by Cedar Dvorin
As a Medicare counselor, the most frequent question is “Why is it so complicated?” In my 20 years with the State Health Insurance Assistance Program, I’ve helped Medicare beneficiaries and their caregivers with the many decisions and choices they are called on to make. A common problem is the continued high expense for those who need care for vision (other than eye diseases), hearing, and dental. My work shows that Medicare has become overly complicated for current enrollees. It needs a reset. If given a chance, currently proposed Medicare For All legislation would do exactly that.
Medicare started in 1965 with two parts: Part A (hospital insurance) and Medicare Part B (health insurance). Part D, (drug insurance) went into effect in 2006. Part C (private insurance plans) started about 1986.
Most people pay no premium for Part A but there is a deductible ($1,632 in 2024). That is not an annual deductible; it applies to the beneficiaries’ share of costs for the first 60 days of any Medicare-covered inpatient hospital care. More costs follow.
Medicare Part B is closer to typical health insurance. It covers visits to health care providers, outpatient hospital services, durable medical equipment, etc. In 2024 the standard monthly premium will be $174.70. The premium rises with income.
Many private companies offer Part C “Medicare Advantage” (MA) plans, Medicare prescription drug coverage (PDPs), and Medicare Supplement (Medigap) plans. These provide options for people who want more coverage than traditional Medicare parts A and B. This year (2024) Medicare beneficiaries here in Alexandria can choose among 34 Medicare Advantage plans. Some are HMOs (enrollees must see a provider in the network or they will pay 100% out-of-pocket) others are PPO (enrollees pay more if they go out of network) and one is a PFFS (Private Fee for Service Plan). PFFS plans will pay any provider, but not all providers accept payment from the plan. Some enrollees only find out their doctor won’t take their MA plan payment when they go to their appointment. Another problem is that MA plans are too-often aggressively marketed. This generates complaints from beneficiaries and adds to the confusion.
Most people love getting Medicare but are disappointed to learn that dental services, vision services, and hearing aids are not covered. Many don’t know what long-term care is, until they need it and find out it is not covered by Medicare. People who want dental and vision services, hearing aids or long-term care find out they are all notoriously expensive even if they can get insurance.
Currently-proposed Medicare For All legislation (H.R.3421 & S.1655) would remove these pitfalls. Current Medicare recipients (and everyone else) should support it.
The advantage of dropping Medicare Advantage
Significantly, Medicare For All would remove profit-driven Medicare Advantage and long term care plans. During my time working for Arlington County VICAP (Virginia Insurance Counseling and Assistance Program), people often called to complain that companies found nefarious ways to avoid paying for care. For example, they can require that a primary care provider make a referral to specialists or other services before the plan will pay. Many beneficiaries complain that they are stuck in appeal limbo, needing a service that the plan has denied. It is difficult to select a plan because the patient does not know which services will be denied until after they have enrolled and paid a premium. In order to select the “best” plan, beneficiaries need to do extensive research and will likely also need to call one or more insurance companies for additional information.
Each of the Medicare Advantage plans have different costs and, while they must provide all the services that original Medicare covers, they can charge different amounts. For example, some Medicare Advantage plans are offered at no premium, although the Part B premium must always be paid. They earn their profits by restricting provider networks, by denying services, and by upcoding charges that Medicare pays them.
Too many Medicare Advantage plans have “ghost networks.” These are lists of providers, supposedly in the plan’s network – but when an enrollee tries to make an appointment they find out the provider is no longer with the plan or they can’t get an appointment for months.
People without Medicare should also want Medicare For All
Even with commercial insurance, many fall into the pitfalls of the insurance market. Many products cover an unacceptably small portion of the cost. Because few companies are willing to enter the expensive long-term care insurance market, affordable long-term care insurance might not be available at all. In all cases, patients are forced into a complicated dance between coverage, benefits and premiums. The Kaiser Family Foundation recently published a report about the ever-increasing costs of health insurance.
According to the Kaiser Family Foundation, annual premiums for employer-sponsored family health coverage reached $23,968 this year, with workers on average paying $6,575 toward the cost of their coverage. The average deductible among covered workers in a plan with a general annual deductible is $1,735 for single coverage. Workers at firms with fewer than 200 workers on average contribute nearly $2,500 more toward family premiums than those at larger firms ($8,334 vs. $5,889). In fact, a quarter of covered workers at small firms pay at least $12,000 annually in premiums for family coverage.
Long-term care
Under Medicare For All, everyone will be covered for all necessary medical expenses, including prescriptions, dental, vision, hearing, and long-term care. In fact, no health insurance covers long term care; a separate plan, from a for-profit insurance company, is required. Otherwise, long term care is paid-for out of pocket.
Because long-term care insurance premiums are too expensive for most people, many people do without; or hope to qualify for Medicaid. Medicaid pays for long-term care in a nursing home or some in-home care, but only when individuals have no more than $2,000 in assets, an unacceptably cruel level of poverty (if a spouse is in the home, they may have up to $148,620 in assets).
After all these years it is long past time for a Medicare reset. Medicare For All is our chance to obtain healthcare that serves people over profit.
Cedar Dvorin has provided Medicare counseling and counselor training since 1991, when the State Health Insurance Assistance Programs (SHIP) first started. She worked for the Florida Department of Elder Affairs and, later, as a VICAP (Virginia Insurance Counseling and Assistance Program) coordinator for Arlington County and the City of Alexandria. Currently retired, she continues to volunteer as a VICAP counselor.