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Improving Medicare Advantage

December 10, 2009 • Volume 9, Issue 48

There are insurance companies that will sell you, for no premium besides the regular Part B premium, a Medicare private health plan, like a Medicare HMO, that will cap your out-of-pocket spending at, for example, $3,000.

Too good to be true?

It frequently is.

The catch is in the fine print (see sample below): The advertised out-of-pocket limit specifically excludes the types of costly services where a cap provides important financial protection. Inpatient hospital care does not count toward the cap, nor does chemotherapy or radiation treatment, for which enrollees pay the same 20 percent as in Original Medicare. The daily charge for care at a skilled nursing facility—if you need therapy to recover from a stroke, for example—is also not covered under this plan’s out-of-pocket limit. Not only that, but the plan starts charging after ten days in a SNF—ten days before Original Medicare begins assessing daily copayments.

Medicare Advantage plans with benefits that shift costs onto the sickest, most vulnerable people with Medicare are sold throughout the country. There are plans that exclude from their out-of-pocket limit copayments for care from doctors or “any health care professional.” There are plans that have no out-of-pocket cap at all, even though they charge premiums that are twice as much as plans that do have an out-of-pocket cap.

People with Medicare deserve better. Under Original Medicare, a supplemental “Medigap” plan or retiree coverage from a former employer typically provides protection against medical costs that can lead to bankruptcy. For people enrolled in a Medicare private health plan, only the plan itself can provide this protection. The best way to guarantee this protection is through a comprehensive, out-of-pocket limit.

The Centers for Medicare & Medicaid Services (CMS) has proposed regulations that would require all Medicare private health plans to include an out-of-pocket cap covering all Medicare services. The maximum level for the out-of-pocket cap would be set each year by CMS. The Medicare Rights Center enthusiastically supports this proposed new protection for people with Medicare.

Together with other provisions, the proposed rule would help clean up the Medicare Advantage marketplace, getting rid of plans that fail to deliver decent care or customer service or quality benefits. The proposed regulation represents a long overdue step toward making the Medicare Advantage program work for consumers, not just insurance companies.

The Medicare Rights Center is now on Twitter. Follow us at www.twitter.com/medicarerights.


Medical Record

“A regulatory requirement to provide an out-of-pocket limit is necessary because CMS’ efforts to use the annual Call Letter and the benefit review process to encourage provision of an out-of-pocket cap have not been fully successful. While the terms of the 2010 Call Letter did result in additional plans establishing an out-of-pocket limit at the CMS-recommended threshold, there remain many plans that do not include such a limit in their benefits (and leave enrollees liable for high out-of-pocket costs for coinsurance), establish a limit well above the CMS-recommended level or exclude some Part A and B services from their out-of-pocket caps. These benefit designs discourage enrollment by beneficiaries with high health care needs, particularly when there are alternative plans with out-of-pocket caps at, or below, the CMS-established threshold. Plans that advertise an out-of-pocket cap, but exclude important services, are particularly confusing to consumers.” (Comments on CMS Proposed Rules for Medicare Advantage and Part D Programs, Medicare RightsCenter, December 2009)

“$3,000 out-of-pocket limit. There is no limit on cost sharing for the following services:
Medicare Services:

(Sample 2010 Summary of Benefits, December 2009)

“Based on program experience and efforts to curb discriminatory benefit packages, we are proposing that all local MA plans include an annual out-of-pocket cap on members' total cost-sharing liability for Part A and Part B services, the amount of which will be set annually by CMS. Given that regional PPO plans already are required to have an annual cap on member out-of-pocket costs and that many local MA plans already have such limits, we believe that requiring the inclusion of such a limit in plan design is necessary in order to avoid discouraging enrollment by individuals who utilize higher than average levels of health care services.” (Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs, Centers for Medicare & Medicaid Services, October 2009)

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Medicare Part D Appeals Help for Advocates Is Here!

Medicare Rights Center’s new Medicare Part D Appeals: An advocate’s manual to navigating the Medicare private drug plan appeals process offers an easy-to-understand, comprehensive overview of the entire appeals process, including real-life case examples, a glossary of important appeals terms, a sample protocol for advocates, and links to important resources.

Register for a FREE copy of this great resource.

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Medicare Part D Monitoring Project

The Medicare Rights Center would like to hear about your experience, or that of someone you know, enrolled in a private drug plan. With information about what the issues are with Medicare Part D, we will be able to demand that those problems be fixed.

Submit your story at http://www.medicarerights.org/issues-actions/tell-your-story.php.

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The Louder Our Voice, the Stronger Our Message

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Asclepios—named for the Greek and Roman god of medicine who, acclaimed for his healing abilities, was at one point the most worshipped god in Greece—is a weekly e-newsletter designed to keep you up-to-date with Medicare program and policy issues, and advance advocacy strategies to address them. Please help build awareness of key Medicare consumer issues by forwarding this action alert to your friends and encouraging them to subscribe today.

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The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives.

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Get answers to your Medicare questions from Medicare Interactive at http://www.medicareinteractive.org.

The Medicare Rights Center is on Twitter. Follow us at www.twitter.com/medicarerights.