JustCare

Category: Your Coverage Options

  • Coronavirus: Should you get the 2023 booster shot?

    Coronavirus: Should you get the 2023 booster shot?

    The next Covid-19 booster shot should now be available from your local pharmacy, health clinic or doctor’s office. Medicare pays for it in full, whether you are enrolled in Traditional Medicare or a Medicare Advantage plan. If you are in a Medicare Advantage plan, the booster shot should be covered in full from network pharmacies, but perhaps not if you go out of network for the booster. Should you get the booster shot?

    The Food and Drug Administration just approved the booster as safe and effective. The booster shot protects people from the current Covid 19 variants in the US. The Centers for Disease Control panel of advisors believes that everyone over six months old should get it. Some argue that if only older adults are vaccinated, it will mean 100,000 additional hospitalizations.

    Fewer than one in five Americans got the Covid-19 booster that was approved in 2022. But, the data show that people who got the booster had a much lower likelihood of getting very sick or dying.

    Many people are getting Covid-19 now and more people are being hospitalized for it than earlier in the summer. More still are expected to be hospitalized this fall and winter.

    The list price of the booster is $130. But Medicare pays for it under Part B. Medicaid also covers it. And, so does commercial insurance. If you are uninsured, the federal government’s Bridge Access Program covers the vaccine at Federally Qualified Health Centers and at Walgreens, CVS and some other pharmacies.

    While the booster shot might only keep people from getting Covid for a few months, it still reduces the likelihood of being hospitalized and dying for a much longer period of time.

    The booster was tested on monkeys and mice, not people. But, around the world, billions of people have gotten the booster safely.

    Should you get the booster shot? You probably should not get the booster shot if you’ve had Covid in the last two months. Otherwise, many recommend you get the booster shot soon. If you are planning to travel over the winter holidays, you might wait until early November to get the booster. You then increase the likelihood that the vaccine protects you from infection during your travels.

    Some doctors question the value of the booster for people who have had Covid-19 and have been vaccinated one or more times. They believe that this alone should keep them from getting seriously ill from Covid-19, even if they get Covid.

    Should you get the Covid booster, the RSV vaccine and the flu shot at the same time? It might be smart to space them out.

    Free Covid tests: The federal government is once again offering free Covid tests beginning September 25. Click here to get four free tests sent to your home.

    Here’s more from Just Care:

  • New Medicare rule should lower health care costs for 860,000 people

    New Medicare rule should lower health care costs for 860,000 people

    The Centers for Medicare and Medicaid Services just finalized a rule to make it easier for people with Medicare on low incomes to enroll in Medicare Savings Programs. More than 850,000 people should more easily qualify for lower health care costs. The rule eliminates a lot of the paperwork involved in qualifying for Medicare Savings Programs.

    Medicare Savings Programs or MSPs help people with low incomes who do not qualify for Medicaid to save money on their Medicare premiums and other out-of-pocket costs. There are four low-income programs, the Qualified Medicare Beneficiary Program or QMB, the Specified Low-Income Beneficiary Program or SLMB, the Qualified Individual Program or QI and the Qualified Disabled & Working Individual (QDWI) Program.

    If your income is no more than $1,235 ($1,663 married) and your assets do not exceed $9,090 ($13,630 married), you should qualify for the Qualified Medicare Beneficiary Program. If you qualify, you do not need to pay Medicare Part A or Part B premiums, and your physicians and other Medicare providers cannot charge you deductibles, coinsurance, or copayments for services Medicare covers. You also cannot be charged more than a $4.30 copay for a Medicare Part D prescription drug.

    If your income is higher than $1,235 but no more than $1,478 ($1,992 married) and your assets do not exceed $9,090 ($13,630 married), you should qualify for the Specified Medicare Beneficiary Program. If you qualify, you will have help paying your Medicare Part B premiums. You’ll also pay no more than $10.35 in 2023 for each drug your Medicare drug plan covers.

    If your income is higher than $1,478 but no more than $1,660 ($2,239 married) and your assets do not exceed $9,090 ($13,630 married), you should qualify for the Qualified Individual Program. If you qualify, you will have help paying your Medicare Part B premiums. You’ll also pay no more than $10.35 in 2023 for each drug your Medicare drug plan covers.

    If you have a disability, are working and lost your Social Security disability benefits and Medicare premium-free Part A because you returned to work, you could qualify for the Qualified Disabled & Working Individual (QDWI) Program, which helps pay for your Part A premiums only.

    This all said, navigating the application process for these Medicare Savings Programs through state Medicaid offices can be challenging. And, it is estimated that about half of the people who qualify for these programs are not enrolled in them. Today, about 10 million people with Medicare are enrolled. This new CMS rule makes it far easier to enroll.

    For example, the new rule means that many SSI recipients will automatically be enrolled in the QMB program, which picks up their Medicare Part B premiums and cost sharing.

    Here’s more from Just Care:

  • What happens when a Medicare Advantage plan endangers people’s health?

    What happens when a Medicare Advantage plan endangers people’s health?

    Medicare Advantage plans delay and deny care inappropriately, putting their members’ health at risk. Enrollees with serious medical conditions can find themselves unable to get critical care. As a general rule, the government does nothing to stop the wrongful delays and denials of care or to protect people in Medicare Advantage plans that are failing to cover their enrollees’ medically necessary care. Before signing up for a Medicare Advantage plan or deciding to remain in one, consider the consequences if you take a big fall or are diagnosed with a serious health condition.

    Twice now, the HHS Office of the Inspector General has found widespread and persistent delays and denials of care and coverage in Medicare Advantage plans. But, the government never names names. Similarly, the American Hospital Association has reported that some Medicare Advantage patients are not able to get essential hospital care. “Inappropriate denials for prior authorization and coverage of medically necessary services are a pervasive problem among certain plans in the MA program. This results in delays in care, wasteful and potentially dangerous utilization of fail-first requirements for imaging and therapies, and other direct patient harms.”

    The Centers for Medicare and Medicaid Services (CMS), the government agency that oversees Medicare, tells people that MA plans “must” cover the same services as Traditional Medicare, but there’s a profound difference between theory and practice. Despite reports of bad acts by insurers offering MA, CMS does not have the resources to monitor the Medicare Advantage plans adequately. Even when the OIG identifies bad actors, CMS appears to lack the political will to name the bad actors, let alone punish the bad actors appropriately.

    Moreover, some MA plans are failing to pay hospitals and other providers adequately, denying 18 percent of their claims inappropriately, according to the OIG. People enrolled in these Medicare Advantage plans are at risk of losing access to their local hospitals, which cannot afford continuing contracts with Medicare Advantage plans that don’t pay their bills.

    On rare occasions, CMS will temporarily freeze enrollment in some Medicare Advantage plans as a penalty for their bad acts. But, when it does, CMS does not alert members to the inappropriate denials. Moreover, it has no way to prevent these Medicare Advantage plans from continuing to delay and deny care inappropriately.

    Worse still, even when cautioned about bad actor Medicare Advantage plans—for example, by a local hospital—enrollees have little recourse. They generally cannot enroll in Traditional Medicare because, as a rule, they have no ability to buy supplemental coverage to fill coverage gaps. When they can get supplemental coverage, they often can’t afford it.

    Here’s what must happen to protect people with Medicare enrolled in, or thinking of enrolling in, a Medicare Advantage plan:

    1. The government, insurance sales agents, and all Medicare Advantage marketing materials must warn people with Medicare that they may be enrolling in a Medicare Advantage plan with high rates of coverage denials and high delay rates, jeopardizing their access to care. They must disclose denial rates and delay rates for each Medicare Advantage plan.
    2. The government, insurance sales agents, and all Medicare Advantage marketing materials must warn people with Medicare that they may be enrolling in a Medicare Advantage plan with high rates of payment denials, jeopardizing their access to care. It must disclose payment denial rates for each Medicare Advantage plan.
    3. The government, insurance sales agents, and all Medicare Advantage marketing materials should make clear that the government has no way to ensure that people enrolling in a Medicare Advantage plan will get the same benefits they get in Traditional Medicare and remove any language or suggestion to the contrary. The issue is not whether Medicare Advantage plans “must” cover the same benefits as Traditional Medicare, but whether they are doing so.
    4. The government must conduct annual audits of all Medicare Advantage plans and publicly identify all of them that have coverage and care denial rates of 10 percent or higher.
    5. The government must publish on its web site and send notices to people enrolled in any Medicare Advantage plan that has a 10 percent or greater denial rate.
    6. The government must give people a meaningful option to enroll in Traditional Medicare, with a limit on financial liability no higher than the lowest limit available in a Medicare Advantage plan; the cap should cost the government $10 less per person than the government spends on enrollees in Medicare Advantage. Right now, CMS must provide a Traditional Medicare option through its Innovation Center that caps out-of-pocket costs in Traditional Medicare no higher than the lowest level set by a Medicare Advantage plan.
    7. The government must establish a set of automatic escalating penalties to impose on Medicare Advantage plans that violate their contractual obligations, either through a ten percent denial rate or higher.
    8. To ensure the financial stability of hospitals, CMS should pay hospitals for MA enrollees directly whenever an MA plan has a payment denial rate above 10 percent and deduct hospital expenses from the MA plans’ capitated rate.

    In addition, the government should make clear in all its materials the annual maximum out-of-pocket costs in Medicare Advantage plans and advise people to check the maximum in any Medicare Advantage plan they are enrolling in. It should require Medicare Advantage plans to include this information prominently in all marketing materials. Sales agents should be required to disclose this information as well.

    As the American Hospital Association has said, “strong, decisive and immediate enforcement action is needed to protect sick and elderly patients, the providers who care for them and American taxpayers who pay MA plans more to administer Medicare benefits to MA enrollees than they do to the Traditional Medicare program . . . . In the recent contract year 2024 Medicare Advantage Rule, CMS noted that a number of the established regulations were already requirements under the health plan terms of participation in the MA program. Given MAOs historic lack of adherence to these rules, Congress should establish stronger programs to hold plans accountable for non-adherence. Additional requirements are insufficient without enforcement action and penalties to support compliance.”

    For too long, our federal government has allowed insurance corporations to mislead the public about Medicare Advantage, without revealing that all Medicare Advantage plans are different and that some are engaged in widespread and persistent delays and denials of care and coverage. Our federal government has failed to protect people from these bad actor insurers. These corporate insurers have endangered the lives of tens of thousands of people, to date. Their bad practices must end before the corporate insurers endanger the health and well-being of tens of thousands more older and disabled Americans.

    Here’s more from Just Care:

  • Family caregiving: Costly, lonely and stressful work

    Family caregiving: Costly, lonely and stressful work

    Most Americans want to grow old in their homes, where they are most comfortable, not in a facility. But, because the US does not support paid caregiving, which is extremely costly, the job generally falls to family caregivers, which is challenging financially, emotionally and logistically. Michelle Cottle writes an opinion piece for The New York Times on the costly and too often lonely job of family caregiving.

    With little if any help, about 42 million Americans care for an aging person, 50 and older. That is challenging work emotionally and financially. Because the US is an aging nation, more Americans will find themselves as unpaid caregivers needing support.

    By AARP’s projections, unpaid family caregiving amounts to some $600 billion of free services in 2021. A lot of caregiving time can be spent commuting. The cost of not being able to work fulltime or at all drives some caregivers into bankruptcy. Caregivers forego a projected $522 billion a year in income.

    Typically, 25 percent of caregivers’ income goes to helping with expenses of the people they are caring for, such as home modifications, medical bills and housing.

    The stress too often causes declines in health, both mental and physical. Studies show that caregivers are more prone to suffer from depression and cancer and are more likely to die younger than people who are not caregivers.

    We have no system in place to train caregivers to undertake their myriad responsibilities. As the health care system evolves and creates additional burdens on individuals, caregivers often must assume responsibility for providing treatment to their loved ones, such as caring for wounds, administering injections and taking care of IV lines. They must also tackle the myriad health insurance obstacles to care and coverage, generally without assistance.

    Caregivers need to take a rest periodically. But, the cost of hiring caregivers can be extremely high. And, paid caregivers are few and far between in many communities.

    The Biden Administration planned to invest $400 billion in strengthening home care, providing training for caregivers and ensuring they are paid well enough to want to take on the responsibilities. But, Congress ended up cutting these provisions out of the Build Back Better bill in 2022. The President’s current budget proposal calls for $150 billion in Medicaid home care services, but Republicans are unlikely to support it.

    There are bills in Congress to support states in building a corps of trained caregivers. But, the cost of hiring caregivers is generally prohibitive. Medicare does not cover caregiver services except in very limited situations for short periods of time, under its home health benefit. It only covers care for people who are homebound and need skilled nursing or therapy services on an intermittent basis. And, even when it provides coverage, it is extremely limited, perhaps 12 hours a week.

    Medicaid sometimes does pay for caregiving services. But, to qualify, in most states, you can have no more than $2,000 in assets (the value of your home and car are excluded). Moreover, many people with Medicaid are on long waitlists to get caregiving services at home.

    Some states, such as Washington State, have their own long-term-care insurance program. Maine has a pilot program. About a quarter of the states have some paid family and medical leave or allow workers to use some of their sick time for caregiving.

    Here’s more from Just Care:

  • If you’re billed for a Medicare procedure, you likely should not pay

    If you’re billed for a Medicare procedure, you likely should not pay

    Phil Galewitz reports from Kaiser Health News on Thomas Greene, a patient with Medicare, whose anesthesiologists billed him directly  for a procedure because Medicare would not pay the bill. But, as a general rule, if you have Medicare and your treating physician performs a service, you are not responsible for the cost, even if Medicare does not cover the service. So, if you’re billed for a Medicare procedure, you likely should not pay the bill.

    Medicare rules protect you from almost ever being liable for the majority of the cost of medical services you receive. There’s always 20 percent coinsurance for medical care in Traditional Medicare. But, if you have supplemental coverage, you usually have no out-of-pocket costs.

    If you’re in a Medicare Advantage plan, you should also have most of your medical costs covered with a copay.  But, even if Medicare ends up denying coverage, if an in-network provider delivers a treatment, you are not liable for the cost.

    With Medicare, the only time that you’re responsible for the cost of a service your doctor provides is if the physician tells you in advance that Medicare won’t pay for the service, and you sign a written waiver agreeing to pay for the service yourself.

    Notwithstanding the rules, some providers might bill you anyway for services. For example, in the Kaiser Health News story, a large private-equity owned anesthesiology group billed Greene, the Medicare patient, for its services because it had billed Medicare too late to get paid for the services. When Greene didn’t pay, it sent the bill to a collection agency.

    For months, the patient had to fend off notices from collection agencies and law firms. They refused to relent. But, Greene’s Medicare statement showed he was not liable for the cost of the services.

    Fortunately, Greene called a free Medicare hotline in his state and was advised that he should not pay the bill. The counselor then contacted the collection agencies that were billing the patient and explained that they had no right to bill him. Since then, he has not received a collection notice.

    If you receive a bill for a Medicare-covered service you had no reason to believe would not be covered, don’t pay it. Contact your State Health Insurance assistance Program or SHIP for free help or call 1-800 Medicare.  You can and should also file complaints against providers and collection agencies online.

    Medicare rarely punishes providers for violating billing rules and sending bills to collection, when they have no right to do so.  Both the providers and the collection agencies should know the rules and should be penalized for violating them.

    Here’s more from Just Care:

  • This Fall, talk to your doctor about getting an RSV vaccine

    This Fall, talk to your doctor about getting an RSV vaccine

    It’s just about that time of year again, when flu season hits. This year, there’s a new vaccine, covered in full under Medicare Part D, which helps prevent coughs and shortness of breath resulting from an RSV respiratory infection. But, the New York Times reports that some pharmacies are charging people with Medicare more than $300 for the vaccine.

    RSV or respiratory syncytial virus kills as many as 10,000 people in the US every year and leads to as many as 160,000 hospitalizations. Two new FDA-approved vaccines have a very high likelihood of preventing hospitalizations and death from respiratory tract disease. But some commercial insurers are not covering it.

    According to the CDC, RSV is a common respiratory virus. Symptoms tend to be mild and cold-like, a runny nose, coughing, sneezing, fever or wheezing. But, sometimes people become short of breath or face lower oxygen levels. You can catch RSV from other people, usually through coughs or sneezes coming in contact with your nose or mouth or eyes. You can also catch it from touching a surface that has the virus on it.

    The CDC recommends that adults 60 years and older get a single dose of RSV vaccine, if your primary care doctor agrees. Older adults and people with weakened immune systems are at the highest risk of hospitalization from RSV. Older adults living in nursing homes or long-term care facilities are also at high risk. You can get the vaccine at the same time that you get your flu shot or other vaccines.

    Blue Cross, Blue Shield won’t cover the vaccine because it is not yet on the centers for Disease Control’s vaccine schedule for older adults.

    Here’s more from Just Care:

  • Social Security turns 88 today; it’s time to expand its benefits

    Social Security turns 88 today; it’s time to expand its benefits

    On August 14th, 1935, President Franklin D. Roosevelt signed Social Security into law. Eighty-eight years later, our Social Security system is among the most successful and popular government programs in history. Nearly every worker pays premiums (Federal Insurance Contributions or FICA) for Social Security. In return, workers receive insurance benefits when they retire, become disabled, or lose a family breadwinner. Social Security is secure, efficient, and the most important source of retirement income for the vast majority of Americans. Social Security does have one major flaw, though: Benefits are too low.

    The average Social Security benefit is only $1700 a month — considerably lower than in peer nations. That is not enough for working families to enjoy a secure retirement or make ends meet when tragedy strikes in the form of serious and permanent disabilities or death. It’s not surprising that our nation is facing a retirement income crisis. Too many Americans fear that they must work until they die, because they will not be able to retire without a drastic decline in their standard of living. Expanding Social Security is the solution.

    Social Security Works was founded to fight the fearmongering about our Social Security system. Today is Social Security’s 88th birthday. 

    The good news is that Democrats have plans to expand our Social Security system. President Joe Biden ran on a promise to expand Social Security, and Congressional Democrats have introduced multiple bills to do so. One of these is the Social Security 2100 Act, which is sponsored by Rep. John Larson (D-CT) and co-sponsored by over 175 of his fellow House Democrats. Another is the Social Security Expansion Act, which is sponsored by Senators Bernie Sanders (I-VT) and Elizabeth Warren (D-MA).

    These bills, as well as numerous other expansion proposals, have much in common. They would keep Social Security strong for generations to come (averting the modest shortfall that some politicians have used as an excuse to demand benefit cuts). They would increase benefits for everyone, with additional targeted increases for low-income beneficiaries, family caregivers, the very old, and others. Additionally, they would update the annual cost-of-living adjustment to reflect the real expenses beneficiaries face and prevent benefits from eroding.

    These are common sense proposals that enjoy broad support from Americans across the political spectrum. Indeed, 83 percent of Democrats, 73 percent of independents, and 73 percent of Republicans want to expand Social Security and pay for it by making the wealthy contribute their fair share. Yet, not a single Republican member of Congress is signed on to a bill expanding Social Security benefits.

    We’ve gotten Republicans on the record―and helped defeat them when the public learns the truth.

    The truth is, Republicans in Congress support cutting Social Security and ultimately ending the program as we know it. This is laid out in the budget proposal from the Republican Study Committee (RSC), a group that counts about 70 percent of House Republicans as members.

    The RSC budget would raise the retirement age to 69, which is mathematically equivalent to a 13 percent benefit cut. It would also decimate middle-class benefits — benefits those workers have earned and paid for. The Republican goal is to turn Social Security into a flat, poverty-level benefit — so that it loses political support and can be destroyed.

    Nor is the RSC budget the only Republican plan to cut Social Security. Every major Republican Presidential candidate, including Donald Trump, is on the record supporting Social Security cuts. Republican politicians are ignoring the will of their voters in favor of protecting their wealthy donors.

    Republicans have also been waging a quiet war on the Social Security Administration (SSA), the agency that administers the program. Since 2010, largely-Republican controlled Congresses have slashed SSA’s budget by 17 percent — even as the number of beneficiaries grew by 22 percent. This has forced the agency to lay off thousands of workers, close field offices, and reduce hours.

    SSA needs adequate funding, and strong leadership. President Biden has nominated former Maryland Governor Martin O’Malley to serve as SSA Commissioner. Biden has also requested a ten percent increase in funding for SSA. The best 88th birthday gifts Congress could give Social Security are to swiftly confirm O’Malley and grant Biden’s funding request.

    Then, Congress should take up legislation to expand Social Security. If Republicans refuse, Democrats should make Social Security a major issue in next year’s election — and urge voters to support the party that is working to expand, instead of cut, their earned benefits.

    Social Security is the cornerstone for our nation’s economic stability. Together, we can build on that cornerstone and bring prosperity to everyone in this country!

    Here’s more from Just Care:

  • 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: