Medicare beneficiaries need more help navigating the program, experts say

More needs to be done to help Medicare beneficiaries — especially low-income beneficiaries — navigate their participation in the program, several experts said Friday.

“Low-income Medicare beneficiaries navigate complex and fragmented sources of insurance coverage…not just within Medicare, between choosing a Medicare Advantage plan or traditional Medicare, but also among the patchwork of programs that complement Medicare and help lower out-of-pocket costs for low-income people,” which include Medicaid, said Eric Roberts, PhD, of the University of Pittsburgh School of Public Health.

“Additional eligibility rules for these programs are restricted and exclude many people with low to moderate incomes from assistance,” Roberts explained during a webinar presented by the Alliance for Health Policy and sponsored by the Commonwealth Fund. and Arnold Ventures.

A big problem for low-income beneficiaries is that there are no limits in the program for out-of-pocket expenses, said Tricia Neuman, executive director of the Medicare Policy Program at the Kaiser Family Foundation. .

For example, “Medicare does not have a reimbursable cap on Part D prescription drugs,” she said. “It’s something that’s been talked about a lot over the past two years, and it’s something that was included in the Balanced Budget Act that passed the House and is now stalled in the Senate. .”

Neuman stressed that this raises “serious concerns,” especially for very expensive specialty drugs prescribed. Additionally, she added that Medicare generally does not cover expensive long-term services and supports.

“Dental services are generally not covered, and routine hearing and vision exams are not covered – all of which have been the subject of political discussion, but none of which have crossed the line. arrived,” she said.

Because of all the coverage gaps, the average Medicare beneficiary pays $6,150 a year out of pocket on premiums and services. For those aged 85 and over, this amount almost doubles to reach $12,063 per year.

More and more Medicare beneficiaries are enrolling in Medicare Advantage, for several reasons, Neuman noted. For example, these plans often provide additional benefits that traditional health insurance does not cover, such as eye exams or fitness programs. Also, “you get it all [the benefits] in one, and you don’t need an additional plan [or] a separate part D [drug] plan,” she said, and added that these plans also tend to have low payouts.

However, there are trade-offs with Medicare Advantage that beneficiaries are often unaware of, such as a restricted provider network. There may also be pre-authorization restrictions that do not apply to traditional health insurance. “There is also cost sharing for services that may or may not be important for people when they are healthy, but which could be a problem for people when they are sick,” she said. .

Finally, if people leave Medicare Advantage and switch back to traditional Medicare, they often cannot purchase a Medigap policy — also known as Medicare supplemental insurance — because they have a pre-existing condition. “The ‘problem guaranteed’ protections that people know well from the Affordable Care Act don’t apply to Medigap, so people with pre-existing conditions in almost any state can be denied a plan” , explained Neuman.

And despite lower premiums for some plans, a higher percentage of Medicare Advantage enrollees — 19% — reported cost-related issues, compared to just 15% of traditional Medicare enrollees. The lower percentage for the latter group was likely due to their additional coverage; in fact, 30% of traditional Medicare enrollees who did not have an add-on plan reported cost-related issues. “These are trends we’re watching and they’re important because as Medicare spending continues to rise, out-of-pocket costs will continue to be a serious concern,” she said.

On a more positive note, there is evidence that Medicare can reduce racial and ethnic gaps in access to care, said Loren Saulsberry, PhD, of the University of Chicago’s Department of Public Health Sciences. She quoted a 2021 JAMA internal medicine study led by Jacob Wallace, PhD, of the Yale School of Public Health, which found that Medicare eligibility at age 65 was associated with reduced racial and ethnic disparities in insurance coverage, access to care and self-reported health.

However, Saulsberry explained that while Medicare may improve these outcomes in some ways, “it doesn’t quite bring all populations to parity.”

Procedural issues also cause problems for Medicare beneficiaries, according to Lindsey Copeland, JD, director of federal policy at the Medicare Rights Center. Although people who start taking Social Security at age 65 are notified of their Medicare eligibility, those taking Social Security later — which includes a growing number of beneficiaries — are not notified.

“As a result, many people bear the burden of navigating Medicare’s complex enrollment process alone, often with disastrous effect,” due to Medicare’s late enrollment penalty, she said.

For example, if someone waited 7 years after first becoming eligible for Medicare to enroll, “they have to pay 70% more each month as long as they have Medicare, which amounts to a penalty to life,” Copeland said. “An example for 2022 would be that since Part B’s base premium this year is $170.10, their monthly premium with a penalty would be $289.17.”

Currently, about 776,2000 people are paying a late registration penalty, she said.

“Financial challenges, along with rising health care costs, including prescription drug costs, outdated program rules and onerous administrative requirements can make it difficult for many recipients to get the care they need. need,” Copeland concluded. “It’s really critical that policy makers step in to help reduce these barriers to care.”

  • Joyce Frieden oversees MedPage Today’s coverage in Washington, including stories about Congress, the White House, the Supreme Court, professional health associations and federal agencies. She has 35 years of experience in health policy. To follow

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