Medicare鈥檚 open enrollment period began Tuesday, and people 65 and older have until Dec. 7 to decide on their health insurance for the upcoming year.
Many existing plans have been changed or removed, and with an increased push for Medicare Advantage plans, there is growing concern that more seniors will enter 2025 with inadequate benefits.
Medicare Advantage is also a major source of anxiety for hospitals, as several hospital chief executive officers said the plans further their financial strains and reduce the ability to care for patients.
鈥淚t鈥檚 apropos that it鈥檚 called Medicare Advantage because I believe it takes advantage of our 65 and older population,鈥� Delta Health Chief Executive Officer Jonathan Cohee said.
鈥淵ou lose money with every one of those plans (by) providing services that are not going to get reimbursed in some hospitals,鈥� he added. 鈥淲e will (provide those services) ... simply because our community members have no other place to go, but it鈥檚 not a sustainable model.鈥�
CHANGES IN COVERAGE & COST
John Ahern is a counselor with Grand Junction鈥檚 branch of the State Health Insurance Assistance Program, a nonprofit of volunteers who offer unbiased advice to Medicare beneficiaries. According to him, the stakes are especially high this year.
鈥淚鈥檝e been doing this a little over 10 years, and (the new 2025 plans) are the biggest changes I鈥檝e seen in 10 years,鈥� Ahern said.
Specifically, Ahern said that seven, or one-third, of current Medicare Advantage plans in Mesa County won鈥檛 be offered for 2025, 12 new plans will be added and the remaining plans will change in one way or another.
One change Ahern noted is the maximum out-of-pocket cost, which essentially limits how much participants can pay before insurance covers the rest. He added that three of the six Medicare Advantage plans will raise their out-of-pocket costs by more than $1,000.
Deductibles 鈥� the amount someone must pay before insurance covers any portion of the cost 鈥� have also become more common in Medicare Advantage plans. Among the 2024 Medicare Advantage plans, six included a deductible; for the upcoming year, 18 plans have a deductible.
Aside from Medicare Advantage plans, about 40% of the Medicare Drug plans will end this year, and only two plans will be added.
Ahern said it鈥檚 important to check whether your plan will be offered again because participants under the expiring plans will be reassigned by their insurer.
鈥淲hen a plan ends, the insurance company assigns them to another plan, not knowing their budget, medications or doctor, and oftentimes the assignment is very bad for a person because they go to a doctor and suddenly they鈥檙e paying the whole bill,鈥� he said.
One of the other major changes will be to the PERA plans. According to Ahern, the out-of-pocket cost, deductible and benefits will remain the same, but the premium (a monthly fee for having the insurance) will increase by $197 a month, almost $2,400 a year.
Ahern said although Medicare Advantage plans are largely prohibitive, they can be the right plan for certain people, so reviewing your options with a State Health Insurance Assistance Program counselor or insurance agent is the best way to ensure you select the right plan.
However, he said State Health Insurance Assistance Program is not financially incentivized or limited to certain plans like insurance agents are.
The State Health Insurance Assistance Program will accept walk-ins every Thursday, at their office 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.
HINDRANCE TO HOSPITALS
Medicare, Medicare Advantage plans especially, are also a substantial worry for hospitals and health providers.
The chief executive officers of Community Hospital (Chris Thomas), Delta Health (Cohee) and Family Health West (Korrey Klein) all said the plans hinder their abilities to care for patients while placing a financial strain on hospitals that choose to accept Medicare Advantage.
Cohee said the limited coverage of services and providers results in most Medicare Advantage patients requiring care that will only be covered through an approved prior authorization.
According to Community Hospital鈥檚 Thomas, those prior authorizations are almost always rejected. He said there have been several instances where they received prior authorization and provided the service, only for the insurer to backtrack and deny reimbursement afterwards.
Thomas and Cohee both said that even when the hospitals are reimbursed, the payment is always less than the actual cost of care. That tension has caused several hospitals nationwide to refuse certain (if not all) Medicare Advantage plans.
鈥淚 think there鈥檚 going to be a tipping point where we just finally say we鈥檙e not taking any Medicare Advantage plans anymore because it is just such a challenge,鈥� Thomas said. 鈥淲e don鈥檛 get paid what it costs us to provide the care to begin with, but then for them not to even pay us for the services we do provide, I think it鈥檚 getting to a point where there鈥檚 going to be a line in the sand.鈥�
Still, the number of Medicare Advantage enrollees has grown each year. According to Ahern, more than half of the 35,000 Mesa County residents enrolled in Medicare have an Medicare Advantage plan.
That proliferation of Medicare Advantage plans has strained hospitals to the point where the CEOs have made it their mission to teach as many people as possible about Medicare Advantage and what they should consider.
Family Health West CEO Klein has facilitated several community presentations on the open enrollment and Medicare, and he will host one more at 10 a.m. on Oct. 30 at Community Hospital. He said that while Medicare Advantage is largely disadvantageous to the hospitals, it鈥檚 possible that some people can find value in an Medicare Advantage plan.
鈥�(One factor is) how much risk or anxiety you want to take,鈥� Klein said. 鈥淪ome seniors will pay a more expensive premium for a more robust plan, knowing that they鈥檒l have less worry about health care costs over the next year; whereas someone else might be willing to take the risk at a lower premium, hoping they don鈥檛 get sick.鈥�
Klein said what鈥檚 most important for beneficiaries is to consider how healthy they are, what sort of care they anticipate needing, what their most expensive prescriptions are and which plans cover which medicines. He said most Medicare Advantage plans are limited to one state, so people who travel often or live part-time in another state should consider traditional Medicare.
鈥淜eep (your traditional Medicare) 鈥� it should be that simple,鈥� Cohee said. 鈥淭he Medicare Advantage plans make their money off of limiting your services. You鈥檙e going to limit your network and the specialties that you can (see).
鈥淭hey are ultimately in control of your medical future, and that鈥檚 the scary thing.鈥�