Medicare beneficiaries can buy Medicare Supplement Insurance, or Medigap, to help cover certain out-of-pocket costs associated with Medicare Part A and/or Part B. (If you’re shopping during Medicare open enrollment, Oct. 15 to Dec. 7, remember that people with Medicare Advantage can’t buy Medigap plans.)

For example, depending on which plan type you choose, a Medigap policy could cover the 20% Medicare Part B coinsurance for office visits and the $1,600 deductible before Medicare Part A starts to pay for inpatient hospital care.

Medigap policies are sold by private health insurance companies. They’re regulated by the federal government and have certain standard benefits. But shopping for them isn’t always straightforward.

Shoppers might expect higher prices to come with more benefits, but that’s not always the case. Here are three scenarios to watch for so you don’t end up paying too much.

1. Paying more for the same coverage

New Medicare beneficiaries in most states can choose from up to eight out of 10 letter-named Medigap plan types: A, B, D, G, K, L, M and N. Each plan type offers a different set of benefits. (Medigap Plans C and F aren’t available to new Medicare members.)

“One of the most common and popular counseling tips we provide is that all plans of the same letter, i.e., A, B, C, D, are exactly the same. So there is no reason to pay more for one Plan A, B, C, D, over another,” Maureen McIntyre, CEO of Connecticut’s North Central Area Agency on Aging, which offers free Medicare counseling for local residents, wrote in an email.

It’s worth comparing quotes for the plan type you want. Companies might differ in terms of customer service and minor non-Medicare perks, but there’s no additional coverage to gain from buying a more expensive Plan G policy when a cheaper one is available, for example.

2. Paying more for less coverage

Of the eight standard Medigap plan types available, Plan A has the most basic benefits and Plan G is the most comprehensive.

One might expect Plan A to cost less than other plan types with more coverage. But sometimes lower-coverage plans are priced higher.

For example, for a 65-year-old female nonsmoker in Chicago, Cigna quotes monthly premiums of $152.06 for Medigap Plan G and $169.33 for Medigap Plan A, with identical discounts built into both rates. The lower-coverage option (Plan A) costs $17.27 more per month.

“While it is not typical for Plan A plans to be rated higher than Plan G, we recognize that this can sometimes happen, due to the actuarial experience and cost relativities related to those plans,” a Cigna spokesperson wrote in an email.

Plan A might have higher premiums if the insurance company expects members with Plan A to have more expensive claims, even though Plan G has more coverage, according to the Cigna spokesperson.

Representatives for State Farm, Mutual of Omaha and Blue Cross and Blue Shield of Texas offered similar explanations for instances when their quotes showed Plan A priced higher than Plan G.

When you’re shopping, your own budget is what matters, so compare prices carefully to find the most cost-effective option.

3. Paying too much for add-ons

Some companies offer add-ons for purchase with their Medigap plans. For example, UnitedHealthcare’s “wellness extras” packages include access to a 24/7 nurse line, vision, hearing and dental discounts and a gym membership. (In some locations, these perks are included at no additional cost.)

Sometimes adding these packages might have unexpected effects on the price of the plan.

For example, here’s what it costs to add UnitedHealthcare’s wellness extras — the same package — to two plans for a 65-year-old female nonsmoker in Dallas:

• Plan G: $6.62 per month ($133.22 for the base plan, or $139.84 with extras).

• Plan A: $174.80 per month ($130.81 for the base plan, or $305.61 with extras).

These extras might be compelling with Plan G, but the drastically higher price to add the same perks to Plan A is a much worse deal.

On the other hand, there are also scenarios when add-ons make the whole package cheaper.

In Columbus, Ohio, UnitedHealthcare quotes $91.71 per month for Medigap Plan A for a 65-year-old female nonsmoker. But Plan A with wellness extras costs $87.23 — $4.48 cheaper. Even if you never use any of the extras, Plan A with the add-ons would still be a better deal than the option without them.

This article was written by NerdWallet and was originally published by The Associated Press. 

The article Watch for These 3 Medigap Shopping Surprises to Avoid Overpaying originally appeared on NerdWallet.

Lynn Cooper was going through an awful time. After losing her job in 2019, she became deeply depressed. Then the COVID-19 pandemic hit, and her anxiety went through the roof. Then her cherished therapist — a marriage and family counselor — told Cooper she couldn’t see her once Cooper turned 65 and joined Medicare.

“I was stunned,” said Cooper, who lives in Pittsburgh and depends on counseling to maintain her psychological balance. “I’ve always had the best health insurance a person could have. Then I turned 65 and went on Medicare, and suddenly I had trouble getting mental health services.”

The issue: For decades, Medicare has covered only services provided by psychiatrists, psychologists, licensed clinical social workers, and psychiatric nurses. But with rising demand and many people willing to pay privately for care, 45% of psychiatrists and 54% of psychologists don’t participate in the program. Citing low payments and bureaucratic hassles, more than 124,000 behavioral health practitioners have opted out of Medicare — the most of any medical specialty.

As a result, older adults anxious about worsening health or depressed by the loss of family and friends have substantial difficulty finding professional help. Barriers to care are made more acute by prejudices associated with mental illness and by ageism, which leads some health professionals to minimize older adults’ suffering.

Now, relief may be at hand as a series of legislative and regulatory changes expand Medicare’s pool of behavioral health providers. For the first time, beginning in January, Medicare will allow marriage and family therapists and mental health counselors to provide services. This cadre of more than 400,000 professionals makes up more than 40% of the licensed mental health workforce and is especially critical in rural areas.

Medicare is also adding up to 19 hours a week of intensive outpatient care as a benefit, improving navigation and peer-support services for those with severe mental illness, and expanding mobile crisis services that can treat people in their homes or on the streets.

“As we emerge from the COVID-19 public health emergency, it is abundantly clear that our nation must improve access to effective mental health and substance use disorder treatment and care,” Meena Seshamani, deputy administrator of the Centers for Medicare & Medicaid Services, said in a July statement.

Organizations that have advocated for years for improvements in Medicare’s mental health coverage applaud the changes. “I think we are, hopefully, at a turning point where we’ll start seeing more access to mental health and substance use disorder care for older adults,” said Deborah Steinberg, senior health policy attorney at the Legal Action Center in Washington, D.C.

For years, seniors in need of mental health aid have encountered obstacles. Although 1 in 4 Medicare recipients — including nearly 8 million people under 65 with serious disabilities — have some type of mental health condition, up to half don’t receive treatment.

Cooper, now 68 and a behavioral health policy specialist at the Pennsylvania Association of Area Agencies on Aging, bumped up against Medicare’s limitations when she tried to find a new therapist in 2020: “The first problem I had was finding someone who took Medicare. Many of the providers I contacted weren’t accepting new patients.” When Cooper finally discovered a clinical social worker willing to see her, the wait for an initial appointment was six months, a period she describes as “incredibly stressful.”

The new Medicare initiatives should make it easier for people in Cooper’s position to get care.

Advocates also note the importance of expanded Medicare coverage for telehealth, including mental health care. Since the pandemic, older adults have been able to get these previously restricted services at home by phone or via digital devices anywhere in the country, and requirements for in-person appointments every six months have been waived. But some of these flexibilities are set to expire at the end of next year.

Robert Trestman, chair of the American Psychiatric Association’s Council on Healthcare Systems and Financing, called on lawmakers and regulators to maintain those expansions and continue to reimburse mental health telehealth visits at the same rate as in-person visits, another pandemic innovation.

Older adults who seek psychiatric care tend to have more complex needs than younger adults, with more medical conditions, more disabilities, more potential side effects from medications, and fewer social supports, making their care time-consuming and challenging, he said.

Several questions remain open as Medicare enacts these changes. The first is, “Will CMS pay mental health counselors and marriage and family therapists enough so they actually accept Medicare patients?” asked Beth McGinty, chief of health policy and economics at Weill Cornell Medicine in New York City. That’s by no means guaranteed.

A second: Will Medicare Advantage plans add marriage and family therapists, mental health counselors, and drug addiction specialists to their networks of authorized mental health providers? And will federal regulators do more to guarantee that Medicare Advantage plans provide adequate access to mental health services? This kind of oversight has been spotty at best.

In July, researchers reported that Medicare Advantage plans include, on average, only 20% of psychiatrists within a geographic area in their networks. (Similar data is not available for psychologists, social workers, and psychiatric nurses.) When older adults have to go out-of-network for mental health care, 60% of Medicare Advantage plans don’t cover those expenses, KFF reported in April. With high costs, many seniors just skip services.

Another key issue: Will legislation proposing mental health parity for Medicare advance in Congress? Parity refers to the notion that mental health benefits available through insurance plans should be comparable to medical and surgical benefits in key respects. Although parity is required for private insurance plans under the 2008 Mental Health Parity and Addiction Equity Act, Medicare is excluded.

One of the most egregious examples of Medicare’s lack of parity is a 190-day lifetime limit on psychiatric hospital care, a feature that deeply affects members with serious conditions such as schizophrenia, severe depression, or post-traumatic stress, who often require repeated hospitalization. There is no similar curb on hospital use for medical conditions.

An upcoming Government Accountability Office report examining differences between the cost and use of behavioral health services and medical services in traditional Medicare and Medicare Advantage plans may give Congress some guidance, suggested Steinberg, of the Legal Action Center. That investigation is underway, and a date for the report’s release hasn’t been set.

But Congress can’t do anything about the all-too-common assumption that seniors feeling overwhelmed or depressed should “just grin and bear it.” Kathleen Cameron, chair of the executive committee for the National Coalition on Mental Health and Aging, said “there’s a lot more that we need to do” to address biases surrounding the mental health of older adults.

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We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.

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(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2023 KFF Health News. Distributed by Tribune Content Agency, LLC.

CORRECTION: In a story on Page 4 of the Medicare Guide, the phone numbers to receive help from SHINE were wrong. The correct phone number for Osceola, Seminole, Brevard, and Orange county seniors to receive help through SHINE is 407-514-0019. 

Read the digital e-edition version of our Medicare Guide here.

Consumers know it’s fall when stores start offering Halloween candy and flu shots — and airwaves and mailboxes are filled with advertisements for Medicare options.

It’s annual open enrollment time again for the 65 million Americans covered by Medicare, the federal health program for older people and some people with disabilities.

From Oct. 15 to Dec. 7, enrollees in either the traditional program or Medicare Advantage plans, which are offered by private insurers, can change their coverage. (First-time enrollees generally sign up within a few months of their 65th birthday, whether that’s during open enrollment season or not.)

There are a few new features for 2024, including a lower out-of-pocket cost limit for some patients taking expensive drugs.

No matter what, experts say, it’s a good idea for beneficiaries to examine their current coverage because health and drug plans may have made changes — including to the pharmacies or medical providers in their networks and how much prescriptions cost.

“The advice is to check, check, and double-check,” said Bonnie Burns, a consultant with California Health Advocates, a nonprofit Medicare advocacy program.

But as anyone in the program or who helps friends or relatives with coverage decisions knows, it is complicated.

Here are a few things to keep in mind.

Know the Basics: Medicare vs. Medicare Advantage

People in traditional Medicare can see any participating doctor or hospital (and most do participate), while those in Medicare Advantage must select from a specified list of providers — a network — unique to that plan. Some Advantage plans offer a broader network than others. Always check to see if your preferred doctors, hospitals and pharmacies are covered.

Because traditional Medicare doesn’t cover prescriptions, its members should also consider signing up for Part D, the optional drug benefit, which includes a separate premium.

Conversely, most Medicare Advantage plans include drug coverage, but make sure before enrolling because some don’t. These private plans are advertised heavily, often touting that they offer “extras” unavailable in traditional Medicare, such as dental or vision coverage. Read the fine print to see what limits, if any, are placed on such benefits.

Those 65 and older joining traditional Medicare for the first time can buy a supplemental, or “Medigap,” policy, which covers many out-of-pocket costs, such as deductibles and copays, which can be substantial. Generally, beneficiaries have a six-month window after they enroll in Medicare Part B to purchase a Medigap policy.

So, switching from Medicare Advantage back to traditional Medicare during open enrollment can raise issues for those who want to buy a supplemental Medigap policy. That’s because, with some exceptions, private insurers offering Medigap plans can reject applicants with health conditions, or raise premiums or limit coverage of preexisting conditions.

Some states offer beneficiaries more guarantees that they can switch Medigap plans without answering health questions, although rules vary.

Making all of this more confusing, there is a second open enrollment period each year, but it’s only for those in Medicare Advantage plans. They can change plans, or switch back to traditional Medicare, from Jan. 1 to March 31.

Drug Coverage Has Changed — For the Better

Beneficiaries who signed up for a Part D drug plan or get drug coverage through their Medicare Advantage plan know there are a lot of copays and deductibles. But in 2024, for those who require a lot of high-priced medications, some of these expenses will disappear.

President Joe Biden’s Inflation Reduction Act places a new annual limit on Medicare beneficiaries’ out-of-pocket costs for drugs.

“That policy is going to help people who have very expensive medications for conditions like cancer, rheumatoid arthritis, and hepatitis,” said Tricia Neuman, senior vice president and head of the KFF Medicare policy program.

The cap will greatly help beneficiaries who fall into Medicare’s “catastrophic” coverage tier — an estimated 1.5 million Americans in 2019, according to KFF.

Here’s how it works: The cap is triggered after patients and their drug plans spend about $8,000 combined on drugs. KFF estimates that, for many patients, that means about $3,300 in out-of-pocket spending.

Some people could hit the cap in a single month, given the high prices of many drugs for serious conditions. After reaching the cap, beneficiaries don’t have to pay anything out-of-pocket for their medicines that year, potentially saving them thousands of dollars annually.

It’s important to note that this new cap won’t apply to drugs that are infused into patients, generally at doctor’s offices, such as many chemotherapies for cancer. Those medicines are covered by Medicare Part B, which pays for doctor visits and other outpatient services.

Medicare next year is also expanding eligibility for some low-income beneficiaries to qualify for low- or zero-premium drug coverage that comes with no deductibles and lower copayments, according to the Medicare Rights Center.

Insurers offering Part D and Advantage plans might have also made other changes to drug coverage, Burns said.

Beneficiaries should check their plan’s “formulary,” a list of covered drugs, and how much they must pay for the medications. Be sure to note whether prescriptions require a copayment, which is a flat dollar amount, or coinsurance, which is a percentage of the drug cost. Generally, copayments mean lower out-of-pocket costs than coinsurance, Burns said.

Help Is Available

In many parts of the country, consumers have a choice of more than 40 Medicare Advantage plans. That can be overwhelming.

Medicare’s online plan finder provides details on the Advantage and Part D drug plans available by ZIP code. It allows users to drill down into details about benefits and costs and each plan’s network of health providers.

Insurers are supposed to keep their provider directories up to date. But experts say enrollees should check directly with doctors and hospitals they prefer to confirm they participate in any given Advantage plan. People concerned about drug costs should “check whether their pharmacy is a ‘preferred’ pharmacy and if it’s in network” under their Advantage or Part D plan, Neuman said.

“There can be a significant difference in out-of-pocket spending between one pharmacy and another, even in the same plan,” she said.

To get the fullest picture of estimated drug costs, Medicare beneficiaries should look up their prescriptions, the dosages, and their pharmacies, said Emily Whicheloe, director of education at the Medicare Rights Center.

“For people with specific drug needs, it’s also a good idea to contact the plan and say, ‘Hey, are you still covering this drug next year?’ If not, change to a plan that is,” she said.

Additional help with enrollment can be had for free through the State Health Insurance Assistance Program, which operates in all states.

Beneficiaries can also ask questions via a toll-free hotline run by Medicare: 1-800-633-4227, or 1-800-MEDICARE.

Insurance brokers can also help, but with a caveat. “Working with a broker can be nice for that personalized touch, but know they might not represent all the plans in their state,” said Whicheloe.

Whatever you do, avoid telemarketers, Burns said. In addition to TV and mail advertisements, telephone calls hawking private plans bombard many Medicare beneficiaries.

”Just hang up,” Burns said.

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.

©2023 KFF Health News. Distributed by Tribune Content Agency, LLC.

• Costs vary depending on the services and drugs you use. The best way to find which plan is best for you and your particular situation is to use Medicare’s online Plan Finder, which allows you to factor in your health conditions and the medications you take and compare costs. Go to Medicare.gov and choose the “Find Health and Drug Plans” button.
• Florida’s Serving Health Insurance Needs of Elders (SHINE) volunteer counselors provide free, unbiased guidance to seniors and their caretakers.  To find your local counseling sites, visit floridashine.org or call 1-800-963-5337. It’s helpful to have a list of all your doctors, medications, dosages and monthly usage before meeting with a SHINE counselor.
• You can also get help directly from Medicare by calling toll-free 1-800-633-4227, or visit online at Medicare.gov. The government workers there generally have less time to spend with you than the SHINE volunteers do. The Medicare Support Hotline is available 24/7, except for some federal holidays, and can provide help in English and Spanish.
• The Medicare Rights Center works to ensure access to affordable health care for older adults and people with disabilities. Call 800-333-4114 or visit medicarerights.org.
• Details on Medicare Open Enrollment are available online in the U.S. Government Medicare handbook: https://www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf

Local SHINE Offices

To make an appointment with a SHINE counselor in Orange, Seminole, Osceola or Brevard counties call 407-450-7234.

To make an appointment with a SHINE counselor in Lake and Sumter counties call 1-800-96-ELDER or 1-800-262-2243.

To make an appointment with a SHINE counselor in Volusia County call 904-391-6644.

To make an appointment with a SHINE counselor in Polk County call 1-800-336-2226.

• From Oct. 15 to Dec. 7— You can switch from Medicare to Medicare Advantage, or do the reverse and return to Original Medicare. You also can switch Medicare Advantage plans, or change prescription drug plans, known as Part D. If you did not enroll in Part D plans when you were first eligible for Medicare, you can do so during this period.
• Jan. 1, 2024 — Changes made during fall enrollment will take effect.
• Jan. 1 to Mar. 31 —If you have a Medicare Advantage plan, you can change to a different plan or switch to Original Medicare (and join a separate Medicare drug plan) once during this time. Any changes you make will be effective the first day of the month after the plan receives your request.
• Exceptions — You can make changes to your Medicare Advantage and Medicare prescription drug coverage anytime in 2024 if you have special circumstances, such as if you move, are no longer eligible for Medicaid, your plan goes out of business, or you lose coverage from your employer.
• 5-Star Special Enrollment — You can switch to a 5-star rated Medicare Advantage plan, if there is one available in your area, from Dec. 8, 2023 through Nov. 30, 2024. You can make this switch only once during this time period.

During open enrollment, you can make changes such as join, switch, or drop a private insurer’s Medicare Advantage plan for 2024 or a Medicare Part D prescription drug plan. When you are 65, there are two routes you can go: A Medicare Advantage plan offered by a private insurer, which includes hospital care, physician care, prescription drug coverage and other benefits. Or, Original Medicare, provided by the federal government, which includes hospital care and physician care, and pair it with a Part D drug plan.

This year there are more reasons to do your homework and consider your options.

“Plans change every year,” said Bob Rees, vice president of Medicare Member Loyalty for eHealth insurance agency. “Look beyond monthly premiums at the full cost and determine if your plan is changing. You may not be required to change plans, but look to see if your out-of-pocket costs are changing, and that may be a good reason to make a switch.”

What’s new with Medicare Advantage?

Centers for Medicare & Medicaid Services expects more people to enroll in Medicare Advantage plans in 2024, estimating enrollment at approximately 50% of Medicare eligible seniors, compared to approximately 48% for 2023.

While premiums, deductibles, co-pays and out-of-pocket maximums for Medicare Advantage plans differ greatly, every person with Medicare Advantage coverage must pay the Medicare Part B premium (part of Original Medicare) in addition to their private plan’s premium. If enrollees choose to stay in their plan, most will experience little or no premium increase for next year. In Florida, the average premium will increase slightly by 79 cents.

But there are more than premiums to consider.

In choosing among Medicare Advantage plans, an important determinant in 2024 is whether your doctor and preferred hospital will continue to accept your Medicare Advantage plan.  Becker’s Healthcare reports a growing number of hospitals and health systems nationwide are pushing back and dropping the private plans altogether. The reason: Excessive prior authorization denial rates and slow payments from insurers. You also will want to see if your primary care doctors and specialists are in the network, and look at whether a plan includes dental and vision coverage.

“If you keep it simple and ask ‘Are my doctors in network? Are my hospitals in network?’ — by doing that you will eliminate half the plans,” said Evan Tunis with Florida Health Insurance in Coral Springs. “Once you are done with that, ask, ‘Am I okay with an HMO or do I want bigger access to doctors and hospitals, and in that case maybe I need to go with a PPO.’”

Also in 2024: Your plan must notify you if your provider is leaving the network so you have time to choose a new plan. You’ll get this notice if it’s a primary care or behavioral health provider and you have gone to that provider in the past three years.

For the last few years, Medicare Advantage plans have added more supplemental benefits that change yearly, such as dental, vision, meal delivery or gym memberships. Jenny Chumbley Hogue, an analyst for medicareresources.org , said that trend will continue in 2024. “There are going to be even richer benefits,” she said. “If those things are important to you, then it’s important to look at the options.”

However, experts say don’t pick a plan just because of a benefit like dental or vision. It’s more useful to find a plan that covers your cover your health care providers and your medications.

Saving on drug costs

Where you likely will see big differences in 2024 is in the drug plans, also known as Medicare Part D. Your Annual Notice of Change for a Part D plan will arrive in the mail  and say how much the insurer will pay for prescriptions as well as rules regarding which pharmacies are included. The notice also will break out the costs of buying prescriptions via mail order versus at a retail pharmacy.

Florida will offer 21 stand-alone Medicare prescription drug plans, according to Centers for Medicare & Medicaid Services, Of those, 81% of people with a stand-alone Medicare Part D option will have access to a plan with a lower premium than what they paid in 2023.

The average Part D plan’s premium will decrease slightly, from $56.49 in 2023 to an expected $55.50 in 2024. Many plans will have improved benefits for drug coverage costs, including a $35 cost-sharing limit on a month’s supply of insulin and  free adult vaccines recommended by the Advisory Committee on Immunization Practices, including the shingles and COVID-19 boosters.

Not every drug plan’s premium will decline.

“It will depend on the prescription drug plan, but we anticipate that while some carriers will decrease their premiums, others will nearly double their rates,” said Chumbley Hogue with medicareresources.org.

Chumbley Hogue said beyond just looking at the premium, check your prescriptions to see what tier of coverage they are and how much your out-of-pocket costs will be at various pharmacies.  If a medication falls into a different tier within a plan in 2024, that could make it  significantly more costly for you.

Three major changes in Part D drug plans will go into effect in 2024:

• People with Medicare prescription drug coverage who fall into the catastrophic phase of the prescription drug benefit won’t have to pay anything out of pocket during that phase for covered prescription drugs.
• Everyone qualifying for Medicare’s Extra Help subsidies won’t pay anything for Part D premiums and deductibles and will pay a reduced amount for generic and brand-name drugs. You’ll be eligible for Extra Help if your 2023 income was under $21,870 ($29,580 for a couple) and have less than $16,660 in resources other than a primary residence, vehicles and personal possessions (below $33,240 for married couples). If you meet the thresholds, you’ll want to sign up for Extra Help when enrolling in a Part D plan. Enrollees can save nearly $300 per year, on average, according to estimates.
• In the deductible phase, Part D enrollees pay 100% of their drug costs up to  $545 in 2024 compared to $505 in 2023. Not all Part D plans charge a deductible, but some do.

Traditional Medicare

Florida’s seniors enrolled in Original Medicare will receive better mental health care coverage in 2024. You pay nothing for your yearly depression screening if your doctor or health care provider accepts assignment.  New this year, Medicare will cover mental health services provided by marriage and family therapists and mental health counselors as well as intensive outpatient program mental health services.

During the pandemic, seniors were able to have their telehealth appointments covered by Medicare. This will continue for now. You can still get telehealth services at any location in the U.S., including your home until the end of 2024.

For 2024, Medicare is prohibited from covering weight loss drugs, worth noting with the popularity of Ozempic and Wegovy. There are efforts underway to change that, but it won’t happen in 2024. However, Medicare is covering acupuncture, up to 12 visits in 90 days for chronic lower back pain and an additional eight visits if you are showing improvement.

If you have Original Medicare and want a supplemental plan, also known as Medigap, Tunis said there are some well-priced plans available in South Florida this year. He suggests shopping around.

“Look for a carrier who has been in South Florida a decent amount of time,” Tunis said. “You don’t want a carrier who has only offered supplemental insurance one or two years. If they know the market, they are not going to be shocked if one year claims outnumber premiums. You want that rate stability with a company that has has been here.”

Cindy Krischer Goodman reports on health for the South Florida Sun Sentinel. She can be reached at cgoodman@sunsentinel.com.

When several representatives from private health insurance companies called on him a few years ago to offer Medicare Advantage plan contracts so their enrollees could use his hospital, Bleak sent them away.

“Come back to the table with a better offer,” the chief executive recalled telling them. The representatives haven’t returned.

Battle Mountain is in north-central Nevada about a three-hour drive from Reno, and four hours from Salt Lake City. Bleak suspects insurance companies simply haven’t enrolled enough of the area’s seniors to need his hospital in their network.

Medicare Advantage insurers are private companies that contract with the federal government to provide Medicare benefits to seniors in place of traditional Medicare. The plans have become dubious payers for many large and small hospitals, which report the insurers are often slow to pay or don’t pay.

Private plans now cover more than half of all those eligible for Medicare. And while enrollment is highest in metropolitan areas, it has increased fourfold in rural areas since 2010. Meanwhile, more than 150 rural hospitals have closed since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. Largely rural states such as Texas, Tennessee, and Georgia have had the most closures.

Medicare Advantage growth has had an outsize impact on the finances of small, rural hospitals that Medicare has designated as “ critical access.” Under the designation, government-administered Medicare pays extra to those hospitals to compensate for low patient volumes. Medicare Advantage plans, on the other hand, offer negotiated rates that hospital operators say often don’t match those of traditional Medicare.

“It’s happening across the country,” said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association, whose members include small-town hospitals.

“Depending on the level of Medicare Advantage penetration in individual communities, some facilities are seeing a significant portion of their traditional Medicare patient or beneficiary move into Medicare Advantage,” Cochran-McClain said.

Kelly Adams is the CEO of Mesa View Regional Hospital, another rural hospital in Nevada. He said he applauds Battle Mountain’s Bleak for keeping Medicare Advantage plans out of his hospital “as long as he has.”

Mesa View, which is a little more than an hour’s drive east of Las Vegas, has a high percentage of patients enrolled in Medicare Advantage plans.

“Am I going to say I’m not going to take care of 40% of our patients at the hospital or the clinic?” Adams said, adding that it would be a “tough deal” to be forced to reject patients because they didn’t have traditional Medicare.

Mesa View has 21 Medicare Advantage contracts with multiple insurance companies. Adams said he has trouble getting the plans to pay for care the hospital has provided. They are either “slow pay or no pay,” he said.

In all, the plans owe Mesa View more than $800,000 for care already provided. Mesa View lost about $1.3 million taking care of patients, according to its most recent annual cost report.

NRHA’s Cochran-McClain said the growth in the plans also narrows options for patients because “the contracting that is happening under Medicare Advantage frequently has an influence on steering patients to specific types of providers.” If a hospital or provider does not contract with a Medicare Advantage plan, then a patient may have to pay for out-of-network care. That generally wouldn’t happen with traditional Medicare, which is widely accepted.

At Mesa View, patients must drive to Utah to find nursing homes and rehabilitation facilities covered by their Medicare Advantage plans.

“Our local nursing homes are not taking Medicare Advantage patients because they don’t get paid. But if you’re straight Medicare, they’d be happy to take that patient,” Adams said.

David Allen, a spokesperson for AHIP, an industry trade group formerly known as America’s Health Insurance Plans, declined to respond to Bleak’s and Adams’ specific concerns. Instead, he said enrollees are signing on because the plans “are more efficient, more cost-effective, and deliver better value than original Medicare.”

Centers for Medicare & Medicaid Services press secretary Sara Lonardo said CMS has acted to ensure “that private insurance companies are held accountable for providing quality coverage and care.”

The reach of private Medicare Advantage plans varies widely in rural areas, said Keith Mueller, director of the Rural Policy Research Institute at the University of Iowa College of Public Health. If recent trends continue, enrollment could tip to 50% of all rural Medicare beneficiaries in about three years — with some regions like the Upper Midwest already higher than 50% and others lower, such as Nevada and the Mountain States, but trending upward.

In June, a bipartisan group of Congress members, led by Sen. Sherrod Brown (D-Ohio), sent a letter urging federal agencies to do more to force Medicare Advantage insurers to pay health systems what they owe for patient care.

In an August response, CMS Administrator Chiquita Brooks-LaSure wrote that a final rule issued in April made “impactful changes” to speed up care and address concerns about prior authorization — when a hospital and patient must get advance permission for care to ensure it will be covered by an insurer. Brooks-LaSure noted another proposed rule that, once finalized, could mandate that insurers provide specific reasons for denying care within seven days.

Hospital operators Adams and Bleak also want more federal action, and fast.

Bleak at Battle Mountain said he knows Medicare Advantage plans will eventually move into his area and he will have to contract with them.

“The question is,” Bleak said, “how can we match the reimbursement so that we can sustain and keep our hospitals in these rural areas viable and strong?”

(KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2023 KFF Health News. Distributed by Tribune Content Agency, LLC.

Consumers know it’s fall when stores start offering Halloween candy and flu shots — and airwaves and mailboxes are filled with advertisements for Medicare options.

It’s annual open enrollment time again for the 65 million Americans covered by Medicare, the federal health program for older people and some people with disabilities.

From Oct. 15 to Dec. 7, enrollees in either the traditional program or Medicare Advantage plans, which are offered by private insurers, can change their coverage. (First-time enrollees generally sign up within a few months of their 65th birthday, whether that’s during open enrollment season or not.)

There are a few new features for 2024, including a lower out-of-pocket cost limit for some patients taking expensive drugs.

No matter what, experts say, it’s a good idea for beneficiaries to examine their current coverage because health and drug plans may have made changes — including to the pharmacies or medical providers in their networks and how much prescriptions cost.

“The advice is to check, check, and double-check,” said Bonnie Burns, a consultant with California Health Advocates, a nonprofit Medicare advocacy program.

But as anyone in the program or who helps friends or relatives with coverage decisions knows, it is complicated.

Here are a few things to keep in mind.

Know the Basics: Medicare vs. Medicare Advantage

People in traditional Medicare can see any participating doctor or hospital (and most do participate), while those in Medicare Advantage must select from a specified list of providers — a network — unique to that plan. Some Advantage plans offer a broader network than others. Always check to see if your preferred doctors, hospitals and pharmacies are covered.

Because traditional Medicare doesn’t cover prescriptions, its members should also consider signing up for Part D, the optional drug benefit, which includes a separate premium.

Conversely, most Medicare Advantage plans include drug coverage, but make sure before enrolling because some don’t. These private plans are advertised heavily, often touting that they offer “extras” unavailable in traditional Medicare, such as dental or vision coverage. Read the fine print to see what limits, if any, are placed on such benefits.

Those 65 and older joining traditional Medicare for the first time can buy a supplemental, or “Medigap,” policy, which covers many out-of-pocket costs, such as deductibles and copays, which can be substantial. Generally, beneficiaries have a six-month window after they enroll in Medicare Part B to purchase a Medigap policy.

So, switching from Medicare Advantage back to traditional Medicare during open enrollment can raise issues for those who want to buy a supplemental Medigap policy. That’s because, with some exceptions, private insurers offering Medigap plans can reject applicants with health conditions, or raise premiums or limit coverage of preexisting conditions.

Some states offer beneficiaries more guarantees that they can switch Medigap plans without answering health questions, although rules vary.

Making all of this more confusing, there is a second open enrollment period each year, but it’s only for those in Medicare Advantage plans. They can change plans, or switch back to traditional Medicare, from Jan. 1 to March 31.

Drug Coverage Has Changed — For the Better

Beneficiaries who signed up for a Part D drug plan or get drug coverage through their Medicare Advantage plan know there are a lot of copays and deductibles. But in 2024, for those who require a lot of high-priced medications, some of these expenses will disappear.

President Joe Biden’s Inflation Reduction Act places a new annual limit on Medicare beneficiaries’ out-of-pocket costs for drugs.

“That policy is going to help people who have very expensive medications for conditions like cancer, rheumatoid arthritis, and hepatitis,” said Tricia Neuman, senior vice president and head of the KFF Medicare policy program.

The cap will greatly help beneficiaries who fall into Medicare’s “catastrophic” coverage tier — an estimated 1.5 million Americans in 2019, according to KFF.

Here’s how it works: The cap is triggered after patients and their drug plans spend about $8,000 combined on drugs. KFF estimates that, for many patients, that means about $3,300 in out-of-pocket spending.

Some people could hit the cap in a single month, given the high prices of many drugs for serious conditions. After reaching the cap, beneficiaries don’t have to pay anything out-of-pocket for their medicines that year, potentially saving them thousands of dollars annually.

It’s important to note that this new cap won’t apply to drugs that are infused into patients, generally at doctor’s offices, such as many chemotherapies for cancer. Those medicines are covered by Medicare Part B, which pays for doctor visits and other outpatient services.

Medicare next year is also expanding eligibility for some low-income beneficiaries to qualify for low- or zero-premium drug coverage that comes with no deductibles and lower copayments, according to the Medicare Rights Center.

Insurers offering Part D and Advantage plans might have also made other changes to drug coverage, Burns said.

Beneficiaries should check their plan’s “formulary,” a list of covered drugs, and how much they must pay for the medications. Be sure to note whether prescriptions require a copayment, which is a flat dollar amount, or coinsurance, which is a percentage of the drug cost. Generally, copayments mean lower out-of-pocket costs than coinsurance, Burns said.

Help Is Available

In many parts of the country, consumers have a choice of more than 40 Medicare Advantage plans. That can be overwhelming.

Medicare’s online plan finder provides details on the Advantage and Part D drug plans available by ZIP code. It allows users to drill down into details about benefits and costs and each plan’s network of health providers.

Insurers are supposed to keep their provider directories up to date. But experts say enrollees should check directly with doctors and hospitals they prefer to confirm they participate in any given Advantage plan. People concerned about drug costs should “check whether their pharmacy is a ‘preferred’ pharmacy and if it’s in network” under their Advantage or Part D plan, Neuman said.

“There can be a significant difference in out-of-pocket spending between one pharmacy and another, even in the same plan,” she said.

To get the fullest picture of estimated drug costs, Medicare beneficiaries should look up their prescriptions, the dosages, and their pharmacies, said Emily Whicheloe, director of education at the Medicare Rights Center.

“For people with specific drug needs, it’s also a good idea to contact the plan and say, ‘Hey, are you still covering this drug next year?’ If not, change to a plan that is,” she said.

Additional help with enrollment can be had for free through the State Health Insurance Assistance Program, which operates in all states.

Beneficiaries can also ask questions via a toll-free hotline run by Medicare: 1-800-633-4227, or 1-800-MEDICARE.

Insurance brokers can also help, but with a caveat. “Working with a broker can be nice for that personalized touch, but know they might not represent all the plans in their state,” said Whicheloe.

Whatever you do, avoid telemarketers, Burns said. In addition to TV and mail advertisements, telephone calls hawking private plans bombard many Medicare beneficiaries.

”Just hang up,” Burns said.

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.

©2023 KFF Health News. Distributed by Tribune Content Agency, LLC.

Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she got surprising news from her Medicare Advantage plan: It would no longer pay for her care because she was well enough to go home.

At the time, she could not walk more than a few feet, even with assistance — let alone manage the stairs to her front door, she said. She still needed help using a colostomy bag following major surgery.

“How could they make a decision like that without ever coming and seeing me?” said Sullivan, 76. “I still couldn’t walk without one physical therapist behind me and another next to me. Were they all coming home with me?”

UnitedHealthcare — the nation’s largest health insurance company, which provides Sullivan’s Medicare Advantage plan — doesn’t have a crystal ball. It does have naviHealth, a care management company bought by UHC’s sister company, Optum, in 2020. Both are part of UnitedHealth Group. NaviHealth analyzes data to help UHC and other insurance companies make coverage decisions.

Its proprietary “nH Predict” tool sifts through millions of medical records to match patients with similar diagnoses and characteristics, including age, preexisting health conditions, and other factors. Based on these comparisons, an algorithm anticipates what kind of care a specific patient will need and for how long.

But patients, providers, and patient advocates in several states said they have noticed a suspicious coincidence: The tool often predicts a patient’s date of discharge, which coincides with the date their insurer cuts off coverage, even if the patient needs further treatment that government-run Medicare would provide.

“When an algorithm does not fully consider a patient’s needs, there’s a glaring mismatch,” said Rajeev Kumar, a physician and the president-elect of the Society for Post-Acute and Long-Term Care Medicine, which represents long-term care practitioners. “That’s where human intervention comes in.”

The federal government will try to even the playing field next year, when the Centers for Medicare & Medicaid Services begins restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions.

Medicare Advantage plans, an alternative to the government-run, original Medicare program, are operated by private insurance companies. About half the people eligible for full Medicare benefits are enrolled in the private plans, attracted by their lower costs and enhanced benefits like dental care, hearing aids, and a host of nonmedical extras like transportation and home-delivered meals.

Insurers receive a monthly payment from the federal government for each enrollee, regardless of how much care they need. According to the Department of Health and Human Services’ inspector general, this arrangement raises “the potential incentive for insurers to deny access to services and payment in an attempt to increase profits.” Nursing home care has been among the most frequently denied services by the private plans — something original Medicare likely would cover, investigators found.

After UHC cut off her nursing home coverage, Sullivan’s medical team agreed with her that she wasn’t ready to go home and provided an additional 18 days of treatment. Her bill came to $10,406.36.

Beyond her mobility problems, “she also had a surgical wound that needed daily dressing changes” when UHC stopped paying for her nursing home care, said Debra Samorajczyk, a registered nurse and the administrator at the Bishop Wicke Health and Rehabilitation Center, the facility that treated Sullivan.

Sullivan’s coverage denial notice and nH Predict report did not mention wound care or her inability to climb stairs. Original Medicare would have most likely covered her continued care, said Samorajczyk.

Sullivan appealed twice but lost. Her next appeal was heard by an administrative law judge, who holds a courtroom-style hearing usually by phone or video link, in which all sides can provide testimony. UHC declined to send a representative, but the judge nonetheless sided with the company. Sullivan is considering whether to appeal to the next level, the Medicare Appeals Council, and the last step before the case can be heard in federal court.

Sullivan’s experience is not unique. In February, Ken Drost’s Medicare Advantage plan, provided by Security Health Plan of Wisconsin, wanted to cut his coverage at a Wisconsin nursing home after 16 days, the same number of days naviHealth predicted was necessary. But Drost, 87, who was recovering from hip surgery, needed help getting out of bed and walking. He stayed at the nursing home for an additional week, at a cost of $2,624.

After he appealed twice and lost, his hearing on his third appeal was about to begin when his insurer agreed to pay his bill, said his lawyer, Christine Huberty, supervising attorney at the Greater Wisconsin Agency on Aging Resources Elder Law & Advocacy Center in Madison.

“Advantage plans routinely cut patients’ stays short in nursing homes,” she said, including Humana, Aetna, Security Health Plan, and UnitedHealthcare. “In all cases, we see their treating medical providers disagree with the denials.”

UnitedHealthcare and naviHealth declined requests for interviews and did not answer detailed questions about why Sullivan’s nursing home coverage was cut short over the objections of her medical team.

Aaron Albright, a naviHealth spokesperson, said in a statement that the nH Predict algorithm is not used to make coverage decisions and instead is intended “to help the member and facility develop personalized post-acute care discharge planning.” Length-of-stay predictions “are estimates only.”

However, naviHealth’s website boasts about saving plans money by restricting care. The company’s “predictive technology and decision support platform” ensures that “patients can enjoy more days at home, and healthcare providers and health plans can significantly reduce costs specific to unnecessary care and readmissions.”

New federal rules for Medicare Advantage plans beginning in January will rein in their use of algorithms in coverage decisions. Insurance companies using such tools will be expected to “ensure that they are making medical necessity determinations based on the circumstances of the specific individual,” the requirements say, “as opposed to using an algorithm or software that doesn’t account for an individual’s circumstances.”

The CMS-required notices nursing home residents receive now when a plan cuts short their coverage can be oddly similar while lacking details about a particular resident. Sullivan’s notice from UHC contains some identical text to the one Drost received from his Wisconsin plan. Both say, for example, that the plan’s medical director reviewed their cases, without providing the director’s name or medical specialty. Both omit any mention of their health conditions that make managing at home difficult, if not impossible.

The tools must still follow Medicare coverage criteria and cannot deny benefits that original Medicare covers. If insurers believe the criteria are too vague, plans can base algorithms on their own criteria, as long as they disclose the medical evidence supporting the algorithms.

And before denying coverage considered not medically necessary, another change requires that a coverage denial “must be reviewed by a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the service at issue.”

Jennifer Kochiss, a social worker at Bishop Wicke who helps residents file insurance appeals, said patients and providers have no say in whether the doctor reviewing a case has experience with the client’s diagnosis. The new requirement will close “a big hole,” she said.

The leading MA plans oppose the changes in comments submitted to CMS. Tim Noel, UHC’s CEO for Medicare and retirement, said MA plans’ ability to manage beneficiaries’ care is necessary “to ensure access to high-quality safe care and maintain high member satisfaction while appropriately managing costs.”

Restricting “utilization management tools would markedly deviate from Congress’ intent in creating Medicare managed care because they substantially limit MA plans’ ability to actually manage care,” he said.

In a statement, UHC spokesperson Heather Soule said the company’s current practices are “consistent” with the new rules. “Medical directors or other appropriate clinical personnel, not technology tools, make all final adverse medical necessity determinations” before coverage is denied or cut short. However, these medical professionals work for UHC and usually do not examine patients. Other insurance companies follow the same practice.

David Lipschutz, associate director of the Center for Medicare Advocacy, is concerned about how CMS will enforce the rules since it doesn’t mention specific penalties for violations.

CMS’ deputy administrator and director of the Medicare program, Meena Seshamani, said that the agency will conduct audits to verify compliance with the new requirements, and “will consider issuing an enforcement action, such as a civil money penalty or an enrollment suspension, for the non-compliance.”

Although Sullivan stayed at Bishop Wicke after UHC stopped paying, she said another resident went home when her MA plan wouldn’t pay anymore. After two days at home, the woman fell, and an ambulance took her to the hospital, Sullivan said. “She was back in the nursing home again because they put her out before she was ready.”

©2023 KFF Health News. Distributed by Tribune Content Agency, LLC.