Posts Tagged "Medicare"

Good Riddance Medicare Donut Hole!

Medicare’s donut hole is the bane of existence for retirees with expensive medications.

They will get substantial relief in 2025, when the Inflation Reduction Act, signed by President Biden last week, will cap all retirees’ annual drug copayments at $2,000. Monthly drug plan premiums are not included in this cap.

The cap will effectively eliminate the donut hole that currently requires retirees to pay 25 percent of the cost of their prescription drugs until they reach a threshold amount. The threshold increases every year and hit $7,050 this year.

A relatively small group of about 1.5 million retirees pay more than $2,000 for their prescriptions. But many of them are spending $5,000, $10,000 or more.

“It’s going to be an amazing thing” if the cap is implemented as Congress intended, said Ashlee Zareczny, compliance supervisor for Elite Insurance Partners, a Medicare health insurance broker outside Tampa.

Some of her firm’s retired clients pay so much for their medications that they have to make difficult choices between medications and food or other essential items. People who rely on Social Security “shouldn’t have to make those choices,” Zareczny said.

The cap will apply to all Medicare beneficiaries, whether they get their prescription drug coverage through a Part D plan or Medicare Advantage insurance plan, she said.

Under the current system, insurers that sell Medicare drug plans have a $480 maximum they are permitted to charge for the deductible. After meeting the deductible, retirees make their predetermined copayments under the insurance plan. They enter the donut hole after they spend $4,430 out of pocket, and then they are required to pay 25 percent of the cost of their drugs until they reach a threshold that pushes them into the catastrophic phase of Medicare’s drug coverage.

Once the catastrophic coverage kicks in, however, they are still responsible for 5 percent of the remaining drug costs. In 2024 – a year before the $2,000 cap goes into effect – the new healthcare law will eliminate the 5 percent copay.

The cap on total spending will protect any retiree who develops a medical condition requiring them to take very expensive medications. Currently, there is no limit on how much they may have to spend.

And, Zaraczny said, “They’re not prepared to put forth this money.” …Learn More

The Many Facets of Retirement Inequality

Retirement inequality is a thread running through several articles that have appeared here this year.

One blog that was particularly popular with our readers distinguishes retirees who have enough wealth to maintain the same spending levels throughout retirement from those who will, over time, have to cut back and reduce their standard of living.

The research behind the article – “Health and Wealth Drive Retirees’ Spending” – makes clear that wealth is just one component of a satisfying lifestyle. Even retirees who can afford to maintain their living standard may not be healthy enough to enjoy their money to the fullest. The retirees who have both – health and wealth – are best equipped to maintain their pre-retirement lifestyle.

Homeownership also marks a dividing line between the haves and have-nots. A home is one of retirees’ largest sources of wealth. Although most are hesitant to withdraw home equity, the ones who have equity and tap it to pay medical bills see large, positive health benefits, according to “Using Home Equity Improves Retirees’ Health.”

Pensions are another dividing line. “Retirees with Pensions Slower to Spend 401(k)s” shows the value of having guaranteed income from defined benefit pensions, which are all but extinct outside the public sector. …Learn More

Limiting Medical Debt: a 50-State Ranking

Lawmakers in Maryland, California and Maine have made the most effort to prevent residents from drowning in medical debt. Texas, South Carolina and Tennessee do the least.

This is the assessment of an organization known as Innovation for Justice, a team of researchers at the University of Arizona and the University of Utah. They ranked the 50 states on whether they have taken myriad steps to minimize medical debt. These legislative measures range from restrictions on the healthcare industry’s billing and collection practices to how debt claims are handled in the courts.

Medical debt is the single largest category of consumer debt, and the Kaiser Family Foundation estimates that 100 million Americans are behind on paying their medical or dental expenses – and a quarter of them owe more then $5,000.

This project would be important at any time and is even more so during a pandemic when many people have incurred medical debt for COVID. Some of that debt is even for bills the federal government would’ve paid on behalf of the uninsured cashiers, drivers, retail workers, restaurant servers and cooks who were on the front lines in the worst days of the pandemic.

Putting the state rankings into a national perspective, the consumer protections to prevent the accumulation of debt are not exactly impressive. Only three of the 50 states qualify as having good protections. The researchers ranked another 27 states as weak and 20 as poor.

Compare Medical Debt Policies by US StatesMaryland, which sits at the top of the medical debt scorecard, satisfies most of the researchers’ criteria for debt reduction. State lawmakers have limited residents’ debt by mandating that patients be screened for health insurance or government health benefits. The state also regulates hospital billing practices, instructing them to offer a payment plan before sending a patient’s bill to collections and requiring that bills itemize every charge, every payment, and whether charity care has been provided to the patient.

Last but not least, Maryland expanded its Medicaid program, as encouraged by the Affordable Care Act, to extend subsidized or free health insurance to more of its low-income workers. Medical debt has been reduced in the states that expanded their coverage. The lowest-ranked states – Texas, South Carolina and Tennessee – are among the states that have not expanded Medicaid.

Visit the medical debt scorecard to see what your state is – or isn’t – doing. …Learn More

Get Help with Medicare Coverage Denials

The United States has a notoriously complex healthcare system, and Medicare is no different.

In the early months of the pandemic, the Medicare Rights Center received a large number of calls to its telephone help line from people over 65 who had suddenly been laid off and lost their employer coverage. Even when there isn’t a crisis, the center’s staff and volunteers answer all manner of questions about Medicare enrollment rules, insurance options, and what to do when an insurance company denies them coverage.

Sarah Murdoch is the center’s director of client services and oversees the helpline. She spoke with Squared Away about the common issues retirees face and how they can address them.

Question: Your helpline fielded 42,000 questions about Medicare in 2020 and 2021. How does that compare to past years?

It’s in that ballpark year to year – around 20,000 questions. But we saw, within that 42,000, a shift in the actual trends.

Throughout the pandemic, particularly in 2020 when there were lockdowns and people were getting laid off left and right, we got a lot of calls from people who unexpectedly had no income. We heard from people who had insurance through their job and that was not an option anymore. Or they were already on Medicare and were trying to figure out how to pay their costs, or they were laid off and had to figure out how to get into Medicare. That has eased up but was a big thing we saw in the beginning of the pandemic.

We also had questions related to benefits for low-income people. We told people who suddenly had zero income about the income requirements for the Medicare Savings Program, Medicaid, and the state pharmaceutical assistance programs – anything that can lessen the hardship.

In 2020 and 2021, nearly a third of the complaints on your helpline were about service denials by insurers that provide Medicare Advantage or Part D drug plans. Start with Advantage plan denials – are they a big issue for retirees?

The Medicare Advantage plans often have doctor and hospital networks, whereas original Medicare doesn’t have networks. People may be denied coverage by an Advantage plan if they have an out-of-network provider. It could also be a denial of a medical service or a prescription medication. We do see it more but it’s hard to tease that out from the fact that more people are just enrolled in Medicare Advantage.

Do Medigap supplements to Medicare have similar issues with denial of coverage?

Medigap is different – the plans are never making their own claim determinations. If something is approved by original Medicare, then Medigap is going to pay for it as long as the retiree has a Medigap plan that has that type of coverage. In the Medicare Advantage policies, however, insurers are making the claims determination. All of the insurance companies have their own claims adjusters making those decisions – as opposed to contractors who process claims for the Medigap plans on behalf of the Centers for Medicare and Medicaid Services. The Medigap insurer isn’t making any decisions as to whether something is covered or not – it has already happened at the government level. …Learn More

Using Home Equity Improves Retiree Health

Retirees spend $1,500 more per year, on average, for medical care after a diagnosis of a serious condition like lung disease or diabetes.

Often, the solution for individuals who can’t afford such big bills is to scrimp on care or avoid the doctor altogether. But older homeowners can get access to extra cash if they withdraw some of the home equity they’ve built up over the years.

While the money clearly provides financial relief for retirees, a new study out of Ohio State University finds that it is also good for their health. Every $10,000 that Medicare beneficiaries extracted from their homes greatly improved their success in controlling a chronic or serious disease.

Among the retirees who had hypertension or heart disease, for example, one standard used to determine whether the condition was under control was whether blood pressure levels stayed below 140/90, which the medical profession deems an acceptable level. The people who tapped their home equity were more likely to stay below these levels than those who did not.

This is one of several studies in recent years to tie financial security to home equity, a resource many retirees are reluctant to tap. A study in 2020 found that older homeowners were less likely to skip medications due to cost after they had extracted equity through a refinancing, home equity loan, or reverse mortgage.

But this new research is the first attempt to connect the strategy to retirees’ actual health. The analysis followed the health of more than 4,000 homeowners for up to 15 years after they were diagnosed with one of four conditions – lung disease, diabetes, heart conditions, or cancer. …Learn More

Low-Income Retiree Gets Financial Coach

Every state should have what Delaware has: a program that helps low- and moderate-income seniors find a financial survival strategy.

Stand by me logoSince it opened in 2013, the program, Stand by Me 50+, has connected more than 2,300 older residents – mostly retirees – with federal and state aid programs, advised them of Social Security’s rules, and helped them pay medical bills or eliminate debt. The services are free.

Kathleen Rupert, a financial coach and head of the organization, helped one man in his 70s pay off $13,000 in debt. Another retiree doubled his income from Social Security after she determined that he was eligible for his late wife’s $1,700 benefit. About 44 percent of the program’s clients have monthly income of $1,500 or less.

“We go wherever the need is – to senior housing, senior centers, community centers, libraries,” she said. “We set up appointments at Panera Bread or Hardee’s – wherever they’re available.”

Squared Away interviewed three clients who said the financial solutions they got from the program have given them peace of mind. Here is the first client’s account of how Stand by Me 50+ helped her.

Peggy Grasty with great granddaughters, Aaliyah Gale and Quamiylah Sease.Peggy Grasty with great granddaughters, Aaliyah Gale and Quamiylah Sease.

Peggy Grasty retired in 2010 after two decades at Elwyn, a non-profit social services agency where she was a supervisor and worked with people with mental disabilities. She continues to help people – voluntarily. The 71-year-old takes other retirees under her wing who need assistance because they have trouble walking or aren’t as capable as her.

She initially contacted Stand by Me because she couldn’t make ends meet. She has a comfortable, federally subsidized apartment in Wilmington, Delaware. But her income is limited to a $1,500 Social Security check and a $53 pension from a job long ago waxing floors and driving a bus for a Pennsylvania middle school.

Stand by Me got help for Grasty through two programs: federal SNAP food stamps and a Delaware non-profit that pays low-income residents’ medical bills. By doing this type of work, the program addresses a real need. Although myriad financial assistance programs are available for low-income workers and retirees, they are frequently unaware of the programs, assume they don’t qualify, or may need help navigating the application process. …Learn More

Nursing Home Staffs’ Vax Rates by State

One in four of the more than 900,000 Americans who have died from COVID resided in nursing homes. Yet two years into the pandemic, hesitancy about protective vaccines persists in the facilities in many states.

In January, the Supreme Court upheld a regulation by the Biden administration that required all staff to be vaccinated in long-term care facilities that receive Medicare or Medicaid funding, which is pretty much all of them.

But a newly released rundown of state vaccination rates may not provide much comfort to vulnerable elderly residents and their families living in Ohio, Oklahoma, and Missouri, which rank at the bottom – only about 70 percent of nursing home staff were fully vaccinated as of Jan. 30, according to the Kaiser Family Foundation. The national average was 84 percent.

The highest vaccination rates – 99 percent of staff – were in Massachusetts, Maine, New York, and Rhode Island.

Kaiser’s vaccination rates were calculated based on the staff working in 10,600 U.S. nursing homes who’ve received two doses of the Pfizer or Moderna mRNA vaccines or one shot of Johnson & Johnson’s traditional vaccine. The rates exclude booster shots, which are not part of the federal mandate. The nationwide booster rate for staff, which Kaiser provides separately in its report, is a low 28 percent – the Hawaii, New Mexico and California rates are double that.

A partial reason for the wide range of vaccination coverage is that states have different deadlines for complying with the federal mandate – some were in January and some are in February. But numerous states, including Louisiana, Tennessee, and Virginia, have low vaccination rates because they are, despite the Supreme Court ruling, seeking other legal avenues to challenge the mandate.

The size of a state’s population of people over 65 doesn’t seem to have much bearing on vaccination rates in nursing homes. …Learn More