The Medicare Thread

[muted reborn]

You can have a different company provide Part D than A+B? Well, shit. That changes things. My Mom is on Part A, B and D and I'm first trying to figure out how the fuck medicare works, and then if she should switch Part D. I have much to learn, this is some cryptic shit you guys are sorting through, I had no idea.

[Nobody Famous]

Y... I have much to learn, this is some cryptic shit.

Watching YouTube videos is what brought it all together for me, all the acronyms and names and parts and plans and rules.

You want to start with the high level, e.g. Medicare Advantage vs Medicare Supplement (Medigap) Plan explanations. Here's one such vid, there are others I bookmarked this one because it's pretty good. Here's another. Hope this helps.

[bobz]

You can have a different company provide Part D than A+B?

You kind of have to. A+B is administered by the gubment, D is subsidized but administered privately. The "Medicare" that's administered privately (Advantage plans) isn't actually Medicare; you trade in your A+B+D for a private package that takes your govt subsidies that would have otherwise funded your Medicare ABD.

[Cono Este]

If you take insulin, and are on a brand name, chances are it’s not on any formularynext yr. Tresa a, fiasco etc.

Probably cause they capped them at $35, so you just get the generic now.

I just had two cases in a row, not trying to be political, but this is the crap we end up with.

Check medicare.gov

[fomofo]

Curious, what is the "crap", exactly? Is the generic insulin an inferior product?

[Cono Este]

Not everyone can take the generic, and not every brand is super expensive, so they’re pissed.

Plus, basic humolog was always 25-50 at Walmart before. I’ve bought it myself.

It’s all a stunt, same as the $2000 cap, no ins co is going to lose money, they will make other changes to make it up. Raise deductible, premiums or limit formulary.

Hmm 2000?




Thank god they didn’t get away with it and took a dirt nap last week. Hopefully this is all reversed.

You asked.

[Bunion 2020]

The “Great Grab,” gleefully tabbed as “Medicare Advantage” has begun.

Every year we are treated to an unending flood of advertisements on every medium imaginable emanating from for-profit health insurers. Their medical expertise is bloviated by such people as Joe Namath and William Shatner, neither particularly qualified to comment on Medicare except for their age. Anyone who has missed these deceptive spots has either been out of the country, oblivious to every news or entertainment medium, or brain dead.

The objective of these ads is to lure as many older citizens as possible into a trap called “Medicare Advantage.” It all sounds great, but most of it is an avaricious grab from the federal program originally set up to ensure that all citizens in our country are provided adequate healthcare in their later years or if they’re disabled. Or both.

Medicare Advantage is no advantage for seniors or people with disabilities, and certainly not for people with chronic, long-term health problems. On the contrary, Medicare Advantage is a ruse by private health insurance companies squeezing their way into the federal budget to grab as much of the Medicare funds as possible without having to do much to justify any of it. In fact, these private health care companies are the robber barons dipping into a pot of money that was solely for the healthcare needs of elderly and disadvantaged citizens.

https://dailymontanan.com/2024/11/14...ed-healthcare/

[fomofo]

Not everyone can take the generic, and not every brand is super expensive, so they’re pissed.

Plus, basic humolog was always 25-50 at Walmart before. I’ve bought it myself.

I'm pretty ignorant about insulin, but a cursory search sez 90% or more of diabetics can take generic insulin. So why wouldn't putting a cap on the patient's price be a good thing (at least a good start)? Seems like there are a lot of people in this boat who would benefit?

https://cbs12.com/news/cbs12-news-i-...eneric-insulin

It’s all a stunt, same as the $2000 cap, no ins co is going to lose money, they will make other changes to make it up. Raise deductible, premiums or limit formulary.

Hmm 2000?



Thank god they didn’t get away with it and took a dirt nap last week. Hopefully this is all reversed.

You asked.

I'm not sure why you attached the same pic twice. Is your point that the drug companies are still getting the full price (from the Gov?), even if the patient ends up paying less? Is that the "stunt"?

From a high view, wouldn't you agree the Healthcare system as is is inherently inefficient, and also that lack of competition and transparency combined with inefficiency inevitably leads to higher costs? If you take an incremental "nip here" approach, (which is seemingly the most that has been able to be done), with the result that it will "bloat there" (and make up the diff), what conclusion do you draw? Do nothing, cause nothing is doable?

If a really good (genius?) engineer were to examine the health care system to make improvements if not restructure the whole kit and caboodle where do you think he would start? That is if the point of the whole thing was to deliver quality care at the best cost for the people served, not maximize profit for owners and shareholders.

[fomofo]

Dirt naps for all!

President-elect Trump has picked doctor and TV personality Mehmet Oz to run the Centers for Medicare and Medicaid Services (CMS), he announced on Tuesday.

https://www.axios.com/2024/11/19/tru...oz-cms-cabinet

[CarlMega]

Dirt naps for all!

President-elect Trump has picked doctor and TV personality Mehmet Oz to run the Centers for Medicare and Medicaid Services (CMS), he announced on Tuesday.

https://www.axios.com/2024/11/19/tru...oz-cms-cabinet

LOL. Buckle up seniors! You're about to be Oz'd.

[skaredshtles]

LOL. Buckle up seniors! You're about to be Oz'd.

...

[Cono Este]

There is a panel of docs that set medicare rates. So we’re already getting hosed. Oz will just line their pockets.

[Cono Este]

I'm pretty ignorant about insulin, but a cursory search sez 90% or more of diabetics can take generic insulin. So why wouldn't putting a cap on the patient's price be a good thing (at least a good start)? Seems like there are a lot of people in this boat who would benefit?

https://cbs12.com/news/cbs12-news-i-...eneric-insulin



I'm not sure why you attached the same pic twice. Is your point that the drug companies are still getting the full price (from the Gov?), even if the patient ends up paying less? Is that the "stunt"?

From a high view, wouldn't you agree the Healthcare system as is is inherently inefficient, and also that lack of competition and transparency combined with inefficiency inevitably leads to higher costs? If you take an incremental "nip here" approach, (which is seemingly the most that has been able to be done), with the result that it will "bloat there" (and make up the diff), what conclusion do you draw? Do nothing, cause nothing is doable?

If a really good (genius?) engineer were to examine the health care system to make improvements if not restructure the whole kit and caboodle where do you think he would start? That is if the point of the whole thing was to deliver quality care at the best cost for the people served, not maximize profit for owners and shareholders.

Lots of people don’t react the same to generics. It should be their or their doctors choice. I see it all the time. I’m not fine with telling people what to do.

Basic humilog is an older insulin, and it’s always been $25 at Walmart.

So now we’ve capped it at 35, so it makes sense the part d plans won’t offer the expensive stuff.

I posted that screen shot because on medicare itself, for 2025, I’m not seeing costs capped at 2000.

The donut hole went away, which is good though.

Make what you want of that, but it’s hard telling people their shit will cost 4000, when the politicians are saying 2000. Something ain’t right here.


Everyone needs to check their drugs carefully. Medicare.gov

[fomofo]

Lots of people don’t react the same to generics. It should be their or their doctors choice. I see it all the time. I’m not fine with telling people what to do.

Basic humilog is an older insulin, and it’s always been $25 at Walmart.

So now we’ve capped it at 35, so it makes sense the part d plans won’t offer the expensive stuff.

I posted that screen shot because on medicare itself, for 2025, I’m not seeing costs capped at 2000.

The donut hole went away, which is good though.

Make what you want of that, but it’s hard telling people their shit will cost 4000, when the politicians are saying 2000. Something ain’t right here.

Everyone needs to check their drugs carefully. Medicare.gov

Yea, I don't understand the supposed cap not being honored, but me not understanding is par for this course. If you don't, with your system familiarity, that's alarming.

Couple of background articles on the insulin situation...

https://apnews.com/article/biden-ins...c973a1b89c2200

https://www.kff.org/policy-watch/the...ap-in-medicare

Salient point (which you have rightfully focused on) in bold...

Under the insulin copay cap that took effect under the Inflation Reduction Act, insulin users in all Part D plans pay no more than $35 per month for any insulin product covered by their Part D plan.

It will be interesting to see how much the new regime takes an axe to all things healthcare related, and what their concept of a plan will leave in its stead.

[fomofo]

There is a panel of docs that set medicare rates. So we’re already getting hosed. Oz will just line their pockets.

In June 2020, Oz co-authored a Forbes article with George Halvorson, the former CEO of Kaiser Permanente, that proposed a "Medicare Advantage for All" system that they dubbed "Medical Advantage."

The plan proposed eliminating employer-provided insurance so every American who is not on Medicaid would be enrolled in a Medicare Advantage plan. Doing so would "give security to all Americans concerned about the quality and cost of care," they wrote.

https://www.newsweek.com/what-dr-oz-...dicare-1989533

The celebrity doctor’s 2022 financial disclosure for his Senate run details holdings in stocks like UnitedHealth, CVS and Johnson & Johnson — potentially creating conflicts in the way he runs Medicare and Medicaid programs.

https://www.forbes.com/sites/amyfeld...e-and-medicaid

I guess this and other stuff will all be hashed out in the confirmation hearings.

If there are any.

[fomofo]

Back to Part D coverage, this is on the Medicare site...

New for 2025: $2,000 cap on covered Part D drugs

Starting in 2025, all Medicare plans will include a $2,000 cap on what you pay out-of-pocket for prescription drugs covered by your plan. If your out-of-pocket spending on covered drugs reaches $2,000 (including certain payments made on your behalf, like through the Extra Help program), you’ll automatically get “catastrophic coverage.” That means you won’t have to pay out-of-pocket for covered Part D drugs for the rest of the calendar year. If you have a Medicare plan with drug coverage, compare plans during Medicare Open Enrollment (October 15 – December 7) to make sure your plan covers the drugs you take and meets your needs.

https://www.medicare.gov/drug-covera...e-coverage-gap

My understanding is once you've chosen a Part D prescription drug plan you're pretty much locked into that plan for the year. Say during the coverage year something happens and you need a new prescription drug, perhaps on an ongoing basis. In that case you're only capped at $2k out of pocket if that particular drug happens to be in your plan formulary? If it's not then there is no out of pocket cap?

I guess in addition to carefully reviewing the plan formulary to make sure any drugs you're currently taking are covered you need to get your crystal ball out and try to anticipate any other drugs you might need to take, otherwise you could have uncapped out of pocket.

[Cono Este]

In June 2020, Oz co-authored a Forbes article with George Halvorson, the former CEO of Kaiser Permanente, that proposed a "Medicare Advantage for All" system that they dubbed "Medical Advantage."

The plan proposed eliminating employer-provided insurance so every American who is not on Medicaid would be enrolled in a Medicare Advantage plan. Doing so would "give security to all Americans concerned about the quality and cost of care," they wrote.

https://www.newsweek.com/what-dr-oz-...dicare-1989533

The celebrity doctor’s 2022 financial disclosure for his Senate run details holdings in stocks like UnitedHealth, CVS and Johnson & Johnson — potentially creating conflicts in the way he runs Medicare and Medicaid programs.

https://www.forbes.com/sites/amyfeld...e-and-medicaid

I guess this and other stuff will all be hashed out in the confirmation hearings.

If there are any.

The politics of medicare are interesting, not surprising reps like the advantage stuff.

Some “expert” medicare types in my field say OZ will be pro MA, obviously.

So long as original medicare is available, nothing wrong with options. In 2024, you got a lot of free shit in the MA plans, nuthin wrong with that.

Tip of day. The united health care supplements give you free gym memberships. Plan g etc.

[fomofo]

The politics of medicare are interesting, not surprising reps like the advantage stuff.

Subtle, but this guy leans that way. (or so it seemed to me.) That said, there's some good/useful info in this vid. If you're trying to sort out Plan D prescription cost/coverage stuff could be worth a watch.



Also informative...

Tip of day. The united health care supplements give you free gym memberships. Plan g etc

Can you use that for a ski pass? ;-)

[J. Barron DeJong]

The politics of Medicare Advantage suck, TBH:

Medicare Advantage will cost an extra $83 billion this year

As you know, there are two basic types of Medicare: traditional fee-for-service (FFS) plans, where doctors get paid for services rendered; and Medicare Advantage plans (MA), where doctors are paid a set annual amount for each patient.
In theory, MA plans should be cheaper. In reality, they game the system in two ways. First, they subtly tune their services to attract healthier patients (gym memberships, acupuncture, etc.). Second, they increase their coding intensity.
Wuzzat? Well, the annual payment for each patient is risk-adjusted: the sicker the patient, the bigger the payment. So MA plans benefit by making their patients look sicker than they really are. They do this by coding lots of ailments, even those that don't require treatment. More codes means the appearance of more sickness, which in turn means a higher risk-adjusted payment.
How does this net out? Here's a chart from MedPAC showing how much the government pays MA plans compared to how much they'd pay if the same patients were in traditional FFS plans:
That extra $83 billion for the current year is just shy of 10% of all Medicare spending. It's a lot.
I myself am in a Medicare Advantage plan because it's a great deal. That is, it's a great deal for me personally because my plan can afford to give me extra bennies thanks to the extra money they get from the feds. Needless to say, a great deal for me doesn't mean it's a great deal for the rest of you, whose taxes are paying for this.
So thanks!

https://jabberwocking.com/medicare-a...ion-this-year/

[Nobody Famous]

Subtle, but this guy leans that way. (or so it seemed to me.) That said, there's some good/useful info in this vid. If you're trying to sort out Plan D prescription cost/coverage stuff could be worth a watch.

Also informative...

I learned a lot from this guy's YT channel when I was signing up, he was one of the top three that I spent time watching.

[Nobody Famous]

Tip of day. The united health care supplements give you free gym memberships. Plan g etc.

IMO those memberships are not free.

About a year ago when I was signing up I spent a lot of time waffling on this ‘benefit.’ Obsessing over it.

On medicare.gov you can easily see the upcharge for this benefit (once you know the details). There will be two versions of the same plan, UHC for example, differing in cost by about $30 to 35 per month. The higher cost sometimes will have in the description ‘wellcare benefits’ or something similar. I had the feeling the insurance carriers purposely made it hard to understand the difference from the medicare.gov descriptions.

I decided to go without it, i.e., save $30 per month. Biggest reason was if I ever wanted to turn off this benefit later in life it was *not* going to be a case of simply making a phone call. A change would require underwriting, it’s part of that concept the supplement plan and insurer you choose at initial signup is the one you should be prepared to stick with for the rest of your life, because any changes will require underwriting. When you are 75 or 80 years old do you still want to be paying for a gym membership like this?

I also observed something that could not have been a coincidence. Every broker I talked to would firstly point to the plans with the gym benefit, and I had to ask them about the same plans without the benefit.

Broker: “Based on your criteria here are the three plans I’d recommend for you.” Me: “isn’t there a lower cost version of this plan without the gym benefit?” Broker: “Ah, let me see, … ah yes there is, it’s $30 per month less.” Me: “WTF do I have to ask this?” No, I actually didn’t say that last thing but by the second or third time it happened it’s exactly what I was thinking, and what I wanted to say.

This happened with two national brokers – people I called after watching their YouTube videos – and two local brokers. It was a pattern not a coincidence being initially steered first to the plans with the benefit and only after asking did the brokers fess up to the same plan being available without the benefit. Made me question if there was commission, incentive involved to steer new signups to the plans with the gym memberships.

Every time I hear it mentioned I’m still second guessing whether forgoing this was a good idea or not. On the one hand when you’re 75 or 80 years old do you still want to be paying $360 per year for a gym membership? The other argument is yes, you do want to stay active, healthy and engaged when you get into that age range, and health insurers are probably doing a good deed encouraging this behavior. One of my neighbors -- an academic in health care -- says it's seemingly small decisions like this that could have a big impact on your health and longevity as you age.

[fomofo]

Humana said last week it planned to jettison “a few hundred thousand” of its Medicare Advantage enrollees that have become unprofitable. CVS says it will get rid of about 10% of its MA enrollment, which would be around 430,000 of America’s seniors and disabled people.

Most of those folks likely will be able to enroll in another insurer’s MA plan (although the options will be more limited in many counties), but they likely will find that their premiums will be higher, their benefits skimpier, and that some of their preferred doctors and hospitals are not “in-network.” As HEALTH CARE un-covered has reported, a growing number of physician practices and hospitals are now refusing to take Medicare Advantage patients.

https://healthcareuncovered.substack...e-about-to-pay

[fomofo]

The politics of Medicare Advantage suck, TBH:

Medicare Advantage will cost an extra $83 billion this year

https://jabberwocking.com/medicare-a...ion-this-year/

More on that...

When patients moved from traditional Medicare, where doctors aren't encouraged to find additional diagnoses, to UnitedHealth Medicare Advantage plans and received care from the company's doctors, they appeared to acquire previously undiagnosed maladies, according to the Journal's analysis of Medicare data between 2019 and 2022.

https://www.wsj.com/health/healthcar...le_email_share

[Cono Este]

Double check you still have a drug plan. A lot of seniors were dropped from plans that left the mkt and are now just finding out at the counter. They didn’t open their mail, or couldn’t open it cause they’re old.

If that has happened, call medicare immediately and ask for an exemption. If you don’t, you’ll be fined and forced to wait a yr!




NAICE!

[XXX-er]

Sir Frederick Grant Banting

Sir Frederick Grant Banting (November 14, 1891 – February 21, 1941) was a Canadian pharmacologist, orthopedist, and field surgeon. [ 3 ] For his co-discovery of insulin and its therapeutic potential, Banting was awarded the Nobel Prize in Physiology or Medicine with John Macleod

invented by a Canuck and this year it will be free to Canucks along with dentalcare cuz of some guy with a turban