Priority Issues Across Medicare, Part 1: Original Medicare

The Medicare Rights Center’s work touches all aspects of the Medicare program, including Original Medicare (OM), private Medicare Advantage (MA) and Part D prescription drug plans, and supplemental coverage like Medigaps.

Our Focus 

Our policy work centers beneficiaries and our commitment to the Medicare promise of guaranteed, high quality, and affordable coverage. We endeavor to safeguard Medicare’s foundational principles—universality, comprehensive benefits, and adaptability to beneficiaries’ diverse needs.

How We Develop Our Priorities

Our policy priorities are informed by the needs of Medicare beneficiaries. We learn of these needs through calls to our national helpline. For example, in our most recent helpline trends report, 41% of callers had questions about Medicare affordability and cost-assistance programs; 27% had access to care questions such as coverage, billing, or denials; 24% had questions about Medicare enrollment; and 8% were a mix of various issues. Importantly, most of these calls occurred before major prescription drug changes through the Inflation Reduction Act went into effect.

While some of these issues are common across all areas, including affordability, access to benefits, and care quality, others, like network adequacy, are concentrated in a subset of coverage options. In today’s article, we are focusing on OM; a future installment will discuss other aspects of the program.

Original Medicare

OM establishes the base Medicare benefits package and offers free choice of providers.

Enrollment

A beneficiary’s Medicare journey starts with enrollment. Medicare Rights continues its efforts to improve the enrollment process and offer guidance on enrollment steps, but our work starts even sooner, as many people do not know when—or even if—they need to take action to enroll. We continue to urge Congress to pass the Beneficiary Enrollment Notification and Eligibility Simplification (BENES) 2.0 Act (H.R. 4960) which would require the federal government to provide advance notice to people approaching Medicare eligibility about basic enrollment rules, filling a longstanding gap in outreach and education.

Access to Care and Benefit Gaps

Original Medicare helps beneficiaries get high-quality care with a free choice of providers, but the benefits package is less robust than it should be. Medicare Rights supports modernizing this structure and expanding benefits as needed, including to wrap in comprehensive dental, hearing, and vision care, coverage of durable medical equipment outside of the home and better coverage of in-home care, and a cap on out-of-pocket spending.

Affordability Plus Assistance Programs

Benefit gaps and the lack of an out-of-pocket cap are part of a larger story around affordability. Many beneficiaries live on fixed or limited incomes. Half of all beneficiaries, nearly 33 million people, live on $43,200 or less per year, and one quarter have less than $18,950 in savings. Health care costs comprise a large and disproportionate share of beneficiaries’ limited budgets: Nearly 30% of Medicare households spend 20% or more of their income on health care, compared to only 7% of non-Medicare households.

These pressures create impossible choices. Beneficiaries who cannot afford care may be forced to go without it; more than one-third (36%) delayed or skipped care in 2023 due to affordability concerns. In addition to leading to worse outcomes and quality of life, the cost to Medicare is also extreme, as beneficiaries who forgo treatment and experience declining health as a result may require more expensive interventions later, like emergency department visits, hospital admissions, or nursing facility stays. 

These circumstances make eligibility for and enrollment in assistance programs like Medicaid, the Low-Income Subsidy (LIS, or “Extra Help”), and the Medicare Savings Programs (MSPs) vital for the well-being of millions of beneficiaries. Medicaid provides wrap-around coverage to fill in Medicare’s benefit gaps and ensure people with low incomes can access care, LIS helps enrollees afford their Part D costs, and MSPs help cover Part B costs.

We support streamlined enrollment processes, enhanced eligibility, and eliminating administrative barriers to these programs. 

Access to Medigap

The absence of a program-wide out-of-pocket cap means many people with OM rely on Medigaps to provide some cost certainty. However, these plans offer fewer consumer protections than most insurance products, which can create problems. For example, while it is relatively easy for a Medicare beneficiary to enroll in an MA plan on an annual basis, there are limited windows of opportunity to join a Medigap plan.

This means that people who want to switch from MA to OM may not have the option to purchase affordable supplemental coverage, which may effectively lock them into MA. While limiting beneficiary costs in OM would best address this disconnect—and move to a more level playing field between OM and MA—in the interim, for Medicare beneficiaries to have true freedom of choice concerning their coverage options, Medigap plan access must be strengthened. 

Our Mission

To gain our support, any reforms must uphold Medicare’s universality, protect current benefits, and ensure the program meets the evolving needs of diverse beneficiaries through high-quality, affordable care.