Medicare Advantage: A Powerful Tool for Aging in Place (Just in Time for Open Enrollment!)

As families plan for aging in place, maintaining independence at home rather than moving to a nursing home or assisted living facility is key. Medicare plays a pivotal role in either facilitating or frustrating aging in place plans. Original Medicare (Parts A and B) offers limited support for home-based care, but Medicare Advantage (MA) plans (Part C), offered by private insurers, significantly enhance options for home care, telehealth, and post-hospital recovery. These plans not only cover everything Original Medicare does but also provide supplemental benefits tailored to aging in place, often improving health outcomes and reducing costs. With Open Enrollment (October 15–December 7) approaching, understanding MA’s advantages is critical for  families committed to staying home.

Why Medicare Advantage for Aging in Place?

Aging in place involves services like home care (e.g., help with bathing, meal prep), short-term disability support (e.g., recovery from surgery), and long-term care (e.g., chronic condition management). Original Medicare covers short-term skilled home health care (nursing, therapy) if you’re homebound and a doctor certifies medical necessity, but it excludes ongoing custodial care, short-term disability income, and most non-skilled home care. Moreover, original Medicare incentivized institutional care by paying for institutional rehabilitation for a period of time following a three-day hospitalization. MA plans bridge these gaps with flexible, home-focused benefits, often reducing out-of-pocket costs and supporting independence.

Recent data underscores MA’s impact: studies show MA enrollees have lower hospital readmission rates compared to Original Medicare (even with shorter periods necessary for rehabilitation), thanks to enhanced care coordination and home-based services. For aging-in-place families, this translates to fewer disruptions and better recovery at home.

Key Medicare Advantage Benefits Over Original Medicare

Here’s how MA plans enhance aging-in-place elements, with specific advantages in telehealth, hospital-at-home programs, in-home physical/occupational therapy (PT/OT), and transitions from hospital to long-term care, plus other post-hospitalization perks:

●Home Care (e.g., aides, meal prep):

• Original Medicare Coverage (2025): Limited to skilled care (nursing, therapy) if homebound; no custodial care (e.g., bathing). 

• MA Advantages: MA plans can pay for help that isn’t strictly medical, unlike Original Medicare. This includes: aides (someone to assist with daily tasks like bathing or dressing), for about 20–40 hours per month (e.g., a few hours a week); meal delivery services that bring prepared meals to your home, helping if cooking is hard; and, home modifications like grab bars in the bathroom to make your home safer and easier to navigate.  These are typically limited to in-network providers (out of network may not be covered or might cost you) and prior authorization is often required. 

• Potential Cost Savings & Health Outcomes: Potentially saves $200–$500/month on meals or $4,000–$6,000/month on aides; reduces nursing home risk (average cost: $100,000+/year).

●Short-Term Disability (e.g., post-surgery): 

• Original Medicare Coverage (2025):  Up to 100 days skilled nursing/home health; 20% coinsurance after day 20 ($204/day in 2024) possibly covered by supplemental insurance.

• Medicare Advantage Advantages: Lower copays, durable equipment (walkers), temporary aides. Expenses typically counts toward out-of-pocket max ($3,000–$8,000/year).

• Potential Cost Savings & Health Outcomes: Caps costs vs. Original Medicare's unlimited coinsurance; 10–15% fewer ER visits due to better recovery support.

●Long-Term Care (e.g., chronic conditions): 

• Original Medicare Coverage (2025):  No custodial care; limited chronic management.

• MA Advantages:  Partial non-skilled care like bathing, dressing, or eating, which don’t require a nurse or doctor (unlike "skilled" care like wound treatment). Medicare Advantage (MA) plans may cover some of these non-skilled services for a limited number of hours (e.g., 20–40 hours per month) to help you stay at home. Original Medicare doesn’t cover this kind of help at all unless you’re homebound and need skilled care too.  Chronic Special Needs Plans (C-SNPs) are special types of MA plans designed for people with ongoing health conditions like diabetes, heart failure, or lung disease (COPD). These plans often include extra benefits like devices or services that check your health at home (e.g., blood sugar monitors or telehealth check-ins with a nurse). This helps you manage your condition without frequent hospital visits.  Pair with Medicaid/insurance for full coverage.

• Potential Cost Savings & Health Outcomes:  Offsets 10–20% costs ($100–$300/month); C-SNPs cut hospitalizations by 10–15%.

●Telehealth: 

• Original Medicare Coverage (2025):  Covers office visits, mental health via video/audio; home-based until Sept. 30, 2025, then rural-only for non-mental health. 20% coinsurance.
• MA Advantages:  With MA plans, you can use telehealth (like video or phone calls with doctors) from your home at any time, regardless of where you live (urban or rural); original Medicare, however, may limit home-based telehealth after September 30, 2025, to rural areas for most non-mental health services, requiring you to visit a clinic or hospital for telehealth in urban areas. MA plans often allow telehealth visits using just a phone call (no video needed), which is great if you don’t have a smartphone or reliable internet. Original Medicare covers audio-only for mental health and some services through September 2025, but MA plans may extend this option for more types of visits (like routine check-ups) even after that date. 

MA plans also cover a wider range of telehealth services than Original Medicare. Beyond standard doctor visits or mental health sessions, MA might include quick check-ins with nurses, medication reviews, or chronic condition management (e.g., diabetes monitoring). MA plans may cover telehealth for routine check-ins, follow-ups after hospitalization, chronic disease management (e.g., COPD or diabetes), and even physical/occupational therapy (PT/OT) guidance. Original Medicare sticks to a narrower list, like office visits and mental health. For example, an MA plan might let a nurse call to check your blood pressure readings, reducing the need for in-person visits.

These extra services help keep you healthy at home without frequent in-person visits.

• Potential Cost Savings & Health Outcomes:  Improves access (43% fewer missed follow-ups); vital for rural Ohioans post-Sept. 2025.  MA plans often have $0–$20 copays for telehealth, compared to Original Medicare’s 20% coinsurance (e.g., $50 for a $250 specialist visit). Some plans waive copays entirely for telehealth to encourage use. Telehealth counseling, often expanded in MA, improves post-hospital recovery by addressing depression, common in 20% of elderly post-discharge.

●Hospital at Home: 

• Original Medicare Coverage (2025):  No dedicated program; skilled home health only if homebound.

• MA Advantages: Covers acute care at home (IV meds, monitoring) as inpatient alternative. 

• Potential Cost Savings & Health Outcomes: Reduces readmissions by 20–30% in pilots; lowers infection risk vs. hospitals.

●In-Home Physical/Occupational Therapy (PT/OT): 

• Original Medicare Coverage (2025):  Covers if medically necessary (no cap, $2,410 threshold); 20% coinsurance.  Medicare will pay for in-home PT (to improve movement, strength, or balance) or OT (to help with daily tasks like dressing or cooking) only if a doctor says it’s needed for your health. For example, you might need PT after a hip replacement to regain mobility or OT after a stroke to relearn daily activities. For in-home coverage under Part A (home health benefit), you must be homebound (hard to leave home without help) and need skilled care (like therapy from a licensed professional). A doctor must certify this. If you’re not homebound, Part B may cover PT/OT as outpatient services, even at home, as long as it’s medically necessary.  

In 2025, Medicare starts paying closer attention once your PT or OT costs hit $2,410 per year (this applies to PT and speech therapy combined, or OT separately). After this threshold, providers must add a special code (KX modifier) to your claims to confirm the therapy is still needed. Medicare usually keeps paying if justified, but it’s a checkpoint to ensure necessity.

You pay 20% of the cost for each PT/OT session, and Medicare covers the other 80%. For example, if a session costs $100, you pay $20 out of pocket. This applies after you meet the Part B deductible ($257 in 2025). If you’re getting in-home care under Part A’s home health benefit (and you’re homebound), there’s no coinsurance for those services. 

• Medicare Advantage Advantages: Lower copays ($20–$50), extended sessions, non-homebound access. MA plans often reduce the 20% coinsurance to a fixed copay (e.g., $20–$50 per session) or waive it entirely, saving you money compared to Original Medicare’s uncapped 20%.  Some MA plans cover in-home PT/OT even if you’re not strictly homebound, making it easier to get therapy at home for aging in place. MA plans may also include virtual PT/OT (via telehealth) or home safety modifications (like ramps) to complement therapy, boosting recovery compared to Original Medicare.

• Potential Cost Savings & Health Outcomes: Unlike Original Medicare, MA plans have an annual out-of-pocket maximum ($3,000–$8,000 in 2025), so your PT/OT costs won’t spiral indefinitely. MA’s coordinated care (e.g., therapy paired with nurse check-ins) reduces hospital readmissions, as therapy continuity prevents setbacks like falls (5–8% of readmissions).

●Hospital-to-LTC Transition (MMI): 

• Original Medicare Coverage (2025): Medicare only pays for skilled care if it’s helping you get better or maintain your abilities. If your doctor decides you’ve reached a point where more care won’t improve your condition (called “maximum medical improvement”), Medicare stops covering it. For example, if you’re recovering from a stroke but can’t make more progress with therapy, Medicare will say the skilled care isn’t needed anymore, even if you still need help or assistance, even if needed on a daily basis throughout the day. Skilled care means specialized care from trained professionals, like nurses giving injections or physical therapists helping you regain strength after surgery. It’s different from everyday help (like bathing or cooking), which can be provided by non-professionals like family, and for which Medicare doesn’t cover.  

If you’re in a skilled nursing facility (like a rehab center after a hospital stay), Medicare Part A covers up to 100 days per “benefit period” (a specific time frame tied to your condition). But this coverage stops earlier if your condition isn’t improving. For the first 20 days, Medicare pays 100%; for days 21–100, you pay a daily copay (about $204 in 2024). If you hit 100 days or stop improving before that, Medicare stops paying, and you’d need to cover the full cost (often $300–$500/day) or find other help, like Medicaid.

• Medicare Advantage Advantages:  Flexible prior authorization, extended SNF days, care managers for transitions.  MA plans offer advantages over Original Medicare for managing care, particularly when moving from a hospital to a skilled nursing facility (SNF) or home. It’s about making transitions smoother and potentially extending coverage for certain services.

Prior authorization is when your MA plan needs to approve certain services (like therapy or nursing home stays) before they’re covered. Unlike Original Medicare, which has strict rules about when care is “medically necessary,” MA plans can be more flexible in approving these services. For example, they might okay extra therapy sessions or specialized care if it helps you stay out of the hospital, even if Original Medicare would deny it. Extra days can give you more time to recover without paying huge out-of-pocket costs (SNFs can cost $300–$500/day without coverage). This supports aging in place by helping you return home stronger.

MA plans often assign a care manager (like a nurse or social worker) to guide you through transitions in care, like when moving from a hospital to an SNF, home, or another care setting. They help coordinate things like therapy schedules, medication plans, or follow-up doctor visits. They also make sure everyone (doctors, therapists, family) is on the same page.  These managers reduce confusion and mistakes (like wrong medications), making your move from hospital to home smoother and safer. This can prevent you from going back to the hospital.

• Potential Cost Savings & Health Outcomes:  Flexible Prior Authorization  means you might get extra PT/OT at home to avoid a nursing home,  reducing reliance on institutional care.  MA care managers reduce hospital readmissions by significantly by ensuring proper medication and follow-up care (e.g., >15% fewer heart failure readmissions with MA coordination).  By way of illustration, a care manager might arrange telehealth check-ins or home PT to keep you stable after leaving an SNF, cutting risks like medication errors (reducing hospital readmissions).

●Utilization of Technology: Remote Patient Monitoring (RPM) and More: 

• RPM Defined: RPM uses devices like blood pressure cuffs, glucose monitors, or wearable heart rate trackers that send data to your doctor from home. MA plans, particularly Chronic Special Needs Plans (C-SNPs), often cover these for conditions like diabetes, heart failure, or COPD.

• Original Medicare Coverage (2025): Limited RPM coverage (only specific codes like 99453–99457 for chronic conditions).

• Medicare Advantage Advantages:   Unlike Original Medicare, which has limited RPM coverage, MA plans may include RPM as a supplemental benefit, covering device costs or monitoring services. For example, a 2025 Humana MA plan in Ohio offered free glucose monitors and monthly nurse check-ins for diabetic patients.

• Potential Cost Savings & Health Outcomes: RPM significantly reduces ER visits  by catching issues early (e.g., high blood sugar spikes). A 2024 study showed MA’s RPM programs improved blood pressure control in 60% of hypertensive patients within 6 months.  For example, If you have heart failure, an MA plan might provide a scale to monitor weight daily (fluid retention is a red flag). Data goes to your doctor, who can adjust meds via telehealth, preventing hospital trips.

• Other Technologies: 

• Smart Home Devices: Some MA plans cover or subsidize devices like motion-sensor lights or fall detection systems (e.g., integrated with Alexa or Apple Watch) as part of home safety benefits. These reduce fall risks, a leading cause of readmissions (5–8% of elderly cases).

• Health Apps and Portals: MA plans often provide apps for scheduling telehealth, tracking vitals, or accessing care coordinators. For instance, UnitedHealthcare’s 2025 MA plans include a portal for real-time medication reminders, boosting adherence significantly.

• Virtual PT/OT: Some MA plans offer virtual physical or occupational therapy sessions, guiding exercises via video to maintain mobility after in-person sessions end. This is rare in Original Medicare.

MA plans don’t cover all non-skilled care needs, especially if you need help 24/7. To fill this gap, you can combine MA with Medicaid (a state program for low-income people), private long-term care insurance, or spend-down of your personal assets and property. For example, Ohio’s PASSPORT program (through Medicaid) can cover more in-home aide hours if you qualify (income under $2,901/month in 2025). Private insurance can also help pay for ongoing care costs that MA doesn’t fully cover.

Moreover, some plans present challenges that only a Medicare Specialist would know.  It is imperative that, in addition to conducting your own investigation, you consult with a Specialist who can guide you based on "inside" information that might be unavailable to you, or at least hard to access and assess.

In short,  MA plans can give you some help with daily tasks and tools to monitor chronic illnesses at home, but they too are limited. To get full support for staying at home long-term, you’ll likely need to add Medicaid, private insurance, or asset spend-down to cover the rest.  If you select the latter, your assets will last longer, leaving a greater chance that assets will pass to heirs rather than being consumed by long=term care expenses. 

Additional MA Benefits for Post-Hospital Recovery

When Original Medicare’s benefits cease (e.g., after 100 skilled nursing days or when PT/OT no longer shows “progress”), MA plans offer unique supports to maintain health and prevent setbacks:

• Care Coordination: Dedicated managers ensure medication reconciliation and follow-ups, reducing readmissions by 8–20%. For example, a 2025 study by Providence VNA Home Health showed medication reconciliation cut 30-day hospitalizations from 12% to 9% for heart failure patients.

• Supplemental Benefits: Meal delivery, transportation, or flex cards ($50–$300/year for OTC items) support nutrition and mobility, reducing malnutrition-related readmissions.

• Behavioral Health: Expanded telehealth counseling addresses post-hospital depression, improving physical recovery by 10–15%.

• Out-of-Pocket Caps: MA caps annual costs ($3,000–$8,000), unlike Original Medicare’s unlimited costs, ensuring affordability for ongoing care.

Ohio Context: Why MA Matters Now

Recent Ohio developments, like the September 2, 2025, Ohio Supreme Court ruling previously discussed on this blog, (State ex rel. LeadingAge Ohio v. Ohio Dept. of Medicaid), highlight Medicaid funding shortfalls for nursing homes ($527 million in 2024-2025), threatening care quality for 66,000 residents. MA’s home-based benefits offer a buffer, reducing reliance on facilities and aligning with programs like Ohio’s PASSPORT waiver, which supports in-home aides for those with income under $2,901/month.

Steps to Leverage MA for Aging in Place

Assess Needs: Consult a doctor or geriatric care manager to outline required services (e.g., PT/OT, home mods).

Compare Plans: Use Medicare.gov’s Plan Finder to identify plans with telehealth, in-home care, or C-SNPs. Prioritize low out-of-pocket maximums and strong Ohio networks.

Speak with a Specialist: A Medicare specialist is a must, not only to access your needs and goals, but to advise regarding which plans are best, and which specific plan is best for you and your circumstances.  

Enroll Strategically: Switch during Open Enrollment (October 15–December 7). Check for Special Needs Plans for chronic conditions.

Maximize Benefits: Request prior authorization early; combine with Veterans benefits, Area Agencies on Aging, or long-term care insurance. Track annual allowances.

Plan for Gaps: Budget for premiums ($0–$200/month) and copays; use trusts (e.g., $154,140 Community Spouse Resource Allowance in 2025) or Medicaid planning to cover full custodial care.

Monitor Health: Use MA’s telehealth and care coordination to prevent setbacks, leveraging data like 43% fewer missed follow-ups.

A Call to Action

Medicare Advantage plans empower Ohio families to age in place with dignity, offering cost savings, flexible care, and better health outcomes, like  fewer readmissions and !improved recovery. Amid uncertainties like Ohio’s Medicaid disputes, MA’s home-focused benefits are a lifeline. Don’t wait!  For tailored strategies, consult an elder law attorney or your State Health Insurance Assistance Program (SHIP). Secure your aging-in-place plan now to avoid facility costs and thrive at home.

Open Enrollment! NCOA Considerations

The National Council on Aging (NCOA), the national voice for every person's right to age well, is encouraging all individuals with Medicare to evaluate their coverage during this year's Open Enrollment, which runs from October 15 through December 7, 2024, for coverage effective in 2025.

The Annual Enrollment Period is too often a lost opportunity for people with Medicare. Research shows that only about 10% of individuals use this chance to switch plans. The result is they can end up overspending for coverage they don't need or use.

"This year, the stakes are higher than ever," said Josh Hodges, NCOA's Chief Customer Officer. "With inflation at a 40-year high and a recent U.S. Census report showing that poverty increased among Americans age 65 and older, it's critical that people with Medicare use this time to make sure their plan meets their budget and their health care needs."

"When assessing options, we recommend individuals look at cost, coverage, and convenience," Hodges said. "Every year, Medicare plans change, and so do people's personal health situations. Medicare can be confusing, but NCOA offers trusted resources to help."

BenefitsCheckUp® is an NCOA tool that helps people with Medicare determine if they may be eligible for the Medicare Savings Programs and Medicare Extra Help—two programs that help cover health care costs for people with low and moderate incomes.

Another trusted resource is the State Health Insurance Assistance Program (SHIP) network. There are SHIPs in every state, and they provide local, in-depth, and objective insurance counseling and assistance to Medicare-eligible individuals, their families, and caregivers.

Of course, you can also speak with a private independent Medicare Specialist.

For more information, please visit www.ncoa.org/Medicare.

PRIMARY SOURCE: Save Money by Evaluating your Medicare Plan, Today's Caregiver (last accessed October 15, 2024)(slight alterations added).

About NCOA  

The National Council on Aging (NCOA) is the national voice for every person's right to age well. We believe that how we age should not be determined by gender, color, sexuality, income, or zip code. Working with thousands of national and local partners, we provide resources, tools, best practices, and advocacy to ensure every person can age with health and financial security. Founded in 1950, we are the oldest national organization focused on older adults. Learn more at www.ncoa.org and @NCOAging. 

Taking Advantage of Medicare Open Enrollment

Medicare Open Enrollment Period, October 15th through December 7th, can pay off in significant savings and/or significant additional benefits. Medicare Fall Open Enrollment Period is the time you can join, switch, or make other changes to Medicare drug and health plans.

In Medicare, individuals must choose one of two paths: original fee-for-service Medicare, or a federally subsidized Medicare Advantage plan, which typically operates like a health-maintenance or preferred-provider organization. Many who opt for traditional Medicare also purchase a private "Medigap" policy, as well as a separate prescription-drug policy, to patch holes in their coverage.

In recent years, Medicare Advantage plans have gained in popularity, in part because, when compared with a Medigap policy, they generally cover a wider array of benefits, often including prescription drugs and dental care. Many also charge lower premiums, but require members to use the plan's network of providers.  As previously reported on this Blog, Medicare Advantage premiums are estimated to decline to their lowest in 13 Years. 

How, then, should Medicare beneficiaries prepare for Open Enrollment? Here’s a checklist from The Senior Citizens League:

1. Review: By now, people covered by Medicare Part D or Medicare Advantage plans should have received an Annual Notice of Changes for 2020 from their current plan. In addition to changes to the premiums, the notice will explain increases, if any, in the deductible, copayments and coinsurance. The notice will tell you where to find information about the pharmacies in the drug plan’s network, and it will refer to “the drug list” or plan formulary of covered drugs which usually can be found online or requested from the plan. What the notice does not include is a list of the drugs you currently take, the tiers that your drugs will be on in 2020, whether coverage has been dropped for any of your drugs in 2020, or what those drugs will cost if co-insurance is charged.  Plans will provide most of that information, but it requires either calling your plan directly and speaking to someone who can estimate the cost of your drugs in 2020, or obtaining the advice and counsel of a professional, such as the professionals at Harding Harding & Associates, Inc., who will help evaluate your plan changes.  Once you have this information, it’s very important to compare all your health and drug plan options to find your lowest-costing coverage.
2. Gather and write legibly: Gather all of the drugs you currently take and carefully make a list, printing the name of the drug, dosage, quantity taken per day, and quantity required per month. Do this for each drug taken. Make sure your writing is legible. Type and print it out if possible. Keep this list on file where you can find it easily. Not only will you need it to compare drug plans, it’s handy to take with you on each visit to your doctor.
3. Get free, unbiased assistance from a Medicare counselor: You can get great help from a local Medicare benefit counselor who provides free one-on-one counseling through State Health Insurance Programs (SHIPs). Local contact information can be found at: https://www.shiptacenter.org. Call and make appointment now, because Open Enrollment will take more time than usual this year. The Medicare Drug Plan Finder comparison tool which counselors use to compare drug plans and estimate costs has recently been re-designed. “It’s likely to take longer than usual to sort through plans and determine the best choice for clients while all of us are learning how to use the new system,” Johnson says.
4. Narrow your choices and contact the prospective drug plans directly to confirm details: Once you have picked out three or so plans that look like your best bets, contact the plans directly to confirm the details. This includes coverage of all your drugs, estimated co-pays and co-insurance, which pharmacies participate and other questions you may have.
5. Switch plans by going through the Medicare website: It’s better to switch plans through the Medicare website than trying to do so directly with the insurer. This way Medicare will make sure your previous plan unenrolls you by the end of the year and your new coverage begins on January 1, 2020 with the new plan. Your SHIP Medicare benefits counselor can help you do this.

If you need help call 1-800-Medicare (1-800-633-4227) or contact your local area agency on aging to get free one-on-one counseling.

For more information: 

• Visit the Medicare website at www.medicare.gov, or call toll free at 1-800-MEDICARE (1-800-633-4227).
• Medicare Advantage Premiums Decline to Lowest in 13 Years With Open Enrollment Approaching.
• Preparing for Medicare Open Enrollment

Medicare Advantage Premiums Decline to Lowest in 13 Years With Open Enrollment Approaching

Medicare Open Enrollment begins on October 15, 2019, and ends on December 7, 2019.  Ahead of Medicare Open Enrollment, the Centers for Medicare & Medicaid Services (CMS), announced that, on average, Medicare Advantage premiums in 2020 are expected to decline 23 percent from 2018, while plan choices, benefits and enrollment continue to increase. The Medicare Advantage average monthly premium will be the lowest in the last thirteen years for the more than 24 million people with Medicare who are projected to enroll in a Medicare Advantage plan for 2020.

HHS Secretary Alex Azar described the changes as providing “lower costs, more options, and benefits tailored to patients’ needs." 

This news comes as the agency releases the benefit and cost-sharing information for Medicare Advantage and Part D prescription drug plans for the 2020 calendar year. Specific highlights include:

• The Medicare Advantage average monthly plan premium is expected to decrease 14 percent to $23.00 (estimated) in 2020 from an average of $26.87 in 2019. Since 2017, the average monthly Medicare Advantage premium has decreased by an estimated 27.9 percent. This is the lowest that the average monthly premium for a Medicare Advantage plan has been since 2007.
• Beneficiaries will have more plan choices, with about 1,200 more Medicare Advantage plans operating in 2020 than in 2018.
• The average number of Medicare Advantage plan choices per county will increase from about 33 plans in 2019 to 39 plans in 2020. This represents an increase of 49 percent since 2017.
• Medicare Advantage continues to be popular, with enrollment projected to increase to an all-time high of 24.4 million beneficiaries from the current enrollment of 22.2 million, out of approximately 60 million people currently enrolled in Medicare. Enrollment in Medicare Advantage in 2020 is expected to have increased by 30.6 percent since 2017.
• Coupled with the previously announced 13.5 percent decline in the average monthly basic Part D premium, beneficiaries have saved about $2.65 billion in Medicare Advantage and Part D premium costs since 2017. The projected average monthly basic Part D premium of $30 in 2020 is the lowest the Part D basic premium has been since 2013.
• The continued decline in Medicare Advantage and Part D premiums over the past three years is estimated to save taxpayers nearly $6 billion in the form of lower Medicare premium subsidies.

CMS has, according to these recent announcements, " taken several actions over the last two years to protect and strengthen the Medicare Advantage and Part D programs, driving competition and lowering costs," including:

• Providing beneficiaries with more choices due to CMS removing limits requiring meaningful differences among a Medicare Advantage Organization’s plans beginning in 2019.
• Reducing burden for Medicare Advantage and Part D plans through streamlining government review and approval of marketing materials.
• Expanding access to reduced cost sharing and additional benefits for enrollees with certain conditions, such diabetes and congestive heart failure, due to the agency’s reinterpretation of uniformity in 2018. About 300 plans in 2020 will offer up to 1.3 million Medicare Advantage enrollees with access to such benefits.
• Expanding opportunities for seniors to choose Medicare Advantage plans that are providing new supplemental benefits, or extra benefits, that are tailored to their specific needs to help them maintain their health. In 2020, about 500 plans will provide approximately up to 2.6 million Medicare Advantage enrollees with access to expanded primarily health related supplemental benefits, such as adult care services or caregiver support services.
• Expanding opportunities for chronically ill patients to choose Medicare Advantage plans that offer a broader range of supplemental benefits that are not necessarily health-related but may help to improve or maintain their health. For example, chronically ill beneficiaries enrolled in a Medicare Advantage plan can now receive meal delivery in more circumstances, transportation for non-medical needs like grocery shopping, and home environment services in order to improve their health or overall function as it relates to their chronic illness. About 250 plans in 2020 will offer access to these types of supplemental benefits reaching an estimated 1.2 million enrollees.
• Implementing recent legislation  to give seniors access to Medicare Advantage additional telehealth benefits so enrollees can use telehealth technology to access more providers in more parts of the country. For 2020, over half of all plans will offer additional telehealth benefits, reaching approximately up to 13.7 million Medicare Advantage enrollees.
• Providing clinicians with more information on out-pocket-costs and lower cost alternatives for prescription drugs so they can discuss with beneficiaries at the time a prescription is written.
• Providing beneficiaries with more drug choices and empowering beneficiaries to select a plan that best meets their needs by allowing plans to cover prescription drugs differently depending on the reasons for which they are prescribed, an approach used in the private sector.

Although there are additional lower-cost choices, it will, according to CMS, be easier than ever to compare Medicare Advantage and Part D plans on Medicare.gov. As the 2020 Medicare Open Enrollment period approaches, CMS for the first time in a decade launched a modernized and redesigned Medicare Plan Finder – what CMS reports is |the most used tool on Medicare.gov – that allows users to shop and compare Medicare Advantage and Part D plans as well as compare pricing between original Medicare, Medicare prescription drug plans, Medicare Advantage plans and Medicare supplemental insurance or Medigap policies.

CMS anticipates updating Medicare.gov with the 2020 Medicare Advantage and Part D premiums and cost-sharing information and releasing the Star Ratings for Medicare Advantage and Part D plans in early October.

 During open enrollment, Medicare beneficiaries can compare coverage options like Original Medicare and Medicare Advantage and choose health and drug plans for 2020. Medicare health and drug plan costs and covered benefits can change from year to year, so people with Medicare should look at their coverage choices and decide on the options that best meet their health needs.  Even with the assistance of a newly redesigned Medicare.gov., you should consider expert advice and consultation.  For these reasons, we strongly urge clients to establish a relationship with a trusted adviser.  Locally, many of our clients use the advisers at Harding, Harding & Associates. 

If you want to keep your current Medicare coverage, you do NOT need to re-enroll.  But, you may want to seek expert guidance whether this is a wise decision.

If you need additional help you can also call 1-800-MEDICARE, or contact your State Health Insurance Assistance Program. You can obtain contact information for any State here.  Simply type your state name in the first window, and type SHIP in the second.

To view the premiums and costs of 2020 Medicare Advantage and Part D plans, go here.

For state-by-state information on Medicare Advantage and Part D in 2020, go here.

Preparing for Medicare Open Enrollment

Oct. 15 marks the start of Medicare's seven-week annual election period, when current beneficiaries can add, drop or switch prescription-drug plans and make other coverage changes.

In Medicare, individuals must choose one of two paths: original fee-for-service Medicare, or a federally subsidized Medicare Advantage plan, which typically operates like a health-maintenance or preferred-provider organization. Many who opt for traditional Medicare also purchase a private "Medigap" policy, as well as a separate prescription-drug policy, to patch holes in their coverage.

In recent years, Medicare Advantage plans have gained in popularity, in part because, when compared with a Medigap policy, they generally cover a wider array of benefits, often including prescription drugs and dental care. Many also charge lower premiums, but require members to use the plan's network of providers.

The Affordable Care Act has sparked fears that Medicare Advantage plans, which cover about 30% of Medicare beneficiaries, will raise premiums, reduce benefits and pare their networks of doctors and hospitals. The reason: Under the law, Medicare will reduce payments to Medicare Advantage plans by some $156 billion by 2022, to bring per-person payments in line with those of traditional Medicare.

Citing the ACA, the nation's largest Medicare Advantage insurer, UnitedHealth Group, has cut an estimated 10% to 15% of the doctors and hospitals from its nationwide network. Consumer advocates say the insurer targeted providers with the sickest and most expensive patients, leaving patients in the middle of treatments in the lurch. The company says the changes enable it to better coordinate care and denies that patients in the middle of treatments are adversely affected, extending exceptions to members in active treatment.

Because some of the cuts occurred at times of the year when patients are unable to switch plans, Sen. Sherrod Brown (D., Ohio) and Rep. Rosa DeLauro (D., Conn.) recently introduced legislation that would bar insurers from dropping providers outside of Medicare's annual open-enrollment period.

Because Medicare Advantage can change annually, it's important to examine your options during open enrollment, from Oct. 15 to Dec. 7.  You should call your providers to make sure they still participate in your plan.  You can also use the "Plan Finder" tool at medicare.gov to compare premiums, copayments and deductibles for Part D prescription-drug plans in your area.

During open enrollment, you can switch to either a Medicare Advantage plan or to traditional Medicare, which allows you to see any doctor who takes Medicare. From Jan. 1 to Feb. 14, Medicare Advantage participants may switch to traditional Medicare.

Medicare beneficiaries whose claims are denied should also know that, despite rising backlogs in Medicare's appeals system, two recent lawsuits indicate that those who press their cases have a good chance of success. The procedure differs depending on whether you're in traditional Medicare, a Medicare Advantage plan or a Part D prescription-drug plan. Typically, each appeal can be heard five times, the last time in a federal court.

Since 2010, success rates in the first two rounds of appeals of denied claims for home health-care coverage have plunged to 5% or less, according to a class-action lawsuit the nonprofit Center for Medicare Advocacy in Willimantic, Conn., filed on June 4 in the U.S. District Court in Connecticut against the Department of Health and Human Services, which oversees the agency that administers Medicare.

The center's director of litigation, Gill Deford, told the Wall Street Journal that consumers who want a "meaningful review of their Medicare claims" should continue to the third round of appeal—before an administrative law judge—where odds of success jump to 40% or more.

The average wait for a decision from an administrative law judge is 398 days, up from 95 days in 2009, according to HHS. In a federal lawsuit filed Aug. 26, also in Connecticut, the Center for Medicare Advocacy seeks to force the government to take steps so that appeals can be decided within the 90 days the Medicare statute requires.

When appealing, ask your doctor for a letter explaining why you need the treatment in question. Those who go before an administrative law judge may benefit from retaining a medical or legal advocate. Most State Health Insurance Assistance Programs provide free counseling.

This post is based upon a Wall Street Journal article which can be read here.