Medicare Advantage plans began as an effort to reduce costs in the dwindling federal budget by offering preventive health coverage for less money than traditional Medicare. Medicare Advantage plans are also touted as an affordable option for consumers, but Jonathan Coffee, CEO of Delta Health, said this couldn’t be further from the truth. He said lower monthly premiums are appealing to people on fixed incomes, but they cover far fewer health care providers and services should they ultimately require medical care. This plan typically includes vision and dental services, but most medical procedures and procedures are not covered without prior approval. Pre-authorization is when a provider requests coverage from an insurance company and must demonstrate need for it. Delta Health Board member and state Rep. Matt Soper (R-Delta) said the private companies that run Medicare Advantage plans profit by keeping money from the government that isn’t used for reimbursement. Because of this, prior approval is often refused. care. Soper said private Medicare companies bill the federal government far more than they actually spend on Medicare patients, making Medicare Advantage plans more expensive than traditional Medicare. He said there was. Specifically, Soper said Medicare Advantage costs taxpayers $7 billion more each year than traditional Medicare.
Medicare’s open enrollment period begins Tuesday, and people 65 and older have until Dec. 7 to decide on health insurance for the coming year.
With many existing plans being modified or eliminated and a growing push for Medicare Advantage plans, there are growing concerns that more seniors will arrive in 2025 with inadequate benefits.
Medicare Advantage is also a major source of concern for hospitals, with several hospital CEOs saying the plan would further increase their financial burden and reduce their ability to care for patients.
“It’s aptly called Medicare Advantage because we think we can take advantage of the over-65 population,” said Jonathan Coffee, CEO of Delta Health.
“All of these plans end up losing money by providing services that are not reimbursed by some hospitals,” he added. “We’re going to[provide those services]…simply because members of our community have nowhere else to go. But it’s not a sustainable model.”
Changes in coverage and costs
John Ahearn is a counselor with the Grand Junction branch of the State Health Insurance Assistance Program, a nonprofit volunteer organization that provides unbiased advice to Medicare beneficiaries. The stakes are particularly high this year, he said.
“I’ve been working on this for a little over 10 years, and (the new 2025 plan) is the biggest change I’ve seen in 10 years,” Ahern said.
Specifically, Ahearn said seven, or one-third, of Mesa County’s current Medicare Advantage plans will not be offered in 2025, 12 new plans will be added, and the remaining plans will have some He said it would change in shape.
One of the changes Ahern pointed to is maximum out-of-pocket costs, which essentially limits how much participants can pay before insurance covers the rest. He added that three out of six Medicare Advantage plans will increase out-of-pocket costs by more than $1,000.
Deductibles (the amount you must pay before insurance covers some of your costs) have also become common in Medicare Advantage plans. Six of the 2024 Medicare Advantage plans included a deductible. For next year, 18 plans have deductibles.
Apart from Medicare Advantage plans, about 40% of Medicare drug plans will end this year, with only two plans being added.
Ahern said it’s important to find out if your plan will be offered again, as people with expired plans will be reassigned by their insurance companies.
“When an insurance plan ends, the insurance company assigns the person to another plan without knowing about the budget, drugs, or doctors. In many cases, that assignment is very bad for the person. Because if you go there, all of a sudden you’re paying full price,” he said.
Another major change is to the PERA plan. Copays, deductibles and benefits will remain the same, Ahern said, but premiums (the monthly fee to have insurance) will increase by $197 a month, or nearly $2,400 a year.
Ahern said that while many Medicare Advantage plans are cost-prohibitive, they may be appropriate for certain people, so discuss your options with your state Health Insurance Assistance Program counselor or insurance agent. The best way to ensure you choose the right plan is to get the right plan.
But he said the state’s health insurance subsidy program is not financially incentivized or limited to specific plans like insurance agencies.
The State Health Insurance Assistance Program accepts walk-ins every Thursday from 9 a.m. to noon until open registration closes at its office, 422 White Ave., Suite 090. Alternatively, you can make a reservation by calling 970-243-9839 ext. 1.
Disruption to the hospital
Medicare, especially Medicare Advantage plans, is also a major concern for hospitals and health care providers.
The CEOs of Community Hospitals (Chris Thomas), Delta Health (Cohee), and Family Health West (Corey Klein) all said the plan would provide financial support to hospitals that choose to accept Medicare Advantage. He said it is both a burden and an impediment to his ability to care for patients.
Cohee said most Medicare Advantage patients require care that is not covered without prior authorization because of limited coverage of services and providers.
According to Community Hospital’s Thomas, these prior permissions are almost always denied. He said there have been several instances where services were provided with prior authorization, but the insurance company subsequently backed out and refused to reimburse.
Thomas and Coffee said that even when hospitals are reimbursed, the amount paid is always less than the actual cost of treatment. This tension has led some (if not all) hospitals across the country to refuse certain Medicare Advantage plans.
“I think there’s going to be a tipping point where people will finally say they’re not going to get a Medicare Advantage plan anymore because it’s going to be so difficult,” Thomas said. “We don’t get paid to provide care in the first place, but then I think we’ve reached a red line where we don’t even get paid for the services we provide.” Suna is. ”
Still, the number of Medicare Advantage enrollees is increasing every year. More than half of the 35,000 Mesa County residents enrolled in Medicare are enrolled in Medicare Advantage plans, Ahern said.
The proliferation of Medicare Advantage plans is putting a strain on hospitals, so much so that CEOs have made it their mission to educate as many people as possible about Medicare Advantage and what to consider.
Family Health West CEO Klein has hosted several community presentations on open enrollment and Medicare and will host another at the community hospital on Oct. 30 at 10 a.m. He said that while Medicare Advantage is primarily bad for hospitals, some people may see value in a Medicare Advantage plan.
“(One factor is) how much risk and anxiety you want to take,” Klein said. “Some seniors pay higher premiums for more robust plans, knowing they will have less to worry about next year’s medical bills. Others pay higher premiums for more robust plans, hoping they won’t get sick. Some may take the risk.”
Klein said the most important things for beneficiaries are how healthy they are, what type of care they expect to need, what their most expensive prescriptions are, and which plans and which ones. He said that consideration should be given to whether medicines are covered. He said most Medicare Advantage plans are limited to one state, so people who travel frequently or live part-time in another state should consider traditional Medicare.
“Keep[traditional Medicare]in place. It should be simple,” Coffee said. “Medicare Advantage plans make money by limiting services. You limit your network and the specialties you can do (see).
“Ultimately, they control the future of medicine, and that’s what’s scary.”
