Category: Medicare Changes
Articles/updates regarding Medicare costs and coverage.
It’s doctors who usually know what’s best for your health. When President-elect Donald Trump nominated Rep. Tom Price (R., Ga.), an orthopedic surgeon, to head the Department of Health and Human Services (HHS), he must have thought the same thing. Trump is hoping that Price takes a doctor-oriented approach to reforming the nation’s healthcare system.
And that reform begins with repealing and replacing the Affordable Care Act (ACA), or Obamacare. To Trump, Price is the man to get the ball rolling. Not only is he a licensed and trained physician, but he’s also been a fierce critic of Obamacare and an advocate for overhauling the nation’s entitlement programs.
During his time in Congress, Price has been a leader on both projecting the disastrous impacts of Obamacare and developing positive solutions for improved access to healthcare for all Americans. He was one of the first representatives to draft his own plan to replace Obamacare, the Empower Patients First Act. After refining his plan, Price introduced it as a bill, which has been co-sponsored by several other representatives.
Price’s plan focuses on reforms that doctors care about. During his 12 years in Congress, he consistently argued for limited government and less spending. His legislation will likely mirror his actions as HHS Secretary: removing governmental red tape from doctors and giving Americans more control over their health care.
“As a physician,” he said in the House in 2007, “I know oh so well how the intervention of the state and federal government into the practice of medicine destroys the ability to take care of people. It makes it so you can’t provide quality health care for children and moms and dads.”
According to some, Price’s proposed replacement for Obamacare will offer tax credits to everyone, regardless of income, and help develop health savings accounts for beneficiaries who are not covered by their employers, Medicare, Medicaid, or other sources.
“We wanted to get away from the connection to income,” Price said in 2015. “I’ve become convinced over the past three to four years that it’s much more wise to relate the tax credits to age.” The legislation proposes tax credits of $1,200 per year for people aged 18-35, $2,100 for those aged 35-50, and $3,000 for those over 50.
Besides designing an innovative replacement for Obamacare, Price also wants to rework Medicaid and Medicare. Instead of entitlements, Price wants to convert Medicaid into block grants to states and require “able-bodied” applicants to meet work requirements to receive healthcare benefits. Regarding Medicare, Price supports the idea of moving from a “defined benefit” to a “defined contribution,” where the government would give older or disabled Americans financial help for them to buy private insurance policies.
While it’s still unclear whether Price’s ideas and legislation will receive the bipartisan support to become viable replacements for Obamacare, it’s clear that the nominated HHS Secretary has some thoughtful and innovative ideas on how to improve the nation’s healthcare system.
“There is much work to be done,” Price said in November, “to ensure we have a health care system that works for patients, families, and doctors; that leads the world in the cure and prevention of illness; and that is based on sensible rules to protect the well-being of the country while embracing its innovative spirit.”
To learn more about nominated HHS Secretary Rep. Tom Price and his doctor-oriented approach to reforming the nation’s healthcare system, visit mymedicareplanner.com and contact Tommy Chamouris. Tommy and his staff are committed to protecting senior citizens and helping them navigate through the “Medicare maze”—at no additional cost. See our ad on page 1 of Boomer magazine.
In a weekend interview with The Washington Post, President-elect Donald Trump offered some surprising news, declaring he is nearly finished with his plan to replace President Obama’s Affordable Care Act. Trump, who is less than a week away from beginning his four-year presidential term, did not reveal the specifics of his health care replacement but vowed his plan would “have insurance for everybody.”
Trump continued, “There was a philosophy in some circle s that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”
While Trump did not elaborate on the details of his plan, he did reveal that it’s formulated down the to the “final strokes.” He said he is waiting for his secretary of health and human services, Rep. Tom Price (R-Ga.), to be confirmed before he releases the specifics.
While he was tight-lipped about most aspects of his plan, which will replace most aspects of Obamacare, he did make his intentions to target pharmaceutical companies well known. He revealed that drug companies will be forced to negotiate on Medicare and Medicaid prices. Trump also declared his plan will have lower deductibles because he plans to fight pharmaceutical companies over drug prices. “They’re politically protected, but not anymore,” he said
In developing his replacement plan, Trump acknowledged that he paid attention to critics who say that repealing the Affordable Care Act would put coverage at risk for more than 20 million Americans covered under the law’s insurance exchanges and Medicaid expansion.
“We’re going to have insurance for everybody,” Trump said. “It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people” He also insisted that Americans “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”
Last week, Congress took a big step toward dismantling the ACA by approving a budget resolution that would begin repealing the healthcare law. According to House Speaker Paul Ryan (R-Wis.), the budget vote gives Congress “the tools we need for a step-by-step approach to fix these problems and put Americans back in control of their health care.”
While Trump seems all but ready to reveal and implement his replacement plan, there will likely be months of debate and Congressional infighting before the law is passed. However, Trump has warned Congress that he will use the power of his presidency (and social media) to let the American people know that Washington politicians are delaying the implementation of his replacement plan. He noted, “The Congress can’t get cold feet because the people will not let that happen.”
–
To learn more about President-elect Trump’s comments about his forthcoming Obamacare replacement plan and his declaration to fight pharmaceutical companies over drug prices, visit mymedicareplanner.com and contact Tommy Chamouris. Tommy and his staff are committed to protecting senior citizens and helping them navigate through the “Medicare maze”—at no additional cost. See our ad on page 1 of Boomer magazine.
Since Trump’s election last November, there has been a lot of speculation over how the President-elect will overhaul and revamp America’s healthcare industry.
With his recent appointments of Seema Verma to serve as the Administrator of the Centers for Medicare and Medicaid Services, and Georgia Representative Tom Price as head of the U.S. Department of Health and Human Services, there is more clarity on Trump’s vision; and, despite the hysteria, many within the health industry are encouraged by what could be in store.
Throughout the election, Donald Trump declared he would “repeal and replace” the Affordable Care Act. Now that he’s elected, it seems highly likely that Trump will deliver on his promise. Although many predicted this would be a nightmare scenario, it seems that hospitals and health insurers are pleasantly surprised with the President-elect’s first steps.
Trump’s appointments of Rep. Price and Verma, along with his recent softening on some aspects of the Affordable Care Act, is a signal to some insiders that instead of chaos, he is preparing an orderly transition to replace Obama’s health program with a plan that healthcare companies may want.
Rep. Price is an orthopedic surgeon who has drafted legislation to replace the ACA. Meanwhile, Verma has close ties to Vice President-elect Mike Pence and helped design his ACA Medicaid expansion model, Healthy Indiana Plan 2.0. She has also advised several states on how to add elements such as health savings accounts and employment requirements to their programs. If both are confirmed, experts predict more power will be granted to states in crafting individual insurance plans and Medicaid programs.
“Pence and Trump have made a big deal about giving the states more flexibility and autonomy in managing their Medicaid programs and [Verma] would appear to be the perfect person, given her expertise, to manage that rollout of more state flexibility,” said Robert Laszewski, president of Health Policy and Strategy Associates.
Of course, some have been critical of Trump’s choices and his declaration to repeal and replace the ACA. There is a fear that millions of Americans will instantly lose health insurance and there will be even more uncertainty surrounding Medicare and Medicaid. However, lawmakers, including House Majority Leader Kevin McCarthy, have indicated that although they will work to repeal the ACA immediately, there will be a two-year transition period to phase out the law and citizens currently insured by the program won’t be left without a safety net.
One plan, proposed by House Speaker Paul Ryan, will offer individual insurance with a form of Federal subsidies, provide block grant funding for Medicaid, create vouchers for Medicare coverage, and the eliminate the advance paid premium subsidies for individual insurance. Many believe Ryan’s plan will serve as the foundation of the eventual replacement plan. In the meantime, members in Congress have been already asking healthcare companies for input and advice on functional alternatives for the ACA.
While the future of healthcare under the Trump administration is still uncertain, the President-elect’s recent appointments and proposals have excited many healthcare professionals, including Kathleen Harrington, chair of Policy of Government Relations for the Mayo Clinic. Harrington is pleased with what she has heard so far from the administration over the past few weeks. She notes, “We are very encouraged with the approach we’re hearing so far from President-elect Trump in terms of having a focused review and removing certain parts of it.”
To learn more about Donald Trump’s recent appointments and his plans to reform America’s healthcare system, visit mymedicareplanner.com and contact Tom Chamouris. Tom and his staff are committed to protecting senior citizens and helping them navigate through the “Medicare maze”—at no additional cost. See our ad on page 1 of Boomer magazine.
Nearly a third of all Medicare beneficiaries may face a significant increase in their premium costs in 2017, if Congress doesn’t act soon. According to the federal government’s board of healthcare trustees June 2016 report, participants of Medicare Part B—nearly 51 million Americans in 2016—could face a 22 percent premium increase next year.
The report warned Washington lawmakers that Medicare’s trust fund for inpatient care will be exhausted in 2028, two years earlier than was previously projected. While this finding is of grave concern, the more immediate worry, according to the report is the steep premium increase for Part B beneficiaries scheduled to take place in 2017.
Medicare Part B covers doctor visits and other types of outpatient care, and people with higher annual incomes who would see the largest increases. By law (the Social Security Act’s “hold harmless” provision), premiums for most Medicare recipients cannot exceed their increase in Social Security payments. However, according to the Wall Street Journal, the adjustment is expected to be just 0.2% in 2017 due to low inflation. As a result, Medicare couldn’t pass along a premium increase greater than the dollar increase in Social Security payments to an estimated 70 percent of beneficiaries who will be “held harmless” in 2017.
In order to account for this discrepancy, Medicare would have to spread its cost increases across the remaining 30 percent of beneficiaries not “held harmless,” which is its higher earners. The trustees’ report predicts that individuals earning between $85,001 and $107,000 and couples earning between $170,001 and $214,000 would have their monthly premiums raise from $170.50 a person this year to about $204.40 in 2017. And it gets worse. For those earning more than $214,000 ($428,000 for couples), the increase is about $467.20 a month, nearly $100 more than 2016 costs. Increases this extreme will have a significant impact on the millions of Americans living on fixed incomes.
Potential premium hikes will likely affect higher earners, if the predictions from the trustees’ report come to pass, all Medicare beneficiaries will see their annual Part B deductibles rise in 2017. The report cautions that the deductible costs will increase by nearly $40, from $166 in 2016 to $204 in 2017. “Everyone on Part B will be liable for the full increase,” says Tricia Neuman, senior vice president and an expert on Medicare at the Kaiser Family Foundation. Medicare is expected to have 53.5 million participants in Part B in 2017, meaning nearly 3 million more beneficiaries than this year will be liable to pay this deductible increase.
There is still time for Congress to intervene this fall and prevent this potentially devastating increase. Last year, lawmakers reduced an impending 52 percent premium increase for Medicare beneficiaries not “held harmless” with a deal in the budget agreement that raised premiums by only 16 percent instead. However, the trustees’ report cautioned Washington to address Medicare’s financial challenges now, “Taking action sooner rather than later will permit consideration of a broader range of solutions and provide more time to phase in changes so that the public has adequate time to prepare.”
To learn more about what this potential premium increase means and how you can prepare, visit mymedicareplanner.com and contact Tom Chamouris. Tom and his staff are committed to protecting senior citizens and helping them “navigate through the Medicare maze.” My Medicare Planner will offer guidance and help you find the plan that’s best for you—all at no additional cost.
Submitted by Kevin Hollister
Anthem bought Cigna for $54 billion last week. Aetna bought Humana for $37 billion this month. What does that mean for consumers?
This image is from ModernHealthcare.com.
If there are fewer companies to compete with, rates could rise. Historically, mergers of big insurers have caused the price of premiums to increase.Some suggest that prices will go down.
Insurance companies say the deals would substantially reduce their own costs, allowing them to charge consumers less for their plans.
Some say the future of the deals is uncertain.
The mergers will be reviewed by the federal government, with special attention paid to anti-trust laws. Some believe they won’t go through at all. If the deals are upheld, they won’t go into effect until 2016.
Insurers aren’t the only ones joining forces.
- CVS, the largest drugstore company in the US, bought Target Pharmacy for $2 billion in June. The 1,660 Target Pharmacies nationwide will eventually be CVS pharmacies.
- Centene, a Medicare and Medicaid health plan provider, bought Health Net, a health plan provider in the same industry, for $7 billion in early July.
- The biggest generic drug producer in the world, Teva, bought Allergan, a manufacturer of generic drugs best known for making Botox, over the weekend for $40.5 billion.
- Insurers are merging because they want to cover more of the market. With the influx of customers from the Affordable Care Act, and the revenue from Medicare and Medicaid, they are buying companies with these strengths.
- When one subset of the industry begins merging and combining market power, the companies on the other side want to do the same. To maintain power in negotiations and stay afloat in the changing industry, companies see merging as the answer.
Tom says:
“Generally speaking, when an industry like the insurance industry begins to see mergers of the largest companies, it portends less competition and more price control between the remaining behemoths. Such mergers will be examined closely by the government for anti-trust violation. I will leave you with these quotes.”
“In an environment where the scales are already tipped, we are extremely concerned about the market imbalance this creates for medical practices and patients,” said Dr. Halee Fisher-Wright [of the MGMA]… “This will do nothing more than inflate healthcare premiums and decrease payments to physicians in favor of insurance companies and shareholders’ profits.” – Forbes
“One of the main goals of the Affordable Care Act was to restore competition in the health insurance sector,” said David Balto, a former policy director at the Federal Trade Commission who is now in private practice in Washington. “This consolidation will reverse these gains of the Affordable Care Act.” – Forbes
Will the Anthem-Cigna deal cost you money?
To find out what other changes could come with the health insurance mergers, click here.
Medicare will reimburse doctors
who talk with patients about
end-of-life care
Coverage for end-of-life counseling was not included in the Affordable Care Act, but some insurance companies have begun to offer coverage. More companies are expected to when Medicare finalizes the plan.
The proposal will be decided on November 1st.If this has been helpful, please feel free to forward this email to family and friends. Please contact us at [email protected] to be added to our email list.
Medicare Proposes paying for end-of-life counseling in sweeping physician payment rule
Modern Healthcare
In a draft of Medicare’s first physician payment rule since Congress scrapped the sustainable growth-rate formula, the CMS proposes paying for end-of-life counseling and revises several quality-incentive programs that will be rolled into a new comprehensive program in 2019.
Medicare Plans to Pay Doctors for Counseling on End of life
The New York Times
Medicare, the federal program that insures 55 million older and disabled Americans, announced plans on Wednesday to reimburse doctors for conversations with patients about whether and how they would want to be kept alive if they became too sick to speak for themselves.
Get ready for a long read. Last week, the Obama Administration announced a five-year program to test alternative payment models for Medicare Part B drugs. The program will try new methods relating to drug prices, patient outcomes and physician payments starting next year.
Currently, Medicare pays doctors an extra 6% of the price of the drug they administer, which gives providers a bigger payment when they choose medications that cost more. This can lead to prescribing more expensive drugs, which sometimes differ from cheaper drugs only in price.
What is a Part B Drug?
Not all prescriptions are filed under Part D. Drugs that beneficiaries don’t take on their own, like those that are administered by injection or infusion at a doctor’s office, fall under Part B.
This image is from ModernHealthcare.com.
What will the program do?
There will be two phases. The first phase, which would go into effect later this year, would decrease Medicare’s additional payment from 6% to 2.5%, and use a flat payment of $16.80 per drug per day. The Centers for Medicare and Medicaid Innovation are looking to see how these changes affect the way doctors prescribe medications.
The next phase, which could begin as soon as early next year, will include a series of value-based purchasing options, based on price and effectiveness of drugs. Each strategy will be tested in a different geographic area:
- Decreasing or ending cost-sharing for Part B drugs, so that beneficiaries may access effective drugs more easily
- Creating tools for providers to choose drugs with evidence of their effectiveness and other information
- Options for different payments based on the effectiveness of a drug
- Using a benchmark, or standard rate or payment, for similar drugs
- Connecting patient outcomes with drug prices by partnering with drug companies
What are people saying?
The Obama Administration, Centers for Medicare and Medicaid Services and advocates say that the decision for which drug to prescribe should be made with factors such as effectiveness, quality, the patient’s need, and price.
Those against the payment models call it an “absurd experiment,” and believe that doctors know what’s best for the patient, and should be free to prescribe without government oversight. Some doctors in certain specialties are concerned about losing major percentages of their profits.
Comments can be submitted on the program until May 9th.
Will any group be negatively affected?
Some specialists will be more impacted than others by the program. Oncologists, Ophthalmologists, and Rheumatologists, who make a significant profit with Medicare’s drug payments, would see the biggest change in money earned. Primary Care and Family Practice Physicians would see a 44% rise in Part B drug payments, as they typically prescribe and administer cheaper drugs than other specialists.
This image is from ModernHealthcare.com.
To read more about the Part B payment program, see this NPR article.
The full proposition of the program is available online at the Federal Register.
About 20 new generic drugs will be on the market at the end of this year. The patents on the brand drugs have expired, allowing drug manufacturers to create generic versions. Most aren’t on the Medicare Plan Finder yet, and won’t be released until later in 2016.
Sometimes, companies will try to expand their patent, allowing for more time before a generic can be produced. Revenues for brand drugs drop dramatically when their generic versions are introduced. Generic drugs can take over 90% of a brand drug’s sales.
Here a few popular drugs that will soon have a generic version:
- Crestor – Rosuvastatin Calcium
Treats high cholesterol. Available in May. - Benicar – Olmesartan Medoxomil
Treats high blood pressure. Available in October. - Zetia – Ezetimibe
Treats high cholesterol. Available in December. - Proair HFA – Albuterol Sulfate
Treats asthma, COPD and others. Available in December. 
This image is from RxPreferred.com. Click on the image or link to see it enlarged
Fast Facts
- The price of generics is usually 80-85% less than brands.
- Once introduced, generics take about 90% of a brand’s sales.
- Generics must match the brand’s active ingredient, strength, type of medicine, effects, performance, and standards of testing.
- Generics can differ from brands in color and shape, label and packaging, and flavors and preservatives.
- There are two types of generics: Generic Equivalents, with the same active ingredients, and Generic Alternatives, with different active ingredients. Generic Alternatives are not prescribed as often, and require a separate prescription to be filled.
What is Telehealth?
Telehealth is using technology to communicate information and deliver health and health-related education services. It’s a broad term. Even if you aren’t especially tech-savvy, you’ve used telehealth if you’ve ever emailed your doctor or refilled a prescription online or over the phone. Video conferencing with your doctor to diagnose symptoms is an example of telehealth that isn’t widely used now, but could be in the future. Telehealth differs from telemedicine in their scope: telehealth is much wider, encompassing more aspects of health care.
There are four main “domains” of telehealth, from the Center for Connected Health Policy:
- Live Video: Real-time interaction between two parties: a provider and the recipient of health services.
- Store-and-Forward: A patient, using e-communication, shares a documented history of health, in videos or images, with a provider. The provider uses the documentation to deliver health services after evaluating it.
- Remote Patient Monitoring (RPM): A patient sends information to a provider using e-communication for status updates when the patient is released to their home or a care facility.
- Mobile Health (mHealth): Most often used to reach a broad audience by a healthcare organization or another group when promoting education or health practices. These are accessed through mobile phones and tablets.
The future is now
Last year, UnitedHealthcare announced that it would partially or completely cover video chats with doctors by 2016, though it’s not clear if their Medicare plans would be included. They believe virtual visits could be cheaper and easier than going to a doctor’s office.
Last month, a bipartisan group of U.S. Senators and Representatives introduced a bill that would “expand telehealth services through Medicare,” called the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act. The law would also “improve care outcomes, make it easier for patients to connect with their healthcare providers, and help cut costs for patients and providers.” So far, the bill has not been reviewed by committee. Currently, Medicare doesn’t cover all telehealth costs.
Current Advantage and Prescription Drug Plan customers are not affected
The Centers for Medicare and Medicaid Services brought sanctions against Cigna-Healthspring January 21.
Cigna-Healthspring cannot enroll new beneficiaries into its Medicare Advantage and Prescription Drug plans. They are also prevented from marketing efforts. Cigna supplement plans are not involved in the suspension. The sanctions will be removed when the problems are solved, which will be decided by Medicare.
Why?
The sanctions are a result of Cigna’s poor responses to customer complaints and appeals, and problems with the Part D formulary and benefits. These problems led to difficulty obtaining and denials of treatment and medications, and increased costs.
What about those in the plans?
Current members of Cigna-Healthspring Advantage and Prescription Drug Plans are not affected. Coverage will remain and the hope is that Cigna, under the oversight of Medicare, will solve the problems that led to the sanctions.
If you’ve experienced problems with your Cigna-Healthspring plan, file a complaint with them or with Medicare. Fill out the Medicare Complaint Form here, or learn more about complaints on Medicare.gov.
How long will this last?
The sanctions will be withdrawn when the problems are fixed. That could last as long as six months, a year, or possibly into 2017. Cigna must submit a plan to correct the issues to Medicare by January 29.