Medicare meets Obamacare.

This blog's target audience is retired teachers in WNY, which means that Medicare is probably at the top of your list of questions about the Affordable Care Act (ACA).

Before addressing the specifics of the ACA with regard to Medicare, however, we need to do a little background work on some of the details of Medicare's inner workings.

Medicare comes in two "flavors": traditional (sometimes called "fee-for-service" Medicare) and Medicare Advantage plans. Seventy-five percent of Medicare participants are in traditional Medicare while the remaining 25% are in Medicare advantage plans. That 3/1 ratio of traditional Medicare participants to Medicare advantage participants is important, and will have a tremendous bearing on how you personally view the Medicare changes in the ACA.

Traditional Medicare is run by the government. It consists of Part A (hospital costs), Part B (doctor costs) and Part D (prescription drug costs). There is no cost to the participant for Part A, although there is a deductible for each hospital admission. Participants pay a monthly premium of $96.40 (or close to this amount) for Part B coverage. There is a yearly deductible for Part B costs. In addition Medicare only pays 80% of the covered Part A and B expenses. Traditional Medicare participants may, if they choose, purchase supplemental (Medigap) insurance to cover all or part of these costs not covered by Medicare. Traditional Medicare participants may also purchase Part D drug insurance through private insurance companies approved by Medicare.

Traditional Medicare is a "fee-for-service" plan. Whenever you receive a covered medical service, Medicare provides a set fee for that service to the provider. Medicare providers have agreed to accept whatever fee Medicare provides as payment in full. (Actually, Medicare only pays 80% of this fee to the provider. The other 20% is billed to the patient or their Medigap insurance, if they have purchased it.) If you receive no covered services during a year, Medicare spends no money on your behalf. There is no upper limit on your yearly cost to Medicare if you do receive covered services.

Medicare Advantage plans (also known as Medicare Part C) began in the 1970's with the idea that the private sector could do Medicare more cheaply than the government. Over the years, Congress has made several changes to Medicare Advantage so that its focus now is attracting more private participation.

Medicare Advantage plans are run by private insurance companies such as Univera, Independent Health, etc. Medicare pays these companies a flat fee to provide hospital and doctor services to their members. Some Medicare Advantage plans also include Part D drug coverage, while others require that their members purchase it as a separate entity.

While participants in traditional Medicare are free to use any doctor or hospital and do not require a referral to see a specialist, Medicare Advantage plans usually require members to use only hospitals or doctors in their network. Going "out-of-network" usually results in the member paying either a larger share of the cost or, in some cases, the full cost of the service.

If you are unsure which "flavor" of coverage you have, if you pay a "co-pay" when seeing your doctor, you are probably a Medicare Advantage member.

Medicare Advantage members also pay their Part B premium to Medicare, usually through direct deduction from the Social Security payment each month. The amount that Medicare pays to the Medicare Advantage insurer for each member is a flat rate based on the average yearly cost to Medicare of traditional Medicare participants in your county.

And there's the rub. Medicare currently pays Medicare Advantage insurers about 15% more for each member than the average cost to Medicare for a traditional Medicare participant.


Many Medicare Advantage providers use this extra money to provide services not covered by traditional medicare such as dental, eyeglasses and gym memberships.

Everyone agrees that Medicare has financial problems. The Part B premium, for example, covers only about 25% of the cost of doctor services to Medicare participants. We Medicare participants often boast that we're "paying our way" through our premiums. Sadly, that's simply not the case.

The ACA attempts to help stem the rise in Medicare costs by scaling back the increase in payments to Medicare advantage providers by about $322 billion over the next 10 years. Note that this is NOT a decrease of $322 billion from the current payment level. Instead, it is a decrease in the expected rise in these payments.

If you are one of the 3-out-of-4 traditional Medicare participants, you will probably view this as a good thing. There will be no change in your Medicare services and the overall cost of Medicare will be $322 billion closer to being under control.


If you are the 1-out-of-4 person who participates in a Medicare Advantage plan, you will likely see some decrease in the "extra" services such as gym memberships.


To be fair, however, with everyone paying the same dollars into Medicare, it's hard to make a case that it's fair that Medicare spend an extra 15% on 25% of participants allowing them to receive benefits that the other 75% do not receive. And, in addition, we help bring Medicare costs under control.


And, this $322 billion in savings is used to help pay the costs of the ACA.


Believe it or not, there's even more to say about Medicare in the next post.

[NOTE: Click here for an excellent side-by-side comparison of traditional vs Medicare Advantage provided at the Medicare website. Click here to download a much more complete explanation of Medicare Advantage plans from the Kaiser Family Foundation.]