For each person who chooses to enroll in a Part C Medicare Advantage or other Part C plan, Medicare pays the health plan a set amount every month ("capitation"). The capitated fee associated with a Medicare Advantage plan is specific to each county in the United States and is primarily driven by a government-administered benchmark/bidding process that uses that county's average per-beneficiary FFS costs from a previous year as a starting point to determine the benchmark.
Medicare Part D is optional prescription drug coverage. If you have Original Medicare, you can get this coverage through a Medicare Prescription Drug Plan, offered through private Medicare-approved insurance companies. These plans offer stand-alone prescription drug coverage that work alongside Original Medicare, Part A and Part B. A Medicare Advantage Prescription Drug plan also provides the Medicare Part D benefit, covering all Medicare benefits under a single plan.
The Silver&Fit program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit, the Silver&Fit logo and Something For Everyone are trademarks of ASH and used with permission herein. ASH is an independent company that is solely responsible for fitness services it is providing. American Specialty Health does not offer Blue Cross or Blue Shield products or services.
Enrollment in the public Part C health plan program, including plans called Medicare Advantage since 2005, grew from zero in 1997 (not counting the pre-Part C demonstration projects) to over 21 million in 2018. That 21,000,000-plus represents about 35% of the people on Medicare. But today over half the people fully signing up for Medicare for the first time, are choosing a public Part C plan of some type.
You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2620 each calendar year. However, this limit does NOT include charges from your provider that exceed Medicare- approved amounts (these are called “Excess Charges”) and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.
The CBO projected that raising the age of Medicare eligibility would save $113 billion over 10 years after accounting for the necessary expansion of Medicaid and state health insurance exchange subsidies under health care reform, which are needed to help those who could not afford insurance purchase it. The Kaiser Family Foundation found that raising the age of eligibility would save the federal government $5.7 billion a year, while raising costs for other payers. According to Kaiser, raising the age would cost $3.7 billion to 65- and 66-year-olds, $2.8 billion to other consumers whose premiums would rise as insurance pools absorbed more risk, $4.5 billion to employers offering insurance, and $0.7 billion to states expanding their Medicaid rolls. Ultimately Kaiser found that the plan would raise total social costs by more than twice the savings to the federal government.
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In the 1970s, less than a decade after the beginning of fee for service Medicare, Medicare beneficiaries gained the option to receive their Medicare benefits through managed, capitated health plans, mainly HMOs, as an alternative to FFS Original Medicare, but only under random Medicare demonstration programs. The Balanced Budget Act of 1997 formalized the demonstration programs into Medicare Part C, introduced the term Medicare+Choice as a pseudo-brand for this option. Initially, fewer insurers participated than expected, leading to little competition. In a 2003 law, the capitated-fee benchmark/bidding process was changed effective in 2005 to increase insurer participation, but also increasing the costs per person of the program.
Most but not all Medicare Advantage plans (and many of the other public managed-care health plans within Medicare Part C) include integrated self-administered drug coverage similar to the standalone Part D prescription drug benefit plan. The federal government makes separate capitated-fee payments to Medicare Advantage plans for providing these Part-D-like benefits if applicable just as it does for anyone on Original Medicare using Part D.
If you enroll within 30 days following your 65th birthday, or if you have 6 months of continuous prior coverage, the 6-month waiting period for pre-existing conditions will be waived. Pre-existing conditions are conditions for which medical advice was given, or treatment was recommended by or received from a physician within six months before the effective date of coverage. If you wait until after the deadline to enroll, you may have a waiting period for pre-existing conditions and may have to complete a medical questionnaire.
Both House Republicans and President Obama proposed increasing the additional premiums paid by the wealthiest people with Medicare, compounding several reforms in the ACA that would increase the number of wealthier individuals paying higher, income-related Part B and Part D premiums. Such proposals are projected to save $20 billion over the course of a decade, and would ultimately result in more than a quarter of Medicare enrollees paying between 35 and 90 percent of their Part B costs by 2035, rather than the typical 25 percent. If the brackets mandated for 2035 were implemented today,[when?] it would mean that anyone earning more than $47,000 (as an individual) or $94,000 (as a couple) would be affected. Under the Republican proposals, affected individuals would pay 40 percent of the total Part B and Part D premiums, which would be equivalent of $2,500 today.
Medicare Part A provides payments for in-patient hospital, hospice, and skilled nursing services. Part B provides payments for most physician and surgical services, even some in hospitals and skilled nursing facilities, as well as for medically-necessary outpatient hospital services such as ER, surgical center, laboratory, X-rays and diagnostic tests, certain preventative medical services, and certain durable medical equipment and supplies. Part C health plans, including Medicare Advantage plans, not only cover the same medical services as Parts A and B but also typically include an annual physical exam and vision and/or dental coverage of some sort not covered under Original Medicare Parts A and B. Less often, hearing and wellness benefits not found in Original Medicare are included in a Medicare Advantage plan. The most important difference between a Part C health plan and FFS Original Medicare is that all Part C plans, including capitated-fee Medicare Advantage plans, include a limit on how much a beneficiary will have to spend annually out of pocket; that amount is unlimited in Original Medicare Parts A and B.
Sicker people and people with higher medical expenditures are more likely to switch from Medicare Advantage plans to Original Medicare. This statistic is primarily driven by people on Medicaid in custodial care at nursing home; such people no longer have need of any Medicare supplement, either a public Part C plan or a private Medigap or group retirement plan. The Part C risk adjusted payments to Medicare Advantage plans are designed to limit this churn between types of Medicare (managed vs. FFS), but it is unclear how effective that policy is.
"Health Care Choices for Minnesotans on Medicare 2013" (PDF) lists Medicare Part D prescription health plans and the coverage for each. Also includes general information on Medicare prescription coverage. It is published by the Minnesota Board on Aging and distributed by the Senior LinkAge Line, 1-800-333-2433. The Senior LinkAge Line representatives assist people of all ages in looking for lower-priced prescriptions.
In December 2011, Ryan and Sen. Ron Wyden (D–Oreg.) jointly proposed a new premium support system. Unlike Ryan's original plan, this new system would maintain traditional Medicare as an option, and the premium support would not be tied to inflation. The spending targets in the Ryan-Wyden plan are the same as the targets included in the Affordable Care Act; it is unclear whether the plan would reduce Medicare expenditure relative to current law.
Medicare Part A is usually provided at no cost if you are eligible for Medicare; however, in the event that you are required to pay for Part A, the highest monthly payment will be $426. The nationwide standard Part B premium has been set between $104.90 and $335.70, with an annual deductible of $147. Plan D has an annual deductible of $325. You can review the different plan premiums, costs and deductibles at: https://www.bluecrossmn.com/Page/md/en_US/medicare-basics#tab-1.
If you change your mind and want to switch back to Original Medicare in the future, you’ll be able to do so during the annual open enrollment period (October 15 to December 7) or the annual Medicare Advantage open enrollment period (January 1 to March 31, annually starting in 2019), and you’ll have an opportunity to also enroll in a Medicare D plan at that point, regardless of how long you’ve been enrolled in Medicare Advantage. But if you’ve been on the Medicare Advantage plan for more than a year, there is no requirement that Medigap plans be guaranteed issue for people switching back from Medicare Advantage to Original Medicare, so if you’ve got health conditions, it may be expensive or impossible to get another Medigap plan.
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Nearly one in three dollars spent on Medicare flows through one of several cost-reduction programs. Cost reduction is influenced by factors including reduction in inappropriate and unnecessary care by evaluating evidence-based practices as well as reducing the amount of unnecessary, duplicative, and inappropriate care. Cost reduction may also be effected by reducing medical errors, investment in healthcare information technology, improving transparency of cost and quality data, increasing administrative efficiency, and by developing both clinical/non-clinical guidelines and quality standards.