By Don Kenton Henry editor, agent, broker 

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

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

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

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

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

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

Thank you so much, D. Kenton Henry

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

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

Email: Allplanhealthinsurance.com@gmail.com

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FEATURE ARTICLE

Open enrollment for 2023 ACA coverage: what to expect

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

Image: fifeflyingfife / stock.adobe.com

Louise Norris

• Health insurance & health reform authority
• September 26, 2022

Reviewed by our health policy panel.

Key takeaways

• ACA open enrollment will look mostly familiar this fall.
• Open enrollment dates and deadlines for 2023 plans
• Insurers entering and leaving individual and family markets
• The ‘family glitch’ fix will help some buyers.
• How are ACA premiums changing for 2023?
• You can start doing your plan shopping research now.

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

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

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

ACA open enrollment will look mostly familiar this fall

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

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

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Open enrollment dates and deadlines for 2023 plans

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

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

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

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

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

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

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

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Insurers entering and leaving individual and family markets

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

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

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

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

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

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

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

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

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

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

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The ‘family glitch’ fix will help some buyers

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

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

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

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

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How are ACA premiums changing for 2023?

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

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

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

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

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You can start doing your plan shopping research now

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

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

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

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

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

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

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

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

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

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

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

D. Kenton Henry

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

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

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FEATURE ARTICLE 1

KAISER HEALTH NEWS

POLICY-ISH

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

May 3, 20225:00 AM ET

SUSAN JAFFE

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

Phelan M. Ebenhack/AP

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

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

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

This story was produced in partnership with Kaiser Health News.

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

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

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

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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.

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.

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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