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Senior advocates say new draft guide to Medicare distorts facts. Here’s what you need to know

Medicare & You is the government’s seminal guide to all things Medicare, and is a primary resource used by consumers in each year’s annual enrollment season beginning Oct. 15. As such, it is or should be the gold standard of reliable information for more than 65 million people already enrolled in Medicare and the millions of people who newly enroll each year.

According to three leading senior advocacy groups, however, the 2019 draft version of Medicare & You has unfairly tilted the playing field. After reviewing the draft, the three groups – the Center for Medicare Advocacy, Justice in Aging, and the Medicare Rights Center – said it contained false statements that appear designed to convince people that private Medicare Advantage (MA) insurance plans are superior to original Medicare.

“Medicare & You is the core Medicare communication to beneficiaries,” the groups said in a joint letter to Seema Verma, head of the Centers for Medicare & Medicaid Services (CMS). “It is critical that the information in the Handbook be fairly and accurately presented. Beneficiaries making important choices about their coverage need to be able to rely on the Handbook for unbiased information that they can trust. However, when comparing Original Medicare and Medicare Advantage, the 2019 draft Handbook does not meet this standard, distorting and mischaracterizing the facts in serious ways.”

A spokesperson for CMS provided what I can only construe as a non-responsive response. It said, in part, “CMS is committed to empowering seniors and people with disabilities to make informed choices related to their Medicare coverage. We continue to look for better ways to explain to consumers the options they have under the Medicare program. Through feedback and consumer testing, we continue to modify and improve the content to help consumers make informed health care decisions.” The spokesperson added that a final version of the handbook would be mailed in September to 43 million households.

So what should you know? Here are some highlights of the original Medicare and MA plans and how the new handbook frames them:

Original Medicare
This includes Parts A and B. Part A helps pay for covered care in hospitals, nursing homes, and other institutions. It includes hospice, which is covered in institutions and also in a person’s home. Part B covers expenses for doctors, outpatient expenses, and durable medical equipment. Part B pays only 80 percent of covered expenses. Original Medicare is managed by the government, using a network of private Medicare administrative contractors (MACs) around the country.

Many people with original Medicare also get a Medigap supplemental policy from a private insurer to pay for things that aren’t fully covered by original Medicare. People with original Medicare who want prescription drug coverage must purchase a standalone Part D drug plan.

Medicare Advantage
These are private insurance plans that were authorized in their current form by the 2003 law that created Part D drug plans. They usually are health maintenance organizations (HMOs) that require people to use doctors and hospitals in their plan’s provider network and include Part D coverage. The plans’ provider networks usually can offer cheaper coverage more cheaply than traditional Medicare, which permits enrollees to use any doctor or health-care institution in the country that participates in Medicare and accepts its payment rates.

MA plans must cover everything that’s covered by original Medicare. Most MA plans use some of their provider network cost savings to cover things that original Medicare does not cover, including limited dental, vision and hearing benefits — plus gym-club memberships. They also offer annual limits on out-of-pocket expenses. People with MA plans are not allowed to purchase Medigap policies.

How popular are these plans?
MA plans have surged in popularity during the past 15 years. They now represent roughly a third of all Medicare, with original Medicare holding two-thirds of the market. CMS bureaucrats consistently supported expansion of MA plans during the Obama years and Trump appointees have if anything stepped up their advocacy.

Who supports which plans?
Under both administrations, there is support for MA plans because managed care has the potential to produce better health outcomes for less money than does original fee-for-service Medicare. The latter doles out health care regardless of whether it is cost effective or even good for a patient’s health. MA plans, by contrast, are better vehicles for tying health spending to positive outcomes.

In the Trump White House, there also is strong support for private insurance solutions versus government-run programs. The bottom line of the concerns by Medicare advocacy groups is that CMS is improperly putting its hand on the scales to tilt them further in favor of MA plans.

What critics say
The Medicare Rights Center released a copy of the draft 2019 Medicare & You handbook along with detailed examples of what it saw as improper comparisons between MA plans and original Medicare.

In several comparative discussions of the two approaches to Medicare, CMS downplays the possible shortcomings of getting care from a limited network of health providers in an MA plan, which involve not only a limited number of providers but also geographic limitations of where a plan provides coverage. At the same time, the draft handbook fails to emphasize that users of original Medicare can use any Medicare-licensed providers anywhere in the nation.

The bottom line
The handbook also creates the impression that MA plans are less costly to seniors than original Medicare. This may or may not be true; it depends on the types of coverage selected and a beneficiary’s individual medical needs.

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