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.
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.
I am a volunteer Medicare counselor and I am a long-time reader of Just Care. I have been searching for ways to alert people to the Medicare Advantage situation. The “Original Medicare vs. Medicare Advantage” section of the Medicare and You Handbook (pages 11 and 12 in 2024) is almost useless. For example “Out-of-pocket costs vary – plans may have lower or higher out-of-pocket for certain services.” Really?
I have one complaint about your excellent coverage of the endlessly complicated Medicare system.
You always imply that the Original Medicare path includes Medigap. You do this in a lot of ways. You never mention the cost of Medigap and I think it is because you just consider it a cost people must bear. Medigap is not mandatory. And the premiums are very high. But the total cost analysis, for most people, is just too difficult.
I am pretty old, but I can see the end of Medicare in my lifetime. Since I began counseling, the share of Medicare Advantage has gone from about 20% of Medicare eligibles to 50%. What happens when it gets to 80 or 100%? What will cost discussions sound like then?