What you need to know when Medicare enrollment opens

Many existing plans have been modified or eliminated, and with the increased implementation of Medicare Advantage plans, there are growing concerns that many seniors will enter 2025 with inadequate benefits.

Medicare Advantage is also a major source of concern for hospitals, as several top hospital officials have said that the plans are increasing their financial problems and reducing the ability to care for patients.

“It’s apropos that it’s called Medicare Advantage because I believe it takes advantage of our 65 and older population,” said Delta Health CEO Jonathan Cohee.

“You lose money with each of those plans (by) providing services that cannot be reimbursed to other hospitals,” he added. “We will (provide those services) … simply because our residents have nowhere else to go, but it’s not a sustainable model.”

CHANGES IN OPERATIONS AND COSTS

John Ahern is a consultant for the Grand Junction branch of the State Health Insurance Assistance Program, a nonprofit organization of volunteers who provide unbiased advice to Medicare beneficiaries. According to him, the stakes are very high this year.

“I’ve been doing this for over 10 years, and (the new 2025 plans) are the biggest changes I’ve seen in 10 years,” Ahern said.

Specifically, Ahern said that seven, or a third, of the current Medicare Advantage plans in Mesa County will not be offered for 2025, 12 new plans will be added and the remaining plans will change in one way or another.

Another change Ahern noted is more out-of-pocket costs, which essentially limit how much participants can pay before insurance covers the rest. He added that three out of six Medicare Advantage plans will raise their out-of-pocket costs by $1,000.

Deductibles — the amount a person must pay before insurance covers any part of the cost — are also more common in Medicare Advantage plans. Among the 2024 Medicare Advantage plans, six included deductibles; for next year, 18 plans have a deductible.

Except for Medicare Advantage plans, about 40% of Medicare Drug plans will end this year, and only two plans will be added.

Ahern said it’s important to check if your plan will be offered again because participants under expiring plans will be reassigned by their insurance.

“When the plan ends, the insurance company assigns them another plan, without knowing their budget, medicine or doctor, and often that work is very bad for the person because they go to the doctor and suddenly you pay the entire debt; ” he said.

One of the biggest changes will be in PERA projects. According to Ahern, out-of-pocket costs, deductibles and benefits will remain the same, but the premium (the monthly fee for having insurance) will increase by $197 per month, to about $2,400. per year.

Ahern said that while Medicare Advantage plans are very restrictive, they can be the right plan for certain people, so exploring your options with a Health Insurance Assistance Program advisor or insurance agent is the way to go. the best way to make sure you choose the right plan.

However, he said the Health Insurance Assistance Program is not financially motivated or limited to certain projects such as insurance agents.

The National Health Insurance Assistance Program will accept walk-ins every Thursday, at their office at 422 White Ave., Suite 090, between 9 a.m. and noon, until the end of open enrollment. . Alternatively, appointments can be made by calling 970-243-9839 ext. 1.

INTERRUPTION PREFACES

Medicare, Medicare Advantage Plans in particular, is also a major concern for hospitals and health care providers.

The CEOs of Community Hospital (Chris Thomas), Delta Health (Cohee) and Family Health West (Korey Kline) all say the plans hinder their ability to care for patients while putting financial pressure on select hospitals. to accept Medicare Advantage.

Cohee said that poor coordination of services and providers results in many Medicare Advantage patients needing care that will only be covered with prior approval.

According to Thomas of the Community Hospital, those first approvals were almost always denied. He said that there have been several occasions where they have received pre-approval and provided the service, only for the insurance to back out and deny reimbursement afterwards.

Both Thomas and Cohee said that even when hospitals are reimbursed, the payment is often less than the actual cost of care. That controversy has led several hospitals across the country to reject some (if not all) Medicare Advantage plans.

“I think there’s going to be a tipping point where we end up saying we’re not going to take Medicare Advantage plans anymore because it’s such a challenge,” Thomas said. “We are not paid how much it costs us to start by providing care, but now that they don’t pay us and the services we provide, I see that it has reached a point where there will be a line. sand.”

However, the number of Medicare Advantage enrollees has increased each year. According to Ahern, more than half of Mesa County’s 35,000 Medicare enrollees have a Medicare Advantage plan.

The proliferation of Medicare Advantage plans has affected hospitals to the point where CEOs have made it their mission to educate as many people as possible about Medicare Advantage and what to consider.

Family Health CEO West Klein has hosted several public presentations on open enrollment and Medicare, and will host another at 10 a.m. Oct. 30 Community Hospital. He said that while Medicare Advantage is very risky for hospitals, it is possible that some people may find value in the Medicare Advantage plan.

“(The other thing is) how much risk or concern you want to take,” Klein said. “Some seniors will pay a premium for a more robust plan, knowing they won’t have to worry as much about health care costs next year; while another person may be willing to take a risk for less money, hoping that he will not get sick.”

Klein said the most important thing for beneficiaries is to consider how healthy they are, what kind of care they expect, what their most expensive prescriptions are and what plans cover drugs. Most Medicare Advantage plans are limited to one state, so people who travel frequently or live temporarily in another state should consider traditional Medicare, he said.

“Keep (your traditional Medicare) — it should be that easy,” Cohee said. “Medicare Advantage plans make their premiums lower to reduce your services. You will reduce your network and the special things you can afford (them).

“Ultimately they control your medical future, and that’s the scary thing.”