CEO: Health Insurance Decision Time
September 25, 2024
(Published as a Letter to the Editor in The Carrollton Democrat)
By Scott Thoreson, Carroll County Memorial Hospital Chief Executive Officer
It used to be that for people of Medicare age that it was a simple decision to transition from an employer-provided or self-provided health insurance plan to what is now known as “traditional Medicare.” Starting in 1997 with the Balanced Budget Act, “Medicare Choice” plans, as it was known then, now known as “Medicare Advantage” (also known as Medicare Part C) came into being; and over a period of time, have now come to represent more than 50% of the seniors, more than “traditional Medicare” plans here in Missouri. Some reasons for this are that premiums are generally less for Medicare Advantage compared to Traditional Medicare, and there could be extra benefits such as dental coverage or coverage for eyeglasses, health clubs or even home delivered meals.
Medicare is an alphabet soup of programs: Medicare A is for hospital, skilled nursing facility, hospice care and home health care coverage with various requirements and deductibles. There is no annual premium for Medicare A, provided individuals have worked 10 years or more in the United States. Individuals with less than 10 years of work experience in the United States will need to pay a monthly premium.
Medicare B pays for doctor’s appointments and other outpatient services to include lab, radiology, physical therapy and other services with likely a 20% co-insurance requirement to be paid by the patient, unless the patient has a supplemental plan, also known as a Medi-gap policy. The premium for Medicare Part B is $174.70 each month in 2024, depending on income. Higher income patients may need to pay more through Income-Related Monthly Adjustment (IRMA) which kicks in for individuals earning more than $103,000 per year or $206,000 for married couples.
Medicare C is also known as Medicare Advantage and is the program where Medicare has allowed private insurance companies to receive a payment from the US government and patients, and in return offers to take on the financial risk of caring for this group of patients.
Medicare D is a voluntary outpatient prescription drug benefit for people with Medicare provided through private plans that contract with the federal government. Enrollees pay a monthly premium for this coverage, which averaged $32.74 in 2023 and people with higher income have higher Part D premiums.
The healthcare community has begun making important decisions regarding their willingness to accept various Medicare Advantage plans. Hospitals and doctors have reviewed the reimbursement they are receiving, as well as the processes that they have gone through to receive payment, and many have determined that it is not worth the effort. As a result, they have decided to not accept assignment and become part of the particular network for that Medicare Advantage plan. Patients need to know what hospitals, clinics and doctors are “in-network” before they decide to choose a Medicare Advantage plan versus Traditional Medicare. A USA Today article quoted Chris Van Gorder, President and CEO of Scripps Health in California. He described Medicare Advantage offerings as “delay, deny or don’t pay” plans, as “they are in the business of making money.”
At CCMH we have struggled with various Medicare Advantage plans getting patient prior approval to obtain a diagnostic test or perhaps getting a patient admitted to our swing-bed program following an acute hospitalization. I am getting closer myself to Medicare age, and based on what I know as a health care administrator, I am set on enrolling in Traditional Medicare and getting a Medicare supplement plan to pay for what is not paid for by Medicare. I will also enroll in Medicare Part D to cover pharmacy charges. Another consideration to keep in mind is that if you choose a Medicare Advantage plan, compared to Traditional Medicare, you may not be able to have a Medicare supplement plan agree to pick you up for coverage at a later date.
I hope that his article has educated you a bit more on the various programs offered through Medicare, as well as some of the considerations taking place by America’s hospitals and clinics regarding network participation with Medicare Advantage plans. If you have a question you would like addressed in this column please, send it to info@ccmhospital.org. I wish you good health!
More in this Series:
CEO: Hospital Week 2024 (Published May 13, 2024)
https://www.carrollcountyhospital.org/news/ceo-hospital-week-2024
CEO: Community Health Needs Initial Assessment (Published April 24, 2024)
https://www.carrollcountyhospital.org/news/ceo-community-health-needs-initial-assessment
CEO: Cybersecurity (Published February 14, 2024)
https://www.carrollcountyhospital.org/news/ceo-cybersecurity
CEO: End of Year Reflections (Published December 29, 2023)
https://www.carrollcountyhospital.org/news/ceo-end-of-the-year-reflections
CEO: Coding Matters (Published November 22, 2023)
https://www.carrollcountyhospital.org/news/ceo-coding-matters
CEO: Maternity Care Desert (Published October 25, 2023)
https://www.carrollcountyhospital.org/news/ceo-maternity-care-desert
CEO: Rural Emergency Hospitals (Published September 20, 2023)
https://www.carrollcountyhospital.org/news/ceo-rural-emergency-hospitals
CEO: Primary Care Provider (Published August 23, 2023)
https://www.carrollcountyhospital.org/news/ceo-primary-care-provider
CEO: Supply Shortages (Published June 28, 2023)
https://www.carrollcountyhospital.org/news/ceo-supply-shortages
CEO: CCMH Named Top 20 Critical Access Hospital (Published June 14, 2023)
https://www.carrollcountyhospital.org/news/ceo-ccmh-named-top-20-critical-access-hospital
CEO: Hospital Week 2023 (Published May 3, 2023)
https://www.carrollcountyhospital.org/news/ceo-hospital-week-2023
CEO: Prior Authorizations (Published April 5, 2023)
https://www.carrollcountyhospital.org/news/ceo-prior-authorizations
CEO: Staff Shortage and Open Positions (Published February 8, 2023)
https://www.carrollcountyhospital.org/news/ceo-staff-shortage-and-open-positions
CEO: End of Year 2022 (Published December 14, 2022)
https://www.carrollcountyhospital.org/news/ceo-end-of-2022
CEO: Purpose of the Foundation (Published November 10, 2022)
https://www.carrollcountyhospital.org/news/purpose-of-the-foundation
CEO: Health Insurance Portability and Accountability Act (Published September 28, 2022)
https://www.carrollcountyhospital.org/news/ceo-health-insurance-portability-and-accountability-act
CEO: CCMH Providers (Published August 24, 2022)
https://www.carrollcountyhospital.org/news/ceo-ccmh-providers
CEO: Financial Assistance (Published July 20, 2022)
https://www.carrollcountyhospital.org/news/ceo-financial-assistance
CEO: Social Determinants of Health (Published June 29, 2022)
https://www.carrollcountyhospital.org/news/ceo-social-determinants-of-health
CEO: National Hospital Week (Published May 11, 2022)
https://www.carrollcountyhospital.org/news/ceo-national-hospital-week
CEO: Why Healthcare is Expensive (Published May 4, 2022)
https://www.carrollcountyhospital.org/news/ceo-why-healthcare-is-expensive
CEO: A Hospital is Still a Business (Published March 16, 2022)
https://www.carrollcountyhospital.org/news/ceo-a-hospital-is-still-a-business
CEO: Different Types of Hospital Ownership (Published February 1, 2022)
https://www.carrollcountyhospital.org/news/ceo-different-types-of-hospital-ownership
CEO: Holiday Message (Published December 20, 2021)
https://www.carrollcountyhospital.org/news/ceo-holiday-message