JustCare

Tag: Costs

  • Health insurance industry continues to mislead on high costs of Medicare Advantage

    Health insurance industry continues to mislead on high costs of Medicare Advantage

    Whatever you say about Medicare Advantage–the Medicare health plans administered by private insurance companies–one thing is undeniably true: Medicare Advantage costs more than traditional Medicare and has cost more–all in, more than a hundred billion dollars more–since its inception. But, AHIP, the trade association representing health insurance corporations, is doing its damnedest to deny the high cost of Medicare Advantage, misleading the public on its costs.

    In a new report by Wakely, which AHIP commissioned to counter government claims about Medicare Advantage’s high costs, Wakely attempts to support AHIP. But, Wakely concludes its report with the following “limitations,” wholly undercutting its analysis and shifting responsibility for inaccuracies onto AHIP: “The assumptions and resulting estimates included in this report and produced by the model are inherently uncertain. Users of the results should be qualified to use it and understand the results and the inherent uncertainty. Actual results may vary, potentially materially, from our estimates. Wakely based this analysis primarily on CMS published data, which are subject to revision over time. It is the responsibility of AHIP to review the assumptions carefully and notify Wakely of any potential concerns.”

    Medicare Advantage costs more than traditional Medicare in three very different ways. Medicare Advantage costs more in dollars spent by the government, about four percent more per percent than traditional Medicare, according to the Medicare Payment Advisory Commission or MedPac. And, it is projected that Medicare Advantage will cost $600 billion more over the next nine years.

    Medicare Advantage costs more out of pocket than traditional Medicare with supplemental coverage for people with costly health care needs, in many cases. Annual out-of-pocket costs in Medicare Advantage can be as high as $7,550 for in-network care alone, while supplemental coverage costs about $2,500 a year. Moreover, in some instances, Medicare Advantage plans force people to go out of network if they want to use high quality specialists and top specialty hospitals; then, people must bear all those costs themselves.

    Medicare Advantage costs more than traditional Medicare in terms of health and well-being for people whom Medicare Advantage plans keep from getting the care they need. Sometimes, Medicare Advantage enrollees cannot afford their copays and forgo care. Sometimes, people’s Medicare Advantage plans second-guess their treating physicians and inappropriately deny them care. According to the American Hospital Association and many physicians, some people end up with disabling conditions waiting for needed care. Some die, needlessly.

    Medicare Advantage is also draining the Medicare Trust Fund needlessly. And, because Medicare Advantage costs the government more money, Medicare Advantage drives up Medicare Part B premiums for everyone with Medicare, including people in traditional Medicare.

    Yes, for people fortunate to need relatively little health care, Medicare Advantage costs less than traditional Medicare with supplemental coverage. Anyone who enrolls in Medicare Advantage saves money on the cost of the supplemental coverage they need to fill coverage gaps in traditional Medicare, since traditional Medicare does not have an out-of-pocket cap. But, given all the costs of enrolling in Medicare Advantage and the likelihood that people will need costly care at some point, joining a Medicare Advantage plan could mean playing Russian Roulette with your health.

    If Congress is not going to end the Medicare Advantage program altogether, which it should, the government must overhaul it. First and foremost, Medicare must stop paying Medicare Advantage plans a flat upfront fee regardless of the cost or quality of care Medicare Advantage plans cover. Until it does, you can expect that Medicare Advantage plans will take the government’s money and run with as much of it as possible.

    Here’s more from Just Care:

  • Paying more for a Medicare Advantage plan is likely a waste

    Paying more for a Medicare Advantage plan is likely a waste

    If you are choosing a Medicare Advantage plan, keep in mind that you are taking a big gamble: You can’t know whether it will cover the care you need when you need it. The star-rating system is a farce. And, paying more is likely a waste. It’s not a proxy for better quality, according to a new study in JAMA Health Forum.

    The authors find that quality of care in Medicare Advantage does not differ in a meaningful way across premium levels. In fact, they find that there is tremendous variability in quality at each premium level. That said, the authors do report slightly higher quality of care and patient experience in higher-premium plans.

    The takeaway: If you can’t afford the supplemental coverage you need for traditional Medicare and you are choosing among Medicare Advantage plans, you should not choose the Medicare Advantage plan with the higher premium on the theory that it will provide you with better quality care.

    A second takeaway: The additional premium you choose to pay for a Medicare Advantage plan might not bear any relation to significant copays you might face should you need costly care. Those out-of-pocket costs are unknown. Because they can be high, many people end up skipping or delaying needed care in order to avoid paying these costs.

    The bottom line: With Medicare Advantage, what you think is more could very well be less. Higher premiums and “additional benefits” may end up delivering far less than you might think. The problem is that you likely won’t find out the financial and administrative barriers to care you face until it’s too late to disenroll.

    Here’s more from Just Care:

  • One in seven diabetics struggle to pay for insulin

    One in seven diabetics struggle to pay for insulin

    About nine percent of Americans–30 million people in the US–have diabetes. A new Yale study finds that 14 percent of insulin users—-almost one in seven of them–struggle to pay for insulin. Democrats in Congress tried to include a provision in the Inflation Reduction Act that would have limited the cost of insulin to $35 a month for everyone, but only the limit on insulin costs for people with Medicare survived.

    Seven million Americans use insulin every day. Its price has doubled in the last ten years. After covering costs for food and housing, 14 percent of diabetics must spend at least 40 percent of their remaining income on insulin.

    The Yale researchers found that 1.2 million diabetics reached “catastrophic spending” on insulin in a single year. Of those, 800,000 were people with Medicare.

    Insulin is not the only health care cost for people with diabetes. Among other things, they need glucose monitors and insulin pumps. These costs are too often prohibitive.

    Notably, the researchers found that people with Medicaid, who have more comprehensive coverage than people with Medicare, were less than half as likely to reach catastrophic spending on insulin.

    Prices for insulin have soared since Eli Lilly launched Humalog, an insulin brand. Back in 1996, a vial cost $21. Today, that same vial costs more than $210. The Yale study’s lead author believes that insulin prices are likely to keep rising.

    The researchers also found that people with Medicare felt the burden of high insulin costs more than any other cohort of people with diabetes because their average annual income is lower. Provisions in the Inflation Reduction Act are intended to keep insulin prices from rising more than the rate of inflation for people with Medicare as well as to cap out-of- pocket insulin costs at $35 a month. Already, at least one Medicare Part D prescription drug plan in every state covers insulin at $35 a month. But, $35 a month for insulin alone is prohibitively expensive for a lot of people with Medicare.

    The researchers argue that any government savings from not making insulin affordable to people with Medicare in the short-term will mean much higher health care spending in the long-term. We can expect to see greater disabilities among people with diabetes who can’t afford their insulin, more hospital admissions, and more emergency room visits stemming from complications.

    Here’s more from Just Care:

  • Drug provisions in the reconciliation bill should lower your costs

    Drug provisions in the reconciliation bill should lower your costs

    Last week, I laid out the Medicare prescription drug provisions in the reconciliation bill. They are noteworthy. Among other benefits, for the first time, people with Medicare Part D prescription drug coverage will spend no more than $2,000 out of pocket for their drugs, and Medicare will be allowed to negotiate the price of 100 prescription drugs through 2030. If you’re taking costly medicines, these provisions should lower your drug costs significantly.

    Beginning in 2023, Medicare drug prices cannot rise faster than inflation. If they do, the manufacturer must pay a rebate to the federal government. So, you should no longer see your Part D prescription drug costs rise more than the rate of inflation. The base year for measuring cumulative price changes is 2021.

    In 2024:

    • if you reach the catastrophic coverage phase of your Part D coverage, meaning that you have spent $7,050 out of pocket for covered drugs, you will no longer have to pay five percent of the cost of your drugs. You will have no drug copay.
    • if your income is under 150 percent of the federal poverty level, you will be eligible for full Extra Help benefits, which cover your Part D out-of-pocket costs.
    • your Part D premium cannot increase more than six percent a year.

    In 2025, your maximum out-of-pocket Part D drug costs will drop to $2,000 a year.

    In 2026, Medicare will begin negotiating drug prices for 10 Part D brand-name drugs. The law is silent as to the drugs for which Medicare will negotiate prices, other than that they must be high-cost and have been on the market for at least nine years since FDA approval. The Secretary of Health and Human Services will choose the drugs for which prices will be negotiated.

    In 2027, Medicare will negotiate drug price for 15 Part D drugs.

    In 2028, Medicare will negotiate another 15 drugs in Medicare Part D and Part B.

    In 2029, Medicare will negotiate the price of 20 drugs.

    It’s not clear when we will know which drugs will have negotiated prices or how these prices will affect people who take these drugs. Even today, each Medicare Part D drug plan might charge you a different amount out of pocket for a particular drug, depending upon a variety of factors.

    Steve Maas points out in the Washington Post, that a blood pressure medicine, lisinopril, could cost you nothing or as much as $29 at the same pharmacy with Part D. Without insurance, it costs $4 at Walmart. Maas takes a basket of drugs and reveals that, overall, at least for the five drugs he chooses, you will save a lot of money using the pharmacy at your local Giant supermarket over going to CVS, $11 v. $46.55.

    How will the Secretary of HHS arrive at the negotiated price? We don’t know yet whether the Secretary will be able to achieve the deep discounts that other wealthy countries are able to negotiate or a much smaller discount. But, most likely the latter, given politics in the US. And, then there’s the question of how much of the discounts the Part D plans will pass along to their members in terms of out-of-pocket costs.

    There is a price ceiling for drugs whose prices are negotiated, which depends upon how long the brand-name drug has been on the market. The lowest ceiling is 40 percent of the drug’s fair price (which there’s a formula for calculating), for drugs that have been on the market for at least 16 years. The highest ceiling is 75 percent for drugs on the market between nine and 12 years.

    There is a penalty on manufacturers for non-compliance. Manufacturers must pay an excise tax of 65 percent of the prior year’s sales of that drug, which increases by 10 percent every quarter up to 95 percent. And, if the drug has a negotiated price that the manufacturer opts not to charge, the manufacturer could pay a penalty of as much as 10 times the difference between the price it charges and the negotiated price.

    What does this all mean for the Medicare Part D plans? If there’s any way they can avoid including the negotiated drugs on their pharmacies, they might try to do so, because they might not profit as much from them. We know that CVS excludes some generics from its formularies, forcing enrollees to pay more for their brand-name equivalents, surely because CVS maximizes profits in that fashion.

    Part D prescription drug plans have way too much freedom to take advantage of the system and drive up costs for their enrollees. Enrollees are at an enormous disadvantage because drug tiers and coverage can change at almost any time. People truly cannot choose the Part D plan that’s right for them.

    Unfortunately, Congress does not have the authority to include drug price negotiation for working people in the reconciliation bill. It can only include provisions that affect the federal budget directly. As a result, millions of Americans will continue to import drugs from abroad for personal use. While it is not technically legal, to date, the government has never prosecuted anyone for doing so.

    Here’s more from Just Care:

     

  • Nearly 100 million Americans are now struggling to afford healthcare

    Nearly 100 million Americans are now struggling to afford healthcare

    Dan Witter reports for Gallup on the horrifying situation facing nearly 100 million Americans forced to choose between their health care and other basic needs.  The latest Gallup poll from June 2022 shows that almost four in 10 Americans had to skip or postpone health care, forgo other basic needs, or borrow money to pay for their health care. 

    The poll data indicate that more than one in four (26 percent) Americans are skipping care or delaying care because of the cost. We already know from prior research that thousands of older adults with Medicare end up dying because they cannot afford the out-of-pocket costs of their heart and other critical medicines. Just a $10.40 copay increase leads them to stop filling their prescriptions. 

    People with low incomes struggle most to pay for their care. More than half of households with annual incomes below $48,000 had to forgo some basic necessities in order to afford their care. And, 43 percent of adults with annual incomes under $24,000 skipped a medical procedure or did not fill a prescription because of the cost, in the six months preceding the poll.

    Wealthy Americans are far from immune from the burden of high health care costs. Nearly one in five households with annual incomes of $180,000 or higher are having to forgo spending on other basic needs to pay for their health care.

    Women fare worse than men paying for health care. About 30 percent of women have had to skip or delay health care because of the cost. But, many men are not prepared for these costs either. About 22 percent report struggling with health care costs.

    Women, particularly those younger than 50, are disproportionately being compelled to cut back on health care due to its rising costs. Three in 10 women overall (30%) report having done so, compared with 22% of men — and this percentage swells to 36% among women under 50.

    Skipping health care often comes in conjunction with people spending less on utilities and food. And 60 percent of people who borrowed money to cover necessities also skipped or delayed health care. 

    As difficult as it is for people to pay for needed health care, the poll data shows that, right now, people are most worried about the cost of gasoline (43 percent) and food (34 percent). Only 3 percent of respondents put health care at the top of the list. 

    Of note, Democrats (33 percent) are less concerned than Republicans and Independents (43 percent) about rising health care costs. People of color are more concerned than white adults. 

    Lastly, people hold little hope that either the federal government or their state government will keep costs down. Nearly six in ten Americans are “not at all confident” their representatives in Congress will help them.  

    Most Americans are aware that health care costs continue to increase at a rapid rate. At the moment, increases are not as fast as other sectors. But, that is likely based on pre-negotiated rates established for 2023, pre-inflation, and is likely to change.

    JAMA reported that drug launch prices are up 20 percent a year in the 13 years between 2008 and 2021. In effect, they are ten times higher!!!

    Here’s more from Just Care:

  • The Elder Index helps you see the cost of growing old

    The Elder Index helps you see the cost of growing old

    Lots of older adults are able to manage the cost of aging with some combination of Social Security income and retirement income, and some manage on Social Security income alone,. But, the cost of growing old quickly becomes unaffordable for most when they have health issues. Judith Graham reports for Kaiser Health News on the Elder Index, a web tool that helps you see what it will cost to grow old based on where you live.

    The Elder Index reveals the income that older adults require to live independently. Social Security benefits do not cover a big chunk of their basic needs, even if they are in good health, 68% for people who live alone and pay rent and 81% for couples.

    The Elder Index also shows that both nationally, and in every state, older Americans need far more to live than the federal poverty level might suggest. Nationally, older adults in good health who rent their homes need annual incomes of more than twice the federal poverty level to cover their basic needs, $27,096 v. $12,996.

    The majority of older women (54 percent) are living on annual incomes that are inadequate to cover the cost of basic necessities including health care. Forty-five percent of men are in a similarly fragile predicament.

    Researchers at the Gerontology Institute, University of Massachusetts, developed the Elder Index. You enter your location and your health status–poor, good or excellent–and the Elder Index tells you how much money you need to cover basic necessities in old age. Costs are significant, more so for people living alone than for couples, as well as for home homeowners with mortgages than renters and people in poor health.

    Last year, pre-inflation at nine percent, the data show that around 11 million older Americans could not afford basic necessities. Almost five million single older women, two million single older men, and more than two million older couples are economically insecure as a result of their low incomes. Now, the numbers are certainly higher.

    In New York City, where I live, the Elder Index reports that, each month, a single person in good health who does not own a home, needs $3,056: $1,682 for rent, $454 for health care, $252 for transportation, $275 for food and $393 for miscellaneous. Someone in poor health needs $3,300, an additional $244. Someone in excellent health needs $2,921.

    In New York City, single homeowners in excellent health without a mortgage spend the least, $2,224. If they have a mortgage, their monthly costs soar by nearly $2,000 to $4,203.Couples in excellent health and without a mortgage fare best, $3.068 in monthly costs. That amount rises to $3,826 if they are in poor  health. It rises further to $5,805 if they have a mortgage.

    Congress needs to do better for older Americans, among other things, through relief on property taxes and expanding eligibility for programs that lower people’s health care costs, including Extra Help and Medicare Savings Programs.

    Here’s more from Just Care:

  • Does Medicare Part D save you money on generic drugs?

    Does Medicare Part D save you money on generic drugs?

    A new Avalere analysis reveals that more than half of people with Medicare Part D paid the full cost of their generic drugs at least one time in 2020, in some cases as much as they would pay for brand-name drugs. Sarai Radriguez reports for Health Payer Intelligence on the increasing number of people with Medicare Part D who pay the full cost of their generic drugs.

    In the three years between 2017 and 2020, the percent of people with Medicare getting no help from their Part D prescription drug coverage to pay for their generic drugs in at least one instance rose from 45 percent to 63 percent. Their copays were in the same tier as brand-name drugs.

    Drugs for which people paid the full cost included drugs to treat thyroid issues as well as musculoskeletal, cardiotonic, thyroid issues and anxiety. Curiously, a higher percentage of people in low-income subsidy benchmark plans (Extra Help plans) (68 percent) paid the full price of their generics than people in non-benchmark plans (62 percent).

    Medicare Part D plans cannot charge their enrollees more for copays than their negotiated price for a drug. But, they can put generic drugs on high copay tiers, while getting higher discounts for brand-name drugs. So, that’s what they are doing increasingly to maximize their profits. As a result, some brand-name drugs cost enrollees less out of pocket than their generic substitutes during the catastrophic coverage phase of the Part D benefit, even though they cost Medicare more.

    If the skinny version of Build Back Better passes–the reconciliation bill–it would allow federal drug price negotiation for some brand-name drugs without generic substitutes. But, it does nothing to ensure that Part D prescription drug insurers are offering their enrollees coverage at the lowest price possible, for example, at the prices you can get through Mark Cuban’s Cost Plus Pharmacy.

    Here’s more from Just Care:

  • Expect high out-of-pocket costs if you’re hospitalized, with insurance–and fight them

    Expect high out-of-pocket costs if you’re hospitalized, with insurance–and fight them

    Michael Levenson reports for the New York Times on a woman who had to go to court to avoid paying hundreds of thousands of out-of-pocket health care costs. The woman, Lisa Melody French, went to her local hospital for back surgery. The hospital told her to expect about $1,300 in out-of-pocket costs given her health insurance; but, because she received out-of-network care and the hospital “misread” her insurance, it charged her $229,000.

    If you’re hospitalized and have commercial health insurance, including Medicare Advantage, you could be faced with higher out-of-pocket costs than you expected. You have little control over the doctors who see you and are at high risk of out-of-network doctors providing your care. They generally can’t charge above Medicare’s rate, but that can still be a lot. That said, depending on your income, you could qualify for charity care if you are in a non-profit hospital.

    Ms. French challenged her hospital charges in Colorado state court. Fortunately, the Colorado Supreme Court ruled in her favor. She was liable for only $766.74. It took eight years for her to get that decision.

    How did Ms. French end up with more than $200,000 in out-of-pocket costs? Centura Health, which runs the hospital that provided the surgery, billed her because her providers were out of network and her insurer would not cover their charges. And, Ms. French signed two agreements to pay all hospital charges after the hospital told her that her estimated out-of-pocket costs would be $1,300.

    Out-of-network rates can be ridiculously inflated: The out-of-network charges were the hospital’s full rates–the amounts listed on its “chargemaster.” The court ruled in Ms. French’s favor because she did not know there was a chargemaster and had never agreed to pay its rates. The hospital did not tell her anything about the chargemaster nor would it disclose the chargemaster during the litigation, claiming that the chargemaster was proprietary, a trade secret.

    Hospitals should not be able to charge any rate they please for out-of-network care: Chargemasters “have no basis in reality,” according to Gerard Anderson, a Johns Hopkins professor. They are not tied to the actual cost of a given treatment or procedure. Likely for this reason, hospitals tend to keep them confidential. President Trump ordered that hospitals make this information public, but they have never done so in a way that anyone can understand.

    Patients have no way to comparison shop for hospital care: Since patients have no clue what procedures providers will undertake, no control over them and little information about their costs, patients have no way to comparison shop for their care.

    What if you’re in a Medicare Advantage plan? As with insurance for working people, with Medicare Advantage plans, corporate health plans that cover Medicare benefits, your costs can be insanely high, especially if you’re in an HMO; in an HMO, if you see out-of-network providers, there is no limit on your out-of-pocket costs.

    Here’s more from Just Care:

  • Medicare: 2020 facts and figures

    Medicare: 2020 facts and figures

    Today, Medicare covers 65 million older and disabled Americans. What does that mean for the US budget, national health care spending and the future of Medicare? A new Kaiser Family Foundation interactive, the facts about Medicare spending, takes a deep dive into the 2020 data.

    One in five Americans now have Medicare. And, although people with Medicare use three times more health care services than younger people, Medicare represents 20 percent of national health care spending. Traditional Medicare, which covers slightly more than half of the Medicare population is extremely cost-effective, with less than two percent of its budget going towards administrative costs. In sharp contrast, Medicare Advantage plans take 15 percent of their budget for administration and profit.

    About one-eighth of the federal budget–$769 billion–covers Medicare costs. In 20 years, those costs have almost quadrupled. And, projections are that Medicare costs will double in the next ten years because the Medicare population is growing, as are health care costs. By 2060, there will be 93 million people with Medicare.

    What does Medicare cost per enrollee? Each person with Medicare cost an average of $14,400 in 2020, up from $5,800 in 2000.

    Why is Medicare growing so much? People are living longer. There are more people 80 and older, and, by 2060, they will represent one-third of the population over 65.  Today, they represent about one-fourth the population over 65. Of note, the percentage of people over 90 will double, from 5 percent of those over 65 today to 10 percent in 2060. (The Kaiser paper does not speak to the high cost of Medicare Advantage, which has already cost Medicare over $100 billion more than traditional Medicare and is projected to cost an additional $600 billion over the next nine years.)

    Where is Medicare spending highest? Today, nearly half of all Medicare spending (48 percent) happens under Medicare Part B for outpatient services. Inpatient services under Medicare Part A represent 40 percent of Medicare spending. Prescription drugs represent the remaining 12 percent.

    Medicare Advantage spending is growing faster than traditional Medicare, eating into the Medicare Trust Fund. Today, the government spends about four percent more per person in Medicare Advantage than in traditional Medicare.

    How much are people with Medicare spending out of pocket? People with Medicare are spending a lot more out of pocket than they used to. Over the last 2o years, out-of-pockets costs have gone from about 15 percent of the average Social Security benefit to 19 percent. Medicare premiums represented 6 percent of people’s average Social Security benefit in 2002; they now represent 10 percent.

    Consequently, people with Medicare–most of whom rely heavily on Social Security to make ends meet in retirement–have increasingly less to spend on other necessities.

    The Part A Trust Fund, which pays for inpatient care, is projected to stop being able to pay full benefits as of 2026. At that point, it will only be able to cover 91 percent of those benefits, unless Congress steps in, which it has always done.

    Here’s more from Just Care:

  • Medicare Advantage benefits: Appearances v. reality

    Medicare Advantage benefits: Appearances v. reality

    The Commonwealth Fund’s latest report on Medicare Advantage “benefit design” provides what I would call the standard take, highlighting Medicare Advantage’s out-of-pocket cap and “additional benefits,” as if those are the most important differences. It also assumes that what you see with Medicare Advantage is what you get rather than explaining that appearances belie reality with Medicare Advantage.

    The report questions some of the lack of detail available about Medicare Advantage additional benefits. But, the report overlooks the biggest point about Medicare Advantage plan benefits–they tend to be withheld, delayed and denied a lot more than people might imagine.

    People with Medicare (and everyone else) should be able to assume that the health plan they enroll in will cover all the medical treatments that they need. But, each Medicare Advantage plan has different prior authorization and specialty referral requirements, provider networks, and out-of-pocket costs. Each also has different proprietary rules for when they will pay for particular treatments and different rates of inappropriate delays and denials of care. All of these elements are part of the “benefit” package and can mean the difference between getting needed care and being forced to forgo it.

    Medicare Advantage plans often rely on proprietary algorithms to determine whether care is covered. They always make their own decisions about medical necessity that lead to their spending nearly 25 percent less on medical and hospital care than traditional Medicare. Medicare Advantage plans cover fewer services and fewer costly services than traditional Medicare. The Office of the Inspector General has found that Medicare Advantage plans engage in widespread inappropriate delays and denials of care and coverage.

    You can’t know what you need to know about a Medicare Advantage plan’s benefits before you enroll. The consequence: You can’t meaningfully distinguish among Medicare Advantage plans and you take a huge risk when you enroll. The Commonwealth Fund’s experts warn that people know little about the extra benefits Medicare Advantage plans offer–who gets them, how frequently, where, and at what cost to them. Putting aside additional benefits, people know little about the standard benefits Medicare Advantage plans cover–who gets them, when, how frequently, where, and at what cost to them. For example, Medicare Advantage plans must cover physical therapy, but they decide–with no meaningful oversight– when it is warranted, how often an enrollee will get treatment, from whom and the copay.

    The Fund highlights that nine in ten Medicare Advantage plans offer dental, vision and/or hearing benefits. But, it does not explain that narrow provider networks and high out-of-pocket costs keep a large number of people from taking advantage of these benefits. Rather, it says that Medicare Advantage “may have more limited provider networks or prior-authorization requirements for some services” as if this is simply a possibility when it fact it is the norm.

    On the issue of costs, the report explains that lack of standardization of costs in Medicare Advantage keeps people from knowing what their costs will be in different Medicare Advantage plans. The majority of people in Medicare Advantage plans are in HMOs, which have no out-of-pocket cap for out-of-network care, an issue which the report omits; and, out-of-pocket costs are a barrier to care for many low- and middle-income enrollees.

    Also of note and overlooked in the report: The cost of supplemental coverage in traditional Medicare, which has no out-of-pocket cap, tends to be far lower than the out-of-pocket cap for in-network care in Medicare Advantage. Moreover, we do not know typical out-of-pocket costs in Medicare Advantage because no independent reliable data is available.

    For sure, costs in Medicare Advantage can be very high for people whose medically necessary care is wrongly denied or not available in-network, potentially keeping people from getting needed care. For example, many Medicare Advantage plans do not have centers of excellence in-network that people may want to use for complex conditions. If enrolless can’t afford to pay out of pocket, they can be forced to forgo medically necessary care.

    Here’s more from Just Care: