Providers Say Medicare Advantage Plans Make It Difficult For Enrollees To Receive Much
In 2018, responding to a wave of overdose deaths, Congress passed legislation requiring Medicare to pay for services at opioid treatment programs for the first time.
But two years after Medicare began covering those programs, which use methadone and other medications to help reduce opioid use and overdose deaths, providers say their efforts are being hindered by Medicare Advantage private insurance companies that administer benefits to about half of the Medicare population.
They say the tactics Medicare Advantage has long used to control health care costs can also delay or block access to patient care, which can be especially dangerous or deadly for someone with a substance use disorder.
Once a patient reaches out for treatment, theyre not going to sit around and wait. If you dont get people into treatment that day, youve kind of lost them to the street, and thats what is the most concerning, said Jay Higham, CEO of Behavioral Health Group, which operates 120 opioid treatment programs in 24 states.
Opioid treatment programs say they usually must first get approval from Medicare Advantage plans for their services to be paid for, a process that can take several days or weeks. Patients have been told they must pay for a portion of their care and get referrals from primary care doctors before starting treatment.
Such obstacles have led some opioid treatment programs to be more selective about which Advantage plans they work with.
Consider Your Other Costs
Out-of-pocket costs can quickly build up over the year if you get sick. The Medicare Advantage Plan may offer a $0 premium, but the out-of-pocket surprises may not be worth those initial savings if you get sick. The best candidate for Medicare Advantage is someone who’s healthy,” says Mary Ashkar, senior attorney for the Center for Medicare Advocacy. “We see trouble when someone gets sick.”
Financial Assistance And Beneficiary Resources
When your vision care is not covered by insurance , you may need to consider other ways to save.
Charitable organizations: Some organizations may be able to help, including:
- EyeCare America is a program offered through the American Academy of Ophthalmology that offers free vision exams to people over age 65 if they qualify. Keep in mind that although the program covers an exam, it does not cover corrective lenses.
- Lions Club International may have local offices that can provide free or low-cost eye exams and glasses in your area.
- New Eyes is a nonprofit organization that provides free prescription glasses to people who have low income. You must meet financial requirements to participate.
Coupons and vouchers:You may be able to find online discounts for vision care from sites like Groupon and Living Social. You may also be interested in the following sources:
- AARP membership may give you access to discounts at several retail clinics through EyeMed.
- Coast to Coast Vision, a program from the Federation of American Consumers and Travelers , offers discounts for eye exams and corrective lenses.
- OneSight offers a voucher program to people with low incomes.
Financing:You may be able to negotiate with your healthcare provider to pay for services in installments. You may need to pay this back with interest.
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How To Choose The Best Medicare Advantage Plan
Comparing Medicare Advantage plans requires you to understand your health care needs and think about what each type of plan offers. If you have a chronic health condition and want to be able to keep using a specific doctor or facility, youll want health coverage that they accept. If you take prescription drugs, some plans may offer lower out-of-pocket costs than others.
Here are some questions to ask as you evaluate Medicare Advantage plans:
Do you have to get a referral to see specialists?
What benefits does each plan include?
Are all of your prescription drugs covered, and how much will they cost?
Are your doctors covered?
What Is The Average Cost Of Medicare Supplement Insurance
The estimated average monthly premium for a Medicare Supplement plan can range from $150 to around $200, depending on the state you live in and your insurer.
Just like Medicare Advantage plans, its good to shop around65-year-olds stand to save an average of $840 a year with Medicare Supplement Plan G or $648 a year with Plan N if they enroll in the lowest-cost option available in their areas, according to a price comparison analysis by eHealth, Inc.
We continue looking at how private plans and Medicare can be more efficient, effective and equitable for people, says Jacobson. The good story here is in the data. Weve seen pretty consistently that inequities are much smaller in Medicare than any other source of coverage.
Confused About Medicare Supplement Insurance Options?
Find committed, licensed agents who work to understand your coverage needs and find you the best Medicare option. Click Get A Quote or call 866-402-0504 to speak with a licensed insurance agent today.
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Medicare Advantage Plans In 2024 May Include:
We can provide you with a comprehensive overview of the plans and benefits available in your area.
Speak with a licensed agent now
Some of the insurance companies offer Medicare Advantage plans in 2024:
This is just a small list of several companies.
We can help take the guesswork out of selecting your health coverage for 2024. Our licensed insurance agents are available to help you compare the available plans in your area, so you can make an informed decision that fits your needs and is accepted by your doctors.
Call us today to get started. 1-888-517-4661
Costs With Original Medicare Include:
- The Part B premium
- A low-cost or $0 plan premium
- A plan deductible
- Copays for covered health services and items
A note about financial protection: A really great benefit with a Medicare Advantage plan though is there is a limit on your out-of-pocket costs . This can really help keep your Medicare costs under control. Original Medicare does not provide any financial protection like this.
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What Can You Do During Medicare Advantage Open Enrollment Period
This enrollment period gives you a chance to revisit your plan choice and make changes if you need to. The changes you can make include the following:
- Switch to a different Medicare Advantage plan .
- Drop your Medicare Advantage plan and go back to Original Medicare .
- Enroll in a Medicare Prescription Drug plan , if you go back to Original Medicare.
Which Path You Take Will Determine How You Get Your Medical Care And How Much It Costs
by Dena Bunis, AARP, Updated November 29, 2022
En español | As you think about how Medicare will cover your health care needs, your first major decision should be whether you want to enroll in federally run original Medicare or select a Medicare Advantage plan, the private insurance alternative.
Think of it as choosing between ordering the prix fixe meal at a restaurant, where the courses are already selected for you, or going to the buffet , where you must decide for yourself what you want.
If you elect to go with original Medicare, your buffet will include Part A , Part B and Part D . If you decide to go with Part C, a Medicare Advantage plan, it will be more like a set menu, since a private insurer has already bundled together parts A and B and almost always D into one comprehensive plan.
Need Help With Medicare?
Some aspects of your care will be constant whichever plan you choose. Under both choices, any preexisting conditions you have will be covered and you’ll also be able to get coverage for prescription drugs.
But there are significant differences in the way you’ll use Medicare depending on whether you pick original or Advantage. Here’s a comparison of how each works.
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Medicare Advantage And Employer Health Insurance
Beneficiaries can have both Medicare and employer-sponsored health insurance at the same time. But the size of the employer determines primary and secondary coverage.
Medicare, for example, becomes the primary payer if your employer has fewer than 20 employees, meaning Medicare is billed first, your employee health insurance plan second. If your employer has 20 or more employees, your employer plan is the primary payer, and Medicare Advantage is the secondary payer.
Beneficiaries with small group insurance should enroll in Medicare Parts A and B because if they donât, their employer group plan could deny coverage.
Medicare Advantage plans will probably have lower premiums than employer-provided plans. Medicare Advantage also has yearly out-of-pocket limits, something that may not exist with employer-sponsored plans.
Unlike Medicare Advantage, an employer-sponsored plan may not have strict provider networks and may provide more generous drug formularies.
How Much Does A Medicare Advantage Plan Cost
Many Medicare Advantage plans have a $0 premium, so be sure to explore your options. Baethke explains it like this: If you enroll in a plan that does charge a premium, you must pay this fee every month in addition to your Medicare Part B premium, which is around $165 .
Medicare Part Bs coinsurance and the deductible is $226, according to Medicare.gov, and once they are met, your copay under Medicare Advantage is typically 20% of the Medicare-approved amount for most services and products, such as durable medical equipment like glucometers, walkers, hospital beds and more.
What gets many people into financial trouble is not following the rules of their plan, such as using an out-of-network provider or facility or getting products or services from a supplier not approved by Medicare.
Sometimes, patients urgently need this medical equipment and arent thinking about reading the fine print, says Baethke. This is why its so important to understand Medicares DME requirements from the beginning.
Nebulizers, for instance, are DME commonly used to treat conditions that cause difficulty breathing, such as asthma and COVID-19. If your doctor recommends one, Medicare requires you to get the machine through a Medicare-approved supplier. Not doing so will mean a denied claim from your Medicare Advantage insurerand a sizable surprise bill.
To learn more about your costs in specific Medicare Advantage plans, contact the plan or visit Medicare.gov/plan-compare.
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What Is The Difference Between Medicare Advantage Open Enrollment And Medicare Annual Enrollment
There are two main differences between Medicare Advantage Open Enrollment and Medicare Annual Enrollment.
The first one is who can use each period:
- Medicare Annual Enrollment is for anyone who has Medicare and wants to make coverage changes for the upcoming year,
- Medicare Advantage Open Enrollment is only for people who are currently enrolled in a Medicare Advantage plan.
The second difference is the timing. Both happen every year:
- Medicare Annual Enrollment is October 15 December 7,
- Medicare Advantage Open Enrollment is January 1 March 31.
It basically gives you another opportunity to get the coverage you want and need.
The Medicare Advantage Open Enrollment Period is only for Medicare Advantage plan members. You cannot switch from Original Medicare to a Medicare Advantage plan at this time. For that, you generally need to wait until the Medicare Annual Enrollment Period, October 15 December 7.
Why Is Medicare Advantage A Bad Choice
Medicare Advantage can become expensive if you’re sick, due to uncovered copays. Additionally, a plan may offer only a limited network of doctors, which can interfere with a patient’s choice. It’s not easy to change to another plan. If you decide to switch to a Medigap policy, there often are lifetime penalties.
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Why Should I Choose Medicare Advantage
A Medicare Advantage plan covers some of the gaps of Original Medicare and usually offers a $0 premium through a private company. It can be an affordable option for patients who are not currently sick or in need of intense medical care. If a patient’s situation worsens, it might be difficult or expensive to switch plans.
Many Plans Offer Additional Coverage
Medicare Advantage plans offer all the same basic benefits offered by Original Medicare .
But they may not stop there. Many Medicare Advantage plans may also offer additional benefits that are not covered by Medicare Part A or Part B, such as prescription drug coverage, dental, vision, hearing and more.
Some Medicare Advantage plans may offer even more additional benefits, such as transportation to doctors offices and grab bars for home bathrooms.
According to Medicare expert John Barkett, some Medicare Advantage plans started offering new benefits to beneficiaries with chronic illnesses in 2020. To hear more about these benefits, watch the video below.
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Covered Services In Medicare Advantage Plans
With a Medicare Advantage Plan, you may have coverage for things Original Medicare doesn’t cover, like fitness programs and some vision, hearing, and dental services . Plans can also choose to cover even more benefits. For example, some plans may offer coverage for services like transportation to doctor visits, over-the-counter drugs, and services that promote your health and wellness. Plans can also tailor their benefit packages to offer these benefits to certain chronically-ill enrollees. These packages will provide benefits customized to treat specific conditions. Check with the plan before you enroll to see what benefits it offers, if you might qualify, and if there are any limitations. Learn more about what Medicare Advantage Plans cover.
How Do Medicare Advantage Plans Work
A Medicare Advantage is another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. If you join a Medicare Advantage Plan, you’ll still have Medicare but you’ll get most of your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare.
These “bundled” plans include
, and usually Medicare drug coverage .
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What Benefits Can I Expect On Medicare Advantage
Medicare Advantage covers everything that original Medicare covers. However, Advantage plans also cover hearing, vision, and dental careâwhich arenât covered under original Medicare. Depending on the plan, Medicare Advantage may also cover things like gym memberships, transportation, and adult day-care.
New to Medicare Advantage plans in 2020, non-medical needs like meal delivery, home air cleaners, and home modifications are now covered by many plans.
Six Reasons Seniors Are Increasingly Choosing Medicare Advantage
Nearly half of all Medicare beneficiaries are enrolled in Medicare Advantage, a popular program that provides affordable, coordinated, patient-centered care and offers additional benefits that address social needs, such as meal support and transportation. Medicare Advantage now serves more than 28 million Americans with Blue Cross and Blue Shield companies collectively covering more than four million people in Medicare Advantage plans.
Medicare Advantage has a proven track record of reducing costs and improving care as an effective public-private partnership between health insurers and the government. Not surprisingly, enrollment in Medicare Advantage plans more than doubled between 2011-2021. A quick look at the facts shows why beneficiaries are increasingly choosing Medicare Advantage over the traditional fee-for-service Medicare program.
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Medicare Advantage Vs Original Medicare
The Medicare program covers 62 million disabled individuals and seniors 65 and older, nearly 42% of whom are enrolled in Medicare Advantage plans, policies provided by private insurance companies that contract with the Medicare program.
Medicare Advantage plans are becoming more popular, and some experts predict that most Medicare beneficiaries will be enrolled in a Medicare Advantage plan by 2030.
Original Medicare is a fee-for-service plan, meaning providers are paid for each service they provide. Original Medicare pays for about 80% of medical costs, which is why nearly 15 million beneficiaries carry supplemental policies to fill in coverage gaps and mitigate out-of-pocket expenses.
With Original Medicare and a supplemental plan, most of your costs result from predetermined, monthly premiums. As a result, the costs with Original Medicare are front-loaded, making it much easier to budget for health costs with Original Medicare than Medicare Advantage, where the costs occur on the back end of care.
How plan administration could affect your health care
With Medicare Advantage, health plans and providers are usually paid based on a global-risk or full-risk model, meaning they are paid a sum of money up front to manage patient care, giving them incentives to keep patients healthy and out of the hospital.
Original Medicare Vs Medicare Advantage: Coverage
Original Medicare covers inpatient hospital and skilled nursing services Part A and doctor visits, outpatient services and some preventative care Part B.
Medicare Advantage plans cover all the above , and most plans also cover prescription drugs . Additionally, Medicare Advantage plans each offer extra benefits, which while they vary by plan and provider, may include coverage for dental, vision, hearing, fitness programs, rides to doctor appointments and more.
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What Do Medicare Advantage Plans Cover
Medicare Advantage plans provide all of your Part A and Part B coverage and must cover all medically necessary services. Many plans also offer prescription drug coverage and additional programs not covered by Original Medicare. To enroll in a Medicare Advantage Plan, you must already have Original Medicare Part A and B coverage.
Part C: Medicare Advantage Plan
These plans are part of the government’s Medicare program, but are offered and managed through private insurers, like Cigna. Medicare Advantage Plans may include plan extras not found in Original Medicare. You must be enrolled in Medicare Part A and Part B to join.