JustCare

Category: Your Coverage Options

  • 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:

  • As the US population ages, how will people afford long-term care?

    As the US population ages, how will people afford long-term care?

    Americans are finding it increasingly difficult to meet their and their loved ones’ long-term care needs. Congress continues to sit on its hands, while some states are taking action. Mark Miller writes for the New York Times about the need for Congress to step in on behalf of all Americans who could need long-term care and, in the meantime, what some states are doing to help their residents.

    The vast majority of Americans will need some kind of long-term care as they age, be it help with bathing, dressing and toiletting, other activities of daily living, or full-time home care or nursing home care. Only about one in five Americans will not need long-term care. For now, there’s no hope of Congressional action, as ensuring people’s long-term care needs are met costs money, and Republicans have taken raising taxes to cover additional healthcare costs off the table.

    The average cost for one year of nursing home care was nearly $110,000 two years ago. Yet, nearly seven in ten Americans have done little if any planning and saving to cover the costs of their long-term care needs. Not even one in six Americans believe they are prepared financially, if they need long-term care. Those who are unprepared will likely have to count on family and friends to volunteer their time to care for them, if they do not qualify for Medicaid.

    Medicaid does cover long-term care. It is an invaluable benefit. But, in order to get Medicaid, your income and assets need to be extremely low. Thankfully, in many states, if your income and assets are above the eligibility level, your health care expenses can bring your income and assets down to the Medicaid eligibility level so you can qualify for Medicaid.

    Most people do not realize that Medicare does not cover long-term care. At best, people might qualify for 100 days of nursing home care, but that’s only if they’ve been hospitalized for at least three days in the 30 days prior to admission in a nursing home. And, people in Medicare Advantage plans rarely get coverage for more than a very short nursing home stay. People also might qualify for very limited Medicare-covered home care, and that’s only if they’re homebound and need either intermittent skilled nursing or therapy services.

    Washington State is the first state to launch its own publicly-administered long-term care program, the WA Cares Fund,  States such as California and Minnesota might do the same in time. The issue is that covering long-term care is not only expensive, but tricky to implement.

    In Washington State, long-term care benefits will be available to everyone beginning in 2026, and everyone will pay in for those benefits during their working lives through a 0.58 percent payroll contribution. The maximum benefit will only be $36,500, a fraction of the total amount most people will need to spend on home care. The Washing State benefit should help with a year of home care costs.

    Washington State might save on Medicaid expenses through this long-term care program. That’s what the state is hoping. Because of the program, some people will not need to spend down all their assets to qualify for Medicaid. But, nothing is clear at this point.

    Some questions still need to be answered. For example, what if people also have private long-term care insurance? And, will people who contribute to the program lose their right to benefits if they move out of Washington state?

    All this said, Washington State is doing its residents a major service. Private long-term care insurance has always been a gamble, with “level” annual premiums able to double out of nowhere; it becomes increasingly unaffordable over time and offers benefits that are generally more limited than people realize.

    Here’s more from Just Care:

  • Can we fix our broken health care system without reining in costs?

    Can we fix our broken health care system without reining in costs?

    Aaron Carroll writes for the New York Times about how to fix our broken health care system.

    Notwithstanding all the ways the Covid-19 pandemic exposed fissures in our health care system, bringing with it more than one million deaths, Congress is doing precious little to address uninsurance and underinsurance and their consequences for our health and well-being.  Carroll studied health systems in five other wealthy countries to appreciate differences between them and the US. Carroll suggests that universal health care is the solution to our broken system, whatever it looks like; he doesn’t see health care costs in the US as a stumbling block.

    We spend more per person on health care than any other country, and health outcomes are generally significantly worse than in every other wealthy country, including life expectancy. So, what does the United Kingdom, France, Australia and New Zealand do differently? They all guarantee health care coverage to their citizens.

    Carroll posits that in every other significant way these other wealthy countries are different from one another. But, these countries not only share guaranteed universal coverage. They all have a sets price for most health care goods and services. It’s that combination, along with significant restrictions on insurance company profits, that make health care affordable for their citizens.

    Australia, New Zealand and Canada all offer government-provided coverage,  sometimes called single-payer.  Australia and New Zealand’s single-payer systems allow people to buy private insurance to improve their access to care. Canada does not allow that.  Australia’s system requires people to contribute significantly to the cost of their care.

    Carroll says France’s system is not quite single-payer because people get their coverage through different systems. But, it is primarily with government funding, either through their jobs or some other means, and with significant government rules and regulations. France requires people to pay upfront for their outpatient care and then reimburses them for the cost.

    Britain likely offers the most robust coverage of all these countries. Most services come with no out-of-pocket costs. Britain’s system is different from single payer because it is not insurance-based. Rather, the government employs physicians and owns hospitals and covers people’s care directly.  The British system is socialized medicine. While people can have private insurance for enhanced benefits, almost no one does.

    Singapore offers everyone only catastrophic coverage for high-cost services. People can buy private insurance to supplement the public coverage, but few do.

    Carroll acknowledges that public hospital systems in all these countries make a huge difference in improving access to care, eliminating competition for profits. It seems hard to imagine how the US moves to that system to reduce costs and improve access, given the very limited number of public hospitals here. Is there any way to open up the Veterans Administration hospitals to all Americans? And, even if there were, would that give people living in remote areas adequate access to care?

    Carroll points up that housing, food and education also contribute significantly to better health. Other countries invest in these “social determinants of health.” The US does not, but we could.

    Carroll suggests that if we allocated some of our health care budget to the social determinants of health, we would likely see far better health outcomes. But, we are currently on the reverse trajectory, cutting this discretionary spending, such as food stamps. With all the money we invest in health care, Carroll has hope of realigning these investments. He thinks it’s simply a matter of political will.

    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:

  • Escort requirements keep people from receiving medical procedures

    Escort requirements keep people from receiving medical procedures

    Paula Span reports for the New York Times on outpatient procedures that require patients to have someone to escort them out of the doctor’s office. Consequently, sometimes patients must forego important care because they have no one to escort them out of the doctor’s office afterwards. These escort requirements are a particular challenge for people living alone, without friends and family to assist them.

    There are a range of outpatient procedures for which some physicians require you to have an escort. For example, if you need a colonoscopy or cataract surgery, to name two procedures that require anesthesia, you might not be able to get an appointment if you don’t have an escort to pick you up after the service. Without the name and contact information for your escort, doctors might not allow you to schedule these procedures.

    Easy access to transportation home after a procedure is not enough. Some physicians require people to have someone to get them from the doctor’s office to the taxi or car and then from the taxi or car into their homes. The concern is that the patient might have a bad reaction to the anesthesia and end up in a stupor or vomiting or totally disoriented.

    Not every doctor requires an escort. But, some doctors do. One person enrolled in an Aetna Medicare Advantage plan could not find a doctor to perform a procedure he needed unless he had an escort. But, he did not have one, and Aetna won’t cover the cost of the medical escort.

    An escort requirement is a big issue for many people who live alone and don’t have people to turn to for help. They might need a procedure to stay healthy. But,  if they also need an escort for their safety, they are in a quandary.

    Is there a way to avoid having an escort? If you do not have an escort to accompany you to a procedure where an escort is required, you should ask your health care providers that require escorts whether they would allow you to wait in their offices for several hours after a procedure in lieu of having an escort. Sometimes they will.

    How to get an escort? You might try contacting your local church or religious institution. Or, if you’re up to it, look into volunteering in your community for credits. Organizations like TimeBank allow you to bank credit from your own volunteering to enable you to get a volunteer to escort you home from the doctor.

    Here’s more from Just Care: