About thehealthinsuranceanswerman

Kenton graduated in 1978 with a degree in Social Work from Indiana University and returned to Texas where he had lived in Tyler and McAllen as a youth. After working as a counselor for the Harris County Department of Mental Health and Retardation and the Texas Department of Health and Human Services as a Child Protective Services caseworker, he moved into the private sector where he had a five year career as a pharmaceutical sale representative for Adria Laboratories and Stuart Pharmaceuticals. In 1986, Kenton became a career agent for The Mass Mutual where he learned the life, health and executive disability market. Wishing to be independent, he moved to The Woodlands, Texas in 1991 and formed ALL PLAN MED QUOTE. In 1995 he was one of the first insurance agents to begin marketing health insurance via his original website Allplaninsurance.com, eventually becoming licensed in thirty three states. For the last twenty-two years he has specialized in medical insurance. In 2005--as his clients began to age into Medicare--he began to focus on the "Medicare related insurance market" in order to better serves their needs. After twenty-seven years in the industry, he remains committed to his profession and his clients, particularly to the latter as they transition through and adjust to the "Affordable Care Act" (ACA), commonly referred to as health care reform.

Consider The Disadvantages of Medicare Advantage As Well As Advantages (before locking yourself out of Medicare Supplement)

Posted on April 6, 2024 by thehealthinsuranceanswerman

By D. Kenton Henry Editor, Agent, Broker

05 April 2024

In addition to owning the first insurance agency in The Woodlands, Texas, and most of the United States, to create a website (Allplaninsurance.com) in 1995, I was among the first to offer Medicare Advantage and Medicare Part D Prescription Drug Plans (MAPD plans) to Medicare recipients following their creation by the Medicare Modernization Act of 2003. Congress created them to provide a lower premium insurance product as an alternative to Medicare Supplement policies, which has been the standard insurance product to serve as secondary insurance covering medical expenses not paid by Original Medicare. And—with premiums as low as $0—they have certainly done that. Contrary to what may be the common perception of the public, every good agent has a little bit of social worker in them and wants to think they have really helped a person and improved their situation. As an agent (before the advent of Medicare Advantage plans), I would sit across coffee tables from prospective clients living in single-wide trailers and subsisting on social security income alone. I would watch tears come in their eyes as they told me they simply did not have another dime to spend on insurance, leaving me to drive off and them no better off for my visit. So, from that standpoint, they have been a source of great relief for me as well as my clients.

In addition to lower premiums, MAPD plans offer other advantages. Specifically, they are:

The convenience of combining medical coverage with prescription drug coverage under the cover of one policy. Effectively eliminating the necessity of paying a second premium for the latter.
The provision of “extra” benefits such as dental, vision, and hearing benefits
“Guaranteed Approval” during the Annual Election Period October 15th and December 7th and the option of changing your plan each January 1 as the plans and your needs change.
Premiums are not age-based and do not increase due to age as one gets older.

Seniors are inundated with seemingly endless television and radio commercials promoting Medicare Advantage plans ad infinitum. But while they drive home the advantages mentioned above, they virtually never mention the disadvantages or compromises that come with electing them over a Medicare Supplement policy. There are many reasons for this, but this is the one most relevant to you:

Medicare, like Social Security, is hemorrhaging dollars. Please don’t take it from me. Google it. Financial prognosticators project it will enter a default position by 2031. Medicare trustees say the Part A (Hospital and Skilled Nursing coverage) program will begin running deficits again in 2025, drawing down the trust fund until it depletes in 2031. After that date, the program will not bring in enough money to fully pay out Part A benefits. *(See Feature Article 2 below.)

Now, we all know our government will just tax us more, and our treasury will print enough more money to keep things going. But the bottom line is that Medicare is seeking any way of saving money and limiting its losses. The easiest way to do this is to lower its share of claims. The easiest way to lower its share of claims is to increase enrollment in Medicare Advantage plans relative to Medicare Supplement. And why is that?

Opposed to Supplement, Advantage plans . . .

1) Force the insured member to share in more expenses as the medical claims come in.

2) They influence the member to utilize a limited network of providers or pay a higher cost for not.

3) They subject the member to preauthorization of medical tests and procedures, often resulting in significant delays in treatment. *(See Feature Article 1, 2 and 3 below.)

4) Advantage plans that combine prescription drug coverage with medical coverage (MAPD plans) lock the member into a drug plan that may not provide the lowest total cost for drugs or cover them in the first place.

5) Once a member foregoes Medicare Supplement in favor of an Advantage plan beyond 12 months, they may find themselves locked into an Advantage plan—and out of a Medicare Supplement plan—due to preexisting medical conditions for the remainder of their lives.

One reason for these differences in how things are covered is that when a person elects Medicare Advantage, their benefits and administration are assigned to the insurance plan and company issuing it and away from Medicare. Medicare no longer plays a role in your coverage. As Advantage plans are allocated a limited amount of dollars per plan member, the companies will seek to limit expenditures. Recent adjustments in budgets for the plans will result in more of this. *(See Feature Articles below.)

And now, we learn that in addition to the increasing number of denials for tests and procedures by Advantage plans, Medicare is allocating less money to cover benefits, resulting in an actual reduction in benefits in 2025. Depending on the Medicare Supplement plan option (A-N) one elects, these compromises seldom, if ever, apply to their coverage.

All this being said, we get back to affordability and the reality that Medicare Supplement premiums will increase due to the member’s age as the member ages. This could bring me back to that coffee table where clients simply can no longer afford their premiums. While their costs for treatment may increase, some will need a lower premium to afford some type of coverage. Those people should know I offer Medicare Advantage plans from virtually every major carrier in one’s county or region. These include (among others) Aetna, Anthem, AARP Unitedhealthcare, BlueCross BlueShield, Cigna, Kelseycare Advantage, and Wellcare.

Regardless of your situation, I offer whatever product is appropriate and best suited to meet your Medicare-related insurance needs. When you work with me, I will be an advocate on your behalf. I represent you over the insurance company. Yes, I still have a little bit of social work in me.

Please get in touch with me. I am waiting to answer your questions and assist you with your coverage.

D. Kenton Henry

Office: 281.367.6565 Text my cell 24/7 @ 713.907.7984 Https://TheWoodlandsTXHealthInsurance.com Https://Allplanhealthinsurance.com

* For the latest in health and Medicare Related Insurance News, please follow me on my blog @ Https://HealthandMedicareInsurance.com

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Feature Article 1

Becker’s Hospital CFO Report

Financial Management

Hospitals’ Medicare Advantage problem hits an inflection point

Jakob Emerson – 5 April 2024

The tensions between hospitals and Medicare Advantage plans continue to grow. With the program hitting nearly 34 million enrollees in March, paired with recent policy moves by the federal government, the scene has been set for those relations to worsen.

“The relationship between hospitals and managed care is strained at best right now,” Chip Kahn, president and CEO of the Federation of American Hospitals, told Becker’s. “[Insurers] are finding every way to not pay for the care that Medicare beneficiaries should receive. I don’t know how the issue gets worse — we’re at a critical stage, and I think CMS is sending those signals.”

On April 1, CMS finalized a slight decrease in MA benchmark payments for 2025. The agency has also issued more strict prior authorization rules this year and cracked down on when MA plans must cover inpatient care.

The health insurance industry has said the new rates will “put even more pressure on the benefits and premiums” of MA beneficiaries, a warning that individual insurers have also issued in recent months.

“Payers know that they’re going to have to cut supplemental benefits, and premiums may even have to go up, but I wouldn’t want to be the first one to do it,” Scott Ellsworth, founder and president at Ellsworth Consulting, told Becker’s. Mr. Ellsworth is a former insurance executive, overseeing entire divisions at Centene, Optum and a BCBS plan throughout his career.

“Seniors have seen their benefits get better every year, but now we’re at an inflection point and the free lunch is over,” he said. “There is going to be a sharing of the pain. Providers have disproportionately shared the pain and now you’re seeing many of them say ‘enough is enough, we’re out.'”

In 2023, Becker’s reported on at least 15 hospitals and health systems nationwide that dropped some or all of their Medicare Advantage contracts. Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.

“It’s become a game of delay, deny and not pay,” Chris Van Gorder, president and CEO of San Diego-based Scripps Health, told Becker’s in September. “Providers are going to have to get out of full-risk capitation because it just doesn’t work — we’re the bottom of the food chain, and the food chain is not being fed.”

Scripps terminated MA contracts in January for its integrated medical groups, citing an annual loss of $75 million on its contracts with insurers.

In March, Bristol (Conn.) Health announced it was eliminating 60 positions, 21 of which are occupied and will result in layoffs. Its CEO, Kurt Barwis, laid blame on Medicare Advantage saying, “All the nice-to-haves are being taken out by the lack of insurance payment and the lack of reimbursement.”

In January, the Healthcare Financial Management Association released a survey of 135 health system CFOs, which found that 16% of systems are planning to stop accepting one or more MA plans in the next two years. Another 45% said they are considering the same but have not made a final decision. The report also found that 62% of CFOs believe collecting from MA is “significantly more difficult” than it was two years ago.

“Medicare Advantage net reimbursement right now is terrible for hospitals — our clients average about 85 cents on the dollar, and it’s only getting worse,” Mr. Ellsworth said. “MA is a race to the bottom, and I would argue that we’ve hit that bottom. Payers are going to struggle with this too, but no one wants to be the first to blink.”

Medicare Advantage denials increased almost 56% for the average hospital from January 2022 to July 2023, according to data from a joint American Hospital Association and Syntellis report. The denials and inconsistent reimbursement led to a 28% drop in hospital cash reserves.

Both Mr. Ellsworth and Mr. Kahn noted that it isn’t feasible for most health systems to completely walk away from Medicare Advantage, given that it now makes up more than half of the Medicare population. Instead, many hospitals are paring down contracts and looking for payer partners that align best with their financial objectives. Some systems are even exploring launching their own MA plan built in tandem with one insurer. Others have partnered with grocers or other health systems.

“We will ultimately pick a couple of partners going forward, and I think a lot of health systems are going to do this,” Will Bryant, CFO of Chapel Hill, N.C.-based UNC Health, told Becker’s in November. “They’re going to be the partners who act like partners and not who deny care in order to bolster their billions of dollars of quarterly earnings.”

Sachin Jain, MD, CEO of SCAN Group — one of the nation’s largest nonprofit Medicare Advantage companies — cautioned hospitals that dropping MA plans is a short-term trend that is “going to backfire in a big way for these large health systems.”

“You’re a nonprofit system saying you’re no longer going to accept the insurance that low-income people actually have,” he said. “We’ll see how that works out for you.”

Dr. Jain said any public policy program is going to create unintended consequences, adding, “What I would say to anybody who’s critical about the program is that you’re right, but let’s fix that.”

Former CMS Administrator Don Berwick, MD, told Becker’s in February that the battle between hospitals and Medicare Advantage is a “manifestation of an underlying broken system in which everyone that gives care wants to give more, and everyone that pays for care wants to pay less.”

“To me, the untold story yet is about the physicians and nurses who don’t feel directly tied to ongoing Medicare Advantage trends, but they are certainly immersed in a changing financial landscape,” Dr. Berwick said. “As venture capital, private equity and ownership of healthcare by private interests increases, it changes their worlds, what it’s like to practice, their feelings about themselves, and the degrees of freedom they have to care for their patients. That chicken is going to come home to roost.”

Despite the tensions with hospitals, the MA program has bipartisan support in Congress and a 95% quality satisfaction rating among enrolled members in 2023. There are about 4,000 MA plans being offered this year nationwide, and MA members spend an average of $2,434 less on out-of-pocket costs and premiums per year compared to traditional Medicare enrollees.

“Medicare Advantage is very important, especially for low-income seniors,” Mr. Ellsworth said. “Hospitals need to acknowledge the reimbursement problem and proactively address their relationships [with payers] head-on.”

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Feature Article 2

Medicare Won’t Have Enough Money to Pay Full Benefits After 2031: Report

Money Magazine

By: Adam Hardy

Editor: Brad Tuttle

Published: Apr 05, 2023

The fund covering Medicare‘s hospital-insurance benefits is now projected to run out of money in 2031, according to a new report by Medicare trustees.

This new insolvency date gives policymakers three more years than previously estimated to address impending financial setbacks that are facing the social safety net program, which provides health care benefits to tens of millions of Americans.

The ultimate insolvency date will likely change, the trustees say, due to difficulties in accurately projecting program expenditures. That leaves the exact timeline unclear for lawmakers to hash out a plan to mend Medicare’s finances, which could require an increase in taxes, a cut in benefits or a combination of both to keep benefits paying out in full.

What the report says

In a report released Friday, Medicare’s Board of Trustees provided the latest snapshot of the program’s finances. On the whole, Medicare is on sounder financial footing than indicated in last year’s trustee report, though financial shortfalls still loom.

Medicare hospital insurance benefits, aka Medicare Part A, are expected to fully pay out until 2031, a three-year improvement from the last trustee report.
Medicare Part B and Part D do not face insolvency, the report said, because they are funded separately — partially by premiums and general revenue from the U.S. Department of the Treasury. These benefits help cover typical health-insurance and prescription-drug expenses, respectively.
By contrast, Medicare Part A, which generally covers inpatient hospital care, skilled-nursing facility care, home-health care and hospice care, uses a separate reserve that’s funded by a 2.9% Medicare payroll tax. This is the trust fund at risk of insolvency.
In 2022, Medicare’s balance sheet looked better than previous years, the report shows. The hospital-insurance trust fund had a surplus of $54 billion, and Medicare overall brought in about $84 billion more than it paid out.
Nearly every year since 2008, the Part A trust fund has run a deficit, the report notes, with the exception of 2021 and 2022. The fund ran a steep shortfall in 2020 of more than $60 billion, largely because Medicare began making loans to health care providers to increase their cash flow as they grappled with the COVID-19 crisis. Then in 2021, providers began to repay Medicare, leading to the current surpluses.

The surpluses aren’t expected to last, however. Medicare trustees say the Part A program will begin running deficits again in 2025, drawing down the trust fund until it depletes in 2031. After that date, the program would not be bringing in enough money to fully pay out Part A benefits.

Key context

Medicare covered 65 million Americans last year. The vast majority of those people, about 88%, were 65 or older, though the program also provides health coverage to millions of disabled Americans.

Medicare — particularly Part A — has long faced financial issues. The nation’s changing demographic makeup is a big reason why. Because Medicare Part A relies on payroll taxes, it is more susceptible to insolvency when a growing share of the population is older, ultimately changing the worker-to-beneficiary ratio. In other words: less money coming in and more money going out. These demographic changes are also leading to insolvency issues for Social Security.
Compared to Social Security, projections for Medicare’s insolvency are less certain because it’s difficult for the trustees to accurately predict future health care expenditures. This can lead to some larger swings in the predicted insolvency date. By contrast to the trustee’s estimate, the Congressional Budget Office estimates the fund will remain solvent until 2033.
According to the nonprofit Center on Budget and Policy Priorities (CBPP), if Medicare Part A went insolvent, it would still be able to pay out almost all benefits. This leads some experts to call for tempered reactions to the newly projected insolvency date.
“Medicare does not face a financing ‘crisis’ and is not ‘bankrupt,’ as some critics charge,” tweeted Paul Van de Water, a senior fellow at the CBPP who specializes in Medicare. “Even if policymakers took no further action … tax revenues would still cover 89 percent of scheduled benefits” after the insolvency date.

Avoiding Medicare insolvency

Policymakers have several options to avoid impending insolvency headed for Medicare Part A. The trustees note two options that could immediately solve the issue:

The standard 2.9% payroll tax could be immediately raised to 3.52%, which would be enough to plug any financial shortfalls over the next 75 years.
In lieu of a tax increase, expenditures (read: benefits) would need to be reduced immediately by 13%, the trustees say.

Realistically, a combination of the two could work and the benefits cuts and/or tax increases could be implemented over a longer period of time.

Additionally, President Joe Biden released a plan last month to push the insolvency date back by 25 years.

The central change under the president’s plan would be a Medicare payroll tax increase on Americans earning more than $400,000.
Currently, earnings over $200,000 for individuals are taxed at 3.8% (while income under that amount is taxed at the standard 2.9% rate). These rates are split 50-50 between employees and employers.
The president’s plan introduces a new tier for income over $400,000, a tax rate of 5%.

The president’s Medicare proposal — part of a larger 2024 budget plan — is not expected to make it through the Republican-controlled House of Representatives.

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FEATURE ARTICLE 3

Dozens of health systems ask CMS to crack down on Medicare Advantage Denials

Becker’s Hospital CFO Report

Rylee Wilson – Friday, March 22nd, 2024

Over 100 hospitals, health systems and providers signed on to a call for CMS to do more on Medicare Advantage denials.

Members of Premier, a healthcare services company, penned a letter to CMS administrator Chiquita Brooks-LaSure on March 21, requesting CMS collect more data on claims denied by Medicare Advantage plans and take enforcement action against plans not following the coverage rules set out by Medicare.

A survey of Premier’s member hospitals and health systems found 15% of claims to private payers are denied. A slightly higher portion of Medicare Advantage claims, 15.7%, are denied, according to the survey.

On average, hospitals spend $47.77 in administrative costs to appeal a denied Medicare Advantage claim, according to the Premier survey.

In the letter, the health systems asked CMS to monitor how much MA plans spent on direct patient care to address “potentially dire impacts on Medicare beneficiaries and providers.”

“It is imperative that CMS leverage its full authority to ensure that MA plans’ medical loss ratio (MLR) requirements for revenue used for patient care are satisfied in alignment with the benefits to which Medicare beneficiaries are entitled,” the providers wrote.

Dozens of health systems signed the letter, including CommonSpirit Health, Ascension, Advocate Health, AdventHealth and Providence.

The providers also asked CMS to bar MA plans from delaying or denying claims approved through electronic prior authorization and weight patient experience more heavily in its ratings of MA plans.

A growing number of hospital executives have criticized Medicare Advantage, often citing excessive prior authorization hurdles and delayed payments. A handful of systems have moved to drop the program entirely.

FEATURE ARTICLE 3

Nearly 15% of claims submitted to private payers are initially denied

Marty Stempniak | March 22, 2024 | Radiology Business | Economics

Nearly 15% of medical claims submitted to private payers for reimbursement are initially denied, according to new survey data released Thursday.

Denied claims are more prevalent for high-cost treatments, with the average rejected charges at $14,000 and up, Premier Inc. reported. Medicare Advantage and other private payers eventually overturned more than half (54%) of denials, with the claims paid, but only after “multiple, costly rounds of provider appeals.”

The findings are from a national survey of hospitals, health systems and post-acute providers, conducted by the Charlotte-based healthcare improvement company.

“To address these potentially dire impacts on Medicare beneficiaries and providers, we urge CMS to stringently monitor MA plans’ reporting of expenditures on direct patient care,” Premier and 118 member organizations wrote in a March 21 letter to the head of the Centers for Medicare & Medicaid Services. “It is imperative that CMS leverage its full authority to ensure that MA plans’ medical loss ratio requirements for revenue used for patient care are satisfied in alignment with the benefits to which Medicare beneficiaries are entitled.”

Premier partnered with member hospitals to conduct the survey from October to December 2023. A total of 516 hospitals across 36 states, representing 52,123 acute care beds responded. Answers were based on claims submitted to private payers in 2022.

On average, hospitals and other providers incurred a cost of $43.84 per claim to fight denials. With insurers processing about 3 billion claims per year, this equates to $19.7 billion per year in expenses for these reviews. An average of about 3% of all claims denied included those that were already preapproved via prior authorization, Premier noted.

The continued burden from these delays and denials has impacted hospital finances. During the past year, average days of cash on hand at hospitals declined by 44 days or 17%. Meanwhile, days of cash on hand increased among insurers such as UnitedHealth Group (up 25.5% on average since 2019) and Cigna (24.4% on average).

The letter writers—who included numerous large health systems and other provider organizations—want CMS to take enforcement action against MA plans that “fail to abide by the coverage rules of Medicare.”

“Additionally, we note that CMS has moved away from holding MA plans accountable for [Consumer Assessment of Healthcare Providers and Systems] and other patient experience measures in recent rulemaking by reducing the weighting of patient experience and access measures in the Star Ratings program. We recommend that CMS return to its past policy of weighting patient experience and access measures more heavily in the MA Star Ratings methodology, empowering beneficiaries to hold their health plans financially accountable,” the letter stated.

The analysis does not specifically mention radiology services, but it mirrors ongoing problems imaging providers have had with prior authorization and the No Surprises Act (links to previous coverage below).

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IF YOUR MEDICARE SUPPLEMENT PREMIUMS HAVE REACHED OR EXCEEDED $300 PER MONTH THIS MESSAGE IS FOR YOU

Posted on November 21, 2023 by thehealthinsuranceanswerman

MEDICARE ADVANTAGE PPO PLAN WITH $0 OUT-OF-POCKET FOR ALL MEDICAL EXPENSES IN OR OUT OF NETWORK WITH THE EXCEPTION OF RX DRUGS

Clients and Friends,

Medicare’s Annual Enrollment Period and Open Enrollment ends December 7th. If you are in a Medicare Supplement policy it is probably because you want to maintain access to as many doctors, hospitals, and providers as possible. And you know that you may see any medical provider that sees Medicare patients. It is also true that if you have been with your supplement policy a number of years, you have also experienced a premium increase—probably every year on your policy anniversary. And if you are beyond 70 years of age, there’s a good possibility your premiums are $300 or more per month. If you’ve remained with your current policy through continued premium increases it must be because you have one or more medical conditions which have precluded you from moving to a lower cost Medicare Supplement policy with a significantly lower premium. Well, this new option may just provide the solution to your ever increasing costs without compromising your access to medical providers. And it is a Medicare Advantage plan which—if you apply by December 7th (the last day of Open Enrollment)—you will not have to answer any health questions and your approval is guaranteed for a January 1 effective date.

Think about it. No Medicare Part B deductible which is going to $240 in 2024. No cost for any minor or major medical care during the year. A $0 copay for Tier 1 generic drugs. No cost for anything other than Tier 2-5 prescription drugs and no premium for a stand-alone Part D Drug plan to accompany your Medicare Supplement policy! All with no risk of being declined for medical reasons and pre-existing medical conditions covered from day 1.

The greatest challenge in finding the optimal Medicare Advantage Plan is not finding the best benefits or lowest premium and prescription drug costs. It is in finding one’s doctors and hospitals in the provider network of a plan. With this plan you may go in or out of the PPO network and experience $0 out-of-pocket for everything with the exception of Rx drugs beyond Tier 1 Preferred Generics which are still available for a $0 copay!

2024 MEDICARE ADVANTAGE PPO PLAN WITH $0 OUT-OF-POCKET IN OR OUT OF NETWORK WITH THE EXCEPTION OF RX DRUGS

The additional good news is that this plan, utilizing a PPO network, means that—although you should rarely find it necessary to go outside their network of providers—should it be—you may do so at $0 out-of pocket! I believe you will find the benefits and drug costs to be excellent. (see below)

I am recommending you go with this Medicare Advantage Flex (PPO) MAPD for 2024. For proprietary and Medicare compliance regulations, I will not be identifying this plan by name or insurance company. (You must contact me for that.) But HERE ARE THE HIGHLIGHTS:

I) MEDICARE ADVANTAGE PPO PLAN
(Premiums and copays based on your residence in Texas)
Monthly Plan Premium = $238
Health Deductible = $0
Drug Deductible = $545 ($0 deductible for Tier 1 and Tier 2 generic drugs)
“Preferred” Pharmacies which include: CVS, HEB, KROGER, WALMART
Drug Copays:
Tier 1 (Preferred Generic) = $0.00
Tier 2 (Non-Preferred Generic) = $8.00
Tier 3 (Preferred Brand Name) = $47.00
Tier 4 (Non-Preferred Brand Name) = $100.00
Tier 5 Specialty Drugs = 25%

D. Kenton Henry

Agent / Broker @ TheWoodlandsTXHealthInsurance.com and Allplanhealthinsurance.com
Office: 281.367.6565 
Toll Free: 800.856.6556
Text my cell 24/7 @ 713.907.7984
https://TheWoodlandsTXHealthInsurance.com 
FOR THE LATEST IN HEALTH AND MEDICARE RELATED NEW, FOLLOW MY BLOG @ Https://HealthandMedicareInsurance.com

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UNDER AGE 65 2024 INDIVIDUAL AND FAMILY HEALTH INSURANCE ENROLLMENT BEGINS NOVEMBER 1

Posted on October 23, 2023 by thehealthinsuranceanswerman

(WHAT YOU NEED TO KNOW)

By D. Kenton Henry, editor, agent, broker

22 October 2023

Ever since the passage of the Patient Protection and Affordable Care Act (ACA), commonly referred to as “Obamacare”, in 2010, the Department of Health and Human Services has dictated when and under what circumstances an individual and family can apply for and obtain health insurance. This period is known as the Open Enrollment Period, and it is upon us. Each year, between November 1st and December 15th, U.S. citizens and their families may apply for and obtain health insurance effective January 1st of the coming calendar year. From then until January 15th, they may apply for coverage effective February 1st. Beyond that date, they are locked out of any health insurance plan they were not enrolled in when the year ended. Only special circumstances such as losing “creditable” coverage through no fault of their own, moving out of a plan’s area, birth of a child, or death of a covered family member allow them to apply for coverage beyond the Open Enrollment Period. And only if they were insured when the special circumstance occurred and no more than 60 days have passed. Creditable coverage meets all the mandates of the Affordable Care Act, such as guaranteed coverage for pre-existing health conditions, including pregnancy and mental health disorders, along with no out-of-pocket for preventative medicine. All coverage is guaranteed so long as the above requirements are met.

If affordability of health insurance is an issue, Premium Tax Credits (subsidies) are available from the Department of Health and Human Services (DHS) to people or families whose income falls below a certain threshold.

WHO IS ELIGIBLE FOR THE PREMIUM TAX CREDIT?

To receive the premium tax credit for coverage starting in 2024, a Marketplace enrollee must meet the following criteria:

· Have a household income at least equal to the Federal Poverty Level (FPL), which for the 2024 benefit year will be determined based on 2023 poverty guidelines

· Can not have access to affordable coverage through an employer (including a family member’s employer)

· Can not be eligible for coverage through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP)

· Have U.S. citizenship or proof of legal residency (Lawfully present immigrants whose household income is below 100 percent FPL can also be eligible for tax subsidies through the Marketplace if they meet all other eligibility requirements)

· If married, must file taxes jointly

Income: For the purposes of the premium tax credit, household income is defined as the Modified Adjusted Gross Income (MAGI) of the taxpayer, spouse, and dependents. The MAGI calculation includes income sources such as wages, salary, foreign income, interest, dividends, and Social Security.

Your tax credit is based on the household income estimate you put on your Marketplace application.

Income between 100% and 400% FPL: If your income is in this range (in all states) you qualify for premium tax credits that lower your monthly premium for a Marketplace health insurance plan. The lower your income is as a percent of the FPL—the higher your subsidy.

The easiest way to determine whether and for how much you qualify is to call me. You will estimate your 2024 household’s adjusted gross income and my subsidy calculator will tell us (based on the number of people in your household) how much your subsidy will be. If we give the DHS the same information you give me, my calculations are usually accurate to within $3.00 of what you will actually receive. We then apply that subsidy against the premium of the plan you wish to acquire and arrive at your net premium.

The number of people who qualify for subsidies continues to grow. For details on this, please refer to this chart and my feature article 2 below.

As to how much retail (gross) premiums are expected to grow from 2023 to 2024, estimates put the national average at 6%. (For the details on this, please refer to Feature Article 1 below.) Given the rate of core and real inflation, this should not come as a surprise. Acquisition of a subsidy will certainly offset ever-increasing premiums.

As always, the greatest challenge to the consumer and their agent/broker is affordability or obtaining the desired benefits. Instead, it is finding their doctors in the networks of a health plan. In 2024, as it was this year, there will be over 100 different plans available from six to eight different companies, depending on where one resides. Dealing with this myriad of options is where my three decades specializing in health insurance in the Houston area is invaluable. I know which hospitals are in which plan networks, and my provider search tools scan all plans without you having to go from company to company for results. Because I represent every company doing business in Texas, you can acquire information on all of them with one call to me.

Again, Open Enrollment begins November 1st, and for coverage during the entirety of 2024, it ends December 15th. Unlike going to the marketplace (Healthcare.gov) you will get me each time you call my local office with questions and for assistance and service–as opposed to an 800 number where you will get a different individual each time you call. My service is much more personalized and detailed than that of an hourly worker at the end of that toll-free number. If I don’t provide you with the level of service you deserve, I don’t have a client. And if I don’t have a client, I don’t earn a living. And it costs you no more to go through me than directly to the company whose policy you ultimately acquire.

I look forward to working with you and providing the best of service. Please call me.

D. Kenton Henry

Office: 281-367-6565 Text me 24/7 @ 713-907-7984 Email: Allplanhealthinsurance.com@gmail.com

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Https://TheWoodlandsTXHealthinsurance.com Https://Allplanhealthinsurance.com Https://HealthandMedicareInsurance.com

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FEATURE ARTICLE 1:

KFF The independent source for health policy research, polling, and news.

How much and why 2024 premiums are expected to grow in Affordable Care Act Marketplaces

Jared Ortaliza, Matt McGough, Meghan Salaga, Krutika Amin, and Cynthia Cox
Published: Aug 04, 2023

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This analysis of insurers’ preliminary rate filings shows that ACA Marketplace insurers are requesting a median premium increase of 6% for 2024. Insurers cite price increases for medical care and prescription drugs as a key driver of premium growth in 2024, In addition to inflation’s impact on medical costs, insurers point to growth in the utilization of health care, which fell in 2020 but has since returned to more normal levels.

Insurers’ proposed rate changes – most of which fall between 2% and 10% – may change during the review process. Although most Marketplace enrollees receive subsidies and are not expected to face these added costs, premium increases could result in higher federal spending on subsidies.

The analysis can be found on the Peterson-KFF Health System Tracker, an information hub dedicated to monitoring and assessing the performance of the U.S. health system.

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FEATURE ARTICLE 2:

KFF The independent source for health policy research, polling, and news.

News Release

Already at Record High, ACA Marketplace Enrollment Could Increase Further

Tammie Smith

Enhanced Marketplace subsidies have continued to drive up enrollment in the individual market, and the loss of Medicaid coverage by millions of people could contribute to this trend, according to a new KFF analysis. Meanwhile, enrollment in non-ACA-compliant plans is at a record low.

As of early 2023, an estimated 18.2 million people have individual market coverage, the highest since 2016. Individual market enrollment grew by about 29% between early 2020 and early 2023 — a result of enhanced subsidies introduced by the Inflation Reduction Act, increased outreach, and an extended enrollment period.

This enrollment growth could continue in 2023 as states resume Medicaid disenrollments amid the unwinding of the continuous enrollment provision. Some of the people losing Medicaid coverage may be eligible for subsidies on the ACA Marketplaces.

Due in part to the enhanced subsidies, about 4 in 5 individual market enrollees have subsidized coverage — the highest share since the ACA was implemented.

The number of people in non-compliant plans has fallen each year and could decrease further due to the Biden Administration’s proposed rule that would reverse the expansion of short-term plans. An estimated 1.2 million people were in non-ACA-compliant plans in mid-2022, compared to 5.7 million in mid-2015. These short-term plans often do not include certain benefits or coverage for pre-existing conditions and can impose a dollar limit on insurance coverage.

If unsubsidized premiums rise in 2024 due to higher health care prices and utilization, enhanced subsidies could shield most individual market enrollees from increases in their monthly payments.

TOP 10 DRUGS TARGETED FOR MEDICARE’S NEGOTIATED PRICE REDUCTION

Posted on September 7, 2023 by thehealthinsuranceanswerman

*(IF YOU WATCH TV, YOU HAVE SEEN THE HIGH-PROFILE COMMERCIALS FOR THESE DRUGS. IF YOU’VE BEEN PRESCRIBED ANY OF THEM, YOU KNOW HOW HIGH THE COST CAN BE. FOR MANY, PROHIBITIVELY SO. FOR DETAILS ON HOW RELIEF MAY BE COMING, PLEASE READ THE FEATURE ARTICLE AT THE BOTTOM OF MY OWN JUST BELOW.)

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IT’S ALMOST TIME TO RE-SHOP YOUR MEDICARE ADVANTAGE AND DRUG PLAN FOR 2024

By D. Kenton Henry, editor, broker, agent

6 September 2023

With the Labor Day holiday behind us, summer is virtually over. And, the coming of fall brings Medicare’s Annual Election Period (AEP). For those new to Medicare, and as a reminder to those recipients who are not, this period runs from each fall. Beginning October 1, we can preview the new Medicare Advantage and Part D drug plans to determine which, if any, is superior to our current plan, and from October 15 to December 7, enroll in it. Our new plan selection will go into effect on January 1. Of course, if your current plan remains your best option, you need not do a thing, and it will roll right over into the new year. Simply continue to pay your premium.

But how will you know if a superior Medicare Advantage or Part D Drug plan exists for you in the coming year? First, your current drug plan owes you an Annual Notice Of Change (AOC). It must come in your U.S. mail by September 30. If they do not send it, they violate Medicare regulations. So be sure to watch your mail closely. I know we are all being inundated with advertisements this time of year in a frenzied attempt to garner our business, but sort through it long enough to find your AOC!

Then, please review it carefully. While it may remain virtually the same in the coming year, something inevitably changes. Be it the premium, the copays, the out-of-pocket maximum, the doctors and hospitals, or the drugs. Once you are aware of any changes, you must compare your plan to all the new plans in the new year. Or – you may simply call me. I have been in the medical insurance industry since 1986, specializing in Medicare-related insurance and Under Age 65 Individual and Family health insurance. As I and my clientele have grown older, I have focused even more on assisting Medicare recipients.

Researching and identifying a plan that is in my client’s best interest and making my recommendation is an annual service I provide them. While some can do it independently, my familiarity with all the options and the mechanisms for exploring and enrolling in them is so great that many find it easier to sit back and let me do the research for them. Then, if they agree with my recommendation, I am happy to enroll them, making the process go as quickly and smoothly as possible. There is no obligation to take my recommendation, nor is there any fee charged by me whether one does or doesn’t. Should you enroll through me, you will be charged no more for the product than if you walked through the front door and acquired it directly from the insurance company offering it. So I believe you get the benefit of my 37 years of experience in the market at no cost to you. While Medicare requires that I inform you, no one agent can represent every company and plan in the market, I do represent most. I have diligently researched which plans I believe will be most competitive for most people’s purposes and have studied and certified (tested) to be able to insure you with them. And more importantly, I have reviewed all of them relative to your needs before making my recommendation. On the rare occasion I am not appointed (contracted) with a company in your best interest, I will recommend them just the same and encourage you to enroll with them and advise you how to go about that. I do so in the hopes that it will begin a relationship with you and that – next year – I may be appointed with the company with which you wish to enroll.

So, while the leaves don’t fall much around here in October, they do turn brown. And Joe Willy Namath and J.J. Walker will soon be annoying you with their incessant and infernal commercials. Let these things remind you to call me for the answers to your Medicare-related questions and any guidance you would like. Remember, there is no cost to you for such, and, at the very least, you’ll know you are doing everything right and make another friend in the process.

Oh – again! Please read my feature article, which appears directly below this. The current administration is attempting to lower drug costs for Medicare recipients by allowing Medicare to negotiate lower drug prices, for the first time, with pharmaceutical companies. The article identifies 10 of the most expensive drugs they target for lower costs. If you, like me, have been exposed to the never-ending drug commercials accompanying your television programs, you probably can already guess what some of them are. Obviously, advertising works, and the companies must pay for it somehow!

I look forward to hearing from you!

D. Kenton Henry

Office: 281-367-6565 Text me 24/7 @ 713-907-7984 Email: Allplanhealthinsurance.com@gmail.com Https://TheWoodlandsTXHealthInsurance.com Https://HealthandMedicareInsurance.com

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BLOOMERG LAW

Sept. 5, 2023, 4:05 AM

Drugs Up for Medicare Price Cuts Fuel Drugmakers’ Legal Strategy

Ian Lopez: Senior Reporter

Nyah Phengsitthy: Reporter

Drugmakers are poised to change their lawsuits and bring new ones against the Biden administration now that the list of the first 10 drugs subject to Medicare price negotiations is out.

Bristol-Myers Squibb Co., Johnson & Johnson, and other companies with drugs up for negotiation are likely to amend their lawsuits against the price talks under the Inflation Reduction Act to better their chances at taking down the program, legal analysts say.

Amending complaints could bolster the plaintiffs’ chances at overcoming government arguments that they lack standing to sue and allow them to later move for summary judgment or request a preliminary injunction.

Companies like Amgen Inc. and Novo Nordisk that have drugs on the list but haven’t sued yet may do so, or join suits already filed, attorneys say, contributing to a pharmaceutical industry legal strategy geared toward getting the US Supreme Court to intervene.

“Now that the list is announced, we’ll definitely see movement in the lawsuits, because beforehand it was a little more of a theoretical harm,” said Carmel Shachar, a professor at Harvard Law School. “I think we’ll see a big flurry of action when the prices are announced as well, with attempts to hold it up with injunctions and summary judgment.”

Drugmakers and industry groups that sued before the release of Medicare’s list issued statements afterward that they remain steadfast in their position that the price negotiation program is unconstitutional. Eight lawsuits were filed before the list announcement. Another company with a drug on the list, Novartis AG, sued after.

“The IRA’s price control provisions will constrain medical innovation, limit patient access and choice, and negatively impact overall quality of care,” J&J said. “The IRA’s policies put an artificial deadline on innovation, threatening intellectual property protections and shortening the timeframe to deepen our understanding of patients’ unmet medical needs. At the same time, seniors could face bureaucratic barriers to access and potentially higher out of pocket costs even with the IRA’s out-of-pocket cost limits for Part D drugs.”

Attorneys note that some of the lawsuits may be scaled back with the list out, while others are expanded to encompass new claims. Some judges may try and consolidate the litigation, the attorneys say.

They also note that more drugmakers may push courts for a preliminary injunction against the program to buy time while the litigation inches its way to the highest court.

“They’re not going to give this up quietly,” said Yaniv Heled, a professor at Georgia State University College of Law. “You can expect to see lawsuits, and then appeals, and then more lawsuits and then more appeals.”

‘Fight to the Bitter End’

The 10 drugs selected for pricing negotiations are Bristol-Myers and Pfizer Inc.‘s Eliquis, J&J’s Xarelto, Boehringer Ingelheim and Eli Lilly & Co.‘s Jardiance, Merck & Co. Inc.‘s Januvia, AstraZeneca PLC’s Farxiga, Novartis’ Entresto, Amgen’s Enbrel, AbbVie Inc. and J&J’s Imbruvica, J&J’s Stelara, and Novo Nordisk’s Fiasp and NovoLog insulin products.

Pfizer said it wouldn’t be leading negotiations over Eliquis’ list price and that the task would fall to Bristol-Myers. Eli Lilly similarly said the company “will not have any role in whatever price is set” by Medicare for Jardiance.

Novo Nordisk said it “will explore all options that allow us to drive change for people that need it and strive to continue to bring innovative medicines to the market while helping increase access for those that need them,” though it took issue with the government’s approach. Likewise, AstraZeneca said it would “evaluate our next steps over the coming weeks.”

Merck filed the first lawsuit to block the negotiations in June, followed by suits by other drugmakers and their allies, arguing the program was unconstitutional or violated procedural requirements for implementation.

They’re awaiting a decision from Judge Michael J. Newman of the US District Court for the Southern District of Ohio on the U.S. Chamber of Commerce’s request for a preliminary injunction—an ask that could halt the program before negotiations even begin.

The Chamber asked the court to rule before the Oct. 1 deadline when drugmakers must decide if they will enter negotiations. The group said the Biden administration didn’t do its “homework” to understand price control schemes and is rushing for implementation.

“They had a year to research these basic questions,” Neil Bradley, the Chamber’s executive vice president and chief policy officer, said in a press call.

Drugmakers who’ve already filed lawsuits will “fight to the bitter end,” Heled said.

“I can’t imagine that the litigations are going to end before these prices are supposed to take hold or go into force,” Heled said.

Drug manufacturers on the list will also “definitely” want to amend their complaints, said Laura Dolbow, a fellow at the University of Pennsylvania Law School who specializes in administrative law.

Companies may also amend their complaints to include additional causes of actions, said Andrew Twinamatsiko, associate director of the Health Policy and the Law Initiative at Georgetown University’s O’Neill Institute. For example, plaintiffs arguing the program violates the First, Fifth, and Eighth Amendments of the Constitution may consider raising Administrative Procedure Act claims like those in recent lawsuits from AstraZeneca and Boehringer Ingelheim.

Drugmakers “could find a creative way of going around” the drug pricing law’s preclusion of judicial review of prices, he said.

More constitutional claims could emerge, and the courts could have a “remarkably large number of potential avenues to consider,” said Robin Feldman, a law professor at the University of California, San Francisco.

“What are they not claiming?” Feldman said. And “lawsuits already filed have named more constitutional provisions than most people knew existed.”

‘No Standing’

Astellas Pharma Inc., which filed a suit July 14, ended up with none of its products on the list. Legal experts expect Astellas’s case to be dismissed.

The drugmaker said in a statement that no decisions have been made regarding its lawsuit, but it remains confident in its stance that the program “would result in lower costs for the government, but not necessarily reduce out-of-pocket costs for patients.”

The case brought by trade group Pharmaceutical Research and Manufacturers of America also faces possible dismissal.

The Biden administration filed a motion to dismiss the PhRMA suit in the US District Court for the Western District of Texas a day before the list came out, specifically asking that the National Infusion Center Association be dismissed because it lacks standing and failed to allege that the federal program will cause any of its members an injury.

The actions drugmakers with products on the list take now could affect what other manufacturers will do in the future, said Nicholas Bagley, a law professor at the University of Michigan. The experiences of the drugmakers in the first round of negotiations could set the precedent for price talks in later rounds.

“If you’re a manufacturer who doesn’t have a drug listed, you’re likely to sit back and watch these other litigants,” Bagley said.

To contact the reporters on this story: Ian Lopez in Washington at ilopez@bloomberglaw.com; Nyah Phengsitthy in Washington at nphengsitthy@bloombergindustry.com

To contact the editor responsible for this story: Karl Hardy at khardy@bloomberglaw.com

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NOW IS THE TIME TO RE-SHOP YOUR MEDICARE SUPPLEMENT INSURANCE

Posted on June 7, 2023 by thehealthinsuranceanswerman

By D. Kenton Henry, editor, broker
7 June 2023

Everyone with Medicare Supplement knows the value and convenience it provides in allowing the policyholder to seek medical attention from any medical provider that sees Medicare patients. All hospitals see Medicare patients, so, heaven forbid, should we get cancer and want to go to MD Anderson Hospital in Houston—we may go directly there. And, depending on which Medicare Supplement plan we elect, we can be out of virtually nothing for our medical care.

The only real disadvantage to a Medicare Supplement plan is the premium. And it's not the first-year premium upon entering Medicare at age 65, but rather the premium in the ensuing years. This occurs because, as we age, each year, on our policy anniversary, the premium is usually increased to account for the additional risk an insurance company assumes to cover us as we age. The older we are, the more likely we are to generate medical insurance claims, and larger ones at that. Hence, the older we get, the more burdensome our premiums will become.
The only solution to that (while remaining insured)—other than to switch to a Medicare Advantage plan—is to re-shop our supplement plan. Typically, it does not behoove us to do this every year. Assuming our insurance company is ethical and competitive, the savings involved in moving to a more competitive plan won't be large enough to warrant the effort. But by the time we have experienced a second or third annual increase—it will be. In only a few states, is a Medicare Supplement policyholder allowed the right to move to a lower-cost plan and be guaranteed approval. This transition will be accomplished during that state's Open Enrollment Period. Texas has no Open Enrollment Period for Medicare Supplements. In Texas, Open Enrollment only applies to Medicare Advantage and Part D Drug Plans. In Texas, a Medicare recipient can apply for a new Medicare Supplement policy 365 days per year. Still, they must qualify based on their current health and health history. If their health is good, or their medical conditions are well controlled, they may be approved for the new and lower-cost plan. And this can be accomplished while maintaining equal benefits or even upgrading to superior benefits, if available.

If you are wondering if lower-cost Medicare coverage is available and considering applying for such—now is the time to do so. Brokers and agents, like myself, are currently in our slow period. This is because the government (Medicare) dictates when Medicare recipients may apply for a Medicare Advantage or Part D Drug Plan. That is each year between October 15 and December 7—the Open Enrollment Period for those products. Plans applied for during that period are guaranteed approval with a January 1 effective date. Brokers and agents who specialize in Medicare-related insurance products, like myself, begin studying and testing for national tests, which must be passed each fall in order to represent these plans in the coming calendar year, along with certifying (testing) with each insurance company whose product we want to represent. So from September, when most of us study and test, to the end of December, we are inundated with identifying our client's best plan options for the coming year and enrolling them in that product. Even with the best of staff, our market feels as though we are surrounded by "sharks in a feeding frenzy." Especially if we also assist Under Age 65 clients in obtaining Individual and Family health insurance with an overlapping Open Enrollment Period!

So—if you are at all considering obtaining a lower-cost Medicare Supplement plan—now—and the next three months—is the time to do so. I can scan the market to identify equal or superior benefits at meaningful premium savings. Sometimes a very meaningful 30% or more! Once I have done that, I will make the application process go as quickly and smoothly as possible. I charge no fee for my service, and you will be charged no more for the insurance plan than if you acquire it directly from the insurance company itself. You will not cancel your current coverage until we know you have been approved for all pre-existing conditions.

Please email or give me a call. I have been in the industry for 37 years and am not going anywhere. I enjoy what I do, and that is helping others find their best medical coverage at the lowest possible cost.

*(Please see feature article 1 below on prescription drug shortages and feature article 2 on Medicare Advantage Claim Denials.)

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

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FEATURE ARTICLE 1

Drug price caps in Inflation Reduction Act exacerbating shortages, Gottlieb says . . .

THE HILL
BY JULIA SHAPERO - 05/21/23 4:58 PM ET
 
 Former Food and Drug Administration (FDA) Commissioner Scott Gottlieb
Former Food and Drug Administration (FDA) Commissioner Scott Gottlieb said on Sunday that drug price caps in the Inflation Reduction Act are exacerbating drug shortages.
"The features under the Inflation Reduction Act will exacerbate this problem, because it'll prevent these generic manufacturers from being able to take price increases," Gottlieb, who now serves on the board of Pfizer, told CBS' "Face the Nation." 
"For example, if they enter a market for the first time, or they spend a lot of money upgrading a facility to be compliant with state-of-the-art regulations, they're not gonna be able to take a price increase to recoup some of those costs," he added. "So, it's going to come out of their own pocket."
Gottlieb said that sterile injectable drugs are particularly susceptible to shortages, suggesting that they should be carved out of the Inflation Reduction Act. 
"The reimbursement for these drugs under government programs has been driven down very low, something above the marginal cost of manufacturing the drugs, and that's fine when it comes to a pill form drug where there's not a lot that can go wrong."
"But when it comes to an injectable drug, you need to leave a margin in so people can reinvest in manufacturing facilities, make sure they're high quality," he added. "They haven't done that, and things go wrong, and it results in shortages."
A March report from the Senate Committee on Homeland Security and Governmental Affairs found that there were more than 295 active drug shortages at the end of 2022, marking a five-year high.
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FEATURE ARTICLE 2

SENATORS PRESS MEDICARE ADVANTAGE INSURERS OVER CLAIMS DENIALS
FIERCE HEALTHCARE MAY 19, 2023  
By Paige Minemyer

There were no insurers represented on the hearing panel, and the senators instead heard from multiple policy experts, the Office of Inspector General and the widow of a patient who was harmed by care denials and delays. (Getty Images/designer491)
Pharmacy benefit managers weren't the only ones on the hot seat in Congress this week.
The Senate's Permanent Subcommittee on Investigations put Medicare Advantage (MA) plans on notice Wednesday, demanding answers for claims denials. Chairman Richard Blumenthal, D-Connecticut, said in an opening statement during the hearing that the committee sent letters to the three largest MA plans—UnitedHealthcare, Humana and Aetna—seeking documentation on how they make decisions around claims denials.
Blumenthal said these coverage denials have become commonplace for many MA enrollees.
"These denials have become so routine that some patients can predict the day on which they will come," he said.
He added that "there is growing evidence" pointing to MA plans using artificial intelligence and data algorithms in making denials, rather than relying on feedback from physicians or other clinical experts. A recent investigation from Stat found that these tools are taking on an increasing role in coverage decisions, though there is limited oversight and transparency
Blumenthal said the Department of Health and Human Services Office of Inspector General (OIG) has also identified a "large number of cases" where MA insurers refused to authorize services that met coverage requirements under Medicare. For example, a cancer patient seeking a routine scan to determine whether the disease had spread was held up by their insurer for a month, and another payer refused to cover a walker for a patient as they had already received a cane.
"In each of these cases, the insurer's decision overlooked the treating physician's assessment of what their patient needed," Blumenthal said.
There were no insurers represented on the hearing panel, and the senators instead heard from multiple policy experts, OIG and the widow of a patient who was harmed by care denials and delays. Megan Tinker, chief of staff at OIG, said in her submitted statement that in 2018, MA plans denied 1.5 million prior authorization requests, about 5% of the total. In addition, they rejected 56.2 million payment requests, or 9.5%.
Tinker said that between 2014 and 2016, MA plans overturned their own coverage denials 75% of the time when a member or provider appealed the decision. OIG also found that 13% of coverage denials were for services that met Medicare's coverage rules.
Tinker noted in her opening remarks that the program has grown rapidly over the past several years, and enrollment in MA now accounts for more than 50% of total Medicare enrollment.
"Fast growth has increased vulnerabilities and the need for robust program integrity measures," she said. "OIG work has demonstrated that the risk of waste, fraud and abuse in managed care are significant." 
Jean Fuglesten Biniek, Ph.D., associate director of the Program on Medicare Policy at KFF, noted in her submitted remarks that the way payments work in MA may create financial incentives for insurers to deny care. It costs MA plans 83% of what it costs traditional Medicare to cover key services, while they are paid 106% of what the Centers for Medicare & Medicaid Services pays in fee-for-service Medicare, according to data from the Medicare Payment and Advisory Commission.
This means plans retain $2,300 above the cost of paying for a member's care, she said.
She added that there are also significant gaps in the data around prior authorization in MA; for example, there is no information about what services are denied or whether there are certain beneficiaries who are denied care more often. There is also a dearth of detail on how long it takes MA plans to respond to these requests.
"As a result, policymakers don't have the information they need to conduct oversight," she said.

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ACA HEALTH INSURANCE OPEN ENROLLMENT BEGINS NOVEMBER 1 (One health insurance company departs Texas altogether; another ceases Marketplace coverage)

Posted on October 26, 2022 by thehealthinsuranceanswerman

HEALTH AND MEDICARE INSURANCE BLOG 10/25/2022

By Don Kenton Henry editor, agent, broker

As is the case each year, it behooves those in need of “Individual and Family” Affordable Care Act (ACA) compliant health insurance to re-shop their health insurance. This, because the premiums and benefits of your existing plan, and all others, will most certainly change in some respect. If for no other reason than in this circumstance:

If you receive a premium tax credit (subsidy) and the benchmark (second lowest cost Silver plan) premium in your area goes up, subsidy amounts will also go up. Conversely, if the benchmark premium goes down, subsidy amounts will also go down. This is independent of what your own plan’s price does.

Regardless of whether you receive a subsidy, premiums across most states will increase by an average of 7.7%, according to ACA Signups. As described in my feature article below, “That’s a little larger than the overall average rate increases we’ve seen for the last few years (3.5% for 2022, less than 1% for 2021, and a slight decrease for 2020). But an overall average rate change only gives us a big picture; it doesn’t tell you how much your own plan’s premium will change or how much your net premium will change, and it also doesn’t account for the new plans that will be offered for 2023.”

What we do know, is that two insurance companies are exiting the Texas health insurance market to one degree or another. Bright health insurance is exiting altogether, and Friday will cease offering “on-exchange” plans. In other words, plans that are available through the Federal marketplace, Healthcare.gov, for a subsidized premium. They will still offer “off-exchange” plans. What that means is, if you are currently insured by one of these companies and plans exiting Texas, you most certainly want to research and make an informed decision as to what replacement plan is in your best interest. Relative to insurance company expansion in the Texas market, Cigna will begin offering Individual and Family coverage beginning January 1. However, it will be limited to the Dallas-Fort Worth region for the time being.

The feature article does such a fine job of providing a comprehensive summation of the overall 2023 health insurance market that I will not it repeat here. Rather, I implore you, to read it in full. What I provide is local expertise that a national broker or quoting website cannot. Specifically, that is an insight into how each plan compares competitively in features and benefits and quality of local provider networks. I am intimately familiar with the local public’s preference for hospitals and medical providers as well as which health plans give them the greatest access to those, and which do not. My general impression, after 31 years in the Houston health insurance market, is that my client’s access to their doctors and hospitals is more important than premium. Particularly in Montgomery and the counties surrounding the city, as opposed to the city where the younger populace is more concerned with the latter. This is something, national marketers often fail to appreciate.

As you begin to ferret through the myriad of health insurance plan options available to you in 2023, please feel free to contact me for objective, no-fee, no-obligation guidance. I represent all insurance companies that will be issuing policies in southeast Texas and most in the remainder of the state. You may contact me via the email and phone numbers below. In the meantime, you may go to my quoting link where, in the next few days, you may enter your gender, age, and zip code, and conduct your preliminary research before calling me for details and insights. I look forward to working with you and having you as a client.

Thank you so much, D. Kenton Henry

Https://TheWoodlandsTXHealthInsurance.com Https://Allplanhealthinsurance.com Https://HealthandMedicareInsurance.com Office: 281-367-6565 Text my cell 24/7 @ 713-907-7984

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

Email: Allplanhealthinsurance.com@gmail.com

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FEATURE ARTICLE

Open enrollment for 2023 ACA coverage: what to expect

Record-high enrollment in ACA-compliant plans is likely to continue this year – thanks to an extension of the American Rescue Plan’s affordability provisions

Image: fifeflyingfife / stock.adobe.com

Louise Norris

Health insurance & health reform authority
September 26, 2022

Reviewed by our health policy panel.

Key takeaways

The tenth annual open enrollment for ACA-compliant individual/family health coverage is just around the corner. It starts November 1, and will continue through January 15 in most states.

Millions of Americans will enroll or renew their coverage for 2023 during open enrollment. Some have been buying their own health insurance for years, while others are fairly new to the process. And some are currently uninsured or have been covered by plans that aren’t ACA-compliant – such asa healthcare sharing ministry plan or short-term health insurance.

This article will give you an overview of what to expect during the open enrollment period. For even more information about open enrollment, check out our comprehensive guide to open enrollment.

ACA open enrollment will look mostly familiar this fall

In general, this year’s open enrollment period will be fairly similar to last year’s, but with some changes that we’ll address in more detail below:

Each state will continue to use the same exchange/marketplace platform it used last fall (HealthCare.gov in 33 states, and a state-run platform in DC and the other 17 states). And most states will continue to use the same enrollment schedule they used last year.
The Inflation Reduction Act has extended the American Rescue Plan’s subsidy enhancements through 2025, so the subsidy rules that were in effect for 2022 will continue to be in effect for 2023. (There’s no “subsidy cliff” and the percentage of income that you have to pay for the benchmark plan is lower than it used to be.)
Because the subsidy enhancements have been extended, the record-high enrollment we saw this year is likely to continue, and the improved affordability that the American Rescue Plan created will also continue. But that doesn’t mean your premium will stay the same — more on this below.
Brokers and Navigators will continue to provide assistance with enrollment. And Navigator funding is higher than ever before, in an effort to increase outreach and enrollment assistance.
The insurers offering health plans through the exchanges (and outside the exchanges) will generally be the same insurers that offered plans for 2022. But there are several insurers joining the exchange or expanding their coverage area for 2023, and some insurers that are shrinking their coverage areas.
The IRS has proposed a fix for the “family glitch” which will make some families newly eligible for premium subsidies in the marketplace.
Standardized plans are returning to HealthCare.gov. Standardized plans were optional for insurers to offer in 2017 and 2018, but the federal government no longer created standardized plan designs as of 2019. For 2023, standardized plans will once again be available through HealthCare.gov. And they’re no longer optional; insurers are required to offer them.

Open enrollment dates and deadlines for 2023 plans

By now, most people are accustomed to the fact that individual/family health coverage is no longer available for purchase year-round, and instead uses open enrollment and special enrollment periods, similar to those used for employer-sponsored plans. The same open enrollment schedules apply to plans purchased through the exchange/marketplace and to plans purchased from insurance companies through private channels (ie, “off-exchange”).

Open enrollment begins November 1, and in nearly every state, it will continue through at least January 15. (Note that Idaho is an exception: Open enrollment in Idaho starts and ends earlier, running from October 15 to December 15. Idaho is the only state where open enrollment for 2023 coverage will end before the start of the year.)

So in most states, the enrollment schedule will follow the same timeframe that was used last year. And in most states, you’ll need to enroll by December 15 in order to have your coverage take effect on January 1. Enrolling after December 15 will generally result in a February 1 effective date.

One caveat to keep in mind: If your current health plan is terminating at the end of 2022 and not available for renewal, you can select a new plan as late as December 31 and still have it take effect January 1.

Although open enrollment continues through at least mid-January in most states, it’s generally in your best interest to finalize your plan selection in time to have the coverage in force on January 1. We’ve explained this in much more detail here.

In most states, that means you’ll need to enroll or make a plan change by December 15. In terms of the effective date of your coverage, there’s no difference between enrolling on November 1 versus December 15. But waiting until the last minute might feel a bit more stressful, and you might have trouble finding an enrollment assister who can help you at that point. You don’t need to be the first person in line, but it’s good to give yourself a bit of wiggle room in case you run into glitches with the enrollment process or find that you’d like assistance with some or all of it.

Rest assured, however, that open enrollment continues until at least mid-January in most states. So if there’s no way for you to get signed up in the earlier part of the enrollment window, you can most likely complete the process after the start of the year and have coverage in effect as of February.

Insurers entering and leaving individual and family markets

As is always the case, there will be some fluctuation in terms of which insurers offer individual/family health coverage for 2023. For the last several years, the general trend has been toward increased insurer participation in the exchanges. Here’s more about what we saw in 2020, 2021, and 2022.)

That trend is continuing in 2023, with new insurers joining (or rejoining) the exchanges in many states. But there are also some significant insurer exits that existing enrollees need to be aware of.

Several insurers are joining exchanges in the following states for 2023:

Ambetter/Celtic (Alabama)
Cigna (Texas, Indiana, and South Carolina)
Ascension Personalized Care (Alabama, Tennessee, and Texas)
Aetna (Delaware, California, Illinois, New Jersey)
UnitedHealthcare (Kansas, Mississippi, Missouri, Ohio)
AmeriHealth (Delaware)
Taro Health (Maine)
Blue Cross Blue Shield of Nebraska (Nebraska)
Moda Health (Idaho)
Luke’s Health Plan (Idaho)
CareSource (North Carolina)
Imperial Insurance Companies (Texas)
Select Health of South Carolina (South Carolina)

But there are also some insurers exiting the marketplaces in several states, including:

Oscar Health (Exiting Arkansas and Colorado, but remaining in nine other states.)
Bright Health (Exiting the individual/family market in all 17 states where they currently offer these plans, resulting in approximately a million exchange enrollees needing to select new plans; previously, Bright has planned to exit six states and remain in 11 other states, but that changed as of October 2022, when they announced a full exit from the individual market. Anyone with an individual/family plan from Bright Health — in any state — will need to switch to a different insurer for 2023. It’s possible, however, that Bright Health might continue to offer “an immaterial amount” of individual market plans in some states.)
WPS Health Plan Inc. is exiting the on-exchange market in Wisconsin, but will continue to offer off-exchange plans.
Friday Health Plans is exiting the on-exchange market in Texas, but will continue to offer off-exchange plans in Texas. Friday has not announced any exits in the other states where they offer plans in the exchange.

Even in states where the participating 2023 insurers will be the same ones that offered coverage in 2022, there may be service area changes in some states. This could result in an insurer’s plans becoming newly available in some areas, or no longer available in some areas.

Last year, we detailed the things that people need to keep in mind if a new insurer is joining the exchange. All of those points are still applicable for people in areas where new insurers will offer plans in 2023.

The main takeaway point is that it’s important to actively compare your available plan options, as opposed to just letting your existing plan auto-renew. One of the new plans (or another existing plan) might end up being a better fit for your needs. But it’s also possible that the benchmark plan’s pricing could change significantly, affecting the amount of your subsidy. If the price of your current plan shoots up, a comparable plan will likely be available for about what you paid this year (if your income and family size haven’t changed).

It’s also worth keeping in mind that the insurer’s estimate of what you’re likely to pay in the coming year, provided in a letter this fall, may be inaccurate – again, because of a shift in its pricing relationship to this year’s benchmark plan. You’ll get a separate letter from the exchange with details about your subsidy amount for 2023 and the amount you’ll pay if you let your current plan renew. But it’s also essential to log onto the exchange, update your information, and learn what your current plan and alternative plans will cost in 2023.

The ‘family glitch’ fix will help some buyers

Ever since ACA-compliant plans debuted in the fall of 2013, people have been ineligible for subsidies if they’re eligible for an employer-sponsored health plan that’s considered affordable. And the affordability determination has always been based on the cost of employee-only coverage, without taking into account the cost to add family members to the plan. But if the employer-sponsored plan was deemed affordable, the entire family was ineligible for subsidies in the marketplace, as long as they were eligible to be added to the employer’s plan. This is known as the “family glitch,” and it has put affordable health coverage out of reach for millions of Americans over the years.

Earlier this year, the IRS proposed a long-awaited fix for the family glitch, which is expected to be in place by the time open enrollment gets underway. Under the proposed rule change, the marketplace will do two separate affordability determinations when a family has access to an employer’s plan: one for the employee, and one for total family coverage. If the employee’s coverage is considered affordable but the family’s is not, the rest of the family will potentially be eligible for subsidies in the marketplace.

Some families will still find that they prefer to use the employer’s plan, despite the cost. But some will find that it’s beneficial to put some or all of the family members on a marketplace plan, even while the employee continues to have employer-sponsored coverage.

The main point to keep in mind here is that it’s important to double check your marketplace options this fall – even if you looked in the past and weren’t eligible for subsidies due to an offer of employer-sponsored coverage.

How are ACA premiums changing for 2023?

The only way to know for sure what your 2023 premium will be is to watch for correspondence from your insurer and exchange. They will notify you this fall about changes to your plan for 2023, including the new premium (and subsidy amount if you’re subsidy-eligible; most people are).

There’s a lot of variation from one plan to another in terms of pricing changes, and your net (after-subsidy) premium will also depend on how much your subsidy changes for 2023. But here’s a general overview of what to keep in mind:

Across most of the states, the preliminary average rate change for 2023 amounts to a 7.7% increase, according to ACA Signups. Final rates aren’t yet available in many states, but we’re generally seeing final rates that tend to be a bit lower than the insurers proposed. (This is partly due to the Inflation Reduction Act — which was enacted after insurers filed their rates and which will result in slightly smaller-than-proposed rate increases for some plans — and partly due to state regulators’ actions to reduce rates during the review process).
That’s a little larger than the overall average rate increases we’ve seen for the last few years (3.5% for 2022, less than 1% for 2021, and a slight decrease for 2020). But an overall average rate change only gives us a big picture; it doesn’t tell you how much your own plan’s premium will change or how much your net premium will change, and it also doesn’t account for the new plans that will be offered for 2023.
If the benchmark (second-lowest-cost Silver plan) premium in your area goes up, subsidy amounts will also go up. Conversely, if the benchmark premium goes down, subsidy amounts will also go down. This is independent of what your own plan’s price does. It can be possible, for example, for your plan’s premium to go up while the benchmark premium goes down (perhaps because a new insurer takes over the benchmark spot), resulting in a more significant increase in the actual amount you pay each month. This is why it’s so important to pay close attention to the information you receive from your insurer and the exchange, and to carefully consider all of your options during open enrollment.

As open enrollment draws closer, we’ll continue to update our open enrollment guide and our overview of each state’s marketplace.

You can start doing your plan shopping research now

If you already have marketplace coverage, keep an eye out for correspondence from the marketplace and your insurer. If you currently have off-exchange coverage, be sure to check your eligibility for subsidies in the marketplace; you might find that you can get a much better value by switching to a plan offered through the marketplace.

And if you’re currently uninsured or enrolled in non-ACA-compliant coverage, you’ll definitely want to look at the plan options that are available to you during open enrollment, and check your eligibility for subsidies. You might be surprised to see how affordable your coverage can be. The average enrollee is paying $133/month this year, and more than a quarter of enrollees are paying less than $10/month. Although specific plan prices change from one year to the next, this same overall level of affordability will continue in 2023.

MEDICARE DRUG PLANS AND MORE FOR 2023: GOOD NEWS AND NOT AS GOOD NEWS

Featured

Posted on October 12, 2022 by thehealthinsuranceanswerman

By D. Kenton Henry editor, agent, broker 12 October 2022

In a year in which the annual inflation rate is over 9%, and the core inflation rate over 6%, there is some good news relative to Medicare Part D 2023 Drugs and Plan costs. And it comes just in time as the approximately 64 million Americans on Medicare will be electing their drug coverage during the “Annual Election Period” from October 15th through December 7th, for coverage to begin January 1.

While Medicare Part A (hospital and skilled nursing facility) coverage has been paid for during the working careers of most Americans or their spouses, Part B (out-patient coverage) has not. Medicare accesses an income-adjusted monthly premium based on a “two-year look-back at one’s income tax return. (for details refer to Chart 1, and Feature Article 1, below)

The base premium for individuals earning $97,000 or less, and couples filing jointly earning $194,00 or less, will be down $5.20 per month from $170.10 to $164.90. The Medicare Part B out-patient deductible will be down $7.00 from $233.00 to $226.00 in 2023. Although these decreases are nominal, to say the least, they are a move in the right direction.

The “not as good news” is that Part A Inpatient hospital costs to the beneficiary will be increasing. The inpatient hospital deductible is going to $1,600 for each admission – due to a different medical condition – or the same medical condition separated by 60 days or more. And the daily coinsurance for days 61-90 is going to $400 and for lifetime reserve days to $800. It is easy to see that most can ill afford to be liable for the cost of an extended hospital stay without supplemental coverage, such as Medicare Supplement or Medicare Advantage, to pay these expenses. (for details, refer to Chart 2 below)

Relative to Medicare Part D Prescription Drug Plans, the headline subject of this article, the best news is probably not that premiums are actually decreasing for many of the approximately 30 plan options available. Surveys show that Americans are more concerned about the price of their drugs than their plan premiums. So, more good news is that the cost of insulin – which has historically created something of a hardship for dependent diabetic patients – will be limited to a $35.00 monthly cap on insulin copays for Part D enrollees. In addition, all vaccines recommended for adults by the CDC will be available at no cost.

If not reversed, even greater cost savings are scheduled for 2024 and beyond. Here are some of the highlights:

2024

i) Part D enrollees entering the “catastrophic” phase of coverage will not owe any additional copays for the year. In other words, they will have 100% coverage.

ii) Part D premiums will be capped at a maximum price increase of 6% annually through 2029. Additionally, the government will expand eligibility for financial assistance.

2025

i) Out-of-pocket Medicare drug costs will be capped at $2,000 each year.

ii) Additionally, Part D enrollees will be able to spread out copay costs over the entire year, preventing hardship created by extremely high one-time bills.

2026

This will be the first year Medicare will be permitted to negotiate the cost of drugs. This will be limited to 10 drugs in 2026, increasing to 60 drugs by 2029.

These proposed changes all sound encouraging. Let us hope they survive to fruition. In the meantime, it is my job to assist my clients, and prospective clients, in identifying their lowest “total” cost Part D Drug plan for each calendar year. While people get fixated with monthly premium, one’s lowest total cost is the sum of their plan’s premium + any deductible due before their drugs become available for copays or coinsurance + their copays or coinsurance. We are seeking the lowest sum. It can be a tedious and confusing task for many and I assume that task for any client or prospective client requesting assistance.

For 2023 plan marketing, Medicare mandates I post the following disclaimer:

While I offer most, “I do not offer every plan available in your area. Please contact Medicare.gov or call 1-800-MEDICARE to get information on all your options.”

That being dispensed with, permit me to add – When someone requests I research the market for their lowest “total” cost drug or Medicare Advantage Plan, I not only employ proprietary software, but I utilize Medicare’s own data to make my recommendation. So rest assured, I have thoroughly reviewed all their options in the market before making my recommendation.

I do not charge a fee for my services. If you do not take advantage of my recommendation, you are out of nothing but the time we have spent together in arriving at it. However, if I introduce you to an insurance product, and you elect to apply for it, I only hope you will go through me to do so. You are not obligated to. Then, and only then, will I be compensated directly by the insurance company whose product you elect. The key to you is – you will pay no more premium for that product than if you were to walk in the front door of that company and purchase it directly from them. All companies in the Medicare Part D and Medicare Advantage market pay me the same so my objectivity is assured. Therefore, I like to think, you gain all the expertise my 36 years in the industry has to offer you at no additional charge. This is as opposed to a different person each time at the end of a toll-free number. I encourage you to take advantage of my offer and I look forward to establishing a working relationship with you.

D. Kenton Henry

All Plan Med Quote

Https://TheWoodlandsTXHealthInsurance.com Https://Allplanhealthinsurance.com Https://HealthandMedicareInsurance.com Office: 281-367-6565 Text my cell 24/7 @ 713-907-7984

d. kenton henry, Health insurance, kenton henry medplus messenger administrator, Medicare, Medicare Advantage, medicare part d, Patient Protection and Affordable Care Act, thewoodlandstxhealthinsurance.com

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CHART 1

Full Part B Coverage
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	Total Monthly Premium Amount
Less than or equal to $97,000	Less than or equal to $194,000	$0.00	$164.90
Greater than $97,000 and less than or equal to $123,000	Greater than $194,000 and less than or equal to $246,000	$65.90	$230.80
Greater than $123,000 and less than or equal to $153,000	Greater than $246,000 and less than or equal to $306,000	$164.80	$329.70
Greater than $153,000 and less than or equal to $183,000	Greater than $306,000 and less than or equal to $366,000	$263.70	$428.60
Greater than $183,000 and less than $500,000	Greater than $366,000 and less than $750,000	$362.60	$527.50
Greater than or equal to $500,000	Greater than or equal to $750,000	$395.60	$560.50

CHART 2

Part A Deductible and Coinsurance Amounts for Calendar Years 2022 and 2023 by Type of Cost Sharing
	2022	2023
Inpatient hospital deductible	$1,556	$1,600
Daily coinsurance for 61^st-90^th Day	$389	$400
Daily coinsurance for lifetime reserve days	$778	$800

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FEATURE ARTICLE 1

CMS: Medicare Part B Premiums, Deductibles Will Decrease in 2023

Monthly Medicare Part B premiums will fall to $164.90 in 2023, marking a $5.20 decrease from this year, while Part A premiums are set to increase by $4 to $7.

Source: CMS Logo

By Victoria Bailey

September 27, 2022 – Medicare Part B premiums and deductibles will decrease in 2023, while Part A costs will rise, according to a fact sheet released by CMS.

Medicare Part B offers coverage for physician services, outpatient hospital services, certain home healthcare services, durable medical equipment (DME), and other medical services not covered by Medicare Part A.

The standard monthly premium for Part B enrollees will be $164.90 compared to $170.10 in 2022. The annual deductible will be $226, decreasing $7 from $233 in 2022.

Dig Deeper

The 2022 premiums included a contingency margin for projected Part B spending on the Alzheimer’s disease drug Aduhelm. However, 2022 saw lower-than-expected spending on Aduhelm and other Part B services, leading to larger reserves in the Part B account of the Supplementary Medical Insurance (SMI) Trust Fund. This trust fund helps limit Part B premium increases, resulting in lower premiums for 2023.

Individuals with Medicare who take insulin through a pump supplied through the Part B DME benefit will not have to pay a deductible starting on July 1, 2023. In addition, cost-sharing will be capped at $35 for a one-month supply of covered insulin.

In 2023, Medicare beneficiaries who are 36 months post-kidney transplant can choose to continue Part B coverage of immunosuppressive drugs despite no longer being eligible for full Medicare coverage. These individuals will have to pay a monthly premium of $97.10 for immunosuppressive drug coverage.

Medicare beneficiaries with incomes greater than $97,000 will have higher Part B premiums. For example, monthly premiums will range from $230.80 to $560.50 for high-income beneficiaries. Similarly, monthly immunosuppressive drug coverage premiums will vary from $161.80 to $485.50 for high-income beneficiaries.

The While Part B costs will decrease in 2023, Part A costs are set to increase.

Medicare Part A offers coverage for inpatient hospital services, skilled nursing facility care, hospice care, inpatient rehab, and home healthcare services.

The Medicare Part A inpatient hospital deductible for beneficiaries admitted to the hospital will be $1,600 in 2023, rising from $1,556 in 2022. This deductible covers beneficiaries’ share of costs for the first 60 days of inpatient hospital care.

For days 61 through 90 of hospitalization, beneficiaries will have to pay a coinsurance amount of $400 per day, up from $389 in 2022. Past 90 days, the coinsurance will rise to $800 per day. The daily coinsurance for individuals in skilled nursing facilities will be $200 for days 21 through 100 of extended care services, up from $194.50 in 2022.

The majority of Medicare beneficiaries do not have to pay a Part A premium because they have worked at least 40 quarters in their life, the fact sheet noted. However, for those who have not, 2023 premiums are increasing.

Individuals who have at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage will have a Part A monthly premium of $278 in 2023, compared to $274 in 2022.

Individuals with less than 30 quarters and those with disabilities will have to pay the full 2023 premium of $506 per month, which is $7 higher than in 2022.

The fact sheet also shared 2023 information on Medicare Part D costs. Premiums for Medicare Part D, which offers drug coverage, vary from plan to plan. Around two-thirds of beneficiaries pay premiums directly to their plan, while the other third have their premiums deducted from their Social Security benefit checks.

Beneficiaries with incomes above $97,000 must also pay an income-related monthly adjustment amount in addition to their Part D premium. The amounts will range from $12.20 to $76.40 for high-income beneficiaries.

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FEATURE ARTICLE 2

6 Policies To Reduce Prescription Drug Prices, Boost Competition

As prescription drug spending climbs, ACHP is calling on policymakers to reduce high prescription drug prices and enhance market competition.

By Victoria Bailey

September 02, 2021 – The Alliance of Community Health Plans (ACHP) is urging the federal government to take action and lower prescription drug prices with a set of recommended actions.

The costs of prescription drugs continue to rise each year, but policymakers have done little to address it. ACHP’s list of suggestions ranges from increasing drug pricing transparency to expanding the use of biosimilars.

Catastrophic Medicare Part D prescription drug spending has been on the rise for over a decade. Seniors do not have an out-of-pocket cap for Medicare Part D, which can leave them with high costs in the catastrophic phase.

Dig Deeper

ACHP’s first recommendation is to redesign the Medicare Part D benefit including creating an out-of-pocket healthcare spending cap for seniors and to ensure that consumers will not owe anything during the catastrophic phase. Drug companies should also have to assume financial responsibility for each Part D phase and take some of the pressure off of Medicare.

Medicare should also receive resources to allow the program to negotiate lower drug prices for their beneficiaries, ACHP suggested.

ACHP’s next recommendation was for the federal government to allow the US Department of Health and Human Services (HHS) to negotiate prices for expensive prescription drugs that have no generic or biosimilar competition. These drugs were responsible for 60 percent of Part D spending in 2019, the fact sheet noted.

Currently, HHS has no power over competitive drug pricing.

Policymakers should also extend price negotiation to the commercial market to keep drug companies from shifting costs to non-Medicare consumers.

High-cost drugs that face no competition should also have an International Pricing Index applied that will limit the price to no more than 120 percent of its average international market price. The previous administration supported a similar approach through its Most Favored Nation model, but the Biden administration has proposed to rescind that model.

ACHP also urged the federal government to increase the use of biosimilars by informing clinicians and patients of the products and by persuading the Federal Trade Commission to increase biosimilar presence on the drug market. There are 29 FDA-approved biosimilars that are more affordable than other prescription drugs, but less than 12 are available on the market.

Increasing reimbursement rates for biosimilars could also improve utilization, the fact sheet stated.

ACHP’s suggestions also targeted drug companies’ unjustifiable raising of drug prices. At the beginning of 2021, 735 drugs prices increased up to 10 percent without reason.

Prescription drug prices often increase faster than the inflation rate, therefore ACHP recommended that drug manufacturers should have to provide rebates for drug price increase above the inflation rate.

Drug companies should also have to follow a price transparency rule that would require manufacturers to report and justify price increases, ACHP stated.

One example is the FAIR Drug Pricing Act, introduced in the Senate in 2019 and referred to the Committee on Health, Education, Labor, and Pensions. This Act would require drug manufacturers to notify HHS and submit a transparency and justification report 30 days before increasing the price of certain drugs by more than 10 percent.

Lastly, the ACHP recommended that the federal government encourage the use of transparent fee-based pharmacy benefit managers (PBMs). Traditional PBMs are typically not transparent about rebates, which can encourage high-cost drug use, whereas transparent fee-based PBMs pass rebates and discounts onto payers and earn revenue through a clear administrative fee.

Payer organizations have turned to the federal government to get prescription drug prices under control, as pharmaceutical companies are not budging.

In January 2021, AHIP called on the Biden Administration to focus on solutions that would protect Americans from higher drug prices.

The issue is pressing, not only for the seniors on whom some of ACHP’s recommendations focused but for all Americans. AHIP reported that the highest portion of commercial health insurance premiums goes toward prescription drug costs, making prescription drug pricing a widespread concern.

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

Posted on May 10, 2022 by thehealthinsuranceanswerman

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.

A 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!

Posted on April 26, 2022 by thehealthinsuranceanswerman

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

Posted on April 19, 2022 by thehealthinsuranceanswerman

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