MA plans feature a network of doctors and hospitals that enrollees must use to get the maximum payment, whereas supplements tend to provide access to a broader set of health care providers, said Shawnee Christenson, an insurance agent with Crosstown Insurance in New Hope. While that might sound good to beneficiaries, supplements can come with significantly higher premiums, Christenson said.
In 2015, Medicare provided health insurance for over 55 million—46 million people age 65 and older and 9 million younger people. In January 2018, they have issued the new medicare (Red, White and Blue) cards to all the beneficiaries. [1] On average, Medicare covers about half of the healthcare charges for those enrolled. The enrollees must then cover their remaining costs either with supplemental insurance, separate insurance, or out of pocket. Out-of-pocket costs can vary depending on the amount of healthcare a Medicare enrollee needs. These out-of-pocket costs might include deductibles and co-pays; the costs of uncovered services—such as for long-term, dental, hearing, and vision care—and supplemental insurance premiums.[2]
A 2001 study by the Government Accountability Office evaluated the quality of responses given by Medicare contractor customer service representatives to provider (physician) questions. The evaluators assembled a list of questions, which they asked during a random sampling of calls to Medicare contractors. The rate of complete, accurate information provided by Medicare customer service representatives was 15%.[99] Since then, steps have been taken to improve the quality of customer service given by Medicare contractors, specifically the 1-800-MEDICARE contractor. As a result, 1-800-MEDICARE customer service representatives (CSR) have seen an increase in training, quality assurance monitoring has significantly increased, and a customer satisfaction survey is offered to random callers.
A Medicare Advantage Health Plan (Medicare Part C) may provide more help at a lower cost than traditional Medicare plus Medigap. Instead of paying for Parts A, B and D, you enroll through a private insurance company that, in many cases, covers everything provided by Parts A, B and D and may offer additional services. You pay the Medicare Advantage premium along with your Part B premium in most cases.

The PPACA instituted a number of measures to control Medicare fraud and abuse, such as longer oversight periods, provider screenings, stronger standards for certain providers, the creation of databases to share data between federal and state agencies, and stiffer penalties for violators. The law also created mechanisms, such as the Center for Medicare and Medicaid Innovation to fund experiments to identify new payment and delivery models that could conceivably be expanded to reduce the cost of health care while improving quality.[87]
As part of a broad set of overall reforms aimed to control the total cost of Medicare (e.g., large cuts in hospital and skilled nursing facility payments under Part A; adding surtaxes to Part D), the Patient Protection and Affordable Care Act (ACA) changed Trustee payments to Medicare Advantage and other Part C plans—versus what they otherwise would have been—by adjusting the way the statutory county benchmarks that kick off the annual Part C Medicare Advantage bidding process were calculated. The intention was to bring the capitated payments closer to the average costs of care per person under Original Medicare.
The maximum length of stay that Medicare Part A covers in a hospital inpatient stay or series of stays is typically 90 days. The first 60 days would be paid by Medicare in full, except one copay (also and more commonly referred to as a "deductible") at the beginning of the 60 days of $1340 as of 2018. Days 61–90 require a co-payment of $335 per day as of 2018. The beneficiary is also allocated "lifetime reserve days" that can be used after 90 days. These lifetime reserve days require a copayment of $670 per day as of 2018, and the beneficiary can only use a total of 60 of these days throughout their lifetime.[24] A new pool of 90 hospital days, with new copays of $1340 in 2018 and $335 per day for days 61–90, starts only after the beneficiary has 60 days continuously with no payment from Medicare for hospital or Skilled Nursing Facility confinement.[25]
There are two ways for providers to be reimbursed in Medicare. "Participating" providers accept "assignment," which means that they accept Medicare's approved rate for their services as payment (typically 80% from Medicare and 20% from the beneficiary). Some non participating doctors do not take assignment, but they also treat Medicare enrollees and are authorized to balance bill no more than a small fixed amount above Medicare's approved rate. A minority of doctors are "private contractors," which means they opt out of Medicare and refuse to accept Medicare payments altogether. These doctors are required to inform patients that they will be liable for the full cost of their services out-of-pocket in advance of treatment.[60]

All Medicare Advantage Plans must include a limit on your out-of-pocket expenses for Part A and B services. For example, the maximum out-of-pocket cost for HMO plans in 2018 is $6,700. These limits tend to be high. In addition, while plans cannot charge higher copayments or coinsurances than Original Medicare for certain services, like chemotherapy and dialysis, they can charge higher cost-sharing for other services.
Definition: Number of children and youth ages 0-21 enrolled in Medi-Cal in January of each year (e.g., in January 2013, 3,955,298 California children/youth were enrolled in Medi-Cal).Number of children and youth ages 0-21 enrolled in Medi-Cal in January of each year per 1,000 children/youth (e.g., in January 2013, 346.5 per 1,000 California children/youth were enrolled in Medi-Cal).
Upon receiving beneficiary eligibility information from DPSS, Health Care Options mails each recipient an enrollment packet. The packet contains enrollment materials as well as explains that the beneficiary must choose a health plan, what health plans are available, and that if the enrollment form is not completed and received at Health Care Options in 30 days a health plan will be chosen for them. When Health Care Options chooses a health plan for the beneficiary, it is called default or "automatic assignment."
© 2018 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
Additionally, the PPACA created the Independent Payment Advisory Board ("IPAB"), which is empowered to submit legislative proposals to reduce the cost of Medicare if the program's per-capita spending grows faster than per-capita GDP plus one percent.[87] While the IPAB would be barred from rationing care, raising revenue, changing benefits or eligibility, increasing cost sharing, or cutting payments to hospitals, its creation has been one of the more controversial aspects of health reform.[113] In 2016, the Medicare Trustees projected that the IPAB will have to convene in 2017 and make cuts effective in 2019.
Retirement of the Baby Boom generation — which by 2030 is projected to increase enrollment to more than 80 million as the number of workers per enrollee declines from 3.7 to 2.4 — and rising overall health care costs in the nation pose substantial financial challenges to the program. Medicare spending is projected to increase from $523 billion in 2010 to just over $1 trillion by 2022.[20] Baby-boomers' health is also an important factor: 20% have five or more chronic conditions, which will add to the future cost of health care. In response to these financial challenges, Congress made substantial cuts to future payouts to providers as part of PPACA in 2010 and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and policymakers have offered many additional competing proposals to reduce Medicare costs further.
You will pay one-half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $5240 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.
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.
As with all HMOs—no matter whether a person is on Medicare or not—persons who enroll in a Medicare Advantage or other Part C HMO cannot use certain specialist physicians or out-of-network providers without prior authorization from the HMO, except in emergencies. In almost all Medicare Advantage plans—HMO or otherwise—the beneficiary must choose a primary care physician (PCP) to provide referrals and the beneficiary must confirm that the plan authorizes the visit to which the beneficiary was referred by the PCP. As with all HMOs, this can be a problem for people who want to use out-of -network specialists or who are hospitalized and are forced to use out-of-network doctors while hospitalized. Many Medicare Advantage PPO plans permit a subscriber to use any physician or hospital without prior authorization, but at a somewhat higher expense.
When you apply for Medicare, you can sign up for Part A (Hospital Insurance) and Part B (Medical Insurance). Because you must pay a premium for Part B coverage, you can turn it down. However, if you decide to enroll in Part B later on, you may have to pay a late enrollment penalty for as long as you have Part B coverage. Your monthly premium will go up 10 percent for each 12-month period you were eligible for Part B, but didn’t sign up for it, unless you qualify for a special enrollment period.
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