Category: Your Coverage Options

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
Dental care is increasingly unaffordable
The cost of dental care has become prohibitively expensive for the vast majority of Americans. In a new study by Synchrony, more than nine in ten Americans say that they would consider putting off getting dental care because of the cost, reports Pete Grieve for Money.

Medicare does not cover dental care. And, people with Medicare should note that when Medicare Advantage plans offer dental benefits , the benefits tend to be extremely limited. As a result, many people in Medicare Advantage plans that claim to offer dental benefits are still not able to get dental care. In some cases, there are only a small number of in-network dental providers and it can be hard to see them. In other cases, the out-of-pocket costs for dental care are limited and unaffordable. Do not join a Medicare Advantage plan because of its dental benefits before checking closely to see what those benefits are.

Note: Even though Traditional Medicare does not cover dental care, people in Traditional Medicare get dental care at the same rate as people in Medicare Advantage plans.

The problem in getting dental care for most people is the cost; the price of dental care keeps rising, faster than inflation. Dental care costs are up 5.6 percent this year. The American Dental Association Health Policy Institute claims that costs are up because supplies and materials cost more, as do lab fees and labor. It wold not be surprising if private equity firms buying up dental practices are driving up dental costs as well.

The Synchrony researchers found that more than half (58 percent) of the 1,335 respondents surveyed said they could not afford dental care, even though many of them had dental insurance. Of course, when people do not have dental insurance, it’s all the harder for them to afford critical dental care.Three in four people without dental coverage said they could not afford dental care.

For the typical adult between 20 and 79 years old, dental insurance can cost as much as $51,000 during a lifetime. In addition, if people need dental implants or other complex dental care, dental procedures can cost tens of thousands of dollars.

Consequently, 92 percent of adults studied said they were thinking about holding off getting dental care because of the cost. Even for emergency dental care, more than four in five adults (83 percent) were thinking about not getting care.

The older you are, the harder it is to afford dental care. Two in three older people said that dental care was unaffordable as compared to 51 percent of young adults.

Here’s more from Just Care:
October 18, 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.

Here’s more from Just Care:
October 11, 2023
2023: Four things to know if your income is low and you have Medicare
Today, 12.3 million older adults and people with disabilities are enrolled in both Medicare and Medicaid. Almost three out of four of them (71.1 percent) are eligible for full Medicaid benefits, the remaining 28.9 percent are enrolled in a Medicare Savings Program. While Medicare is an earned health care benefit for people over 65 and people with disabilities, Medicaid is a means-based benefit for people with limited incomes and savings. Medicare and Medicaid work together to provide a more comprehensive set of benefits for people with low incomes.
1. Medicaid picks up many health care costs that Medicare does not cover: Depending upon your income and assets, along with which state you live in, you might qualify for full Medicaid benefits in addition to Medicare. Medicaid would be your secondary insurance, paying after Medicare. It generally covers the gaps in Medicare, including the Part B premium, the Part D drug premium, deductibles and coinsurance. It sometimes covers routine dental care and travel to and from the doctor’s office and some long-term care. No matter where you live, if you meet state-specific criteria, you will have coverage for nursing home care. Depending which state you live in, and your care needs, you might also be eligible for home or community-based care. In addition, there are several Medicaid/Medicare demonstration projects underway testing new ways to deliver home care for people with Medicare, in one project with the help of therapists, nurses and handymen.
2. Your state Medicaid office or SHIP program can help you know whether you qualify for full Medicaid or other low-income assistance. Even if your income or assets are over the limit, many states have what are called “spend-down” programs that allow you to qualify for Medicaid after you have spent some of your own money for health care. If you own a home, Medicaid does not count your home as an asset. To contact your state Medicaid office, click here and to learn about free and low-cost resources, including the State Health Insurance Programs (SHIP), click here.
3. Some states enroll people with Medicaid and Medicare in commercial managed care plans: These Medicare Advantage plans might create obstacles to care through limited networks and inappropriate delays and denials of care. But, no matter what state you live in, you should have the right to disenroll and switch to traditional Medicare if you’d like. If you have both Medicare and Medicaid, your out-of-pocket costs in traditional Medicare should be very little or nothing. Contact your state Medicaid office to learn about options in your state.
4. Even if your income or assets are too high to qualify for full Medicaid benefits, Medicare Savings Programs, (administered by state Medicaid programs), may cover some of the gaps in Medicare. Four different Medicare Savings Programs fill different Medicare coverage gaps, depending upon your income and assets. For example, in 2023, the Qualified Medicare Beneficiary Program, QMB, picks up the cost of Part A premiums; Part B premiums, deductibles, coinsurance, and copayments. To qualify, your individual monthly income cannot exceed $1,235 (married $1,663) and assets $9,090 (married $13,630) plus $1,5oo for burial funds. To learn more about these programs and which health care costs they pick up, click here.
In addition to Medicaid and Medicare Savings Programs, there are thousands of government and charitable programs that provide free and low-cost services across the country.

Here’s more from Just Care:
October 9, 2023
Ignore Medicare Advantage ads; they misrepresent costs and benefits
Two new reports, one from the Commonwealth Fund and one from the Kaiser Family Foundation, highlight the deceptive marketing in Medicare Advantage, a program administered by corporate health insurers that too often misrepresents their benefits and costs. Many Medicare Advantage plans fail to cover the care, particularly the costly care, their enrollees need. In short, if you want care from the doctors you know and trust, without insurance companies overruling their treating decisions, you should enroll in Traditional Medicare.
The marketing of Medicare Advantage has meant endless ads everywhere you turn. There’s literally hundreds of billions of dollars in profits available to be reaped by corporate health insurers each year. And, they want as much of these profits as they can get their hands on. The problem is that they profit more when their enrollees get less care.

With lots of people complaining about countless marketing calls, misleading advertising and unscrupulous sales tactics, the Biden administration has put in place new regulations in the past year. It’s not at all clear that they work, given that the corporate health insurers know that they can get away with a lot and face little if any accountability for their bad acts.

The Commonwealth Fund survey found that sales agents wrongly asked people for their Social Security or Medicare numbers in many cases. You should not give this information out; it is not allowed in most instances.

People are generally overwhelmed by their Medicare choices. They have too many options and it is virtually impossible to distinguish among them. So, they often stay with their current coverage.

The Kaiser Family Foundation reports that “in 2023, Medicare beneficiaries can choose from an average of 43 Medicare Advantage plans, offered by 9 different insurers, the highest number ever available. Traditional Medicare beneficiaries selecting prescription drug coverage can choose from an average of 24 stand-alone Part D plans.”

A lot of people turn to friends and family for advice. Others rely on insurance brokers. Don’t trust insurance brokers who profit from steering you to particular Medicare Advantage plans. Contact your state health insurance assistance program, SHIP, or the Medicare Rights Center at 800-333-4114 for free unbiased counseling.

In the Commonwealth survey, about a third of people with Medicare wanted to know more about their out-of-pocket costs and benefits in a Medicare Advantage plan v. Original Medicare. It’s critical people understand them as there have been a large number of complaints from people with Medicare about misleading information by the Medicare Advantage plans and the insurance brokers they hire about costs and benefits. Unfortunately, costs and benefits are not as simple to understand as they should be.

Here’s what you need to know: In Medicare Advantage, out-of-pocket costs can be as high as $8,300 in 2023 for in-network care, and you will pay for the full cost of care if you go out of network. Because many plans engage in widespread denials and delays of care and have networks with limited numbers of physicians, it can be hard to get in-network care.

And, as for the “extra” dental and hearing benefits that many Medicare Advantage plans promote, beware. They sound great in theory, but are often difficult to take advantage of. In many cases, you must use a set of providers who are inconvenient or unavailable or your out-of-pocket costs can be extremely high. The data show that more people in traditional Medicare get dental care than in Medicare Advantage.

Here’s more from Just Care:

Medicare Advantage: Tune out the Joe Namath ads

Four things to think about when choosing between traditional Medicare and Medicare Advantage plans

OIG finds widespread inappropriate care denials in Medicare Advantage

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

Ohio and Virginia hospitals warn residents they could stop taking Medicare Advantage patients
October 4, 2023
Misleading Medicare marketing: Insurance industry appears to be pulling strings at Medicare

It’s almost time for Medicare Open Enrollment, which begins on October 15. There’s a lot you should know. But, the insurance industry appears to be pulling the strings at Medicare, and there’s a lot the government isn’t telling you. You could easily be misled. Here’s what the Centers for Medicare and Medicaid Services should be saying about your Medicare options instead of misleading the public.

Costs in Original Medicare, sometimes called Traditional Medicare
Truth: You pay 20 percent of the cost of Medicare’s approved rate for medical services, a deductible for hospital services and, sometimes, copays for other inpatient services. If you have Medicaid, Medicare supplemental coverage or retiree coverage, all or most of these costs are covered. If you are enrolled in a Medicare Savings Program, some or most of these costs are covered. If you don’t use a lot of care, you spend little.
Costs in Medicare Advantage
Truth: If you’re in a Medicare HMO, you’ll pay the full cost for out-of-network care. Since it can be hard to find certain providers who will see you, you could easily end up going out of network for your care. Plans have a yearly limit on out-of-pocket costs for in-network care that varies. Be sure to check what the limit is. You will typically pay around $5,000 out of pocket and as much as $8,300 in 2023 and higher in 2024, if you need a lot of care. If you join a Medicare Advantage plan, once you meet that limit, you will pay nothing more for in-network care. If you don’t use a lot of care, you spend little.

Coverage in Original Medicare
Truth: Medicare covers medical services and supplies in hospitals, doctors’ offices, and other health care facilities. Services are either covered under Part A or Part B. You do not need a referral or prior authorization. Your treating physician determines what care is reasonable and necessary.
Coverage in Medicare Advantage
Truth: Most Medicare Advantage plans require you to get approval or prior authorization before they will cover your costly care, often causing delays. The health insurer offering your plan determines what care is reasonable and necessary, not your treating physician. The biggest Medicare Advantage plans engage in widespread and persistent delays and denials of care and coverage that the government can’t prevent, as the OIG has twice reported. Too often plans don’t cover the benefits that they are legally required to cover. The government usually does not cancel contracts with these plans, nor does it disclose which plans are delaying and denying a lot of care. And, the star-rating system is misleading, at best.

Supplemental coverage in Original Medicare

Truth: If you have Medicaid, it will pick up virtually all of your out-of pocket-costs. Medicare Savings Programs will pick up many of your costs as well. Retiree coverage will sometimes pick up some or all of these costs. Medigap will also pick up all or some of these costs.

Supplemental coverage in Medicare Advantage

Truth: You cannot buy supplemental coverage to cover your out-of-pocket costs if you’re in a Medicare Advantage plan. If you’re lucky and don’t need care, you could spend little out of pocket. But, health insurance is about today and tomorrow. If you end up needing costly care, you could spend as much as $8,300 out of pocket for in-network care alone, depending upon the plan you choose. And, if you go out of network, you will be liable for the full cost of your care, except in emergencies.

Doctors and hospital choice in Original Medicare

Truth:Your care is covered from virtually any doctor or hospital in the US without the need for a referral or prior authorization. Almost all doctors and hospitals take Medicare.

Doctors and hospital choice in Medicare Advantage

Truth: You almost always need to use health care providers in the plan’s network for your care to be covered. And, networks can be limited. Also, plan directories are often inaccurate, so check with the providers you use. Don’t assume they will see you, even if they are in the provider directory. Some plans offer out-of-network coverage but require you to pay more out of pocket for out-of-network care.

Prescription drug coverage in Original Medicare
You’ll need to join a Medicare drug plan (Part D) to get drug coverage.
Prescription drug coverage in Medicare Advantage
Most Medicare Advantage plans include drug coverage. If not, you might be able to join a Part D plan.

Quality of care in Original Medicare

Truth: It’s up to you to choose quality providers.

Quality of care in Medicare Advantage

Truth: There is no way to assess quality of care in a Medicare Advantage plan. These plans do not share complete and accurate data with the government, and the data they share is generally at least a couple of years old. Independent studies suggest less access to top quality doctors, hospitals and nursing facilities in Medicare Advantage than in Original Medicare.

Travel coverage in Original Medicare

Truth: Original Medicare covers care anywhere in the US without a referral or prior authorization. There are no restrictions on where in the US you get care in Original Medicare, a consequential difference between Original Medicare and Medicare Advantage

Travel coverage in Medicare Advantage

Truth: Plans don’t usually cover care outside your community, except in emergencies. If you’re in a PPO, you will get some coverage out of network, but you will generally be responsible for 40 percent of the cost.

October 2, 2023
If you’re in a Medicare Advantage plan, watch out! Your doctor or hospital might no longer be in-network
Health care providers across the country look to be dropping their Medicare Advantage plan contracts like flies. Sometimes, physicians or hospital systems cancel contracts with Humana, UnitedHealthcare, Aetna, Cigna and other health insurers because they deny too many prior authorization requests, causing patient safety concerns. Sometimes, these health insurers fail to pay physicians and hospitals what they owe them. Whatever the reason, if you’re in a Medicare Advantage plan, watch out. Your doctors or hospital might no longer be in-network.

Over the last few years, Medicare Advantage plans have been found to inappropriately delay and deny care. The Office of the Inspector General has twice now reported widespread and persistent inappropriate denials of care in some Medicare Advantage plans, with an average of 13 percent of claims wrongly denied. However, our government won’t tell us which Medicare Advantage plans are the bad actors.

Data as basic as Medicare Advantage plan denial rates and disenrollment rates are not publicly available. Social Security Works has sent a Freedom of Information Act to the Centers for Medicare and Medicaid Services, requesting this information. But, so far, Social Security Works has not received a substantive response.

Instead, we are seeing several large hospital systems and physician groups end their contracts with corporate health insurers offering Medicare Advantage. Most recently, MedPage Today reports that “two influential medical groups with San Diego-based Scripps Health are cancelling their Medicare Advantage contracts for 2024 because of low reimbursement and prior authorization hassles, leaving 30,000 enrolled seniors to look for new doctors, or different coverage.”

The problem is not going away but rather looks to be getting worse. As Becker’s reports:
- Mayo Clinic in Arizona and Florida no longer contracts with most Medicare Advantage plans.
- Samaritan Health Services in Oregon terminated its contract with UnitedHealthcare.
- Scripps is terminating Medicare Advantage contracts for its integrated medical groups in California.
- Stillwater Medical Center, a 117-bed hospital in Oklahoma ended contracts will all its MA plans. It said that MA plans denied 22 percent of prior authorization requests; traditional Medicare denied 1 percent.
- Brookings Health System, a 49-bed hospital in South Dakota ended its MA contracts effective 2024.
- St. Charles Health System in Oregon is still on the fence but told its patients to enroll in Traditional Medicare.
- Baptist Health Medical Group in Louisville, Kentucky ended its Medicare Advantage contract with Humana.
- Adena Regional Medical Center is ending its Medicare Advantage contract with Anthem BCBS and managed Medicaid plans in Ohio, effective Nov. 2.
- Regional Medical Center in Missouri ended its Medicare Advantage contract with Cigna and plans to drop Aetna and Humana in 2024.
Here’s more from Just Care:
September 27, 2023
It’s once again time to get your flu shot!
It’s important to get the flu shot every year, no matter how old you are. It’s particularly important for older adults. And, it is all the more important with Covid-19 surging. Now that it’s sweater weather, it’s time to get your flu shot!

Talk to your doctor about getting the flu shot and about whether you should get a special vaccine available for people over 65. The good news: Medicare covers the full cost of a flu shot.

You do not need to go to the doctor’s office for your flu shot. You can likely get the flu shot at your local pharmacy or your local supermarket. More pharmacies are offering drive-through and curbside flu shots, in addition to in-store vaccines.

Why get the flu shot now? That’s how you best protect yourself, the people you love and your community. The flu, like Covid-19, can be lethal. It kills thousands of people each year. Because people have been taking precautions against Covid-19 though, in 2021-22, the CDC found a significant drop in hospitalizations and deaths from the flu. Ten thousand people in the US were hospitalized from the flu and 5,000 people died. Older adults are more likely to die from the flu than younger people.

The flu vaccine takes between two and four weeks to become effective. So, even if you get it now, it might not protect you from the flu until the end of October. It will not protect you from Covid-19, though the symptoms can be quite similar–a cough, a cold, sore throat, fever. You should also talk to your doctor about getting the Covid-19 booster shot, now available; also ask whether you should get the new RSV vaccine.

Sometimes the flu shot will not keep you from getting the flu. However, even if you get the flu, the flu shot reduces the odds that it will be a severe case. The flu shot may keep you from being hospitalized for the flu or, worse still, from being in the intensive care unit of the hospital. It also reduces your risk of death.

You shouldn’t wait to get the flu shot. No one knows whether the flu season will begin this month or next. You want to protect yourself as soon as possible.

You need the flu shot even if you haven’t gotten the flu before. (There is one exception: People who are allergic to the flu vaccine.) There is only benefit from getting the flu shot. The flu shot cannot give you the flu.

Here’s some good news: Everything you are doing to protect yourself from Covid-19–social distancing, wearing a mask and regular hand washing–should also minimize your chance of getting the flu!

A version of this post was originally published on September 9, 2020.

Here’s more from Just Care:
September 25, 2023