Tag: Medicare

Quick Guide to Recent Changes to Medicare

The Consolidated Appropriations Act (CAA) and the Inflation Reduction Act (IRA) improve program benefits, clarify enrollment rules, eliminate coverage gaps, and strengthen the program for the estimated 64.5 million Americans who have Medicare health care coverage. These changes to Medicare provide important protections and strengthen the program, but navigating the changes can be complicated. To help the aging and disability networks who are fielding questions and making sure that the people they serve are aware of these changes, this blog post provides an overview of the changes that are most important for older adults and people with disabilities to be aware of. For people who need additional help, ACL’s State Health Insurance Assistance Program (SHIP) offers one-on-one assistance, counseling, and education to Medicare beneficiaries, their families, and caregivers to help them make informed decisions about their care and benefits.

CAA Medicare Provisions

The CAA revised key Medicare enrollment rules and timelines for coverage to become effective. It also extended limited eligibility to cover immunosuppressive drugs for kidney transplant patients under age 65.

Key Medicare Enrollment Rules

Most people (88%) qualify for Medicare when they celebrate their 65th birthday. The remaining 12% qualify due to disability.

Most people who qualify based on age need to enroll in Medicare when they turn 65, even if they have other health insurance. People can defer enrollment in a few situations. For example, if they (or their spouse) are still working for an employer that has 20 or more employees and have health insurance through that employer, they can wait to enroll in Medicare until they are not.

People who do not apply when they are first eligible usually have to wait until the next open enrollment period to get coverage. In addition, most will have to pay higher premiums — forever — if they enroll late.

People who receive Social Security retirement or disability benefits (or Railroad Retirement benefits) are automatically enrolled in Medicare when they become eligible, but everyone else needs to apply. Unfortunately, many people do not understand this, or mistakenly believe they qualify for delayed enrollment, and they do not enroll when they should.

Read the full article from the Administration for Community Living.

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Medicare Advantage Special Needs Plans for dual eligible (Medicare and Medicaid) clients

Medicare Advantage Special Needs Plans are available to clients who are eligible for Medicare and Medicaid (dual eligible). Special Needs Plans provide additional benefits to clients beyond what traditional Medicare and Medicaid provide including, but not limited to, care coordination, gym memberships, transportation to medical appointments and meal delivery.

Click the below link to learn more.

dual-eligible-special-needs-plan

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Medicare’s Mental Health Coverage: What’s Included, What’s Changed, and What Gaps Remain

How prevalent are mental health issues among Medicare beneficiaries?

About one in four Medicare beneficiaries live with mental illness — conditions such as depression, anxiety, schizophrenia, and bipolar disorder — but only 40 percent to 50 percent receive treatment.1 The prevalence of mental illness is about equal among beneficiaries enrolled in traditional Medicare (31%) and those in Medicare Advantage plans (28%), although variation in data sources and measurement make comparisons difficult.2

Mental illness is experienced most by those beneficiaries under age 65 who qualify for Medicare via disability, as well as by low-income beneficiaries dually eligible for Medicare and Medicaid.3 It is also more pervasive in beneficiaries from American Indian/Alaska Native and Hispanic communities relative to other racial and ethnic groups.4

Which mental health services does Medicare cover?

Medicare covers both outpatient and inpatient services as well as prescription drugs to treat mental illness.5 Traditional Medicare and Medicare Advantage plans generally follow the same coverage rules, and some also cover additional services, like grief counseling, or offer other tailored benefits through special needs plans catering to beneficiaries with mental illness.6

Inpatient services. Medicare Part A covers inpatient mental health services in both general hospitals and psychiatric hospitals, but the latter is limited to 190 total days per beneficiary across their lifetime. Traditional Medicare beneficiaries pay a deductible and coinsurance for each benefit period, which, for hospital services, begins on the day of admission and ends after a beneficiary has had no inpatient care for 60 consecutive days. Cost-sharing requirements vary across plans for Medicare Advantage enrollees.

Outpatient services. Medicare Part B covers outpatient mental health services delivered by psychiatrists or other physicians, clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, and physician assistants. The services covered include standard services like psychiatric evaluation, individual and group therapy, and medication management. After paying their annual deductible, traditional Medicare beneficiaries pay 20 percent of the Medicare-approved amount for covered services. As with inpatient services, cost-sharing requirements vary across Medicare Advantage plans.

Medication. For traditional Medicare beneficiaries, mental health medications are covered by Medicare Part D. Beneficiaries in a Medicare Advantage plan also may have a Part D prescription drug plan or another drug plan that follows Part D rules. All Medicare drug plans are required to cover antidepressant, anticonvulsant, and antipsychotic medications, as well as a wide range of other psychotropic medications like anti-anxiety drugs. Specific medications covered and out-of-pocket costs vary by drug plan.

Read the full article from the Commonwealth Fund.

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Open Enrollment Period for Health Insurance

Open enrollment for most medical plans, including Medicaid and Medicare, starts November 1st and goes through early to mid-December. This is the time to sign up, renew, or change coverage to best suit your family’s situation. If you wish to estimate how much how health insurance will cost your family without giving any information to a government entity, you can visit the KFF Health Insurance Marketplace Calculator, which provides estimates for health care premiums through marketplaces, aka health insurance exchanges.

For individuals who are on, or expect to be on Medicare, the open enrollment for 2023 is open now through January 15th. If enrolled by December 15, coverage will start January 1, 2023. Medicare is generally for those 65 years or older, but certain younger individuals with disabilities, End-Stage Renal Disease, or ALS can be eligible. For step-by-step instructions on how to sign up for Medicaid or change plans in Medicaid, visit the medicaid.gov or healthcare.gov websites.

For more information on health insurance available through the health insurance exchanges, visit either healthcare.gov or wahealthplanfinder.gov. Medicaid, also known as Apple Health in Washington state, is available through the Washington Health Plan Finder. Many uninsured children, aged 18 and under, who are a part of a low-to-medium income family, are likely to be eligible for free health insurance through Apple Health. A full breakdown of the program and income requirements is available.

Help is available for those who are having a difficult time navigating the health insurance landscape.  Washington Health Plan Finder has step-by-step instructions for applying and navigators to help apply.

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The Average Medicare Beneficiary Has a Choice of 43 Medicare Advantage Plans and 24 Part D Stand-Alone Plans for Coverage in 2023

For 2023, the typical beneficiary has a choice of 43 Medicare Advantage plans as an alternative to traditional Medicare, a new KFF analysis finds. That’s an increase of 5 plans on average from 2022, adding even more choices to the Medicare Advantage marketplace, which is poised to become the dominant way Medicare beneficiaries get their health coverage and care.

In addition, the typical beneficiary has a choice of 24 Medicare Part D stand-alone prescription drug plans for 2023, a second KFF analysis finds, one more than in 2022.

These findings are featured in two briefs released by KFF today that provide an overview of the Medicare Advantage and Medicare Part D marketplace for 2023, including the latest data and key trends. Medicare’s open enrollment period began Oct. 15 and runs through Dec. 7.

Medicare Advantage

More than 28 million Medicare beneficiaries – 48 percent of all eligible beneficiaries – are enrolled in Medicare Advantage plans, which are mostly HMOs and PPOs offered by private insurers. Enrollment is projected to cross the 50 percent threshold as soon as next year.

For 2023, a typical beneficiary has 43 Medicare Advantage plans to choose from in their local market, including 35 plans that offer Part D drug coverage. In total, 3,998 Medicare Advantage plans will be available across the country.

Read the full article from KFF.

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A Review of 62 Studies Finds Few Big Differences Between Traditional Medicare and Medicare Advantage on a Variety of Measures

Enrollees in Medicare Advantage Were More Likely to Get Routine Check-ups and Immunizations, While Those in Traditional Medicare Were More Likely to Receive Care in the Highest-Rated Hospitals. Rates of Satisfaction Were Similar Among Both Groups.

With the Medicare open enrollment period set to begin Oct. 15, a perennial decision faced by Medicare beneficiaries is whether to get their coverage through traditional Medicare or the private plans known as Medicare Advantage.

A new KFF review of 62 studies published since 2016 that compares Medicare Advantage and traditional Medicare on measures of beneficiary experience, affordability, utilization, and quality finds few differences that are supported by strong evidence or have been replicated across multiple studies. For example, beneficiaries in both coverage types reported similar rates of satisfaction with their care and overall measures of care coordination.

Notably, relatively few studies specifically examined specific subgroups of interest, such as beneficiaries from communities of color, living in rural areas, or dually eligible for Medicare and Medicaid, making it difficult to assess the strength of the findings or how broadly they apply.

In some areas, however, the research identified noteworthy differences between Medicare Advantage and traditional Medicare, including:

Medicare Advantage:

  • Medicare Advantage enrollees were more likely than those in traditional Medicare to report having a usual source of care. They were also more likely to receive preventive care services, such as annual wellness visits and routine checkups, screenings, and flu or pneumococcal vaccines.
  • Medicare Advantage enrollees reported better experiences getting needed prescription drugs than traditional Medicare beneficiaries overall. However, among beneficiaries with diabetes, cancer, or a mental health condition, findings were mixed.
  • Most studies found that utilization of home health services and post-acute skilled nursing or inpatient rehabilitation facility care was lower among Medicare Advantage enrollees than traditional Medicare beneficiaries, but were inconclusive as to whether that was associated with better or worse outcomes.

Traditional Medicare:

  • A somewhat smaller share of traditional Medicare beneficiaries than Medicare Advantage enrollees experienced a cost-related problem, mainly due to lower rates of cost-related problems among traditional Medicare beneficiaries with supplemental coverage. (But traditional Medicare beneficiaries without supplemental coverage had the most affordability-related difficulties.)
  • Traditional Medicare outperformed Medicare Advantage on measures such as receiving care in the highest-rated hospitals for cancer care or in the highest-quality skilled nursing facilities and home health agencies.

In other areas, though, findings were mixed or showed little difference between Medicare Advantage and traditional Medicare based on multiple studies.

Among the findings:

  • There were generally no differences in the aggregate number of hospital days or average length of stay for common medical admissions.
  • Neither Medicare Advantage nor traditional Medicare consistently performed better across all quality measures.
  • Additionally, two analyses of several measures of beneficiary experience found no differences between the two groups in experiences with wait times and in the share reporting trouble finding a general doctor, being told that their health insurance was not accepted, and being told they would not be accepted as a new patient.

Findings related to the use of other health care services, including hospital care and prescription drugs, and condition-specific quality of care measures varied – likely due to differences in data and methodology across studies.

Interest in how well Medicare Advantage plans serve their growing and increasingly diverse enrollee population has never been higher, as Medicare Advantage, for the first time, is projected to enroll more than half of all eligible Medicare beneficiaries next year, making it the main way that Medicare beneficiaries get their coverage and care. In comparison, just over a decade ago in 2010, 25 percent of the eligible population was in a Medicare Advantage plan.

The Medicare open enrollment period runs through Dec. 7.

The full analysis, Beneficiary Experience, Affordability, Utilization, and Quality in Medicare Advantage and Traditional Medicare: A Review of the Literature, as well as more data and analyses about Medicare Advantage, are available at kff.org.

Look Up Your Hospital: Is It Being Penalized By Medicare?

Under programs set up by the Affordable Care Act, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. For the readmission penalties, Medicare cuts as much as 3 percent for each patient, although the average is generally much lower. The patient safety penalties cost hospitals 1 percent of Medicare payments over the federal fiscal year, which runs from October through September.

Click here to look up your hospital.

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A Record 3,834 Medicare Advantage Plans Will be Available in 2022

A record 3,834 Medicare Advantage plans will be available across the country as alternatives to traditional Medicare for 2022, a new KFF analysis finds. That’s an increase of 8 percent from 2021, and the largest number of plans available in more than a decade.

At the same time, the number of Medicare Part D stand-alone prescription drug plans that will be offered in 2022 is decreasing by 23 percent to 766 plans, primarily the result of firm consolidations leading to fewer plan offerings sponsored by Cigna and Centene, according to another new KFF analysis.

These findings are featured in two briefs released by KFF today that provide an overview of the Medicare Advantage and Medicare Part D marketplace for 2022, including the latest data and key trends over time. Medicare’s open enrollment period began Oct. 15 and runs through Dec. 7.

Medicare Advantage

More than 26 million Medicare beneficiaries – 42 percent of all beneficiaries – are currently in Medicare Advantage plans, which are mostly HMOs and PPOs offered by private insurers that are paid to provide Medicare benefits to enrollees.

In 2022, a typical beneficiary will have 39 plans to choose from in their local market. But the number of Medicare Advantage plans available varies greatly across the country, with an average of 42 plans in metropolitan areas and 25 plans in non-metropolitan areas. In 2022, 25 percent of beneficiaries live in a county where they can choose among 50 Medicare Advantage plans.

Most Medicare Advantage plans (89%) include prescription drug coverage. Fifty-nine percent of these plans do not charge any additional premium beyond Medicare’s standard Part B premium. More than 90 percent of non-group Medicare Advantage plans offer some vision, telehealth, hearing, or dental benefits.

Despite the average beneficiary having access to plans offered by nine different firms, Medicare Advantage enrollment is concentrated in plans operated by UnitedHealthcare, Humana, and Blue Cross Blue Shield affiliates. Together, UnitedHealth and Humana account for 45 percent of Medicare Advantage enrollment in 2021.

Part D

As a result of consolidations in the stand-alone drug plan market, the typical Medicare beneficiary will have a choice of 23 stand-alone drug plans next year, seven fewer than in 2021. Beneficiaries receiving low-income subsidies (LIS) will also have fewer premium-free plan choices in 2022, which could make it more difficult for some enrollees to find a premium-free plan that covers all their prescription medications. In the stand-alone drug plan market, 8 out of 10 enrollees next year are projected to be in stand-alone plans operated by just four firms: CVS Health, Centene, UnitedHealth, and Humana.

The estimated average monthly premium for Medicare Part D stand-alone drug plans is projected to be $43 in 2022, based on current enrollment, while average monthly premiums for the 16 national stand-alone drug plans available in 2022 are projected to range from $7 to $99.


Nearly three-fourths, or 10 million, of the 13.3 million stand-alone drug plan enrollees who don’t qualify for low-income subsidies will have to pay higher premiums next year if they stick with their current plan, and many will also face higher deductibles and cost sharing for covered drugs. While the average weighted monthly PDP premium is increasing by $5 between 2021 and 2022 (from $38 to $43), nearly 4 million non-LIS enrollees (28%) will see a premium increase of $10 or more per month. Substantially fewer non-LIS enrollees (0.2 million, or 2%) will see a premium reduction of the same magnitude.

In addition to these two new analyses, KFF has updated its collection of frequently asked questions about Medicare Open Enrollment to help beneficiaries understand their options during the annual open enrollment period. A recent KFF analysis found that 7 in 10 Medicare beneficiaries say they did not compare their options during a recent open enrollment period. Comparing and choosing among the wide array of Part D plans can be difficult, given that plans differ from each other in multiple ways, beyond premiums, including cost sharing, deductibles, covered drugs, and pharmacy networks. Comparing Medicare Advantage drug plans may be made more difficult by the fact that not only drug coverage varies but also other features, including cost sharing for medical benefits, provider networks, and coverage and costs for supplemental benefits.