Image: The Hill
Image: The Hill

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 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.

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This past Monday, July 25, the Department of Health and Human Services (HHS) proposed a new model to pay hospitals that treat Medicare beneficiaries for heart attacks, cardiac bypass surgery, hip replacements, and other hip surgeries with an emphasis on controlling costs and improving outcomes for patients.

If implemented, this “bundled” payment model would shift Medicare payments from quantity to quality by creating incentives for hospitals to deliver better care at a lower cost.

According to the Centers for Medicare and Medicaid Services (CMS), who published a fact sheet about the proposed rule, “These models would reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital re-admissions, and speed recovery.”

Under this proposed bundle payment model, hospitals that admit patients for a heart attack, bypass surgery, or hip/femur fracture treatment will be offered a target price from Medicare for all of the services during inpatient stay and for 90 days after discharge.

The hospitals that work with physicians and others to deliver the needed care for less than the target price, while also meeting or exceeding quality standards, would receive the savings achieved. Meanwhile, hospitals with costs exceeding the target price would be required to repay Medicare.

Hospitals would be incentivized to provide high-quality care. Each hospital would be assessed on quality metrics appropriate to each episode. These assessments would use performance and improvement on required measures and the submission of voluntary data for other quality measures, according to the CMS fact sheet.

“Today’s proposal is an important step to improving the quality of care Americans receive and driving down costs. By focusing on episodes of care and rewarding successful recoveries, bundled payments encourage hospitals to coordinate care to achieve the best outcomes possible for patients.” HHS Secretary Sylvia Burwell said on Monday.

HHS noted that in 2014 alone, more than 200,000 Medicare beneficiaries were admitted into hospitals for either heart attack treatment or bypass surgery, which cost Medicare over $6 billion. In addition, the costs of surgery, hospitalization, and recovery were wide-ranging for these patients. Cost varied by 50 percent across hospitals, according to the HHS.

The proposed mandated bundle payment model would standardize and curb these costs by holding hospitals responsible for the cost and quality of care provided to Medicare beneficiaries. Under the current model, Medicare typically pays hospitals and doctors separately for each service; hospitals and doctors that do more get paid more. Ideally, the new model would emphasize overall health outcomes, rather than the volume of services provided.

“We think this is a significant positive step forward on behalf of patients. I think we are moving at the right pace. That’s absolutely where I would want the delivery system to be focused,” said CMS Chief Medical Officer Patrick Conway.

If approved, this bundled payment model would be phased in over a five-year period, beginning July 1, 2017. Once the plan is implemented, this model would be mandatory for nearly every hospital accepting Medicare beneficiaries in 98 metropolitan areas.

My Medicare Planner is committed to educating and protecting senior citizens and helping them navigate through the “Medicare maze.” Tom Chamouris and his staff offer guidance and help seniors find the Medicare plan that’s best for them—all at no additional cost.  See our ad on page 1 of Boomer magazine.


With insurance mega-mergers pending, the  existing competition may become even less.



This image is by The Commonwealth Fund.

A national study by The Commonwealth Fund found that in 97% of counties “there is little to no competition in Medicare Advantage insurance markets.” Competition in any market is good, because it pushes the companies to provide better services and prices than their competitors. However, when there are only a few companies, there are no forces pushing them to work for the consumer.

Here are some takeaways from the study:

  • Rural counties have the least amount of competition.
  • In urban counties, the competition is still lacking: 81 out of the 100 counties with the most Medicare beneficiaries were found to be noncompetitive markets.
  • Only one of those 100 counties, Riverside, CA, was classified as competitive.
  • The Medicare Advantage markets are cornered by six insurers. The three companies with the biggest reach are UnitedHealth (38 counties), BlueCross (13 counties) and Humana (12 counties). Together, they control nearly two-thirds of all counties.

The Medicare Advantage market is a small but significant portion of the program. About 30 percent of beneficiaries have Advantage plans, which is roughly 16 million seniors.

But UnitedHealth, BlueCross and Humana are big in more than one market. The Government Accountability Office recently found that those three insurance companies cover 80 percent of Medicare beneficiaries across all markets.

With the pending mergers between insurance giants Anthem and Cigna, and between Aetna and Humana, that we covered previously, the competition will certainly not improve.

The American Medical Association released results of a study focusing on the Anthem-Cigna and Aetna-Humana mergers, and what effect they would have on insurance markets. They studied markets without the impact of the mergers, and found:

  • Three-fourths of urban areas are already ‘highly concentrated” with low competition.
  • 41 percent of urban areas have one insurance company with over half the market share.

Ultimately, the American Medical Association found that the mergers would decrease already low levels of competition by enhancing companies’ market power, which means it will “encourage one or more firms to raise price, reduce output, diminish innovation or otherwise harm consumers as a result of diminished competitive constraints or incentives.”

Studying the effects of the merger, the AMA found:

  • The Anthem-Cigna merger would be anti-competitive in the combined markets of 14 states, including Virginia.
  • The merger between Anthem and Cigna would enhance market power in 85 metropolitan areas in 13 states, including Virginia. Overall, 14 states would see significant decreases in competition from the deal, according to the study.
  • The Aetna-Humana merger would increase market power in 15 metropolitan areas in 7 states, not including Virginia. In total, the study says the effects of the merger would be seen in 14 states, where competition would lessen sharply.
  • tom
  • Tom Says:
    “Prepare yourself-  this will be the outcome of the mergers for Medicare beneficiaries throughout the country and in Virginia particularly.
    This is also a preview of the Annual Enrollment Period, starting October 7, for those who want to change their Medicare Advantage or Medicare Part D plans.”

To read the study by The Commonwealth Fund, click here.

For more on the American Medical Association’s study, see this New York Times article.


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


In the last month, four of the five biggest health insurance companies have entered major mergers. The “Big 5” are UnitedHealth, Anthem, Cigna, Aetna and Humana; all but UnitedHealth (the largest) are involved in the deals. If the mergers are approved, the “Big 5” would become the “Big 3”, who would hold over half (52%) of the Medicare Advantage market. The companies insure approximately half of the entire insurance market.
Some speculate that prices will go up.
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.
Why is everyone merging?
  • 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.


For more than 24 years, The Medicare State Health Insurance Assistance Program (SHIP) has advised, educated, and empowered individuals to navigate their state-specific Medicare choices. In addition, SHIP helps beneficiaries resolve fraud and abuse issues, billing problems, appeals, and enrollment in low-income health assistance programs. In 2015, SHIP provided assistance to more than seven million individuals with Medicare.

The Medicare State Health Insurance Assistance Program (SHIP) network is a critical resource for the elderly, disabled and families needing help to make informed decisions about their Medicare coverage options and enrollment decisions. Today’s Medicare beneficiary must choose among more than 20 prescription drug plans, 19 Medicare Advantage plans, and various supplemental insurance policies, all with different premiums, cost sharing, provider networks, and coverage rules.

Last week the Senate Appropriations Committee targeted two critical programs for significant cuts, and/or elimination for Fiscal Year 2017. The two programs targeted are The Medicare State Health Insurance Programs,(SHIP)  which is slated to lose all of its $ 52.1 million in funding. The second critical program is The Senior Community Service Employment Program. (SCSEP)

Eliminating SHIPs would leave millions of older Americans, people with disabilities, and families who need help applying for benefits, comparing coverage options, filing appeals, and navigating a complex program stranded without assistance.  Max Richtman, President and CEO of The National Committee to Preserve Social Security and Medicare stated “Senate appropriators have turned their backs on a growing number of people who will need SHIP services to navigate the complexities of Medicare coverage by proposing to eliminate program funding.”

The Senior Community Service Employment Program, (SCSEP) which is funded by the Older Americans Act provides subsidized, service based training for low income persons aged 55 and older who are unemployed, and have poor employment prospects. Cutting this program could result in fewer seniors receiving services, and less income due to deceased working hours. It would be devastating to the seniors who work and depend on this program.

Final decisions to cut the programs have not been made. The full Senate is expected to vote on the budget bill in the fall. If this is important to you, please take action by contacting your congressman to reject the imposed cuts, and to take steps to secure The State Health insurance Assistance Programs and  The Senior Community Service Employment Programs are funded.

For more information on our featured article visit

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.

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

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.

✶ In the very near future, Tom will have Word Seek, Crossword and Sudoko books for clients. If you would like one, please respond to this email or call us at 804-788-1965 ✶

The companies are suspended from enrolling new customers and marketing to Medicare beneficiaries.

If you have United American or First United American Life, your plan will remain the same, and is not affected by this suspension.
You do not need to change your plan.


United American’s Part D homepage, which says that they are not taking new enrollees. It reads, “Thank you for your interest in our Medicare Prescription Drug Plans. We are not able to take enrollments into our plans at this time.”

United American Insurance Company and First United American Life Insurance Company have the highest rates of complaints in the Medicare Part D program, and had been dealing with those complaints, and other aspects of customer service, inappropriately.

In a letter to the CEO of Torchmark Corporation, which owns United American and First United Life, a Medicare official says the sanctions will start on August 1, 2015. They will continue indefinitely, until the Centers for Medicare & Medicaid Services are convinced that the company’s’ failures have been addressed and corrected, and will be prevented in the future.

Medicare began investigating Torchmark in 2012, when they found multiple violations regarding coverage determinations for Part D, as well as the handling of customers’ appeals and grievances. Torchmark was fined $150,000 in April 2013 for these violations. In a follow-up investigation, Medicare found that Torchmark had not corrected the violations from 2012, and in September 2014, fined them $40,000. Medicare called the problems “widespread and systemic” failures, which had remained uncorrected for over two years.

In the letter, Medicare listed 8 total violations, including:

  • Failing to fully address grievances, and failing to resolve grievances within Medicare’s time guidelines, or as cases required.
  • Wrongly categorizing coverage determinations as re-determinations, and mislabeling both as grievances or customer services questions.
  • Neglecting to forward coverage determinations to the Independent Review Entity in a timely manner.
  • Causing improper denials of payment under Part D by neglecting to perform Part B vs. Part D determinations for transplant medications.
  • Failing to include specific information about why an enrollee was denied coverage.
  • Neglecting to enforce changes recommended by the Independent Review Entity to fix previous violations.

These resulted in unnecessary delays or denials of prescription drugs, financial hardship for customers, lapses in coverage and other consequences, like sending bills to the wrong customers.


Tom says:
Medicare is keeping close tabs on companies that don’t listen to their customers. This is a line you don’t want to cross as a Medicare insurance company. They have sanctioned many companies in the past for this very same issue (see the links below on sanctioned companies). It is good to know that the government has it’s eye on the behavior of Medicare insurance companies.

Read the letter that Medicare sent to Torchmark here.

Medicare has issued sanctions in the past to companies who were negligent. See these links (here, here and here)
for more background information.

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