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Health Insurance / Medical Insurance

Is it Medicare or Medicare benefit I should choose?

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As a person reaches age 65 or encounters a qualifying medical event, they may sign up for Medicare. Medicare isn’t a one-size-fits-all insurance plan, however. Original Medicare has multiple parts, as well as a hybrid alternative called Medicare Advantage, or Medicare Part C.

When an individual reaches the age at which they will sign up for Medicare, they will need to look at which program would better match them and their needs.

Making the right decision on which program and packages to follow can help a person out of potential medical care taking stress and expenses.

Learn more about the plans and costs of Medicare here.

This article will compare the costs and coverage levels associated with both Medicare and Medicare Advantage

Medicare vs. Medicare Advantage

The best Medicare plan will depend on a person’s needs.
The best Medicare plan will depend on a person’s needs.

Traditional Medicare and Medicare Advantage have different costs significantly. This is because the services have different philosophies that support people with differing medical needs.

Programs for Medicare cost more, as they have to include additional programs. As a result, if a person gets sick and needs more regular treatment, they may have less out- of-pocket costs. A person pays a higher premium so that later costs are not charged.

At the other side, Medicare Advantage has lower premium but higher out- of-pocket costs. Many programs also require a person to pay for prescription drug coverage only for the Medicare Part B premium and $0.

This package may be more appropriate for people who do not often use healthcare services. It can be a drawback to have to pay more out- of-pocket costs if a person requires regular medical attention or medication that is not fully covered by his program, such as imaging, transportation or home care.

The expense of the Medicare Advantage plans, however, varies by geographic location.

A person might switch from Medicare to a Medicare Advantage Package once a year, or vice versa. If they think a plan doesn’t work well for them, they may be able to select another Medicare option.

Costs

It is better to include out-of-pocket expenses alongside the monthly premium when contrasting the Medicare and Medicare Benefit costs.

The chart below breaks down some of the basic costs for such plans.

Plan typeMonthly premium
Medicare Part AThese plans are free if a person qualifies. Otherwise, it is up to $458 per month.
Medicare Part BThese plans cost from $144.60 per month. They may cost more if a person has an income higher than $87,000 per year.
Medicare Part DThe cost varies by plan, but the average monthly premium ranges from $13 to $83, according to the Kaiser Family Foundation (KFF).
Medicare AdvantageAs with Part B, the cost varies by plan. However, in 2019, the average monthly premium was $26.87, according to the Centers for Medicare & Medicaid Services (CMS). Despite this, some Medicare Advantage plans cost much more every month.

Some people opt for a Medicare Advantage package because, according to Medicare.gov, they think they have less out- of-pocket costs.

Medicare Advantage vs. Medicare supplement

Medicare replacement services help a person reduce some of the health-care costs not covered by traditional Medicare. Some people refer to those plans as Medigap as well.

The CMS separates Medicare replacement programs by letter as it does with standard Medicare. As of 2020, people new to Medicare may choose from plans A, B, D, G, K, L, M, and N. However, not all insurers market the same plans across all areas of the country.

Plans also vary from the traditional Medigap plans in Illinois, Minnesota and Massachusetts.

Supplemental Medicare policies will help to cover certain costs, including:

  • copayments for parts A and B
  • up to 3 pints of donated blood
  • coinsurance for skilled nursing facilities
  • yearly out-of-pocket expenses

Individuals with concerns about steep out- of-pocket costs may choose a Medigap Plan. A individual can not, in general, have both a Medicare Advantage plan and a Medigap plan at the same time.

What is Medicare?  

Medicare is a federal health insurance program for individuals aged 65 and older, as well as individuals with certain health conditions and disabilities, such as end-stage kidney disease.

When Medicare was developed by federal government workers they broke it into many different parts. These sections cover various aspects of medical care and include:

  • Part A: Medicare Part A provides hospital coverage, including a hospital stay, hospice care, and necessary care in a skilled nursing facility.
  • Part B: Medicare Part B covers doctors’ visits, outpatient services, medical supplies, and preventive medical care.
  • Part D: Medicare Part D accounts for prescription drug coverage. A person can select a Medicare Part D plan according to the prescriptions they currently take and the copayment with which they are comfortable.

If a person or their spouse were to pay Medicare taxes for 30 quarters of employment, they would receive Medicare Part A at a discounted rate at age 65. If they paid 40 quarters of the same fee, they would get Part A for free. Several exceptions apply to this, and some those, such as younger people with specific disabilities, may qualify sooner.

A person may also opt to pay a monthly Medicare Part A premium if they don’t qualify for the free plan.

Part B Medicare is available at a standard cost that varies only for people with high incomes. The costs of Medicare Part D can vary depending on which plan an patient chooses and how much they receive.

What is Medicare Advantage?

Medicare Advantage is another name for Medicare Part C which includes parts A, B, and D in addition to some additional services, such as dental, hearing, and vision coverage.

Although the parts below identify the most common forms of Medicare Advantage Plan, there are several more available. In fact, the CMS reports that in the United States in 2020 there will be 1,200 more Medicare Advantage plans available than in 2018.

This means that, according to the KFF, approximately 3,148 Medicare Advantage plans are available.

It is important to note, however, that the availability of Medicare Advantage plans can differ per geographic area. For instance, Alaska does not have any Medicare Advantage Plans.

According to the KFF, those areas with higher concentrations tend to have more plans available. For example, there are more than 60 Medicare Advantage Plans available in Miami, Florida and New York City.

Medicare Advantage plans typically fall into various categories including:

Health maintenance organization

A individual usually chooses from a list of preferred providers they will visit to cover healthcare expenses for the plan.

Most health maintenance organization (HMO) programs allow a primary care physician to manage treatment for an individual. That means they generally have to refer a person to a doctor before the insurers cover the cost of the healthcare.

In 2020, according to the KFF, an estimated 64 percent of people with Medicare Advantage plans will have an HMO plan.

Preferred provider organization

A preferred association of providers (PPO) package covers some or all of the expenses from a specified network of health care providers.

Normally a person does not need a doctor’s recommendation to see a specialist under such plans, and generally they have a broader network of providers to choose from than for an HMO plan. PPO plans are, however, typically more costly than HMO plans.

Private fee-for-service

This program allows a person to seek care at a hospital and to pay a fixed amount already decided upon by the insurance company.

A person does not have to seek referrals, or choose a primary care doctor, unlike HMOs and PPOs. Bear in mind, though, that not all doctors who support Medicare would consider a private fee-for-service plan, too.

Special needs plans

A special needs program is a Medicaid package that supports people with a chronic condition of health and other particular needs. Examples of such conditions may include diabetes, renal disease in the end stage, HIV and chronic heart failure.

Since people with these conditions often have specific health needs, factors such as drugs and other necessary services may be taken into account in these plans.

Summary

According to the CMS, about 24.4 million recipients were participating in Medicare Advantage programs, out of the 60 million people enrolled in Medicare in the United States.

In choosing a plan that best suits their needs, people should always weigh up the costs and coverage levels. Neither Medicare nor Medicare Advantage is better, but in specific financial or medical conditions, one may be more suitable for people than the other.

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Health Equity

What is private equity in healthcare?

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In recent years, private equity companies have boosted their involvement in healthcare. While they are focused on increasing profits, many people are concerned that this will have an adverse effect on patient care.

Companies that invest in privately held enterprises are known as private equity firms. While many companies invest in startups and small businesses, a rising number of companies are putting their money into the healthcare sector.

Since 2015, healthcare investments have more than quadrupled. As a result, private equity companies already hold around 25% of hospitals in the United States, and this number is expected to continue to rise.

The hazards and advantages of this are still being debated. The purpose of private equity companies investing in or purchasing hospitals, medical practices, or health systems is to simplify operations and increase profits.

Critics fear that this would compel health-care institutions to prioritize money over patients.

Learn more about private equity in healthcare, including how it works, who it impacts, and the benefits and disadvantages.

Important facts

private equity in healthcare

Over the last two decades, private equity companies have become more involved in the healthcare sector.

The following are some facts and figures:

  • There were 42 private equity acquisitions to buy hospitals or hospital systems between 2003 and 2017. There were 282 hospitals impacted in 36 states.
  • Investments in healthcare by private equity surged from $23.1 billion in 2015 to $78.9 billion in 2019.
  • According to projections, healthcare spending will grow at a rate of 5.5 percent each year through 2027.

What is healthcare private equity?

Private equity firms aggregate funds from a variety of sources. This enables them to amass vast quantities of money that they may invest.

They invest this money in businesses — or shares in firms — and then try to grow the value of those enterprises. The businesses are subsequently sold, and the proceeds are returned to the investors.

Private equity firms frequently purchase failing health systems or hospitals in the healthcare sector. They then attempt to boost earnings.

The following are some of the strategies employed by these businesses:

  • merging multiple healthcare practices
  • reducing staff
  • closing down portions of a hospital or healthcare practice’s operations
  • focusing on growing a specific aspect of a healthcare practice’s offerings
  • renegotiating reimbursement rates with insurers

Why it happens

To make money, private equity firms invest in health systems.

Health practices and providers must be willing to sell in order for this to happen. This can occur if:

  • a hospital or other health practice is struggling to make money
  • complying with regulations is difficult
  • a practice owner is retiring
  • a hospital offers an innovative service or product but needs financial support

What impact does it have on patients?

Private equity agreements have a wide range of repercussions on people. While there is no solid evidence that it improves or degrades treatment, many people are concerned that it may put money before of patients.

In some circumstances, a persistent desire to make money might degrade the quality of treatment.

According to a working paper published in 2021, nursing facilities managed by private equity firms had a 10% higher fatality rate among Medicare patients. It also revealed a decrease in time spent with residents, fewer employees, and inferior staff quality and training.

Despite the decreased quality of care, these nursing facilities were linked to a rise in Medicare costs supported by taxpayers.

Supporters of private equity in healthcare, on the other hand, claim that simplifying procedures and raising profitability might drive new technology investment. This might encourage more innovation, which could lead to better patient results.

Who does it affect most? 

Each private equity deal has a different target — and consequently, different impacts.

They can affect varied groups of people, including:

  • Patients: The impact of private equity on patients varies greatly. Costs can increase, and some people may have more difficulty accessing care.
  • Communities: Private equity investments can shift the balance of healthcare available in a community. For example, if a firm consolidates a health system, this may mean closing hospitals or medical practices.
  • Staff: Healthcare staff may find that their roles shift. Some may lose their jobs, while others may get promotions.
  • Practice and hospital owners: When private equity firms take over, business owners may retain ownership. Then, when the business sells, they could receive a portion of the profits.
  • Competitors: Private equity firms aim to make health systems more competitive. This may mean that other healthcare providers lose patients and revenue.
  • Investors: The goal of private equity investments is to generate profits for investors. In many cases, the annual return is 20–30%. But if the deal fails, investors can lose money.

The advantages and disadvantages

A private equity deal’s precise impact is determined by the company it buys, the changes it makes, and other factors.

The following are some of the possible advantages of private equity in healthcare:

  • profit for investors
  • better management
  • closely following hospital guidelines
  • better insurance reimbursement rates

Some potential drawbacks include:

  • a decline in patient care
  • cost increases for both taxpayers and patients
  • staffing shortages
  • the possibility for upcoding — when a person is recorded as being sicker than they are
  • job loss for some healthcare workers
  • possibly placing a strain on medical ethics

Conclusion

Private equity firms are increasingly engaging in healthcare in the United States. While advocates contend that it boosts innovation, others worry that it harms hospitals and lowers treatment quality.

Private equity businesses are prohibited from harming patients in order to make a profit under healthcare rules and legislation. This provides some protection, and in some situations, greater treatment might result in more revenue.

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Health Insurance / Medical Insurance

What is health insurance?

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Health insurance is a form of insurance coverage that covers the cost of medical and surgical costs of an insured person.

To identify a clinic, hospital, doctor, laboratory, healthcare practitioner, or pharmacy that treats a person, insurers use the word “provider.” The “insured” is the health insurance policy owner or the individual protected by the health insurance coverage.

Either the patient pays out-of-pocket expenses and earns compensation, depending on the form of health insurance policy, or the insurer makes payments directly to the company.

Health insurance is generally provided in workplace compensation packages in countries without universal healthcare coverage, such as the United States.

According to the Kaiser Family Foundation, the number of people with insurance in the U.S. dropped from 44 million in 2013 to less than 28 million in 2016. The researchers put this down to recent legislative changes.

A 2011 Commonwealth Fund study found that a gap in health insurance coverage was faced by one-fourth of all working-age U.S. residents. When they either became unemployed or changed jobs, many individuals in the study lost their health care.

Depending on what form of health insurance a person has, the level of treatment in emergency departments varies greatly.

Types

Two main types of health insurance exist:

Private health insurance: The Centers for Disease Control and Prevention (CDC) states that private health insurance is heavily dependent on the U.S. health care system. In the National Health Interview Study, researchers found that 65.4 percent of people under the age of 65 years in the U.S. had a form of private health insurance coverage.

Public or government health insurance: In this form of insurance, in return for a fee, the state subsidizes healthcare. Examples of universal health insurance in the United States include Medicare, Medicaid, the Veteran’s Health Administration, and the Indian Health Service.

Other types

Through the use of the way they handle their policies and communicate with healthcare providers, people often describe an insurer.

Managed care plans: The insurer would have arrangements with a network of healthcare providers to provide their policyholders with lower-cost medical care under this form of arrangement. There will be penalties and additional costs added to out-of-network hospitals and clinics, but they will provide some treatment.

The more costly the policy is, the more flexible it is likely to be for the hospital network.

Indemnity, or fee-for-service plans: A fee-for-service contract covers all healthcare providers with fair treatment, empowering the insured to select their chosen place of care. The insurer will usually fund an indemnity plan covering at least 80 percent of the costs, while the patient will pay the remaining costs as co-insurance.

Health maintenance organizations (HMOs): These are organizations which directly provide the insured with medical care. Usually, the policy would include a committed primary care doctor who will manage all appropriate care.

HMOs will usually only finance the care referred by this GP and will have negotiated fees to reduce costs for each medical service. Normally, this is the cheapest form of plan.

Preferred provider organizations (PPOs): A PPO is similar to an indemnity plan in that it requires any doctor they prefer to see the insured.

The PPO also has a network of approved providers with which they have negotiated costs.

For out-of-network providers, the insurer will pay less for care. However, without having to see a primary care provider, people on a PPO plan will self-refer to specialists.

Point-of-service (POS) plans: As a combination of an HMO and PPO, a POS plan works. The insured can choose between arranging all services through a primary care doctor, providing treatment within the provider network of the insurer, or using non-providers of the network. The type of plan will dictate the progress of treatment.

Why is the type of insurance plan important?

The type of plan decides how a person will handle getting the care they need and how much cash they will need to spend on the day.

During 2003, the U.S. A new alternative was adopted by Congress, the Health Saving Account (HSA). It is a mix of tax advantages for an HMO, PPO, indemnity plan, and savings account. A policyholder must, however, combine this form with a current insurance plan that has a premium for individuals of over $1,100 and families of $2,200.

HSAs would expand coverage, expanding current plans to accommodate a broader variety of therapies. When an HSA is paid for by an employer on behalf of their workers, the payments are tax-free. In the HSA, a person can build up funds when they are safe and save later in life for instances of bad health.

People with chronic illnesses, such as diabetes, will not be able to save a significant amount in their HSA, however, because they have to pay high medical expenses annually for maintaining their health care.

These policies often have a very high deductible, which means that while premiums can be smaller, individuals often end up covering the full cost of any medical treatment required.

As plan types evolve, there is more overlap. The distinctions between policy types are becoming increasingly blurred.

Managed care strategies are used by the majority of indemnity plans to manage costs and ensure that adequate resources are available to pay for necessary care. Similarly, many managed care plans have embraced certain features of fee-for-service plans.

Legislation

Insurance logo
Make sure you research the insurance legislation in your state.

As part of the Affordable Care Act (ACA) 2010, providing a degree of insurance is actually legally required in the U.S. An person with no health insurance has to pay a fine.

The Individual Mandate in the ACA, however, has been withdrawn from the legislation, meaning that as of 2019, insurance will no longer be a legal obligation in the U.S.

If the policy also protects the children in the family, a person is permitted until the age of 26 years to be insured by their parents, even if they are:

  • married
  • living away from home
  • not financially dependent on their parents
  • eligible to be included on their employer’s cover

Insurance is controlled at the level of the state, which ensures that purchasing a policy in one state varies from doing so in another.

Although state laws may impact the price of a policy, the insurer is responsible for the important decisions regarding the coverage and reimbursements of an individual. People should be sure to address the effect of any evolving laws on their personal policies with their broker or customer services representative.

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Dentistry

Does Medicare cover dental treatment?

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Medicare usually does not cover dental procedures, unless it is a part of emergency or complicated facilities. Nevertheless, Medicare Advantage plans or other health benefits that help a person cover all or a portion of the cost of dental care.

According to the Kaiser Family Foundation, about 37 million Medicare enrollees have no amount of dental coverage.

But there are other ways to secure regular dental coverage, even if it’s not through Medicare itself.

Read in this article about when Medicare will cover dental expenses, and how to ensure coverage if not.

Does Medicare ever cover dental costs?

Dental medical treatment
A person’s Medicare plan may cover dental work if it is a part of emergency or complicated services.

Medicare can cover dental costs that are part of the treatment for a medical condition or injury that underlies it. Some of the dental services covered by Medicare include:

  • dental extractions for cancer treatment involving the jaw or nearby soft tissues
  • jaw reconstruction following an accident or injury
  • oral examinations before a heart valve replacement or kidney transplant

These services may be paid for by different facets of Medicare. For example, if the surgery is done by a non-dentist, Medicare Part B will be responsible for the costs. Part B is Medicare’s medical part, which usually includes doctor visits and health services.

However, funds may come from Medicare Part A if a dentist on the staff of a hospital performs the operation. It portion pays for in-hospital care, services, and treatment.

However, Medicare does not provide regular dental services in the majority of cases. This involves cleanings, extractions, and checks not related to an accident or illness requiring hospitalization.

Also, Medicare does not fund any replacements of lost or extracted teeth, such as dentures and fillings.

What about Medicare Advantage?

Medicare Benefit, or Medicare Part C, is a kind of Medicare provided by private insurance plans. Although policies vary depending on the healthcare provider network, geographic area, and private insurer, some offer regular dental care coverage.

Medicare Advantage incorporates sections A and B, as well as some components of Portion D. This part provides coverage of prescription drugs and other programs.

The types of scheme available can depend on the area a person lives in. Some Medicare Advantage plans require visiting a single physician or hospital group that have provisions with their Medicare Advantage plan.

The same may apply to the dentists in a person’s region as well. An patient may need to see an “in-network” provider to get coverage for their dental services.

Those considering switching to a Medicare Advantage program for expanded dental coverage will look at participating providers in their area as well as what the package would support dental services.

What about Medigap coverage?

Medicare replacement care, or Medigap, is a program that allows an individual to pay an extra fee per month. This premium will cut the out- of-pocket costs that often follow sections A and B of Medicare.

Medigap plans do not cover copayments or dental insurance. These are a way to make Medicare benefit replacements. Because Medicare does not provide dental benefits, Medigap is not helping a individual finance these.

What can people aged 65 and over do about dental coverage?

If a person wishes to have dental coverage associated with Medicare, they should choose a Medicare Advantage program that provides such benefits.

A person must first enroll in Medicare during their initial enrollment period, which begins 3 months before their 65th birthday, includes their month of birth, and continues to 3 months after their birthday to enroll in Medicare Advantage.

If a person fails this period of enrollment, they can enroll in Medicare during the General Enrollment Period, which starts in January and ends in late March.

A individual might subscribe to a Medicare Advantage plan from April through June after this date. To choose a Medicare Advantage package, they must be participating in the Medicare sections A and B. They would probably be required before pay a copayment or penalty to cover any dental expenses.

If a person does not want a Medicare Advantage plan, or if there are no suitable plans in their state, we may choose to buy a separate dental insurance policy.

Private health insurance companies sell dental covered policies. A person may want to study the different plans available to them before buying one, and choose one that best suits their needs.

Other options for dental care include:

  • contacting the local health department to find out if they offer free or low cost dental services at certain times
  • applying for Medicaid benefits, which may help provide dental benefits to some individuals and families (income qualifications may vary by state)
  • contacting local dental or dental hygiene schools to find out if they offer free or low cost services

Community organizations, such as United Way, can also help a person find dental services that are free or low-cost.

Summary

Good dental health is vitally important for general health. Reports have in turn linked poor dental health with a deterioration of other medical conditions, such as diabetes and heart disease.

Even if Medicare doesn’t cover dental health, a person can use Medicare Advantage or other community health services to receive dental benefits.

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