WASHINGTON, DC – Open enrollment for Medicare health insurance is from October 15^th to December 7^th; therefore, eligible persons may be faced with choosing their Medicare plan for the first time or may consider changing plans. They must decide between government-run traditional Medicare or a Medicare Advantage (MA) plan managed by private-health insurance companies. Traditional Medicare is the same as original Medicare. MA is also called Managed Medicare and Medicare Part C and has become an increasingly popular option with total enrollment more than doubling over the past decade. In 2023, Medicare beneficiaries are split almost equally between choosing traditional Medicare and MA. However, neither traditional Medicare nor MA is right for everyone because of the many differences between the plans. Therefore, Medicare-eligible people will need to identify those advantages and disadvantages for each plan before making their choice during the open enrollment period. Although there is much written on this subject, there does not appear to be a direct comparison of the pros and cons of traditional Medicare versus MA.

Traditional Medicare is based on a fee-for-service model. The enrollee can go to doctors and hospitals that accepts Medicare and is responsible for copays and deductibles for services and doctor visits. The doctors and hospitals bill Medicare and the federal government pays them. This plan is managed by the federal government, including Congress and the Centers for Medicare & Medicaid Services (CMS).

Medicare Advantage is based on a managed-care model. The beneficiary can go to doctors and hospitals that are on the MA plan panel and is responsible for copays and deductibles for services and doctor visits. The doctors and hospitals bill the MA plan and the plan pays them. MA plans receive a predetermined monthly risk-adjusted payment from the federal Medicare program to provide health care to the enrollee. CMS allows the MA plans to set their own rates. The private insurance companies negotiate their fee schedule with doctors and hospitals which frequently pay less than traditional Medicare for the same service. The plan is managed by the private-health insurance company and makes a profit by providing health care and keeping the cost for care less than the government payment.

Medicare provides health insurance to 66 million people, consisting of older Americans, and younger people with disabilities and certain chronic diseases. Traditional Medicare, first passed by Congress in 1965, consists of Part A (for in-hospital care), Part B (for outpatient care including doctor visits) and Part D (for prescription drugs). Medicare Part C (the MA plan), authorized by Congress in 1997, covers Parts A and B and usually D (depending on the plan). Therefore, MA bundles hospital, doctor and prescription coverage in one plan.

Working people pay into Medicare through payroll deductions. Both traditional Medicare and MA beneficiaries are also billed after enrollment. Traditional Medicare does not cover all the bills for Part A & B insurance so many beneficiaries obtain supplemental insurance sold by private insurers, known as a Medigap plan, that help to pay some of the remaining costs. People with low resources can qualify for Medicaid or Medicare Savings Plan, administered by the federal government. Medicare Part D insurance is also available through private insurers.

The initial plan selection is of critical importance. Most people are healthier when they enroll in Medicare; however, they can develop more health problems as they get older and their health care utilization can change. In most states, if someone doesn’t sign up for Medicare supplemental insurance when first signing up for Medicare, the insurance companies can either refuse to offer a plan or charge high premiums for a preexisting condition. This may become a costly problem when attempting to transfer from a MA plan to traditional Medicare later on.

Advantages to consider when choosing a traditional Medicare plan are:

• Freedom to go to most any doctor or hospital in the country
• No referral needed to see a specialist
• No prior authorization needed for tests and procedures

Advantages to consider when choosing a MA plan are:

• Extra benefits like basic dental, vision, and hearing services (offered by most plans)
• Over-the-counter medication reimbursement, coverage for buying healthy food, adaptive changes to homes, gym memberships, and/or transportation for medical appointments (offered by some plans)
• An annual out-of-pocket cap
• Only 1 regular payment
• May be less expensive

Disadvantages to consider when choosing a traditional Medicare plan are:

• More regular payments, for Part B, Part D, and a Medigap policy
• May be more costly than MA because there is no annual cap.
• Your insurance agent or broker earns more money for signing people up for a MA plan.

Disadvantages to consider when choosing a MA plan are:

• Restrictive networks of doctors and hospitals to a particular geographic region. Persons requiring medical care while away from home may not have their health care covered. Beneficiaries may not be able to receive specialized surgery or highly advanced therapies if in-network providers do not provide this service.
• Prior authorization required for some services. Beneficiaries frequently may be denied care that they need and would be allowed by traditional Medicare, according to a 2022 reportby the Government Accountability Office (GAO).
• Referrals required to specialist physicians
• Many high medical needs patients were likely to switch from MA plans to traditional Medicare (Brown University study). The 2022 GAO report agreed and felt that the reason was due to the difficulty getting the care needed.
• Many hospitals and doctors are dropping MA plans over payment disputes so beneficiaries lose their doctors and hospitals and have fewer choices for care.

Open enrollment is the time for persons eligible for Medicare health insurance to choose their Medicare plan for the first time or consider changing plans. They must choose between government-run traditional Medicare or a MA plan. The number of eligible persons choosing MA has doubled over the past decade indicating the competitive nature of both choices. However, there is no “one size fits all” when it comes to Medicare plans. Therefore, people who are eligible for Medicare will need to study the advantages and disadvantages for each plan before making their choice. It is important for people to consider “The Triple Aim” of health care of optimal health, a good experience of care, and a fair price. According to Chiquita Brooks-LaSure, CMS Administrator, “I believe it’s critical that people have a choice between traditional original Medicare and Medicare Advantage.”

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Contact: Dr. Dick Needleman, Health reporter, 103.3 AshevilleFM, [email protected]

ASHEVILLE, NC –  November 1, 2023 – The COVID-19 metrics are on the CDC’s COVID Dashboard. For the week ending on October 21^st.

• Hospital admission levels are low in 99 of 100 counties in North Carolina, including Buncombe County, and about 93% of the counties in the U.S. However, they have decreased in North Carolina and Buncombe County from the previous week.
• Between 4.0 to 5.9% of the deaths in North Carolina were due to COVID, the third highest level of 6 groups. This has increased since last week.
• Emergency room visits for COVID-19 are minimal in North Carolina. This represents less than 1.5% of all ER visits, the lowest of 5 levels and fewer than the previous week.

Wastewater monitoring can be used to provide early warning for COVID outbreaks. The Buncombe & Henderson counties wastewater data for the week ending on October 18^th is on the North Carolina COVID Dashboard.

• The number of viral gene copies in each water sample is at a red level representing the highest level of 5 groups, currently between the 80^th and 100^th percentile relative to the past level measured at the same site.
• The 15-day rate of change of the number of viral gene copies in each water sample has increased from the previous week, at 100% or greater, the highest group for a positive rate of change.

Listen to the full report below:

Contact: Dr. Dick Needleman, Health reporter, 103.3 AshevilleFM, [email protected]

ASHEVILLE, NC  – October 11, 2023 – After the recent passage of the 2023-24 North Carolina state budget, the state will expand Medicaid on December 1^st. Medicaid expansion extends coverage to persons making up to 138 percent of the federal poverty level from 100 percent. It is estimated that 600 thousand additional North Carolinians will be eligible for Medicaid. Preparation has included enrollment events, training for groups that provide services to Medicaid beneficiaries, and hiring staff to register eligible people.

The North Carolina Department of Health and Human Services have figured out a way to fast-track this process for about half of the eligible people, numbering 300 hundred thousand.

The federal COVID era rules for keeping people on Medicaid during the pandemic ended on April 1^st. Therefore, states were allowed to remove people from Medicaid if they made too much money to qualify for the federal program for health insurance for low-resource individuals.

Fortunately, North Carolina has a limited Medicaid benefit that provides for family planning benefits for people who make up to 195 percent of the federal poverty level. 300 thousand people recently lost their Medicaid insurance. However, they were enrolled in this limited benefit plan and will be automatically enrolled in the full-benefit Medicaid plan.

Kody Kinsley, the secretary for the North Carolina Department of Health and Human Services, said in an interview, “I wish that the General Assembly had moved faster, and we would be able to have had this program in place before the unwinding so that folks wouldn’t have even had any of this downtime.”

The state has about 2 months to find and enroll the remaining 300 thousand North Carolinians who are now eligible for Medicaid.

Listen to the full report below:

Contact: Dr. Dick Needleman, Health reporter, 103.3 AshevilleFM, [email protected]