30 Policy Goals for Medicare’s Future

#30MedicareGoals

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Category: Access and Affordability

Make Prescription Drugs More Affordable

Medicare Rights supports efforts to meaningfully reduce drug prices and lower costs for both people with Medicare and the program as a whole. Potentially effective strategies include allowing Medicare to negotiate drug prices, increasing pricing transparency and accountability throughout the supply chain, and imposing limits on beneficiary out-of-pocket spending. Changes to the current system must be carefully considered and only adopted if they do not threaten to undermine beneficiary protections or access to medications, such as by weakening the protected classes or introducing additional, inappropriate utilization management strategies.

Allow Open Enrollment, Guaranteed Issue, and Community Rating in Medigap for All People with Medicare

Though Medigaps help a growing number of people with Original Medicare afford needed care, not everyone is eligible to buy the plans, and most are only guaranteed the right to do so during very limited time frames. Congress must ensure that all beneficiaries have access to affordable, high-quality Medigap policies as well as the opportunity to re-evaluate their coverage choices as their needs change. This includes extending the same federal Medigap protections to beneficiaries under 65 as those provided to beneficiaries over 65 and providing for open enrollment, guaranteed issue, and community rating of Medigap for all people with Medicare.

Add a Standard Medicare Out-Of-Pocket Maximum for Beneficiary Cost Sharing

Original Medicare and Part D have no out-of-pocket maximums, exposing beneficiaries to limitless financial risk. While Medicare Advantage (MA) plans do include an out-of-pocket maximum in their benefit packages, this threshold is too high—permitting costs up to $6,700 in 2019. Congress should establish a standardized, affordable, out-of-pocket maximum for Original Medicare, MA, and Part D. To both lower costs for beneficiaries and the system, this change must be coupled with efforts address the underlying problem of high drug prices.

Eliminate the Observation Status Penalty

Medicare beneficiaries who need post-hospital care in a skilled nursing facility (SNF) may be forced to pay out-of-pocket for this care when the hospital chooses to assign them to “observation status” instead of admitting them as an inpatient. Congress should reevaluate the three-day hospital stay requirement, and all days in the hospital should count toward coverage for needed SNF care.

Ease Access to Medicare Low-income Assistance Programs

Medicare’s low-income assistance programs (Medicare Savings Programs and Part D’s Extra Help) were established to help low-income seniors and people with disabilities afford needed medicines. But today, complex, bureaucratic application processes and outdated eligibility thresholds unnecessarily limit participation. These policies must be modernized to reflect financial realities and to align with reforms made elsewhere in the health care system. Accordingly, Congress should ease or eliminate the asset tests for Medicare low-income assistance programs; lower and align eligibility thresholds; and integrate the programs’ application processes, qualifying criteria, and administration.

Address the Medicare Part D “Cliff”

Absent congressional action, an Affordable Care Act provision slowing the growth of the Part D catastrophic coverage threshold will expire after 2019. As a result, Medicare Part D enrollees with high drug costs will have to pay much more out of pocket next year, when the catastrophic coverage threshold increases from $5,100 in 2019 to $6,350 in 2020. Congress must take steps to protect beneficiaries from these higher costs.

Require all States to Enter Part A Buy-in Agreements

Part A Buy-in agreements are contracts between state Medicaid offices and the Social Security Administration that allow eligible individuals with very low incomes and limited assets to enroll in Medicare outside of standard enrollment periods. Not only are Buy-in agreements helpful to beneficiaries who might otherwise face higher costs and gaps in coverage, they reduce state Medicaid costs, decrease costly reliance on emergency room care, and minimize future medical expenses by ensuring that those eligible for Medicare are enrolled in the program. Congress should require all states to enter into Part A Buy-in agreements.

Eliminate the Two-year Medicare Waiting Period for People with Disabilities

In 1972, Congress granted Medicare benefits to people receiving Social Security disability benefits. This historic step forward was marred by an arbitrary limit, requiring that people with disabilities wait a full two years before gaining access to needed coverage. This provision was included merely to cut costs. Now, people with disabilities are at risk of lacking coverage as they wait for Medicare eligibility. They are forced to navigate two benefit start dates and obtain temporary coverage during this gap. Congress should eliminate this outdated, complicated, and confusing waiting period and allow people with disabilities access to Medicare at the same […]

Ensure Parity in Original Medicare and Medicare Advantage

Medicare Rights urges Congress to ensure equity between Medicare Advantage (MA) and Original Medicare, including both the scope of services provided and programmatic spending. This includes guaranteeing equal access to all services, such as supplemental benefits, implementing reforms that will eliminate overpayments to MA plans, and halting abuses of patient categorization rules—known as “upcoding”—that some health plans engage in to secure unacceptably high payments.