(What Consumers Need to Know for the 2026 Marketplace)
D. Kenton Henry – editor, agent, broker
As we approach the 2026 plan year, one of the biggest questions in individual and family health insurance is what will happen to Advance Premium Tax Credits (APTCs)—the subsidies that lower monthly premiums for millions of Marketplace enrollees.
Why This Is Happening
During the COVID era, Congress passed temporary legislation — most recently extended under the Inflation Reduction Act (IRA) — which made Marketplace subsidies more generous and available to more households. These enhanced subsidies are scheduled to expire at the end of 2025, unless Congress acts to extend them.
If they expire, the Marketplace will revert to pre-COVID subsidy rules, which means:
1. Lower income thresholds for subsidy eligibility
Some households who qualified for subsidies under the temporary rules will no longer qualify at all.
2. Smaller subsidies for many who remain eligible
People who received very large subsidies during 2021–2025 would see higher net premiums for 2026, even if their income has not changed.
3. The return of the “subsidy cliff”
Under pre-COVID rules, households with income even slightly above 400% of the Federal Poverty Level received no subsidy. The COVID-era rules removed that cliff. If not renewed, the cliff returns.
This is why some people are seeing early projections showing their 2026 premiums rising sharply.
Where Things Stand in Congress
Both parties publicly acknowledge that the expiration would lead to large premium increases for many families. As of today:
There is broad interest in finding a solution, but
No final legislation has been passed,
No guarantee exists that the enhanced subsidies will continue, and
Any resolution will likely be tied to larger budget negotiations.
In short: Congress is still debating it, and the outcome directly affects what consumers will pay for Marketplace coverage in 2026.
What Consumers Should Expect
Until Congress acts, the Marketplace must begin preparing 2026 rates under the assumption that the enhanced subsidies expire. This means:
Preliminary quotes may show dramatically higher net premiums
Some currently subsidized families may temporarily appear ineligible for assistance
Final 2026 subsidy amounts cannot be known until legislation is passed — if it is passed
It is important to remember that this may change, depending on Congressional action in the coming months.
Practical Guidance for Individuals and Families
Don’t panic if early projections show large increases.
Stay informed — subsidy rules may be extended or modified.
Review your 2026 options with a licensed, experienced broker who can calculate subsidies under both scenarios.
Update income estimates accurately during Open Enrollment; small changes can affect substantial tax credit differences.
Bottom Line
The enhanced ACA subsidies that helped make Marketplace coverage more affordable since 2021 are set to expire after 2025, and Congress has not yet determined whether they will be renewed. Until a resolution is reached, 2026 Marketplace premiums may appear significantly higher for many Americans.
I will continue to monitor developments closely and provide updates as soon as new information becomes available.
Additionally—
It has come to my attention that my clients have been told the First Health PPO network plan is being mistakenly interpreted by them as being an Affordable Care Act (ACA) compliant PPO network. As such, they incorrectly believe any and all of their pre-existing health conditions will be covered and that all preventive exams and medicine will be covered at no out-of-pocket cost to them. This is wrong and here is the truth, as confirmed by me and ChatGPT:
✅ 1. There are no ACA-compliant PPO plans available in Texas individual/family (On- or Off-Exchange)
Texas has not had a true ACA-compliant individual market PPO option for several years. All carriers (BCBSTX, Ambetter, United/Optum, Aetna CVS, Oscar, Cigna, Moda, etc.) offer only:
EPOs
HMOs
These networks limit out-of-network benefits and require referrals or tighter network management.
A PPO requires:
National or multi-state contracted provider access
True out-of-network benefits
No referral requirement
No carrier has offered this in the ACA individual Texas market since around 2017–2018.
✅ 2. Aetna is not selling ACA individual/family plans in Texas for 2026 (and has already exited)
Your clients may be confused because Aetna offers:
Medicare Advantage PPOs
Employer-based PPOs
First Health networks tied to group/other products
But Aetna does NOT offer ACA individual/family plans in Texas for 2026.
So if someone believes they have an “Aetna PPO” under an ACA plan, they are mistaken. It is either not an ACA plan, or they are misinterpreting the network type.
✅ 3. If their plan is marketed as “PPO-like,” it is almost certainly:
a) A short-term medical plan
These frequently use PPO networks—including Aetna’s First Health—but they are:
NOT ACA-compliant
Do NOT cover pre-existing conditions
Can cap benefits
Can deny claims based on underwriting
b) A health-sharing ministry
Often marketed as “PPO plans” because they use rented networks, but also:
Not insurance
Not regulated as insurance
No claim guarantees
No ACA protections
c) A fixed-benefit plan that uses First Health or MultiPlan PPO
Again:
Not insurance
No ACA protections
No out-of-pocket maximums
No guaranteed coverage
d) A direct primary care + medical indemnity bundle
These are sometimes misrepresented as “PPO plans,” but they are not.
✅ 4. How to confirm instantly whether the client is on ACA-compliant coverage
Ask for one of the following:
A) The name of the carrier.
If it’s not:
BCBSTX
Cigna
Ambetter
UnitedHealthcare (UHC Marketplace)
Aetna CVS (in some states, but NOT Texas 2026)
Moda
Oscar (until exit)
…then it’s almost certainly not ACA-compliant.
B) A copy of the Summary of Benefits & Coverage (SBC).
All ACA plans must include an SBC — short-term plans and sharing ministries do not.
C) Their monthly bill or ID card.
If it says things like:
First Health Network
MultiPlan PPO
PHCS PPO
Aetna PPO
United Healthcare Choice/Choice Plus PPO
…that is almost certainly a non-ACA plan.
✅ 5. Bottom line for you:
If you believe you they are on an ACA-compliant “Aetna PPO” for individual/family coverage:
You are not. No such product exists in the Texas ACA market. You are almost certainly on a short-term plan, health-sharing product, or fixed-benefit plan using a rented PPO network.
This is an excellent opportunity for ne to help you transition to true ACA coverage, where you will regain:
Pre-existing condition protection
Essential health benefits
No annual/lifetime caps
And – perhaps most importantly – Out-of-pocket maximum protection
Please feel free to call me with any questions you may have or for assistance in obtaining 2026 ACA compliant health insurance. I will make the quoting and application process go as quickly and smoothly as possible whether you quailify for a subsidy or not.
The Open Enrollment Period for a January 1 effective date ends December 15th. You have until January 15th to obtain an effective date of February 1.
D. Kenton Henry Office: 281-367-6565 Text my cell 24/7@ 713-907-7984 Email: Allplanhealthinsurance.com@gmail.com
By D. Kenton Henry, Editor / Agent / Broker — TheWoodlandsTXHealthInsurance.com, AllPlanHealthInsurance.com, HealthandMedicareInsurance.com 30 October 2025
Each November in Texas marks more than just the start of the new health insurance year—it’s your gateway to securing coverage for the year ahead. This time around, the 2026 individual and family health insurance market is undergoing noticeable changes. Here’s what you need to know—and how you can be ready.
1. Why 2026 matters
Open enrollment for 2026 policies begins November 1, 2025, and runs until January 15, 2026 for most Texas consumers. If you don’t act in this window, you could be locked out of making changes until next year unless a qualifying life event occurs. Given major shifts among carriers and plan options, early action is more important than ever.
2. Carrier changes you should track
One of the major headlines: Aetna will exit the Texas individual and family market beginning in 2026. That means if you currently have an Aetna plan, your policy will not renew for 2026. You’ll need to select a different carrier in the upcoming enrollment period.
Other carriers are repositioning their offerings, adjusting networks, benefits, and rates. Even if your carrier is staying, plan names and design may change. As your broker, I’ll review all available options from multiple carriers and ensure you’re not simply renewing by default.
3. What this means for you
No automatic renewal: If your carrier exits the market, your current plan will not carry over. You’ll receive a Notice of Change—or termination—and need to select a new plan.
Shop your options: Differences between plans are not only about monthly premiums. Review networks, cost-sharing, deductibles, out-of-pocket maximums, and whether benefits match your healthcare needs.
Subsidy changes: The federal subsidy rules continue to evolve. Even small changes in income, household, or eligibility can shift your subsidy level. I’ll help you analyse eligibility for Advance Premium Tax Credits (APTC) and other cost-saving tools.
Timing matters: Beginning November 1, I’ll be available to assist you through the selection process—not just on carriers and plans, but on ensuring accurate enrollment to avoid coverage gaps.
4. Why working with a broker matters
As an independent broker specializing in medical insurance since 1986, I work with virtually every major carrier licensed in Texas. My services to you are free of charge. My goal is to ensure you get the best plan that fits your health needs, budget, and preferences—especially in a year of significant market change. Rather than navigating dozens of plan names on your own, let me do the heavy lifting and help you make an informed choice.
5. What to do now
Gather your information – your current health plan, recent premium receipts, summary of benefits, and any health changes.
Schedule your review – open enrollment kicks off November 1. If you’d like early preparation, I’m available now to pre-review your situation so you’re ready to act.
Act during the window – November 1 through January 15 is your open period. Plans go into effect January 1, 2026, or, depending on carrier rules, as early as December 1, 2025.
Don’t wait – with carrier exits and plan redesigns in motion, the sooner you start the review, the better your chance of finding the optimal match.
Working together, we’ll turn these market shifts into an advantage—so instead of scrambling when notices arrive, you’ll move confidently into 2026 with coverage aligned to your needs.Let me handle the complexity so you can focus on your life, your health, and your goals.
If it’s after hours, or you simply prefer, you can do preliminary research before calling me by obtaining quotes from my quoting engine. You do NOT have to log in to obtain them but be certain to call me afterwards with questions, and assistance in finding your providers within the networks, as well as applying. CLICK HERE: https://allplaninsurance.insxcloud.com/get-a-quote
D. Kenton Henry Editor · Agent · Broker TheWoodlandsTXHealthInsurance.com * AllPlanHealthInsurance.com * HealthandMedicareInsurance.com
D. Kenton Henry Editor, agent, broker 30 SEPTEMBER 2025
Medicare 2026: Welcome clients and prospective clients! Before reading this (if you have not already), you should go to your mail box and retrieve your 2026 Annual Notice of Change from Medicare. You were due to receive it no later than today per Center For Medicare Rules and Regulations. If will give you a good idea if you need to re-shop your Medicare Advantage or Part D Drug plan for the coming calendar year. If not, the following changes may.
10 changes to review before the Annual Election period, often referred to as the Open Enrollment (Oct 15–Dec 7)
If you’re on Medicare, 2026 brings important updates—especially to prescription drug coverage. The Part D out-of-pocket cap rises to $2,100, the standard deductible becomes $615, and Medicare’s first negotiated drug prices start on January 1, 2026. Medicare Advantage also gets new guardrails around prior authorization and appeals, and some supplemental “perks” are being narrowed. Check your Annual Notice of Change (ANOC) (it should arrive by Sept 30) and compare your plan options—small differences can mean big savings. If you’d like help, I’ll review your medications, doctors, and benefits to make sure you’re in the right fit for January 1.
Here is an itemized list of the 10 Key Changes:
Medicare changes your 2026 plan review should cover
1) Part D’s annual out-of-pocket cap rises to $2,100. Once a member’s 2026 Part D out-of-pocket spending reaches $2,100, they’ll pay $0 for covered Part D drugs for the rest of the calendar year.
2) The standard Part D deductible increases to $615. Plans can’t set a deductible higher than $615 in 2026 under the redesigned Part D rules.
3) Drug price negotiations start showing up at the counter. Medicare’s first set of negotiated Maximum Fair Prices (MFPs) for 10 widely used Part D drugs take effect January 1, 2026. Members should review their ANOC and plan formularies to determine how these prices impact their medications.
4) Insulin and adult vaccines: protections continue. Part D insulin remains capped and no-deductible; starting in 2026, the cap is the lesser of $35, 25% of the MFP, or 25% of the negotiated price. ACIP-recommended adult vaccines remain $0 under Part D.
5) “Pay-over-time” for prescriptions auto-renews. The Medicare Prescription Payment Plan (monthly billing instead of paying large amounts at the pharmacy) auto-renews in 2026 unless the member opts out. It smooths payments but doesn’t lower total costs—good to remind clients who tried it in 2025.
6) Medicare Advantage prior-auth and appeals guardrails tighten. For 2026, CMS says MA plans must honor previously approved inpatient admissions (can only reopen for obvious error or fraud), and CMS closes appeals loopholes so members and providers receive required notices and can appeal adverse coverage decisions. Expect fewer mid-stay reversals. Centers for Medicare & Medicaid Services
7) Limits on certain “extra perks” in MA (SSBCI) take effect. CMS codified non-allowable Special Supplemental Benefits for the Chronically Ill—examples include non-healthy food, alcohol, tobacco, and life insurance. Some plans may rebalance extras as a result.
8) Star Ratings update: new/returning measures. 2026 Stars add or reintroduce measures like Kidney Health Evaluation for Patients with Diabetes plus Improving/Maintaining Physical and Mental Health (weight = 1). Tougher cut points in 2026 may shift plan bonuses and benefit richness—worth watching locally.
9) Part D benefit design shifts behind the scenes. Liability shares change across phases (plans, manufacturers, CMS), and there’s a new subsidy for selected (negotiated) drugs. Members may see formulary/tier adjustments—another reason to compare plans.
10) ANOC timing: what to tell clients. Remind everyone: Annual Notice of Change (ANOC) letters arrive by September 30 each year; if they didn’t see one, call the plan. Open Enrollment runs Oct 15 – Dec 7 for Jan 1 effective dates.
Check your Annual Notice of Change (ANOC) (it should arrive by Sept 30) and compare your plan options—small differences can mean big savings. If you’d like help, I’ll review your medications, doctors, and benefits to make sure you’re in the right fit for January 1.
Other Developments
Some Medicare Advantage supplemental benefits (i.e. nutrition support, OTC medicine) may be reduced in favor of core services.
In six states, prior authorizations for certain Original Medicare services will be tested.
Part B and Part D premiums and deductibles are both set to increase—Part B premium up ~11.6%, and Part D premium by about 6%.
Who Am I?
In addition to being the editor of this blog I have has been helping individuals and families navigate the health and Medicare insurance landscape since 1986. With nearly four decades of experience, he specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D prescription drug plans.
As an independent broker, I am appointed with virtually every competitive, A-rated Medicare insurance company in Texas, Indiana, Ohio, and Michigan. This broad access allows him to recommend the plan that truly best fits each client’s needs.
Above all, I work for my clients—not the insurance companies. You will never pay more by enrolling through me than you would if you purchased an insurance product directly from the carrier. My mission is to provide clear guidance, personalized recommendations, and ongoing support to ensure my clients get the coverage and peace of mind they deserve.
If you have any questions about 2026 Medicare Part D prescription drug plans, Medicare Advantage, or Medicare Supplement (Medi-Gap) policies, please give me a call.
Average premiums, benefits and plan choices for Medicare Advantage and the Medicare Part D prescription drug program should remain relatively stable next year, CMS said in a Sept. 26 news release. But MA enrollment is projected to decrease 900,000 in 2026.
Despite a slight dip in available MA plans nationally, over 99% of Medicare beneficiaries will still be able to access an MA plan.
The agency estimates the premiums for MA plans to drop from $16.40 to $14.00. On average, the total premium for standalone Part D is estimated to fall $3.81. CMS’ July forecast predicted elevated Medicare Part D base premium increases in the neighborhood of 6%.
By D. Kenton Henry Editor, HealthandMedicareRelatedInsurance.com Agent, Broker 28 January 2025
Hello again, and welcome to 2025! Early last October, just prior to the Medicare Annual Election Period (AE), I informed you of the many changes coming to Medicare Part D Prescription Drug Plans in the coming calendar year in which we now find ourselves. I explained the pros and cons that many of you are now experiencing in real time. On the positive side, I am certain many are celebrating that their annual drug costs (for Part D covered drugs) can never go beyond the new annual maximum out-of-pocket (OOP) of $2,000! And, hopefully, you are not experiencing the negatives—such as learning your Rx drug (which was previously covered) is no longer or its price has increased dramatically! Once again, we realize the government can giveth or taketh away.
But there is one thing in which you have a certain amount of control, and this is the ideal time of year to exercise that control. During the AEP, insurance companies, agents, and brokers work overtime seven days a week to see that their clients, and prospective clients, are guided to the Medicare Advantage and Part D Drug plans that best meet their needs. To do this correctly, an agent must understand the client’s needs and objectives and then do, what is often, extensive research to ensure a person’s drugsare covered and they have access to their preferred providers. In some cases, this can take minutes and, in others, hours over repeated phone calls. In most cases, you won’t get the latter from a company employee on the end of an 800 number, but you will get it from me.
Now that the AEP ended December 7th, agents have much more time to assist you in improving the cost of your Medicare Supplement coverage. As you may know, Medicare Supplement is not subject to annual enrollment periods in Texas or most states. What this means, is you can re-shop your Supplement coverage to find identical (or improved) coverage 365 days per year. The incentive for doing so is that you may save 30% or more in premiums. Because Medicare Supplement premiums go up each year as we age, it doesn’t take too many years before most of us begin to wonder if our premium is still reasonable or competitive. The reality is, if your policy is three years or older, you will indeed safe significantly by switching to a policy with the same letter designation, e.g., Plan G. I have many clients whose policy premiums had increased to well over $300 per month that I was able to lower (with new coverage) to less than $200 per month!
Additional reasons to re-shop now are that a few “A” rated companies are particularly interested in expanding their block of business. This does not imply a compromise in the quality of their customer service or rate stability. It simply means that through prudent management and staff expansion, they can be more competitive, significantly lowering your premium. Additionally, you may now have a spouse, or in some cases, simply another adult living with you—making your new policy available for a “Household Discount”. Typically, these discounts can lower your premium 7-12%, and—if the other person is covered by the same company—that discount will apply to their existing policy also!
So what is the catch? The catch is that now that you have been in Medicare Part B 6 months or more, you must go through underwriting and be approved for the new coverage based on your current health and relatively recent health history. The bottom line is, if your current conditions are well controlled with medication, you do not suffer from any chronic condition that poses a long-term liability to the insurance company, and you have no pending surgeries or hospitalizations—you are a good candidate for replacement coverage. The worst scenario is you are declined. In this case, all you are out of is the small amount of time you took to complete the application.
THE FOLLOWING IS A SYNOPSIS OF THE PROS AND CONS OF RE-SHOPPING YOUR COVERAGE:
Re-shopping a Medicare Supplement (Medigap) policy can provide several advantages for recipients, especially if their needs or circumstances have changed since they first enrolled. Here are the key benefits:
1. Cost Savings
Premium Reduction: Medigap premiums can vary significantly between providers for the same coverage. Shopping around may uncover lower premiums for the same plan (e.g., Plan G or Plan N).
Health Status Discounts: If your health has improved since your initial enrollment, you might qualify for a lower premium rate with another insurer.
Household Discounts: Some insurers offer discounts if multiple members of the household enroll in their Medigap plans.
2. Better Coverage Options
Change in Needs: If your healthcare needs have increased or decreased, you might find a plan that better aligns with your current situation, such as switching from a high-deductible plan to one with lower out-of-pocket costs.
Additional Benefits: New Medigap plans might include perks like fitness programs, telehealth, or wellness benefits that weren’t available when you initially enrolled.
3. Access to New Insurers
Competitive Market: New insurers entering the market may offer attractive rates or better customer service than your current provider.
Provider Reputation: Switching to a more reputable insurer can improve your overall satisfaction and ensure reliable claims processing.
4. Avoiding Rate Increases
Age-Based Increases: Some policies increase rates as you age. Shopping around may allow you to switch to a community-rated policy where premiums are based on a group average rather than individual age.
Annual Adjustments: If your current insurer has raised premiums significantly, exploring alternatives can help you lock in a more stable rate.
5. Improved Customer Service
If your current insurer has poor customer service or limited support, switching to a provider with higher satisfaction ratings can enhance your overall experience.
6. Medicare Advantage Comparison
While re-shopping Medigap policies, some recipients may realize that a Medicare Advantage (Part C) plan is more cost-effective or suitable for their needs. These plans often include additional benefits like dental, vision, and hearing coverage.
7. Regulatory Benefits
Guaranteed Issue Rights: In some situations (e.g., losing coverage or moving), recipients have guaranteed issue rights, allowing them to switch Medigap plans without medical underwriting.
Trial Rights: If you tried a Medicare Advantage plan for less than 12 months and decide to switch back to Original Medicare, you may have a guaranteed right to re-enroll in a Medigap plan.
8. Customizing for Future Needs
Planning ahead for potential healthcare changes can ensure that you are prepared for costs that might arise later, such as skilled nursing care or extensive outpatient services.
Considerations When Re-Shopping
Medical Underwriting: Outside of guaranteed issue periods, you may need to answer health questions, which could affect your eligibility or rates.
Plan Standardization: All Medigap plans with the same letter (e.g., Plan G) offer identical core benefits, regardless of the insurer, making it easier to compare prices.
Timing: The best time to switch is typically during your open enrollment period or when you have guaranteed issue rights.
By re-shopping their Medigap policy, Medicare recipients can ensure they are getting the best value and coverage for their evolving needs.
I am an independent agent with more than three decades in the medical insurance industry. As I have aged, so have my clients, and Medicare-related insurance (Supplement, Advantage, Part D) has become my specialty. I represent virtually every “A” rated insurance company in Texas as well as three others. I provide objective advice based on empirical numbers inclusive of costs and satisfaction surveys.
Significantly, I do not charge a fee for my service. You are charged no more for acquiring a product through me than if you went in the front door of the insurance company whose product you elected and acquired it directly from them!
Please allow me to assist you in lowering the cost of your Medicare-related insurance. I look forward to working with you!
By D. Kenton Henry Editor, Agent, Broker HealthandMedicareInsurance.com 11 September 2024
Welcome, fellow boomers and others blessed to have lived long enough to find yourself here. I believe you recognize that the information in my blog posts can contribute to this leg of our journey being the longest and most rewarding. I’m right here with you and doing my best to make it so for all of us. Coming changes in 2025 Medicare plans are significant, so please read this and feel free to take notes. They could impact you and probably will.
We will begin with what your Medicare Part B premium to Medicare for Out-Patient Care will go to: For those earning less than $105,000 your premium will go to $185.00 (up from $174.70) For those in the highest income bracket, earning greater than $500,000 your premium will go to $628.90 (from $594.00) For every income block in between, couples filing jointly, and what Part D premiums to Medicare will go to, please click on this link and scroll down: https://www.irmaacertifiedplanner.com/2025-irmaa-brackets/
An Annual Notice of Change (AOC) from your Medicare Part D prescription drug plan or a private insurer’s Medicare Advantage plan is due you. It will arrive in the United States mail and, per Medicare rules, by September 30th. So, like the pretty woman in the image above, open it and read it. It outlines how much your premiums, deductibles, and co-pays will differ in the coming year. Will your drugs be covered, and will your current drug plan even be available? We don’t yet know. Mutual of Omaha notified agents and brokers that it is withdrawing altogether from the Part Drug plan market beginning January 1. If you are currently with them or have any other plan that is exiting the marketplace, follow the instructions in the next paragraph.
According to eHealth, a mere 36% of those surveyed claim the AOC to be “readily understandable.” The author of the attached article recommends you spend at least 30 minutes reviewing it. However, if you finish this article, you can cut that time considerably. If you have finished all and still feel you are among the remaining (up to) 64%—please call me @ 281-367-6565.
This article is a follow-up to my last blog post on September 3rd. “MAJOR CHANGES IN MEDICARE PART D DRUG PLANS ARE COMING OUR WAY (what we know. and one thing we don’t know).” To read it, please click on this link. (if necessary, copy and paste it in your browser’s URLbox and hit enter):
Well, now we know more of the potential compromises mentioned or alluded to in that article. All of these are covered in detail in Feature Article 1 below.
The changes addressed here are largely because of the new $2,000 per year limit on Medicare Part D drug costs in 2025 (versus $8,000, plus 5% thereafter, in 2024). That leaves Medicare Part D insurance companies looking for ways to compensate for the additional costs shifting from you to them. Come January, you will meet a new deductible of up to $590 (from $545) for applicable drugs. Typically, your plan will apply this to brand-name drugs and not Tier 1 or Tier 2 generics.
Beyond that, the Gap, commonly referred to as the “donut hole” (in which you were previously responsible for 25% of your drug costs), has been eliminated entirely. You will have entered the “Initial Coverage” phase in which your elected drug plan will pay 65% of your applicable drug costs, and you will pay 25%. The Manufacturer (pharmaceutical company) will discount the remaining 10%. When you hit your maximum Out-of-Pocket (OOP) threshold of $2,000, you enter “Catastrophic Coverage”. At that point, your plan will pay 60%. Reinsurance (CMS, the Center for Medicare Services, i.e., the government) will pay 20%, and the Manufacturer will pay the remaining 20%. You will pay $0.
This, of course, sounds very well and good! And for those utilizing large quantities of drugs, or expensive drugs, this will indeed be of great benefit. But in what ways may the drug plans “compensate” for the additional costs they will bear? Much of such was referenced or alluded to above. However, please permit me to drill down on potential measures drug plans may take to offset their increased share of your drug cost. *(I am a Medicare Insurance product broker and not a C.P.A. As such, I will not address the impact on the taxpayer of their increased share of Medicare drug costs in this forum. wink. wink 😉
The drill down:
In addition to the higher deductible, higher premiums may be in store. But it could have been a lot worse. CMS did health insurance companies a favor with a “premium-stabilization” plan. In 2025, they will give them a subsidy in exchange for not “slapping members with exorbitant premium hikes. So, “what might have been a 40%, 50%, or higher premium increase may only be as high as 25%. Either way, it will be a sticker shock when some see how their premiums changed.” *(a paraphrase a quote in Feature Article 1)
The Kaiser Family Foundation says the average cost of a stand-alone Part D drug plan is $43. I have seen previews of premiums which will be $0, but others, have risen. In addition to your premium, co-pays for your drugs could go substantially higher. If your drug plan is obligated to charge you less for (or cover more of) a particular drug, are they simply going to charge you more for others?
And what about “Value Added Benefits” (VAB) available in some Medicare Advantage Plans? These include vision, hearing, and dental services. Other examples include acupuncture, bathroom safety devices, and wigs for hair loss. And what about your gym membership? Embedded dental insurance has been dramatically cut back or removed completely.
VAB are not covered by Original Medicare. Medicare Advantage has been able (often along with a $0 premium) to offer these things as an additional incentive to encourage enrollment in their plans. However, because you left Original Medicare and “assigned” the administration of your benefits and claims to the Advantage company when you enrolled, your plan can choose to provide these ancillary benefits that Original Medicare does not. Or they can choose to cover them no longer. This discretion is on their part because the provision of VAB benefits is not codified in law or per CMS regulation. Resultingly, they are not guaranteed. They are optional benefits that the plans have the right to withdraw at any time. I hope you can continue to “workout” at the gym, at your plan’s expense, in 2025 and beyond. But be prepared to purchase a home gym kit if you learn your membership is downgraded or your Advantage plan disappears entirely.
With no obligation, please feel free to contact me for clarification of these relevant issues and additional guidance in navigating the Medicare system and the changes referred to here. I’m in Medicare with you. I am a “Boomer” who has spent the better part of his life in the medical insurance market. For years, I have assisted individuals, families, and businesses in identifying and enrolling in health insurance plans that came as close as I could get them to fully meeting their medical insurance wants and needs.
To sum things up, I work for my clients. I work for you. Not the insurance company. I study, take their tests, and “certify” to represent their products each calendar year. I just completed certifying with approximately 14 companies in preparation for marketing their products in 2025. They do not pay to renew my licenses or my Errors and Omissions insurance, nor do they cover my office insurance and expenses. Neither they, nor anyone else, pay me wages or a salary. And that is great! I knew and understood those terms when I went out on my own. And that is precisely why I did it. I did not want to be beholden to the insurance company.
After becoming independent, the list of companies I was contracted with grew to over 40 during the 1990s. That number has changed as many of those companies went the way of the steam engine with “Obamacare” and all the red tape and regulations that come with it and remaining in the industry. But I persist. I remain positioned to provide you with virtually every available Medicare and health insurance product in your region.
In conclusion:
If you’re reading this, chances are you remember Jim Rockford (a private detective, portrayed by the actor the late James Garner) in his TV show, The Rockford Files (you can hear the opening music now, can’t you?). In the prelude to each episode, you see his cassette recording answering machine and hear the message, “This is Jim Rockford. At the tone, leave a message …”.
Should you get mine, please do the same. Or you may simply text me.
FORTUNE Richard Eisenberg Updated Mon, Aug 26, 2024
Why this year’s Medicare Annual Notice of Change will be vital reading for beneficiaries
In this article:
If you’re on Medicare, you’ll be getting one or two Annual Notice of Change letters in your mail or email this September about your 2025 coverage and costs. You may be tempted to ignore what looks like junk, as nearly a third of recipients do, according to an eHealth survey.
Don’t.
“So often, a person who is quite happy with their plan and doesn’t bother to look at their Annual Notice of Change then gets a nasty surprise in January” when the plan’s new costs and coverage kick in, says Danielle Roberts, author of 10 Costly Medicare Mistakes You Can’t Afford to Make and founding partner of Boomer Benefits, which sells Medicare policies.
What is an Annual Notice of Change?
An Annual Notice of Change from your Medicare Part D prescription drug plan or a private insurer’s Medicare Advantage plan lays out how much your premiums, deductibles, and co-pays will differ in the year ahead and whether the plan will even be offered. (Medigap plans don’t send these notices because they don’t change much year to year.)
An Annual Notice of Change from your Part D plan also says whether your prescriptions will be covered and, if so, how much you’ll pay. A Medicare Advantage Notice of Change will tell you if your doctors and hospitals will remain in the plan’s network.
While this information is always essential to make smart choices during Medicare’s eight-week open enrollment period (Oct. 15 – Dec. 7), experts say reading your Annual Notice of Change is especially important in 2024.
“There is an excellent chance that something is changing on your plan,” says Roberts. “This year, more than ever, we can expect big changes in the plans.”
Surprising effect of the $2,000 prescription drug cap
That’s largely due to a major Medicare change coming in 2025: the new $2,000 cap on out-of-pocket costs for prescriptions covered by a Part D plan.
Since Part D health insurers will be on the hook for more prescription costs due to the cap, they’ll be looking for ways to compensate.
That could mean higher premiums (currently $43 a month for stand-alone plans, on average, according to KFF), deductibles, and co-pays—possibly substantially higher than in 2024.
“I have been very, very concerned about what the $2,000 cap was going to do to Part D premiums,” says Roberts.
The prescription drug change in 2025 could also lead to your Part D plan no longer covering certain medications you take or raising prices of ones it will.
Medicare Advantage plans—some facing profit squeezes currently—often include Part D coverage, so they may respond to the $2,000 cap by trimming or eliminating benefits to keep their popular $0 premiums intact, experts expect.
As a result, your Medicare Advantage benefits that original Medicare can’t offer—such as dental, vision, hearing, and gym memberships—could be less attractive than in 2024, or possibly gone entirely.
“It really will be important to understand what’s changing in the coming year in my current plan and does the plan still fit?” says eHealth CEO Fran Soistman. “Does it still provide the value that it did when I elected to go in it in the first place?”
Reading and understanding the Notice of Change
Your Annual Notice of Change will tell you—if you can understand it.
Only 36% of Medicare beneficiaries surveyed by eHealth said their Annual Notice of Change letter is “readily understandable.”
Figure on spending about 30 minutes closely reading your Annual Notice of Change to see exactly what will be different in 2025 and whether you’ll want to switch plans or coverage next year as a result.
During open enrollment, you can switch from your current Part D plan to another, from your Medicare Advantage plan to another, from Medicare Advantage to original Medicare as well as from original Medicare to a Medicare Advantage plan.
But don’t feel compelled to switch plans just because your Annual Notice of Change says your premium will go up a little or a benefit will be trimmed slightly.
“If there’s a modest benefit decrease or premium increase, but they’re satisfied with what the carrier is providing, people shouldn’t make a change,” Soistman says.
However, he added, if a medication you take will no longer be covered or your physician or hospital won’t be in network, that’s an important change that may persuade you to switch coverage.
The Medicare Plan Finder on Medicare’s site will let you compare Part D and Medicare Advantage plans for 2025.
And, as Philip Moeller writes in the forthcoming revised edition of his book, Get What’s Yours for Medicare, if your Medicare Advantage plan won’t include your favorite doctor or hospital in its network in the year ahead, it’s legally obligated to work with you to identify other physicians or hospitals in its network that you’d like.
A new program to help avoid big premium hikes
To help prevent drastic Part D premium increases, the government’s Centers for Medicare and Medicaid Services recently threw a bone to health insurers with a premium-stabilization plan.
Medicare will provide a special subsidy to those insurers for 2025 in exchange for avoiding slapping members with exorbitant premium hikes.
“It should take what might have been a 40%, 50%, or higher premium increase down to probably 25%,” says Soistman. “It’s still going to be a bit of sticker shock when some people see how their premiums changed.”
Roberts says, “I’m still somewhat concerned about premiums, but I feel a little better after the stabilization program announcement.”
Getting help if your Medicare plan will change
After reading your Annual Notice of Change, you may want to get help deciding on the right Medicare plans for 2025 and to understand the implications of coming changes to your plans.
You can ask a Medicare broker or agent for assistance; there’s a directory at the National Association of Benefits and Insurance Professionals site. The sooner you do, the better, since agents and brokers will be swamped near the end of open enrollment.
“At Boomer Benefits, we have to stop taking new requests after Thanksgiving,” says Roberts.
If one of your prescriptions won’t be covered by your Part D plan in 2025, call your doctor to see if another covered medication would be okay or if you should find a new plan that includes it, Roberts advises.
For information about Part D and Medicare Advantage plans without purchase recommendations, try yourState Health Insurance Assistance Program or visit Medicare’s site or call Medicare’s toll-free number.
More time for open enrollment?
Soistman believes all the changes coming to Part D and Medicare Advantage plans for 2025 will push back the arrival of the Annual Notice of Change documents to the last two weeks of September.
If so, this will give people with the plans less time than normal to read the notices before open enrollment.
The eHealth agency has asked the Centers for Medicare and Medicaid Services to extend open enrollment by about five days to give beneficiaries, insurers, and Medicare brokers more time. Boomer Benefits favors the extension, too.
So far, the government hasn’t responded to eHealth’s proposal.
Could the 2025 open enrollment become Medicare’s equivalent of the Department of Education’s FAFSA financial-aid form fiasco of chaos and confusion?
“I don’t think it will be quite as drastic. I think it is going to be a year of change, though,” says Soistman. “And change is hard for people.” ********* Please follow me follow D. Kenton Henry @Https://HealthandMedicareInsurance.com
In addition to owning the first insurance agency in The Woodlands, Texas, and most of the United States, to create a website (Allplaninsurance.com) in 1995, I was among the first to offer Medicare Advantage and Medicare Part D Prescription Drug Plans (MAPD plans) to Medicare recipients following their creation by the Medicare Modernization Act of 2003. Congress created them to provide a lower premium insurance product as an alternative to Medicare Supplement policies, which has been the standard insurance product to serve as secondary insurance covering medical expenses not paid by Original Medicare. And—with premiums as low as $0—they have certainly done that. Contrary to what may be the common perception of the public, every good agent has a little bit of social worker in them and wants to think they have really helped a person and improved their situation. As an agent (before the advent of Medicare Advantage plans), I would sit across coffee tables from prospective clients living in single-wide trailers and subsisting on social security income alone. I would watch tears come in their eyes as they told me they simply did not have another dime to spend on insurance, leaving me to drive off and them no better off for my visit. So, from that standpoint, they have been a source of great relief for me as well as my clients.
In addition to lower premiums, MAPD plans offer other advantages. Specifically, they are:
The convenience of combining medical coverage with prescription drug coverage under the cover of one policy. Effectively eliminating the necessity of paying a second premium for the latter.
The provision of “extra” benefits such as dental, vision, and hearing benefits
“Guaranteed Approval” during the Annual Election Period October 15th and December 7th and the option of changing your plan each January 1 as the plans and your needs change.
Premiums are not age-based and do not increase due to age as one gets older.
Seniors are inundated with seemingly endless television and radio commercials promoting Medicare Advantage plans ad infinitum. But while they drive home the advantages mentioned above, they virtually never mention the disadvantages or compromises that come with electing them over a Medicare Supplement policy. There are many reasons for this, but this is the one most relevant to you:
Medicare, like Social Security, is hemorrhaging dollars. Please don’t take it from me. Google it. Financial prognosticators project it will enter a default position by 2031. Medicare trustees say the Part A (Hospital and Skilled Nursing coverage) program will begin running deficits again in 2025, drawing down the trust fund until it depletes in 2031. After that date, the program will not bring in enough money to fully pay out Part A benefits. *(See Feature Article 2 below.)
Now, we all know our government will just tax us more, and our treasury will print enough more money to keep things going. But the bottom line is that Medicare is seeking any way of saving money and limiting its losses. The easiest way to do this is to lower its share of claims. The easiest way to lower its share of claims is to increase enrollment in Medicare Advantage plans relative to Medicare Supplement. And why is that?
Opposed to Supplement, Advantage plans . . .
1)Force the insured member to share in more expenses as the medical claims come in.
2) They influence the member to utilize a limited network of providers or pay a higher cost for not.
3) They subject the member to preauthorization of medical tests and procedures, often resulting in significant delays in treatment. *(See Feature Article 1, 2 and 3 below.)
4)Advantage plans that combine prescription drug coverage with medical coverage (MAPD plans) lock the member into a drug plan that may not provide the lowest total cost for drugs or cover them in the first place.
5)Once a member foregoes Medicare Supplement in favor of an Advantage plan beyond 12 months, they may find themselves locked into an Advantage plan—and out of a Medicare Supplement plan—due to preexisting medical conditions for the remainder of their lives.
One reason for these differences in how things are covered is that when a person elects Medicare Advantage, their benefits and administration are assigned to the insurance plan and company issuing it and away from Medicare. Medicare no longer plays a role in your coverage. As Advantage plans are allocated a limited amount of dollars per plan member, the companies will seek to limit expenditures. Recent adjustments in budgets for the plans will result in more of this. *(See Feature Articles below.)
And now, we learn that in addition to the increasing number of denials for tests and procedures by Advantage plans, Medicare is allocating less money to cover benefits, resulting in an actual reduction in benefits in 2025. Depending on the Medicare Supplement plan option (A-N) one elects, these compromises seldom, if ever, apply to their coverage.
All this being said, we get back to affordability and the reality that Medicare Supplement premiums will increase due to the member’s age as the member ages. This could bring me back to that coffee table where clients simply can no longer afford their premiums. While their costs for treatment may increase, some will need a lower premium to afford some type of coverage. Those people should know I offer Medicare Advantage plans from virtually every major carrier in one’s county or region. These include (among others) Aetna, Anthem, AARP Unitedhealthcare, BlueCross BlueShield, Cigna, Kelseycare Advantage, and Wellcare.
Regardless of your situation, I offer whatever product is appropriate and best suited to meet your Medicare-related insurance needs. When you work with me, I will be an advocate on your behalf. I represent you over the insurance company. Yes, I still have a little bit of social work in me.
Please get in touch with me. I am waiting to answer your questions and assist you with your coverage.
Hospitals’ Medicare Advantage problem hits an inflection point
Jakob Emerson – 5 April 2024
The tensions between hospitals and Medicare Advantage plans continue to grow. With the program hitting nearly 34 million enrollees in March, paired with recent policy moves by the federal government, the scene has been set for those relations to worsen.
“The relationship between hospitals and managed care is strained at best right now,” Chip Kahn, president and CEO of the Federation of American Hospitals, told Becker’s. “[Insurers] are finding every way to not pay for the care that Medicare beneficiaries should receive. I don’t know how the issue gets worse — we’re at a critical stage, and I think CMS is sending those signals.”
On April 1, CMS finalized a slight decrease in MA benchmark payments for 2025. The agency has also issued more strict prior authorization rules this year and cracked down on when MA plans must cover inpatient care.
The health insurance industry has said the new rates will “put even more pressure on the benefits and premiums” of MA beneficiaries, a warning that individual insurers have also issued in recent months.
“Payers know that they’re going to have to cut supplemental benefits, and premiums may even have to go up, but I wouldn’t want to be the first one to do it,” Scott Ellsworth, founder and president at Ellsworth Consulting, told Becker’s. Mr. Ellsworth is a former insurance executive, overseeing entire divisions at Centene, Optum and a BCBS plan throughout his career.
“Seniors have seen their benefits get better every year, but now we’re at an inflection point and the free lunch is over,” he said. “There is going to be a sharing of the pain. Providers have disproportionately shared the pain and now you’re seeing many of them say ‘enough is enough, we’re out.'”
In 2023, Becker’sreported on at least 15 hospitals and health systems nationwide that dropped some or all of their Medicare Advantage contracts. Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.
“It’s become a game of delay, deny and not pay,” Chris Van Gorder, president and CEO of San Diego-based Scripps Health, told Becker’s in September. “Providers are going to have to get out of full-risk capitation because it just doesn’t work — we’re the bottom of the food chain, and the food chain is not being fed.”
Scripps terminated MA contracts in January for its integrated medical groups, citing an annual loss of $75 million on its contracts with insurers.
In March, Bristol (Conn.) Health announced it was eliminating 60 positions, 21 of which are occupied and will result in layoffs. Its CEO, Kurt Barwis, laid blame on Medicare Advantage saying, “All the nice-to-haves are being taken out by the lack of insurance payment and the lack of reimbursement.”
In January, the Healthcare Financial Management Association released a survey of 135 health system CFOs, which found that 16% of systems are planning to stop accepting one or more MA plans in the next two years. Another 45% said they are considering the same but have not made a final decision. The report also found that 62% of CFOs believe collecting from MA is “significantly more difficult” than it was two years ago.
“Medicare Advantage net reimbursement right now is terrible for hospitals — our clients average about 85 cents on the dollar, and it’s only getting worse,” Mr. Ellsworth said. “MA is a race to the bottom, and I would argue that we’ve hit that bottom. Payers are going to struggle with this too, but no one wants to be the first to blink.”
Medicare Advantage denials increased almost 56% for the average hospital from January 2022 to July 2023, according to data from a joint American Hospital Association and Syntellis report. The denials and inconsistent reimbursement led to a 28% drop in hospital cash reserves.
Both Mr. Ellsworth and Mr. Kahn noted that it isn’t feasible for most health systems to completely walk away from Medicare Advantage, given that it now makes up more than half of the Medicare population. Instead, many hospitals are paring down contracts and looking for payer partners that align best with their financial objectives. Some systems are even exploring launching their own MA plan built in tandem with one insurer. Others have partnered with grocers or other health systems.
“We will ultimately pick a couple of partners going forward, and I think a lot of health systems are going to do this,” Will Bryant, CFO of Chapel Hill, N.C.-based UNC Health, told Becker’s in November. “They’re going to be the partners who act like partners and not who deny care in order to bolster their billions of dollars of quarterly earnings.”
Sachin Jain, MD, CEO of SCAN Group — one of the nation’s largest nonprofit Medicare Advantage companies — cautioned hospitals that dropping MA plans is a short-term trend that is “going to backfire in a big way for these large health systems.”
“You’re a nonprofit system saying you’re no longer going to accept the insurance that low-income people actually have,” he said. “We’ll see how that works out for you.”
Dr. Jain said any public policy program is going to create unintended consequences, adding, “What I would say to anybody who’s critical about the program is that you’re right, but let’s fix that.”
Former CMS Administrator Don Berwick, MD, toldBecker’s in February that the battle between hospitals and Medicare Advantage is a “manifestation of an underlying broken system in which everyone that gives care wants to give more, and everyone that pays for care wants to pay less.”
“To me, the untold story yet is about the physicians and nurses who don’t feel directly tied to ongoing Medicare Advantage trends, but they are certainly immersed in a changing financial landscape,” Dr. Berwick said. “As venture capital, private equity and ownership of healthcare by private interests increases, it changes their worlds, what it’s like to practice, their feelings about themselves, and the degrees of freedom they have to care for their patients. That chicken is going to come home to roost.”
Despite the tensions with hospitals, the MA program has bipartisan support in Congress and a 95% quality satisfaction rating among enrolled members in 2023. There are about 4,000 MA plans being offered this year nationwide, and MA members spend an average of $2,434 less on out-of-pocket costs and premiums per year compared to traditional Medicare enrollees.
“Medicare Advantage is very important, especially for low-income seniors,” Mr. Ellsworth said. “Hospitals need to acknowledge the reimbursement problem and proactively address their relationships [with payers] head-on.”
The fund covering Medicare‘s hospital-insurance benefits is now projected to run out of money in 2031, according to a new report by Medicare trustees.
This new insolvency date gives policymakers three more years than previously estimated to address impending financial setbacks that are facing the social safety net program, which provides health care benefits to tens of millions of Americans.
The ultimate insolvency date will likely change, the trustees say, due to difficulties in accurately projecting program expenditures. That leaves the exact timeline unclear for lawmakers to hash out a plan to mend Medicare’s finances, which could require an increase in taxes, a cut in benefits or a combination of both to keep benefits paying out in full.
What the report says
In a report released Friday, Medicare’s Board of Trustees provided the latest snapshot of the program’s finances. On the whole, Medicare is on sounder financial footing than indicated in last year’s trustee report, though financial shortfalls still loom.
Medicare hospital insurance benefits, aka Medicare Part A, are expected to fully pay out until 2031, a three-year improvement from the last trustee report.
Medicare Part B and Part D do not face insolvency, the report said, because they are funded separately — partially by premiums and general revenue from the U.S. Department of the Treasury. These benefits help cover typical health-insurance and prescription-drug expenses, respectively.
By contrast, Medicare Part A, which generally covers inpatient hospital care, skilled-nursing facility care, home-health care and hospice care, uses a separate reserve that’s funded by a 2.9% Medicare payroll tax. This is the trust fund at risk of insolvency.
In 2022, Medicare’s balance sheet looked better than previous years, the report shows. The hospital-insurance trust fund had a surplus of $54 billion, and Medicare overall brought in about $84 billion more than it paid out.
Nearly every year since 2008, the Part A trust fund has run a deficit, the report notes, with the exception of 2021 and 2022. The fund ran a steep shortfall in 2020 of more than $60 billion, largely because Medicare began making loans to health care providers to increase their cash flow as they grappled with the COVID-19 crisis. Then in 2021, providers began to repay Medicare, leading to the current surpluses.
The surpluses aren’t expected to last, however. Medicare trustees say the Part A program will begin running deficits again in 2025, drawing down the trust fund until it depletes in 2031. After that date, the program would not be bringing in enough money to fully pay out Part A benefits.
Key context
Medicare covered 65 million Americans last year. The vast majority of those people, about 88%, were 65 or older, though the program also provides health coverage to millions of disabled Americans.
Medicare — particularly Part A — has long faced financial issues. The nation’s changing demographic makeup is a big reason why. Because Medicare Part A relies on payroll taxes, it is more susceptible to insolvency when a growing share of the population is older, ultimately changing the worker-to-beneficiary ratio. In other words: less money coming in and more money going out. These demographic changes are also leading to insolvency issues for Social Security.
Compared to Social Security, projections for Medicare’s insolvency are less certain because it’s difficult for the trustees to accurately predict future health care expenditures. This can lead to some larger swings in the predicted insolvency date. By contrast to the trustee’s estimate, the Congressional Budget Office estimates the fund will remain solvent until 2033.
According to the nonprofit Center on Budget and Policy Priorities (CBPP), if Medicare Part A went insolvent, it would still be able to pay out almost all benefits. This leads some experts to call for tempered reactions to the newly projected insolvency date.
“Medicare does not face a financing ‘crisis’ and is not ‘bankrupt,’ as some critics charge,” tweeted Paul Van de Water, a senior fellow at the CBPP who specializes in Medicare. “Even if policymakers took no further action … tax revenues would still cover 89 percent of scheduled benefits” after the insolvency date.
Avoiding Medicare insolvency
Policymakers have several options to avoid impending insolvency headed for Medicare Part A. The trustees note two options that could immediately solve the issue:
The standard 2.9% payroll tax could be immediately raised to 3.52%, which would be enough to plug any financial shortfalls over the next 75 years.
In lieu of a tax increase, expenditures (read: benefits) would need to be reduced immediately by 13%, the trustees say.
Realistically, a combination of the two could work and the benefits cuts and/or tax increases could be implemented over a longer period of time.
Additionally, President Joe Biden released a plan last month to push the insolvency date back by 25 years.
The central change under the president’s plan would be a Medicare payroll tax increase on Americans earning more than $400,000.
Currently, earnings over $200,000 for individuals are taxed at 3.8% (while income under that amount is taxed at the standard 2.9% rate). These rates are split 50-50 between employees and employers.
The president’s plan introduces a new tier for income over $400,000, a tax rate of 5%.
The president’s Medicare proposal — part of a larger 2024 budget plan — is not expected to make it through the Republican-controlled House of Representatives.
Dozens of health systems ask CMS to crack down on Medicare Advantage Denials
Becker’s Hospital CFO Report
Rylee Wilson – Friday, March 22nd, 2024
Over 100 hospitals, health systems and providers signed on to a call for CMS to do more on Medicare Advantage denials.
Members of Premier, a healthcare services company, penned a letter to CMS administrator Chiquita Brooks-LaSure on March 21, requesting CMS collect more data on claims denied by Medicare Advantage plans and take enforcement action against plans not following the coverage rules set out by Medicare.
A survey of Premier’s member hospitals and health systems found 15% of claims to private payers are denied. A slightly higher portion of Medicare Advantage claims, 15.7%, are denied, according to the survey.
On average, hospitals spend $47.77 in administrative costs to appeal a denied Medicare Advantage claim, according to the Premier survey.
In the letter, the health systems asked CMS to monitor how much MA plans spent on direct patient care to address “potentially dire impacts on Medicare beneficiaries and providers.”
“It is imperative that CMS leverage its full authority to ensure that MA plans’ medical loss ratio (MLR) requirements for revenue used for patient care are satisfied in alignment with the benefits to which Medicare beneficiaries are entitled,” the providers wrote.
Dozens of health systems signed the letter, including CommonSpirit Health, Ascension, Advocate Health, AdventHealth and Providence.
The providers also asked CMS to bar MA plans from delaying or denying claims approved through electronic prior authorization and weight patient experience more heavily in its ratings of MA plans.
A growing number of hospital executives have criticized Medicare Advantage, often citing excessive prior authorization hurdles and delayed payments. A handful of systems have moved to drop the program entirely.
FEATURE ARTICLE 3
Nearly 15% of claims submitted to private payers are initially denied
Nearly 15% of medical claims submitted to private payers for reimbursement are initially denied, according to new survey data released Thursday.
Denied claims are more prevalent for high-cost treatments, with the average rejected charges at $14,000 and up, Premier Inc. reported. Medicare Advantage and other private payers eventually overturned more than half (54%) of denials, with the claims paid, but only after “multiple, costly rounds of provider appeals.”
The findings are from a national survey of hospitals, health systems and post-acute providers, conducted by the Charlotte-based healthcare improvement company.
“To address these potentially dire impacts on Medicare beneficiaries and providers, we urge CMS to stringently monitor MA plans’ reporting of expenditures on direct patient care,” Premier and 118 member organizations wrote in a March 21 letter to the head of the Centers for Medicare & Medicaid Services. “It is imperative that CMS leverage its full authority to ensure that MA plans’ medical loss ratio requirements for revenue used for patient care are satisfied in alignment with the benefits to which Medicare beneficiaries are entitled.”
Premier partnered with member hospitals to conduct the survey from October to December 2023. A total of 516 hospitals across 36 states, representing 52,123 acute care beds responded. Answers were based on claims submitted to private payers in 2022.
On average, hospitals and other providers incurred a cost of $43.84 per claim to fight denials. With insurers processing about 3 billion claims per year, this equates to $19.7 billion per year in expenses for these reviews. An average of about 3% of all claims denied included those that were already preapproved via prior authorization, Premier noted.
The continued burden from these delays and denials has impacted hospital finances. During the past year, average days of cash on hand at hospitals declined by 44 days or 17%. Meanwhile, days of cash on hand increased among insurers such as UnitedHealth Group (up 25.5% on average since 2019) and Cigna (24.4% on average).
The letter writers—who included numerous large health systems and other provider organizations—want CMS to take enforcement action against MA plans that “fail to abide by the coverage rules of Medicare.”
“Additionally, we note that CMS has moved away from holding MA plans accountable for [Consumer Assessment of Healthcare Providers and Systems] and other patient experience measures in recent rulemaking by reducing the weighting of patient experience and access measures in the Star Ratings program. We recommend that CMS return to its past policy of weighting patient experience and access measures more heavily in the MA Star Ratings methodology, empowering beneficiaries to hold their health plans financially accountable,” the letter stated.
The analysis does not specifically mention radiology services, but it mirrors ongoing problems imaging providers have had with prior authorization and the No Surprises Act (links to previous coverage below).
Ever since the passage of the Patient Protection and Affordable Care Act (ACA), commonly referred to as “Obamacare”, in 2010, the Department of Health and Human Services has dictated when and under what circumstances an individual and family can apply for and obtain health insurance. This period is known as the Open Enrollment Period, and it is upon us. Each year, between November 1st and December 15th, U.S. citizens and their families may apply for and obtain health insurance effective January 1st of the coming calendar year. From then until January 15th, they may apply for coverage effective February 1st. Beyond that date, they are locked out of any health insurance plan they were not enrolled in when the year ended. Only special circumstances such as losing “creditable” coverage through no fault of their own, moving out of a plan’s area, birth of a child, or death of a covered family member allow them to apply for coverage beyond the Open Enrollment Period. And only if they were insured when the special circumstance occurred and no more than 60 days have passed. Creditable coverage meets all the mandates of the Affordable Care Act, such as guaranteed coverage for pre-existing health conditions, including pregnancy and mental health disorders, along with no out-of-pocket for preventative medicine. All coverage is guaranteed so long as the above requirements are met.
If affordability of health insurance is an issue, Premium Tax Credits (subsidies) are available from the Department of Health and Human Services (DHS) to people or families whose income falls below a certain threshold.
WHO IS ELIGIBLE FOR THE PREMIUM TAX CREDIT?
To receive the premium tax credit for coverage starting in 2024, a Marketplace enrollee must meet the following criteria:
· Have a household income at least equal to the Federal Poverty Level (FPL), which for the 2024 benefit year will be determined based on 2023 poverty guidelines
· Can not have access to affordable coverage through an employer (including a family member’s employer)
· Can not be eligible for coverage through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP)
· Have U.S. citizenship or proof of legal residency (Lawfully present immigrants whose household income is below 100 percent FPL can also be eligible for tax subsidies through the Marketplace if they meet all other eligibility requirements)
· If married, must file taxes jointly
Income: For the purposes of the premium tax credit, household income is defined as the Modified Adjusted Gross Income (MAGI) of the taxpayer, spouse, and dependents. The MAGI calculation includes income sources such as wages, salary, foreign income, interest, dividends, and Social Security.
Your tax credit is based on the household income estimate you put on your Marketplace application.
Income between 100% and 400% FPL: If your income is in this range (in all states) you qualify for premium tax credits that lower your monthly premium for a Marketplace health insurance plan. The lower your income is as a percent of the FPL—the higher your subsidy.
The easiest way to determine whether and for how much you qualify is to call me. You will estimate your 2024 household’s adjusted gross income and my subsidy calculator will tell us (based on the number of people in your household) how much your subsidy will be. If we give the DHS the same information you give me, my calculations are usually accurate to within $3.00 of what you will actually receive. We then apply that subsidy against the premium of the plan you wish to acquire and arrive at your net premium.
The number of people who qualify for subsidies continues to grow. For details on this, please refer to this chart and my feature article 2 below.
As to how much retail (gross) premiums are expected to grow from 2023 to 2024, estimates put the national average at 6%. (For the details on this, please refer to Feature Article 1 below.) Given the rate of core and real inflation, this should not come as a surprise. Acquisition of a subsidy will certainly offset ever-increasing premiums.
As always, the greatest challenge to the consumer and their agent/broker is affordability or obtaining the desired benefits. Instead, it is finding their doctors in the networks of a health plan. In 2024, as it was this year, there will be over 100 different plans available from six to eight different companies, depending on where one resides. Dealing with this myriad of options is where my three decades specializing in health insurance in the Houston area is invaluable. I know which hospitals are in which plan networks, and my provider search tools scan all plans without you having to go from company to company for results. Because I represent every company doing business in Texas, you can acquire information on all of them with one call to me.
Again, Open Enrollment begins November 1st, and for coverage during the entirety of 2024, it ends December 15th. Unlike going to the marketplace (Healthcare.gov) you will get me each time you call my local office with questions and for assistance and service–as opposed to an 800 number where you will get a different individual each time you call. My service is much more personalized and detailed than that of an hourly worker at the end of that toll-free number. If I don’t provide you with the level of service you deserve, I don’t have a client. And if I don’t have a client, I don’t earn a living. And it costs you no more to go through me than directly to the company whose policy you ultimately acquire.
I look forward to working with you and providing the best of service. Please call me.
D. Kenton Henry
Office: 281-367-6565 Text me 24/7 @ 713-907-7984 Email: Allplanhealthinsurance.com@gmail.com
This analysis of insurers’ preliminary rate filings shows that ACA Marketplace insurers are requesting a median premium increase of 6% for 2024. Insurers cite price increases for medical care and prescription drugs as a key driver of premium growth in 2024, In addition to inflation’s impact on medical costs, insurers point to growth in the utilization of health care, which fell in 2020 but has since returned to more normal levels.
Insurers’ proposed rate changes – most of which fall between 2% and 10% – may change during the review process. Although most Marketplace enrollees receive subsidies and are not expected to face these added costs, premium increases could result in higher federal spending on subsidies.
The analysis can be found on the Peterson-KFF Health System Tracker, an information hub dedicated to monitoring and assessing the performance of the U.S. health system.
Enhanced Marketplace subsidies have continued to drive up enrollment in the individual market, and the loss of Medicaid coverage by millions of people could contribute to this trend, according to a new KFF analysis. Meanwhile, enrollment in non-ACA-compliant plans is at a record low.
As of early 2023, an estimated 18.2 million people have individual market coverage, the highest since 2016. Individual market enrollment grew by about 29% between early 2020 and early 2023 — a result of enhanced subsidies introduced by the Inflation Reduction Act, increased outreach, and an extended enrollment period.
This enrollment growth could continue in 2023 as states resume Medicaid disenrollments amid the unwinding of the continuous enrollment provision. Some of the people losing Medicaid coverage may be eligible for subsidies on the ACA Marketplaces.
Due in part to the enhanced subsidies, about 4 in 5 individual market enrollees have subsidized coverage — the highest share since the ACA was implemented.
The number of people in non-compliant plans has fallen each year and could decrease further due to the Biden Administration’s proposed rule that would reverse the expansion of short-term plans. An estimated 1.2 million people were in non-ACA-compliant plans in mid-2022, compared to 5.7 million in mid-2015. These short-term plans often do not include certain benefits or coverage for pre-existing conditions and can impose a dollar limit on insurance coverage.
If unsubsidized premiums rise in 2024 due to higher health care prices and utilization, enhanced subsidies could shield most individual market enrollees from increases in their monthly payments.
*(IF YOU WATCH TV, YOU HAVE SEEN THE HIGH-PROFILE COMMERCIALS FOR THESE DRUGS. IF YOU’VE BEEN PRESCRIBED ANY OF THEM, YOU KNOW HOW HIGH THE COST CAN BE. FOR MANY, PROHIBITIVELY SO. FOR DETAILS ON HOW RELIEF MAY BE COMING, PLEASE READ THE FEATURE ARTICLE AT THE BOTTOM OF MY OWN JUST BELOW.)
IT’S ALMOST TIME TO RE-SHOP YOUR MEDICARE ADVANTAGE AND DRUG PLAN FOR 2024
By D. Kenton Henry, editor, broker, agent
6 September 2023
With the Labor Day holiday behind us, summer is virtually over. And, the coming of fall brings Medicare’s Annual Election Period (AEP). For those new to Medicare, and as a reminder to those recipients who are not, this period runs from each fall. Beginning October 1, we can preview the new Medicare Advantage and Part D drug plans to determine which, if any, is superior to our current plan, and from October 15 to December 7, enroll in it. Our new plan selection will go into effect on January 1. Of course, if your current plan remains your best option, you need not do a thing, and it will roll right over into the new year. Simply continue to pay your premium.
But how will you know if a superior Medicare Advantage or Part D Drug plan exists for you in the coming year? First, your current drug plan owes you an Annual Notice Of Change (AOC). It must come in your U.S. mail by September 30. If they do not send it, they violate Medicare regulations. So be sure to watch your mail closely. I know we are all being inundated with advertisements this time of year in a frenzied attempt to garner our business, but sort through it long enough to find your AOC!
Then, please review it carefully. While it may remain virtually the same in the coming year, something inevitably changes. Be it the premium, the copays, the out-of-pocket maximum, the doctors and hospitals, or the drugs. Once you are aware of any changes, you must compare your plan to all the new plans in the new year. Or – you may simply call me. I have been in the medical insurance industry since 1986, specializing in Medicare-related insurance and Under Age 65 Individual and Family health insurance. As I and my clientele have grown older, I have focused even more on assisting Medicare recipients.
Researching and identifying a plan that is in my client’s best interest and making my recommendation is an annual service I provide them. While some can do it independently, my familiarity with all the options and the mechanisms for exploring and enrolling in them is so great that many find it easier to sit back and let me do the research for them. Then, if they agree with my recommendation, I am happy to enroll them, making the process go as quickly and smoothly as possible. There is no obligation to take my recommendation, nor is there any fee charged by me whether one does or doesn’t. Should you enroll through me, you will be charged no more for the product than if you walked through the front door and acquired it directly from the insurance company offering it. So I believe you get the benefit of my 37 years of experience in the market at no cost to you. While Medicare requires that I inform you, no one agent can represent every company and plan in the market, I do represent most. I have diligently researched which plans I believe will be most competitive for most people’s purposes and have studied and certified (tested) to be able to insure you with them. And more importantly, I have reviewed all of them relative to your needs before making my recommendation. On the rare occasion I am not appointed (contracted) with a company in your best interest, I will recommend them just the same and encourage you to enroll with them and advise you how to go about that. I do so in the hopes that it will begin a relationship with you and that – next year – I may be appointed with the company with which you wish to enroll.
So, while the leaves don’t fall much around here in October, they do turn brown. And Joe Willy Namath and J.J. Walker will soon be annoying you with their incessant and infernal commercials. Let these things remind you to call me for the answers to your Medicare-related questions and any guidance you would like. Remember, there is no cost to you for such, and, at the very least, you’ll know you are doing everything right and make another friend in the process.
Oh – again! Please read my feature article, which appears directly below this. The current administration is attempting to lower drug costs for Medicare recipients by allowing Medicare to negotiate lower drug prices, for the first time, with pharmaceutical companies. The article identifies 10 of the most expensive drugs they target for lower costs. If you, like me, have been exposed to the never-ending drug commercials accompanying your television programs, you probably can already guess what some of them are. Obviously, advertising works, and the companies must pay for it somehow!
Drugs Up for Medicare Price Cuts Fuel Drugmakers’ Legal Strategy
Ian Lopez: Senior Reporter
Nyah Phengsitthy: Reporter
Drugmakers are poised to change their lawsuits and bring new ones against the Biden administration now that the list of the first 10 drugs subject to Medicare price negotiations is out.
Bristol-Myers Squibb Co., Johnson & Johnson, and other companies with drugs up for negotiation are likely to amend their lawsuits against the price talks under the Inflation Reduction Act to better their chances at taking down the program, legal analysts say.
Amending complaints could bolster the plaintiffs’ chances at overcoming government arguments that they lack standing to sue and allow them to later move for summary judgment or request a preliminary injunction.
Companies like Amgen Inc. and Novo Nordisk that have drugs on the list but haven’t sued yet may do so, or join suits already filed, attorneys say, contributing to a pharmaceutical industry legal strategy geared toward getting the US Supreme Court to intervene.
“Now that the list is announced, we’ll definitely see movement in the lawsuits, because beforehand it was a little more of a theoretical harm,” said Carmel Shachar, a professor at Harvard Law School. “I think we’ll see a big flurry of action when the prices are announced as well, with attempts to hold it up with injunctions and summary judgment.”
Drugmakers and industry groups that sued before the release of Medicare’s list issued statements afterward that they remain steadfast in their position that the price negotiation program is unconstitutional. Eight lawsuits were filed before the list announcement. Another company with a drug on the list, Novartis AG, sued after.
“The IRA’s price control provisions will constrain medical innovation, limit patient access and choice, and negatively impact overall quality of care,” J&J said. “The IRA’s policies put an artificial deadline on innovation, threatening intellectual property protections and shortening the timeframe to deepen our understanding of patients’ unmet medical needs. At the same time, seniors could face bureaucratic barriers to access and potentially higher out of pocket costs even with the IRA’s out-of-pocket cost limits for Part D drugs.”
Attorneys note that some of the lawsuits may be scaled back with the list out, while others are expanded to encompass new claims. Some judges may try and consolidate the litigation, the attorneys say.
They also note that more drugmakers may push courts for a preliminary injunction against the program to buy time while the litigation inches its way to the highest court.
“They’re not going to give this up quietly,” said Yaniv Heled, a professor at Georgia State University College of Law. “You can expect to see lawsuits, and then appeals, and then more lawsuits and then more appeals.”
‘Fight to the Bitter End’
The 10 drugs selected for pricing negotiations are Bristol-Myers and Pfizer Inc.‘s Eliquis, J&J’s Xarelto, Boehringer Ingelheim and Eli Lilly & Co.‘s Jardiance, Merck & Co. Inc.‘s Januvia, AstraZeneca PLC’s Farxiga, Novartis’ Entresto, Amgen’s Enbrel, AbbVie Inc. and J&J’s Imbruvica, J&J’s Stelara, and Novo Nordisk’s Fiasp and NovoLog insulin products.
Pfizer said it wouldn’t be leading negotiations over Eliquis’ list price and that the task would fall to Bristol-Myers. Eli Lilly similarly said the company “will not have any role in whatever price is set” by Medicare for Jardiance.
Novo Nordisk said it “will explore all options that allow us to drive change for people that need it and strive to continue to bring innovative medicines to the market while helping increase access for those that need them,” though it took issue with the government’s approach. Likewise, AstraZeneca said it would “evaluate our next steps over the coming weeks.”
Merck filed the first lawsuit to block the negotiations in June, followed by suits by other drugmakers and their allies, arguing the program was unconstitutional or violated procedural requirements for implementation.
They’re awaiting a decision from Judge Michael J. Newman of the US District Court for the Southern District of Ohio on the U.S. Chamber of Commerce’s request for a preliminary injunction—an ask that could halt the program before negotiations even begin.
The Chamber asked the court to rule before the Oct. 1 deadline when drugmakers must decide if they will enter negotiations. The group said the Biden administration didn’t do its “homework” to understand price control schemes and is rushing for implementation.
“They had a year to research these basic questions,” Neil Bradley, the Chamber’s executive vice president and chief policy officer, said in a press call.
Drugmakers who’ve already filed lawsuits will “fight to the bitter end,” Heled said.
“I can’t imagine that the litigations are going to end before these prices are supposed to take hold or go into force,” Heled said.
Drug manufacturers on the list will also “definitely” want to amend their complaints, said Laura Dolbow, a fellow at the University of Pennsylvania Law School who specializes in administrative law.
Companies may also amend their complaints to include additional causes of actions, said Andrew Twinamatsiko, associate director of the Health Policy and the Law Initiative at Georgetown University’s O’Neill Institute. For example, plaintiffs arguing the program violates the First, Fifth, and Eighth Amendments of the Constitution may consider raising Administrative Procedure Act claims like those in recent lawsuits from AstraZeneca and Boehringer Ingelheim.
Drugmakers “could find a creative way of going around” the drug pricing law’s preclusion of judicial review of prices, he said.
More constitutional claims could emerge, and the courts could have a “remarkably large number of potential avenues to consider,” said Robin Feldman, a law professor at the University of California, San Francisco.
“What are they not claiming?” Feldman said. And “lawsuits already filed have named more constitutional provisions than most people knew existed.”
‘No Standing’
Astellas Pharma Inc., which filed a suit July 14, ended up with none of its products on the list. Legal experts expect Astellas’s case to be dismissed.
The drugmaker said in a statement that no decisions have been made regarding its lawsuit, but it remains confident in its stance that the program “would result in lower costs for the government, but not necessarily reduce out-of-pocket costs for patients.”
The case brought by trade group Pharmaceutical Research and Manufacturers of America also faces possible dismissal.
The Biden administration filed a motion to dismiss the PhRMA suit in the US District Court for the Western District of Texas a day before the list came out, specifically asking that the National Infusion Center Association be dismissed because it lacks standing and failed to allege that the federal program will cause any of its members an injury.
The actions drugmakers with products on the list take now could affect what other manufacturers will do in the future, said Nicholas Bagley, a law professor at the University of Michigan. The experiences of the drugmakers in the first round of negotiations could set the precedent for price talks in later rounds.
“If you’re a manufacturer who doesn’t have a drug listed, you’re likely to sit back and watch these other litigants,” Bagley said.
There is good news in the SE Texas Medicare Advantage Market! It announces a new Medicare insurance plan which provides what is likely the greatest access to medical providers to date. It allows a member may go to any provider that sees Medicare patients. This equates access to that of the Medicare Supplement (Medigap) plans I typically encourage my clients to enroll in. And the out-of-pocket expenses are $0! There is not even the Part B annual out-patient deductible of $233 which applies to the most popular Medigap Plan G!
Additionally, it provides the convenience of Medicare Advantage Part D Drug (MAPD) plans because it includes Part D Prescription Drug coverage. This means one need not pay an additional premium for a standalone drug plan to accompany their medical coverage because your medical and drug coverage is included under the cover of one policy.
*(The details of this plan are described by the insurance company in the Feature Article below.)
FOR WHOM IS THIS PLAN BEST SUITED?
In my opinion, it is best suited for the older Medicare recipient for whom their Medigap and Part D drug plan premium now exceeds $215.40 – the monthly premium for this Medicare Advantage Plan. Someone who has just turned age 65 will find their Medigap premium combined with a low-cost Part D drug plan competitive for quite some time. However, as they get older, the total cost can greatly exceed the premium for this Advantage plan. Additionally, unless they have Medigap Plan F, they remain responsible for the annual Part B deductible noted above.
As we age, many of us acquire moderate to significant pre-existing medical conditions. In Texas, and most states, when their Medigap premium becomes burdensome, Texans cannot enroll in a new, and lower cost, Medigap plan and be guaranteed approval. They must go through underwriting and risk being declined due to their health history. With Medicare Advantage plans this cannot happen as approval is guaranteed during the eligible enrollment periods.
WHAT ARE THE DISADVANTAGES OF THIS MAPD PLAN?
First, as implied above, if someone is a relatively younger Medicare recipient – with little in the way of brand name drug usage – their combined premium for medical and drug coverage can be considerably lower than the premium for this MAPD plan.
Furthermore, because this plan combines one’s drug plan with their medical plan – one is tied, or captive to, its Part D drug coverage. Coverage which may not be the best drug coverage available to them in the Part D market.
Lastly, Medicare Supplement Plans (Medigap) are created by and standardized by the Centers for Medicaid and Medicare Services (CMS). They can only be changed by legislation. If legislation would result in a change in their benefits, the insured member would most likely be “grandfathered” or, otherwise, allowed to keep their existing coverage.
With this new “Flex PPO” plan from a major health insurance company, the company could decide to eliminate it in any new calendar year. CMS is not going to mandate an equivalent benefit Advantage Plan. And if none is available – the member is likely to find themselves with an alternative offering less access to providers and with out-of-pocket expenses. Or a member could move to a new area where equivalent coverage is not available.
These are all considerations that must be made before transitioning from Medigap – or another Medicare Advantage plan to this Advantage Plan. Regardless, unless one is just qualifying for Medicare due to age or disability – or losing access to another Medicare Advantage Plan – they will not be allowed to enroll in this new plan until this year’s Annual Election Period October 15th – December 7th.
When that time comes, do not hesitate to contact me for assistance in determining if this option is in your best interest and assistance in enrolling.
**(Due to compliance concerns the company will not be identified at this time. You may contact me for that information as well as all details of the plan. The following is their notice to agents and brokers.)
We want to remind you of our new Medicare Advantage Flex (PPO)SM plan that’s currently available for Medicare age-ins or those eligible for Special Enrollment.
Features include:$0 Copay/coinsurance, $0 deductible, no out-of-pocket costs – and it’s open access. Members can visit any provider nationwide who accepts Medicare. And it includes prescription drug coverage!
NOTICE DATED 04.25.2022 FROM:
Important Information Regarding Your Provider Plan Coverage Thank you for enrolling in the Medicare Advantage Flex (PPO)SM plan.
With this plan you can:
• See any provider accepting Medicare whether inside or outside the plan service area.
• See any health care provider, at no additional cost, when traveling nationwide.
• Access care from any provider who accepts Medicare assignment and bills Blue Cross and Blue Shield.
• You are not required to obtain authorization for out-of-network services, however, services must meet medical necessity criteria to be covered.
• We also offer a traveler benefit for members leaving the service area for six months or less. If you plan to travel and be away from home for up to six months, contact customer service. SAVE THIS Below is a provider notification card for you to keep and present when seeking care from a provider. This will ensure your medical claims are processed in a proper and timely manner. If you have any questions, please call the number on the back of your member ID card.
• Write your name and member ID number on the front of the provider notification card
• Carefully remove and fold card
• Keep this card with your member ID card
• Take both cards to all health care provider appointments Thank you for being a Medicare Advantage Flex (PPO) plan member. Carefully punch out and fold this card
Dear Provider:
• As a provider, you do not need to be a Medicare Advantage Flex (PPO)SM contracting provider to see and treat this member.
• Members can see any provider who accepts payment from Medicare.
• If you are a provider with any of our MA networks, authorization requirements apply.
• The member’s coverage level is the same whether or not a provider is in the network for the Medicare Advantage Flex (PPO).
• At a minimum, eligible claims will be reimbursed at the Medicare Allowed Amount.
While inflation has costs for necessities, such as gas and food items, skyrocketing to an average of 8.5% in March and much higher for the aforementioned items – Social Security saw fit to only increase the Income Benefit to SSI recipients to 5.9%. Seniors, many of whom are subsisting on fixed incomes, might be able to cut their need for gasoline, but I do not know any who can get by without food, shelter, and electricity. Many are struggling to pay their bills already, and inflation shows little sign of abating.
This was only until 09/2021, at which time, apparently only apples inflated lower than our current rate of inflation.
But how about the argument that all this inflation is due to Putin and the war in Ukraine? Russia launched a full-scale assault on Ukraine February 22. One month after the end of the timeline in the chart below.
When was our current president inaugurated? . . . Answer: January 20, 2021. Take a look at the green line above charting the Consumer Price Index on that date. (I will leave it at that.)
To add insult to injury, the Centers for Medicare and Medicaid Services (CMS) increased Part B (outpatient care) premiums by 15% to a base premium -for those with an annual income of less than or equal to $91,000 – to $170.10 per month. Thank you very much!
However, as described in Feature Article 1 below, due in part to a 50% cut in the cost of a $56,000 Part D covered drug, CMS is considering reducing that Part B Premium. My experience is that the government seldom gives back what they are already receiving . . . but one can only hope.
For those involved in Marketplace medical coverage – health insurance for individuals and families under the age of 65 – the opposite action on the part of the Department of Health and Human Services may occur. Specifically, the extended enhanced premium tax credits made available by the American Rescue Plan, which enabled an additional 3 million Americans to receive a subsidy lowering their net monthly premium to as low as $0, are set to expire at the end of the year. As described in Feature Article 3 below, it is estimated 4.9 million more people will go uninsured if enhanced benefits are not extended. Never mind it is estimated the extension of such would increase the federal deficit by $305 billion dollars. Of course, the Treasury can simply print more money, further increasing inflation and diminishing the buying power of one’s paycheck or Social Security Income.
Lastly, medical expenses are no exception to inflation. If you wonder why health insurance premiums or out-of-pocket costs for healthcare are being affected, refer to article 3 below. They start high and increase as one goes from a doctor’s office to an Urgent Care facility to a hospital emergency room. Avoid the latter unless it is a true emergency because it will cost an average of $444 for low to moderate severity treatment. Heaven, forbid you have an overnight stay in a hospital without medical insurance because the average cost is $11,700. As cited in the chart below, it only goes up depending on the type of insurance you have.
Should your stay extend to three days, expect to cost to be an average of $30,000. And what if you don’t have health insurance? Here are the average costs of various treatments.
Take a look at what you might pay for each hospital bill without insurance:
*(Data from the Agency for Healthcare Research and Quality)
While I cannot guarantee we have seen the worst of inflation – let alone that the government is going to provide us any meaningful relief in the immediate future. But I am here to assist you in acquiring medical coverage, which gives you access to the care and treatment you need to regain or preserve your health without being financially ruined. I will do my best to help you maintain access to as many of your preferred medical doctors and hospitals as the present market allows. I do not charge a fee for my services. There is no additional cost for the insights and value of my 36 years of experience in the health and Medicare-related insurance market. Neither is there any additional cost in acquiring an insurance product through me than if you walked through the door of your preferred insurance company and purchased their product directly from them. There is no obligation to take my learned advice.
Please give me a call and let’s discuss your situation before the very busy “Open Enrollment” Periods are upon us and everyone is scrambling to mitigate what are almost certain to be the increasing costs of health care
AHIP applauded CMS for covering the drug and “related services such as PET scans if required b the trial protocol.”
Other stakeholders said that now the coverage decision has been finalized it is time for CMS to take action on lowering Part B premiums.
CMS has yet to announce any final decision on Part B premiums, which is increased by 15% for 2022. A key reason was the $56,000 price tag for Aduhelm.
However, Department of Health and Human Services Secretary Xavier Becerra announced in January that the agency was rethinking the 15% hike after Biogen halved the price of Aduhelm in December.
Becerra told reporters on Tuesday before the coverage decision that he was waiting to see what “CMS gives back to us in terms of their assessment and then once we get that information we will see where we go.”
CMS told Fierce Healthcare on Friday that it has yet to decide on a redetermination for the premium.
But advocates are hoping the agency moves faster on scaling back the premium hike.
“Medicare beneficiaries struggling to pay their bills need relief from this year’s premium increase as soon as possible,” said Max Richtman, president and CEO of the National Committee to Preserve Social Security and Medicare.
Pharma and Alzheimer’s disease patient advocacy groups slammed the decision, however, noting that it will hamper access to the drug.
“CMS has further complicated matters by taking the unprecedented step of applying different standards for coverage of medicines depending on the FDA approval pathway taken, undermining the scientific assessment by experts at FDA,” said Nicole Longo, spokeswoman for the Pharmaceutical Research and Manufacturers of America, in a statement.
End to ACA tax credits could leave 3 million uninsured
But extending the enhanced credits would increase the federal deficit by $305 billion over 10 years.
By Alan Goforth | April 08, 2022 at 09:32 AM
Congress would need to act by midsummer to give marketplaces, insurers and outreach programs time to prepare for the 2023 open enrollment period.
More than three million people could lose insurance coverage if enhanced premium tax credits included in the American Rescue Plan expire at the end of this year, according to a new report from the Urban Institute. The American Rescue Plan Act of 2021 increased credits for Marketplace insurance coverage and extended eligibility to more individuals.
“If Congress does not extend these benefits, marketplace enrollment will most likely fall and the number of people uninsured will increase,” said Jessica Banthin, senior fellow at the organization. “Our findings show that 4.9 million fewer people will be enrolled in subsidized Marketplace coverage in 2023 if the enhanced credits aren’t extended. This comes at a pivotal time when millions of people will be losing Medicaid as the public health emergency expires.
Average charges for 8 common procedures across ER, retail and urgent care settings
Alia Paavola – Wednesday, March 30th, 2022
In 2020, the median charge for a 30- to 44-minute new patient office visit ranged from $164 in a retail clinic to $234 in an urgent care center, according to a March report from Fair Health.
For the report, Fair Health, an independent nonprofit focused on enhancing transparency of healthcare costs and health insurance information, analyzed billions of private healthcare claims records from its database.
Below is the average charge for eight common procedures, as identified by CPT code, performed in retail, urgent care and emergency room settings:
healthandmedicareinsurance.com 
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