30 Policy Goals for Medicare’s Future
Thinking ahead to the next 30 years, it’s critically important to broadly modernize benefits in both Original Medicare and private Medicare plans. At the same time, it’s essential to pursue changes that improve how 60+ million people with Medicare navigate their coverage on a daily basis. In no particular order, here are our evolving 30 policy goals for Medicare’s future.
1. Make Prescription Drugs More Affordable
Medicare Rights supports efforts to meaningfully reduce drug prices and lower costs for both people with Medicare and the program as a whole. Potentially effective strategies include allowing Medicare to negotiate drug prices, increasing pricing transparency and accountability throughout the supply chain, and imposing limits on beneficiary out-of-pocket spending. Changes to the current system must be carefully considered and only adopted if they do not threaten to undermine beneficiary protections or access to medications, such as by weakening the protected classes or introducing additional, inappropriate utilization management strategies.
2. Allow Open Enrollment, Guaranteed Issue, and Community Rating in Medigap for All People with Medicare
Though Medigaps help a growing number of people with Original Medicare afford needed care, not everyone is eligible to buy the plans, and most are only guaranteed the right to do so during very limited time frames. Congress must ensure that all beneficiaries have access to affordable, high-quality Medigap policies as well as the opportunity to re-evaluate their coverage choices as their needs change. This includes extending the same federal Medigap protections to beneficiaries under 65 as those provided to beneficiaries over 65 and providing for open enrollment, guaranteed issue, and community rating of Medigap for all people with Medicare.
3. Add a Standard Medicare Out-Of-Pocket Maximum for Beneficiary Cost Sharing
Original Medicare and Part D have no out-of-pocket maximums, exposing beneficiaries to limitless financial risk. While Medicare Advantage (MA) plans do include an out-of-pocket maximum in their benefit packages, this threshold is too high—permitting costs up to $6,700 in 2019. Congress should establish a standardized, affordable, out-of-pocket maximum for Original Medicare, MA, and Part D. To both lower costs for beneficiaries and the system, this change must be coupled with efforts address the underlying problem of high drug prices.
4. Eliminate the Observation Status Penalty
Medicare beneficiaries who need post-hospital care in a skilled nursing facility (SNF) may be forced to pay out-of-pocket for this care when the hospital chooses to assign them to “observation status” instead of admitting them as an inpatient. Congress should reevaluate the three-day hospital stay requirement, and all days in the hospital should count toward coverage for needed SNF care.
5. Ease Access to Medicare Low-income Assistance Programs
Medicare’s low-income assistance programs (Medicare Savings Programs and Part D’s Extra Help) were established to help low-income seniors and people with disabilities afford needed medicines. But today, complex, bureaucratic application processes and outdated eligibility thresholds unnecessarily limit participation. These policies must be modernized to reflect financial realities and to align with reforms made elsewhere in the health care system. Accordingly, Congress should ease or eliminate the asset tests for Medicare low-income assistance programs; lower and align eligibility thresholds; and integrate the programs’ application processes, qualifying criteria, and administration.
6. Address the Medicare Part D “Cliff”
Absent congressional action, an Affordable Care Act provision slowing the growth of the Part D catastrophic coverage threshold will expire after 2019. As a result, Medicare Part D enrollees with high drug costs will have to pay much more out of pocket next year, when the catastrophic coverage threshold increases from $5,100 in 2019 to $6,350 in 2020. Congress must take steps to protect beneficiaries from these higher costs.
7. Require all States to Enter Part A Buy-in Agreements
Part A Buy-in agreements are contracts between state Medicaid offices and the Social Security Administration that allow eligible individuals with very low incomes and limited assets to enroll in Medicare outside of standard enrollment periods. Not only are Buy-in agreements helpful to beneficiaries who might otherwise face higher costs and gaps in coverage, they reduce state Medicaid costs, decrease costly reliance on emergency room care, and minimize future medical expenses by ensuring that those eligible for Medicare are enrolled in the program. Congress should require all states to enter into Part A Buy-in agreements.
8. Eliminate the Two-year Medicare Waiting Period for People with Disabilities
In 1972, Congress granted Medicare benefits to people receiving Social Security disability benefits. This historic step forward was marred by an arbitrary limit, requiring that people with disabilities wait a full two years before gaining access to needed coverage. This provision was included merely to cut costs. Now, people with disabilities are at risk of lacking coverage as they wait for Medicare eligibility. They are forced to navigate two benefit start dates and obtain temporary coverage during this gap. Congress should eliminate this outdated, complicated, and confusing waiting period and allow people with disabilities access to Medicare at the same time they receive their disability benefits.
9. Ensure Parity in Original Medicare and Medicare Advantage
Medicare Rights urges Congress to ensure equity between Medicare Advantage (MA) and Original Medicare, including both the scope of services provided and programmatic spending. This includes guaranteeing equal access to all services, such as supplemental benefits, implementing reforms that will eliminate overpayments to MA plans, and halting abuses of patient categorization rules—known as “upcoding”—that some health plans engage in to secure unacceptably high payments.
10. Provide Medicare Coverage for More Home Health and Long-term Care Services
Medicare (including Original Medicare and Medicare Advantage) does not cover many long-term services and supports. And it covers help with activities of daily living, like eating and bathing, only in very limited circumstances. Reflecting broad national trends, many callers to the Medicare Rights national helpline seek help paying for this care. Congress must modernize the Medicare program to meet this growing need by expanding coverage for services that allow beneficiaries to remain in their homes and for family caregiver supports, like respite care and adult day health care, and by filling existing coverage gaps, such as eliminating the requirement that Medicare beneficiaries need skilled care and be homebound to qualify for home health coverage, as well as the “use in the home” limitation on DME.
11. Strengthen Non-Medicare Home and Community-Based Services
Because Medicare generally does not cover many home and community-based services (HCBS) and long-term services and supports (LTSS), older adults and people with disabilities rely on a constellation of other programs to fully participate in their communities, including Medicaid and the Older American’s Act (OAA). Accordingly—while developing alternative, longer-term LTSS financing solutions—Congress must ensure these programs are up to the task. This includes best positioning Medicaid to serve beneficiaries in the least restrictive, most appropriate setting by expanding the Independence at Home demonstration, reauthorizing the Balancing Incentive Program, and making both the Money Follows the Person program and the HCBS spousal impoverishment protections permanent. At the same time, Congress must adequately fund OAA and other programs that help older adults and people with disabilities maintain their health and independence.
12. Support Family Caregivers and Strengthen the Health Care Workforce
The nation’s fragmented LTSS system means that people with Medicare who desire to age in the community often largely rely on unpaid family caregivers and undervalued home care workers to do so. Congress must better support these families and paid workers, including by creating federal paid family and medical leave that recognizes caring for relatives of all ages, adequately funding annually appropriated HCBS and caregiver support programs, and recruiting and retaining a robust home care workforce.
13. Address the Social Determinants of Health
Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. While comprehensively addressing the root causes of and health outcomes associated with social determinants of health is a complex, long-term endeavor, there are steps policymakers can take today to more holistically meet the needs of people with Medicare. We encourage policymakers to ensure that effective approaches are equally available to all beneficiaries.
14. Cover Oral Health Care
Despite the wealth of evidence that oral health is related to physical health, Medicare excludes routine dental care from coverage. While some Medicare Advantage plans may offer dental benefits, this coverage is often limited and can be inconsistent both across plans and from year to year. To address this unmet need, Congress must add a comprehensive oral health benefit to Part B. To best reflect the evidence base and align with the scope of current Medicare coverage, this benefit should be structured to include both medically necessary procedures as well as preventive care, and subject to the same cost sharing rules as other Part B services.
15. Cover Vision and Hearing Care
Lack of hearing coverage can increase the risk of dementia and contribute to social isolation, which can in turn heighten one’s risk for depression and chronic illness. Similarly, uncorrected vision acuity loss can also cause other, significant health issues and adversely affect quality of life. Despite these troubling—and costly—consequences, Medicare does not cover many routine vision or hearing care needs. While some Medicare Advantage (MA) plans may offer supplementary vision or audiology coverage, quality and cost vary considerably from plan to plan. The absence of meaningful coverage for these basic health needs represents a stark gap in coverage for older adults and people with disabilities. Congress should add standardized, high-quality, affordable vision and hearing benefits to Original Medicare and MA plans.
16. Provide Mental Health Parity in Medicare
Medicare is not fully subject to the federal law requiring equivalent coverage for mental and physical health conditions. As a result, unequal treatment remains. For instance, Medicare caps coverage for care at inpatient psychiatric hospitals at 190 days over a beneficiary’s lifetime. This same limit does not apply to inpatient psychiatric care received at non-specialized facilities, or for non-psychiatric care. Congress should eliminate this and other barriers to care, and ensure the full range of mental health services providers are eligible for Medicare reimbursement.
17. Expand Access to Telehealth
When thoughtfully designed and carefully implemented, telehealth can facilitate cost-effective care delivery. While administrative and legislative telehealth expansions tend to focus on increasing access within Medicare Advantage, we encourage policymakers to pursue parity with Original Medicare, so that all beneficiaries can access these services. Policymakers must also ensure robust consumer protections are in place before broadening telehealth options and require plans and providers to demonstrate how they intend to address inequalities in access to the internet and devices so that telehealth benefits are available to all enrollees.
18. Pass the BENES Act
Complex Medicare enrollment rules and lack of notification cause tens of thousands of older adults and people with disabilities to face lifetime penalties, coverage gaps, and other harmful consequences. The Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act (S. 1280/H.R. 2477) would help people avoid making these costly errors by modernizing the Part B enrollment process. It would ensure that people approaching Medicare eligibility receive clear and timely information about Medicare Part B enrollment rules, simplify Part B enrollment periods, and improve transitions to Medicare by eliminating needless gaps in coverage.
19. Expand Special Enrollment Period (SEP) Rights
More people new to Medicare should have access to a Special Enrollment Period (SEP), allowing them to more easily enroll in Medicare after their existing coverage ends. Currently, federal law only grants a SEP to individuals with employer-sponsored group coverage and for eight months after that coverage ends. Making SEPs more widely available would help prevent enrollment errors that often result when people transition to Medicare from other, non-employer coverage. Medicare Rights supports making SEPs available to people with pre-Medicare coverage other than employer-sponsored group health plans, including COBRA, VA coverage, retiree insurance, and Marketplace plans.
20. Strengthen Equitable Relief
Limited avenues for relief are available to those who make mistakes when enrolling in Medicare. Specifically, beneficiaries facing lifetime penalties and gaps in coverage can only remedy their situation if they can prove that an agent of the federal government misinformed them about enrollment rules. Yet many people turn to their employer or health plan—not a federal agency—when transitioning to Medicare. To provide adequate recourse for those who make honest enrollment mistakes, Congress should expand equitable relief to include misinformation from non-federal sources, such as employers, employer-sponsored or individual market health plans, and insurance brokers.
21. Reduce or Eliminate the Part B Lifetime Late Enrollment Penalty
Erroneously delaying Medicare Part B can have significant consequences—including a lifetime premium penalty. Designed to encourage enrollment when first eligible, this late enrollment penalty is also imposed on those who simply make a mistake. For as long as they have Medicare, these individuals will pay the regular monthly Part B premium plus an additional 10 percent for each year they delayed signing up. While it is important that a penalty appropriately deter anyone who might actively seek to avoid Medicare enrollment, it must not punish those who make honest mistakes. Congress should enact policies to reduce or eliminate lifetime premium penalties for beneficiaries who were misinformed or uninformed about Medicare enrollment rules.
22. Consolidate and Standardize Medicare Advantage and Part D Plans
Selecting a Medicare Advantage (MA) or Part D plan is a daunting task for many. Alarmingly, only 13 percent of Medicare beneficiaries opt to reevaluate their coverage options year to year—despite annual changes to premiums, plan coverage rules, and cost-sharing. This decision-making process is likely to become even more difficult, as plans adopt new flexibilities around uniformity and benefit design. Congress should enact legislation to consolidate MA and Part D plan choices and standardize options in order to facilitate informed beneficiary decision-making.
23. Improve Decision-Making Tools
Policymakers must ensure that people with Medicare have access to accurate, actionable, personalized information they need to make optimal coverage decisions, both initially and annually. This includes improving Medicare Plan Finder—the federal government’s primary enrollment tool—to be more accurate complete, and easy to use. Similarly, Medicare Advantage and Part D plans should be required to provide a tailored Annual Notice of Change to all enrollees. This notice should be based on claims data and clearly describe how the plan will change in the coming year.
24. Prohibit Medicare Advantage Plans from Dropping Doctors Mid-year without Cause
Beneficiaries enrolled in Medicare Advantage (MA) plans should be able to count on stability in their plan networks and the knowledge that their doctors will be there when they need them. Congress should pass legislation that prohibits MA plans from dropping doctors without cause in the middle of the plan year and strengthens beneficiary notice regarding provider network changes.
25. Adequately Fund Medicare Outreach Programs
Medicare State Health Insurance Program (SHIP) counselors—most of whom are highly-trained volunteers—provide one-on-one, unbiased, personalized counseling to Medicare beneficiaries, helping them understand their rights and coverage options. And through the Medicare Improvements for Patients and Providers Act (MIPPA), SHIPs, Area Agencies on Aging, and Aging and Disability Resource Centers help low-income Medicare beneficiaries access programs that make their health care and prescription drugs affordable. Congress should adequately fund these programs and make MIPPA permanent in order to better meet current and future needs.
26. Improve Pharmacy Counter Communications with Beneficiaries
Knowing why a prescription drug is denied at the pharmacy counter is critical to helping beneficiaries determine their next steps—whether it is working with their physician to secure an alternative or appealing for coverage from their Part D plan. All Part D plans should be required to provide an individually tailored denial notice at the pharmacy counter, explaining why the prescription cannot be filled. Further, this notice should count as a coverage determination—eliminating a needless step in the appeals process for Medicare beneficiaries.
27. Improve Medicare Advantage and Part D Denial Notices
Among the most common calls to the Medicare Rights helpline are those from beneficiaries who were denied access to a health care service or prescription medication and don’t know how to proceed. Congress should require CMS to ensure Medicare Advantage and Part D plan denial notices include the correct information (including clinical content), are available in languages other than English, and are accessible to diverse health literacy levels.
28. Allow Independent Redeterminations
The first level of appeal following a plan’s initial decision must be a truly independent and good-faith effort to determine coverage eligibility. This would better ensure that plans are accurately effectuating their coverage determination decisions. Congress should pass legislation requiring that a plan’s initial coverage decision be reviewed by an independent entity, rather than the plan itself. In addition, overturned decisions must trigger a review of the file and necessary employee training.
29. Improve Transparency, Data Collection, and Plan Oversight
All Part D appeals conversations are hampered by limited data and transparency in the process. Beneficiaries and advocates alike can struggle not only to track an individual’s specific claims, but also plans’ or system-wide patterns that may be tied to hundreds of thousands of Medicare beneficiaries improperly going without their needed medication. Further, better data could lead to better solutions, as a more transparent system will lend itself to targeted recommendations and self-correction. Congress should require CMS to conduct and make publicly available a comprehensive, in-depth analysis of the Part D appeals process. In part, this analysis should include data collection on specialty tier medications and should extend to all levels of appeals, from plans through the Medicare Appeals Council and federal court.
30. Allow Appeals on the Part D Specialty Tier
When medically necessary, people with Part D have the right to request that their plan allow them to pay less for high-cost medications when a similar, lower-cost medicine is available on their plan’s formulary—this is known as a tiering exception. Unfairly, these same rights are not granted to beneficiaries whose prescription drugs are placed on the plan’s specialty tier, where cost-sharing can be exorbitant. Congress should pass legislation allowing Medicare beneficiaries the right to a tiering exception for specialty tier medications.