Medicare Issues
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Medicare Issues
Welcome to Medicare season. From October 15th to December 7th those of us who are Medicare subscribers are busy evaluating plans and trying to decide what to do.
I received a request asking if I could help a reader decide which Medicare program to choose. We will start with some background material on Medicare first.
Background
Brought online July 30, 1965, Medicare was originally public insurance paying private providers. When people retired then there was often no insurance available and so debt and bankruptcy for seniors was what waited for many. Premiums for medicare are paid through payroll taxes. This program was largely responsible for the desegregation of medicine in the US. It doesn’t get much recognition for that.
Original Medicare
Here is the government site as a reference. Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities and people with End-Stage Renal (kidney) Disease.
There three parts to original Medicare
Medicare Part A (Hospital Insurance)
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. There is most often not a cost for Part A.Medicare Part B (Medical Insurance)
Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. There is a separate cost for Part B.Medicare Part D (prescription drug coverage)
Helps cover the cost of prescription drugs (including many recommended shots or vaccines). To get Medicare drug coverage, you must join a Medicare-approved plan that offers drug coverage. There is often a separate cost for this and you must actively choose it if you want it.
Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). You pay for services as you get them. When you get services, you’ll pay a deductible at the start of each year, and you usually pay 20% of the cost of the Medicare-approved service, called coinsurance. If you want drug coverage, you can add a separate drug plan (Part D).
Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. A Medicare Supplement Insurance (Medigap) policy can help pay some of the remaining health care costs, like copays, coinsurance, and deductibles. Some Medigap policies also cover services that Original Medicare doesn't cover, like emergency medical care when you travel outside the U.S.
Medicare Advantage (Part C)
Medicare Advantage is a Medicare-approved plan from a private company that offers an alternative to Original Medicare for your health and drug coverage. These “bundled” plans include Part A, Part B, and usually Part D. Plans may offer some extra benefits that Original Medicare doesn’t cover — like, hearing, and dental services. Medicare Advantage Plans have yearly contracts with Medicare and must follow Medicare’s coverage rules.
About half the people eligible for Medicare choose one of these plans. We have written in the past that they have much higher denial of service rates than traditional medicare and charge the government (not you) $1000/month/person or more to provide you with this coverage. That said, it meets the needs of some. Just be sure you understand that this is private insurance - not public.
Regarding denial of claims, it is hard to get a hold of the data, but according to the Kaiser Family Foundation in 2021 Medicare Advantage plans denied about 6% of all pre-authorizations - far higher than Traditional Medicare which I think is is between 3 % and 4%.
In fact, the Office of the Inspector General at HHS found that 13% of the pre-authorization denials by Medicare Advantage plans were for things covered by traditional Medicare because those plans use clinical data to make decisions. But wait there’s more. 18% of the Medicare Advantage payment denials were for things that Traditional Medicare covers. I have a call in to the OIG regarding getting access to their data and will share it when it shows up. The OIG report is here.
Advice
Traditional Medicare
If you want traditional Medicare, consider adding a gap plan and a drug plan. It will likely increase the monthly cost but Medicare has a fairly low claims denial rate. The gap plan should be able to help with the Medicare 20% copay. You may still have a deductible depending on the plan you choose
Here is a link at the medicare.gov site where they will provide information on what kind on gap and drug plans are available in your area. We reviewed those - called some of the providers, decided how much risk we were willing to buy down and then arranged for a gap and drug plan for my wife. She chose a low cost drug plan in case of something really serious but we also buy prescriptions with Good RX or some other pharmacy discount card because overall we find that can sometimes be cheaper.
There is also a network of people who are not out to sell you anything you may wish to call for advice - it is the state health insurance assistance program (SHIP). You can find them at this website. https://www.shiphelp.org/
Medicare Advantage
If you’re considering one of these, here is a Medicare.gov link comparing different types of Medicare Advantage Plans (PPO, HMO, etc.). It is good to decide whether you want to be locked into an HMO or have a little more flexibility with a PPO etc.
It’s also good idea to know the claims and pre-authorization denial rates but that data is hard to get. Here is a link to a page where you can get contact info for your state’s insurance commissioner. I haven’t found many of them willing to share denial data.
Here is a link to a Kaiser Family Foundation report on Medicare Advantage denials. It has some company denial rates in it.
Good Luck
Summary
There is a lot to consider with Medicare. It isn’t easy and we should keep in mind that none of this would be necessary if we had Universal Healthcare, like HR 3421, The improved Medicare for All Act. I’m just saying.
RESOURCES
Healthcare Advocacy (Us)
Website
Our Newsletter resources including reproductive healthcare
Healthcare Advocacy Reading List
Find My Elected Officials
Contact the White House https://www.whitehouse.gov/contact/
Contact State and Federal Representatives
By phone: (202) 224-3121
By email: democracy.io
Important Healthcare Resources
League of Women Voters Healthcare Reform Toolkit
Organizations to Contact
National Nurses United Medicare4All
Physicians for a National Health Program
One Payer States
Healthcare Now
Reproductive Health
NARAL - Pro Choice America
Charley. chatbot abortion resource - make sure to use a secure incognito browser if you live in a state that has banned abortion
Planned Parenthood
Miscarriage and Abortion Hotline has references about where to procure abortion medications. They also assist women in the process of self managed abortion or miscarriage by phone or text and will respond in an hour. Details and hours of operation at their website.
United State of Women Reproductive health page (bottom of the page) has important resources such as medical support, access to Telehealth, prescriptions by mail, and legal support references.
Practice careful communications - The Digital Defense Fund has a number of tips to keep texts, calls, and internet use private. Here is their site.
If you need financial help with an abortion try abortionfunds.org
Claims Denials and Appeals & What to Do
Appeal a Healthcare Decision
Appeal/Negotiate a Hospital Bill
Disinformation Management
Cybersecurity Infrastructure Security Agency
Save Democracy
Chop Wood, Carry Water by Jessica Cravens
RESISTBOT
Link to the RESISTBOT site to learn more
Link to Chop Wood, Carry Water RESISTBOT write up
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I heard someone talking about the public perception of health care. We need to move away from a money for service point of view towards a basic public need. The metaphor that was used was that of a public utility.
I mean that we have learned to expect public roads, working sewer systems, heat and water. And hopefully in the future we can expect healthcare.
If you can, go with a Medi-GAP policy—not Medicare Advantage. Start with the best GAP insurance you can.
Medicare Advantage banks on having enough healthy participants to offset expensive, unhealthy patients, and guess what? As you age, things aren’t going to improve. In my area, Medicare Advantage has been getting publicity for denying claims, even for in-network care.
Another reason to avoid Medicare Advantage: Once you’re in, it’s very hard to switch out. You have to show you do not have a number of pre-existing conditions before a private, -Gap insurer will take you on. So, get the best -Gap policy you can at the get-go.