Under new government
rules, these plans could start paying for rides to the doctor, home health
aides, and other services. Emphasis on "could"
The Centers for Medicare & Medicaid
Services has announced it will allow Medicare Advantage plans the ability to
offer a wide range of additional services.
If you’re insured
through a Medicare Advantage policy or you plan to sign up for one in the next
year or two, you could soon be playing in a new ballgame.
That’s because two
recent government actions will allow these counterparts to traditional Medicare
to offer more benefits, including services to help improve and prolong a sick
person’s life as well as equipment to help prevent accidents and emergencies.
Think everything from grab bars to palliative care, therapeutic massage
to respite support for caregivers.
The catch: Not
everyone enrolled in the plan will necessarily be eligible to use the new
benefits. And anyone who gets benefits from traditional Medicare will be left
out entirely.
Here’s what you need
to know about the upcoming changes.
What sets Medicare
Advantage apart
First a little
background. Private insurers sell Medicare Advantage plans as an alternative to
traditional Medicare.
The plans cover
hospitalization and doctor visits for the same premium as you would pay for
traditional Medicare, currently $134 a month for most people. Advantage plans
are allowed to offer additional benefits not provided by traditional Medicare,
such as dental and vision coverage. And many Advantage policies incorporate
pharmaceutical drug coverage known as Medicare Part D into the plan.
The extra services
usually entail a modest additional premium—an average of $36 a month, including
drug coverage, according to the Kaiser Family Foundation. In many cases, the
extra cost is less than what you’d pay to buy traditional Medicare, a Part D
policy to cover prescription drugs, and a supplemental Medigap plan for help
with out-of-pocket costs, such as deductibles and coinsurance.
As a result, the
Medicare Advantage market, which is currently dominated by two huge insurers,
United Health and Humana, has been growing. According to KFF data, 33% percent
of Medicare recipients purchased advantage plans in 2017, up from 19% in
2007.
The list of extras is
getting bigger
Thanks to an April
ruling from the Centers for Medicare & Medicaid Services, Medicare
Advantage plans will be able to offer a wide range of additional services, starting
as soon as next year.
In a memo explaining
the new rules, CMS explains that it is reinterpreting what it calls “primarily
health related” supplemental benefits. The new rules expand the definition
beyond strict medical care to include “services used to diagnose illnesses,
compensate for physical impairments, treat the impact of injuries or health
conditions and reduce avoidable emergency care.”
New benefits could include adult
daycare, home health aides, rides to the doctor, even therapeutic massage
This opens the door
to coverage that is currently not included in either Medicare Advantage or
traditional Medicare plans.
The list of
possibilities is long and covers a multitude of services to help older adults
with acute or chronic medical conditions as well as the people who care for
them.
These include adult
daycare; home-based palliative care, which focuses on improving quality of life
for seriously ill patients; home health aides to provide personal care;
non-opioid pain management, which could include therapeutic massage; memory
fitness services; and respite and counseling services for caregivers.
Equipment to keep
frail older adults safer at home are also on the list, such as grab bars and
stair rails. So are services to make everyday living a little easier, such as
home-delivered meal and transportation to and from doctor visits, as well as
some over-the-counter health items, like pill cutters and personal activity
trackers.
Restrictions in the
fine print
Before you get too
excited, Philip Moeller, author of Get What’s Yours for Medicare:
Maximize your Coverage, Minimize Your Costs, points out
that everyone who wants these benefits won’t qualify for coverage.
“Supplemental benefits must still focus
direction on an enrollee’s health care needs and be recommended or provided by
a licensed medical professional,” the CMS says. In plainer English, that means
you will only be covered for the new services if it will address a previously
diagnosed health issue and your doctor has prescribed it.
For instance, you may
really want a grab bar in the bathroom because you’ve been feeling a little
unstable, but that’s probably not enough to qualify for coverage. According to
early interpretations of the rules, you’d need to have already fallen or shown
other medically diagnosed signs of instability for your Advantage plan to pick
up the tab.
Expect a slow roll
out
One additional
change, courtesy of the CHRONIC Care Act passed by Congress earlier this year,
doesn’t kick in until 2020.
Designed to provide
more benefits to people with chronic conditions such as heart disease or
diabetes, the act gives Medicare Advantage plans additional flexibility to
cover other non-medical benefits, such as wheelchair ramps and access to
telehealth and home health services.
Providers are
expected to roll out these new benefits, along with the ones approved by CMS
for the 2019 plan year, slowly and cautiously. “Insurers are very sensitive to
new underwriting risks, especially in areas where they haven’t had experience,
don’t know the extent of usage and don’t know what the costs will be,” Moeller
explains.
“Insurers are very sensitive to new
underwriting risks.”
Phillip Moeller, author
Get What’s Yours for Medicare
So far there have
been no announcements from insurers about changes to their Advantage plans.
Details are expected in early fall, before the Medicare annual enrollment
period begins on October 15.
Moeller and others
speculate that some big insurers will embrace a handful of the new benefits
only. “Next year, when the CHRONIC changes kick in, we could see more action,”
says Moeller.
All enrollees won’t
get equal access
The most confusing
and, for some consumer advocates, alarming point about the Medicare Advantage
changes: All benefits will not be available to all Medicare Advantage
policyholders, says David Lipschutz, senior policy attorney at the Center for
Medicare Advocacy.
“Until now Medicare
Advantage had to offer the same benefits to all enrollees in a certain service
area, usually a county,” Lipschutz explains. If one policyholder was eligible
for twice-yearly dental checkups, every policyholder in that plan in a specific
service area would receive coverage for twice-yearly checkups.
“Insurers now have greater leeway in
determining who gets what benefit.”
David Lipschitz, senior policy attorney
Center for Medicare Advocacy
But a new
interpretation of the rules by CMS will allow Medicare Advantage insurers to
target benefits to specific policyholders with a diagnosed medical need, as
with the grab bar example. Or, they may reserve memory care services only for
those patients who have been diagnosed with a form of dementia.
“Insurers now have
greater leeway in determining who gets what benefit,” Lipschutz says.
He and other consumer
advocates worry this wiggle room will cause plenty of confusion.
Consumers, for
example, may flock to Medicare Advantage plans hoping to take advantage of the
new benefits only to find they do not qualify for them. In addition, consumer
advocates worry, insurers may be able to market more heavily toward healthier
patients, who may not need the extra benefits and who cost less to insure.
Traditional Medicare
gets the short end of the stick
None of the new
benefits will available to people who are insured through traditional Medicare,
and CMS says it has no plans to add benefits to the traditional plans.
Aside from the extra
costs the government would incur, there is a perception that Advantage plans,
which are offered by private insurance companies that negotiate rates with
healthcare providers within their network, are better equipped to administer
the new benefits in the most cost-efficient manner, Moeller explains.
Traditional Medicare, which reimburses providers for each service rendered, is
regarded as less efficient.
The merits of that
argument can and no doubt will be argued for years to come. In the meantime,
says Lipschutz, the scales are tipping toward Medicare Advantage.
“There are likely
folks who will benefit from the changes,” he says. “But we’re concerned this
leaves behind the two thirds of Medicare recipients with traditional Medicare.”
https://considerable.com/medicare-advantage-is-expanding-coverage-but-not-everyone-will-benefit/
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