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From left, pharmacists Brent Talley of North Carolina, Scott Pace of Arkansas, and Clint Hopkins of California. (ELIZABETH TALLEY; KORI GORDON; JOEL HOCKMAN)
By Susan Jaffe | KFF Health News | June 11, 2024
Category: Medicare Advantage
Your Doctor or Your Insurer? Little-Known Rules May Ease the Choice in Medicare Advantage
By ,
Bart Klion (Hans Pennink for KFF Health News)
Bart Klion, 95, and his wife, Barbara, faced a tough choice in January: The upstate New York couple learned that this year they could keep either their private, Medicare Advantage insurance plan — or their doctors at Saratoga Hospital.
The Albany Medical Center system, which includes their hospital, is leaving the Klions’ Humana plan — or, depending on which side is talking, the other way around. The breakup threatened to cut the couple’s lifeline to cope with serious chronic health conditions.
Klion refused to pick the lesser of two bad options without a fight.
..With rare exceptions, Advantage members are locked into their plans for the rest of the year — while health providers may leave at any time. …But a few years ago, CMS created an escape hatch by expanding special enrollment periods, or SEPs, which allow for “exceptional circumstances.” Beneficiaries who qualify can request SEPs to change plans or return to original Medicare. [Continued on KFF Health News]…
Dodging the Medicare Enrollment Deadline Can Be Costly
By , 
Angela M. Du Bois, a retired software tester in Durham, North Carolina, wasn’t looking to replace her UnitedHealthcare Medicare Advantage plan. She wasn’t concerned as the Dec. 7 deadline approached for choosing another of the privately run health insurance alternatives to original Medicare.
But then something caught her attention: When she went to her doctor last month, she learned that the doctor and the hospital where she works will not accept her insurance next year.
Faced with either finding a new doctor or finding a new plan, Du Bois said the decision was easy. “I’m sticking with her because she knows everything about me,” she said of her doctor, whom she’s been seeing for more than a decade.
Du Bois isn’t the only one tuning out when commercials about the open enrollment deadline flood the airwaves each year — even though there could be good reasons to shop around. But sifting through the offerings has become such an ordeal that few people want to repeat it. Avoidance is so rampant that only 10% of beneficiaries switched Medicare Advantage plans in 2019.
Once open enrollment ends, there are limited options for a do-over…. [Continued on Kaiser Health News and NPR]…
Uncle Sam Wants You … to Help Stop Insurers’ Bogus Medicare Advantage Sales Tactics
By ,
People gathered at the U.S. Capitol in Washington, D.C. in July protested denials and delays in private Medicare Advantage plans. (Alex Wong/Getty Image)
After an unprecedented crackdown on misleading advertising claims by insurers selling private Medicare Advantage and drug plans, the Biden administration hopes to unleash a special weapon to make sure companies follow the new rules: you.
Officials at the Centers for Medicare & Medicaid Services are encouraging seniors and other members of the public to become fraud detectives by reporting misleading or deceptive sales tactics to 800-MEDICARE, the agency’s 24-hour information hotline. Suspects include postcards designed to look like they’re from the government and TV ads with celebrities promising benefits and low fees that are available only to some people in certain counties.
The new rules, which took effect Sept. 30, close some loopholes in existing requirements by describing what insurers can say in ads and other promotional materials as well as during the enrollment process. [Continued on Kaiser Health News and NPR]…
Feds Rein In Use of Predictive Software That Limits Care for Medicare Advantage Patients
By ,
This article also ran in The Washington Post.
Judith Sullivan was recovering from major surgery at a Connecticut nursing home in March when she got surprising news from h 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. NaviHealth’s 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.
…Next year, the Centers for Medicare & Medicaid Services will begin restricting how Medicare Advantage plans use predictive technology tools to make some coverage decisions.[Continued on Kaiser Health News and The Washington Post.]…
Nursing Home Surprise: Advantage Plans May Shorten Stays to Less Time Than Medicare Covers
“The health plan can determine how long someone is in a nursing home typically without laying eyes on the person.”
By Susan Jaffe | Kaiser Health News | October 4, 2022 | This KHN story also ran on 
“This seems unethical,” said daughter Amy Loomis, who feared what would happen if the Medicare Advantage plan, run by UnitedHealthcare, ended coverage for her mother’s nursing home care. The facility gave Christopherson a choice: pay several thousand dollars to stay, appeal the company’s decision, or go home.
But instead of being relieved, Christopherson and her daughter were worried because her medical team said she wasn’t well enough to leave.
Health care providers, nursing home representatives, and advocates for residents say Medicare Advantage plans are increasingly ending members’ coverage for nursing home and rehabilitation services before patients are healthy enough to go home. [Full story in and Fortune, Kaiser Health News, The Philadelphia Inquirer, and Yahoo News]
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Seeking to Shift Costs to Medicare, More Employers Move Retirees to Advantage Plans
By Susan Jaffe | Kaiser Health News | March 3, 2022 | This KHN story also ran in Fortune and The Dallas Morning News.
…
Medicare’s Open Enrollment Is Open Season for Scammers
By Susan Jaffe | Kaiser Health News | November 11, 2021 | This KHN story also ran in The Washington Post.
In response, the Centers for Medicare and Medicaid Services has threatened to penalize private insurance companies selling Medicare Advantage and drug plans if they or agents working on their behalf mislead consumers. The agency has also revised rules making it easier for beneficiaries to escape plans they didn’t sign up for or enrolled in only to discover promised benefits didn’t exist or they couldn’t see their providers.
The problems are especially prevalent during Medicare’s open-enrollment period, which began Oct. 15 and runs through Dec. 7. A common trap begins with a phone call like the one Linda Heimer, an Iowa resident, received in October. [Full story in The Washington Post and Kaiser Health News.]
Under New Cost-Cutting Medicare Rule, Same Surgery, Same Place, Different Bill
By Susan Jaffe | Kaiser Health News | March 21, 2021 | This KHN story also ran in The Washington Post
For years, Medicare officials considered some surgeries so risky for older adults that that the insurance program would cover the procedures only for patients admitted to the hospital. Under a new Medicare policy that took effect this year, these operations can be provided to patients who are not admitted. But patients still have to go to the hospital. The change saves Medicare money while patients can pay a larger share of the bill — for the same surgery at the same hospital. [Full story in The Washington Post and Kaiser Health News.]
… Website Errors Raise Calls For Medicare To Be Flexible With Seniors’ Enrollment
Seniors will be able to change plans any time next year if they discover their coverage doesn’t provide what the government’s Plan Finder promised.
By Susan Jaffe | Kaiser Health News | December 6, 2019 | This article also ran on
Saturday is the deadline for most people with Medicare coverage to sign up for private drug and medical plans for next year. But members of Congress, heal
th care advocates and insurance agents worry that enrollment decisions based on bad information from the government’s revamped, error-prone Plan Finder website will bring unwelcome surprises.
Beneficiaries could be stuck in plans that cost too much and don’t meet their medical needs — with no way out until 2021.
On Wednesday, the Centers for Medicare & Medicaid Services told Kaiser Health News that beneficiaries would be able to change plans next year because of Plan Finder misinformation, although officials provided few details. [Continued at Kaiser Health News or NPR.] …
As Medicare Enrollment Nears, Popular Price Comparison Tool Is Missing
By Susan Jaffe | Kaiser Health News | October 8, 2019 | This article also ran in the
Millions of older adults can start signing up next week for private policies offering Medicare drug and medical coverage for 2020. But many risk wasting money and even jeopardizing their health ca
re due to changes in Medicare’s plan finder, its most popular website.
For more than a decade, beneficiaries used the plan finder to compare dozens of Medicare policies offered by competing insurance companies and get a list of their options. Yet after a website redesign six weeks ago, the search results are missing crucial details: How much will you pay out-of-pocket? And which plan offers the best value? [Continued at Kaiser Health News, San Francisco
Social Security Error Jeopardizes Medicare Coverage For 250,000 Seniors
By Susan Jaffe | Kaiser Health News | June 6, 2019 | This KHN story also ran on 
At least a quarter of a million Medicare beneficiaries may receive bills for as many as five months of premiums they thought they already paid.
But they shouldn’t toss the letter in the garbage. It’s not a scam or a mistake.
Because of what the Social Security Administration calls “a processing error” that occurred in January, it did not deduct premiums from some seniors’ Social Security checks and it didn’t pay the insurance plans.
[Continued at Kaiser Health News or NPR ]
…Trumpeted New Medicare Advantage Benefits Will Be Hard For Seniors To Find
By Susan Jaffe | Kaiser Health News | November 9, 2018 | This KHN story also ran on
For some older adults, private Medicare Advantage plans next year will offer a host of new benefits, such as transportation to medical appointments, home-delivered meals, wheelchair ramps, bathroom grab bars or air conditioners for asthma sufferers.
But the new benefits will not be widely available, and they won’t be easy to find.
Of the 3,700 plans across the country next year, only 273 in 21 states will offer at least one. About 7 percent of Advantage members — 1.5 million people — will have access, Medicare officials estimate.
That means even for the savviest shoppers it will be a challenge to figure out which plans offer the new benefits and who qualifies for them.
Medicare officials have touted the expansion as historic and an innovative way to keep seniors healthy and independent. Despite that enthusiasm, a full listing of the new services is not available on the web-based “Medicare Plan Finder,” the government tool used by beneficiaries, counselors and insurance agents to sort through dozens of plan options. [Continued at Kaiser Health News, NPR and CNN]…
No More Secrets: Congress Bans Pharmacist ‘Gag Orders’ On Drug Prices
Update: After this article was posted Oct. 10th, the President signed the legislation into law later that day.
By Susan Jaffe | Kaiser Health News | October 10, 2018 | This KHN story also ran on 
For years, most pharmacists couldn’t give customers even a clue about an easy way to save money on prescription drugs. But the restraints are coming off.
When the cash price for a prescription is less than what you would pay using your insurance plan, pharmacists will no longer have to keep that a secret.
…But there’s a catch: Under the new legislation, pharmacists will not be required to tell patients about the lower cost option. If they don’t, it’s up to the customer to ask. [Continued at Kaiser Health News and at NBC News]
…Medicare Advantage Plans Cleared To Go Beyond Medical Coverage — Even Groceries
By Susan Jaffe | Kaiser Health News | April 3, 2018 | This KHN story also ran on 
Air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals may be among the new benefits added to Medicare Advantage [private insurance] coverage when new federal rules take effect next year.
The Institute for Aging in San Francisco helps seniors get to doctor appointments and social activities. (Photo/Susan Jaffe)
…But patient advocates including David Lipschutz. senior policy attorney at the Center for Medicare Advocacy, are concerned about those who may be left behind. “It’s great for the people in Medicare Advantage plans, but what about the majority of the people who are in traditional Medicare?” he asked. “As we tip the scales more in favor of Medicare Advantage, it’s to the detriment of people in traditional Medicare.” [Continued at Kaiser Health News, The Philadelphia Inquirer, The Washington Post and CNN Money]
…Lifting Therapy Caps Is A Load Off Medicare Patients’ Shoulders
Last month’s budget deal means Medicare beneficiaries are eligible for physical and occupational therapy indefinitely. Plus, prescription drug costs will fall for more seniors.
By Susan Jaffe | Kaiser Health News | March 14, 2018 | This KHN story also ran on
Physical therapy helps Leon Beers, 73, get out of bed in the morning and
Leon Beers gets help from caregiver Timothy Wehe. (Bert Johnson for KHN)
maneuver around his home using his walker. Other treatment strengthens his throat muscles so that he can communicate and swallow food, said his sister Karen Morse. But in mid-January, his home health care agency told Morse it could no longer provide these services because he had used all his therapy benefits allowed under Medicare for the year.
… Under a recent change in federal law, people who qualify for Medicare’s [physical, occupational and speech] therapy services will no longer lose them solely because they used too much.
“It is a great idea,” said Beers. “It will help me get back to walking.” [Continued at Kaiser Health News, NPR and The Washington Post]
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A Few Pointers To Help Save Money And Avoid The Strain Of Medicare Enrollment
By Susan Jaffe | Kaiser Health News | Oct. 17, 2017 | This article also ran in 
and 
Older or disabled Americans with Medicare coverage have probably 
noticed an uptick in mail solicitations from health insurance companies, which can mean only one thing: It’s time for the annual Medicare open enrollment.
Most beneficiaries have from Oct. 15 through Dec. 7 to decide which of dozens of private plans offer the best drug coverage for 2018 or whether it’s better to leave traditional Medicare and get a drug and medical combo policy called Medicare Advantage.
Some tips for the novice and reminders for those who have been here before can make the process a little easier. [Continued at Kaiser Health News, USA Today and The Washington Post]
…Medicare Bars New ‘Seamless Conversion’ Efforts For Some Seniors
By Susan Jaffe | Kaiser Health News | October 28, 2016 | This KHN story also ran in 
The federal government is temporarily blocking more health insurance companies from automatically moving customers who become eligible for Medicare into Medicare Advantage plans while officials review the controversial practice.
They also will issue rules soon for plans that already have permission to make these switches, known as “seamless conversion,” according to a memo from Michael Crochu
nis, acting director of the Medicare Enrollment and Appeals Group at the Centers for Medicare & Medicaid Services.
Under current rules, an insurer can transfer customers who have purchased policies through an Affordable Care Act insurance exchange or other commercial plans when they become eligible for Medicare, typically at age 65. An insurer must give an individual 60 days’ advance written notice of the switch; if a person doesn’t opt out, that enrollment takes effect automatically.
… The decision to prohibit additional insurers from pursuing Medicare Advantage conversions comes after Kaiser Health News and The Washington Post identified problems with the practice in July. Some seniors did not know they had different coverage until receiving out-of-network providers’ bills for thousands of dollars. Others got the news when they received a Medicare Advantage membership card they hadn’t requested — with the name of a new primary care doctor they didn’t know. [Continued in Kaiser Health News and The Washington Post]…
Some Seniors Surprised To Be Automatically Enrolled In Medicare Advantage Plans
By Susan Jaffe | Kaiser Health News | July 27, 2016 | This KHN story also ran in
Only days after Judy Hanttula came home from the hospital after surgery last November, her doctor’s office called with bad news: Records showed that instead of traditional Medicare, she had a private Medicare Advantage plan, and her doctor and hospital were not in its network.
Neither the plan nor Medicare now would cover her medical costs. She owed $16,622.
“I was panicking,” said Hanttula, who lived in Carlsbad, N.M., at the time. After more than five hours making phone calls, she learned that because she’d had individual coverage through Blue Cross Blue Shield when she became eligible for Medicare, the company automatically signed her up for its own Medicare Advantage plan after notifying her in a letter. Hanttula said she ignored all mail from insurers because she had chosen traditional Medicare.
“I felt like I had insured myself properly with Medicare,” she said. “So I quit paying attention to the mail.”
With Medicare’s specific approval, a health insurance company can enroll a member of its marketplace or other commercial plan into its Medicare Advantage coverage when that individual becomes eligible for Medicare. Called “seamless conversion,” the process requires the insurer to send a letter explaining the new coverage, which takes effect unless the member opts out within 60 days. [Continued in The Washington Post and Kaiser Health News]…
When Medicare Advantage Drops Doctors, Some Members Can Switch Plans
By Susan Jaffe | Kaiser Health News | March 29, 2016 | This KHN story also ran on 
Eliza Catchings has been seeing doctors at the Christie Clinic in central Illinois since 1957. But just after receiving this year’s WellCare Medicare Advantage member card, the insurer told her the clinic was leaving WellCare’s provider network and she would have to choose new doctors.
“I was terrified,” said Catchings, 79, who gets care for diabetes and heart problems. But she was helped by a little-noticed change in federal policy.
Medicare Advantage plans sold by private insurers are an alternative to traditional Medicare, but they cover services only from doctors, hospitals and other providers that are in the insurer’s network. Although providers are allowed to drop out of the plans any time, members can usually change only during the annual sign-up period in the fall. There are exceptions, but until recently losing a provider was not among them.
After insurers dropped hundreds of providers in 2013, the Centers for Medicare and Medicaid Services issued rules giving people a “special enrollment period” to change plans or join regular Medicare if there was a “significant” change in their provider network. The policy took effect in 2015 and applies only to Medicare Advantage members, not to the plans CMS oversees in the health law’s marketplaces. …Yet officials didn’t explain what they considered significant or what would trigger the option.
In the past eight months, Medicare officials have quietly granted the special enrollment periods to more than 15,000 Medicare Advantage members in seven states, the District of Columbia and Puerto Rico based on provider cuts. These decisions offer important details about how members can get permission to follow their doctors who leave their plans. … Medicare doesn’t publicize the option, and few beneficiaries may know about it. Representatives who answered calls earlier in March to Medicare’s toll-free number said nothing could be done. [Continued on Kaiser Health News or NPR]
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Don’t Just Renew Your Medicare Plan. Shopping Around Can Save Money.
By Susan Jaffe | October 15, 2015 | Kaiser Health News in collaboration with Money magazine
Ten years after a prescription drug benefit was added to Medicare, 39 million older or disabled Amer
icans have coverage to help pay for their medicine, including most of the 17 million with private insurance policies known as Medicare Advantage, an alternative to traditional Medicare.
The annual enrollment
period for these private drug and Advantage plans for 2016 starts Thursday and runs through Dec. 7.
It pays to shop around. The monthly cost is increasing an average 26 percent for UnitedHealthcare’s AARP MedicareRx Saver Plus while the First Health Value Plus plan
is dropping an average 13 percent, according to an analysis of the 10 most popular drug plans by Avalere Health, a research firm.
Some actual costs may be even more dramatic. In Albany, N.Y., the price of a Cigna-HealthSpring drug plan is going up 36 percent, according to the StateWide Senior Action Council, a New York consumer group. [More in Kaiser Health News or Money magazine]
…Medicare Advantage Plans Need Tougher Oversight, GAO Says
| Connecticut Health Investigative Team Writer | October 5, 2015
Federal investigators have found that Medicare officials rarely enforce rules for private insurance plans intended to make sure beneficiaries will be able to see a doctor when they need care.
It’s a problem many Connecticut seniors know too well. In 2013, UnitedHealthcare, the nation’s largest health insurance company, dropped hundreds of health care providers from its 
Connecticut Medicare Advantage plan, including 1,200 doctors at the Yale Medical Group and Yale-New Haven Hospital. Medicare Advantage beneficiaries scrambled to find new insurance or new doctors while the Fairfield and Hartford counties medical associations went to court to try to stop the terminations.
The report by the Government Accountability Office, the investigative arm of Congress, said that Medicare did not check provider networks to ensure that doctors were available to beneficiaries and cited Connecticut as a “case study” in what can go wrong.
The GAO report shows that Medicare “was not verifying network adequacy. That’s their job and they abdicated that responsibility,” said U.S. Rep. Rosa DeLauro, D-New Haven, who requested the investigation along with other members of the Connecticut congressional delegation. MORE
…Want a good laugh? Head to the hospital.
By Susan Jaffe KAISER HEALTH NEWS | July 7, 2015 | This KHN story also ran in 
Every month, a group of older adults goes to Washington’s Sibley Memorial Hospital, but they don’t see a doctor or get tests. They’re not sick. They come just for laughs.
Joanne Philleo, 79, enjoys a joke at the monthly “Laugh Cafe” event at Sibley Memorial Hospital. (Amanda Voisard for The Washington Post)
They gather in a room next to the hospital cafeteria for the “Laugh Cafe,” one of the activities offered to local seniors, including the 7,300 members of Sibley’s Senior Association. The price of admission is one joke, recited out loud. Experts say laughing can be good for your health, and everyone in the room strongly agrees.
…The association for those age 50 or older also offers other activities, including French and Italian conversation classes, day trips to museums, a current events group, and — the latest addition — tango lessons. In addition, members receive discounts on hospital parking and at the gift shop, pharmacy and restaurant. In all, more than 10,000 seniors participate.
Sibley is one of several hospitals in the Washington area — along with others across the country — offering social activities and other benefits to help seniors stay healthy and out of the hospital, while encouraging them to visit. Participants do not need to have been patients.
But some experts are concerned that the activities are less about health than about marketing to Medicare beneficiaries, especially those who can go to the hospital of their choice when they need care because they are not enrolled in private insurance plans with limited provider networks.[Continued in Washington Post]…
Obamacare, Private Medicare Plans Must Keep Updated Doctor Directories In 2016
By Susan Jaffe | March 9, 2015 | Kaiser Health News and also published in
Starting next year, the federal government will require health insurers to give millions of Americans enrolled in Medicare Advantage plans or in policies sold in the federally run health exchange up-to-date details about which doctors are in their plans 
and taking new patients.
Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals and other health care providers that can change during the year. Networks can also vary among plans offered by the same insurer. So it’s not always easy to figure out who’s in and who’s out, and many consumers have complained that their health coverage doesn’t amount to much if they can’t find doctors who accept their insurance. [More from KHN] [More in USA Today]
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Medicare May Help Seniors If Advantage Plans Drop Doctors
By Susan Jaffe | December 23, 2014 Connecticut Health Investigative Team and The Hartford Courant
Next year, seniors with private Medicare Advantage insurance policies whose doctors leave their plan may be able to leave, too, under a new Medicare rule.
The Centers for Medicare & Medicaid Services (CMS), which oversee Medicare Advantage programs, will create a special three-month enrollment period in any state 
where insurers make network changes “considered significant based on the affect or potential to affect, current plan enrollees,” according to an update to Medicare’s Managed Care Manual.
The special enrollment period – if granted by CMS – would allow Medicare Advantage members to 
switch out of their plans and join traditional Medicare or another Medicare Advantage plan whose provider network includes their doctors.
…U.S. Sen. Richard Blumenthal criticized the new rule because it’s not clear what “significant” network changes would trigger a special enrollment period. Instead, he spearheaded a letter sent last Friday to Medicare chief Marilyn Tavenner, asking her to prohibit mid-year provider network changes. The letter was also signed by U.S. Sens. Sherrod Brown of Ohio and Rand Paul of Kentucky, along with U.S. Reps. Rosa DeLauro, Joe Courtney, Jim Himes, Elizabeth Esty and 13 other members of Congress.
“This blatant bait and switch should not be allowed,” they wrote. [CONTINUED in Connecticut Health Investigative Team and in The Courant ] …