Medicare Advantage

Changes to Medicare Advantage – What Can You Expect in 2019?

For more information on Medicare, please call the number below to speak with a healthcare specialist


In early April, the Centers for Medicare & Medicaid Services (CMS) released its 2019 Medicare Advantage and Part D Rate Announcement and Call Letter, announcing changes to Medicare Advantage and Part D for 2019. Some of the guidelines, such as policy changes concerning supplemental benefits, tightening of regulations concerning opioids and support for longer duration of physical therapy, will affect consumers directly. Other, more complex changes in the way Medicare reimburses providers and ranks insurers may have significant long-term effects.

Key Insurer Changes

While Original Medicare is a program through which the government pays healthcare providers for services rendered to patients 65 and over, in Medicare Advantage the government pays private insurance companies a fixed amount per person to pay healthcare providers. About a third of Medicare recipients are enrolled in Medicare Advantage plans, with the percentage choosing Medicare Advantage trending upward and premiums decreasing slightly. The relationship between Medicare and its private counterpart affect the changes announced for 2019.

First, although Medicare reimbursement rates are uniform, different private insurers have the freedom to adjust the premiums and co-pays they charge for specific services, with each Advantage plan making slightly different changes for 2019. Second, Medicare will release its star ranking in October and now allow participants to change from insurers ranked with three or fewer stars to five-star plans at any time with no penalty. Finally, insurers now have increased flexibility to add new forms of supplemental coverage to their plans.

Provider Reimbursement

Perhaps the most significant change that Medicare is undergoing is philosophical, shifting from reimbursement rates based primarily on cost to using complex metrics to evaluate outcomes. Along with routine annual adjustments of a few percentage points to reimbursement rates for thousands of individual treatments, overall reimbursement rate-setting philosophy has a significant effect on the cost of medical care.

Over the long term, such shifts may change co-payments, which providers are willing to accept Medicare plans, and even the ways in which certain medical conditions are treated. Eventually, these changes should result in a trifold emphasis on preventive care, support services, and initiatives supporting aging in place and hospice care. Some Medicare Advantage insurers may be more proactive than others in anticipating these changes, meaning greater differentiation between companies.

Physical Therapy

A major change for Medicare participants in all plans was the enactment in the federal budget bill of February 2018 of a permanent solution to the issue of hard caps on physical therapy services. American Physical Therapy Association President Sharon L. Dunn, PT, PhD, describes removal of the physical therapy cap as a victory for patients.

Opioid Restrictions

In response to the growing opioid addiction epidemic, Medicare will be tightening restrictions on prescribing opioids, particularly in conjunction with other drugs that have been shown to increase the possibility of opioid dependency. Prescribers will now also restrict long-term, high-dose prescriptions.

New Medical Transport and Other Supplemental Benefits

Perhaps the most exciting change for 2019 is what CMS describes as “reinterpreting the standards for health-related supplemental benefits in the Medicare Advantage program to include additional services … including coverage of non-skilled in-home supports and other assistive devices.” Translation: more services to help enrollees with everyday support. Medicare Advantage plans may now choose to offer reimbursement for non-emergency transportation to medical appointments, including rides provided by sharing services such as Uber and Lyft, along with various assistive devices and services that enable beneficiaries to live safely in their own homes for longer. This represents part of an ongoing philosophical shift towards enhancing quality of life and investing in preventive care.