Benefits for Seniors

Seniors

Medicare beneficiaries actually gained a lot from Obamacare. But most don't seem to understand this.

Prescription drugs became less costly but not dramatically. Screening tests to detect and manage diseases became more readily available to seniors.

♦ There is no longer a fear of being denied health insurance. If you are over the age of 65 but not eligible for Medicare, you can purchase health insurance even if you have a pre-existing health condition.

Prescription costs will be affected

Historically, seniors faced a complicated coverage gap known as the 'Donut Hole.' Thanks to the Inflation Reduction Act, the Donut Hole has been completely eliminated. It has been replaced by a hard cap on your out-of-pocket drug costs.

Medicare Part D prescription drug plans for 2027 plan year now feature a hard $2,400 annual cap on out-of-pocket prescription drug costs. Once a senior spends $2,400 in a calendar year, they owe $0 for their covered Part D drugs for the remainder of that year.

♦ This cap is indexed annually to keep pace with the growth of overall Part D drug spending, it will continue to shift slightly each plan year.

♦ What a person actually pays may not go down. Pharmaceutical companies and benefit managers can be expected to try to raise prices to maintain profits.

Health Screenings and Wellness Visits

Medicare beneficiaries are eligible to receive many preventive services with no out-of-pocket costs.

These include flu shots, tobacco cessation counseling, as well as no-cost screenings.

♦ Copayments and deductibles have been eliminated for preventive services and screenings for cervical cancer, diabetes, colonoscopies, mammograms, bone mass density tests and others.

• Colonoscopies done for screening purposes are covered at no cost. However, a colonoscopy or sigmoidoscopy conducted for polyp removal or biopsy may be coded as a surgical procedure that would then require you to pay something.

Seniors can also get an annual wellness visit so they can talk to their doctor about any health concerns.

♦ A little caution. The wellness visit is covered at no cost but most doctors are creative and will tack on a second office visit charge. If challenged the doctor's office will just say you discussed something "outside" of the scope of the wellness visit. Good luck figuring out what that was.

• Blood work done for a wellness visit is not covered at 100%. If you have a Medicare Advantage plan, you will likely get by with a small copay of $15 to $25 for these blood tests.

Medicare Advantage Plans

Medicare Advantage Plans will now be required to spend at least 85% of their revenue on actual health care with things like advertising and bonuses being more closely monitored.

Advantage plans will no longer be allowed to charge its members more than traditional Medicare for specialized services like chemotherapy administration and skilled nursing home care.

Improving care for seniors after they leave the hospital

The Community Care Transitions Program will help high risk Medicare beneficiaries who are hospitalized avoid unnecessary re-admissions by coordinating care and connecting patients to services in their communities.

The law also puts new requirements on hospitals to make a greater effort to be help their patients avoid being quickly readmitted to the hospital.

Linking payment to quality outcomes

The law establishes a hospital Value-Based Purchasing program (VBP) in traditional Medicare.

♦ This program offers financial incentives to hospitals to improve the quality of care.

Hospital performance is required to be publicly reported, beginning with measures relating to heart attacks, heart failure, pneumonia, surgical care, health-care associated infections, and patients’ perception of care.