of the Inspector General recently released a report expressing concerns about high inappropriate denial rates in some Medicaid health plans.

    One great Medicare program that coordinates care for dual-eligibles is PACE, the Program of All-Inclusive Care for the Elderly. If you are a dual-eligible, look into the non-profit PACE programs in your area. They are often unable to take new enrollees, but if you can get on a waitlist, do so. To qualify for the medical and social services they provide, you must be at least 55 years old and be able to live in your home safely but need a nursing home level of care. For more information on PACE, click here. Note: Beware of for-profit PACE programs.

    Here’s more from Just Care:

  • New study finds you can’t meaningfully choose among Medicare Advantage plans

    New study finds you can’t meaningfully choose among Medicare Advantage plans

    You’ve probably heard me say this before, but I’ll say it again: The less corporate health insurers spend on your care, the more of your premium dollars they can keep. What’s worse is that states and the federal government generally do not begin to have the resources to protect Americans from health plans that inappropriately refuse to cover needed care. Not surprisingly, there’s a new report out from the Urban Institute finding that the federal government’s star-rating system for Medicare Advantage plans neither promotes quality nor helps people distinguish effectively among their Medicare health plans choices.

    In other words, if you’re in a Medicare Advantage plan or thinking about enrolling in one, keep in mind that the insurance companies offering these plans have both a financial incentive to inappropriately delay and deny your care and the ability to do so with near impunity.

    The Health and Humans Services’ Office of the Inspector General has now issued two reports finding that many Medicare Advantage plans engage in inappropriate delays and denials of care and coverage. The federal government, through the Centers for Medicare and Medicaid Services (CMS), is charged with overseeing these health plans and helping you make an informed choice among them. But, it is not disclosing important information you need to make an informed choice.

    What should you do to avoid unnecessary delays and denials of care and coverage? If you can afford traditional Medicare, you should not face barriers to care or inappropriate delays and denials of coverage. There is no corporate health insurer coming between you and your doctors. But, if you don’t have Medicaid or supplemental retiree insurance to fill gaps in your Medicare coverage, you will need to buy “Medigap” supplemental coverage.

    If you opt for a Medicare Advantage plan to save the cost of supplemental insurance, keep in mind that a health plan with a five star rating may inappropriately delay or deny your care. Here’s why, according to the Urban Institute’s latest report:

    • The rating system is based on an overall assessment of several Medicare Advantage plans an individual corporate health insurer offers. So, if one of those plans is terrible, it could still get a four or five-star rating if others of the plans are deemed to offer good care.
    • The Centers for Medicare and Medicaid Services (CMS) does not take account of certain deficiencies with Medicare Advantage plans in its star ratings, including rates of inappropriate delays and denials of care and coverage.
    • CMS inflates its scores, giving high star ratings too often.
    • CMS does not focus its star-rating measures on whether Medicare Advantage plans meet the needs of people with costly and complex conditions. Because health insurance is about protecting people from unforeseen health problems, this is a serious flaw.

    Keep in mind that insurance should be about covering your unforeseen health care needs. if you get sick and need costly care, your out-of- pocket costs in a Medicare Advantage plan can be as high as $8,300 for in-network care, this year alone.

    Advocates are working hard to get CMS to publish delay and denial rates of individual Medicare Advantage plans. Some plans, we are told, have problematically high denial rates. For sure, those health plans should be avoided and the government should have a duty to, at the very least, let you know about them, as well as to penalize them heavily. If Medicare Advantage plan are jeopardizing the health and well-being of their enrollees, the government should be canceling their contracts.

    Here’s more from Just Care:

  • Need a shrink? Your Medicare Advantage plan might not think so

    Need a shrink? Your Medicare Advantage plan might not think so

    Reed Abelson reports for the New York Times on the difficulty people in Medicare Advantage plans can have getting mental health care. Too often there are no psychiatrists in their Medicare Advantage plan network, according to a new study published in Health Affairs. If you would like to see a shrink and have your care covered–if you’d like to get any specialty care and ensure it is covered– traditional Medicare is likely to be a better option than a Medicare Advantage plan.

    Researchers were not able to find even one psychiatrist in more than half of the Medicare Advantage plan networks they analyzed. Even in the networks with psychiatrists, psychiatrists were few and far between; fewer than one in four psychiatrists in the area were in network. And, it’s not clear that these psychiatrists were taking new patients.

    Loneliness is a huge challenge for many older adults, only aggravated by the Covid-19 pandemic. Many older adults need to see a psychiatrist for their mental well-being. About 25 percent of people with Medicare suffer from depression, anxiety or another mental illness. But, the Commonwealth Fund has found that not even half of them get mental health care.

    There are too few psychiatrists in the US. So, it can be hard to find a psychiatrist no matter what health insurance coverage you have. But, the researchers note, people with Medicaid and people in state health insurance exchange plans created by the Affordable Care Act have considerably better access to psychiatrists than people in Medicare Advantage.

    Lack of access to mental health care in Medicare Advantage plans is a problem getting mounting attention. Senator Ron Wyden’s team on the Senate Finance Committee conducted a study of Medicare Advantage plans in Oregon and could not find a single psychiatrist taking new patients in any of their networks. Senate Wyden described their networks as “ghost networks” at a recent Senate Finance Committee hearing. In Medicare Advantage plans outside Oregon, Senate Finance staff could not get an appointment with a mental health provider more than 80 percent of the time.

    A psychiatrist from the American Psychiatric Association testified at the Senate Finance Committee hearing that as hard as it is for psychiatrists to deal with insurance company paperwork, it is all the harder for them to deal with administrative requirements imposed by Medicare Advantage plans. “Many of the challenges and frustrations are emphasized in the Medicare Advantage plans.”

    The researchers who published the Health Affairs study found that some insurers offering Medicare Advantage plans pay mental health providers less than the Original Medicare rate. That impedes access to care for people in Medicare Advantage plans and should be prohibited.

    Here’s more from Just Care:

  • Congress sits on its hands while Medicare Advantage insurers gouge taxpayers and enrollees

    Congress sits on its hands while Medicare Advantage insurers gouge taxpayers and enrollees

    The Medicare Advantage program, Medicare Part C, which allows corporate health insurers to contract with the government to offer Medicare benefits, was born with the assumption that it could save Medicare money. Instead, a new report out of the mainstream USC Schaeffer Center for Health Policy and Economics estimates that Medicare Advantage plans are costing taxpayers and people with Medicare an additional $75 billion in overpayments this year alone. The report only confirms findings by University of California at San Diego professor, Richard Kronick, of massive government overpayments to Medicare Advantage, but Congress sits on its hands.

    Republicans in Congress don’t seem to care about eliminating all the waste in Medicare Advantage. It’s the health insurers offering Medicare Advantage plans that will help fund their 2024 reelection campaigns. And, that’s not something they want to jeopardize. Many Democrats in Congress also appear to live in fear of losing support from the corporate health insurers and are doing little to address the massive overpayments, as they should.

    How do these Medicare Advantage overpayments happen? Medicare Advantage overpayments happen for a variety of reasons, but the largest reason is that people enrolled in Medicare Advantage are considerably healthier than people in traditional Medicare.  Because of a defective payment system, the government pays Medicare Advantage plans as if their enrollees are sicker than people in traditional Medicare. The high proportion of people who are healthy in Medicare Advantage cost these Medicare Advantage plans on average less than $1,000 a year as compared to the more than $12,000 a year the government typically pays Medicare Advantage plans to care for them.

    MedPac, the agency overseeing these government payments, has calculated the overpayments at $27 billion this year because the Medicare Advantage plans assign multiple diagnosis codes to their enrollees in order to boost their earning and often get quality bonus payments as well. But, MedPac has not factored into its calculations the $50 billion or so a year in Medicare Advantage overpayments resulting from the Medicare Advantage population being so much healthier than the traditional Medicare population.

    The researchers at USC appreciate that the Medicare payment system for Medicare Advantage plans is defective and needs an overhaul. Paying the insurers offering Medicare Advantage plans as the government currently does leads to massive overpayments. The researchers, however, do not speak to the fact that the defective payment system–upfront payments unrelated to the cost of services delivered– also leads to massive inappropriate delays and denials of care to people. People with cancer, heart disease, stroke and other costly and complex conditions are most at risk–and that’s most of us, if not now, down the road.

    The USC researchers like the idea of competitive bidding among MA plans as an alternative to the current payment system, which I hear is a nonstarter from the MA plans’ perspective. That shouldn’t matter, but it does. Regardless, competitive bidding doesn’t address the need to ensure that the payment system stops creating a disincentive for the Medicare Advantage plans to withhold care from the people who most need it–the 10 percent of people with Medicare with the costliest conditions.

    The government’s payment system will be right only if and when the Medicare Advantage plans are promoting their high value care for people with cancer, heart disease and stroke. Until then, consider enrolling in traditional Medicare if you can. If you enroll in Medicare Advantage, beware the Medicare Advantage plans engaged in widespread delays and denials of care. The administration is not naming them for the most part. And sometimes, it is giving them four and five-star ratings.

    Here’s more from Just Care:

  • Why doesn’t Medicare cover Ozempic and other drugs for weight loss?

    Why doesn’t Medicare cover Ozempic and other drugs for weight loss?

    While Medicare covers certain services to treat obesity, Medicare is not allowed to cover Ozempic and other drugs for weight loss under the law establishing Medicare Part D prescription drug coverage. Still, the pressure is on to get Medicare to cover them, Rylee Wilson reports for Becker’s.

    To treat obesity, Medicare covers obesity screening, behavioral counseling, and bariatric surgery. But, the Medicare Part D prescription drug law prohibits Medicare from covering weight-loss drugs and a range of other drugs, such as drugs that treat erectile dysfunction. That could change for weight-loss drugs, given the efficacy of new weight-loss drugs and the public pressure to cover them.

    GLP-1 drugs, such as Ozempic, are more effective for weight loss than the older drugs. Putting aside these drugs, which come with an enormous price tag, Medicare can’t even cover older weight-loss drugs that cost less. Even when they cost less, spending for all these weight-loss drugs are over the long-term. People generally need to take these drugs indefinitely to sustain their weight loss.

    One New England Journal of Medicine study found that covering new weight-loss drugs would increase Medicare spending by more than $25 billion a year. In addition, one of the study’s authors said that these drugs are not cost-effective; they are not so much better than the older generation drugs to justify their huge price tags.

    Today, people must pay more than $10,000 out of pocket for GLP-1 drugs to treat weight loss. If Medicare decides to cover these drugs for weight loss, it will mean higher Part D premiums for everyone with Medicare. Given the drug price monopoly that US drug manufacturers still have—without negotiated drug prices—there’s no end to drug company price gouging.

    Medicare does cover Ozempic and related drugs to treat diabetes.

    Note: Medicare Part D drug coverage will have a $2,000 out-of-pocket cap beginning in 2025. For some people, that’s a huge benefit. But, $2,000 is still unaffordable for a large cohort of people with Medicare. And, as Part D premiums rise, more and more people with Medicare will struggle to afford the premiums for their prescription drug coverage.

    Here’s more from Just Care:

  • 2023: Medicare data and trends

    2023: Medicare data and trends

    The Kaiser Family Foundation has new Medicare data: Who’s enrolled, costs, trends and more. Not surprisingly, Medicare spending represents a large share of total government spending (13 percent of the federal budget in 2021), and spending will rise over the next few decades as older adults represent a larger share of the population.

    Today, more than 65 million Americans benefit from Medicare, about 20 percent of Americans. By 2060, more than 93 million Americans are projected to benefit from Medicare.

    In 2020, about 17 percent of the US population were people over 65–56 million. By 2060, people over 65 will constitute 25 percent of the US population. One third of people over 65 will be over 80.

    Medicare per person and overall spending have grown enormously in the last 20 years as health care costs have increased.  Per person spending is up to $15,700 from $5,800 in 2000. Overall spending is now at $744 billion a year, up from $200 billion in 2000. And, spending is projected to rise to more than double that, $1.7 trillion, by 2033.

    A lot of Medicare’s increased cost can be attributed to Medicare Advantage. Payments to these health plans has tripled in the last decade, from $137 billion to $403 billion. And, the government overpays these plans—as much as 20 percent more than Traditional Medicare, according to a new study out of USC. The percentage of people enrolled in Medicare Advantage plans has doubled from 25 percent to 50 percent.

    People with Medicare are using more services, and costs of services are rising significantly. Costs are also up significantly since 2000 because Medicare began covering prescription drugs in 2004. That said, Medicare pays significantly less for most services than private insurers because it negotiates provider rates.

    Today, people with Medicare pay a lot more for their care than in the past. Medicare Part B premiums consume 10 percent of the typical Social Security benefit, up from 6 percent.  If you include Parts A and B deductibles, 19 percent of a typical Social Security check goes to Medicare costs, up from 15 percent.  And, then there’s the cost of long-term care at home or a nursing home, dental, hearing and vision care, and prescription drug coverage and copays.

    Here’s more from Just Care:

  • Medicare now covers power seat lifts for wheelchairs in some cases

    Medicare now covers power seat lifts for wheelchairs in some cases

    Medicare is required by law to cover all medically reasonable and necessary health care services with certain exceptions, such as vision, hearing, dental and long-term services and supports. Of course, when it’s not black and white, our government decides which services are medically reasonable and necessary and should be covered. The Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, has decided that power seat lifts should be covered.

    Of course, every time Medicare covers a product or service that makes people’s lives easier and improves their health and well-being, it’s a huge benefit. Yet, as Medicare covers more costly items, Part B premiums rise and out of pocket costs for people with Medicare become increasingly unaffordable. To keep costs down, Congress needs to step in and negotiate better prices for many products Medicare covers, including prescription drugs, as well as eliminate overpayments to Medicare Advantage plans.

    Medicare has always covered wheelchairs and, in certain cases, power wheelchairs, for people who are unable to get around their homes without one. But, Medicare had not covered the power seat lift that allows people in a wheelchair to sit at a counter or access items they could not otherwise access in their homes. The government’s argument back in 2006 was that the power seat elevation system was not primarily medical in nature.

    The industry making the seat-lift device, along with the disability community, lobbied hard for its coverage. They argued that from a health equity perspective, lower income people can experience worse health outcomes than people with more income are not because they can afford to pay for the seat lift themselves. “Allowing beneficiaries with a permanent disability to access technology to stand, reach, and function in their home and community, is not a luxury, nor is it an item of convenience, but a necessity.”

    The health equity argument is compelling.  On those grounds, however, Medicare should be spending as much on people in Traditional Medicare as it does on people in Medicare Advantage, giving traditional Medicare an out-of-pocket spending limit, among other things. Instead, most people with Medicare cannot afford to enroll in Traditional Medicare and are forced into Medicare Advantage plans. They do not have the meaningful choice between Traditional Medicare and Medicare Advantage, which is available to people with higher incomes.

    Of note, Medicare still does not cover the power standing device that would allow wheelchair-bound people to stretch their legs and bear weight, which also has significant health benefits, according to some experts.

    Here’s more from Just Care:

  • Don’t assume a five-star Medicare Advantage plan will provide the care you need

    Don’t assume a five-star Medicare Advantage plan will provide the care you need

    Laura Beerman writes for Health Leaders on the flaws in the Medicare Advantage star-rating system. If you asked me, I’d tell you it’s a farce. The gaming that goes on to get four and five-star ratings is unacceptable. And, even with a five-star rating, the Medicare Advantage plan may be engaged in widespread and persistent delays and denials of care. Don’t assume a five-star Medicare Advantage plan will provide you with the care you need.

    You can’t know whether a particular Medicare Advantage plan will endanger your health if you need costly and complex care, in part because the government hides information about plans engaged in bad acts. While you should avoid Medicare Advantage plans that do not have four or five-star ratings, you are taking a huge gamble even if you sign up with Medicare Advantage plans that have four and five-star ratings. These ratings do not reflect whether you will be covered for care from top flight doctors and hospitals or how much hassle you will face getting the care you need. And, that’s what you should care about when choosing a Medicare Advantage plan.

    The health insurers offering Medicare Advantage tend to love the star-rating program. If they can get the stars, they earn huge additional revenue from the government. And, believe it or not, the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare Advantage, allows the insurers to bundle together several Medicare Advantage plans when applying for star-ratings. So, if one Medicare Advantage plan performs poorly based on the measures CMS uses to give stars, it can still “look” good in terms of the number of stars it has.

    If you don’t believe me, just read this piece by two former leaders at CMS: The Emperor Has No Clothes: “[T]he Five-Star program, while well intended, primarily creates a ‘performing to the test’ result rather than solid and important quality improvements in outcomes.”

    In fairness, CMS has gotten a bit tougher in its standards for doling out five and four-star ratings to Medicare Advantage and Part D prescription drug plans. But, not nearly tough enough. Nor has CMS created standards that would actually reflect whether a Medicare Advantage or Part D plan is engaged in massive inappropriate delays and denials of care and coverage or does a good job of managing your care. More than half of all Medicare Advantage plans in 2023 had a four or five-star rating!

    Alignment Health, Elevance Health, Humana, and UnitedHealthGroup all received four or five-stars for their Medicare Advantage plans, as did Kaiser Permanente. Again, don’t assume much positive about these plans when it comes to whether they are covering their enrollees’ care as required under their contracts.

    Aetna Medicare Advantage plans fared worse than others with only 21 percent of its Medicare Advantage plans receiving four or five-star ratings. Should you avoid Aetna Medicare Advantage plans with three-star ratings? It’s not clear, but probably. They are being paid as much as $1 billion less in 2024 because of the lost stars, which means they will have less money to spend on your care.

    MedPAC, the independent agency that oversees Medicare Advantage quality, has said several times in its annual report to Congress: “[T]he Commission has been increasingly concerned that Medicare’s approach to quality measurement is flawed because it relies on too many clinical process measures.” In 2023: “Over the years, the Commission has determined that the QBP [Quality Bonus Program] is flawed and does not provide a reliable basis for evaluating quality across MA plans in meaningful ways…”

    Here’s more from Just Care:

  • What we don’t know about Medicare Advantage plans

    What we don’t know about Medicare Advantage plans

    The Kaiser Family Foundation just released a report detailing the many data gaps in Medicare Advantage–the corporate health plan option administered by private health insurers. This missing data is needed to assess Medicare Advantage plan performance and value.

    The government requires relatively little data from the Medicare Advantage plans and does not make much of it available for public scrutiny. Moreover, some of the required data is inadequate or incomplete, Yet, the Centers for Medicare and Medicaid Services, which oversees Medicare, rarely holds the Medicare Advantage plans accountable for failing to provide accurate data.

    Congress needs to step in to require MA plans to turn over data that people can use to make an informed choice of a Medicare Advantage plan if they’d like. And, it needs to include penalties for Medicare Advantage plan failure to disclose complete and accurate information.

    Here are some of the questions for which we have no answers:

    • Which plans have the highest rates of denials and which have the lowest?
    • Which plans have the highest rates of prior authorizations and for which types of services?
    • How quickly do Medicare Advantage plans respond to prior authorization requests?
    • Why do Black Medicare Advantage enrollees disenroll from Medicare Advantage plans and why do white enrollees disenroll?
    • What share of enrollees use the “extra” Medicare Advantage benefits and what is their income, ethnicity and health status?

    The Centers for Medicare and Medicaid Services (CMS) does not have the answers to any of these questions. Without the answers, CMS is forcing people to take big risks when they join a Medicare Advantage plan. How can anyone assume that any particular Medicare Advantage plan offers value or will provide them with the care they need. For example, CMS does not require the Medicare Advantage plans to report the types of services for which there are high levels of prior authorization requests and denials.

    The insurers offering Medicare Advantage plans also do not have to distinguish among the plans they offer when they do provide data to CMS. So, if some of their plans have particularly high denial rates and others have low rates, CMS would not know.

    Bottom line: There is no way for people to make an informed choice about a Medicare Advantage plan.

    Here’s more from Just Care: