Some Constructive Criticism On RFKjr's Senate Hearings...

The Good, bad, and ugly.

As most might know I was a high level HMO Claims Auditor and Manager who supervised a group of about a dozen other auditors for Verity Medical Foundation in San Jose. I even help defend ourselves against a CMS audit in Los Angeles ~2018 when we were the MSO for AllCare IPA in Lynwood if I remember correctly? Anyhow, I think I’m uniquely qualified to weigh in and give Bobby’s Senate presentation a little critique.

I took two snippets from each day and created this 5min video with my commentary embedded so I can explain further where Bobby was strong and where I wish Bobby would have spoke to someone like me before going into the lion’s den.

I’d like to preface this critique by saying I dig Bobby and I hope he is confirmed. Bobby is no saint and nobody else is either, he had his strengths but I’m not here to blow warm air you your skirt, I was a little butt hurt there was no mention of the huge amount of vax injured. I was also butt hurt listening to Bobby say he supports Polio and MMR vaccines and the childhood schedule. Hey I get it and I’m willing to give Bobby a pass for needing to bend over in this theater. I’m keeping my fingers crossed he gets confirmed then throws off the sheep’s skin and shows big pharma the teeth I think he has. I think you are about to go all in and your actions as HHS Secretary will determine where your eternal soul will go. God Bless you Bobby.

Critique #1) Dual Eligibles aka the Medi-Medi patient:

Why are dual eligible medi-medi patients not being served well, as opposed to Bobby himself who has a Medicare Senior Advantage plan and “is very happy with it” as he stated to Senator Dr. Cassidy in Day 1 testimonies? The real devil in the details is with Bobby’s secondary or supplemental insurance that he must have, because Bobby for sure does not have Medicaid as his secondary insurance. As most of us who’ve dealt with insurance before are familiar with deductibles, co-pays, and co-ins obligations, we know that Medicare publishes a maximum reimbursable fee schedule and from there Medicare will pay 80% of that fee leaving a 20% obligation to the patient. Medicare calls this a co-ins obligation. From here this 20% gets billed to the secondary insurance for them to pick up. Medicare also has an annual deductible of ~$125 which used to be $100/yr for many many years. Your secondary in most cases will cover the deductible portion.

So here’s the rub, say I’m Bobby’s twin and I go in and get all the same services Bobby gets at the same hospital on the same day and get all the same labs and x-rays, etc… The difference between Bobby and I is that I’m a Medi-Medi Advantage Care recipient with let’s say Blue Cross Medicaid as my secondary. All my services are identical to Bobby we even see all the same doctors, as matter of fact since we’re twins Dr. Gupta even grabs our testicles at the same time and tells us to cough, but not in each others faces obviously.

Well Dr. Gupta will get paid the full $100 for Bobby’s office visit, $80 form Bobby’s primary Medicare and $20 from Bobby’s secondary which we will call it AARP.

Dr. Gupta will only expect $80 for Albertito’s office visit reimbursement because when my $20 crosses over to Blue Cross Medicaid, the provider is told sorry Charlie, per contract our maximum allowable reimbursement is $70 and you Dr. Gupta have already been reimbursed more than our max payment. Therefore per contract Dr. Gupta you are obligated to perform a contractual adjustment known as a “Medicaid Cutback”¹ and write the balance off, and simply move on.

Let it be known as a Chargemaster I will tell you in California the Medicaid rates are set at about 70% of the full 100% Medicare maximum reimbursement and across the board on average. Very few services exists where Medicaid actually pays more than Medicare does, one item is the cataract surgery. If there is a ophthalmologist reading this article please chime in and tell me I’m not wrong. Medicare pays ~$800ish while Medicaid pays ~$1000ish for a cataract surgery. Many factors go into calculating a relative value for this surgery but one of the main factors is that it’s calculated that a physician needs about 35min OR time to perform this operation. Most ophthalmologists with a ton a surgeries under their belt can get this procedure done in under 20mins these days because of the sharp blade and the fact the IOL lens can be folded like a taco and inserted with a quarter incision instead of the full half moon incision like in the old days and before the folding taco IOL lens.

Ok so what’s the problem? Services were rendered at same hospital or clinic, same exam room, same doctor and quality of care was excellent for Bobby and I, we even shared a soy latte at the local Starbucks afterwards?

The problem is Dr. Gupta chose to decline his participation in the Medicaid program and would have or should have notified me before services were rendered with an Advanced Beneficiary Notice (ABN) that I would be obligated to reimburse (pay) the 20% even though I had secondary Medicaid coverage! No ABN and Gupta is shit out of luck, if a ABN was properly executed I’m SOL, that’s how it’s suppose to work. Dr. Gupta could even be so fed up and burned in the past trying to bill his patients directly and setting up payment plans that he just decides to not even accept Medi-Medi patients at all, but continue to see people like Bobby all day long that have Medicare with some other secondary non-Medicaid coverage.

Can you guys see the problem with Dr. Gupta that he currently has every right to cherry pick his patients? Is it legal? Yes.

Here’s another problem with the greedy Dr. Gupta… Let’s say I’m a cash pay patient with no insurance and I come in and ask Gupta how much do I need to pay for a office visit? Gupta tells me, that will be $300 and payment is accepted before services are rendered. I say wow, I know you get paid $100 from an Advantage Plan and you even need to bend over, get pre-authorization and wait 30 to 45 days for payment? I offer Gupta $150 and the office manager screams at me like she has just been insulted and asks me to leave. Not even a counter offer of like $200 which I probably would have paid because I have no other choice.

The system is upside down but it’s where we are at, and there are many doctor like Dr. Gupta and with a God complex. Hay screw that, the 1st hard fast ball pitch I’d throw at physicians chins is to obligate them to Medicaid participation if they want to be Medicare providers at all. Believe me, this move alone would beat most physicians into reasonableness real quick!

I wouldn’t leave the providers out in the rain however, I would maybe give a small 3% bump in Medicare reimbursement but fix that Medicaid Cutback bullshit so the provider doesn’t take it in the ass so much, maybe just a little? This means the government has to go a little deeper in their Medicaid purse in exchange for obligating providers to Medicaid if they want to continue to see Medicare patients.

Believe me the current winners in this managed care scheme is the Insurance Managed Care companies like Blue Cross, UHC, Cigna, Aetna, etc. gang raping the government just in management fees for running a HMO, a claims shop, utility management department, etc…

Apples to apples I think Uncle Sam could even save money by reimbursing physicians more, and do away with the managed care system we currently are saddle bagged with….

Critique #2) Medicaid premiums are too high? Most Medicaid recipients are not happy?

I don’t even know what to say on the premiums? This was a swing and a whiff in my opinion. Premiums² is a good sound bite, but it’s not the major or foremost reason people are not happy with their Medicaid. Who doesn’t like their Medicaid Visa Gold Card? You are almost right Bobby, accept recipients do like their almost free Medicaid Visa Gold Card there is just virtually no providers in town willing to participate in Medicaid except your local county hospital which is basically obligated to participate. The bottle necks in the ER rooms are just ridiculous because the ER’s are filled with runny noses and fevers. Sorry but the stick and carrot approach is needed here again with the providers. It does suck pretty hard for most Medicaid recipients when your only option is a grungy county hospital.

Also maybe if Medicaid started to reel back in the Family PACT program (Planning Access Care Treatment)³ the government tit could save billions on condoms, Birth control pills, contraception of every kind including permanent sterilization. The real bullshit in this seemingly well meaning program that exists all over the country is that age requirement is people of child baring age, and SS# are “self reported” meaning your are on your honor to give the correct SS# to participate in the program, your SS# will not be double checked. Oh yes, you also have to be a resident of California and the meaning of resident means if you slept in California last night then you qualify as a resident. Condoms! Condoms! Get your free condoms, birth control pills and cinnamon flavored lubes and jellies at your local high school daycare center! What, your high school doesn’t have a daycare center attached for kids having kids? Shiiiit Lemon we are way ahead here in San Jo and all these daycare centers in the high schools have sleeves of hot Medicaid FPACT cards ready to go and can be activated right at the front desk. Just like you write your name on the back of your credit card, you write your name on your teal colored Medicaid card. Be sure not to call it a green card, it’s too confusing for the Mexicans! lol

Real story, I once had a kid sign up for Family Pact and his name was Fast Johnson. Kids, they get so crafty so quickly. He was 15yrs old or at least that’s what he wrote down and was given a Rx for a full bag of condoms to get at the pharmacy less than a mile away.

Bobby might also want to fix the Presumptive Eligibility (PE) Program⁴ for all the pregnant ladies that seemingly pop out the bushes. Medicaid will presume the girl is eligible for full coverage Medicaid services and issue a Medicaid PE ID# which OB’s have the application and ID# there ready to go and activate. The short list of services are covered immediately, the ID# technically doesn’t even need valid patient demographics to bill Medi-Cal (Medicaid in California). If the provider needs to perform a service in the interest of continuity of care or emergency but it’s not covered on the short list of Presumptive Eligibility services, the provider will have a small window of retro-billing once the recipient is issued full Medicaid Eligibility. You send the retro bills (services) to Medicaid under the newly minted ID# and include the PE ID# in box 19 of the CMS-1500 form. The public would be surprised how many day of delivery services which technically isn’t covered under the Presumptive Eligibility program, but are involved. So many hospitals use a lot of resources making sure these ladies become full scope eligible so the hospital can go back and do the reto-billing. Santa Clara County Valley Hospital (SCVMC) will practically call up the girl everyday after delivery and ask have you completed your application yet? Can you mail it or drive it down here? I've even known a biller or two drive to the girls house or apartment and pick up the completed application.

Critique #3) What is Medicare Part A, B, C, D?

Yikes Bobby! What can I say, it was as easy as saying A⁵B⁶C⁷D is In-patient, Out-patient, Managed Care, and Rx. Bobby got Part C correct but would have helped his cause if he threw in the word HMO or managed care or Advantage. Bobby left a crack for that lady Senator to pounce and play semantics with Bobby, but Bobby knew what he was talking about even though he didn’t quip it out better.

BTW, there are some people that have Part A only, but it’s super super rare for a recipient to have part B only and not Part A. I’m not even sure Part B only even exists? No way is the government tit going to allow seniors (mostly) NOT have hospital coverage, otherwise what hell is everybody paying into social security for?

Critique #4) You should have or could have described your plan or a plan…

I wish Bobby would have coughed up some silhouette of a plan when asked by the Senator Doctor. It sucked a little for me because it felt like Bobby came to the table carrying President Trump’s nut sack and place them on the table instead of his own? I think Bobby has a plan, but this theater is not the venue to let your hair down and lay it all out.

Dang Bobby, you should have walked in wearing your spurs and slapped the first person close enough in the lips and say Medicaid is paying more, Medicare is paying a skosh more, and I’m going to take this stick a beat the physicians in the back of the knees with it until they are beaten into reasonableness. Providers are getting obligated to Medicaid it’s that simple. As for my big punch in your mouth, I’m doing away with Obama Care because it turns out its one of the biggest grifts around! Boom! Mic drop for Bobby!

Critique #5) Not a peep on the multitudes of vax injured

This a big group that fights for and supports Bobby online and on platforms like Twitter-X, Telegram, BitChute, Rumble, MeWe, Minds, Gab, and even Meta Facebook. I can tell you this, they feel jilted. It’s definitely what I sense by the responses watching Bobby dance for the theater. I’m not vax injured but all I can say is ouch!

Footnotes:

Types of Medicaid Cutbacks:

1. Funding Reductions:

   • Federal Funding: Proposals or actions to decrease the federal contribution to Medicaid. This could involve reducing the Federal Medical Assistance Percentage (FMAP), which determines how much of the cost of Medicaid is borne by the federal government versus the states.

   • Block Grants or Per Capita Caps: Suggesting a switch from open-ended federal funding to a fixed amount (block grants) or a capped amount per enrollee (per capita caps), which could limit federal spending but potentially result in reduced state funding for Medicaid if costs exceed these limits.

2. Eligibility Restrictions:

   • Work Requirements: Adding conditions like mandatory work or community engagement requirements for certain Medicaid recipients, which could lead to people losing coverage if they don't comply.

   • Narrowing Eligibility Criteria: Tightening who qualifies for Medicaid by lowering income thresholds or changing other eligibility parameters.

3. Benefit Reductions:

   • Cuts in Covered Services: States might reduce the scope of services covered under Medicaid, such as limiting dental care, vision services, or certain therapies.

   • Provider Payments: Lowering the reimbursement rates for healthcare providers, which might affect the willingness of providers to accept Medicaid patients.

4. Administrative Changes:

   • Increased Red Tape: Introducing more stringent or frequent eligibility verification processes, potentially leading to higher disenrollment rates due to administrative hurdles.

1. Impact of Medicaid Cutbacks:

• Coverage Loss: The most direct impact is the potential for millions of people to lose their health insurance coverage, especially those who are at or near the poverty line, children, pregnant women, the elderly, and people with disabilities.

• Health Outcomes: Reduced access to healthcare can lead to poorer health outcomes, increased emergency room visits, and higher long-term healthcare costs due to untreated conditions.

• Economic Effects: Medicaid not only provides healthcare but also supports jobs in the healthcare sector. Cuts can lead to job losses and reduced economic activity in healthcare-related industries. Additionally, when people lose health coverage, they might become less productive due to health issues, affecting the broader economy.

• State Budgets: States might face increased pressure on their budgets if federal funding decreases, leading to a choice between raising state taxes, cutting other programs, or further reducing Medicaid benefits or eligibility.

• Disparities: Cuts often disproportionately affect minority populations, rural communities, and other vulnerable groups who rely more heavily on Medicaid for healthcare.

Current Context:

• Recent discussions and proposals from political parties, especially noted in posts on X and web articles, suggest significant planned reductions in Medicaid funding to offset tax cuts or other fiscal policies.

• There are concerns about the sustainability of Medicaid expansion under the Affordable Care Act, with some states and federal policymakers contemplating changes like those mentioned above.

In summary, a Medicaid cutback can take many forms, but the core idea is reducing the program's scope, funding, or accessibility, which could have profound effects on health care coverage and public health in the U.S. Given the complexity and political nature of these discussions, changes to Medicaid are often hotly debated and can shift with political leadership and public policy priorities.

2. Medicaid recipients may or may not have premiums, depending on several factors including state policies, income levels, and specific eligibility groups. Here's a detailed look based on the available information:

• Income-Based Premiums:

  • States have the option to charge premiums to Medicaid enrollees, but there are federal limits. Typically, premiums can only be charged to recipients whose incomes exceed certain thresholds, generally above 150% of the Federal Poverty Level (FPL).

  • For example, some states might charge premiums or enrollment fees to pregnant women and infants with family income at or above 150% FPL, or to certain disabled working individuals.

• Waiver Programs:

  • Some states implement premiums through Section 1115 waivers, which allow for more flexibility in program design. States like Arkansas, Indiana, Iowa, Michigan, and Montana have had such waivers allowing them to charge premiums to some enrollees. However, these waivers are subject to federal approval and can change.

• Exemptions:

  • Certain groups are generally exempt from premiums, including most children, pregnant women, and individuals with very low incomes (typically below 150% FPL). Vulnerable groups like institutionalized individuals and those in specific Medicaid eligibility categories might also be exempt from premiums.

• Compliance and Enforcement:

  • There have been instances where compliance with premium payments has been low. For example, in some states, a significant portion of enrollees do not pay their premiums, yet they might not lose coverage immediately due to state policies or federal rules during certain periods like public health emergencies.

• Recent Trends:

  • Recent policy changes or clarifications can affect who pays premiums. For instance, some states have moved towards eliminating premiums for certain groups, like children, since the Affordable Care Act (ACA) made changes to Medicaid eligibility.

• Medicaid and Medicare "Dual Eligibles":

  • For individuals who are eligible for both Medicaid and Medicare (dual eligibles), Medicaid can pay for Medicare Part A and Part B premiums through the Medicare Savings Programs (MSPs), but this does not directly relate to Medicaid premiums.

Given this complexity, whether a Medicaid recipient has to pay premiums largely depends on state-specific policies, income level, and the particular Medicaid eligibility category they fall into. States vary in how they apply these premiums, with some choosing not to impose them at all, while others use them as a tool to promote personal responsibility or manage program costs.

To get the most accurate information about premiums for Medicaid in a specific state or for a particular situation, one should consult with the state's Medicaid agency or a benefits counselor. Remember, this information can change with new legislation or policy updates.

3. Medi-Cal's Family Planning, Access, Care, and Treatment (Family PACT) program is a state initiative in California aimed at providing comprehensive family planning services to low-income individuals. Here's a detailed look at the Family PACT program:

Purpose:

The primary goal of Family PACT is to ensure that low-income individuals have access to family planning services to reduce unintended pregnancies and promote reproductive health.

Eligibility:

• Income: Individuals must have a family income at or below 200% of the federal poverty level.

• Reproductive Capability: Eligible participants must be capable of getting pregnant or causing a pregnancy.

• No Other Coverage: Participants should not have other insurance covering family planning services unless specific conditions apply (e.g., their insurance doesn't cover contraceptives, or they have a high deductible they can't meet).

Services Covered:

Family PACT provides a broad range of family planning services including:

• Contraceptive Methods: Birth control pills, IUDs, implants, emergency contraception, and sterilization.

• Sexually Transmitted Infection (STI) Testing and Treatment: Screening for STIs, counseling, and treatment.

• Pregnancy Testing and Counseling: Including options counseling for positive pregnancy tests.

• Health Education: Information on reproductive health, contraception, and prevention of STIs.

Program Operations:

• Enrollment: Healthcare providers, not county welfare offices, determine eligibility and enroll clients into the program. Upon enrollment, clients receive a Health Access Programs (HAP) card or have Family PACT eligibility added to their existing Medi-Cal Benefits Identification Card (BIC).

• Confidentiality: Services are confidential, which is particularly important for minors who might not want their parents to know about their use of family planning services.

• Provider Network: A variety of healthcare providers can participate, including primary care clinics, solo practitioners, and hospitals that meet specific criteria and are enrolled in Medi-Cal.

Changes and Updates:

• Transition to CalHEERS: The program is moving from an older system to the California Healthcare Eligibility, Enrollment, and Retention System (CalHEERS) for Family PACT client enrollment, changes, and deactivations by early 2025. This includes the end of physical HAP cards, transitioning to digital versions accessible through the Family PACT portal.

Limitations:

• Pregnancy: If a participant becomes pregnant, they are no longer covered by Family PACT for pregnancy-related services but might be eligible for presumptive eligibility for pregnant people until they give birth.

• Non-Family Planning Services: Family PACT does not cover general health services; for other health needs, individuals might need to look into Medi-Cal, Covered California, or other programs.

Benefits:

• Cost: All services under Family PACT are provided free of charge to eligible individuals.

• Accessibility: With a wide network of providers across California, access to services is relatively straightforward.

Conclusion:

Family PACT is a critical component of California's strategy to improve reproductive health outcomes by ensuring that family planning services are accessible to those who might otherwise struggle to afford them. The program not only helps in reducing unintended pregnancies but also plays a role in public health by addressing STIs and promoting informed reproductive choices.

4. Medi-Cal's Presumptive Eligibility (PE) Program is designed to provide immediate, temporary health coverage for specific groups of people who appear to meet Medi-Cal eligibility criteria. Here's an overview of how the program works:

Purpose:

The main goal of the Presumptive Eligibility Program is to ensure that individuals who are likely to qualify for Medi-Cal can access medical care quickly, particularly in urgent situations or when they need immediate health services, without going through the full eligibility determination process initially.

Eligible Groups:

• Pregnant Women: Pregnant individuals can receive presumptive eligibility for prenatal care, labor, delivery, and postpartum care.

• Children: In some counties, children might be eligible for PE, although this can vary by local implementation.

• Adults: Depending on the state's policy at any given time, certain adults, particularly those in the expansion group under the Affordable Care Act (ACA), might qualify for PE. This includes adults without dependent children who meet income requirements.

How It Works:

• Enrollment: Eligible individuals can be enrolled for presumptive eligibility by qualified providers like hospitals, clinics, or county welfare departments. These providers can determine presumptive eligibility if they have been certified by the state to do so.

• Coverage Duration: PE coverage lasts for a limited time, usually up to 60 days, during which the individual can receive Medi-Cal benefits while their full application for ongoing Medi-Cal is processed.

• Application for Full Medi-Cal: During this period, the individual should apply for full Medi-Cal coverage. The PE period gives them time to gather necessary documents and complete the application process without interruption in care.

Benefits During PE:

• While under PE, individuals can access services that are generally covered by Medi-Cal, including:

  • Medical visits

  • Hospitalization

  • Laboratory services

  • Medications (although specifics can depend on the state's formulary)

  • Emergency services

Limitations:

• Temporary: PE is not permanent coverage; it's merely a bridge to help individuals get necessary care while their full eligibility is being assessed.

• Provider Participation: Not all healthcare providers participate in the PE program, so individuals might need to seek care from specific facilities or providers.

• Service Coverage: While most essential services are covered, there might be some limitations or exclusions compared to full Medi-Cal coverage.

Implementation:

• State-Level Decisions: The specifics of how PE is implemented can vary by state or even by county within California, as counties might have different policies or procedures for PE enrollment.

• Funding: The state and federal government share the cost of services provided under PE, similar to regular Medi-Cal.

Benefits:

• Immediate Access: Offers immediate healthcare access which can be crucial for pregnant women or during health emergencies.

• Reduces Uncompensated Care: Helps reduce the burden on healthcare providers for uncompensated care by providing temporary coverage to those likely to qualify for Medi-Cal.

Conclusion:

Medi-Cal's Presumptive Eligibility Program underscores the commitment to ensuring that vulnerable populations receive timely medical attention. It serves as a stopgap measure, providing immediate healthcare services while the more comprehensive eligibility review process takes place, thereby promoting better health outcomes and reducing healthcare disparities.

5. Medicare Part A is primarily concerned with hospital insurance. Here's a breakdown of what it typically covers:

• Inpatient Hospital Care: This includes semi-private rooms, meals, general nursing, and drugs administered as part of your inpatient treatment. Part A covers care in acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, and inpatient care as part of a qualifying clinical research study.

• Skilled Nursing Facility Care: After a hospital stay of at least three days, Medicare Part A will cover care in a skilled nursing facility for up to 100 days, but only for conditions related to your hospital stay. This includes skilled nursing care, rehabilitation services, and other related services.

• Hospice Care: For those who are terminally ill, Part A covers pain relief, symptom management, and support for the patient and their family. Hospice care can be provided at home, in a nursing home, or in a dedicated hospice facility.

• Home Health Care: If you are homebound and need part-time or intermittent skilled nursing care, Part A (or Part B, depending on the scenario) can cover home health services. This includes services like physical therapy, occupational therapy, and speech-language pathology when ordered by a doctor.

• Inpatient Care in a Religious Nonmedical Health Care Institution: For those with religious objections to medical care, Medicare Part A can cover non-medical care in facilities that meet certain criteria.

Costs Associated with Medicare Part A:

• Premiums: Most people don't pay a premium for Part A if they or their spouse paid Medicare taxes while working for at least 40 quarters. If not, there's a monthly premium.

• Deductibles and Co-payments: There's a deductible for each benefit period, which starts when you're admitted to the hospital and ends after you've been out for 60 days in a row. After the deductible, you pay nothing for the first 60 days of inpatient hospital care. For days 61-90, there's a daily coinsurance amount. Beyond 90 days, you can use "lifetime reserve days" with a higher daily coinsurance.

• Skilled Nursing Facility: After the first 20 days, you pay a daily coinsurance amount for days 21-100. After 100 days, you pay all costs.

6. Medicare Part B is the medical insurance component of Medicare, which covers services that are medically necessary for the diagnosis or treatment of health conditions as well as some preventive services to help maintain your health. Here's what Part B typically covers:

• Doctor Visits: This includes visits to your primary care physician as well as specialists.

• Outpatient Care: Services you receive while not admitted to a hospital, like in a doctor's office, clinic, or hospital outpatient department.

• Preventive Services: Many preventive services are covered to help prevent illness or detect it early, including screenings, vaccinations (like flu shots), and counseling for conditions like obesity or tobacco use.

• Diagnostic Tests: This includes lab tests, X-rays, EKGs, MRIs, and other diagnostic imaging.

• Durable Medical Equipment (DME): Items like wheelchairs, walkers, oxygen equipment, and other equipment necessary for home use.

• Home Health Services: If you're homebound and need part-time or intermittent skilled nursing care, physical therapy, occupational therapy, speech-language pathology, or medical social services, Part B can cover these when ordered by a doctor.

• Ambulance Services: When transportation by other means would endanger your health.

• Mental Health Services: Outpatient mental health care, including therapy and counseling.

• Some Medications: Medications that are administered by a doctor, like injections or infusions that are not self-administered, are covered under Part B, not Part D (which covers most prescription drugs).

Costs Associated with Medicare Part B:

• Premium: Unlike Part A, most people pay a monthly premium for Part B. The premium can vary based on income, with higher earners paying more (known as the Income-Related Monthly Adjustment Amount or IRMAA).

• Deductible: There's an annual deductible you must meet before Medicare starts to pay for services.

• Coinsurance or Copayments: After the deductible, typically, you pay 20% of the Medicare-approved amount for most services, while Medicare pays the other 80%.

• Excess Charges: If a provider does not accept Medicare assignment (meaning they do not agree to take Medicare's approved amount as full payment), they can charge up to 15% more than the Medicare-approved amount for covered services, which you would be responsible for.

7. Medicare Part C, also known as Medicare Advantage, is an alternative way for individuals to receive their Medicare benefits. Here's a detailed overview:

What is Medicare Part C?

Medicare Part C plans are offered by private insurance companies that are approved by Medicare. These plans provide all the benefits of Original Medicare (Part A and Part B) but can also offer additional benefits that Original Medicare does not cover:

• Inclusion of Part A (Hospital Insurance) and Part B (Medical Insurance): Part C plans must cover at least all services that Original Medicare covers, often with different rules for how you get services like referrals to see specialists or out-of-network care.

• Additional Benefits: Many Part C plans include:

  • Prescription Drug Coverage (Part D): Often integrated into the plan, eliminating the need for a separate Part D plan.

  • Vision, Dental, and Hearing Services: Which are not typically covered by Original Medicare.

  • Wellness Programs, Fitness Benefits, and Preventive Care: Some plans offer gym memberships, nutrition programs, or additional wellness services.

  • Telehealth: Enhanced access to virtual medical consultations.

How Does It Work?

• Enrollment: To join a Medicare Advantage Plan, you must be enrolled in both Medicare Part A and B. During specific enrollment periods (like the Initial Enrollment Period, Annual Election Period, or Special Election Periods), you can choose a Part C plan.

• Network of Providers: Most Medicare Advantage Plans are either Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs):

  • HMO: Requires you to use healthcare providers within the plan's network, except in emergencies. You usually need a referral to see a specialist.

  • PPO: Offers more flexibility to see out-of-network providers at a higher cost, but you don't necessarily need referrals to see specialists.

• Costs:

  • Premium: In addition to the Part B premium, you might have to pay a premium for the Part C plan itself, though some plans might offer $0 premiums.

  • Deductibles and Co-payments/Coinsurance: These can vary significantly by plan. Some plans have no deductible, while others might have one similar to or different from Original Medicare's.

  • Out-of-Pocket Maximum: Medicare Advantage Plans have an annual limit on how much you pay out-of-pocket for covered services, which Original Medicare does not have.

• Service Area: Your coverage is generally limited to a geographic area. If you move outside this area, you might need to change plans.

Considerations:

• Flexibility vs. Coverage: While Part C can offer additional benefits and potentially lower out-of-pocket costs, it might limit your choice of doctors and hospitals compared to Original Medicare.

• Plan Changes: Plans can change their benefits, provider networks, and costs annually, which means you should review your plan each year during the Annual Election Period.

• Quality of Plans: Medicare rates Part C plans based on a star-rating system, which can help you choose a high-quality plan.

Conclusion:

Medicare Part C provides an alternative to Original Medicare that can be more comprehensive for some people, particularly those who benefit from the additional services or prefer a more managed care approach. However, it's important to compare plans carefully, considering network availability, costs, and additional benefits, as these can greatly influence your healthcare experience and expenses.

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