WHY DID YOUR DRUG PRICES GO UP IN YOUR MEDICARE PART D DRUG PLAN!

Op-Ed by D. Kenton Henry                                                                                          Editor, agent, broker 10 May 2022

As a Medicare recipient, each fall during Medicare’s Annual Election Period (AEP) – from October 15th to December 7th – you are allowed to select a new Part D Drug Plan for the coming calendar year. 

Did you research which of the approximately 30 Part D Drug Plans available to you would result in your lowest total costs in 2022? Did you select a plan because it quoted the lowest price and coinsurance for your drugs? Midyear, to your surprise, you have been informed the cost of your drug(s) is now much higher!

If you did, you are not alone. As a Medicare recipient, and an agent/broker working on behalf of Medicare clients, I am not only frustrated but somewhat embarrassed by this phenomenon. The reason for the latter is because one of the primary services I provide clients is to, during the AEP, quote the price of each of their prescription drugs and their lowest total cost drug plan for the coming new year. Clients rely on me for accurate information and base their drug plan selection on my research and quotes. When suddenly they are notified that their drugs’ actual price is higher or will be increasing midyear, it reflects poorly on me. Even though the information I provided them was accurate at the time and price discrepancies are beyond my control. 

As my feature news article from Kaiser Health (below) explains, “As early as three weeks after Medicare’s drug plan enrollment period ends on December 7th, insurance plans can change what they charge members for drugs – and they can do it repeatedly.” 

Please read the article for full disclosure about how this is allowed to happen. Suffice it to say, many Medicare recipients are living on a fixed income, and this practice makes it very difficult for them to budget appropriately and pay their drug and remaining bills. As a consumer, my opinion is that this practice is unconscionable and inexcusable. It seems if a pharmaceutical company wants a particular drug company to include its drug in their plan’s formulary, they should quote a price and be contractually committed to, and obligated to, providing that drug at that price for the entire coming calendar year. As with a fixed mortgage or purchase agreement, the terms should be locked in for the life of the contract. Again, in my opinion, anything less assumes the character of a “bait and switch” transaction.

Feature Article 2 highlights the pushback on brand name drug coverage by Medicare while pointing out the preferred treatment in lower drug costs for Medicaid recipients. Their savings are provided by discounts and coupons vs the drug cost for those in Medicare who do not receive those.

In terms of working with me as a professional, I will continue to provide my clients the most accurate price and dispensing information for Rx drugs and the Part D Drug plans available to them. This will be the case for purposes of the AEP; because they are new to Medicare; or because they need to change plans due to a residential move and plan availability. I do not charge a fee for this service. 

In the meantime, do not hesitate to contact me with any questions or assistance you might require. Not only as they relate to Medicare but for you or family members who might not yet be eligible for Medicare. My services and terms apply to Under Age 65 health insurance, as well. 

D. Kenton Henry

Office: 281.367.6565 Text my cell @ 713.907.7984 Email: Allplanhealthinsurance.com@gmail.com https://TheWoodlandsTXHealthInsurance.com https://www.Allplanhealthinsurance.com                                                      

FOR THE LATEST IN HEALTH AND MEDICARE RELATED INSURANCE NEWS FOLLOW MY BLOG @ https://HealthandMedicareInsurance.com

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FEATURE ARTICLE 1

KAISER HEALTH NEWS

POLICY-ISH

Drug plan prices touted during Medicare open enrollment can rise within a month

May 3, 20225:00 AM ET

SUSAN JAFFE

Retiree Donna Weiner shows some of the daily prescription medications for which she pays more than $6,000 per year through a Medicare prescription drug plan. She supports giving Medicare authority to negotiate drug prices.

Phelan M. Ebenhack/AP

Something strange happened between the time Linda Griffith signed up for a new Medicare prescription drug plan during last fall’s enrollment period and when she tried to fill her first prescription in January.

She picked a Humana drug plan for its low prices, with help from her longtime insurance agent and the Medicare Plan Finder, an online pricing tool for comparing a dizzying array of options. But instead of the $70.09 she expected to pay for her dextroamphetamine, used to treat attention-deficit/hyperactivity disorder, her pharmacist told her she owed $275.90.

“I didn’t pick it up because I thought something was wrong,” said Griffith, 73, a retired construction company accountant who lives in the Northern California town of Weaverville.

This story was produced in partnership with Kaiser Health News.

“To me, when you purchase a plan, you have an implied contract,” she said. “I say I will pay the premium on time for this plan. And they’re going to make sure I get the drug for a certain amount.”

But it often doesn’t work that way. As early as three weeks after Medicare’s drug plan enrollment period ends on Dec. 7, insurance plans can change what they charge members for drugs — and they can do it repeatedly. Griffith’s prescription out-of-pocket cost has varied each month, and through March, she has already paid $433 more than she expected to.

recent analysis by AARP, which is lobbying Congress to pass legislation to control drug prices, compared drugmakers’ list prices between the end of December 2021 — shortly after the Dec. 7 sign-up deadline — and the end of January 2022, just a month after new Medicare drug plans began. Researchers found that the list prices for the 75 brand-name drugs most frequently prescribed to Medicare beneficiaries had risen as much as 8%.

Sponsor Message

Medicare officials acknowledge that manufacturers’ prices and the out-of-pocket costs charged by an insurer can fluctuate. “Your plan may raise the copayment or coinsurance you pay for a particular drug when the manufacturer raises their price, or when a plan starts to offer a generic form of a drug,” the Medicare website warns.

But no matter how high the prices go, most plan members can’t switch to cheaper plans after Jan. 1, said Fred Riccardi, president of the Medicare Rights Center, which helps seniors access Medicare benefits.

Drug manufacturers usually change the list price for drugs in January and occasionally again in July, “but they can increase prices more often,” said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University and a member of the Medicare Payment Advisory Commission. That’s true for any health insurance policy, not just Medicare drug plans.

Like a car’s sticker price, a drug’s list price is the starting point for negotiating discounts — in this case, between insurers or their pharmacy benefit managers and drug manufacturers. If the list price goes up, the amount the plan member pays may go up, too, she said.

The discounts that insurers or their pharmacy benefit managers receive “don’t typically translate into lower prices at the pharmacy counter,” she said. “Instead, these savings are used to reduce premiums or slow premium growth for all beneficiaries.”

Medicare’s prescription drug benefit, which began in 2006, was supposed to take the surprise out of filling a prescription. But even when seniors have insurance coverage for drugs, advocates said, many still can’t afford them.

“We hear consistently from people who just have absolute sticker shock when they see not only the full cost of the drug, but their cost sharing,” said Riccardi.

The potential for surprises is growing. More insurers have eliminated copayments — a set dollar amount for a prescription — and instead charge members a percentage of the drug price, or coinsurance, Chiquita Brooks-LaSure, the top official at the Centers for Medicare & Medicaid Services, said in a recent interview with KHN. The drug benefit is designed to give insurers the “flexibility” to make such changes. “And that is one of the reasons why we’re asking Congress to give us authority to negotiate drug prices,” she said.

CMS also is looking at ways to make drugs more affordable without waiting for Congress to act. “We are always trying to consider where it makes sense to be able to allow people to change plans,” said Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, who joined Brooks-LaSure during the interview.

On April 22, CMS unveiled a proposal to streamline access to the Medicare Savings Program, which helps 10 million low-income enrollees pay Medicare premiums and reduce cost sharing. Enrollees also receive drug coverage with reduced premiums and out-of-pocket costs.

The subsidies make a difference. Low-income beneficiaries who have separate drug coverage plans and receive subsidies are nearly twice as likely to take their medications as those without financial assistance, according to a study Dusetzina co-authored for Health Affairs in April.

When CMS approves plans to be sold to beneficiaries, the only part of drug pricing it approves is the cost-sharing amount — or tier — applied to each drug. Some plans have as many as six drug tiers.

In addition to the drug tier, what patients pay can also depend on the pharmacy, their deductible, their copayment or coinsurance — and whether they opt to abandon their insurance and pay cash.

After Linda Griffith left the pharmacy without her medication, she spent a week making phone calls to her drug plan, pharmacy, Social Security and Medicare but still couldn’t find out why the cost was so high. “I finally just had to give in and pay it because I need the meds — I can’t function without them,” she said.

But she didn’t give up. She appealed to her insurance company for a tier reduction, which was denied. The plan denied two more requests for price adjustments, despite assistance from Pam Smith, program manager for five California counties served by the Health Insurance Counseling and Advocacy Program. They are now appealing directly to CMS.

“It’s important to us to work with our members who have questions about any out-of-pocket costs that are higher than the member would expect,” said Lisa Dimond, a Humana spokesperson. She could not comment about Griffith’s situation because of privacy rules.

However, Griffith said she received a call from a Humana executive who said the company had received an inquiry from the media. After they discussed the problem, Griffith said, the woman told her, “The [Medicare] Plan Finder is an outside source and therefore not reliable information,” but assured Griffith that she would find out where the Plan Finder information had come from.

She won’t have to look far: CMS requires insurers to update their prices every two weeks.

“I want my money back, and I want to be charged the amount I agreed to pay for the drug,” said Griffith. “I think this needs to be fixed because other people are going to be cheated.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation).

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FEATURE ARTICLE 2

Brand-name drug prices weigh heavily on Part D beneficiaries

May 6, 2022

Peter Wehrwein

MHE Publication, MHE May 2022, Volume 32, Issue 5

Beauty may be in the eye of the beholder, but drug price trends are in the way you crunch the numbers.

Beauty may be in the eye of the beholder, but drug price trends are in the way you crunch the numbers.

In a piece posted on the Health Affairs Forefront blog last month, Anna Anderson-Cook, Ph.D., and her colleagues at Arnold Ventures argued that analyses by IQVIA and others that show relatively level or even decreased net drug prices in recent years may be misleading. Arnold Ventures, formerly The Laura and John Arnold Foundation, is a philanthropic organization that supports a variety of criminal justice, education and healthcare projects. In healthcare, it has been one of the main supporters of Civica Rx, a nonprofit drug manufacturer, and the Institute for Clinical and Economic Review, a cost-effectiveness research organization in Boston.

One of the interesting points raised by Anderson-Cook and her colleagues is that overall trends “do not apply to the commercial market or to Medicare Part D, where net prices are both significantly higher and growing more rapidly” than they are for other payers. They cite Medicaid as an example of a payer that skews overall results. Medicaid plans have considerably lower net drug costs (costs after rebates and other discounts) than Part D plans because of Medicaid-specific rebates rules that result in larger rebates for Medicaid programs.

The Arnold Ventures researchers also made the case that year-over-year comparisons of net prices for drugs that are already on the market paint an incomplete picture because of the number and expense of new drugs.

Citing a Congressional Budget Office report, Anderson-Cook and her colleagues noted that in 2017 drugs launched after 2015 cost 12 times as much as drugs already on the market in 2015. What’s more, new drugs tend to do well, sales wise, once they are approved and on the market. The Arnold Ventures researchers pointed to a Part D dashboard maintained by CMS that shows that 30 brand-name drugs launched after 2015 were top sellers in Part D by 2019.

So far the cost of these new brand-name drugs has been offset by the shift from brand-name products to generics among the older drugs. The migration to generics has kept increases in net spending per beneficiary in Part D plans on a relatively even keel, meaning it hasn’t surpassed inflation.

The researchers also noted that at 90% the generic dispensing rate may have reached its upper limit. If brand-name drug costs continue to escalate while the generic market stays at 90%, there will be upward pressure on Part D spending, notwithstanding the level-to-moderate spending in the recent past. They cited a 2021 Medicare Trustees Report that projects that the cost of the Part D program will grow by 6.1% annually over the next five years. Biosimilars to the brand-name biologics may have their intended effect, tugging down prices of the biologics, but so far they haven’t had the same effect on prices that generics have had on small-molecule drugs, say the authors.

Without comprehensive reform, Anderson-Cook and her colleagues concluded, the cost of brand-name drugs will “grow aggressively,” straining the Medicare budget and the resources of the program’s beneficiaries.


					

WHAT MAY BE THE MOST CONVENIENT MEDICARE ADVANTAGE PLAN TO DATE!

By D. Kenton Henry editor, agent

26 April 2022

There is good news in the SE Texas Medicare Advantage Market! It announces a new Medicare insurance plan which provides what is likely the greatest access to medical providers to date. It allows a member may go to any provider that sees Medicare patients. This equates access to that of the Medicare Supplement (Medigap) plans I typically encourage my clients to enroll in. And the out-of-pocket expenses are $0! There is not even the Part B annual out-patient deductible of $233 which applies to the most popular Medigap Plan G!

Additionally, it provides the convenience of Medicare Advantage Part D Drug (MAPD) plans because it includes Part D Prescription Drug coverage. This means one need not pay an additional premium for a standalone drug plan to accompany their medical coverage because your medical and drug coverage is included under the cover of one policy.

*(The details of this plan are described by the insurance company in the Feature Article below.)

FOR WHOM IS THIS PLAN BEST SUITED?

In my opinion, it is best suited for the older Medicare recipient for whom their Medigap and Part D drug plan premium now exceeds $215.40 – the monthly premium for this Medicare Advantage Plan. Someone who has just turned age 65 will find their Medigap premium combined with a low-cost Part D drug plan competitive for quite some time. However, as they get older, the total cost can greatly exceed the premium for this Advantage plan. Additionally, unless they have Medigap Plan F, they remain responsible for the annual Part B deductible noted above.

As we age, many of us acquire moderate to significant pre-existing medical conditions. In Texas, and most states, when their Medigap premium becomes burdensome, Texans cannot enroll in a new, and lower cost, Medigap plan and be guaranteed approval. They must go through underwriting and risk being declined due to their health history. With Medicare Advantage plans this cannot happen as approval is guaranteed during the eligible enrollment periods.

WHAT ARE THE DISADVANTAGES OF THIS MAPD PLAN?

First, as implied above, if someone is a relatively younger Medicare recipient – with little in the way of brand name drug usage – their combined premium for medical and drug coverage can be considerably lower than the premium for this MAPD plan.

Furthermore, because this plan combines one’s drug plan with their medical plan – one is tied, or captive to, its Part D drug coverage. Coverage which may not be the best drug coverage available to them in the Part D market.

Lastly, Medicare Supplement Plans (Medigap) are created by and standardized by the Centers for Medicaid and Medicare Services (CMS). They can only be changed by legislation. If legislation would result in a change in their benefits, the insured member would most likely be “grandfathered” or, otherwise, allowed to keep their existing coverage.

With this new “Flex PPO” plan from a major health insurance company, the company could decide to eliminate it in any new calendar year. CMS is not going to mandate an equivalent benefit Advantage Plan. And if none is available – the member is likely to find themselves with an alternative offering less access to providers and with out-of-pocket expenses. Or a member could move to a new area where equivalent coverage is not available.

These are all considerations that must be made before transitioning from Medigap – or another Medicare Advantage plan to this Advantage Plan. Regardless, unless one is just qualifying for Medicare due to age or disability – or losing access to another Medicare Advantage Plan – they will not be allowed to enroll in this new plan until this year’s Annual Election Period October 15th – December 7th.

When that time comes, do not hesitate to contact me for assistance in determining if this option is in your best interest and assistance in enrolling.

D. Kenton Henry

Office: 281-367-6565

TEXT my cell 24/7 @ 713-907-7984

Email: Allplanhealthinsurance.com@gmail.com

Https://TheWoodlandsTXHealthInsurance.com

Https://Allplanhealthinsurance.com              

Https://HealthandMedicareInsurance.com

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FEATURE ARTICLE 1

**(Due to compliance concerns the company will not be identified at this time. You may contact me for that information as well as all details of the plan. The following is their notice to agents and brokers.)

We want to remind you of our new Medicare Advantage Flex (PPO)SM plan that’s currently available for Medicare age-ins or those eligible for Special Enrollment.  

Features include: $0 Copay/coinsurance, $0 deductible, no out-of-pocket costs – and it’s open access. Members can visit any provider nationwide who accepts Medicare. And it includes prescription drug coverage! 

NOTICE DATED 04.25.2022 FROM:

Important Information Regarding Your Provider Plan Coverage Thank you for enrolling in the Medicare Advantage Flex (PPO)SM plan.

With this plan you can:

• See any provider accepting Medicare whether inside or outside the plan service area.

• See any health care provider, at no additional cost, when traveling nationwide.

• Access care from any provider who accepts Medicare assignment and bills Blue Cross and Blue Shield.

• Find providers by going to http://www.medicare.gov/care-compare. A few things to keep in mind:

• You are not required to obtain authorization for out-of-network services, however, services must meet medical necessity criteria to be covered.

• We also offer a traveler benefit for members leaving the service area for six months or less. If you plan to travel and be away from home for up to six months, contact customer service. SAVE THIS Below is a provider notification card for you to keep and present when seeking care from a provider. This will ensure your medical claims are processed in a proper and timely manner. If you have any questions, please call the number on the back of your member ID card.

• Write your name and member ID number on the front of the provider notification card

• Carefully remove and fold card

• Keep this card with your member ID card

• Take both cards to all health care provider appointments Thank you for being a Medicare Advantage Flex (PPO) plan member. Carefully punch out and fold this card

Dear Provider:

• As a provider, you do not need to be a Medicare Advantage Flex (PPO)SM contracting provider to see and treat this member.

• Members can see any provider who accepts payment from Medicare.

• If you are a provider with any of our MA networks, authorization requirements apply.

• The member’s coverage level is the same whether or not a provider is in the network for the Medicare Advantage Flex (PPO).

• At a minimum, eligible claims will be reimbursed at the Medicare Allowed Amount.

WILL MEDICARE RECIPIENTS FINALLY GET A BREAK? . . . WHY MARKETPLACE INSURED PROBABLY WON’T

By D. Kenton Henry Broker, editor 19 April 2022 

While inflation has costs for necessities, such as gas and food items, skyrocketing to an average of 8.5% in March and much higher for the aforementioned items – Social Security saw fit to only increase the Income Benefit to SSI recipients to 5.9%. Seniors, many of whom are subsisting on fixed incomes, might be able to cut their need for gasoline, but I do not know any who can get by without food, shelter, and electricity. Many are struggling to pay their bills already, and inflation shows little sign of abating.  

This was only until 09/2021, at which time, apparently only apples inflated lower than our current rate of inflation. 

But how about the argument that all this inflation is due to Putin and the war in Ukraine? Russia launched a full-scale assault on Ukraine February 22. One month after the end of the timeline in the chart below. 

When was our current president inaugurated? . . . Answer: January 20, 2021. Take a look at the green line above charting the Consumer Price Index on that date. (I will leave it at that.) 

To add insult to injury, the Centers for Medicare and Medicaid Services (CMS) increased Part B (outpatient care) premiums by 15% to a base premium -for those with an annual income of less than or equal to $91,000 – to $170.10 per month. Thank you very much!  

However, as described in Feature Article 1 below, due in part to a 50% cut in the cost of a $56,000 Part D covered drug, CMS is considering reducing that Part B Premium. My experience is that the government seldom gives back what they are already receiving . . . but one can only hope. 

For those involved in Marketplace medical coverage – health insurance for individuals and families under the age of 65 – the opposite action on the part of the Department of Health and Human Services may occur. Specifically, the extended enhanced premium tax credits made available by the American Rescue Plan, which enabled an additional 3 million Americans to receive a subsidy lowering their net monthly premium to as low as $0, are set to expire at the end of the year. As described in Feature Article 3 below, it is estimated 4.9 million more people will go uninsured if enhanced benefits are not extended. Never mind it is estimated the extension of such would increase the federal deficit by $305 billion dollars. Of course, the Treasury can simply print more money, further increasing inflation and diminishing the buying power of one’s paycheck or Social Security Income. 

Lastly, medical expenses are no exception to inflation. If you wonder why health insurance premiums or out-of-pocket costs for healthcare are being affected, refer to article 3 below. They start high and increase as one goes from a doctor’s office to an Urgent Care facility to a hospital emergency room. Avoid the latter unless it is a true emergency because it will cost an average of $444 for low to moderate severity treatment. Heaven, forbid you have an overnight stay in a hospital without medical insurance because the average cost is $11,700. As cited in the chart below, it only goes up depending on the type of insurance you have. 

 Should your stay extend to three days, expect to cost to be an average of $30,000. And what if you don’t have health insurance? Here are the average costs of various treatments.

Take a look at what you might pay for each hospital bill without insurance: 

 *(Data from the Agency for Healthcare Research and Quality) 

While I cannot guarantee we have seen the worst of inflation – let alone that the government is going to provide us any meaningful relief in the immediate future. But I am here to assist you in acquiring medical coverage, which gives you access to the care and treatment you need to regain or preserve your health without being financially ruined. I will do my best to help you maintain access to as many of your preferred medical doctors and hospitals as the present market allows. I do not charge a fee for my services. There is no additional cost for the insights and value of my 36 years of experience in the health and Medicare-related insurance market. Neither is there any additional cost in acquiring an insurance product through me than if you walked through the door of your preferred insurance company and purchased their product directly from them. There is no obligation to take my learned advice.  

Please give me a call and let’s discuss your situation before the very busy “Open Enrollment” Periods are upon us and everyone is scrambling to mitigate what are almost certain to be the increasing costs of health care

.

Office: 291-367-6565 Text my cell 24/7 @ 713-907-7984 Email: Allplanhealthinsurance.com@gmail.com Https://TheWoodlandsTXHealthInsurance.com Https://Allplanhealthinsurance.com 

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FEATURED ARTICLE 1 

FIERCE HEALTHCARE 

CMS, FDA present united front against criticism of Aduhelm coverage decision 

AHIP applauded CMS for covering the drug and “related services such as PET scans if required b the trial protocol.” 

Other stakeholders said that now the coverage decision has been finalized it is time for CMS to take action on lowering Part B premiums. 

CMS has yet to announce any final decision on Part B premiums, which is increased by 15% for 2022. A key reason was the $56,000 price tag for Aduhelm. 

However, Department of Health and Human Services Secretary Xavier Becerra announced in January that the agency was rethinking the 15% hike after Biogen halved the price of Aduhelm in December.  

Becerra told reporters on Tuesday before the coverage decision that he was waiting to see what “CMS gives back to us in terms of their assessment and then once we get that information we will see where we go.” 

 CMS told Fierce Healthcare on Friday that it has yet to decide on a redetermination for the premium. 

But advocates are hoping the agency moves faster on scaling back the premium hike. 

“Medicare beneficiaries struggling to pay their bills need relief from this year’s premium increase as soon as possible,” said Max Richtman, president and CEO of the National Committee to Preserve Social Security and Medicare. 

Pharma and Alzheimer’s disease patient advocacy groups slammed the decision, however, noting that it will hamper access to the drug. 

“CMS has further complicated matters by taking the unprecedented step of applying different standards for coverage of medicines depending on the FDA approval pathway taken, undermining the scientific assessment by experts at FDA,” said Nicole Longo, spokeswoman for the Pharmaceutical Research and Manufacturers of America, in a statement.

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FEATURED ARTICLE 2 

BENEFITSPRO.COM 

End to ACA tax credits could leave 3 million uninsured 

But extending the enhanced credits would increase the federal deficit by $305 billion over 10 years. 

By Alan Goforth | April 08, 2022 at 09:32 AM 

    

Congress would need to act by midsummer to give marketplaces, insurers and outreach programs time to prepare for the 2023 open enrollment period. 

More than three million people could lose insurance coverage if enhanced premium tax credits included in the American Rescue Plan expire at the end of this year, according to a new report from the Urban Institute. The American Rescue Plan Act of 2021 increased credits for Marketplace insurance coverage and extended eligibility to more individuals. 

“If Congress does not extend these benefits, marketplace enrollment will most likely fall and the number of people uninsured will increase,” said Jessica Banthin, senior fellow at the organization. “Our findings show that 4.9 million fewer people will be enrolled in subsidized Marketplace coverage in 2023 if the enhanced credits aren’t extended. This comes at a pivotal time when millions of people will be losing Medicaid as the public health emergency expires.

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FEATURED ARTICLE 3

 Average charges for 8 common procedures across ER, retail and urgent care settings 

Alia Paavola – Wednesday, March 30th, 2022  

In 2020, the median charge for a 30- to 44-minute new patient office visit ranged from $164 in a retail clinic to $234 in an urgent care center, according to a March report from Fair Health. 

For the report, Fair Health, an independent nonprofit focused on enhancing transparency of healthcare costs and health insurance information, analyzed billions of private healthcare claims records from its database. 

Below is the average charge for eight common procedures, as identified by CPT code, performed in retail, urgent care and emergency room settings: 

Retail 

  • Office outpatient visit 20-29 minutes (99213): $114 
  • Streptococcus test (87880): $36 
  • Immunization administration (90471): $33 
  • Office outpatient visit 30-39 minutes (99214): $159 
  • Office outpatient, new, 30-44 minutes (99203): $164 
  • Flu test (87804): $42 
  • Office outpatient, new, 15-29 minutes (99202): $131 
  • Flu vaccination (90686): $31 

Urgent care 

  • Office outpatient visit 30-39 minutes (99214): $232 
  • Office outpatient visit 20-29 minutes (99213): $174 
  • Office outpatient, new, 30-44 minutes (99203): $234 
  • Streptococcus test (87880): $43 
  • Office outpatient, new, 45-59 minutes (99204): $313 
  • Flu test (87804): $46 
  • Therapeutic, prophylactic or diagnostic injection (96372): $59 
  • Office outpatient visit, new, 15-29 minutes (99202): 178 

Emergency room 

  • Emergency department visit — high severity/life-threatening (99285): $1,262 
  • Emergency department visit — high/urgent severity (99284): $919 
  • Emergency department visit — moderate severity (99283): $624 
  • Electrocardiogram (93010): $54 
  • Single-view chest X-ray (71045): $58 
  • CT head/brain without contrast material (70450): $323 
  • Two-view chest X-ray (71046): $69 
  • Emergency department visit — low/moderate severity (99282): $444 

TIME TO RESHOP YOUR MEDICARE SUPPLEMENT INSURANCE?

Op-ed by D. Kenton Henry Editor, Broker 21 March 2022

Greetings from TheWoodlandsTXHealthInsurance.com, deep in the heart of The Woodlands, Texas, for 31 years now!

The “Annual Election Period” (AEP), when Medicare Recipients can change their Part D Drug Plans or enroll in a Medicare Advantage Plan, has closed for 2022. As always, it will reopen October 15th and run through December 7th, for a January 1 effective date. So (minus extenuating circumstances), people are locked into their existing drug and Medicare Advantage Plans for the remainder of the calendar year. 

During these AEP’s – when I am inundated with clients who instruct me to shop for their best plan for the coming calendar year – I am also asked, by many, to reshop their Medicare Supplement Plan. This in spite of the fact that I can reshop their Medicare Supplement Plan 365 days of the year! I suppose it’s a combination of not knowing this about Supplement plans and their simply being “out of sight … out of mind” until the AEP when every TV and radio ad is telling them to call for the Medicare benefits “they’re entitled to”! 

The first reality is – all Medicare Supplement premiums increase as we age. Couple this with cost increases within Medicare itself – which are inevitably passed on to premiums – and it behooves us to reshop our Medicare plans periodically. I recommend every two to three years.

The second reality is – outside the AEP – January 1 until October 15th – I am in a much better position to give the proper and utmost attention to my clients, and prospective clients, and ensure I am getting them approved for a Medicare Supplement plan for which:

1) they can realistically be fully approved without a rate-up in premium

2) which provides them benefits equal to or appropriate for their needs and

3) saves them significant premium dollars

Things which might provide further incentive to apply for replacement coverage are: 

1) they are now eligible for a “household discount” (typically 7%)

2) they are now in Medicare Supplement Plan F and realize conversion to Plan G will save them such significant premium savings it easily offsets the liability for the Part B calendar year out-patient deductible they will have to meet. Or . . .

3) they wish to save even more and apply for Plan N

Before proceeding to take an application, I make it abundantly clear to a prospective applicant that, now that they are more than six months past their date of enrollment in Medicare Part B – they no longer qualify for “Guaranteed Issue.” This means every applicant must qualify based on their health history. The process entails answering health-related questions and providing physician and prescription drug medications. The thing that most often results in an application being declined for issue is a pending or anticipated surgery or hospital stay. Absent these, if a person’s health issues are relatively controlled with medication, or otherwise – and their weight is relatively proportionate to their height – they stand a good chance of being approved. In which case, I would encourage them to apply for replacement coverage. At that point, the only thing at risk is the time it takes to complete an application. The worst case is a declination, which doesn’t preclude you from being approved at a later date. It is not like a derogatory remark on a credit report!

In conclusion (for those of you old enough to remember and – if you are on Medicare – you are!) now is a time when I am a bit like the “Maytag Repairman”. In other words, with the exception tending to my prospects just turning age 65 and aging into Medicare, I am sitting around waiting for the phone to ring. (smiling emoji)

I hope to hear from you, so please refer to my contact information just below. Aside from this, please read my feature article which follows immediately. It is relevant to all Medicare recipients but especially to those currently enrolled in Medicare Advantage primarily for the purpose of consolidating supplement coverage – such as dental and vision – with their medical insurance. Changes could well be coming. 

D. Kenton Henry Office: 281.367.6565 Text my cell 24/7: 713.907.7984 Email: Allplanhealthinsurance.com@gmail.com 

https://TheWoodlandsTXHealthInsurance.com https://Allplanhealthinsurance.com https://HealthandMedicareInsurance.com

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FEATURE ARTICLE: 

BNN BLOOMBERG

COMPANY NEWS 

Mar 15, 2022

Medicare Watchdog Warns of $12 Billion in Excess Payments

John Tozzi, Bloomberg News

(Bloomberg) — Medicare Advantage is leading the U.S. government to spend billions more on seniors’ medical care than it should and needs a significant makeover, a nonpartisan watchdog said in a report to lawmakers.

The program collected $12 billion in “excess payments” in 2020 over what the U.S. would have paid to cover people who used the private plans under standard Medicare, according to a report by the Medicare Payment Advisory Commission, or MedPAC, released Tuesday. 

Medicare has offered some private-sector version since the 1980s, and the current program, called Medicare Advantage, is nearly two decades old. It allows insurers to sell plans that provide Medicare benefits along with add-ons like dental or vision coverage. That can eliminate the need for consumers to purchase supplemental insurance that picks up costs not covered by Medicare itself.

However, MedPAC said swelling costs could threaten the sustainability of Medicare and a major overhaul of the popular program is urgently needed. The program paid Medicare Advantage plans $350 billion last year, MedPAC said.

Enrollment in Medicare Advantage plans has doubled over the past decade to cover nearly half of Medicare’s 64 million beneficiaries, fetching billions for large insurers including UnitedHealth Group Inc., Humana Inc. and CVS Health Corp.’s Aetna unit that have bet heavily on the business.

  It has also given rise to an ecosystem of smaller companies eager to cash in, such as tech-focused insurers like Clover Health Investments Corp. and Alignment Healthcare Inc., and clinics that cater to seniors on the plans, including Oak Street Health Inc. and Cano Health Inc. 

Many of those companies have seen their shares suffer recently due in part to concerns that it will be more difficult to make profits from the business than investors had once expected. 

Appropriate Pressure

MedPAC, established in the 1990s to advise lawmakers on Medicare policy, has long warned about excess Medicare Advantage payments. Private plans are on pace to cover half of all Medicare beneficiaries next year, according to the latest report, and MedPAC said they should be pushed to pare costs.

Medicare Advantage plans “need to face appropriate financial pressure” in line with providers in the traditional fee-for-service Medicare program, the group said.

According to the report, excess payments are driven by plans getting paid more money by the government for taking care of sicker members. Each month, Medicare Advantage plans receive U.S. funds based on the health of their enrollees. For years, MedPAC and other authorities have claimed that insurers manipulate the system to pump up their revenue.

“These policy flaws diminish the integrity of the program and generate waste from beneficiary premiums and taxpayer funds,” MedPAC wrote. The commission said it supports having private plans as an option for Medicare members, but said they have never saved Medicare money.

Industry Backlash

Trade groups such as America’s Health Insurance Plans and the Better Medicare Alliance have disputed MedPAC’s criticism in the past. They say that the program provides better care than traditional Medicare.

Insurers say Medicare Advantage can eliminate the need to buy additional coverage to paper over gaps in the traditional program, and provide other important benefits like meal delivery or transportation. The plans can also cap out-of-pocket costs, which can be unlimited in Medicare without extra coverage.

Payments to Medicare Advantage plans for extra benefits have increased by 53% since 2019, MedPAC said, “yet we have no data about their use nor information about their value.”

  The commission acknowledged that Medicare Advantage plans can deliver lower-cost care. Yet the savings don’t accrue to taxpayers or others in the program, the commission wrote. 

“These efficiencies are shared exclusively by the companies sponsoring MA plans and MA enrollees, in the form of extra benefits,” the report said.

©2022 Bloomberg L.P.

ENTRY OF AETNA AND UNITEDHEALTHCARE IN 2022 ACA HEALTH INSURANCE MARKET; $ INCREASES IN MEDICARE PREMIUMS AND DEDUCTIBLE

TIME IS RUNNING OUT FOR A JANUARY 1 EFFECTIVE DATE!

Op-ed by D. Kenton Henry Editor, Broker 26 November 2021

In September, I learned Aetna and Unitedhealthcare would be reentering the Texas ACA Underage 65 health insurance market for the first time since 2015. Since then, BlueCross BlueShield has been the only “household name,” a large, financially sound insurance company in the southeast Texas market. This was most welcome news, and I was hopeful these additional peer companies would allow my clients and fellow Texans access to more doctors and hospitals. Finding my client’s preferred doctors and hospitals in a plan network has been my client’s and my greatest challenge since the departure of all PPO network options six years ago. Alas, the hoped-for provider expansion in 2022, at this point, has failed to materialize. From 2015 into 2021, the St. Lukes Hospital system has been the only major hospital system participating in most insurance companies’ HMO networks. Such will remain the case for 2022.

Additionally, the entry of Bright Insurance Company (for the first time) doesn’t even appear to do that. They will limit their policyholder’s access to hospitals will be limited to smaller HCA local community hospitals. At least for the time being.

Doctors have practicing privileges at one or more hospitals. Of course, it follows that when an insurance company has fewer hospitals in their network, they will have fewer participating doctors. And so it seems. Only one health insurance company in the southeast Texas ACA health insurance market allows its clients access to the three major hospital systems in the area. Those hospitals are St. Luke’s, Memorial Hermann, and Houston Methodist. And then, only if you acquire their more expensive Silver or Gold plans. 

However, there is a bit of good news for all Americans in the “Individual and Family” health insurance market. The federal government’s American Rescue Plan has increased the amount of Advance Premium Tax Credit (subsidy) and Cost Sharing Reduction (reduction of deductibles, copays, and coinsurance) available to a household. It also expanded the eligibility for these subsidies. As the feature article below explains, this will qualify more people for both types of savings.  

Furthermore, unemployment effects and increases your potential premium tax credit! The American Rescue Plan exempts up to $10,200 in UI benefits from federal income tax. People who receive UI benefits in 2020 will be able to reduce their adjusted gross income by up to that amount, and so reduce their federal income tax liability.

Please get in touch with me to learn the details on the aforementioned company providing the greatest access to providers and how the expanded subsidies and Cost-Sharing Reductions may improve your health insurance situation.

If you choose to be proactive and would like to do some reconnaissance before calling me for assistance and details, you may click on my quoting link immediately following. When the page opens, ignore the login button. You need not log in. Enter your information. I.e., birth date, zip code, etc. On the next page, click on the top box “SELECT ALL” to clear the selections. Then select “MEDICAL” only, to get started. Otherwise, you will be overwhelmed with options and information. You can always return for dental, etc.)

Click “YES” if you would like to estimate whether you qualify for a subsidy. If so, enter your estimated annual income in 2022 and click “CALCULATE”. It will estimate your subsidy. The estimates are usually accurate to within $3.00. From there, click “NEXT”. You will then see all your plan options and be able to LOOKUP PROVIDERS and see plan details. Or simply call me to do all this for you! 

CLICK HERE TO SEE ALL YOUR ACA HEALTH INSURANCE OPTIONS (IF NECESSARY, COPY THE LINK IN YOUR BROWSER AND HIT ENTER):

https://allplanhealthinsurance.insxcloud.com/

MEDICARE RECIPIENTS:

As the cost for everything, including medical treatment, is going up, so too are Medicare’s premiums and deductibles. As our second feature article below illustrates, the Medicare Part B (outpatient) basic premium is going from $148.50 to $170.10 and it’s calendar year deductible is going from $203.00 to $233.00! You can do the math, but, needless to say, so much for 5% inflation rate projected by the current administration which also does not appear to apply to our cost for gasoline, meat, and energy and food, in general! You’ve already spent the increase in your Social Security Benefit! 

The details of how your Medicare Part B basic premium will may titrate upward relative to your income are clearly outlined in Feature Article 2, just published by the Centers For Medicare and Medicaid Services.

Lastly, if you are making the decision whether to go with a Medicare Advantage Prescription Drug Health Plan vs. a Medicare Supplement policy coupled with a Part D Prescription Drug Plan – please read Feature Article 3 (say it ain’t so, Joe!) below, and carefully weigh your decision. 

Again, please contact me for guidance in how to minimize the impact of these changes and maximize your both your access to providers and quality health care. My 35 years specializing in the health and Medicare related insurance industry have provided me insights beyond that of the average agent/broker/generalist; and my clients access to a far greater number of products and solutions.

D. Kenton Henry TheWoodlandsTXHealthInsurance.com                                                              

Allplanhealthinsurance.com@gmail.com

Office: 281-367-6565

Text My Cell @ 713-907-7984

Https://TheWoodlandsTXHealthInsurance.com Https://Allplanhealthinsurance.com Https://HealthandMedicareInsurance.com

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FEATURE ARTICLE 1:

11.24.2021

Cost Sharing Reductions on Silver Plans

Two types of Marketplace subsidies:

Advanced Premium Tax Credits(APTC):Lowers the cost of premiums and can be used on any Marketplace plan except for catastrophic plans.

Cost Sharing Reductions(CSR):Lowers the cost of deductibles and can only be applied to Marketplace Silver plans.

This year, many people will qualify for both types of savings!

Why are subsidies more generous this year:

The American Rescue Plan Act increased the amount of APTC and CSR available to a household, and it also expanded the eligibility for these subsidies.

Silver plans vs. other metal levels:

All Marketplace health insurance plans are broken into five types: Platinum, Gold, Silver, Bronze and Catastrophic. You can expect the same level of care fromall metal levels. The difference is how your healthcare costs will be split between you and the insurance company. Metal levels Premium Platinum Highest Gold Silver Bronze Catastrophic Deductible Higher Middle Lower Lowest Lower Middle Higher Highest. If you are eligible for a CSR, you must choose a Silver plan!

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FEATURE ARTICLE 2:

Key Points:

Part B premium for 2022 is $170.10, up $21.60 from 2021.

The annual deductible for all Medicare Part B beneficiaries is $233 in 2022, an increase of $30 from the annual deductible of $203 in 2021.

Follow the link below for more information and the 2022 Medicare Part B Income-Related Monthly Adjustment Amounts

OR SIMPLY READ THE ARTICLE IMMEDIATELY BELOW 

https://www.cms.gov/newsroom/fact-sheets/2022-medicare-parts-b-premiums-and-deductibles2022-medicare-part-d-income-related-monthly-adjustment

Nov 12, 2021 

Centers for Medicare & Medicaid Services

Nov 12, 2021

Fact sheet


2022 Medicare Parts A & B Premiums and Deductibles/2022 Medicare Part D Income-Related Monthly Adjustment Amounts

Nov 12, 2021 

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On November 12, 2021, the Centers for Medicare & Medicaid Services (CMS) released the 2022 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2022 Medicare Part D income-related monthly adjustment amounts.

Medicare Part B Premium and Deductible

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A. 

Each year the Medicare Part B premium, deductible, and coinsurance rates are determined according to the Social Security Act. The standard monthly premium for Medicare Part B enrollees will be $170.10 for 2022, an increase of $21.60 from $148.50 in 2021. The annual deductible for all Medicare Part B beneficiaries is $233 in 2022, an increase of $30 from the annual deductible of $203 in 2021.

The increases in the 2022 Medicare Part B premium and deductible are due to:

  • Rising prices and utilization across the health care system that drive higher premiums year-over-year alongside anticipated increases in the intensity of care provided.
  • Congressional action to significantly lower the increase in the 2021 Medicare Part B premium, which resulted in the $3.00 per beneficiary per month increase in the Medicare Part B premium (that would have ended in 2021) being continued through 2025.
  • Additional contingency reserves due to the uncertainty regarding the potential use of the Alzheimer’s drug, Aduhelm™, by people with Medicare. In July 2021, CMS began a National Coverage Determination analysis process to determine whether and how Medicare will cover Aduhelm™ and similar drugs used to treat Alzheimer’s disease. As that process is still underway, there is uncertainty regarding the coverage and use of such drugs by Medicare beneficiaries in 2022. While the outcome of the coverage determination is unknown, our projection in no way implies what the coverage determination will be, however, we must plan for the possibility of coverage for this high cost Alzheimer’s drug which could, if covered, result in significantly higher expenditures for the Medicare program.

Medicare Open Enrollment and Medicare Savings Programs

Medicare Open Enrollment for 2022 began on October 15, 2021, and ends on December 7, 2021. During this time, people eligible for Medicare can compare 2022 coverage options between Original Medicare, and Medicare Advantage, and Part D prescription drug plans. In addition to the recently released premiums and cost sharing information for 2022 Medicare Advantage and Part D plans, the Fee-for-Service Medicare premiums and cost sharing information released today will enable people with Medicare to understand all their Medicare coverage options for the year ahead. Medicare health and drug plan costs and covered benefits can change from year to year, so people with Medicare should look at their coverage choices annually and decide on the options that best meet their health needs.

To help with their Medicare costs, low-income seniors and adults with disabilities may qualify to receive financial assistance from the Medicare Savings Programs (MSPs). The MSPs help millions of Americans access high-quality health care at a reduced cost, yet only about half of eligible people are enrolled. The MSPs help pay Medicare premiums and may also pay Medicare deductibles, coinsurance, and copayments for those who meet the conditions of eligibility. Enrolling in an MSP offers relief from these Medicare costs, allowing people to spend that money on other vital needs, including food, housing, or transportation. People with Medicare interested in learning more can visit: https://www.medicare.gov/your-medicare-costs/get-help-paying-costs/medicare-savings-programs.

Medicare Part B Income-Related Monthly Adjustment Amounts

Since 2007, a beneficiary’s Part B monthly premium is based on his or her income. These income-related monthly adjustment amounts affect roughly 7 percent of people with Medicare Part B. The 2022 Part B total premiums for high-income beneficiaries are shown in the following table:

Beneficiaries who file individual tax returns with modified adjusted gross income:Beneficiaries who file joint tax returns with modified adjusted gross income:Income-related monthly adjustment amountTotal monthly premium amount
Less than or equal to $91,000Less than or equal to $182,000$0.00$170.10
Greater than $91,000 and less than or equal to $114,000Greater than $182,000 and less than or equal to $228,00068.00238.10
Greater than $114,000 and less than or equal to $142,000Greater than $228,000 and less than or equal to $284,000170.10340.20
Greater than $142,000 and less than or equal to $170,000Greater than $284,000 and less than or equal to $340,000272.20442.30
Greater than $170,000 and less than $500,000Greater than $340,000 and less than $750,000374.20544.30
Greater than or equal to $500,000Greater than or equal to $750,000408.20578.30

Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Beneficiaries who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses, with modified adjusted gross income:Income-related monthly adjustment amountTotal monthly premium amount
Less than or equal to $91,000$0.00$170.10
Greater than $91,000 and less than $409,000374.20544.30
Greater than or equal to $409,000408.20578.30

Medicare Part A Premium and Deductible

Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, inpatient rehabilitation, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A inpatient hospital deductible that beneficiaries pay if admitted to the hospital will be $1,556 in 2022, an increase of $72 from $1,484 in 2021. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. In 2022, beneficiaries must pay a coinsurance amount of $389 per day for the 61st through 90th day of a hospitalization ($371 in 2021) in a benefit period and $778 per day for lifetime reserve days ($742 in 2021). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $194.50 in 2022 ($185.50 in 2021).

Part A Deductible and Coinsurance Amounts for Calendar Years 2021 and 2022
by Type of Cost Sharing
 20212022
Inpatient hospital deductible$1,484$1,556
Daily coinsurance for 61st-90th Day$371$389
Daily coinsurance for lifetime reserve days$742$778
Skilled Nursing Facility coinsurance$185.50$194.50

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $274 in 2022, a $15 increase from 2021. Certain uninsured aged individuals who have less than 30 quarters of coverage and certain individuals with disabilities who have exhausted other entitlement will pay the full premium, which will be $499 a month in 2022, a $28 increase from 2021.

For more information on the 2022 Medicare Parts A and B premiums and deductibles (CMS-8077-N, CMS-8078-N, CMS-8079-N), please visit https://www.federalregister.gov/public-inspection.

Medicare Part D Income-Related Monthly Adjustment Amounts

Since 2011, a beneficiary’s Part D monthly premium is based on his or her income. These income-related monthly adjustment amounts affect roughly 8 percent of people with Medicare Part D. These individuals will pay the income-related monthly adjustment amount in addition to their Part D premium. Part D premiums vary from plan to plan and roughly two-thirds are paid directly to the plan, with the remaining deducted from Social Security benefit checks. The Part D income-related monthly adjustment amounts are all deducted from Social Security benefit checks. The 2022 Part D income-related monthly adjustment amounts for high-income beneficiaries are shown in the following table:

Beneficiaries who file individual tax returns with modified adjusted gross income:Beneficiaries who file joint tax returns with modified adjusted gross income:Income-related monthly adjustment amount
Less than or equal to $91,000Less than or equal to $182,000$0.00
Greater than $91,000 and less than or equal to $114,000Greater than $182,000 and less than or equal to $228,00012.40
Greater than $114,000 and less than or equal to $142,000Greater than $228,000 and less than or equal to $284,00032.10
Greater than $142,000 and less than or equal to $170,000Greater than $284,000 and less than or equal to $340,00051.70
Greater than $170,000 and less than $500,000Greater than $340,000 and less than $750,00071.30
Greater than or equal to $500,000Greater than or equal to $750,00077.90

Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Beneficiaries who are married and lived with their spouses at any time during the year, but file separate tax returns from their spouses, with modified adjusted gross income:Income-related monthly adjustment amount
Less than or equal to $91,000$0.00
Greater than $91,000 and less than $409,00071.30
Greater than or equal to $409,00077.90

Oct 21, 2021

Oct 15, 2021

Oct 15, 2021

Oct 08, 2021

Sep 30, 2021

Contact us

CMS News and Media Group
Catherine Howden, Director
Jason Tross, Deputy Director

Media Inquiries Form
202-690-6145

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FEATURE ARTICLE 3:

11.08.2021

Medicare plans: Be wary of Joe Namath, other celebrity pitchmen | Steve Israel

  •  

Steve Israel for the Times Herald-Record

Mon, November 8, 2021, 7:24 AM·3 min read

In this article:

  •  

Joe Namath

American football player

Explore the topics mentioned in this article

Joe Namath may have delivered the New York Jets’ last Super Bowl championship, but the old quarterback is throwing a bunch of bull on his TV commercials for private Medicare plans.

He’s one of a slew of pitchmen and women selling Medicare Advantage plans to the more than 54 million Americans 65 or over eligible for Medicare. That includes more than 100,000 of us in Orange, Ulster and Sullivan counties.

Joe Namath may have delivered the New York Jets’ last Super Bowl championship, but the old quarterback is throwing a bunch of bull on his TV commercials for private Medicare plans.

Those pitches, which also flood our mailboxes during this enrollment period that ends Dec. 7, complicate what can be a mind-boggling array of insurance choices.

First, some basic facts:

Medicare Advantage is the all-in-one alternative to original Medicare health insurance. Original Medicare includes coverage for hospitalization (Part A), medical visits and procedures (Part B) and, at additional cost, prescription drugs (Part D). Before you enroll in Advantage plans, you must have original Medicare, and you still must pay the Part B premium of $148.50 (in 2021). While Medicare Advantage plans include medical, hospital and drug coverage, they can also feature extra benefits not offered by traditional Medicare, such as dental, hearing and vision coverage with no additional premium.

Especially in those pitches from celebrities like Namath, William Shatner and Jimmie Walker, they can also promise everything from free meal delivery to money deposited in your Social Security account.

But …

“Buyer beware,” says Erinn Braun, Orange County Office for the Aging’s Health Insurance Counseling and Assistance Program coordinator. She provided much information for this column.

Pitches like Namath’s can be misleading or downright deceptive, starting with the red, white and blue colors that insinuate the ads are from the government, as do the state logos on some mailers. While the plans themselves are perfectly legal and may be great for many of the 27 million Americans enrolled in them, they often don’t deliver everything those pitches seem to promise. Plus, those pitches don’t come close to telling the full story of the benefits of those plans – many of which aren’t even offered in your area.

For instance:

Unlike original Medicare, which is accepted by virtually all doctors and hospitals, Medicare Advantage plans include a network of doctors and hospitals you must visit to be insured. So if you hear about a great gastroenterologist in New York City and she isn’t in your Advantage plan’s network, your insurance may not cover your visit. Plus, unlike original Medicare, you may need prior approval for coverage of a medical procedure or equipment such as insulin pumps.

And while the dental and vision coverage of Medicare Advantage plans sounds great, some plans in your area may only include routine visits, not more expensive items like dental implants and eyeglasses. Plus, the average yearly coverage limit of Advantage dental plans ranges from about $1,000 to $1,300, according to the Kaiser Family Foundation. The dentists and eye doctors you visit must also be in the plan’s networks – meaning your eye doctor or dentist may not accept your plan.

Steve Israel

As for those meals and money Joe Willie is pitching?

Again, buyer beware.

A few Advantage plans may offer meal delivery for the qualified but only one or two plans in your county may offer those benefits. And your doctors or hospital may not accept those plans. Same thing goes for that money Namath says could go into your Social Security account. Not only does that money go toward the required payment for Part B of original Medicare, very few plans – if any – in your area may feature that benefit, and those plans may not include your doctors.

Finally, when you call the number provided by Namath and other pitch folks, you’ll reach a salesperson who’s in business to … you guessed it … sell you a Medicare Advantage plan.

For help selecting the right Medicare plan for you, contact your county’s Office of the Aging. Orange: 845-615-3710, Sullivan: 845-807-0241, Ulster: 845-340-3456. A trusted health insurance agent can also help. Medicare.gov and 1-800-Medicare provide a wealth of information.

steveisrael53@outlook.com

This article originally appeared on Times Herald-Record: Medicare pitches: Joe Namath, other celebrities don’t have best advice

MEDICARE ADVANTAGE, DRUG PLANS, AND ACA INDIVIDUAL AND FAMILY HEALTH INSURANCE OPENING FOR 2022 ENROLLMENT

(AETNA AND UNITEDHEALTHCARE RE-ENTER THE ACA INDIVIDUAL AND FAMILY HEALTH INSURANCE MARKET)

By Editor, Agent, Broker

D. Kenton Henry

It is that time of year and, once more, we find ourselves on the cusp of the “Annual Election Period” for Medicare Advantage and Part D Prescription Drug Plans. This is the period when any Medicare recipient may enroll or change their Advantage and / or drug plans for a January 1 effective date. The period runs from October 15th through December 7th.

As if this was not a busy enough time for Medicare insurance product brokers, many of us (like myself) must do “double duty”, during the holidays. This is because the “Open Enrollment Period” for those “Under the Age Of 65“, in need of Individual and Family health insurance, begins November 1 and runs through January 15th. This a one month extension from previous years. However, those wishing to have new coverage effective by January 1 must still enroll by December 15th.

In addition to the extension of the ACA enrollment period, an interesting and positive turn is that Aetna and Unitedhealthcare are re-entering the marketplace in SE Texas for 2022 after a six year hiatus! This brings welcome competition to a market which was vacated by every major carrier – other than BlueCross BlueShield – in January of 2016. While we will not have insight into the details of their health plan options until just before November 1, their names and reputation should garner a lot of attention, not only from consumers but medical providers. It is my hope that more high quality doctors and hospitals will elect to participate in the insurance companies’ provider networks. With Preferred Provider Organization (PPO) network plans eliminated, Health Maintenance Organization (HMO) network plans have been the consumer’s only option since 2016. And with the expansion in the availability of the Advance Premium Tax Credit and Cost Share Reductions, for many, their greatest challenge is no longer being able to afford health insurance but finding their providers in an insurance plan’s network.

And it is the same for me. As an agent / broker with 34 years in medical insurance, my greatest challenge isn’t finding a plan the consumer can afford or the benefits they’re seeking. It’s finding my client’s, and prospective client’s, medical providers participating in a network. While this isn’t a major issue to those new to the area, those of us who have resided here for years, have long established relationships with providers we are reluctant to part with.

I would be extremely pleased if some of the companies in the marketplace elect to offer PPO plans in 2022. But make no mistake, I in no way expect this to happen. The problem for a company considering offering PPO coverage is that if all their peers do not also, they “adversely select” against themselves. In other words, if they are the “only game in town” when it comes to PPO plans, they are going to attract, and garner, an inordinate number of “bad risks”. In other words, insured members with serious pre-existing conditions who need access to a greater number of providers will flock to them vs the insurance company offering access to an HMO network only. They will submit higher and more frequent claims, thereby compounding the potential for “loss” to the insurance company. This is why insurance companies ceased, in unison, offering PPO coverage, in most regions of the United States, in 2016. They want to limit your access to providers, and thereby limit your access to what is likely to be more expensive treatment. Enrolling people in HMO plans is the easiest way to do this. Regardless, my duty, as your agent, is to do my best to find your providers participating in the network of a plan whose benefits meet your needs.

The good news is – two new major carriers will uncertainly increase the number of options available to the consumer in terms of premiums, benefits, and providers. Additionally, several of the insurance companies are lowering copays and deductibles and the Department of Health and Human Services, which oversees the sale of all ACA health insurance, has made it much easier to qualify for a “subsidy” to reduce the policyholder’s share of the premium due, especially for anyone who claimed unemployment benefits any time during 2021.

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MEDICARE IN 2022

In the Medicare related insurance market, increases in variables for 2022 are estimated to be higher than in recent years. Some were not definite as of the end of September. The Part A In-patient deductible is projected to increase but, as of this date, I have no definitive cost. The Part B Out-patient deductible is estimated to be going from $203 to $217 per calendar year and it’s premium is projected to go from $148.50 to $158.50 per month.

There are currently 30 different Part D Drug plans for Texans to choose from. Each covers some drugs but not others. The plan which is best for you is entirely dependent on the drugs you use. Not the drugs your spouse, neighbor, or I use – but the ones you use. The Part D deductible is going from $445 to $480 for the calendar year. A drug plan may choose to have deductible ranging from $0 all the way to$480 before your drugs become available for a copay. With many plans,  the deductible will not apply to Tier 1 and Tier 2 generic drugs. The threshold for entering the “GAP” will occur when the member and plan have paid $4,430. During this time, the member will pay 25% of the cost of their drugs. They will cross over into “CATASTROPHIC COVERAGE” if, and when, the member has personally expended $7,050. At this point, a member will pay $3.95 for a generic drug and $9.85 or 5% of the cost of a brand name drug – whichever is higher.

As a broker for my clients, and prospective clients, my goal is to identify the Medicare Plan, whether Medicare Supplement, Advantage or Part D Drug Plan which is most likely to result in their lowest total out of pocket cost for the calendar year while providing them access to all their providers. The “total cost” is the sum of their premium, any applicable deductible or deductibles, and copays or coinsurance. Our objective is the lowest sum and that plan, or plans, will usually be my recommendation.

To this end, I encourage anyone interested in enlisting my help, to contact me. If you would like me to identify your lowest total cost drug plan for 2022, based on your current or anticipated drug use, email me a list of your Rx drugs and, preferably, the dosages. The latter can make a difference. If you know you want Medicare Advantage, send me a list of doctors and hospitals you feel you must have access to. Please recall that with Medicare Supplement coverage you may obtain treatment from any doctor, hospital, lab, or medical provider, that sees Medicare patients. There are no networks with which to concern yourself. However, with Supplement, unlike most Medicare Advantage plans, you will have to acquire a Part D Prescription Drug Plan to accompany it.  For those using little or only low cost generic drugs, the lowest premium plan for Texans in 2022 will be $6.90 per month.

*(READ FEATURED ARTICLE BELOW ON WASHINGTON’S EFFORTS TO LOWER RX DRUG COST FOR MEDICARE RECIPIENTS)

The name of my insurance agency I opened in 1991, after being in the medical and life insurance industry since 1986, is All Plan Med Quote. It is located in The Woodlands, Texas. In 1995, I created one of the first websites in the country to market health insurance via the internet. It still exists as Allplanhealthinsurance.com. In 2015, I expanded my web presence with TheWoodlandsTXHealthInsurance.com. The primary objective in naming the first two was to convey that (while I work, for the consumer) I am appointed (contracted) with virtually every “A” rated, major and minor insurance company doing business in your geographic region. But the insurance companies do not pay me a guaranteed wage or salary. They compensate me fairly if, and only if, you elect to go through me to acquire their products. But, without my clients, I have no income. So certainly my clients are my priority. Not the insurance companies. And, as my client, you are charged no more by going through me to obtain their product then if you walked through their front door and acquired it directly from them.

Here is a partial list of the companies whose products may, or may not, be appropriate for you, I may introduce to you:

AARP Unitedhealthcare

Aetna

Ambetter

Anthem

BlueCross BlueShield of Texas

Caresource

Cigna

Community Health Choice

Friday

Humana

KelseyCare Advantage

Molina

Mutual of Omaha

Oscar

Scott and White

Unitedhealthcare

Wellcare

D. Kenton Henry Office: 281-367-6565 Text my cell 24/7: 713-907-7984 Email: Allplanhealthinsurance.com@gmail.com

https://thewoodlandstxhealthinsurance.com https://allplanhealthinsurance.com https://healthandmedicareinsurance.com

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*(FEATURE ARTICLE)

Democrats suffer blow on drug pricing as 3 moderates buck party

BY PETER SULLIVAN – 09/15/21 03:11 PM EDT

Democrats’ signature legislation to lower drug prices was defeated in a House committee on Wednesday as three moderate Democrats voted against their party.

Reps. Kurt Schrader (D-Ore.), Scott Peters (D-Calif.), and Kathleen Rice (D-N.Y.) voted against the measure to allow the secretary of Health and Human Services to negotiate lower drug prices, a long-held goal of Democrats.

The vote is a striking setback for Democrats’ $3.5 trillion package. Drug pricing is intended to be a key way to pay for the package. Leadership can still add a version of the provision back later in the process, but the move shows the depth of some moderate concerns.

The three moderates said they worried the measure would harm innovation from drug companies and pushed a scaled-back rival measure. The pharmaceutical industry has also attacked Democratic leaders’ measure, known as H.R. 3, as harming innovation.

The three lawmakers had long signaled their concerns with the drug pricing measure, but actually voting it down in the House Energy and Commerce Committee is an escalation.

A separate committee, the House Ways and Means Committee, did advance the drug pricing measures on Wednesday, keeping the provisions in play for later in the process.

Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.) had implored the three lawmakers to vote in favor of the measure to at least keep the process going. 

“Vote to move forward today,” he said to the moderates in his party. “Vote to continue the conversation.”

Still, Pallone said he is confident that some form of measure to lower drug prices will make it into the final package. The House legislation was already expected to change before the final version, given moderate Democratic concerns in the Senate as well. Senate Democrats are working on their own bill, which is not yet finalized but is expected to be less far-reaching. 

“I know it is going to have drug pricing reform,” Pallone said of the final bill, noting that negotiations with the Senate would continue over the coming weeks. 

Still, the move on Wednesday is a show of force from the moderates. 

Henry Connelly, a spokesman for Speaker Nancy Pelosi (D-Calif.), said Democrats were not giving up on including drug pricing measures. 

“Polling consistently shows immense bipartisan support for Democrats’ drug price negotiation legislation, including overwhelming majorities of Republicans and independents who are fed up with Big Pharma charging Americans so much more than they charge for the same medicines overseas,” he said in a statement after the vote. “Delivering lower drug costs is a top priority of the American people and will remain a cornerstone of the Build Back Better Act as work continues between the House, Senate and White House on the final bill.”

Peters and Schrader both cited concerns about harming drug companies’ ability to develop new drugs, citing the industry’s record during the COVID-19 crisis.

Peters warned that “government-dictated prices” under the bill would cause harm to the “private investment” that backs drug development.

Schrader said the bill would mean “killing jobs and innovation that drives cures for these rare diseases.”

Advocates said the lawmakers were simply beholden to the pharmaceutical industry.

“Reps. Peters, Rice, and Schrader are prioritizing drug company profits over lower drug prices for the American people, particularly for patients with chronic conditions such as diabetes and multiple sclerosis,” said Patrick Gaspard, president of the left-leaning Center for American Progress. “To the contrary of what they contend, their opposition to the drugs proposal threatens the entirety of President Joe Biden’s Build Back Better agenda, which Democrats have campaigned on for years and that they previously voted for.”

Savings from the drug pricing provisions are a key way of paying for other health care priorities in the $3.5 trillion package, including expanding Medicaid in the 12 GOP-led states that have so far refused, expanding financial assistance under ObamaCare, and adding dental, vision, and hearing benefits to Medicare.

The Congressional Budget Office found that H.R. 3 would save about $500 billion over 10 years. Depending on what Senate Democrats can find agreement on, the final drug pricing legislation is expected to be less far-reaching, meaning it will result in fewer savings, though how much less is unclear.

The Senate bill would still allow Medicare to negotiate lower drug prices, but it is expected not to include another provision that would cap drug prices based on the lower prices paid in other wealthy countries. That provision has drawn particular pushback from some moderate Democrats.

Allowing Medicare to negotiate drug prices is extremely popular with voters, with almost 90 percent support in a Kaiser Family Foundation poll earlier this year. Many vulnerable House Democrats support the idea.

https://thewoodlandstxhealthinsurance.com https://allplanhealthinsurance.com https://healthandmedicareinsurance.com

2021 MEDICARE PART D DRUG PLAN CHANGES AND ADVANTAGE PLAN OPTIONS

By D. Kenton Henry Editor, Agent, Broker 6 October 2020                                                                                        

For most of us, 2020 can’t be over soon enough. And so, as we enter the last quarter of this watershed year, we hope to put Covid-19 and the uncertainty of the presidential election behind us in 2021.

While Inflation remains low, lower prescription drug costs have, for the most part, eluded us. And the medical costs of the pandemic have only accelerated Medicare’s path to insolvency, as covered in Featured Article 1, below.

Perhaps as a result, Medicare has seen fit to adjust several of the cost variables of Part D Prescription Drug Plans, as is their option on an annual basis. In Texas, in 2021, there will be 35 different Part D Plans to choose from. Why so many, you ask? Because each company has typically elected to offer different plans, each focusing on the type of drugs someone requires in order to meet their needs without forcing them to purchase an inappropriately high priced plan. Consequently, each plan covers some drugs and not others. A plan will either focus on low cost generics, higher cost brand name or specialty drugs, or something in between. All are priced accordingly. The plan which is best for you is based entirely on the drugs and dosages you use – not the drugs your spouse or neighbor uses.  

On a bit of good news, for those using no prescription drugs, or only low cost generic drugs, the lowest premium plan for Texans is $7.30 monthly. This is down approximately $6 from 2020! Before you get too excited, be reminded that premium is only one factor in determining which drug plan you elect during the OPEN ENROLLMENT PERIOD beginning October 15th and running through December 7th. During this time, it is my job to first assure all your Rx drugs are covered by the plan you choose. Beyond that, I help you identify the Part D Drug Plan which results in your lowest “Total Cost” (LTC) for the coming calendar year. Your LTC is the sum of the premium you pay + any deductible which may be due + the copays or coinsurance you pay for your prescription drugs. When I add those three things, I am looking for your lowest total sum. That will be my plan recommendation. I do this for each of my clients, who requests such, this time of year.

As stated, I asked you not get too excited over the lower premium option. As implied, it does no good to cut your premium in half if your deductible and / or copays double or triple!

The calendar year deductible allowable by Medicare is going to $445 from $435.

You will enter the Gap (donut hole) when a combination of your drug costs and the plan’s costs exceed $4,130. During this time, you’ll pay your copays or coinsurance for your drugs.

You will remain in the Gap until your personal annual out-of-pocket drug costs reach $6,550.

Beyond that you enter Catastrophic coverage wherein you will pay $3.70 for all drugs treated as generics and the greater of 5% or $9.20 for all other drugs for the remainder of the calendar year.

In addition to identifying and electing your lowest total cost drug plan during Open Enrollment you may be someone who wants to re-shop your Medicare Advantage Plan or elect one for the first time. Those who are my client know that, in my 34 years in the business, I have always preferred – where affordable – my client’s elect Medicare Supplement over Medicare Advantage. This is because I want them to have access to as many provider and treatment options as possible. With a Supplement, an insured member may go to any doctor, hospital, or medical provider that accepts Medicare. Pre-authorization of Medical procedures is not required. However, the reality is – we all get older (or we don’t). And as we get older, our Medicare premiums increase. Unfortunately, many of us are living on fixed incomes and these become a burden. Consequently, while making it abundantly clear their access to providers and treatment will be rationed – and they will pay copays and coinsurance as they go – I offer most all the competitive Medicare Advantage Plans available in Houston and the surrounding counties from a total of 6 companies. The premiums can be as low as $0. This year I have added what, in 2020, is the only 5 Star Medicare Advantage Plan in our area.

(Featured Article 2, below, outlines the liabilities you will be exposed to if you attempt to go with Original Medicare alone.)

For those taking my advice and remaining in Medicare Supplement as long as they can afford to do so I, again, offer most all the more competitive plans in our area. Medicare related insurance company proprietary concerns prohibit me from naming them without first obtaining approval so I will forego doing so until such time as you request quotes from me. There is no obligation to acquire any of the aforementioned products from me and no fee assessed by me for my quotes, advice, or purchase of a plan. The premiums for plans purchased through me are identical to those of the insuring companies as if purchased directly from them. However, in the process of consulting with me, you gain my objective opinion garnered from years of experience in the Medicare related insurance market and as a Medicare consumer, myself.

Please call me with your questions and concerns. I eagerly anticipate working with and assisting you in identifying and acquiring the products  you feel will limit your medical expense liabilities while providing the greatest quality of life in terms of health and financial well-being.

My sincerest thanks for considering my services,

D. Kenton Henry

All Plan Med Quote TheWoodlandsTXHealthInsurance.com Allplanhealthinsurance.com Office: 281.367.6565 Text my cell @ 713.907.7984 Email: Allplanhealthinsurance.com@gmail.com

For the latest in health and Medicare-related insurance news go to: Https://HealthandMedicareInsurance.com

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FEATURED ARTICLE 1:

STAT

Covid-19 is accelerating the Medicare trust fund’s dive toward insolvency

By GRETCHEN JACOBSON

SEPTEMBER 3, 2020

ADOBE

The Covid-19 pandemic has claimed another victim: Medicare’s trust fund. The Congressional Budget Office released a report Wednesday projecting that Medicare’s federal Hospital Insurance Trust Fund, which helps pay for Medicare beneficiaries’ hospital bills, will be insolvent by fiscal year 2024. That means there won’t be enough money in the trust fund to fully pay hospitals, doctors, and nursing homes for the care they provide to Medicare beneficiaries.

These projections describe a crisis for Medicare, a program that, together with Social Security, form the bedrock of our country’s retirement safety net and assure that millions of older adults can get the health care they need.

Concerns about the Medicare trust fund are not new. Insolvency projections for the trust fund have varied over the years, but the outlook has not been this dire since 1971. Before the Covid-19 pandemic, Medicare trustees had projected that the trust fund would become insolvent in 2026. That time frame has accelerated as payroll tax revenue flowing into the trust fund in the next few years is anticipated to be far lower due to the economic recession resulting from the pandemic.

At the same time, health care costs and money flowing out of the trust fund are similar to pre-pandemic levels. In addition, per-enrollee payments, which pay for each person covered regardless of how much health care that person uses, and which play a growing role in Medicare, blunt any reduction in health care spending.

A weekly digest of our opinion column, with insight from industry experts.

Notably, neither candidate for president has mentioned the Medicare trust fund, much less how they would solidify Medicare’s future. Perhaps that is because while Medicare is an important issue for voters, there are a limited number of options for addressing the trust fund’s solvency, none of which are easy choices during normal times, much less during a recession with an ongoing pandemic.

Regardless of who is elected president, come January his administration and Congress will need to develop a plan to address Medicare’s solvency, and decide who will pay to extend it.

The choices for doing so fall into a few broad categories:require Medicare beneficiaries or taxpayers to pay more to support the program

pay health care providers less for the care they provide to beneficiaries

or increase how much the federal government spends on Medicare.

All of these options have significant drawbacks. With unemployment at its highest level since the Great Depression, Americans likely will have little appetite for new or higher taxes or paying more for Medicare services. Providers have suffered financially during the pandemic and paying them less is also likely to be unpopular. And increasing government spending on Medicare means either increasing the country’s debt or making cuts to other federally funded programs.

There are possible workarounds for these challenges. Taxes could be raised on wealthier Americans, though that might be politically challenging and insufficient on its own to achieve enough savings. Cuts to provider payments could be targeted to those on firmer financial footing or take place in the form of initiatives that improve the efficiency of care.

Lawmakers will likely need a multipronged approach that includes a combination of options to generate enough savings and meaningfully extend the solvency of the trust fund. The sooner lawmakers can lay a road map toward Medicare solvency, the more it will help beneficiaries, their families, and health care providers plan for the future.

Gretchen Jacobson is vice president for Medicare at the Commonwealth Fund.

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FEATURED ARTICLE 2:

CNBC

INVEST IN YOU: READY. SET. GROW.

Some Medicare beneficiaries who catch Covid-19 may face huge bills for care

PUBLISHED FRI, OCT 2 202012:54 PM EDT

Sarah O’Brien@SARAHTGOBRIEN

KEY POINTSOlder Americans, including 74-year-old President Donald Trump, are more at risk for developing complications from Covid-19, especially if they have underlying health conditions.

Among Medicare beneficiaries, there have been more than 1 million cases this year through Aug. 15, according to preliminary data from the Centers for Medicare and Medicaid.

The cost of treatment for Medicare enrollees depends on the specifics of their coverage, which varies from beneficiary to beneficiary. With 74-year-old President Donald Trump testing positive for Covid-19, Medicare beneficiaries may be reminded of their own vulnerability.

For the 62.7 million people enrolled in Medicare —  the majority of whom are age 65 or older —  the coronavirus generally poses a greater health risk. While Congress and regulators have nixed out-of-pocket outlays for testing, the potential cost of treating the virus may pose a greater concern, due to the greater likelihood of individuals in that age group developing complications from the virus.

In the U.S., the pandemic has resulted in more than 7.28 million cases and nearly 208,000 deaths. Among Medicare beneficiaries, there have been more than 1 million cases this year through Aug. 15, according to preliminary data from the Centers for Medicare and Medicaid.

WATCH NOW

VIDEO02:30

President Trump, FLOTUS test positive for Covid-19

More than 284,000 of those involved hospitalizations. Almost half (49%) of those stays lasted one to seven days, according to the data. Roughly 5% last longer than 30 days.  

While some Medicare beneficiaries have additional insurance that covers the out-of-pocket costs — i.e., copays and deductibles — others pay more than their peers for hospital stays and various medical services.

Although most people recover from the coronavirus without requiring significant medicare care, here are costs that could come with Medicare coverage if treatment is needed.

Basic Medicare costs

About 60% of beneficiaries stick with basic, or original, Medicare. Many of them also have additional coverage — e.g., Medicaid, an employer plan or a supplemental policy (Medigap).

Basic Medicare, which has no cap on out-of-pocket spending, consists of Part A (hospital coverage) and Part B (outpatient care). 

If you don’t have additional coverage beyond basic Medicare — 6.1 million beneficiaries did not, at last count — you’d pay a $1,408 Part A deductible if you’re admitted to the hospital.

That would cover the first 60 days per benefit period. Beyond that, daily copays of $352 apply up to the 90th day. Anything above dips from “lifetime reserve” days at a rate of $704 daily. For patients moved to a skilled nursing facility, there is no copay for the first 20 days; it’s $176 after that.

Medical services like doctor’s visits are delivered through Part B. It has a $198 deductible and beneficiaries typically pay 20% of covered services.

If you have a Medigap policy, many of these costs would be covered, either partially or fully. However, Medigap policies have their own rules for enrolling, which can limit who has access to them. And, they can cost several hundred dollars a month.

Meanwhile, Medicare Part D (prescription drug coverage) also has no cap on out-of-pocket spending. The cost of medicine depends on the specifics of coverage. If there’s a deductible with your plan, it can be up to $435.

Advantage Plans

About 24 million Medicare beneficiaries get Parts A and B delivered through an Advantage Plan, which also usually includes prescription drug coverage.

These plans may or may not have a monthly premium on top of what beneficiaries pay for basic Medicare. They also typically have different deductibles and copays from original Medicare, and those costs can vary from plan to plan. 

For instance, while you might not face a Part A deductible of $1,408 for a hospital stay, your Advantage Plan may charge you a daily copay for the time you’re an inpatient.

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FEATURED ARTICLE 3:

RESEARCH ARTICLE

PHARMACEUTICALS & MEDICAL TECHNOLOGY

HEALTH AFFAIRSVOL. 39, NO. 8: COVID-19, HOME HEALTH & MORE     PUBLISHED:AUGUST 2020

Medicare Part D Plans Rarely Cover Brand-Name Drugs When Generics Are Available

Recent press reports and other evidence suggest that Medicare Part D plans may be encouraging the use of brand-name drugs instead of generics. However, the scope of such practices is unclear. We examined Medicare Part D formulary coverage and tier placement of matched pairs of brand-name drugs and generics to quantify how often preferred formulary placement of brand-name drugs is occurring within and across Part D plans and to assess the cost implications for Medicare and its beneficiaries. We found that in 2019, 84 percent of 4,176,772 Part D plan-product combinations had generic-only coverage (that is, the brand-name counterparts were not covered). Another 15 percent covered both the brand-name and generic versions of a product. For the small number of products whose brand-name versions were covered preferentially to their generic equivalents, beneficiary and Medicare prices were generally low for both products. Overall, we found that most Part D plan formularies are designed to encourage the use of generics rather than their brand-name counterparts. Policy makers should continue to monitor Part D formulary coverage patterns to ensure consistent and generous coverage for generic drugs, given their important role in reducing prescription drug spending.

ACA admin. kenton henry Aetna Affordable Care Act agent allplanhealthinsurance.com allplaninsurance.com Barack Obama bluecross blueshield of texas broker Capitol Hill center for medicare and medicaid services d. kenton henry d. kenton henry agent broker department of health and human services donald k. henry donald kenton henry federal health insurance exchange healthandmedicareinsurance.com HealthCare.gov Health insurance health insurance premiums health insurance subsidy Humana Indiana Insurance kenton henry kenton henry medplus messenger administrator Medicare Medicare Advantage medicare part b medicare part d medicare supplement Obamacare ohio Patient Protection Affordable and Care Act Patient Protection and Affordable Care Act Texas texas health insurance the medplus messenger blog the woodlands texas thewoodlandstxhealthinsurance.com unitedhealthcare United States Wall Street Journal

HAS CORONAVIRUS OR PRICE OF OIL RESULTED IN YOUR LOSS OF HEALTH INSURANCE?

by D. Kenton Henry

Are you recently faced with a choice between the high cost of COBRA or going without health insurance? Perhaps we can help.

As if the jobs lost due to lay-offs, furloughs, and the closing of businesses stemming from the coronavirus quarantine wasn’t bad enough, the concurrent and additional losses due to the precipitous drop in the price of oil, have made unemployment rates in Texas soar. For those, like myself, who were present at the time, the situation conjures memories of the oil bust of the 1980’s. The resulting home foreclosures, vehicle repossessions, and mass migration from our state were catastrophic, and our state didn’t fully recover until the mid-’90s. But, as terrible as things were, we never saw oil prices drop “to the negative” as they did a few short weeks ago. We can only hope and take heart in the reality that―because financial fundamentals were so strong prior to the pandemic―this crisis will be much shorter once herd immunity has turned the corner on it―and Saudi Arabia and Russia have ceased attempting to crush the market for the sake of driving out the competition.

UNEMPLOYMENT LINES IN WAKE OF CORONAVIRUS

Regardless, this mass unemployment has resulted in thousands losing their health insurance and has left them faced with accepting the high cost of COBRA or (if employed by companies with less than 20 employees) state-continuation health insurance. If accepting either, the former employee is typically responsible for 100% of the retail premium (inclusive of the portion previously paid by their employer) plus an administrative fee of 2%.

An alternative is to enter the “Individual and Family” health insurance market. If one applies within 60 days of losing their employer-based, credible coverage, they will be guaranteed approval and coverage for any pre-existing health conditions on the first of the month following application. You may obtain quotes for all credible ACA (Affordable Care Act) compliant individual and family plans available to you―as well as an estimate of any subsidy for which you may qualify―by clicking on the link below. Then call us for answers to your questions and assistance in applying for coverage*:

https://allplanhealthinsurance.insxcloud.com

*(you do not need to log-in in order to obtain quotes)

Even when a subsidy is available, many find the premiums for these plans to be unaffordable. For those, “Short-Term” or “Temporary” health insurance may be the answer. As premiums for long-term health insurance continue to rise, more and more people find this to be the case. The advantages are, it can become effective immediately, and you can purchase it for periods up to just short of two years. Because the insurance company knows it will only be obligated to pay claims for a limited period―the premiums will be dramatically lower than those of long-term ACA health insurance. The disadvantage of short-term health insurance is that you first must be approved, and the coverage will not cover pre-existing health conditions. So, if you, or a family member, have any moderate to significant health conditions, you may be declined for coverage or find your pre-existing conditions waived for coverage. But, if you have no health issues or can be approved for coverage and can afford to self-insure for your conditions, you will find this coverage much more affordable!

Our feature article below outlines the trend toward purchasing Short-Term health insurance and the reasons for it. It also introduces a company the clients of TheWoodlandsTXHealthInsurance.com have turned to for years to acquire coverage. From the following link, you can choose from a multitude of deductibles and benefit levels to elect a plan specific to your needs and budget. Once you have narrowed your selection, please call us for answers to your questions and assistance in applying.

You may find you only require this coverage until this unprecedented coronavirus/oil market crisis is behind us or until you obtain your next job with benefits. Regardless, we are here to see you obtain the best coverage for your situation and the best of service thereafter.

CLICK HERE FOR SHORT-TERM HEALTH INSURANCE QUOTES:

https://www.pivothealth.com/product/short-term-health-insurance/agent/89958/?utm_source=89958&utm_medium=Allied&utm_campaign=agents

For customized quotes with from a subsidiary of Unitedhealthcare, inclusive of:

·        Enhanced Short Term Medical – with preventive care coverage on all plans, no limit on urgent care visits with a copay, and no application fees – are now available in 17 states!

·        TriTerm Medical – nearly 3 years of continuous health insurance with coverage for doctor visits, prescriptions, and preventive care – now available to quote in 16 states.

·        HealthiestYou by Teladoc® members now have access to behavioral health and dermatology services (for an additional per-use fee). Using the same convenient app and phone number, they can access these new services in addition to 24/7 access to doctors. *This product is not insurance.

Call us. We will help you sort through all your options in order to elect the best health insurance or your situation.

D. Kenton Henry Editor, Agent Broker TheWoodlandsTXHealthInsurance.com Office: 281-367-6565                                                                                                          Text My Cell 24/7 @ 713-907-7984

http://thewoodlandstxhealthinsurance.com

http://allplanhealthinsurance.com/Health/Individual-and-Family/

https://HealthandMedicareInsurance.com

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insurancenewsnet

April 30, 2020 Top Stories

FEATURE ARTICLE

Survey: Short-Term Health Insurance Demand Increasings

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Pivot Health, a division of HealthCare.com, which is a leader in technology-enabled health insurance solutions, has released new customer survey data that reveals 26% of short-term medical plan purchasers were long-time uninsured, while 29% had recently lost their insurance due to unemployment.

Only 5% of purchasers had moved from an Obamacare plan to a short-term medical insurance plan. The survey also showed 75% of the people who lost employer coverage did not choose COBRA because of cost.

Nearly half (46%) of members selected a short-term plan because they didn’t qualify for a subsidy or they needed something quickly. The survey also found 21% of those who purchased a short-term health insurance plan were influenced by the global coronavirus pandemic.

When asked what is the greatest concern facing the health insurance market today, survey participants said out-of-pocket costs were the No. 1 issue they are concerned about when it came to healthcare.

· 64% are concerned about the high monthly cost of insurance.

· 51% worry about paying for medical bills out of pocket.

· 45% are concerned about high deductibles.

One customer said, “Most Americans cannot afford high-cost insurance. Anything over $100 a month is too much.”

“The survey data reveals that customers are more comfortable buying short-term health insurance plans than they ever have been,” said Jeff Smedsrud, chief executive officer of Pivot Health. “Since Congress has failed to pass legislation to subsidize COBRA plans, which put the entire financial burden on the employee, short-term health plans are becoming a general preference for individuals who need a budget-friendly healthcare solution as they maneuver through life transitions, unemployment or just need economical coverage.”

Download a summary of the survey findings.

About Pivot Health (a division of HealthCare.com)

HealthCare.com is an online health insurance company providing a data-driven shopping platform that helps American consumers enroll in individual health insurance and Medicare plans. HealthCare.com also develops and markets a portfolio of proprietary, direct-to-consumer health insurance and supplemental insurance products under the name Pivot Health. Founded in 2014, the company is headquartered in New York City and is backed by PeopleFund and individual investors including current and former executives of Booking.com and Priceline. HealthCare.com is a 4-time honoree of the Inc. 5000 list of America’s fastest-growing companies and has been recognized by Deloitte as one of the fastest-growing technology companies in North America.

MEDICARE FOR ALL? (AND “THE TOOTH FAIRY PROMISES A 2 YEAR TREASURY NOTE PAYING 10.7% UNDER YOUR PILLOW IN 2020)

OpEd by D. Kenton Henry                                                                                           01 October 2019  HealthandMedicare.com

       VS.                 

I listened to the recent Democrat Presidential Primary Debates, as I listen to the daily sound bites in the media, as candidates try unabashedly to outdo each other. They do this in terms of the massive give-aways they promise us if elected in 2020. They promise these things not just to citizens, but everyone within the border of the United States. My incredulity, upon hearing such, exceeds even those bounds.

Their original promise is “free healthcare for all”. Healthcare free of premiums, deductibles, and copays. Medicare is the vehicle. To which I must ask myself, “Do these people even know the costs involved in Medicare?” “Do they really believe Medicare pays everything?” They would have you believe as much. They are counting on your naivety and lack of familiarity with the subject.

What makes Medicare a convenient and acceptable form of medical coverage for millions of people 65 and older (or disabled for 24 months or more) is it working in conjunction with private insurance plans. That, and thousands of licensed and “Certified” agents and brokers, helping to deliver comprehensive medical coverage at an affordable price. It is a hybrid package that provides as complete protection as available. The insurance plans would not exist without Medicare and, by itself, Medicare leaves the recipient/member exposed to significant liabilities.

Do these candidates, and the average voter know that in 2019:

A hospital admission requires the Medicare member to pay a $1,364 deductible each time they are admitted to the hospital as an inpatient for a separate medical condition, or the same medical condition separated by more than 60 days.

For days beyond 60, they pay $335 per day

Beyond day 90, they pay $682 per day

Eventually― say in the event of a stroke, paralysis, or being severely burned―they will pay all costs.

Part B Co-Insurance, Deductible and Premium

Relative to out-patient medical care, the Medicare member pays 20%, plus can be liable for excess charges above and beyond what Medicare deems “reasonable and customary”.

In addition, Medicare recipients pay an annual deductible of $185 for Medicare Part B (out-patient) medical care and a premium generally beginning at $135.50 per month and increasing to as high as $460.50. The latter depending on one’s adjusted gross income.

Perhaps most important, to take note of, in considering whether “Medicare For All” is even feasible, much less cost effective, is this. Medicare recipients have paid into the Medicare program their entire working careers via Medicare care taxes and payroll deductions. To qualify for Part A, (inpatient) coverage, they must have worked a minimum of 40 quarters or “buy in “with a premium as high as $422 per month.

So, you can see, Medicare is hardly free. And yet these candidates would have you believe it will be provided free of premiums, deductibles, and copays. (Now this is where even The Tooth Fairy raises her eyebrows!) It will be GIVEN, not to just those over 65, but to every man, woman, child, legal, and non-legal citizen or resident of the United States―whether they have paid a dime into the system or not.

Factor all that in and process this. Medicare now spends an average of about $13,600 a year per beneficiary, and in five years, the annual cost is expected to average more than $17,000, the report said.

According to CMS.gov (The Centers for Medicare & Medicaid Services ― refer to featured article 1 below*) The Medicare Board of Trustees predicts Medicare’s two trust funds, for Part A and Part B and D, respectively ― will go broke in 2026!

To put things in perspective, in 1960 there were about five workers for every Social Security beneficiary. The ratio of workers to beneficiaries fell to 3.3 in 2005 and then to 2.8 in 2016. It will decline further to about 2.2 by 2035, when most baby boomers will have retired, officials said.

The aging of the population is another factor in the growth of the two entitlement programs. The number of Medicare beneficiaries is expected to surge to 87 million in 2040, from 60 million this year, according to Medicare actuaries. And the number of people on Social Security is expected to climb to 90 million, from 62 million, in the same period.

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All this and the candidates would have you believe our government can provide free health care to everyone? When it can’t even provide it to our current citizens who have paid into the system their entire working lives! And who exactly is the government? “We The People”. We the tax payers. You and I. Even some of the candidates, admit the proposal will call for more taxes from the middle class. More? Really! One projected cost for Medicare For All is 39 trillion dollars over the first ten year period. The national debt is currently $22 trillion and took since the end of President Andrew Jackson’s administration (1837 and the last time the national debt was fully paid-off) to accumulate that! The combined wealth of all American households is less than $99 trillion. One can only conclude that “Medicare For All” would be a “Welfare System For All”. It would push our country into a socialist economic system to a depth from which it would be impossible to extricate itself.

As a new Medicare recipient, myself, I find the combination of the government program and private insurance working very well for myself and clients, from an insured standpoint. The program’s, and our nation’s, fiscal concerns are a more substantial matter and a topic for another time. With Medicare “Open Enrollment” a mere 15 days away, I can only say, “I hope whoever is President, and controls Congress, in future administrations―while providing a safety net for all American citizens―first and foremost, provides the capable, responsible, American taxpayer quality medical coverage―free of rationing of treatment and access to providers. At an affordable cost.”

D. Kenton Henry, editor HealthandMedicareInsurance.com, Agent, Broker

Email: Allplanhealthinsurance.com@gmail.com https://TheWoodlandsTXHealthInsurance.com https://Allplanhealthinsurance.com https://HealthandMedicareInsurance.com 

 

************************************************************************************Featured article:

Centers for Medicare & Medicaid Services

Press release

Medicare Trustees Report shows Hospital Insurance Trust Fund will deplete in 7 years

Apr 22, 2019 

Medicare Trustees Report shows Hospital Insurance Trust Fund will deplete           in 7 years

Today, the Medicare Board of Trustees released their annual report for Medicare’s two separate trust funds — the Hospital Insurance (HI) Trust Fund, which funds Medicare Part A, and the Supplementary Medical Insurance (SMI) Trust Fund, which funds Medicare Part B and D.

The report found that the HI Trust Fund will be able to pay full benefits until 2026, the same as last year’s report.For the 75-year projection period, the HI actuarial deficit has increased to 0.91 percent of taxable payroll from 0.82 percent in last year’s report. The change in the actuarial deficit is due to several factors, most notably lower assumed productivity growth, as well as effects from slower projected growth in the utilization of skilled nursing facility services, higher costs and lower income in 2018 than expected, lower real discount rates, and a shift in the valuation period.

The Trustees project that total Medicare costs (including both HI and SMI expenditures) will grow from approximately 3.7 percent of GDP in 2018 to 5.9 percent of GDP by 2038, and then increase gradually thereafter to about 6.5 percent of GDP by 2093. The faster rate of growth in Medicare spending as compared to growth in GDP is attributable to faster Medicare population growth and increases in the volume and intensity of healthcare services.

The SMI Trust Fund, which covers Medicare Part B and D, had $104 billion in assets at the end of 2018. Part B helps pay for physician, outpatient hospital, home health, and other services for the aged and disabled who voluntarily enroll. It is expected to be adequately financed in all years because premium income and general revenue income are reset annually to cover expected costs and ensure a reserve for Part B costs. However, the aging population and rising health care costs are causing SMI projected costs to grow steadily from 2.1 percent of GDP in 2018 to approximately 3.7 percent of GDP in 2038. Part D provides subsidized access to drug insurance coverage on a voluntary basis for all beneficiaries, as well as premium and cost-sharing subsidies for low-income enrollees.  Findings revealed that Part D drug spending projections are lower than in last year’s report because of slower price growth and a continuing trend of higher manufacturer rebates.

President Donald J. Trump’s Fiscal Year 2020 Budget, if enacted, would continue to strengthen the fiscal integrity of the Medicare program and extend its solvency.  Under President Trump’s leadership, CMS has already introduced a number of initiatives to strengthen and protect Medicare and proposed and finalized a number of rules that advance CMS’ priority of creating a patient-driven healthcare system through competition.  In particular, CMS is strengthening Medicare through increasing choice in Medicare Advantage and adding supplemental benefits to the program; offering more care options for people with diabetes; providing new telehealth services; and lowering prescription drug costs for seniors.  CMS is also continuing work to advance policies to increase price transparency and help beneficiaries compare costs across different providers.

The Medicare Trustees are: Health and Human Services Secretary, Alex M. Azar; Treasury Secretary and Managing Trustee, Steven Mnuchin; Labor Secretary, Alexander Acosta; and Acting Social Security Commissioner, Nancy A. Berryhill. CMS Administrator Seema Verma is the secretary of the board.

The report is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/index.html.

***************************************************************************************************

*Featured Article #2

Politics

Health insurers ramp up lobbying battle against Medicare-for-all

By Ana Radelat

The CT Mirror |

Aug 12, 2019 | 6:00 AM

Health insurers have joined forces with their longtime foe, the pharmaceutical industry, as well as partnering with the American Medical Association and the Federation of American Hospitals, to form a coalition to fight Medicare-for-all proposals and other Democratic plans to alter the nation’s health care.

As Democratic presidential candidates embrace changes to the nation’s health care system that could threaten Connecticut’s health insurers, the industry is hitting back.

Health insurers have joined forces with their longtime foe, the pharmaceutical industry, as well as partnering with the American Medical Association and the Federation of American Hospitals, to form a coalition to fight Medicare-for-all proposals and other Democratic plans to alter the nation’s health care.

The Partnership for America’s Health Care Future, funded by the insurance industry and its allies, is running digital and television ads aimed at undermining support for Medicare-for-all proposals and plans for a “public option,” a government-run health plan that would compete with private insurance plans.

The partnership was formed a little more than a year ago to protect the nation’s current health care programs, mainly the Affordable Care Act, Medicare and Medicaid.

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The organization’s executive director, Lauren Crawford Shaver, said diverse groups in the coalition found a common cause in 2017 — opposing an attempt by congressional Republicans to repeal the Affordable Care Act.

“We came together to protect the law of the land,” she said.

That battle was won. Coalition members determined they should continue to band together to ward off other political dangers.

“There’s a lot of things we might fight about, but there’s a lot we can agree on,” Crawford Shaver said.

Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts have called for a Medicare-for-all through a single-payer system, in which all Americans would be enrolled automatically in a government plan.

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Warren was among several candidates during the most recent Democratic debates who took aim at health insurers.

“These insurance companies do not have a God-given right to make $23 billion in profits and suck it out of our health care system,” she said.

Other candidates prefer a more modest approach, offering a “public option” or Medicare buy-in plan that would allow Americans to purchase government-run coverage, but unlike Medicare-for-all would not eliminate the role of private insurers.

That split among Democrats also runs through Connecticut’s congressional delegation, with Sen. Richard Blumenthal, D-Conn., and Rep. Jahana Hayes, D-5th District, endorsing Medicare-for-all plans and the other lawmakers supporting Medicare buy-in or public option plans.

The nation’s health insurers oppose all of the Democratic proposals discussed during the two nights of debates.

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The insurers’ message is simple: The Affordable Care Act is working reasonably well and should be improved, not repealed by Republicans or replaced by Democrats with a big new public program. Further, they say, more than 155 million Americans have employer-sponsored health coverage and should be allowed to keep it.

Insurers also say that public option and Medicare buy-in plans would lead the nation down the path of a one-size-fits-all health care system run by bureaucrats in Washington D.C.

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They say offering a public option or a Medicare buy-in would prompt employers to drop coverage for their workers and starve hospitals, especially those in rural areas, since government-run health plans usually reimburse doctors and hospitals less for medical services than private insurers. They also say Medicare-for-all and other Democratic proposals will lead to huge tax increases to pay for the plans.

“Whether it’s called Medicare for all, Medicare buy-in or the public option, the results will be the same: Americans will be forced to pay more and wait longer for worse care,” said Crawford Shaver.

The Partnership for America’s Health Care Future ran its first television ad on CNN just before and after the cable channel ran last week’s debates.

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The commercial showed several “ordinary Americans” at home and work decrying “one-size fits-all” health plans and “bureaucrats and politicians” determining care.

“We need to fix what’s broken, not start over,” the final speaker says.

Members of the Partnership for America’s Health Care Future have a lot of money and influence to wield on Capitol Hill. They spent a combined $143 million lobbying in 2018 alone, according to data from the Center for Responsive Politics.

And coalition members appear eager to spend even more lobbying money this year.

In the first six months of this year, America’s Health Insurance Plan, a health insurer industry group and member of the partnership, spent more than $5 million on lobbying expenses, and is on the way to surpassing the $6.7 million it spent in lobbying last year.

To underscore the health insurance industries’ importance to local economies, AHIP releases a state-by-state data book each year that details coverage, employment and taxes paid.

In Connecticut, the industry employs 12,296 workers directly and generates another 13,586 jobs indirectly, AHIP says. The payroll for both these groups of workers totals over $3.8 billion a year, AHIP says, and the average annual salary in the business is $112,770. The Connecticut Association of Health Plans puts the number higher, saying Connecticut has 25,000 direct jobs related to the health insurance industry, and another 24,000 indirect jobs.

AHIP also estimates that Connecticut collects nearly $200 million a year in premium taxes on health care policies sold in the state.

Connecticut’s reliance on health insurers – and their continuing influence – was on full display during the last legislative session when the insurance companies, led by Bloomfield-based Cigna, derailed

DENTAL INSURANCE: WORTH THE PREMIUM YOU PAY … OR SIMPLY A “TIME PAYMENT PLAN”?

Op-ed by D. Kenton Henry

“Is dental insurance really worth the premium I pay?” is one question I am asked frequently. It is often followed, almost instantly, by―”Or am I simply paying for my dental work on a time a payment plan?”

My answer to both questions is a definitive, “Maybe.”

If you, as the majority do, have dental insurance through your employer, that employer is subsidizing all or part of your premium. This convenience makes for a solution to the equation, more favorable to you. In contrast―if you are self-employed, retired, or otherwise personally have to pay the full amount of a dental insurance premium―the opposite may be true. That is unless you take some straightforward advice, I am about to provide. If you do not, you most likely will only be spreading your cost for dental work over time. Even worse, dental insurance could prove to be a “loss item” in that you will have paid more in premiums than you will ever receive in benefits.

Short of taking a long drive and crossing the Rio Grande into Mexico to obtain your dental work, what can you do to offset the cost of say, a dental implant, which, on this side of the border, is going to run from $3,500 to $7,000?

Let me preface this by with a premise or three:

#1) With no insurance company is “the sky the limit”. I’m referring to the fee they are going to pay a dentist for a particular dental procedure. For example, no insurance company is going to accept a fee of $10,000 for a single porcelain crown. Not even their share of that cost, which is typically 50%. So what is the limit of a fee the insurance company will cover? That limit must be contractually defined, and the limit most insurance companies abide by is, “reasonable and customary” or “reasonable, usual, and customary”. These are empirical standards an insurance company uses to determine whether to pay a fee. Or how much of a fee to pay. If the dentist charges the general prevailing rate in your geographical area, they are going to pay the portion for which they are contractually obligated. Basically, it’s the average charged in your neighborhood. You will be charged more in Beverly Hills, California and less in Brenham, Texas “where the cows think it’s heaven”. Additionally, if “usual” is part of the definition, the fee has to be in line with what this particular dentist charges for a particular procedure. If fee is disproportionate either, or, both, ways―the maximum amount paid by the insurance company will be the limit set in their fee schedule.

#2) A dental insurance plan is either a provider network plan or a non-network plan. If it is a network plan, it is usually either a Dental Preferred Provider Organization (DPPO) Plan or a Dental Health Maintenance Organization (DHMO) Plan. If it is the first, you may go outside the network of dentists with which the insurance company has contracted but will most likely pay a higher cost for doing so. With the latter, you must remain within the network of dentists or, you have no insurance coverage whatsoever. For either of these options, you pay a lower premium than if you purchase a non-network or “any dentist” plan. The reason is that you agree to utilize or, at least, consider utilizing a dentist with whom the insurance company has contracted to charge you a lower fee than they would without the contract. This limits the insurance companies losses and brings increased traffic to the dentist.

#3) This is perhaps the most important part. If you purchase a non-network dental insurance plan, you can, almost, be assured you will be charged more than the insurance company deems acceptable. Additionally, you will be responsible for any dollar amount above their “reasonable and customary” rate. However, if you purchase a network plan, and go within the network of dentists, you will not be held responsible for any “excess” charges. Any charges above the reasonable and customary rate, the dentist will be forced to “write off”. In this situation, you will never have to worry about a surprise bill or claim. If a policy says your share of the bill is 20% or 50%, it will be that and not 20% or 50% plus any excess charges.

Assuming you accept you must acquire a network plan, in order to limit you own losses and surprise dental bills, the challenge becomes, “How do you find a quality dentist willing to accept a lower fee for treating you?” The typical HMO dental provider is typically someone straight out of dental school or who otherwise needs to build their patient base. In return for sending patients their way, the dentist is willing to accept a meaningfully lower fee. If the dentist is a PPO provider, they may have been in business longer, have more experience, and perhaps a reputation for having better skills. But they are willing to accept a somewhat lower fee in return from the many employees a large company may send their way. The dentist who isn’t willing to participate in any network apparently feels they have all the clients they need. That or their reputation is so great it will draw all the traffic they require.

The problem is, unlike a large oil company, as an individual, or family, you don’t bring enough “volume” to the table to bargain for a lower dental fee. At least not by yourself. Therefore, you have to identify and purchase your dental insurance from an insurance company which has the reputation of insuring a large number of employees of that oil company. As well as having a reputation for paying their claims in a timely and efficient manner. A manner such that the dentist wants to be contracted with them. From your standpoint, you want that insurance company to have a reputation for the same when it comes to you and not have to worry about claim disputes.

Another challenge is, at $6,000 for a dental implant, your dental benefit may not go too far. Secondly, does your insurance plan cover implants in the first place? Again, the sky is not the limit. The average dental plan covers a maximum of $1,000 of dental treatment per year. You can pay a higher premium for incremental benefits up to a maximum of $5,000. But a policy which pays that much in year one would cost a fortune and there is typically a twelve-month wait for major dental work to be covered. As such, you may want to find a plan which increases to that limit with each passing year and is available at what you consider a reasonable cost.

How do you find a dental policy which does not subject you to “excess” costs; allows you to see a highly skilled dentist, utilizing the latest technology and performing the most advanced form of treatment; all at a competitive premium? And this from a company which pays the claims they are contractually obligated to pay while doing so in a timely fashion?

This is where I, and my thirty-three years experience in the medical and dental insurance business, come in. My experience as a patient and consumer is even longer. After being in braces for eight years, I had all my front teeth knocked out in an auto accident when they impacted the steering wheel. I was wearing a seat belt, which saved my life, but not a shoulder strap. I’ve had to have the dental work replaced on three occasions since that senior year of high school. This year, I proceeded with what will be one double crown and, ultimately, two implants. (Ouch, is right!) I was not willing to accept this type of work from a mediocre dentist―and certainly did not care to pay cash for it! So I found a policy, issued by a large, financially sound insurance company, with a reputation for excellent customer and claim service. Then I found a policy which ultimately pays the maximum $5,000 annual benefit. In order for it to be affordable to me, it started, December 1 of 2018, at a calendar year benefit of $1,500―immediately went to $2,500 January 1, of this year―and will go to a $5,000 benefit this coming January. So I only paid for a $1,500 benefit for one month before it jumped to a $2,500 benefit! During this year I acquired the double porcelain crown and the bone graft and post for one dental implant. In 2020, I will have the crown for the implant post attached, when my calendar year benefit is $5,000. The second implant is optional, and I will probably have that work done in 2021 when my benefit remains $5K.

Once I knew what company to go with, the final step in selecting my dental insurance policy required finding the right dentist. I reviewed the insurance company’s list of network providers and researched the dentist’s reputation via credentials and reviews. I won’t belabor that but, suffice it to say, I found a dentist who met my requirements. He is very conveniently located relative to any resident of The Woodlands or Spring and, in my opinion, is well worth going to if you reside anywhere in Montgomery County or Northwest Harris County. He utilizes the latest technology, has a great and skilled staff, and a decent, very professional, if not overly effusive, chairside manner.*

In summation, in order to make dental insurance worth your while, you need to:

1) accept you need to acquire a “network provider” dental plan

2) find a policy which pays a reasonable benefit based on your foreseeable need, at an affordable premium and

3) allows you to go to a skilled dentist convenient to you

I have done all the homework for you. For over three decades, I have specialized in medical, Medicare-related, and dental insurance. I provide objective quotes from established “A” rated companies and quality customer service. Among the companies I represent are Aetna, Ameritas, Anthem, BlueCross BlueShield, Cigna, Delta Dental, Humana, and UnitedHealthcare. I am located in the heart of The Woodlands and am accessible from my websites Allplanhealthinsurance.com and TheWoodlandsTXHealthInsurance.com. You may also feel free to contact me at my numbers below.

I look forward to working with and assisting you in acquiring any of the above referenced products.

D. “Kenton” Henry                                                                                                               Editor, Agent, Broker Office: 281-367-6565                                                           Text my cell @ 713-907-7984                          http://TheWoodlandsTXHealthInsurance.com                              http://Allplanhealthinsurance.com                                   http://HealthandMedicareInsurance.com https://linkedin.com/in/kentonhenryinsuranceconsultant

*(Neither I nor my agency and websites are affiliated in any way with a particular dentist or dental office. Neither do we receive compensation from the same for any recommendation we may make.)