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Medicare Blog | Medicare News | Medicare Information

Millions of Part D Enrollees Have Had Out-of-Pocket Drug Spending Above the Catastrophic Threshold Over Time

Posted by www.psmbrokerage.com Admin on Mon, Jul 26, 2021 @ 03:36 PM

drug cost increase

Millions of Part D Enrollees Have Had Out-of-Pocket Drug Spending Above the Catastrophic Threshold Over Time

Medicare Part D enrollees with drug costs high enough to exceed the catastrophic coverage threshold are required to pay 5% of their total drug costs unless they qualify for Part D Low-Income Subsidies (LIS).

With no hard cap on out-of-pocket drug spending, Medicare beneficiaries without LIS who take high-cost drugs for conditions such as cancer, multiple sclerosis, rheumatoid arthritis, or hepatitis C may pay thousands of dollars in out-of-pocket costs for their medications after exceeding the catastrophic threshold.

As seen below, in 2019 almost 1.5 million enrollees had out of pocket(oop) expenses above the catastrophic threshold for at least 1 year.

Looking over a 5 year period, the number of enrollees with oop above catastrophic in at least 1 year was over 2.7 million.

Over a 10 year period the number of enrollees increases to over 3.6 million.


Adding a hard out-of-pocket cap to Part D, as has been proposed by policymakers on both sides of the aisle, would help the growing number of Medicare beneficiaries who take just one very high-priced drug for medical conditions such as cancer or multiple sclerosis, or who take a handful of relatively costly brand or specialty medications to manage chronic illness.

Capping out-of-pocket costs under Part D would protect Medicare beneficiaries against very high levels of out-of-pocket drug costs, including those with one-time catastrophic costs as well as those with high drug expenses year after year. 

While adding a cap on out-of-pocket drug spending under Part D would generate cost savings to enrollees, it could also add costs to the program, unless combined with other policies to lower Medicare drug spending, which are the subject of ongoing discussion in Congress.

 Read the full analysis


Medicare Rights Urges Congress to Prioritize Much Needed Medicare Updates

Posted by www.psmbrokerage.com Admin on Mon, Jul 26, 2021 @ 01:44 PM


Medicare Rights Urges Congress to Much Needed Critical Medicare Updates

This week, as Congress continued to discuss strategies to improve health coverage, Medicare Rights weighed in, urging them to prioritize critical Medicare updates.

The letter, signed by leading Medicare beneficiary advocacy organizations, calls on Congress and the Biden administration to “seize the opportunity to modernize the program, deliver on the promises to improve coverage and reduce prescription drug prices and out-of-pocket costs so that beneficiaries can afford what their doctors prescribe.

The significant gaps in coverage must be addressed, specifically regarding oral health, hearing, and vision services. And barriers to low-income assistance–which is particularly important to older adults of color–must be eliminated.”

To achieve these goals, the letter recommends specific policy changes, including:

  • Fill Harmful Gaps in Coverage by adding a comprehensive oral health benefit, as well as expanded hearing and vision coverage, to Part B.
  • Reduce Prescription Drug Prices and Costs by allowing Medicare to negotiate drug prices; capping and smoothing beneficiary out-of-pocket costs; restructuring the Part D benefit to reduce Medicare’s liability and better align pricing incentives; and repealing safe harbors for pharmaceutical rebates, using those savings primarily for beneficiary improvements.  
  • Streamline Part D Appeals by strengthening data collection, transparency, and oversight; requiring independent redeterminations; allowing tiering exceptions and raising the specialty tier threshold; and improving plan communications with enrollees, 
  • Improve Access to Medicare’s Low-income Programs by eliminating the unduly restrictive asset and eligibility tests for the Part D Low-Income Subsidy (LIS) and Medicare Savings Programs (MSPs), raising the income eligibility limit for the Qualified Medicare Beneficiary (QMB) program to 138% of poverty, and aligning enrollment standards and administrative functions across the programs.
  • Make Coverage More Affordable by establishing a limit on beneficiary out-of-pocket costs, program-wide.
  • Modernize Medigap Rules by expanding protections and purchase rights—including open enrollment, guaranteed issue, and community rating—to all people with Medicare.
  • Expand Access to the Home Health Benefit by relaxing or eliminating the homebound and/or skilled care eligibility triggers and by removing the “at home” restriction for durable medical equipment. 
  • Enhance Chronic Care by strengthening the Medicare Annual Wellness Visit; improving access to Medicare behavioral health services and the Medicare Diabetes Self-Management Training program; and by ensuring the availability of supplemental benefits for those in traditional Medicare.

These long-overdue, commonsense reforms would strengthen Medicare and promote beneficiary well-being. Join Medicare Rights in urging Congress to prioritize these improvements. 

Read the letter.


Introducing Prosperity Life Medicare Supplement Plans

Posted by www.psmbrokerage.com Admin on Mon, Jul 26, 2021 @ 01:29 PM

Tags: Medicare Supplement, Prosperity Life

Medicare Struggles to Expand Diabetes Prevention Program

Posted by www.psmbrokerage.com Admin on Mon, Jul 26, 2021 @ 11:25 AM

blood pressure of man

Medicare Struggles to Expand Diabetes Prevention Program

Over the past decade, tens of thousands of American adults of all ages have taken these diabetes prevention classes with personalized coaching at YMCAs, hospitals, community health centers and other sites.

But out of an estimated 16 million Medicare beneficiaries whose excess weight and risky A1c level make them eligible, only 3,600 have participated since Medicare began covering the two-year Medicare Diabetes Prevention Program (MDPP) in 2018, according to the federal government’s Centers for Medicare & Medicaid Services (CMS).

Researchers and people who run diabetes prevention efforts said participation is low because of the way Medicare has set up the program. It pays program providers too little: a maximum of $704 per participant, and usually much less, for dozens of classes over two years.

It also imposes cumbersome billing rules, doesn’t adequately publicize the programs and requires in-person classes with no online options, except during the pandemic emergency period. Most of the private Medicare Advantage plans haven’t promoted the program to their members.

Now, CMS has proposed to address some but not all of those problems in a rule change. It predicted the changes would reduce the incidence of diabetes in the Medicare population and potentially cut federal spending to treat diabetes-related conditions.

On July 13, the agency proposed shortening the program to one year, starting in 2022, because providers complain that too few beneficiaries complete the second year. That and other changes proposed by Medicare would modestly enhance reimbursement to providers.

The government is also planning to waive a one-time $599 fee that groups offering the classes must pay Medicare to be part of its program. CMS said the rule changes would make it easier and more attractive for MDPP providers, including YMCAs and other local community organizations, to participate.

While providers have welcomed the proposed revisions as marginally helpful, they criticized CMS for not letting them provide classes and counseling to Medicare beneficiaries through online methods including apps, videoconferencing and texting.

Many health insurers covering people under age 65 offer similar diabetes classes online, and they claim success rates comparable to in-person classes.

A key factor limiting providers’ participation up to now is that CMS has tied a bonus payment to beneficiaries’ losing at least 5% of their body weight, which only a minority of participants achieve. But studies show that weight loss of just 2% to 3% can significantly reduce A1c levels and the associated risk of developing diabetes.

Researchers and providers say that payment model hurts organizations that serve low-income and minority groups, whose members are less likely for a variety of reasons to attend all the sessions and achieve 5% weight loss but who still can benefit from the program.

Even without the penalty for not hitting the 5% target, Medicare’s payment rate doesn’t come close to covering the cost of running in-person classes, experts say.

Read the full article


Medicare could cover dental, vision and hearing under new $3.5 Trillion plan

Posted by www.psmbrokerage.com Admin on Mon, Jul 26, 2021 @ 10:28 AM


Medicare could cover dental, vision and hearing under new $3.5 Trillion plan

Medicare, the health insurance program relied on by most older Americans, would cover dental, vision and hearing under a budget agreement.

Although there’s no certainty that everything in the budget blueprint will make it through the full congressional process, Medicare advocates are hopeful that coverage of the extra benefits will come to fruition.

“It would be a significant improvement [to provide coverage] for people who often go without needed care because they can’t afford it and for people who pay a lot for the care they need,” said Tricia Neuman, executive director for the Kaiser Family Foundation’s program on Medicare policy.

Some beneficiaries get limited coverage for dental, vision and hearing if they choose to get their Parts A and B benefits delivered through an Advantage Plan (Part C), which often include those extras. About 40% of beneficiaries are enrolled in Advantage Plans.

However, Lipschutz said, the extra coverage generally is not comprehensive. On the other hand, if expanded benefits — no matter how generous — were required under original Medicare, they’d become standard in an Advantage Plan.

“We’d hope this would enrich benefits for all beneficiaries,” Lipschutz said.


Key Points:

  • There’s no guarantee that the proposal to expand Medicare’s coverage will make it through the full legislative process.

  • It’s uncertain exactly what would be covered and to what degree, although other legislative efforts could provide some clues, including a bill that was introduced last week and another that cleared the House in 2019 but died in the Senate.


Read the full text


2022 Medicare Advantage First Looks Now Available!

Posted by www.psmbrokerage.com Admin on Thu, Jul 15, 2021 @ 04:22 PM

Tags: AEP, First Looks, 2022

Introducing Humana First Looks for 2022

Posted by www.psmbrokerage.com Admin on Wed, Jul 14, 2021 @ 10:42 AM

2022 Humana Plan Information. Learn More - Sell More

Tags: Humana, AEP, First Looks, 2022


Posted by www.psmbrokerage.com Admin on Tue, Jul 13, 2021 @ 03:39 PM

Tags: AEP, 2022

MA Beneficiaries Spend Less than Fee-for-Service Medicare Beneficiaries

Posted by www.psmbrokerage.com Admin on Tue, Jul 06, 2021 @ 03:35 PM

Tags: Medicare Advantage News

Enrollment Trends in Medicare Options

Posted by www.psmbrokerage.com Admin on Tue, Jul 06, 2021 @ 03:06 PM

Tags: Medicare Advantage News

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