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

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

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

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

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

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

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

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

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

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

D. Kenton Henry

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

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

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FEATURE ARTICLE 1

KAISER HEALTH NEWS

POLICY-ISH

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

May 3, 20225:00 AM ET

SUSAN JAFFE

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

Phelan M. Ebenhack/AP

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

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

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

This story was produced in partnership with Kaiser Health News.

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

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

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

Sponsor Message

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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FEATURE ARTICLE 2

Brand-name drug prices weigh heavily on Part D beneficiaries

May 6, 2022

Peter Wehrwein

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

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

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

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

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

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

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

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

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

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


					

TIME TO RESHOP YOUR MEDICARE SUPPLEMENT INSURANCE?

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

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

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

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

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

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

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

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

3) saves them significant premium dollars

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

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

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

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

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

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

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

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

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

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FEATURE ARTICLE: 

BNN BLOOMBERG

COMPANY NEWS 

Mar 15, 2022

Medicare Watchdog Warns of $12 Billion in Excess Payments

John Tozzi, Bloomberg News

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

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

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

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

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

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

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

Appropriate Pressure

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

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

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

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

Industry Backlash

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

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

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

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

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

©2022 Bloomberg L.P.

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

TIME IS RUNNING OUT FOR A JANUARY 1 EFFECTIVE DATE!

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

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

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

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

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

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

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

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

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

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

https://allplanhealthinsurance.insxcloud.com/

MEDICARE RECIPIENTS:

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

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

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

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

D. Kenton Henry TheWoodlandsTXHealthInsurance.com                                                              

Allplanhealthinsurance.com@gmail.com

Office: 281-367-6565

Text My Cell @ 713-907-7984

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

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FEATURE ARTICLE 1:

11.24.2021

Cost Sharing Reductions on Silver Plans

Two types of Marketplace subsidies:

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

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

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

Why are subsidies more generous this year:

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

Silver plans vs. other metal levels:

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

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FEATURE ARTICLE 2:

Key Points:

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

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

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

OR SIMPLY READ THE ARTICLE IMMEDIATELY BELOW 

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

Nov 12, 2021 

Centers for Medicare & Medicaid Services

Nov 12, 2021

Fact sheet


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

Nov 12, 2021 

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

Medicare Part B Premium and Deductible

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

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

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

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

Medicare Open Enrollment and Medicare Savings Programs

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

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

Medicare Part B Income-Related Monthly Adjustment Amounts

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

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

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

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

Medicare Part A Premium and Deductible

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

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

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

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

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

Medicare Part D Income-Related Monthly Adjustment Amounts

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

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

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

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

Oct 21, 2021

Oct 15, 2021

Oct 15, 2021

Oct 08, 2021

Sep 30, 2021

Contact us

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

Media Inquiries Form
202-690-6145

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FEATURE ARTICLE 3:

11.08.2021

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

  •  

Steve Israel for the Times Herald-Record

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

In this article:

  •  

Joe Namath

American football player

Explore the topics mentioned in this article

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

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

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

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

First, some basic facts:

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

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

But …

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

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

For instance:

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

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

Steve Israel

As for those meals and money Joe Willie is pitching?

Again, buyer beware.

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

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

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

steveisrael53@outlook.com

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

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

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

By Editor, Agent, Broker

D. Kenton Henry

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

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

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

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

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

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

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MEDICARE IN 2022

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

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

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

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

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

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

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

AARP Unitedhealthcare

Aetna

Ambetter

Anthem

BlueCross BlueShield of Texas

Caresource

Cigna

Community Health Choice

Friday

Humana

KelseyCare Advantage

Molina

Mutual of Omaha

Oscar

Scott and White

Unitedhealthcare

Wellcare

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

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

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*(FEATURE ARTICLE)

Democrats suffer blow on drug pricing as 3 moderates buck party

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2021 MEDICARE PART D DRUG PLAN CHANGES AND ADVANTAGE PLAN OPTIONS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

My sincerest thanks for considering my services,

D. Kenton Henry

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

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

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FEATURED ARTICLE 1:

STAT

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

By GRETCHEN JACOBSON

SEPTEMBER 3, 2020

ADOBE

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

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

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

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

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

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

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

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

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

or increase how much the federal government spends on Medicare.

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

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

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

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

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FEATURED ARTICLE 2:

CNBC

INVEST IN YOU: READY. SET. GROW.

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

PUBLISHED FRI, OCT 2 202012:54 PM EDT

Sarah O’Brien@SARAHTGOBRIEN

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

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

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

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

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

WATCH NOW

VIDEO02:30

President Trump, FLOTUS test positive for Covid-19

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

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

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

Basic Medicare costs

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

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

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

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

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

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

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

Advantage Plans

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

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

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

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FEATURED ARTICLE 3:

RESEARCH ARTICLE

PHARMACEUTICALS & MEDICAL TECHNOLOGY

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

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

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

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

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

by D. Kenton Henry

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

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

UNEMPLOYMENT LINES IN WAKE OF CORONAVIRUS

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

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

https://allplanhealthinsurance.insxcloud.com

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

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

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

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

CLICK HERE FOR SHORT-TERM HEALTH INSURANCE QUOTES:

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

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

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

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

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

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

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

http://thewoodlandstxhealthinsurance.com

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

https://HealthandMedicareInsurance.com

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insurancenewsnet

April 30, 2020 Top Stories

FEATURE ARTICLE

Survey: Short-Term Health Insurance Demand Increasings

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

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

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

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

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

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

· 45% are concerned about high deductibles.

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

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

Download a summary of the survey findings.

About Pivot Health (a division of HealthCare.com)

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

MEDICARE CHANGES IN 2018 AND HOW THEY MAY AFFECT YOU

By D. Kenton Henry, Editor, Broker, Agent

Each year Medicare recipients and their agents and brokers prepare for upcoming changes in Medicare. This is because all changes have the potential to impact the member’s pocketbook. They may directly affect it or trickle down to the products they use to supplement Medicare.

Here is what we know is changing:

In 2017 you pay:
$1,288 Medicare deductible for each benefit period
• Days 1-60: $0 coinsurance for each benefit period
• Days 61-90: $322 coinsurance per day of each benefit period
• Days 91 and beyond: $644 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)
Beyond lifetime reserve days: all costs

In 2018 you will pay:
$1,316 Medicare deductible for each benefit period
• Days 1-60: $0 coinsurance for each benefit period
• Days 61-90: $329 coinsurance per day of each benefit period
• Days 91 and beyond: $658 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)
• Beyond lifetime reserve days: all costs

PART B DEDUCTIBLE:
The Medicare Part B deductible is $183 in 2017. It is expected to rise in 2018, but the Center For Medicaid and Medicare Services has not, and is not expected to, release that figure until closer to the end of this calendar year.

PART B PREMIUMS:
COST OF LIVING ADJUSTMENT (COLA), I.e., the Social Security Income Payment Adjustment, numbers for the coming year have not been released as of yet. But it’s widely expected that there will be a COLA of around 2 percent for 2018 (as opposed to 0.3 percent for 2017, and zero percent for 2016). CMS has not yet set Part B premiums for 2018, but it’s likely that premiums will level out for all enrollees (except those with high incomes, who always pay more). This because any necessary rate change will be covered by the COLA. In other words, the increase in Part B premiums will be offset by an increase in income payments for low-income recipients.

For high-income Part B enrollees (income over $85,000 for a single individual, or $170,000 for a married couple), premiums in 2017 range from $187.50/month to $428.60/month, depending on income. They will likely rise again for 2018, but there’s another change coming that will affect some high-income Part B enrollees in 2018. As part of the Medicare payment solution that Congress enacted in 2015 to solve the “doc fix” problem, new income brackets were created to determine Part B premiums for high-income Medicare enrollees, and they’ll take effect in 2018.

The high-income brackets start at $85,001 for a single individual and $170,001 for a married couple. Enrollees with income between $85,001 and $107,000 ($170,001 and $214,000 for a married couple) won’t see any changes to their bracket.
But enrollees with income above those limits might be bumped into a higher bracket in 2018, which means their premiums could jump considerably. The highest bracket (i.e., with the highest Part B premium) will now apply to those with income above $160,000 ($320,000 for a married couple), whereas the highest bracket didn’t apply in 2017 until an enrollee’s income reached $241,000 ($428,000 for a married couple). As with the deductible, Medicare Part B premiums for 2018 have not yet been set, but slightly less wealthy Medicare enrollees will begin paying the highest prices for Medicare Part B in 2018.

Here are Medicare Part B Premiums for 2017 (based on a 2-year look-back to 2015):

If your yearly income in 2015 (for what you pay in 2017) was You pay each month (in 2017)

File individual tax return File joint tax return Married Filing Separately
$85,000 or less $170,000 or less $85,000 or less = $134
above $85,000 up to $107,000 above $170,000 up to $214,000 N/A = $187.50
above $107,000 up to $160,000 above $214,000 up to $320,000 N/A = $267.90
above $160,000 up to $214,000 above $320,000 up to $428,000 N/A = $348.30
above $214,000 above $428,000 above $129,000 = $428.60

PART D PRESCRIPTION DRUG PLANS:
The Part D Annual Deductible is $405 in 2018, up from $400 in 2017
Premiums in the State of Texas, e.g., range from a low of $16.70 to a high of $197.10
* On the positive side, the Affordable Care Act is gradually closing the donut hole -technically known as the Gap – in Medicare Part D. In 2018, enrollees will pay just 35% of the plans cost for brand-name drugs while in the donut hole, and 44% of the cost of generic drugs.

2018 PART D COVERAGE GAP STAGE:
Begins after the total yearly drug cost (including what Your plan has paid and what you have paid) reaches $3,750. After you enter the coverage gap, you pay 35% of the drug cost for covered brand-name drugs and 44% of the drug cost for covered generic drugs until your out-of-pocket costs (not including your premiums) total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap.

2018 Catastrophic Coverage Stage:

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and mail-order) reach $5,000, you pay the greater of:

5% of the cost, or
$3.35 copay for generic drugs (including brand drugs treated as generic) and $8.35 copay for all other drugs.

 

*Tip of the 2018 Part D Open Enrollment Period:
When purchasing your prescription drugs at the pharmacy counter, always ask your pharmacist for the lowest possible cost for your drug through their pharmacy. NBC Today Show did a segment today (10.17.17) in which they revealed that many times your copay for the drug, through your insurance, is higher than the lowest cost from the pharmacy. As the photo at the top of this article depicts, sometimes the difference is quite significant. A pharmacist in Magnolia, Texas, explained that a contractual “Gag” order exists between the pharmacy and the pharmacist (or employee) which prevents the latter from disclosing this to the customer. However, once questioned, the pharmacist or employee must disclose accurate information. If the cash price is lower, by all means, pay the cash price and do not let the purchase go through your insurance.

I will keep followers of my blog apprised of, as yet, unannounced changes in Medicare as they become available. In the meantime, to those of you who are my current clients, I would like to extend a sincere thank you for your business and the confidence you have placed in me.

ASSISTANCE IN IDENTIFYING YOUR LOWEST TOTAL COST PART D DRUG PLAN:

You, and those who would consider my services may email or―for those who feel it a more secure method―may fax a list of your prescription drugs and dosages to my secure fax. (I am the only one with access to it.) I will submit your drug regimen to the quoting system which will identify the plan which covers all your drugs at the lowest total cost for the coming calendar year. The lowest-total-cost is the sum of the plan premium, any applicable deductible, and your drug costs. Whether you elect to go through me to acquire it, is at your discretion.

Please email Kenton at:
allplanhealthinsurance.com@gmail.com
or
Fax to my secure fax at:
281.367.4772

I am processing quote requests in the order received.
Thank you so much for taking the time to stay abreast of these relevant changes affecting, and so important to, Medicare recipients. I know many of you are living on fixed incomes, and keeping your costs for protecting yourself from increases in medical care, and insurance, is of vital importance to you.

 http://TheWoodlandsTXHealthInsurance.com   https://HealthandMedicareInsurance.com

SENATE ACA REPEAL AND REPLACE UP IN THE AIR

Senate’s ACA Repeal and Replace Bill Up In Air

― op-ed by D. Kenton Henry

The passage of the Senate’s Affordable Care Act repeal and replace bill, prior to their scheduled July 4th recess, is as up in the air as the fireworks will be coinciding with that illustrious date. With five Republican and additional Democrat senators currently opposed, its passage appears tenuous at best. This, in spite of President Trump’s expressed confidence it will happen.

As a medical insurance broker the past 30 years, I have certainly have an opinion on, and a vested interest in, the passage (or failure) of the bill. The reality is, the Democrats own the current Patient and Protection Affordable Care Act (PPACA). Not one Republican voted for it. Therefore (if repeal fails), come 2018, it will be the Democrat’s law which, I believe, will result in an even greater increase in health insurance premiums we have already seen skyrocket since the Act’s passage. And be certain―we will see an even greater exodus of insurance carriers from the marketplace, leaving some counties―and possibly states―with only one carrier. Or, possibly, none. In which case, Trump and the Republicans can continue to tell the Democrats, “We told you so!”.

The problem for the Republicans is, they were elected on a platform of repeal and replace. As such, there are two ways Republicans can fail the people. The first is by not fulfilling that promise. The second―and quite possibly the larger failure― is to pass something which turns out to be an equal or greater debacle than the PPACA itself. As much as I want to see the Act replaced with something better, upon analysis, I find myself largely in agreement with Senator Rand Paul. This bill almost resembles Obamacare more than it does not. Not only does it continue subsidies based on income, but it maintains ten of the twelve mandated “essential coverage items” which forced premiums up in the first place! The primary objectives of repeal and replace were to give people more control over the coverage they purchase and reject, and to bring premiums down. To acquire just what they need and reject what they don’t, all at a lower cost. As it stands today, the Senate bill cannot accomplish either because the remaining forced mandates will force insurance companies to keep premiums high while rationalizing the subsidies allow enough people to pay them using “other people’s money”. When all is said and done, if the bill passes as is, those who don’t qualify for a subsidy will feel angry and betrayed and our twenty trillion dollar budget deficit will grow at even faster than its current, virtually criminal, rate of escalation. Couple doing away with the individual mandate to purchase and maintain coverage with allowing people to purchase it anytime of the year―in spite of the state of their health―and you have a recipe for absolute failure. Many will refrain from purchasing until they receive a dread diagnosis, then purchase the insurance to force the loss of huge medical claims on someone else! I.e., the insurance companies and those responsible insured members who pay their own premiums. If passed without restrictions on when insurance may be purchased (Open vs. Closed Enrollment), I predict this replacement will fail more quickly than Obamacare has failed.

Who will be the major losers if this bill passes as is? Those individuals who must pay their own premiums; the American taxpayer; and―when the healthy drop coverage because they are no longer forced by law to purchase it―me. Who are the major winners? Employers who will see the mandate to provide coverage for groups of 50 plus dropped, creating an incentive to hire; Medical Device companies who will see taxes on their products repealed, encouraging innovation; those individuals and families who have someone else paying all, or the majority, of their premium; and the insurance companies who continue to be subsidized and receive even greater premiums (subsidized or not) for somewhat diminished coverage. And―in the case of where a broker’s compensation is based on a percentage of premium―me.

Who knows how this will ultimately shake out. All I know is, whatever the result, it will be a mixed bag depending on your position in the equation. Stay tuned and―regardless the result―contact me at 281-267-6565. Whatever your options, unless agents and brokers fall on the chopping block, I intend to be here to assist you identifying and obtaining the option most beneficial to your physical and financial health.

https://healthandmedicareinsurance.com

http://thewoodlandstxhealthinsurance.com

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FEATURED ARTICLE:

Senate health-care draft repeals Obamacare taxes, provides bigger subsidies for low-income Americans than House bill

By Paige Winfield Cunningham By Paige Winfield Cunningham June 21

Senate leaders on Wednesday were putting the final touches on legislation that would reshape a big piece of the U.S. health-care system by dramatically rolling back Medicaid while easing the impact on Americans who stand to lose coverage under a new bill.

A discussion draft circulating Wednesday afternoon among aides and lobbyists would roll back the Affordable Care Act’s taxes, phase down its Medicaid expansion, rejigger its subsidies, give states wider latitude in opting out of its regulations and eliminate federal funding for Planned Parenthood.

The bill largely mirrors the House measure that narrowly passed last month but with some significant changes aimed at pleasing moderates. While the House legislation tied federal insurance subsidies to age, the Senate bill would link them to income, as the ACA does. The Senate proposal cuts off Medicaid expansion more gradually than the House bill,\ but would enact deeper long-term cuts to the health-care program for low-income Americans. It also removes language restricting federally subsidized health plans from covering abortions, which may have run afoul of complex budget rules.

Senate Majority Leader Mitch McConnell (R-Ky.) intends to present the draft to wary GOP senators at a meeting Thursday morning. McConnell has vowed to hold a vote before senators go home for the July 4 recess, but he is still seeking the 50 votes necessary to pass the major legislation under arcane budget rules. A handful of senators, from conservatives to moderates, are by no means persuaded that they can vote for the emerging measure.

Aides stress that the GOP plan is likely to undergo more changes to garner the 50 votes Republicans need to pass it. Moderate senators are concerned about cutting off coverage too quickly for those who gained it under the ACA, also known as Obamacare, while conservatives don’t want to leave big parts of the ACA in place.

As a nod to conservatives, the Senate bill would give states more leeway in opting out of the ACA’s insurance regulations through expanding the use of so-called “1332” waivers already embedded within the law, according to the draft proposal. States could use the waivers to make federal subsidies available even off the marketplaces — but they couldn’t go so far as to lift ACA protections for patients with preexisting conditions.

But it may prove trickier to get moderates on board. Senate leaders are hoping the big draw for them lies in the bill’s more generous income-based approach to insurance subsidies, which closely mirror the subsidies offered under Obamacare.

Subsidies are available to Americans earning between 100 percent and 400 percent of the federal poverty level. Starting in 2020, under the Senate bill, this assistance would be capped for those earning up to 350 percent — but anyone below that line could get the subsidies if they’re not eligible for Medicaid.

The subsidies would also mirror the ACA in that they would be pegged to a benchmark insurance plan each year, ensuring that the assistance grows enough to keep coverage affordable for customers.

The Senate bill would also keep the ACA’s Medicaid expansion around for longer, gradually phasing it out over three years, starting in 2021.

Despite these shifts, moderates are likely to be turned off by how the bill cuts Medicaid more deeply than the House version. But the biggest cuts wouldn’t take effect for seven years, a time frame that could be more politically palatable for members like Sens. Rob Portman (R-Ohio) and Shelley Moore Capito (R-W.Va.).

Under the Senate draft, federal Medicaid spending would remain as is for three years. Then in 2021 it would be transformed from an open-ended entitlement to a system based on per capita enrollment. Starting in 2025, the measure would tie federal spending on the program to an even slower growth index, which in turn could prompt states to reduce the size of their Medicaid programs.

In a move that is likely to please conservatives, the draft also proposes repealing all of the ACA taxes except for its so-called “Cadillac tax” on high-cost health plans in language similar to the House version. Senators had previously toyed with the idea of keeping some of the ACA’s taxes.

The Senate bill would also provide funding in 2018 and 2019 for extra Obamacare subsidies to insurers to cover the cost-sharing discounts they’re required to give the lowest-income patients. Insurers have been deeply concerned over whether the subsidies will continue, as the Trump administration has refused to say whether it will keep funding them in the long run.

The House had a difficult time passing its own measure after a roller-coaster attempt, with the first version being pulled before reaching the floor after House Speaker Paul D. Ryan (R-Wis.) determined he did not have the votes. House Republicans went back to the drawing board and passed their own measure — which would more quickly kill Medicaid expansion and provide less-generous federal subsidies — on May 4.

Even if the Senate measure does pass the upper chamber, it will still have to pass muster with the more conservative House before any legislation could be enacted.

Juliet Eilperin and Amy Goldstein contributed to this report.

Navigator Vs. Insurance Broker: Who To Go To For Your New Affordable Care Act Health Insurance?

By Kenton Henry, Administrator

 
Let me preface this article with an admission. I am a health insurance broker and have been for 27 years. So consider that as you weigh the comparison suggested in the title of this piece.

 
Very shortly (October 1 to be exact) you are going to be able to enroll in a new Affordable Care Act (ACA) compliant health insurance plan to be effective January 1. Having health insurance at that time is no longer an option – it is a mandate. You probably know this by now and there is no need to review the details and I will not be addressing the penalties for not having coverage next year and beyond. Rather, I will be addressing your options for enrolling and factors you might want to weigh before electing the path you take to enrollment. I will strive to be as objective as possible in light of my preface.

 
First, let’s consider going through an insurance agent or broker like myself. Before I could consider selling my first health insurance policy back in 1986, I had to study for and pass my state’s insurance exam in order to obtain my license. I did this initially in Indiana and again in 1991 when I moved to Texas. While not the Bar Exam or Medical Board Exams – on both occasions they were comprehensive tests and I recall spending weeks of self-study in the quiet of the local library for the first and–after 5 years of experience–another week and a 40 hour prep course to boot for the second. They covered my knowledge of things not the benefit of common sense–and they were certainly not IQ tests–but measured my grasp of esoteric insurance laws, regulations, the principles and components of insurance and ethics among other topics. Next, I had to be appointed with an insurance company before I could represent their products. In addition to an application, an appointment entailed a thorough background and credit check. Approximately twenty years ago, every company with whom I applied to for an appointment made it mandatory I purchase errors and omissions coverage just as required of your attorney or doctor. Every person is fallible and the insurance makes certain an agent’s clients can be compensated for any negligence or unintentional mistake on the agent’s part resulting in the client’s harm. Fortunately, I have never had to file a claim with my E & O company nor have I had a complaint filed against me with a state insurance commission. I must also undergo and complete a minimum of 30 hours of continuing education every 24 months in order to keep my license. A record of this is made the State Insurance Commissioner. My license binds me to the same rules and regulations regarding my client’s privacy, confidentiality and personal information as the aforementioned professionals with whom you share the same type of information. Any compromise in it could result in revocation of my license not to mention civil liability on my part.

 
Who pays for these tests, licenses, continuing education and insurance? I do. It comes out of my personal income. Not to mention the cost of all my supplies, office overhead and gas utilized in seeing my clients at their convenience. Oh yeah . . . and I pay for my own health insurance. And I have never minded these expenses. These are merely the costs of doing business and I was happy to pay them when compared to the alternative which would have required being someone’s employee. So these are pretty much the facts as to my professional background, what is required of me and the protection afforded you by such.

 
Before contrasting this with the alternative – consider:
“The 2010 (ACA) law is intended to prod millions of Americans to buy health insurance, many for the first time. Those seeking coverage must provide details on citizenship, family size and income to determine whether they’re eligible for subsidies, and complete a form that can stretch to seven pages.” – Bloomberg 08.23.13

 
And the alternative to licensed agent or broker? As of October 1st, you will also have the option of going through a “Navigator” hired by your state and whose compensation will be subsidized with federal funds. (Clue: federal funds is code for your tax dollars). The Navigator’s job is to be educate you as to your options and help you elect one before being turned over to an enroller, otherwise known as a customer service representative. The latter will make this happen mechanically and it will most likely be accomplished by you going to a link and completing an electronic enrollment form estimated to be up to 21 pages or greater in length. (We don’t know yet. They and the premiums for coverage are yet to be released.)

 
While the requirements will vary from state to state, the federal requirements for Navigators are 20 hours of training. The federal health insurance exchange will apply in Texas, Indiana and Ohio. These are three of four states where I am licensed. There will be no background checks involved in the hiring process for Navigators as we are told there is no time for such. The administration says “we need to get as many people as possible to sign up as quickly as possible.” The Navigators will not be licensed. They will not pay for errors and omissions insurance. You will pay for their supplies, their insurance and their benefits.

 
I certainly don’t have to be your agent but these are factors you might want to consider before seeking assistance in enrolling in your new health insurance plan. If you feel I have unfairly or otherwise misrepresented things, please feel free to comment as much. In the feature articles below, some opposing or off-setting opinions are expressed–mostly by administration officials.

 

 

Admin. – Kenton Henry

 
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Coming Articles: Biggest Traps of the Affordable Care Act for Medicare Recipients
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Feature Articles:

 
BLOOMBERG August 23, 2013

 
State Laws Hinder Obamacare Effort to Enroll Uninsured
By Alex Nussbaum & Alex Wayne – Aug 23, 2013 2:32 PM CT

 
New laws passed by a dozen Republican-led states, the latest in Missouri last month, may make that harder, imposing licensing exams, fines that can run as high as $1,000 and training that almost doubles the hours required by the federal government. Republicans say the measures will protect consumers. Obamacare supporters say they’ll undermine the effort to get as many people as possible enrolled.
The rules are “like voter intimidation,” said Sara Rosenbaum, a health law professor at George Washington University in Washington, D.C., who supports Obama’s act. “In many, many cases these laws may be a direct interference with outreach assistance and that’s going to be quite serious.”
The Obama administration awarded 105 grants last week, steering money to hospitals, social-service agencies, local clinics and other groups. The navigators are meant to offer “unbiased information” to help people through the complexities of the new system, with its deductibles, copays, provider networks and tax credits, according to an Aug. 15 statement from the U.S. Department of Health and Human Services.
October Deadline
The grants were issued barely a month before the online exchanges are scheduled to open for enrollment on Oct. 1. The administration has said about 7 million people may enroll next year and it needs to motivate millions of young, healthy customers to sign up to keep the markets financially stable.
The state laws may complicate that task. The restrictions go farthest in a handful of states like Georgia and Missouri, where Republican legislators have already refused to set up the new insurance websites or spend money to promote the law.
In Florida this week, Governor Rick Scott told a Miami audience that federal privacy protections for consumers working with navigators were “behind schedule and inadequate.” He urged people to use brokers and agents instead.
Georgia Governor Nathan Deal, a Republican, believes navigators need state regulation because they’ll give advice on “a highly complicated and highly important topic,” his spokesman, Brian Robinson, said in an e-mail. They will also handle personal information that is open to abuse.
Consumer Protection
“This is a consumer protection issue more than anything,” said Kenneth Statz, an insurance broker on the legislative council of the National Association of Health Underwriters, a Washington-based group representing agents and brokers. “We just want to make sure that somebody who is sitting down with a consumer, trying to help them make this major decision, is going to be properly prepared.”
The state laws have passed with the backing of insurance agents and brokers, who view the online exchanges as competition and navigators as potential rivals with an unfair advantage absent new rules.
States require agents to be licensed and undergo periodic training, said Statz, who’s based in Brecksville, Ohio. He also has to carry insurance to protect clients who may be hurt by bad advice or malpractice, he said.
The 2010 law is intended to prod millions of Americans to buy health insurance, many for the first time. Those seeking coverage must provide details on citizenship, family size and income to determine whether they’re eligible for subsidies, and complete a form that can stretch to seven pages.
Federal Requirements:
While states controlled by Democrats such as Maryland, New York, Minnesota and Illinois have also passed rules, these generally follow federal requirements, said Mark Dorley, a health-policy researcher at George Washington University.
Other states have been more restrictive.
Georgia’s navigators need a license from the insurance commissioner. Each person assisting the uninsured has to pay a $50 application fee, complete 35 hours of training — 15 more than the federal requirement — pass an exam, and complete a criminal background check. Licenses must be renewed every year, requiring another $50 and 15 more hours of training.
Missouri defines navigators more broadly than the federal government, said Andrea Routh, executive director of the Missouri Health Advocacy Alliance in Jefferson City. Violating certification requirements risks a $1,000 fine.
Seeking License
Routh’s group, which seeks to educate people on the health law, didn’t apply for a grant. It may seek a license just to be safe, she said.
“Anyone who does outreach and education, or anybody who assists anyone with enrollment had better be checking that law to see if they need to be licensed,” she said.
Missouri voters approved a ballot initiative last year barring Governor Jay Nixon, a Democrat, from setting up the exchange without the assent of the Republican-controlled legislature, which has declined to act so far.
The rules may scare off churches, clinics or others who want to help, said Cindy Zeldin, executive director of Georgians for a Healthy Future. The Atlanta-based nonprofit was part of a group that won a $2.1 million grant.
Georgia’s law implies “navigators are somehow problematic,” she said in a telephone interview, “rather than that they’re groups that likely have a history of working in communities and are trusted.”
‘In Conversations’
The Obama administration has been “in conversations with states” to ensure their laws don’t hinder the effort, said Chiquita Brooks-Lasure, a deputy director at the federal health department, in an Aug. 15 conference call with reporters.
The federal law doesn’t require background checks, though navigators must provide quarterly reports and can lose their grants in cases of fraud or abuse. The administration is requiring them to undergo an initial 20 hours of training.
Some people opposed to Obama’s overhaul “want to see it fail,” said Missouri Health’s Routh. “If you put a lot of barriers in place that make it tough for nonprofits to go out and educate people and assist them in understanding the exchange, that may be one way to have it fail.”
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The Washington Post
Health and Science
States scramble to get health-care law’s insurance marketplaces up and running
By Sarah Kliff and Sandhya Somashekhar, Published: August 24
With a key deadline approaching, state officials across the country are scrambling to get the Affordable Care Act’s complex computer systems up and running, reviewing contingency plans and, in some places, preparing for delays.
Oct. 1 is the scheduled launch date for the health-care law’s insurance marketplaces — online sites where uninsured people will be able to shop for coverage, sometimes using a government subsidy to purchase a plan. An estimated 7 million people are expected to use these portals to purchase health coverage in 2014.
The task is unprecedented in its complexity, requiring state and federal data systems to transmit reams of information between one another. Some officials in charge of setting up the systems say that the tight deadlines have forced them to take shortcuts when it comes to testing and that some of the bells and whistles will not be ready.
“There’s a certain level of panic about how much needs to be accomplished but a general sense that the bare minimum to get the system functional will be done,” said Matt Salo, executive director of the National Association of Medicaid Directors. “It will by no means be as smooth and as seamless as people expected.”
Oregon announced this month that it will delay consumers’ direct access to its marketplace, opening the Web site only to brokers and consumer-assistance agents in order to shield consumers from opening-day glitches.
“Even though we’re testing now, once you actually have the system up, you don’t know what the bugs will be,” said Amy Fauver, spokeswoman for Cover Oregon, the state agency implementing the law there.
In California, which has the nation’s largest uninsured population, health officials have begun hinting that they may have a similar problem.
“It’s a complex system, and there’s a lot of navigation that needs to happen,” said Oscar Hidalgo, a spokesman for Covered California. He said the agency will know by early September whether the system will be ready in time.
If not, he said, customers will still be able to log on to the Web site and peruse insurance plans and view prices. When they get to the final step, however, they will not be able to sign up. They will have to contact a customer service representative to complete the final enrollment step.
Officials with the District of Columbia’s Health Link decided to put off building a Spanish version of its Web site until later this year, giving its staff bandwidth to complete other tasks they see more critical to the launch.
Until then, the District will have bilingual call-center workers and in-person helpers who will be able to help Spanish speakers navigate the site.
The hiccups are troubling to advocates, who worry that there will be mistakes that result in people being erroneously rejected by Medicaid or denied subsidies to which they are entitled. They are concerned that impediments will discourage the uninsured from signing up for coverage.
“There will be something up and running, but there will be serious, serious difficulties with it” that could result in delays and errors initially, said Robert H. Bonthius Jr., a lawyer at the Legal Aid Society of Cleveland. “It’s an extremely ambitious program, well-intentioned, that is going to be very difficult to accomplish, and it’s going to be months and maybe years before it really gets sorted out.”
With a key deadline approaching, state officials across the country are scrambling to get the Affordable Care Act’s complex computer systems up and running, reviewing contingency plans and, in some places, preparing for delays.
Oct. 1 is the scheduled launch date for the health-care law’s insurance marketplaces — online sites where uninsured people will be able to shop for coverage, sometimes using a government subsidy to purchase a plan. An estimated 7 million people are expected to use these portals to purchase health coverage in 2014.
See how the states have sided on some of the key provisions of the Affordable Care Act:
The task is unprecedented in its complexity, requiring state and federal data systems to transmit reams of information between one another. Some officials in charge of setting up the systems say that the tight deadlines have forced them to take shortcuts when it comes to testing and that some of the bells and whistles will not be ready.
“There’s a certain level of panic about how much needs to be accomplished but a general sense that the bare minimum to get the system functional will be done,” said Matt Salo, executive director of the National Association of Medicaid Directors. “It will by no means be as smooth and as seamless as people expected.”
Oregon announced this month that it will delay consumers’ direct access to its marketplace, opening the Web site only to brokers and consumer-assistance agents in order to shield consumers from opening-day glitches.
“Even though we’re testing now, once you actually have the system up, you don’t know what the bugs will be,” said Amy Fauver, spokeswoman for Cover Oregon, the state agency implementing the law there.
In California, which has the nation’s largest uninsured population, health officials have begun hinting that they may have a similar problem.
“It’s a complex system, and there’s a lot of navigation that needs to happen,” said Oscar Hidalgo, a spokesman for Covered California. He said the agency will know by early September whether the system will be ready in time.
If not, he said, customers will still be able to log on to the Web site and peruse insurance plans and view prices. When they get to the final step, however, they will not be able to sign up. They will have to contact a customer service representative to complete the final enrollment step.
Officials with the District of Columbia’s Health Link decided to put off building a Spanish version of its Web site until later this year, giving its staff bandwidth to complete other tasks they see more critical to the launch.
Until then, the District will have bilingual call-center workers and in-person helpers who will be able to help Spanish speakers navigate the site.
The hiccups are troubling to advocates, who worry that there will be mistakes that result in people being erroneously rejected by Medicaid or denied subsidies to which they are entitled. They are concerned that impediments will discourage the uninsured from signing up for coverage.
“There will be something up and running, but there will be serious, serious difficulties with it” that could result in delays and errors initially, said Robert H. Bonthius Jr., a lawyer at the Legal Aid Society of Cleveland. “It’s an extremely ambitious program, well-intentioned, that is going to be very difficult to accomplish, and it’s going to be months and maybe years before it really gets sorted out.”
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http://allplanhealthinsurance.com

What is Coming with Your Health Insurance Between Now and January 1!

Just Practical Information On What is Coming with Your Health Insurance Between Now and January 1!

08.12.2013
This is not an editorial. Today’s post is simply non-political, practical information regarding coming changes in health insurance between now and 2016 and beyond. The Patient Protection and Affordable Care Act (PPACA) is law and is on schedule to be fully implemented (for all but groups of 50+) January 1, 2014. For this reason it is my responsibility to inform my clients – and followers of this blog – of what they can expect in the coming months. Specifically, their insurance options and the mechanics involved in transitioning to health plans that provide minimum “essential benefits” that are in compliance with the PPACA. In this post, I will be addressing individuals and families which includes the self-employed and those who have a personal policy because their employer does not provide coverage. All others, including those covered by group plans for less than 50 employees will be addressed in subsequent posts.
First – those of you who currently have a personal or family policy will be allowed to keep your policy until your policy anniversary in 2014. You should check your anniversary date or–if you are my client–call me. Many companies have changed your anniversary date to December 1. This allows you to keep your current plan until December 1, 2014. After that, you must convert to a health care “compliant” plan which will be described below. I can simplify and assist you in this process when the time comes.
If you do not currently have health insurance you must purchase a health policy to be effective January 1 or pay a penalty on your tax return for 2014 and beyond. Another reason you may want to purchase a plan is if you have previously been unable to acquire a policy which covers your pre-existing health condition(s). Your new compliant plan must cover them and health issues will not factor into your cost.
When October 1 arrives (the earliest date you may apply for compliant coverage) I will provide you a link where you will enter your estimated income for 2014. It will instantly tell you whether you qualify for a subsidy. If you do – you are going to want to choose from and apply for plan options in your state health insurance exchange. If your state has not established a state exchange (as is the case in Texas) – you will select from plans in the Federal Health Insurance Exchange. If you do not qualify for a subsidy (which is the case if your income is 400% or greater than the Federal Poverty Level*) – you are probably going to choose a policy offered outside an exchange and direct from an insurance company. The reason being, it is anticipated these plans will offer the same benefits at a lower cost. I can assist you with this option as well.
Below, I will offer further and detailed information on exchanges, plan options and more. Please do not hesitate to call me for clarification or to discuss this information.

Admin. – Kenton Henry

*
FEDERAL POVERTY LEVEL GUIDELINES 2013
http://allplanhealthinsurance.com
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STEP 1:
Note these key dates and deadlines in your calendar:
If your employer offers health insurance, get key dates from your HR department. These are key dates if you’re planning to buy health care through your state’s Marketplace, which is available through a web site, a call, or an in-person visit.
• Oct. 1, 2013: First day you can enroll in a health plan on your state’s Marketplace
• Dec. 31, 2013: Last day you can enroll in a health plan and have your coverage start Jan. 1, 2014
• Jan. 1, 2014: First day you have insurance coverage if you buy a plan in the Marketplace — if, of course, you buy before this date
• March 31, 2014: The last date you can enroll in a plan on your state’s Marketplace to be covered for part of 2014
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Requirements:
* Be a citizen or legal resident.
• Buy your coverage through your state’s or Federal new health insurance Marketplace, also called an “Exchange”.
• Make about $11,490 to $45,960 a year if you are single – or $23,550 to $94,200 a year if you are in a family of four.
If you make less than the lowest amount, you may be eligible for Medicaid. Medicaid will cost you less than you’d save with a tax credit.
Unfortunately, if your state is not expanding Medicaid based on the guidelines in the Affordable Care Act, you may not be able to enroll in Medicaid or be able to get a tax credit. It’s possible that if you make less than $11,490 in 2013, which is the poverty level, you may not qualify for Medicaid if you live in a state that isn’t expanding Medicaid.
In general, you’re not eligible for the tax credits if you could get coverage through a workplace. However, the coverage offered by your employer must be considered affordable. If your company offers a plan that costs more than 9.5% of your income, or that does not cover at least 60% of the cost of covered benefits, you can look for a more affordable plan through your state’s Marketplace and may receive tax credits to lower your costs.
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Insurance Exchanges
State Didn’t Set Up a Marketplace? Relax
You may have heard that not all states will have their own health insurance Marketplace, also called an Exchange. If your state doesn’t set up a Marketplace, what does that mean for you?
Rest assured that no matter which state you live in, you can buy insurance through a Marketplace starting October 2013.
The way you use the Marketplace will be similar in every state. You’ll access a web site, or call, or see someone in person. And you’ll have tools to compare health plans.
But Marketplaces won’t all be the same in every state. There are three ways your state’s Marketplace can be managed — and this affects your choice of health plans and coverage.
1) State-run Marketplaces
Seventeen states are creating their own Marketplaces. These states will have a lot of local control.
Each state will decide which insurance companies can sell policies on its Marketplace.
States also choose the core benefits each plan has to offer. They can set extra requirements for health plans, like benefits that are more generous or more affordable limits on your out-of-pocket costs.
The state is also in charge of getting people to use the Marketplace.
*Indiana and Ohio will have their own State Exchange. Residents of these states should call Kenton Henry @ 800.856.6556
2) Partnerships Between a State and the Government
A few states are teaming up with the federal government to develop Marketplaces.
The federal government:
• Sets up the Marketplace web site and in-person sites
• Decides which health plans will be sold in the partner state
• Sets the benefit levels
• Runs the Marketplace
The states:
• Monitor health plans
• Help people find the best insurance for their needs *(Call Kenton Henry @ 800.856.6556)
• Handle complaints
Federal-run Marketplaces
Some states decided not to set up their own Marketplaces. In those states, the federal government will step in to run the marketplaces directly. It will make all the decisions: how the Marketplace will work, what plans are sold, and how to promote the Marketplace. Each state is considered separately and has its own Marketplace web site. (Texas residents call Kenton Henry @ 800.856.6556)
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Your Insurance Choices in a Marketplace: FAQ

A health insuranceMarketplace, also known as an Exchange, is a one-stop shop for affordable insurance in your state. Your state’s Marketplace has tools to make it easy for you to compare your choices and pick the best for your needs.
On a state Marketplace site, health plans are grouped by levels of coverage — how much the plan will pay for your health care and what services are covered.
Each level is named after a type of metal:
• Bronze
• Silver
• Gold
• Platinum
Bronze plans offer the least coverage and platinum plans offer the most.
How do the bronze, silver, gold, and platinum levels differ?
The metal plans vary by the percentage of costs you have to pay on average toward the health care you receive.
Here are the percentages of health care costs you pay for each type of plan:
• Bronze plan: 40%
• Silver plan: 30%
• Gold plan: 20%
• Platinum plan: 10% of your health care costs.
The way you pay your portion of these costs is in deductibles and copayments or co-insurance.
In general, the more you are willing and able to pay each time for health care service or a prescription, the lower your premium. A premium is your monthly payment to have insurance.
As an example, when you compare the bronze and platinum plans:
With a bronze plan: You pay the most each time you see your doctor or get a medicine. This is also called having higher “out-of-pocket” costs. But in a bronze plan you pay the least premium each month.
With a platinum plan: You pay the least each time you see your doctor or get a medicine. But in a platinum plan you pay the highest premium each month.
How does coverage from a metal plan compare to my current insurance?
The bronze through platinum coverage levels are new. So you probably don’t know how the benefits of the plan you use today compare to them. The coverage level you have now depends on whether you bought your plan:
• From an employer: Your coverage level is likely between a gold and platinum level.
• On your own: Your coverage level is likely between a bronze and silver level.
Having a sense of how the insurance you’re used to compares with the new plans will help you decide on a plan. You should compare the out-of pocket costs you are currently paying, the services provided (including prescription drugs), and anticipated changes in your health.
If you shop for insurance on your state’s Marketplace, you’ll see the health plans organized in this way:
• 1st by metal level: Bronze, silver, gold, or platinum
• 2nd by brand, such as Blue Cross, Cigna, Humana, Kaiser, United, and others
• 3rd by type of health plan, such as HMO, PPO, POS, or high-deductible plans with a health savings account.
The type of health plan affects how much choice you have in providers, the amount of paperwork you have, and your out-of-pocket costs.
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Tax Penalty At-a-Glance: Who Will Pay The Penalty & How Much Is It?
By law, you need to have health insurance by 2014. If you already get insurance through your employer or your partner’s employer, you’re all set. But what happens if you don’t follow this requirement from the Affordable Care Act?
If you can afford health insurance and don’t buy it, you’ll pay a fine when you file your 2013 income taxes in April 2014.
For the first year of the new law, 2014, the fine for not having insurance is the lowest it will be. After that, it goes up steeply in 2015 and again in 2016.
In 2014: There are two ways the government calculates what you owe. You have to pay whichever amount is higher.
• One way is to charge you $95 for each adult and $47.50 for each child, but not more than $285 total per family.
• The other way is to fine you 1% of your family income. If your family makes $50,000 a year, the fine will be $500.
In 2015: There will still be two ways to calculate what you owe. You have to pay whichever amount is higher.
• One way is to charge you $325 for each adult and $162.50 for each child, but no more than $975 total per family.
• The other way is 2% of your family income. If your family makes $50,000 a year, the fine will be $1,000.
In 2016 and beyond: There will still be two ways to calculate what you owe. You have to pay whichever amount is higher.
• One way is to charge you $695 for each adult and $347.50 for each child, but no more than $2,085 per family.
• The other calculation is 2.5% of your family income. If your family makes $50,000 a year, the fine will be $1,250.


http://allplanhealthinsurance.com