Medicare re-enrollment: Time to consider being dissatisfied with a new plan!

It is Medicare re-enrollment season again. It began Oct 15 and runs through the end of the year. This is when, if you are dissatisfied with the Medicare plan that you are in, you can choose a new plan with which to be dissatisfied. I know this, if for no other reason, by the large number of pieces of junk mail telling me of the joy I will have if I enroll in this-or-that Medicare Advantage (MA) plan, not to mention the commercials blanketing television programs. I almost only watch live TV for sports, so I am seeing these on sports shows; I don’t know what it means that sports show ads target seniors. Maybe it’s just that ads on all shows target seniors; it is presumed that we are sitting around doing nothing but watching television so are an audience not only for Medicare Advantage but all kinds of “health” ads, ranging from those for incredibly expensive recombinant-DNA drugs (anything ending in “ab”, for starters) for uncommon conditions to the touting of ineffective (and possibly dangerous) nostrums. At least we don’t see as many ads for mobility scooters “at no cost to you” (albeit to the taxpayers) since some of the vendors went to prison. Unless they are soon to be pardoned, not an impossibility.

There is only one form of real Medicare, “Traditional Medicare” or TM. This is what you paid those Medicare taxes for that were recorded on all your paychecks, to fund the Medicare Trust Fund. Well, at least for Medicare Part A, which covers inpatient care and is what is covered by the Medicare Trust Fund. Medicare Part B, covering outpatient care (including outpatient procedures) is funded by general taxes plus monthly payments from recipients that are graduated by income (based upon the previous year’s tax form, so for the coming year, 2026, based on your last filed return which was for 2024). The base payment this year is $185/month, although subsidies may be available for low-income people. But while TM (unlike MA) does cover you for all Medicare-approved treatment, and it, not the hospital, sets the charge, it does not cover all of what it permits the hospital to charge you. For inpatient care, in particular, it will only pay 80% of whatever it has approved as what a hospital can charge. That is, if Medicare has approved a charge of $1000 for procedure X, it will only pay the hospital $800, and you are on the hook for the rest. So (if you can afford it) you should buy a Medicare Supplement (Medigap) policy to cover that. There are several types, but at least they are standardized benefit packages (labeled by letters A-N, except E, I, and J; these letters not to be confused with the Medicare Parts A, B, C, D). In addition, you are required to have a drug plan (Medicare Part D), which is an additional expense.

Besides being confusing, that is a lot of expense for TM: monthly payments for Part B, Part D, and your Medigap. On top of that it doesn’t cover all the things you may need or want, like vision correction (glasses; it does cover treatment of eye diseases and surgery), or hearing aids. That facilitates the marketing of Medicare Advantage (officially Medicare Part C), as intended: one easy monthly payment (which, depending upon the MA plan, may be completely covered by Medicare without out-of-pocket payments from you) covers it all – inpatient, outpatient, drugs, and glasses, hearing aids and even gym memberships! Why would you not want this?

I have written previously why you may not want MA (The WiSER program to erode your Medicare coverage: Not WISE for you! Sept 22, 2025, Medicare and Medicaid at 60: Need more -- and more threatened -- than at 50!, Aug 6 2025, and other older posts), which boils down to the fact that they are health insurance plans like the one you had, and can, and do, delay and deny coverage for individuals in order to save money (or, really, make more money!) They usually are HMOs or PPOs with a limited panel of doctors and hospitals for which they will pay. While the Medigap and Part D coverage you need with TM are also sold by the same insurance companies, these benefits are much more explicitly stated and required by law to be provided, although there are certainly efforts to get you to use cheaper drugs (usually not the “ab” drugs being advertised in the next commercial!) If you travel a lot, you may find that MA plans are often based in one geographical area. Also, many “destination” hospitals that people travel to in order to receive excellent care for conditions like cancer (eg., Mayo, MD Anderson) do not accept MA. To a large extent, having an MA plan is like having the insurance that non-Medicare recipients have, warts and all. There are reports (such as in Health Care Un-Covered) that, in addition to raising their rates and cutting benefits, MA plans will be “exiting certain markets” (the unprofitable, or really less-profitable-than-they-would-like markets), leaving residents in those areas without available coverage.

"Health Care Un-Covered", the substack founded by Wendell Potter, also reports on the new report from Physicians for a National Health Program (PNHP) “No Real Choice: How Medicare Advantage fails seniors of color”, that shows MA plans increase (rather than decrease, as they claim) racial inequity.

PNHP’s researchers found that communities of color are being steered into MA plans not because they’re better — but because they’re cheaper upfront. This dynamic, dubbed the “Gap Trap,” means that affordability is driving people into coverage that often denies care, delays treatment and locks them into narrow networks.

The old “cheaper up front but not once you get sick” gambit.

Plus, from the PNHP study:

·       Black, Hispanic and Asian/Asian-American beneficiaries are disproportionately concentrated in MA plans that score lowest on quality ratings, while white beneficiaries are more likely to live in counties served by higher-quality plans.

·       One study found that MA prior authorization requests were denied 23% of the time for Black seniors vs. 15% for their white counterparts.

·       Despite industry claims to the contrary, racial and ethnic health disparities in the United States are not being reduced by Medicare Advantage.

·       Studies show that Black enrollees are more likely than white enrollees to choose a 5-star MA plan when offered one. They’re just not offered them as often.

·       Racial minority enrollees in MA suffer from worse clinical outcomes and face barriers accessing best quality care because of restrictive networks and misaligned financial incentives. Black MA enrollees experience higher rates of hospital readmission compared to their white peers.

When is having insurance worse than not having insurance?

And, while we’re talking about the insurance that people not yet on Medicare and not eligible for Medicaid (ie., most Americans) have, it is (you may have noticed) getting more costly. At the present time the government is shut down over disagreement between Democrats and Republicans (including the administration) as to whether subsidies that made enrollment in health insurance through the Affordable Care Act (ACA) actually affordable should be extended. For those who are fortunate enough to have employer-funded health insurance and do not have to buy plans through the ACA exchanges (154 million people), KFF (formerly the Kaiser Family Foundation) reports that covering a family of four now costs almost $27,000 a year, after two straight years of more than 6% increases, and 26% over 5 years. That is a lot, especially if the family is paying a hefty portion of it (often 50% or more) out of pocket.

It's not a good situation for people not yet on Medicare, not for those on Medicaid, not for those receiving subsidies to buy policies through the ACA, and increasingly difficult for those on Medicare or Medicare Advantage. How about we covering 100% of everything through Traditional Medicare, enroll every American of all ages in it, and fund it by not having to pay insurance companies?

Don't miss laughing at, and more important being informed by, this John Oliver video!

Open Enrollment Season for Medicare and Medicare Advantage: What you should know

This is an unusually long post, but I decided it was better to have all the information in one post rather to divide it into two. Hopefully you can find the part/s you feel of use to you.

It is Medicare re-enrollment season again, so it seems to me to be a good time to review some of the key issues seniors should consider when deciding to sign up for the same, or a new plan. I have written about Medicare and Medicare Advantage a number of times (e.g., “Insurers in trouble for the wrong reason: Wall St. wants them to rip you off for even MORE!”, Aug 22, 2024; Medicare Advantage: OK, it's bad for the country, but what about for me?, Dec 6, 2022) and have been critical of Medicare Advantage (MA) plans, but I hope that this piece will be more informational. If you are Medicare eligible, You probably get a lot of “information” from both Medicare and MA plans at this time of year, the former providing nothing that could much help you decide (“it’s all good!”) and the latter not only assuring you that MA is the right thing, but that their MA plan is the best one for you. There are some things you should know, and consider, and I will provide some information and some opinions, trying to carefully label the opinions.

To begin with, it makes a difference if you are first starting on Medicare or are doing your annual re-enrollment (and perhaps changing plans). If you are starting, this is not necessarily the time of year when it happens; it happens whenever you turn 65. At that point, you are required to enroll in Medicare Part A, which is what covers inpatient hospitalization and is the only part paid for by the Medicare Trust Fund, funded by your Medicare deductions. If you are still working and are covered by an employer health plan, you do not need to enroll in Part B yet. Part B, which pays for doctor (and other clinician) fees and all outpatient care (including that rendered while you are actually in the hospital, even sleeping there for a night or two; this is a neat trick but not part of this discussion), is paid for by monthly payments by you, supplemented as necessary by general taxes. The “standard” monthly premium is now $174.70 (if your mean adjusted gross income, MAGI, as a couple is less than $206,000), but it can be decreased or eliminated for low-income people and is higher for high-income people thorough a formula called IRMAA (Income-related monthly adjustment amount). More of this financial information is here, from Medicare, and here from a private counselor. The IRMAA is based on your last tax return, so if you retire in 2024, it will be based on your 2023 return. If you think that you will make a lot less in retirement than you did in the last year you worked, you can appeal this, providing evidence that your MAGI will be less than it was before retirement. Anyway, you must enroll in and pay for Part B once you are no longer covered by your employer’s plan, and if you don’t you are subject to significant penalties.

There are two other letters, Part C and Part D. Part C is Medicare Advantage, about which more in a moment. Part D is the Medicare Drug Plan, passed under the GW Bush administration. It requires Medicare recipients to have such a plan, all of which are sold by private insurance companies, mostly the same ones that sell insurance to pre-Medicare people and also sell Medicare Advantage plans. It is good for them (opinion) as everyone is required to pay them a premium, and they work hard to pay out as little as possible, as do all insurance plans. (See my blog post Medicare Part D: Learn from my mistakes, Dec 13, 2022). I’ll just say now it can be confusing; you may want the plan with the lowest premiums, especially if you are not on drugs that require a high co-pay, but that is sometimes hard to figure out. You gotta do it, though.

Which brings us to the choice between Traditional Medicare (TM), a government funded system available to all eligible people (over 65 and some others with disabilities), and Medicare Advantage, which is not Medicare (despite the name) but a group of private insurance products paid for with Medicare dollars. In general, these are very similar to HMO or PPO plans for pre-Medicare customers. Both have advantages (no pun intended, by me, although the renaming of the program by Congress from Medicare+Choice is apparently an intentional effort to promote it), and disadvantages. A recent Associated Press article (‘Medicare Advantage shopping season arrives with a dose of confusion and some political implications’ Sept 28, 2024) notes that MA benefits are becoming less and choice of plans fewer.

The advantages (OK, I’ll call them plusses) of MA plans include one premium, often completely covered by Medicare dollars with little or no out-of-pocket cost to the recipient, that includes coverage for Part A, Part B, and Part D. It also may include coverage for other things not covered by TM, including glasses, hearing aids, and gym memberships. It may or may not include mental health coverage, and if it does the character and quality of that coverage varies. It rarely if ever includes long-term care. While many of these extra benefits are kind of loss-leaders that cost the insurers little, the big plusses of MA are not needing to pay a Part B or Part D premium in addition, or to buy a Medicare Supplement (no letter code here*) to cover the costs incurred and not paid by TM to its recipients. The big cost for folks with TM is that it only pays 80% of approved charges for hospitalization, so if you have a hospitalization for something that Medicare decides it can be charged $1000 for (this is not what the hospital charges, which can and usually is several times more, but they have to take the Medicare-approved amount), it only pays $800 and you have to pay the $200. Or $2000 if the approved charge is $10,000. Or whatever. It can be and often is a lot, which is why people on TM should buy a Supplement plan that will cover the difference. But cost them more.

So, so far this looks like a win for MA plans over TM: one premium, no Part B or Part D premiums, no need for a Supplement plan to cover the 20%, and some extra perks. This is why they are often well-received by the folks who enroll in them, and what is pitched in their mailings and TV ads. There are, however, some potential (and frequent) minuses to MA plans, which may want to make you consider TM, plus a Supplement.

The key issue is that MA is a private insurance plan, not Medicare, and this can and does result in some limitations as well as some more surprising payment issues, like denial of payment. As I mentioned above, MA programs are like HMO and PPO plans, and this means a limited network of providers (hospital and doctors), usually in your geographic area. Unlike TM, which pays claims from providers on a per-episode basis at the rate set by Medicare, MA plans get your money up front and pays providers based on deals they have negotiated, which is why you are restricted in the places that you can get care (they ones they have the best deals with). This is important, and so it is critical for you to be sure that the places and people from which you get care are “in-network” for them. If you have a second home or travel a lot or spend time with family outside your home region, you want to be sure that you can get non-emergency care there, since MA plans are usually geographic. In addition, you might consider providers you think you might want to get care in the future if something bad happens. For example, many top hospitals that people seek out across the country if they have cancer or another dangerous condition, such as Mayo Clinic, MD Anderson, and Sloan-Kettering, do not accept any MA plans, but do accept TM.

The thing is that these may not seem as important to you if you are 65 and relatively healthy and free glasses and hearing aids and gym memberships are nice, but they increasingly become issues as you age. Older people have more diseases than younger (even younger seniors) and use more care. Consider what your future might hold. If right now you just have a few aches and pains, and take a couple of medications that control some conditions, if you live you will get older and as you get older these are likely to get worse. Sometimes people in MA plans that are actually covering their expensive care can find the insurers urging them to switch to TM, since while those companies are happy to accept your premiums (or those Medicare pays on your behalf, which is, BTW, more than they allocate for TM patients) they are less enthusiastic about paying out large amounts, especially when it can go on and on.

The other big minus that comes from MA plans being private insurance is that they can, and often do, deny coverage for things your doctor has ordered. They can do that. If a procedure or treatment is Medicare-approved, TM simply pays it (although, in hospitalization, only 80%). MA plans, however, like other private insurance plans, can deny coverage for a variety of reasons. With some, denial is almost routine for anything expensive. You can appeal it, but most people don’t. And they can deny it again. And most people won’t keep appealing it. Relatively recent legislation requires MA to pay for any Medicare-approved treatment, but that doesn’t mean that they always do; they can deny on technicalities and even if they must pay fines, it is often considered “a cost of doing business” that is less than actually paying for your care.

So maybe get an MA plan when you are younger and healthier and then switch to TM when you need more care? In addition to this being exactly what the MA plans want – to cover healthy seniors and divest of them when they become expensive to care for, the other big issue is eligibility for and cost of Medicare Supplement (Medigap) plans. Under the law, if you take TM when you first start receiving Medicare, all those offering Supplement plans must offer them to you at “community rates”, that is, not adjusted for your individual health status. But if you sign up for an MA plan, and then a year or ten or 15 down the road decide you want to switch to TM for some reason (maybe you are unhappy with the providers available to you, and want to go to an institution that doesn’t accept MA, or are frustrated with the denials you receive for care that you and your physician think you need), you can at this re-enrollment period. But the “community rating” charge for Supplement plans no longer is required; those companies offering them (often the same ones offering MA) can do underwriting. This means that they can assess your current health status and risks and adjust their premiums upward based on it, or deny you coverage altogether. Since you are often making this change when you are older, sicker, and have greater risk, you may not be able to get, or afford, a Supplement. This is a serious consideration, both when you first get Medicare and in the early years of re-enrollment before you become very sick. And, if you live long enough, you probably will. So seriously think about the decision, including both current and potential future benefits and risk of harm.

Of course, and here is my big opinion, the whole idea of taking something that is GOOD, Medicare, which covers all aged Americans, and turning it over to the private sector to operate as a business where they get paid in advance and try to pay out as little as possible, is BAD. What we need is improved and expanded Medicare for All. Expanded means everyone in our country, not just seniors, are in the same plan; everyone from birth on has Medicare and we do not have a hodgepodge of different programs covering our population. All in it together. Improved means getting rid of all the negatives of the current TM program: paying for 100%, not 80% of approved charges, covering all necessary health issues including dental care, mental health care, and long-term care as well as glasses and hearing aids.

Wouldn’t this cost more? Well, cost whom? The outlay for actual health care for all those expanded and improved services would certainly be more, but the outlay for “health care” which includes profit for insurers, providers, and drug companies would be, for the government and for you out of pocket (unless you are extremely wealthy and can afford it) less. Think about that. Should money you pay, in taxes and out-of-pocket, for health care be used for providing health care to you and your fellow Americans, or should a major portion of it be used to generate huge profits for companies and pay their executives multi-million-dollar salaries?

Think about it.

*Another confusing thing. While Medicare Supplements (MediGap) plans are not as a group assigned a “Part” letter by Medicare, the various plans do have 10 different letter designations, A-D, F, G, K-N (no E, H-J). This is actually good and one of the very few rational and helpful things in US health insurance, as ALL plans of one letter have to offer exactly the same benefits; a K or an N plan from any insurer has to have the same benefits as from any other, so you can just choose the company by cost to you and service. Unfortunately, they do not get better or worse, or more or less comprehensive, as they progress through the alphabet; you have to read what each one covers. That would be asking too much!

 

Drug corporations from manufacturers to retailers are rotten down the line

Drugs, drugs, drugs. We hear a lot about drugs. Especially about the Opioid Crisis, which is a very serious problem in the US. But the other drug problem we hear about is also very serious: the cost of drugs and the inability of people to access the drugs that they need, not to mention to save their lives, because of the cost.

One such drug is insulin, needed by people with Type 1 diabetes to survive. Stories of people dying from, or almost dying from, lack of access to insulin, or having to go to Canada or Mexico to buy it, are both sad and galling.  It is particularly so in the case of insulin because its discoverers wanted it to be free. In 1923, Frederick Banting and his colleagues Charles Best and James Collip sold the patent to the University of Toronto for $1 each, worried that if they did not patent it drug companies would patent an inferior version of insulin (imagine that!) and people would die. The University of Toronto gave the patent royalty-free to drug companies, specifically Eli Lilly.

Unsurprisingly, that marked the end of being motivated by the public interest. As early as 1941, Lilly and two other companies were indicted for price fixing of insulin, and it has gone on from there. In 1982, Lilly was able to synthesize human insulin (previously insulin was made from beef or pork pancreas, which had a lot of reactions, although pork was closer to human and thus preferred). Of course, the price took off. With the complicity of the government, worse in administrations that believed corporate profit (especially for big donors) was more important than human lives, the price continued to rise. This has led us to story after story about people with diabetes, like Josh Wilkerson, dying because they could not afford $1,200 co-pays. Banting and Best are turning in their graves.

Yes, pharmaceutical manufacturers are greedy and evil, whether they make insulin or Epi-Pen or colchicine, or other drugs (like pyrimethamine – see Martin Shrkeli) and deserve every bit of anger, hatred, and scorn that has been visited on them. They are continually the #1 (or, sometimes, #1!) profitable industry in the US, making lots of money because, well, people need their products to live. But they are not the only part of the drug industry that is responsible for bleeding us for profit. They are complicit with insurance companies, who agree to pay the outrageous prices that they demand (because, after all, they just raise their premiums), and with our bought-and-paid-for Congress. For example, when Congress passed the Medicare Part D Drug Act in 2003 it contained a prohibition against Medicare, the nation’s largest insurer, negotiating drug prices, thus ensuring that American pay far more for drugs than people in other countries (there is a reason uninsured folks go to Canada or Mexico)! As I noted recently, the idea is often put forward that without drug company profit, innovation in pharmaceutical discovery would grind to a halt, but in fact nearly 2/3 of discoveries are made outside the US and most of those in the US are discovered through research funded by the National Institutes of Health.

But beyond the usual villains, pharmaceutical and insurance companies, we have the wholesalers, retailers, and “bundlers” of drugs also making out like bandits (they are bandits, even if, thanks to that bought-and-paid-for Congress, their schemes are often legal) from our health needs. The “bundlers”, called Pharmacy Benefit Managers (PBMs) are contracted by large insurers to negotiate for the “best prices” with pharmacy retailers. For a positive spin on what they do, see this piece from “The Balance”. However, they are also responsible for a lot of the high cost of drugs, especially for those with worse, or no, insurance. In addition, they have a lot of practices that enhance their profit at your expense, many explained in this piece from the Commonwealth Fund, such as jacking up the price charged to insurers and pocketing the difference (“spread pricing”) and pocketing rebates from manufacturers. The entire role of PBMs is complex and bewildering, but they play a critical role in the important process of profiting off of your illness.

More recently, we have seen exposure of the nefarious practices of the final link in the chain of getting you your needed medicines, the retail pharmacies themselves. Of course, the old mom-and-pop drugstore on the corner is almost a thing of the past, having been replaced by mega-chain pharmacies such as CVS, Walgreens, Rite Aid and Duane Reed. (Of course, in many big cities they are still on every corner, not just competing with each other but with themselves; in places like New York City they are more ubiquitous than Starbucks!) These chains drove out the small drugstores by underpricing them, but having been successful in that, they have adopted practices that are frequently unethical, sometimes illegal, and always guaranteed to make them more profit. Indeed, two of the largest PBMs are now owned by these chains (Caremark by CVS and Envision by Walgreens), enhancing the vertical integration of the industry.

A New York Times exposé of January 31, 2020 by Ellen Gabler tells how retail pharmacies overwork their employees, sometimes with resultant errors such as patients getting the wrong medicines and often having adverse effects. It was titled “How Chaos at Chain Pharmacies is Putting Patients at Risk”, but this headline, while accurate, does not explain the real reason for the chaos, which is that these pharmacies are using an old and dishonorable technique made famous by Henry Ford in the early days of assembly lines called “speed up”. Speed-up, increasing the expectations for “production” (in this case, number of prescriptions filled per hour) has been a target of union contracts since the 1930s, but as the influence of unions has waned (with the collaboration of pro-corporate legislatures) these practices have increased. Pharmacists may be “professionals” (like nurses and doctors) but whatever your education and training, if you work for a large corporation who sets the rules and standard and has control, you are a worker, and need the protections that all workers should have. The most conscientious of these professionals have protested, often to the state boards that regulate them, as cited in the Gabler article:

In letters to state regulatory boards and in interviews with The New York Times, many pharmacists at companies like CVS, Rite Aid and Walgreens described understaffed and chaotic workplaces where they said it had become difficult to perform their jobs safely, putting the public at risk of medication errors.

They struggle to fill prescriptions, give flu shots, tend the drive-through, answer phones, work the register, counsel patients and call doctors and insurance companies, they said — all the while racing to meet corporate performance metrics that they characterized as unreasonable and unsafe in an industry squeezed to do more with less.

“I am a danger to the public working for CVS,” one pharmacist wrote in an anonymous letter to the Texas State Board of Pharmacy in April.

“The amount of busywork we must do while verifying prescriptions is absolutely dangerous,” another wrote to the Pennsylvania board in February. “Mistakes are going to be made and the patients are going to be the ones suffering.

So is the problem being addressed? You can be sure that it is, by the corporations that run these pharmacies. How? The complaints of the pharmacists are being taken care of in the way that big corporations often do, that is, ignoring them and deleting mention of them from their reports. In a follow up on February 21, 2020, “At Walgreens, complaints of medication errors go missing”, Ms. Gabler writes:

Pharmacy employees at Walgreens told consultants late last year that high levels of stress and “unreasonable” expectations had led them to make mistakes while filling prescriptions and to ignore some safety procedures.

But when the consultants presented their findings at Walgreens’s corporate offices this month, there was no reference to the errors and little mention of other concerns the employees had raised.

That’s because senior leaders at Walgreens had directed the consultants to remove some damaging findings after seeing a draft of their presentation, a review of internal emails, chat logs and two versions of the report shows.

In one instance, Amy Bixler, the director of pharmacy and retail operations at Walgreens, told them to delete a bullet point last month that mentioned how employees “sometimes skirted or completely ignored” proper procedures to meet corporate metrics, according to the chat logs and the draft report.

Good for you, Ms. Bixler! Took care of that problem! You should get a nice bonus this year!

If these practice are of concern to you, they should be. So should the price gouging up and down the line in the pharmaceutical industry, the drive to profit for manufacturers, PBMs, insurance companies, and retail pharmacies to make lots of money off you, or you die. “Your money or your life!” is an old cliché attributed to highwaymen. It should be the mantra of the pharmaceutical industry in this age of unfettered capitalism.

But no highwayman ever had the reach or power or ownership of politicians that these folks do.