Did you fall in the bathroom and fracture your hip? Medicare, if you have it, will pay thousands of dollars for surgery to repair the injury and thousands more for your resulting hospital stay and rehab in a nursing home.
But Medicare wouldn’t have paid $200 to have grab bars installed in your bathroom, or covered the cost of a $22-an-hour aide to assist you in the shower — measures that might have helped you avoid the accident.
For decades, public health experts, doctors, patients and families have lamented this narrow, often counterproductive approach to older Americans’ health care.
“You don’t want somebody with asthma rushing to the emergency room with a breathing problem that could have been prevented with an air conditioner,” said Tricia Neuman, who directs the Medicare policy program at the Kaiser Family Foundation. Yet Medicare covers costly emergency medicine, not window units.
That might start to change next year, though, for those enrolled in Medicare Advantage plans — about a third of those insured by Medicare. Officials announced this spring that they’d “reinterpreted” the definition of “supplemental benefits” for Medicare Advantage.
When Medicare’s open enrollment period begins on Oct. 15, the private insurers that underwrite Advantage plans — which already lure seniors with things traditional Medicare can’t cover, like eyeglasses, hearing aids and gym memberships — will be free to add a long list of new benefits.
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Among those the Centers for Medicare and Medicaid Services will now allow, if they’re deemed health-related: Adult day care programs. Home aides to help with activities of daily living, like bathing and dressing. Palliative care at home for some patients. Home safety devices and modifications like grab bars and wheelchair ramps. Transportation to medical appointments.
“This will potentially help people stay in their homes longer and not have to go to institutions,” Seema Verma, the C.M.S. administrator, said in an interview. “You could provide a simple device or a home modification that could mean the world to a patient, but plans weren’t allowed to do that in the past.”
In 2020, thanks to Congress, the list of possible benefits could expand still further. Incorporated in the budget signed by President Trump, the Chronic Act is intended to help people manage conditions like heart failure and diabetes, in part by authorizing telehealth programs. It, too, will work through Medicare Advantage.
These actions could represent substantial change. Dr. Diane Meier, a geriatrician who directs the Center to Advance Palliative Care at the Icahn School of Medicine at Mount Sinai in New York, called them “a tectonic plate shift.”
“What I find most fundamental is the recognition, by C.M.S. and Congress, that this bright line between ‘medically necessary’ and things necessary to maintain health — like proper nutrition and transportation to a doctor’s office — is an illusion,” she said.
“Failure to invest in simple things like safe housing and transportation means you will invest in hospitalization and emergency room visits” at far higher costs, she added.
Yet celebration may prove premature. Many questions remain about how insurers will respond to the legislative opening.
“We have concerns about where all this is heading,” said David Lipschutz, senior policy lawyer for the Center for Medicare Advocacy. “The scales really are being tipped in favor of Medicare Advantage, with unknown consequences.”
A primer: Medicare Advantage funnels federal dollars to private insurers — United Healthcare and Humana dominate the market — who must cover all Medicare services but can also dangle a number of bonus benefits.
Dentistry, for instance. Original Medicare doesn’t cover it, but with Medicare Advantage, “some plans cover cleaning,” Dr. Neuman said. “Some cover cleaning and extractions. Some might cover a crown every five years.” Now, such extras could expand.
The plans — including premiums and benefits — already vary widely. Enrollees pay the monthly Part B premium ($134 this year, though higher income people pay more) and may pay an additional Medicare Advantage premium. Last year, according to Kaiser Family Foundation analysis, that ran an average $36 a month, including Part D drug coverage.
So Medicare Advantage plans may appear cheaper than standard Medicare combined with Part D and a supplemental Medigap policy — though with co-pays, deductibles and drug formularies, they may not be.
“The key trade-off is that they generally operate with a restricted network of providers,” Dr. Neuman said. Most involve health maintenance or preferred provider organizations.
The proportion of Medicare beneficiaries who opt for these plans has climbed steadily, nonetheless, to 33 percent last year from about 16 percent in 2006. In 10 years, the Kaiser Family Foundation calculates, that figure will reach 42 percent.
“The Medicare Advantage program is very successful,” Ms. Verma said. “We see consistently high marks for satisfaction.”
Additional benefits could accelerate that growth, and Ms. Verma said she hoped they would.
“When people look at making a choice between enrolling in Medicare Advantage or the traditional program, they’re going to see this as a tremendous opportunity,” she predicted.
The immediate changes may be modest. Because C.M.S. announced its new rules in April, and insurers had to submit proposals last month, “there was very little time for the plans to mobilize,” said John Gorman, a consultant for many Medicare Advantage insurers. He expects more significant differences in 2020 and beyond.
What particularly troubles skeptics is that these intended improvements completely bypass most Medicare beneficiaries — the two-thirds who have stuck with traditional Medicare.
You can see why it’s played out this way. Funding for Medicare Advantage programs is capped: C.M.S. provides a set amount, which private insurers can use to provide whichever supplemental benefits they choose, theoretically stoking competition. Any increased costs will be borne by the plans and their enrollees, not the federal budget.
“Republicans have always been some of Medicare Advantage’s biggest boosters,” Mr. Gorman noted. “In effect, you’re shifting deficits onto the private sector.”
As for the remaining Medicare population, “advocates are hoping this provides a pathway to expanded services for all beneficiaries,” Dr. Neuman said.
But Ms. Verma said that could raise costs and would require Congressional action. Moreover, C.M.S. also relaxed the requirement that Advantage plans must provide the same services for all enrollees. Now, they can furnish benefits to those with certain health conditions, not to everyone.
Thus, a plan can tailor its offerings, providing adult day programs, say, only for people with dementia. “If you see a plan advertising certain supplemental services, that’s not necessarily a guarantee the services will be available to you,” Mr. Lipschutz said.
In fact, since the more flexible rules permit but don’t require any of these new benefits, and since insurers won’t reveal the particulars until October, it’s not yet clear what they will offer — or whether these changes might weaken traditional Medicare.
Advantage plans could provide certain benefits one year, then withdraw them the next, in the same way that drug coverage shifts. As for providers, “who’s in-network and who’s not changes by the minute,” Dr. Meier said.
Nationally, consumers interested in Advantage programs can choose from an average 21 plans, most offered through a handful of large insurers.
Once they enroll, few people ever switch. “People find it very tedious, and they have little confidence in their ability to understand how plans differ,” Dr. Neuman said.
Now, those choices will grow still more complicated. The independent counselors at the free State Health Insurance Assistance Programs should probably brace for waves of new clients.
“It’s all going to require experimentation,” Dr. Meier said.
Still, a move to more broadly support the health and well-being of an aging population could mark an important turning point.
“Could” is the key word. “It’s only a possibility,” Dr. Meier said. “But it wasn’t a possibility before.”