Medicare changes in the bill passed on July 4,2025

 Although most health insurance discussions about the reconciliation law passed on July 4, 2025 are about Medicaid, there are significant impacts to Medicare and the Affordable Care that will diminish those programs.  Most of the impacts are difficult to understand, maybe intentionally, but I'll try to describe some of the Medicare impacts so that you can rant and rage to your elected officials about the broken promises of the current administration.

1. In 2023, Centers for Medicare/Medicaid (CMS) issued an order to make it easier for newly Medicare eligible low income people to automatically get help with the cost of Medicare.  The new enrollees currently must apply for those programs separately from enrolling into Medicare to get the benefits and many do not know assistance programs even exist.  The new rules were to go into effect in 2026 (because enrollment systems needed to be enhanced).  This bill stops that initiative and postpones any implementation of it until 2035.  

2. Medicare/Medicaid eligible recipients who reside in nursing homes have consistently encountered "understaffing" in the nursing homes, causing them to have a low quality of care.  Again, in 2023, an order was issued to focus on increasing staffing as part of licensing a nursing facility.  Those staffing regulations have been suspended.  Also, Medicare/Medicaid people will be less able to "age in place" in their residence because there are cut backs in those programs.

3. Lawfully present immigrants who paid payroll taxes for Medicare, will NOT be eligible for enrollment into Medicare even though they paid into the system.

4. This is complex.  There is something called "PAYGO" that relates to the overall cost of Medicare, if it runs a deficit in a given year.  It almost always happens.  Usually the deficit Medicare runs is added to the national debt (I am grossly simplifying this).  If that isn't done, then the Medicare healthcare coverage has to be reduced.  For example, the "free screenings" in Medicare might no longer be "free".

5. Stand alone part D drug plan premium increases and availability of part D plans are at risk.  We already saw some of it in 2025. Prior to 2025, the choices for a part D plan in a given zip code were around 30 plans.  This year it dropped to about 11 plans.  More importantly, the premiums for the plans increased in 2025 but there was a cap on how much premiums could increase and it was no more than $35.  There appears to be no premium increase cap after this year so there is no knowing what part D premiums will look like in 2026.  

The Affordable Care Act insurance has been hit hard too. The subsidies are drastically reduced and the insurance companies are already talking about how the premiums for ACA policies are going up more than 25% in 2026. Many policy holders won't be able to afford the insurance.

Medicare Advantage Horror Story

 Most articles I read about pros and cons on Medicare Advantage plans do not go into "what ifs".  Here's a "what if" that is hair raising:

A person who was seemingly healthy, had a Medicare Advantage plan (notice, I said "had).  They went to visit a grown child in another state.  Unfortunately, they had a severe medical emergency shortly after arriving in that state and were admitted to the hospital.  It was kidney failure. 

Once the person was stabilized and put onto dialysis, the "emergency' was over.  Unfortunately, as soon as it was no longer an emergency, the Medicare Advantage plan also stopped providing medical insurance because the person was not in their home state, and the MA plan is not obligated to provide "national insurance" coverage.  However, the person was too sick to be transported home.  Since they could not be immediately transported back to their home state when the emergency hit, there was also no medical coverage for transporting the very sick person back home.

The only thing the person could do was flip out of the Medicare Advantage plan and flip into Original Medicare (OM), which is possible because Medicare eligible people who are hospitalized get a "Special Enrollment" that allows them to do it. The person was also able to get a medigap, but only the most expensive one which was $400/mo. Also, the OM coverage only became effective the first of the next month, and the MA plan is refusing to cover the hospital days until the end of the month so the person has thousands of dollars of medical expenses to try to force the MA plan to pay by going through an very onerous appeals process.

The person is now "stuck" in another state until they are healthy enough to be able to travel back home.

Medicare enrollment changes for 2025

This is the time of year to reexamine your Medicare insurance and make changes that will be in effect in 2025.  For those of you who elected to enroll in the UHC Medicare Advantage plan, I urge you to look at the 2025 information you have received.  Medicare Advantage plans are reducing benefits and drug coverage because they are making less money (off the federal government).  Make sure you look at what has changed. 

 If you opted out of the IBM insurance and stayed in traditional Medicare with a separate part D plan, look at your part D plan to be sure it will still be the right plan for you in 2025.  You can do that by looking on www.medicare.gov or by calling Medicare (1-800-633-4227).

The biggest change that happens in 2025 is the change to the structure of the drug coverage.  All the phases and changes to copays as you move through the phases are GONE.  The copay you pay for a drug (after you met the deductible) will be the same until your total out of pocket for all copays for all your drugs (and includes the deductible) is $2,000.  At that point, there are no more copays for the rest of the year. As a result, the insurance companies are not making as much money on the providing of drugs.  Therefore, they raised the drug insurance monthly premiums.  The change in drug plan structure happens for MA plans too. 

Some retirees believe, because IBM sponsored the UHC MA plan, IBM is giving UHC money to keep the benefits robust.  I seriously doubt IBM gives UHC any money at all.  If anything, UHC probably gives IBM money!  Reminder, the federal government gives UHC a boat load of money every month for every Medicare Advantage policy holder.  If the policy holder has few claims, UHC gets to keep a  lot of government money.  Your tax dollars at work. However, IBM did give UHC a huge gift when they pushed retirees to UHC.  No need for UHC to spend money to advertise on TV to woo retirees to the plan, no need to pay insurance agents money for commissions, or if UHC does pay commissions, they pay it to IBM!!  

I continue to hear horror stories about Medicare Advantage denial of coverage for policy holders which sometimes ended in a denial of life saving procedures.  When something is too good to be true, it often isn't true.

Never enroll in a Medicare Advantage plan (it is a hazard to your health)

 AI used by brokers to pick plans to sell:

https://generations.asaging.org/medicare-decisions-should-not-be-left-ai

Prior Authorization prevents you from getting the health care you need:

https://ldi.upenn.edu/our-work/research-updates/the-billing-bottleneck-how-medicare-advantage-insurers-use-prior-authorization/

MA patients have lower rate of hospitalizations, and that might not be a good thing:

https://www.fiercehealthcare.com/payers/study-details-why-medicare-advantage-avoidable-hospitalizations-lower-compared-traditional

Humana decided there's more money to make in selling Medicare Advantage that selling Employer Group Health Plans:

fiercehealthcare.com/payers/humana-shed-employer-group-commercial-business

Surprise Billing:

https://www.fiercehealthcare.com/payers/cms-astronomical-volume-surprise-billing-dispute-cases-taking-toll-agency

Kaiser discussion on 2023 Medicare Advantage payments

One of the speakers, Tom Kornfield, spent 10 years at CMS before he went into the private sector.  He has a vested interest in disparaging the payment changes the federal government is trying to make to MA plans.  I point this out because this CMS changes affect his clients and thereby, indirectly affects the consulting fees his firm will get. I find it hard to believe his spin because of it. This is his background: Tom also spent 10 years working at the Centers for Medicare & Medicaid Services (CMS), where he held a variety of positions focused on MA and Part D payment policy. Specifically, Tom analyzed MA bids and payments and changes in MA payment rates, and he created a policy to allow for 5-star MA plans to market and enroll year-round. 

https://www.kff.org/medicare/event/march-21-web-event-unpacking-the-controversy-over-medicare-advantage/

Action Now Initiative March 3, 2023 letter to CMS captures why CMS needs to rein in the excesses of Medicare Advantage Billing:

https://www.arnoldventures.org/stories/whats-going-on-with-medicare-advantage-arnold-ventures-experts-explain

Analysis of how MA plans are sucking money out of Medicare.  It is soooo complicated.  Why won't the federal government stop the shenanigans?

https://www.healthaffairs.org/content/forefront/born-third-base-medicare-advantage-thrives-subsidies-not-better-care

Never enroll in a Medicare Advantage Plan (because they overbill the government)

 This is great analysis about the insurance industry siphoning off  Medicare funds (aka your tax dollars) and destroying Medicare:

https://www.morningstar.com/news/marketwatch/2024032679/medicare-advantage-is-overbilling-medicare-by-22

Never enroll in a Medicare Advantage Plan (ever)

 The interview in "MedPage Today" is great.  It is with a former CMS Administrator who was a doctor.  There are now many, many news reports about the problems with Medicare Advantage insurance. It is a wonder they are still legal!  Just search Medicare Advantage in the "News" category of your search engine and you'll see them.  Some legislators, like Elizabeth Warren, are trying to sound the alarm. 

https://www.medpagetoday.com/special-reports/exclusives/108980

Never enroll in a Medicare Advantage Plan

Unless you live in a state that requires insurance companies to sell you a Medicare Supplement plan, NEVER enroll in a Medicare Advantage plan, no matter how enticing it seems.  People who live in Connecticut, Maine, Massachusetts or New York are not locked into Medicare Advantage plans if they make the switch.  HOWEVER, if they have a health crisis, they will not be able to easily switch to traditional Medicare until certain times of the year. 

Medicare Advantage is so bad that Scripps, a huge provider practice in San Diego, has stop accepting the plans:

https://thecoastnews.com/two-major-scripps-groups-drop-medicare-advantage/

Rural medical areas around the country are being decimated by how bad it is to deal with Medicare Advantage plans:

https://www.nbcnews.com/health/rejecting-claims-medicare-advantage-rural-hospitals-rcna121012

I don't post much anymore because there is nothing else I can say besides kick IBM to the curb and don't use their plan! Don't use any Medicare Advantage plans.  During Fall Open Enrollment, if you can, go back to using traditional Medicare and a medigap.  Your window to "go back" no matter where you live, is closing.  You can switch back to what you had until December 31, 2023 because you had a 12 month "Special Enrollment" such that the federal government allows you to go back.  After December, it is unlikely you can switch to traditional Medicare unless you live in the four states named above.  

IBM Medicare Advantage NYT report March 23, 2023 re federal government efforts to stop MA fraud

 The NY Times published another report about Medicare Advantage antics on March 23rd.  The federal government is trying to reduce the ways MA plans suck money out of the Medicare trust funds and the backlash, not only from the insurance industry but from some medical providers, is despicable. It seems more than just the insurance industry enjoys sucking taxpayer money into their cash registers. 

The insurance industry is fighting hard by not only lobbying but by running ads telling seniors to complain to their representatives that the government is trying to take away their Medicare Advantage plans.  The lengths to which companies go to make money by deceiving the public is mind numbing.  This is the article, but I am not sure if it will be available to non-subscribers:  

https://www.nytimes.com/2023/03/22/health/medicare-insurance-fraud.html

              This letter to the editor is from a retired doctor who applauds the federal actions:

Re “Biden’s Plan to Cut Billions in Medicare Fraud Ignites a Lobbying Frenzy” (news article, March 23):

As a physician for 50 years, now retired, I applaud this article. It shines a bright light on the abuses by Medicare Advantage plans.

These plans, profit-making corporate entities, are focusing on their bottom line. The way to increase profits for a health insurance company is to collect premiums while delivering as little care as possible. These reverse incentives do not occur with original public Medicare.

When I was in private practice I saw how these Medicare “DisAdvantage” plans attracted patients with deceptive advertising but ended up hurting them, delaying or denying care by requiring prior authorization for expensive drugs or procedures.

We should get rid of Medicare Advantage plans. They add cost but no value to the system of health care for seniors. Unfortunately, lobbying money talks, and these very profitable corporate entities have deep pockets, which permit these abuses to continue. This is shameful.

In New York State, passing the New York Health Act would eliminate this expensive middleman and bring affordable health care to all New Yorkers.

Elizabeth R. Rosenthal
Larchmont, N.Y.

IBM Medicare Advantage AI algorithms decide when to deny medical care

The following article, published on March 13,2023, describes how the insurance industry is using Artificial Intelligence algorithms to determine when treatment is no longer medically necessary.  It is truly a horror story.    Is it geriatric genocide?

https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/

The full article is behind a paywall so if you don't subscribe, here's a summary: 

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Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need.   March 13, 2023.  

From STAT, the health industry news site produced by Boston Globe Media.

 

Health insurance companies have rejected medical claims for as long as they’ve been around.

But a STAT investigation found artificial intelligence is now driving their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people.

Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms, nor able to question their calculations.

Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it. If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don’t recover from their illnesses.

“We take patients who are going to die of their diseases within a three-month period of time, and we force them into a denial and appeals process that lasts up to 2.5 years,” Chris Comfort, chief operating officer of Calvary Hospital, a palliative and hospice facility in the Bronx, N.Y., said of Medicare Advantage. “So what happens is the appeal outlasts the beneficiary.”

The algorithms sit at the beginning of the process, promising to deliver personalized care and better outcomes. But patient advocates said in many cases they do the exact opposite — spitting out recommendations that fail to adjust for a patient’s individual circumstances and conflict with basic rules on what Medicare plans must cover.

“While the firms say [the algorithm] is suggestive, it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow,” said David Lipschutz, associate director of the Center for Medicare Advocacy, a nonprofit group that has reviewed such denials for more than two years in its work with Medicare patients. “There’s no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care.”

Medicare Advantage has become highly profitable for insurers as more patients over 65 and people with disabilities flock to plans that offer lower premiums and prescription drug coverage, but give insurers more latitude to deny and restrict services.

Elevance, Cigna, and CVS Health, which owns insurance giant Aetna, have all purchased these capabilities in recent years. One of the biggest and most controversial companies behind these models, NaviHealth, is now owned by UnitedHealth Group.

In comments to federal regulators and interviews with STAT, many providers described rigid criteria applied by NaviHealth, which exercises prior authorization on behalf of the nation’s largest Medicare Advantage insurers, including its sister company UnitedHealthcare as well as Humana and several Blue Cross Blue Shield plans.

“NaviHealth will not approve [skilled nursing] if you ambulate at least 50 feet. Nevermind that you may live alon(e) or have poor balance,” wrote Christina Zitting, a case management director for a community hospital in San Angelo, Texas. 

 

She added: “MA plans are a disgrace to the Medicare program, and I encourage anyone signing up..to avoid these plans because they do NOT have the patients best interest in mind. They are here to make a profit. Period.”

“I’ve still got friends who say, ‘Oh, I’ve got UnitedHealthcare Advantage, and it’s wonderful.’”

“Well, it is,” she said. “Until you need the big stuff.’”

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This is a 3/15/23 "Here & Now" broadcast from WBUR (NPR) interviewing one of the authors of the article (Bob Herman):

https://www.wbur.org/hereandnow/2023/03/15/ai-algorithms-medicare-advantage

Centers for Medicare Advocacy is a stellar non-profit and reported on this issue in April 2022.  It has taken media organizations over a year to do investigative reporting.  Meanwhile, NOTHING changed.  Medicare eligible people are still being sold Medicare Advantage plans as a godsend, while the sellers force the sick ones out of rehabilitation without impunity:

https://medicareadvocacy.org/ai-plus-ma-equals-bad-care-decisions/

"Skilled Nursing News" also discusses the issue in their publication:

https://skillednursingnews.com/2023/03/ai-use-by-medicare-advantage-blamed-for-increased-denial-of-nursing-home-services/

Updated 3/17/23:

This Vox report in the following link is an easy to understand, concise analysis of Medicare Advantage plans.  It includes a reference to the use of AI.  The only aspect missing, is an analysis of the deceptive ways Medicare Advantage insurance agents lure seniors into the plans, much of which is illegal.  Seniors don't have the wherewithal to know what's happening.  In fact, many seniors rely on their insurance agents the way they rely on their doctors.  They believe the agents are working for their best interests. Often, if/when they discover the truth, it's because they are in failing health.

https://www.vox.com/policy/2023/3/17/23639685/insurance-health-care-medicare-advantage-enrollment-growth

IBM Medicare Advantage NYT report March 10, 2023

 Once again, there is a report about employers shifting retirees to Medicare Advantage plans.  The New York Times published this online yesterday and specifically talks about IBM in the article:

https://www.nytimes.com/2023/03/10/business/medicare-advantage-retirement-nyc.html

You need to be a subscriber to read the full article.  It will be in tomorrow's print edition.   There wasn't anything "new" in the article.  Just another acknowledgement that this is happening. 

It is particularly disheartening to read how NYC retirees appear to be the next group of retirees affected by this scheme even though they have what seemed to be an ironclad union contract.  It is also disheartening that, once again, the reporter writes how retiree health insurance benefits are provided because of the good graces of employers.  NO media outlet will acknowledge these benefits were consistently considered as a form of compensation.  

I particularly remember when the unions were negotiating with NYC for salary increases in the 1970's when the city was almost bankrupt but the strike was settled when the city counteroffered with enhanced retiree benefits. I particularly remember it because, at the time, reporters wrote about how the city and the union were "kicking the can down the road" by freezing salary increases but promising retiree benefit enhancements and how the cost of these benefits would overwhelm future administrations.  Neither the union nor NYC acknowledge that history, and now they scream about the cost of retiree benefits being out-of-hand. 

In IBM's case, when IBM promised retiree benefits, for a long time the executive team actually set aside funding for those benefits.  However, as the benefits trust value increased, and the executive team changed players, the demand for ever higher executive compensation needed to be satisfied. Those trust funds were "raided" to satisfy the demand.  It's in "Retirement Heist", by Ellen Schultz.  I referenced that book in an earlier post.

Meanwhile, the travesty of Medicare Advantage depleting Medicare trust funds by pushing more and more seniors into the plans while continuing to maliciously deny policyholders adequate healthcare continues.  The current administration is trying to rein in some of the Medicare trust fund abuse by Medicare Advantage plans (this is described in the NYT article) but it is modest.  Even so, the political opposition scream it is an attack on Medicare.  If they had Pinocchio noses, this lie would give them ten foot long noses. 

Centers for Medicare and Medicaid Services also claim they are putting pressure on MA plans to tap down the denials, but, if anything, it is getting worse. CMS rarely puts pressure on MA insurance providers, no matter who is in the White House. Maybe it's because most CMS leaders end up working for the insurance industry when they leave public service?  Why is that even legal?

Yesterday I counseled someone whose parent was another victim of an MA denial of coverage.  As usual, the MA plan denied additional inpatient treatment at a Skilled Nursing Facility and forced the facility to discharge the patient.  They never advised there could be a second opinion provided by the parent's doctor as part of appealing the discharge. Why would the MA plan do that?  The patient was sucking too much money out of their claim payment bucket so they had to be discharged.  So, the person tried to find "another place" for the parent to go, because going home was not an option given the condition of the parent. And that, my friends, is why Medicare Advantage plans are horrible.