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Tag: Traditional Medicare

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

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

    There are four important factors to consider when choosing between traditional Medicare, which is administered by the federal government, and Medicare Advantage plans, which are administered by corporate health insurers that contract with the government: 1. Coverage, 2. Access, 3. Incentives and 4. Cost.
    1. Coverage: Both traditional Medicare and Medicare Advantage plans cover the same benefit package of medically necessary care. But, Medicare Advantage plans typically cover 25 percent fewer services than traditional Medicare because they tend to take a narrow view of what care is medically necessary and profit more the less care they cover. Traditional Medicare covers care from most doctors and hospitals in the United States.  Medicare Advantage plans generally cover care only from doctors and hospitals in their network and, often, only in your area, except in emergencies or urgent care situations. Medicare Advantage plans generally offer some additional benefits. For more information on the fundamental differences between Medicare Advantage fee-for-service plans and traditional Medicare, click here.
    2. Access: With traditional Medicare, you are covered for all medically necessary care without a referral or prior authorization.  For more information on the easy access you have with traditional Medicare, click here. With a Medicare Advantage plan, you often must have a referral from a primary care physician or prior authorization from your Medicare Advantage plan in order for your care to be covered.
    3. Incentives: With traditional Medicare, your doctors and hospitals have every incentive to provide you with all the care they think you need because traditional Medicare will pay for it. That can lead to overtreatment. Medicare Advantage plans receive a fixed amount from the government to cover your care regardless of how much they spend on your care. Consequently, they might offer incentives for their network doctors and hospitals to withhold needed care. The less money a Medicare Advantage plan spends on your care, the more money the Medicare Advantage plan has for its shareholders. To learn more, read this blog post by Diane Archer and Theodore Marmor on the fundamental difference between traditional Medicare and private insurance.
    4. Cost: Traditional Medicare has no out-of-pocket cap, so you need extra insurance to fill coverage gaps. Some people get this additional insurance from former employers, some buy an individual “Medigap” or Medicare supplemental insurance policy and some qualify for Medicaid, which fills gaps, because their income is low.  With this extra insurance, you will have few if any out-of-pocket costs when you get medical or hospital care. You also need prescription drug coverage, if not through Medicaid or a former employer, through a Medicare Part D drug plan. Without this extra insurance, if you need a lot of costly care, your out-of-pocket costs could be astronomical. With a Medicare Advantage plan, you cannot buy extra insurance to fill coverage gaps. So, unless you can afford copays and deductibles, you might have to forgo care. Depending upon the Medicare Advantage plan, you can be liable for up to $7,550 in out-of-pockets costs–copays, coinsurance and deductibles–for your in-network care alone.  If you are in a Medicare Advantage HMO, there is generally no limit to your out-of-pocket costs if you use doctors who are out of network. If you are in a PPO, your out-of-pocket cap can be as high as $11,300.

    For up-to-date advice you can trust, subscribe to Just Care’s free weekly newsfeed here or by clicking the orange button below.

    Here’s more from Just Care on choosing a health plan:

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  • Medicare Disadvantage: How corporate insurers destroy Medicare

    Medicare Disadvantage: How corporate insurers destroy Medicare

    Merrill Goozner writes for Gooznews about the disadvantage of Medicare Advantage, which is administered through corporate insurers. MedPAC, the agency that oversees Medicare, has warned that, if the government continues to overpay Medicare Advantage plans, Medicare’s financing is in serious jeopardy. MedPAC wants the Medicare Advantage payment system overhauled so health plans can’t simply take the government’s money and run.

    Enrollment in Medicare Advantage is growing. People with lower incomes are more likely to enroll in Medicare Advantage to avoid having to buy Medicare supplemental insurance. Unlike traditional Medicare, Medicare Advantage has an annual out-of-pocket cap, albeit one that forces people to pay as much as $7,550 for their care.

    And, though people who join Medicare Advantage are giving up choice of doctors, coverage anywhere in the country, and the freedom to access care without referrals and prior authorizations, they often get partial coverage for dental or hearing care and an out-of-pocket cap; the government pays Medicare Advantage plans about four percent more per person than it spends on traditional Medicare.

    Medicare Advantage companies bid to offer their plans at about 15 percent less per person than traditional Medicare. They can afford to and still make a big profit since they tend to spend around 25 percent less on medical care than traditional Medicare by restricting access. Moreover, the government pays Medicare Advantage plans a higher rate if they can show more diagnoses for their enrollees–upcoding–even if the Medicare Advantage plans don’t provide enrollees with additional services. In 2020, these overpayments cost between $12 billion and $20 billion.

    The government pays Medicare Advantage plans even more money in the form of “quality bonuses,” stemming from self-reported data. MedPAC says this data is of such low quality that it is of no good value.

    The government is hard-pressed to collect back overpayments to Medicare Advantage. It must go to court to do so at substantial expense. Notwithstanding, 346 members of Congress, including progressives such as Ilhan Omar and Barbara Lee, seem to be ok with these overpayments, recently sending CMS a letter praising Medicare Advantage.

    Medicare Advantage is incredibly profitable because of the high fixed capitated payments per member they receive regardless of whether they cover any care for the member. Private equity and venture-backed physician practices have entered that market, as well as the new direct contracting market in traditional Medicare, which also pays companies to cover people’s care on a capitated basis.

    Goozner says that capitated payments “are the best way to incentivize providers to coordinate care, promote prevention, reduce hospitalizations, improve outcomes and prolong lives.” He cites no evidence that capitated payments do indeed lead to coordinated care, improved outcomes or longer lives. In fact, he concedes that the insurers’ “profits depend not on delivering better care but, for the majority of their enrollees, on narrowing networks and using traditional tools like prior authorization to discourage utilization regardless of its impact on outcomes.”

    In fact, while capitated payments do lead insurers to deny coverage for hospitalization and a whole range of costly services, data from the Office of the Inspector General show that often they do so inappropriately, to maximize profits.

    Goozner argues that fee-for-service payments can lead to overtreatment, which cannot be denied. But, fee-for-service payments can also help ensure that people get all the care that they need. In capitated health plans, undertreatment can be a big issue, particularly for people with complex conditions.

    And, Goozner acknowledges that Medicare Advantage has not reduced the cost of care, just transferred money from physicians and hospitals to insurers. Goozner concludes that Medicare Advantage cannot continue in its current form, gouging taxpayers, with little oversight or accountability. Goozner does not say how Medicare Advantage should be overhauled. Meanwhile, Congress has no plan to overhaul it.

    Congress needs to ensure that Medicare Advantage plans are not overpaid, cover all appropriate care and don’t spend their resources designing and implementing ways to avoid paying for costly care. One way to do so might be for it to dictate not only the benefits Medicare Advantage plans cover, but their coverage policies (so they don’t deny care inappropriately) and pay them based on the cost of services they cover. The Connecticut Medicaid managed fee-for-service model is worth exploring.

    Here’s more from Just Care:

  • Roundup: 2022 Medicare benefits and more

    Roundup: 2022 Medicare benefits and more

    We’re already three months into the new year. It seems time to put together all the information you might need to be on top of your Medicare health care costs and how to save money in 2022.

    What are your typical costs? Even with Medicare, health care costs can be quite high. The typical person spends more than $6,000 out of pocket on premiums, deductibles and coinsurance.

    What are the advantages of traditional Medicare and the risks of Medicare Advantage plans?  Unlike Medicare Advantage, traditional Medicare covers your care from most doctors and hospitals in the US without administrative obstacles. The key reason people do not opt for traditional Medicare is that they need to buy supplemental coverage to fill coverage gaps. because traditional Medicare has no out-of-pocket cap. (People with Medicaid and some people with retiree benefits from their jobs have that coverage.) Supplemental coverage can cost more than $2,000 a year. But, once you have Medicare supplemental coverage, your out-of-pocket costs are quite small. Medicare Advantage has an out-of-pocket cap, but depending upon the plan you choose, you could be responsible for as much as $7,550 out of pocket, posing a serious financial barrier to care. You can’t buy supplemental coverage to fill gaps in Medicare Advantage and generally are limited to coverage for care from a restricted network of doctors and hospitals.

    How to save money on care Medicare does not pay for?

    How to save money on drugs?

    How to save money on emergency care?

    Who to call with questions about Medicare? Avoid agents and brokers, many of whom profit from steering you to coverage that benefits them and might not benefit you. Instead, for free unbiased assistance, call your State Health Insurance Assistance Program or SHIP.

  • Biden administration bent on privatizing traditional Medicare

    Biden administration bent on privatizing traditional Medicare

    There appears to be little light any more between corporate health care and government health care or even between government health care-speak and corporate health care-speak. In the latest government push to privatize traditional Medicare–“ACO REACH”–insurer and investor middlemen will responsible for assuming risk and paying claims. The Biden administration claims its goal is “value-based care,” though decades of evidence show that corporate middlemen drive up costs and do not deliver value for patients.

    What’s happening? The Biden administration is continuing a Trump administration experiment to pay middlemen–often entities with no meaningful medical expertise–a flat fee per patient to “manage care” for people in traditional Medicare. The administration just renamed the “Global Professional Direct Contracting” experiment–which works like Medicare Advantage–ACO REACH. It will privatize traditional Medicare by turning over “care management” read “money management,” to investors and insurers.

    Who will be in the experiment? People with Medicare whose primary care physicians are working for a middleman that contracts with the Centers for Medicare and Medicaid Services as part of “ACO REACH.”

    What’s the value to patients? If you look at the role insurer middlemen play in Medicare Advantage, it is hard to see that ACO REACH offers any possibility of value to patients and easy to see huge risk. Given the scant data available in Medicare Advantage, no one can demonstrate value in the care patients receive. MedPAC, the government’s Medicare oversight agency, has never been able to assess care quality in Medicare Advantage plans because the plans have never given it complete and accurate information that would permit MedPAC to assess value. At the same time, government agencies have found widespread and persistent inappropriate delays and denials of care and coverage putting patients at serious health risk.

    ACO REACH will offer “care coordination,” but what does that mean?  The Center for Medicare and Medicaid Innovation (CMMI) claims the ACO REACH model is somehow going to ensure people in traditional Medicare have their care coordinated in ways that improve health outcomes. But, there is no evidence that people in managed care plans have better health outcomes than people in traditional Medicare. In fact, “care coordination” is often a euphemism for delayed care, less care, and referrals to low-cost providers, none of which is by definition a good thing. Primary care doctors will have financial incentives to minimize costs.

    Will ACO REACH promote health equity? CMMI also says it is promoting health equity through ACO REACH, but there’s no evidence to support that claim. Participants will need to have health equity plans. But health equity plans are far different from results and, so long as cost is a barrier to care, it’s hard to see how participants can reduce health disparities. It’s also hard to imagine how CMS will ensure compliance by participants with model requirements.

    Here’s more from Just Care:

  • 2022: Medicare out-of-pocket costs

    2022: Medicare out-of-pocket costs

    Many if not most Americans breathe a sigh of relief when they are eligible to enroll in Medicare, as they should. Medicare guarantees good affordable health care coverage that is not available to almost anyone under 65. As good as Medicare is though, it does not offer comprehensive coverage but rather comes with sizable out-of-pocket costs.

    A December 20221 AARP Public Policy Institute paper provides the latest information on health care out-of-pocket costs for people in traditional Medicare. They include premiums, deductibles, coinsurance, copays. They also include critical health care services that Medicare still does not cover. Medicare does not cover hearing, dental and vision benefits, nor does it cover long-term care.

    The Public Policy Institute does not address out-of-pocket costs for people in Medicare Advantage plans, explaining  that “The analysis excludes people enrolled in Medicare Advantage plans because their personal spending data were not reliable.” Don’t trust Medicare Advantage plan claims about out-of-pocket costs for their enrollees until they make complete and accurate data available for independent analysis. Based on the data available, Kaiser Family Foundation finds higher out-of-pocket costs for many people in poor health in Medicare Advantage than in traditional Medicare with supplemental coverage.

    People in traditional Medicare now spend an average of $6,168 on health care costs that Medicare does not pay for. Nearly half that amount goes towards the cost of supplemental coverage, which picks up Medicare deductibles and coinsurance. About 27 percent of people’s spending goes towards services Medicare does not pay for.

    In 2018, 10 percent of people with Medicare had out-of-pocket costs of at least $10,816. The top quarter of people with Medicare with the greatest spending averaged $14,123. The bottom 25 percent of people who use the least amount of care spent an average of $1,606.

    People with Medicare spend the most money on long-term care services. People spent an average of $22,953 out of pocket for a nursing home stay in 2018. Other sources of large out-of-pocket expenses were skilled nursing facilities, where out-of-pocket costs averaged $2,216, dental care, for which people spent an average of $924, and prescription drugs, for which expenses averaged $703.

    These out-of-pocket costs are particularly concerning when understood as a percentage of income. More than half of people with Medicare had annual incomes under $26,200 in 2018. Out-of-pocket costs represent 16 percent or more of annual income for half of Americans with Medicare.

    One in ten people with Medicare spent more than half their income (52 percent) or more on health care.

    Here’s more from Just Care:

  • CMS intends to increase overpayments to MA plans

    CMS intends to increase overpayments to MA plans

    Inexplicably and inexcusably, the Centers for Medicare and Medicaid Services has issued a notice that it plans to increase overpayments to Medicare Advantage plans by 7.98% in 2023, Modern Healthcare reports. As it is, MA plans spend $1,680 less per enrollee than traditional Medicare on medical services and are paid four percent more. If changes are to be made, MA payments should be cut, and CMS should invest more in traditional Medicare.

    CMS currently intends to raise rates for Medicare Advantage plans just shy of 8 percent. CMS makes this proposal notwithstanding recent projections that it will overpay MA plans as much as $600 billion over the next eight years if it doesn’t reform its payment system for MA. And, it somehow believes that MA has the means to address health equity and social determinants of health, although data to support that belief is tenuous at best.

    If permitted, the increase in payment to MA plans will be almost twice the increase of last year. For sure, this increase will go to additional benefits and marketing that lures healthy people into MA plans. But, you can be sure that it is all part of a big bait and switch in the foreseeable future when Congress cuts payments to MA plans to shore up the Medicare Trust Fund, and MA plans in turn shift substantial additional costs onto their enrollees.

    CMS currently rewards plans with four- and five-star ratings. But, these ratings are a farce and do not speak to the quality of care people receive in their Medicare Advantage plans. MedPac has said year after year that it cannot assess quality. MA plans do not report complete and accurate data that would allow quality assessment.

    CMS Administrator Chiquita Brooks-LaSure ignores health inequities that MA plans promote by rationing care based on the ability to pay. People with costly health conditions tend to disenroll from Medicare Advantage plans to traditional Medicare when they can, at disproportionately high rates. Traditional Medicare does not discriminate based on the ability to pay and is able to achieve health equity for anyone with supplemental coverage.

    Comments on the notice are due March 4.

    Here’s more from Just Care:

  • 2022: Medicare Part D coverage and costs

    2022: Medicare Part D coverage and costs

    Whether you are enrolled in traditional Medicare or a Medicare Advantage plan, Medicare covers your prescription drugs under Medicare Part D. The vast majority of people with Medicare, 48 million in 2021, are enrolled in a Part D drug plan. Here’s what you need to know about Medicare Part D coverage and costs in 2022.

    Don’t assume that your Part D drug plan will cover your drugs in 2022, even if they did so in 2021. Rather, assume that your costs will go up a lot if you don’t change Part D plans. Each year, these private insurance plans can change dramatically. Kaiser Family Foundation reports on your options.

    Red Alert: Nearly three in four people enrolled in traditional Medicare and a Part D plan will pay higher costs if they do not switch plans in 2022.

    There are 16 national Part D prescription drug plans, with monthly premiums ranging from $7 to $99. SilverScript SmartRx is offering a Part D plan with a $7 monthly premium. AARP MedicareRx Preferred is offering a Part D plan with a $99 monthly premium. Wellcare Value Script has lowered its Part D monthly premium for 2022 from $16 to $12 a month.

    Premiums are typically higher for Part D plans offering enhanced benefits, lower insulin costs, lower cost-sharing and/or low or no deductibles. For example, Part D plans that charge no deductible will have an average monthly premium of $90.

    If you have traditional Medicare, you typically will be able to choose among 23 Part D drug plans. The average monthly premium is $43; for standard Part D plans, the average monthly premium is $35, and for enhanced plans it’s $51. Most people (seven in ten) will have an annual deductible of $480, but the average is $384.

    Cost-sharing for brand name drugs could be as high as 40-50 percent and as low as $0 for preferred generics, depending upon the Part D plan you choose. Preferred brand copays will average $42.

    If you are in a Medicare Advantage plan, you typically will have a choice  of 31 Part D drug plans.

    If you qualify for a low-income subsidy or LIS, there are 198 Part D drug plans for which you will not pay a premium.

    Fewer companies are offering Part D drug plans than ever before, which is largely a result of consolidation in the industry. In 2010, 40 companies offered Part D drug plans. In 2022, 16 companies are offering these plans. Four companies control 80 percent of the market, CVS Health, Centene, UnitedHealth and Humana.

    If you need insulin, no matter what state you live in, you can enroll in an Innovation Center Part D plan to lower your insulin costs. You would have a monthly copayment for your insulin of $35 in all phases of Part D coverage. This option is available to everyone who is not eligible for a low-income subsidy or LIS.

    If your income is low and you are among the 13 million people with Medicare who qualify for a low-income subsidy, you have a choice of some premium-free Part D stand-alone plans in 2022. You can also choose a “non-benchmark” plan and pay a portion of the monthly premium.

    Here’s more from Just Care:

  • Your right to buy a Medigap policy when you enroll in traditional Medicare

    Your right to buy a Medigap policy when you enroll in traditional Medicare

    Between October 15 and December 7, it’s the Medicare Annual Open Enrollment Period, during which time you have the right to enroll in traditional Medicare and disenroll from your Medicare Advantage plan. But, depending upon the circumstances surrounding your enrollment in traditional Medicare and the state you live in, you might not have the right to buy a “Medigap” policy, insurance that fills gaps in traditional Medicare. And, since traditional Medicare does not have an out-of-pocket limit, without supplemental coverage, you put yourself at grave financial risk.

    To be clear, unlike Medicare Advantage, which has an annual out-of-pocket maximum, traditional Medicare has no maximum. But, unlike Medicare Advantage which requires you to pay copays that can total thousands of dollars a year in order to get care, with traditional Medicare you can protect yourself financially through supplemental insurance that fills gaps. You can get supplemental insurance from a former employer or Medicaid, or from a an insurance policy you buy in the individual market, which is sometimes called a Medigap policy.

    However, if you don’t buy a Medigap policy when you first enroll in Medicare, you could end up locked into a Medicare Advantage plan.

    What are your rights to buy a Medigap policy?

    • When you first enroll in Medicare at 65 or later, you have the right to buy a Medigap policy of your choosing, regardless of your age or health, for six months during your initial enrollment period. You should buy the policy when you enroll in traditional Medicare to minimize your out-of-pocket costs.
    • If you enroll in a Medicare Advantage plan when you are first eligible for Medicare at 65 or later, you have the right to buy a Medigap policy if you switch to traditional Medicare within 12 months, up to 63 days after you leave your Medicare Advantage plan.
    • If you are enrolled in traditional Medicare with a Medigap policy and drop that policy to enroll in a Medicare Advantage plan, you have the right to get that Medigap policy back if you disenroll from your Medicare Advantage plan within 12 months of joining, but you must apply for coverage no later than 63 days after you leave your Medicare Advantage plan.
    • If you live in Massachusetts, Minnesota or Wisconsin, you always have the right to buy a Medigap policy but the insurer can charge you more based on your health status if you are not buying the policy during your initial enrollment period.
    • In Massachusetts, Maine, Connecticut and Vermont, you always have the right to buy a Medigap policy and the insurer cannot charge you more based on your health status.
    • If your Medicare Advantage plan leaves or you leave the area and you switch to traditional Medicare, you have a guaranteed right to buy a Medigap policy so long as you do so within 63 days of your Medicare Advantage plan coverage ending.
    • If you have retiree coverage from a former employer that fills gaps in traditional Medicare and that coverage end, you have a guaranteed right to buy a Medigap policy.
    • If your Medicare Advantage plan is found not to comply with its legal obligations or somehow misled you, you have a guaranteed right to buy a Medigap policy.
    • If you are under 65 and have Medicare because you are receiving Social Security Disability Income, you have no guaranteed right to buy a Medigap policy under federal law.

    There are a variety of standardized Medigap plans, some of which fill more gaps in coverage than others. To learn more about your Medigap options and how to choose a Medigap plan, click here.

    Here’s more from Just Care:

  • How to prepare for your doctor’s visit

    How to prepare for your doctor’s visit

    Whether you’re in good health or poor health, in a separate post I explained why it’s important to have a good primary care doctor. And, I’ve provided four questions to help you know whether your primary care doctor is meeting your needs. Here, I want to help you prepare for your doctor’s visit, so that you make the most of it.

    1. Confirm that your doctor accepts your insurance. If you have traditional Medicare, ask if the doctor accepts assignment, which means that the doctor accepts Medicare’s rate as payment in full. If you have a private insurer such as Aetna or Cigna, to save money, make sure the doctor is in-network. Always find out how much more you may have to pay out-of-pocket.
    2. Ask a family member or person you trust to join you. No matter what your age, it’s always good to have a health care buddy, a second pair of ears to listen to the doctor’s advice and, ideally, to take notes. You may also want your buddy to ask questions. The doctor’s visit can be stressful. You can decide to have your buddy be present for some or all of the visit – you are in charge!
    3. Make sure you bring a list of your medications with you, both prescription drugs and over the counter. And, ask your doctor whether you should be taking all these drugs.  It may be that you don’t need to be on a drug or that one drug you’re taking interacts poorly with another one. As you collect the bottles, think of any concerns, side effects or questions you have about your treatments.
    4. Make a list of all the questions you have for your doctor and other information you want to share, including any symptoms and concerns you have about your health. [Editor’s note: If you go alone to the visit, be sure to bring a pen and paper to take notes and repeat the doctor’s advice in order to confirm that you understand it.]
    5. If it’s your first appointment, you want to be sure to let your doctor know about any chronic conditions and any other health problems you have, as well as diseases that run in your family. If possible bring past medical records, test results, and your immunization records. You can ask the last doctor you saw to provide this information to your doctor, or you can sign a release form to have your new doctor’s office request your prior records.  If you are already an established patient of the doctor, be ready to provide your doctor with any major family health updates—for example, if your brother has been recently diagnosed with high blood pressure, or a parent was diagnosed with cancer.
    6. Check with the office if you are expected to come on an empty stomach to your appointment. There are only a few tests that need to be done in the “fasting state” (meaning, no food or drinks other than water for 12 hours). If you are expected to be fasting, tell the office if you are taking medications that require food, or if you think this will be difficult for you for any reason. Remember that most routine tests are not affected by drinking water, but being dehydrated could lead to slightly abnormal results.
    7. If your doctor is suggesting a test or treatment, to avoid overtreatment, be sure to understand why you need it. What are your options? How will it help? Are there side effects?
    8. Be sure that when you leave the office you understand your diagnosis and what you need to do, as well as when and how to contact the doctor and when to make another appointment. If you need a new prescription, make sure you know when to take it and what to do if you experience any side effects.

    [Editor’s note: This post was originally published on June 29, 2016.]

    Here’s more from Just Care:

  • Congress must reduce out-of-pocket costs for people with Medicare

    Congress must reduce out-of-pocket costs for people with Medicare

    Earlier this month, “the Medicare team” inside the federal government sent an email inviting millions of us to mark our calendars for the Oct. 15 start of a 54-day period to enroll in Medicare health plans.

    At the end of the email, Medicare makes a suggestion we felt should be far more prominent and noticeable, one that is akin to what the Surgeon General requires tobacco companies to plaster on a pack of cigarettes: “A plan with the lowest premium might not always provide the lowest total cost to you.”

    Yes, even older adults and people with disabilities who are eligible for Medicare need to worry about high out-of-pocket costs. Whether they are in traditional Medicare, administered directly by the government, a Medicare prescription drug plan or a Medicare Advantage plan, both of which are administered by private health insurers, costs–deductibles, coinsurance and copays–have been rising. Traditional Medicare and the bewildering array of prescription drug plans have no out-of-pocket maximums, and Medicare Advantage plans have a cap that can be as high as $7,550 a year for in-network care alone. According to the Kaiser Family Foundation, millions of people with Medicare, particularly people with modest incomes in poor health, are facing cost-related barriers to care.

    Many members of Congress recognize that health care costs jeopardize health care access and want the reconciliation bill to broaden Medicare benefits to include dental, hearing and vision services. As worthy as that is, capping Medicare out-of-pockets at an affordable level could be even more beneficial for cash-strapped seniors.  Because there is no reasonable cap, people with Medicare too often are forced to go deep into debt to get needed care. Many others forgo this care because of the cost.

    Both Traditional Medicare and Medicare Advantage cover hospital and medical care under Parts A and B. If you’ve worked and paid into Social Security, you qualify for these hospital and medical benefits at relatively low cost. But as health care costs have risen, so has the expectation that even people with Medicare need to put more “skin in the game.”

    Out-of-pocket requirements encompass deductibles, coinsurance and copayments. Deductibles for Medicare hospital and medical coverage are relatively low compared to what workers with private insurance pay these days. Coinsurance is an entirely different story: Traditional Medicare only covers 80 percent of its approved rate for medical services. That means people with Medicare, whose average annual income is less than $30,000, can face thousands of dollars in additional medical bills unless they can afford supplemental coverage, which picks up those costs and protects them financially.

    Medicare Advantage (Part C), the alternative to Traditional Medicare, claims to fill that void, offering an out-of-pocket cap for medical and hospital services and additional benefits. Many Medicare Advantage plans even offer $0 monthly premiums. What could be more enticing to people on retirement incomes?

    The devil is in the details. Medicare Advantage plans drive profits for their corporate parents by charging high and often sudden out-of-pocket costs that are tied to sickness. These costs are often prohibitive, leading people to skip critical care or, as the GAO found in a recent study, disenroll from their Medicare Advantage plans and return to Traditional Medicare when they get sicker.

    Insurers profit at taxpayer expense when that happens. Not only can Medicare Advantage plans consequently avoid covering expensive care, but they can also benefit from the upfront payments the government pays them that they don’t spend. Uncle Sam’s generosity to health insurers explains why many of them are reporting record profits. Many now get most of their revenues from the government, not from private paying customers. UnitedHealthcare, the biggest Medicare Advantage insurer, makes more than twice as much from government programs like Medicare Advantage and Medicaid as it does from its commercial customers.

    Medicare Part D prescription drug coverage also needs a reasonable out-of-pocket cap. One recent study found that when prescription cost-sharing rose as little as $10.40, it increased mortality by nearly 33 percent among the more than 20 percent who stopped taking their medications because of the additional cost.

    To put it more bluntly, many of our parents and grandparents are dying because they have no more skin to put in the game.

    People with Medicare find themselves with formidable health care costs wherever they turn, taking a bigger chunk of their retirement income with each passing year or, worse still, precluding them from getting care. This untenable situation is a key reason that a variety of groups, including several passionate about the health care needs of seniors, have come together to demand that Congress address rising out-of-pocket health care costs.

    Congress is now neck deep in drafting legislation that could easily rein in out-of-pocket costs for everyone with Medicare at no or little additional cost. Medicare Advantage plans are currently receiving rebates of $140 a month per enrollee and at least $40 a month more per enrollee than traditional Medicare in government overpayments. Lawmakers could allocate some of those funds towards lower out-of-pocket costs and a low out-of-pocket cap in both Traditional Medicare and Medicare Advantage.

    Consider that this week, millions of seniors and people with disabilities will stare blankly at an online Medicare enrollment portal, faced with health care out-of-pocket cost projections that for many will be far too costly. Instead of allowing corporate health insurers to grow fat on Medicare, our leaders should direct that money toward lower costs for the most vulnerable among us.

    This piece was originally published on Wendell Potter’s substack; Diane Archer is the co-author.

    Here’s more from Just Care: