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Can Dental Benefits Become a Competitive Advantage?

Posted by www.psmbrokerage.com Admin on Tue, Oct 15, 2019 @ 03:52 PM

Source: https://blog.deftresearch.com/can-dental-benefits-become-a-competitive-advantage

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Tags: Medicare Advantage, dental

92% of Humana’s Medicare Advantage Members are in 4-Star and Above

Posted by www.psmbrokerage.com Admin on Tue, Oct 15, 2019 @ 03:38 PM

Source: https://humana.gcs-web.com/news-releases/news-release-details/92-humanas-medicare-advantage-members-are-4-star-and-above

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Tags: Humana, Medicare Advantage

Medicare Advantage, Part D members shifting to higher-rated plans

Posted by www.psmbrokerage.com Admin on Tue, Oct 15, 2019 @ 11:07 AM

Medicare Advantage, Part D members shifting to higher-rated plans

Medicare Advantage, Part D members shifting to higher-rated plans

CMS unveiled star ratings for both Medicare Part D prescription plans and Medicare Advantage plans that show even more of the plans achieving higher star ratings.

The number of Medicare Part D prescription drug plan members who will be in plans with four stars or more in 2020 rose to 27.6%, up from just 3.5% last year, according to data released by the CMS on Friday. The percentage of four-star or greater Medicare Advantage Part C plans with prescription drug coverage grew to a whopping 81.1% of members in 2020, up from 75.3% in 2019.

The topic of lopsided star ratings toward the high end of the scale has been a sticking point with the Medicare Payment Advisory Commission, which believes $6 billion a year could be saved by revamping the way stars are awarded in the Medicare Advantage program.

Medicare prescription drug plans 2020 star ratings

The percentage of Medicare Part D prescription drug plan members in plans with four stars or more in 2020 rose sharply from the year before.

The average star rating of Part D plans, which are managed by pharmacy benefit management companies and health insurers, has bobbed up and down for years but has always hovered below four stars. The average star rating across the 54 Part D contracts in 2020 was 3.5, up from last year's average rating of 3.34.

Enrollment in Part D prescription drug plans with fewer than three stars dropped to 0.8%, compared to 6.2% last year. Just 5.6% of Part D plans received below three stars, whereas 9.6% did in 2018.

Meanwhile, more than 200 Medicare Advantage plans offering prescription drug coverage, representing 52.4% of these plans for 2020, received at least four stars. Last year, 172, or 45.7% of plans, were part of that category. The average star rating for Medicare Advantage plans with prescription drug coverage was 4.16 for 2020, up from last year's 4.06. Medicare Advantage plans with fewer than three stars dropped to 15%, compared with 21.3% in 2019.

Higher rated plans get larger share of enrollees

More people were enrolled in Medicare Advantage plans with prescription drug coverage that had 4.5- or 5-star ratings.

The CMS star rating system for Medicare's private insurance coverage is meant to hold insurers accountable for the care provided to their members.

Health plans have a financial incentive to provide better quality care for their members, because those that garner four or more stars receive a 5% boost to their monthly per-member payments from Medicare.

Twenty-three individual plans scored five stars for 2020. Twenty of those were Medicare Advantage plans offering prescription drug coverage, including nine new contracts that had not earned the high performing indicator last year. Two of the plans were stand-alone prescription drug plans and one was a Medicare Advantage-only plan.

CVS Health, Humana, UnitedHealth Group and Kaiser Foundation Health Plan were among companies offering five-star plans.

Five individual plans covering more than 73,000 people received a warning from the CMS for consistently low quality ratings. Those plans—owned by QHP Financial Group, Delaware Life Insurance Co., Centers Plan for Healthy Living, Universal Health Services and Magellan Health—have earned ratings of 2.5 stars or fewer for a Medicare Advantage or Part D contract since at least 2018.

CMS Administrator Seema Verma said in a statement that the star ratings in the Medicare Advantage and Part D programs indicate that "seniors will have access to more high-quality plans," and pointed to projections the agency released last month suggesting that in 2020 Medicare Advantage average monthly premiums will hit their lowest point in 13 years.

Source: https://www.modernhealthcare.com/medicare/medicare-advantage-part-d-members-shifting-higher-rated-plans

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Tags: Medicare Advantage, Medicare Part D, star ratings

Medicare Advantage Enrollment Grows 8% Year-Over-Year

Posted by www.psmbrokerage.com Admin on Fri, Oct 11, 2019 @ 01:03 PM

Medicare Advantage Enrollment Grows
8% Year-Over-Year


Gains Concentrated Among Major Players

Medicare Advantage enrollment grew 8.0% from September 2018 to September 2019, according to AIS’s Directory of Health Plans (see a complete month-by-month timeline below), continuing a trend of greater MA gains as more baby boomers, seeking more personalized benefits, age into Medicare. In advance of the Annual Election Period (AEP) starting on Oct. 15, CMS on Sept. 24 said it expects MA enrollment to reach new highs in 2020, growing about 10% to 24.4 million lives.

Growth this past year was concentrated among the largest payers in the MA space, with the top five experiencing enrollment gains of about 16% on average year over year (see breakdown below). The big winner was Aetna Inc., which took on its largest-ever MA expansion in 2019, adding its offerings to more than 350 new counties.

While still on top, market leader UnitedHealthcare’s post-AEP gains were smaller than the 400,000 to 450,000 members (excluding dual eligible Special Needs Plans) the company anticipated, instead adding only about 290,000 lives.

NOTE: All enrollment totals include dual eligible Special Needs Plans (D-SNPs) except where noted. AIS defines post-AEP enrollment as total MA membership as of February 2019.

Source: https://aishealth.com/medicare-and-medicaid/medicare-advantage-enrollment-grows-8-year-over-year-with-gains-concentrated-among-major-players/

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Tags: Medicare Advantage, UnitedHealthcare, aetna

CMS Releases Star Ratings for 2020 Medicare Advantage and Part D Drug Plans Ahead of Medicare Open Enrollment

Posted by www.psmbrokerage.com Admin on Fri, Oct 11, 2019 @ 12:49 PM

Star Ratings:
Medicare Plan Choices in 2020

Administration Drives Access to More High-Quality Medicare Plan Choices in 2020

Consistent with the direction of President Trump’s recent Executive Order on Strengthening and Improving Medicare for Our Nation’s Seniors, the Centers for Medicare & Medicaid Services (CMS) announced today that seniors will have access to more high-quality Medicare Advantage and Part D prescription drug plans in 2020. Most people with Medicare will have access to Medicare Advantage and Part D plans with four or more stars in 2020, and approximately 81 percent of Medicare Advantage enrollees with prescription drug coverage will be in plans with four and five stars in 2020, an increase from 69 percent in 2017.

Medicare Advantage remains a popular choice among beneficiaries and has high satisfaction rates. Due to recent actions CMS has made to protect and strengthen Medicare Advantage, Medicare Advantage plans are better able to compete on the basis of cost and quality. As a result, beneficiaries are benefiting from more plan choices, lower costs and increased quality. As announced last month, on average, Medicare Advantage premiums are expected to decline by 23 percent from 2018, and will be the lowest in the last thirteen years for the more than 24 million people with Medicare who are projected to enroll in Medicare Advantage for 2020. Beneficiaries will have more plan choices, with about 1,200 more Medicare Advantage plans operating in 2020 than in 2018.

“President Trump continues to be the great protector of the Medicare program for our nation’s seniors,” said CMS Administrator Seema Verma. “Thanks to the President’s leadership and commitment, the improvements that CMS has made to the Medicare Advantage and Part D programs means that seniors will have access to more high-quality plans. Proposals for more government in our healthcare – such as Medicare-for-All – would eviscerate the progress we’ve made to strengthen the program by empowering patients to make informed choices in choosing high-quality plans that best fit their needs.”

Approximately 52 percent of Medicare Advantage plans that offer prescription drug coverage will have an overall rating of four stars or higher, compared to approximately 45 percent in 2019. The average star rating for all Medicare Advantage plans with prescription drug coverage has improved to 4.16 out of 5 stars, increasing from 4.02 in 2017.

More Medicare beneficiaries will have access to a greater number of high-quality stand-alone Medicare Part D prescription drug plans. In 2020, based on current enrollment, approximately 28 percent of enrollees will be in stand-alone prescription drug plans with 4 stars or higher, an increase from approximately 3 percent in 2018. And the average star rating for a stand-alone prescription drug plan has improved from 3.34 in 2019 to 3.50 in 2020.

Earlier this year, CMS made improvements to the Medicare Advantage and Part D Star Ratings so that consumers can more easily identify high-value and high-quality plans. The Star Ratings methodology was enhanced to better account for differences in a plan’s enrollee population.

The Star Ratings system helps people with Medicare, their families, and their caregivers compare the quality of health and drug plans being offered. Medicare health and drug plans are given a rating on a 1 to 5 star scale, with 1 representing poor performance and 5 stars representing excellent performance. Medicare beneficiaries can compare health coverage choices and the Star Ratings through the online Medicare Plan Finder tool available at Medicare.gov (https://www.medicare.gov). CMS publishes the Medicare Advantage and Part D Star Ratings every year to measure the quality of, and reflect the experiences of beneficiaries in, Medicare Advantage and Part D plans.

It will be easier than ever to compare Medicare Advantage and Part D plans on Medicare.gov. As the 2020 Medicare Open Enrollment period approaches, CMS for the first time in a decade launched a modernized and redesigned Medicare Plan Finder – the most-used tool on Medicare.gov – that allows users to shop and compare Medicare Advantage and Part D plans (including by total costs of estimated annual drug costs plus premiums) as well as compare costs between original Medicare, Medicare prescription drug plans, Medicare Advantage plans and Medicare supplemental insurance (Medigap) policies.

Medicare Open Enrollment begins on October 15, 2019, and ends on December 7, 2019. During this time, Medicare beneficiaries can compare coverage options like Original Medicare and Medicare Advantage and choose health and drug plans for 2020. Medicare health and drug plan costs and covered benefits can change from year to year, so people with Medicare should look at their coverage choices and decide on the options that best meet their health needs. They can visit Medicare.gov (https://www.medicare.gov), call 1-800-MEDICARE, or contact their State Health Insurance Assistance Program.

For more information on the 2020 Medicare Advantage and Part D Star Ratings, including a fact sheet, please visit: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html, and download the “2020 Part C and D Medicare Star Ratings Data” zip file in the downloads section.

To view the premiums and costs of the 2020 Medicare Advantage and Part D plans, please visit: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/index.html.

Additional Updates:

Tags: Medicare Advantage, Medicare, star ratings

The Mad Rush To Sell Private Medicare Plans To Seniors

Posted by www.psmbrokerage.com Admin on Thu, Oct 10, 2019 @ 04:13 PM

The Mad Rush to Sell Private Medicare Plans to Seniors

The Mad Rush To Sell Private Medicare Plans To Seniors


Health insurers across the U.S. will race to enroll more seniors in lucrative government-backed Medicare plans this month, even as a roiling debate over the role of private companies in health coverage shapes the presidential race.

The plans, known as Medicare Advantage, are the private-sector, taxpayer-financed alternative to traditional Medicare. Selling them has become a crucial profit center for the insurance industry: Baby Boomers are aging into the program, propelling its growth, while at the same time health insurance products sold to people under 65 are facing pressure from all sides.

The private plans also sit squarely in the middle of the race for the presidency: Some candidates for the Democratic nomination, including Senators Bernie Sanders and Elizabeth Warren, have backed a proposal to do away with private health insurance across all markets. Last week, President Donald Trump signed an executive order aimed at bolstering Medicare Advantage, and said Democrats would upend the program.

In 2019, about 22 million people, or roughly a third of all Medicare enrollees, got their Medicare coverage through the private plans. For each person who signs up, the insurers collect a fee from the government. It was $11,545 on average this year, which adds up to about $254 billion. The Medicare Advantage enrollment period opens Oct. 15.

Insurers see it as a lucrative market they can’t afford to pass by. Medicare products are the biggest business at the biggest health insurance company, UnitedHealth Group Inc.’s insurance unit. Centene Corp. agreed to pay $15 billion this year for WellCare Health Plans Inc. in part to get access to the company’s large Medicare business. Startups like Clover Health, which has raised more than $900 million from investors including GV, Alphabet Inc.’s venture capital arm, are targeting Medicare customers with new technologies intended to deliver care more efficiently.

UnitedHealthcare will sell Medicare coverage in 100 new counties in 2020, reaching 90% of the eligible market. Humana Inc., which specializes in Medicare Advantage, will expand to 29 new counties. Humana Chief Executive Officer Bruce Broussard told investors in July that membership was growing at the fastest pace in a decade, and the company expects to add half a million members this year. Cigna Corp., which has a comparatively smaller Medicare business, is expanding to 37 new counties next year and projecting 10% to 15% average annual membership growth through 2025. CVS Health Corp.'s Aetna unit is expanding to 264 new counties in 2020.

Medicare is especially critical to insurers as their traditional business selling health plans to employers and individuals slows. A smaller percentage of the U.S. workforce is enrolled in employer coverage than two decades ago, according to data from the Kaiser Family Foundation, a nonprofit health research group, as the cost of those benefits rises faster than workers’ earnings.

“We all know that 11,000 Americans turn age 65 every day and then the percent of those that choose” Medicare Advantage is accelerating, Anthem Inc. Chief Financial Officer John Gallina said at a conference in June. He called it “a huge opportunity that we’ve missed in the past, that we now need to capitalize on.”

Anthem’s Medicare Advantage membership grew by 25% in the 12 months ending June 2019, far faster than any other category. Anthem is expanding to 77 new counties in 2020.

Seniors in traditional Medicare can go to any doctor or hospital that participates, as most do. Those who choose Medicare Advantage plans trade that freedom of choice for an insurance company’s more limited network. In exchange, they get extra benefits. Medicare Advantage policies often wrap in prescription-drug plans, vision and dental care. Many offer free gym memberships or fitness programs. They also cap members’ total out-of-pocket costs. In traditional Medicare, seniors have to buy policies known as Medicare supplement or Medigap plans to limit their out-of-pocket expenses.

Starting in 2019, a federal rule change permitted Medicare Advantage plans to offer other perks like transportation and meal delivery. The goal is to address so-called social determinants of health, the many non-medical aspects of people’s lives that affect their well-being. Plans will offer a greater variety of those benefits in 2020.

Some Cigna plans in Texas will pay for air conditioners for the first time next year. Anthem will offer pest-control services, because vermin can affect chronic health conditions such as asthma. Carriers are also testing benefits like adult day care; home safety improvements, like grab bars, to prevent falls; and in-home help for people who need assistance bathing or dressing.

“We actually find a lot of beneficiaries are living in environments that really need support and help,” said Martin Esquivel, vice president of Medicare product management at Anthem.

Medicare doesn’t provide those things in its traditional fee-for-service program, partly because of the risk of inappropriate payments or fraud. In Medicare Advantage, the government’s payment to plans is limited, so that risk is managed by the plans.

The growth of Medicare Advantage shows demand for private managed-care plans exists even when seniors have a purely public option. “No one’s forcing them to do this,” said Dan Mendelson, founder of consultant Avalere Health and a partner at private equity firm Welsh Carson Anderson & Stowe. Seniors are increasingly comfortable giving up some choice of doctors in exchange for Medicare Advantage’s perks, he said. “It’s the choice that makes it really remarkable, that seniors are choosing this.”

While two-thirds of Medicare enrollees choose to stick with the original program, that share is declining. Mendelson said Medicare Advantage enrollment has grown by 8% annually in recent years. At that pace, more than half of Medicare members will be in private plans by 2025, he estimates.

Many people can get Medicare Advantage for no additional premium beyond what they pay for traditional Medicare. The average monthly premium for Medicare Advantage is $23 in 2020, down from $26.87 the prior year, according to the Centers for Medicare and Medicaid Services. It’s at the lowest level since 2007.

Plans have historically been paid generously. A decade ago, Medicare paid private plans 14% more than it would have spent for the same beneficiaries in the traditional program, according to the Medicare Payment Advisory Commission, known as MedPAC, which counsels Congress on Medicare policy. That helped finance additional benefits that enrollees found attractive, but it raised the program’s costs and put little pressure on plans to deliver more efficient care. The 2010 Affordable Care Act lowered those payments. They’re now about 1% above traditional Medicare payments, according to MedPAC.

People who choose to enroll in Medicare Advantage plans also typically have lower health spending before they enroll, compared with similar people in traditional Medicare, according to an analysis by the Kaiser Family Foundation. That means the way payments are set “may systematically overestimate expected costs of Medicare Advantage enrollees,” the Kaiser researchers wrote. Plans have been also faulted by government watchdogs for improperly denying care.

Medicare Advantage plans pay about 86% of their premium revenue out in medical claims, a similar proportion to other health insurance products, according to a separate Kaiser Family Foundation report. But the opportunity to profit is higher. Partly because Medicare beneficiaries use more medical care than younger people, there’s more money at stake for each member. Gross margins in Medicare Advantage – the difference between premiums collected and claims paid, before counting administrative costs – are about $1,600 per enrollee, roughly double the value in commercial plans, according to Kaiser’s analysis.

“This appears to be a fairly profitable market,” said Tricia Neuman, director of the Kaiser Family Foundation’s program on Medicare policy. The group sees more carriers enter the market than exit each year. “If it weren’t profitable, they wouldn’t be doing it,” Neuman said.

Big Winners
The market for Medicare Advantage plans has become increasingly concentrated. In 2018, the top four Medicare organizations had 59% of enrollment, up from 46% in 2011, according to MedPAC. And while it may seem like an attractive market, it’s difficult for new competitors to enter.

“We had no idea how hard it would be, how long it would take, the infrastructure we’d have to develop,” said Vivek Garipalli, chief executive officer of Clover Health. The company has about 42,000 members, mostly in New Jersey.

Other new technology-focused insurers are trying to break into the market. Oscar Health announced its first Medicare plans this year. Startup Devoted Health, which is led by former Obama administration officials, raised $360 million to launch its Medicare Advantage plans in 2019.

Those companies are betting that technology can deliver better care more efficiently, by using data to help physicians manage patients with chronic conditions, for example. Medicare Advantage is an ideal proving ground to test that idea, because plans make money if they can deliver savings without compromising quality.

“Health care has effectively had zero productivity gains over the last 20 years,” said Bob Kocher, a partner at venture firm Venrock. The firm backed Devoted Health and Kocher served as the company’s chief medical officer for a year. “There should be a lot of pent-up opportunity here to apply technology to make health care much more productive, and that would also make health care more affordable.”

--With assistance from Hannah Recht.

This article was provided by Bloomberg News.

Source: https://www.fa-mag.com/news/the-mad-rush-to-sell-private-medicare-plans-to-seniors-52068.html

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Tags: Humana, Cigna, Medicare Advantage, UnitedHealthcare, aetna

Scheduled Maintenance For HealthCare.gov

Posted by www.psmbrokerage.com Admin on Thu, Oct 10, 2019 @ 01:37 PM

Scheduled Maintenance For HealthCare.gov

CMS released its
scheduled maintenance windows for HealthCare.gov for the impending open enrollment period. As in recent years, open enrollment is 45 days long; from November 1 to December 15.

Maintenance for HealthCare.gov is scheduled for pre-dawn on November 1 (final prep ahead of  open enrollment) and each Sunday from midnight to noon, EST, except on December 15.

Federal officials selected Sunday mornings because it’s when the website receives the least amount of traffic. During any website downtime, HealthCare.gov will be unavailable.

As in prior years, CMS anticipates actual maintenance periods will be much shorter. Despite the allocation of 60 hours for maintenance last year, the website was down for only 

Photo by Freepik


Tags: Medicare Advantage, Medicare, Medicare Supplement, Medicare Part D

CMS Projects Record-High Medicare Advantage Enrollment in 2020

Posted by www.psmbrokerage.com Admin on Wed, Oct 09, 2019 @ 02:36 PM

CMS Projects Record-High Medicare Advantage Enrollment in 2020

Trump executive order aims to encourage new Medicare benefits

2020 is shaping up to be another competitive year for the Medicare Advantage program, which will feature an additional 600 plan choices and a continued decline in the average monthly premium. With its annual release of the so-called landscape files for the MA and Part D programs, CMS on Sept. 24 said it expects MA enrollment to reach an all-time high of 24.4 million in 2020, up 10% from the current enrollment of 22.2 million.

For 2020, the average monthly MA plan premium will drop by 14% to an estimated $23, the lowest average monthly premium since 2007. As the Affordable Care Act health insurer fee (HIF) returns in 2020, CMS’s bullish enrollment outlook “indicates most plans are prioritizing stability of benefits and enrollment,” observed securities analyst Michael Newshel in a Sept. 24 research note from Evercore ISI.

According to data released alongside the 2020 MA and Part D landscape files, beneficiaries will have an average number of 39 plan choices per county, CMS estimated. Moreover, CMS said there are about 1,200 more MA plans operating in 2020 than in 2018.

According to estimates from Citi Research, there will also be a substantial rise in the number of plans with a $0 monthly premium, with Centene Corp. showing the greatest increase (56%) in $0 premium offerings.

Meanwhile, the Special Needs Plan (SNP) market will continue to expand. According to estimates from Chicago-based consulting firm Clear View Solutions, LLC, there are 171 net new SNP plan IDs, up from 60 net new plans in 2019. In addition, the number of stand-alone Prescription Drug Plan offerings will rise from 1,369 in 2019 to 1,433 next year.

Medicare beneficiaries may begin perusing their 2020 coverage options on Oct. 1. Open enrollment begins on Oct. 15 and ends on Dec. 7.

Source: https://aishealth.com/medicare-and-medicaid/cms-projects-record-high-medicare-advantage-enrollment-in-2020/

Additional Updates:

Tags: Medicare Advantage, Medicare

Trump Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors

Posted by www.psmbrokerage.com Admin on Wed, Oct 09, 2019 @ 02:30 PM

Trump Executive Order on Protecting and Improving Medicare for Our Nation’s Seniors


By the authority vested in me as President by the Constitution and the laws of the United States of America, it is hereby ordered as follows:

Section 1.  Purpose.  The proposed Medicare for All Act of 2019, as introduced in the Senate (“Medicare for All”) would destroy our current Medicare program, which enables our Nation’s seniors and other vulnerable Americans to receive affordable, high-quality care from providers of their choice.  Rather than upend Medicare as we know it, my Administration will protect and improve it.

America’s seniors are overwhelmingly satisfied with their Medicare coverage.  The vast majority of seniors believe that the program delivers high-quality health outcomes.  Medicare empowers seniors to choose their own providers and the type of health insurance that works best for them, whether it is fee for-service (FFS) Medicare, in which the Federal Government pays for covered services, or Medicare Advantage (MA), in which Medicare dollars are used to purchase qualified private health insurance.  “Medicare for All” would take away the choices currently available within Medicare and centralize even more power in Washington, harming seniors and other Medicare beneficiaries.  Throughout their lives, workers and their employers have contributed their own money to the Medicare Trust Fund.  It would be a mistake to eliminate Americans’ healthcare choices and to force them into a new system that is effectively a Government takeover of their healthcare.

“Medicare for All” would not only hurt America’s seniors, it would also eliminate health choices for all Americans.  Instead of picking the health insurance that best meets their needs, Americans would generally be subject to a single, Government-run system.  Private insurance for traditional health services, upon which millions of Americans depend, would be prohibited.  States would be hindered from offering the types of insurance that work best for their citizens.  The Secretary of Health and Human Services (Secretary) would have the authority to control and approve health expenditures; such a system could create, among other problems, delays for patients in receiving needed care.  To pay for this system, the Federal Government would compel Americans to pay more in taxes.  No one — neither seniors nor any American — would have the same options to choose their health coverage as they do now.

Instead of ending the current Medicare program and eliminating health choices for all Americans, my Administration will continue to protect and improve Medicare by building on those aspects of the program that work well, including the market-based approaches in the current system.  The MA component, for example, delivers efficient and value-based care through choice and private competition, and has improved aspects of the Medicare program that previously failed seniors.  The Medicare program shall adopt and implement those market-based recommendations developed pursuant to Executive Order 13813 of October 12, 2017 (Promoting Healthcare Choice and Competition Across the United States), and published in my Administration’s report on “Reforming America’s Healthcare System Through Choice and Competition.”  Doing so would help empower patients to select and access the right care, at the right time, in the right place, from the right provider.

Sec. 2.  Policy.  It is the policy of the United States to protect and improve the Medicare program by enhancing its fiscal sustainability through alternative payment methodologies that link payment to value, increase choice, and lower regulatory burdens imposed upon providers.

Sec. 3.  Providing More Plan Choices to Seniors.  (a)  Within 1 year of the date of this order, the Secretary shall propose a regulation and implement other administrative actions to enable the Medicare program to provide beneficiaries with more diverse and affordable plan choices.  The proposed actions shall:

(i)    encourage innovative MA benefit structures and plan designs, including through changes in regulations and guidance that reduce barriers to obtaining Medicare Medical Savings Accounts and that promote innovations in supplemental benefits and telehealth services;

(ii)   include a payment model that adjusts supplemental MA benefits to allow Medicare beneficiaries to share more directly in the savings from the program, including through cash or monetary rebates, thus creating more incentives to seek high-value care; and

(iii)  ensure that, to the extent permitted by law, FFS Medicare is not advantaged or promoted over MA with respect to its administration.

(b)  The Secretary, in consultation with the Chairman of the Council of Economic Advisers, shall submit to the President, through the Assistants to the President for Domestic and Economic Policy, a report within 180 days from the date of this order that identifies approaches to modify Medicare FFS payments to more closely reflect the prices paid for services in MA and the commercial insurance market, to encourage more robust price competition, and otherwise to inject market pricing into Medicare FFS reimbursement.

Sec. 4.  Improving Access Through Network Adequacy.  Within 1 year of the date of this order, the Secretary shall propose a regulation to provide beneficiaries with improved access to providers and plans by adjusting network adequacy requirements for MA plans to account for:

(a)  the competitiveness of the health market in the States in which such plans operate, including whether those States maintain certificate-of-need laws or other anti-competitive restrictions on health access; and

(b)  the enhanced access to health outcomes made possible through telehealth services or other innovative technologies.

Sec. 5.  Enabling Providers to Spend More Time with Patients.  Within 1 year of the date of this order, the Secretary shall propose reforms to the Medicare program to enable providers to spend more time with patients by:

(a)  proposing a regulation that would eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions, and all other licensure requirements of the Medicare program that are more stringent than applicable Federal or State laws require and that limit professionals from practicing at the top of their profession;

(b)  proposing a regulation that would ensure appropriate reimbursement by Medicare for time spent with patients by both primary and specialist health providers practicing in all types of health professions; and

(c)  conducting a comprehensive review of regulatory policies that create disparities in reimbursement between physicians and non-physician practitioners and proposing a regulation that would, to the extent allowed by law, ensure that items and services provided by clinicians, including physicians, physician assistants, and nurse practitioners, are appropriately reimbursed in accordance with the work performed rather than the clinician’s occupation.

Sec. 6.  Encouraging Innovation for Patients.  Within 1 year of the date of this order, the Secretary shall propose regulatory and sub-regulatory changes to the Medicare program to encourage innovation for patients by:

(a)  streamlining the approval, coverage, and coding process so that innovative products are brought to market faster, and so that such products, including breakthrough medical devices and advances in telehealth services and similar technologies, are appropriately reimbursed and widely available, consistent with the principles of patient safety, market-based policies, and value for patients.  This process shall include:

(i)    adopting regulations and guidance that minimize and eliminate, as appropriate, the time and steps between approval by the Food and Drug Administration (FDA) and coverage decisions by the Centers for Medicare and Medicaid Services (CMS);

(ii)   clarifying the application of coverage standards, including the evidence standards CMS uses in applying its reasonable-and-necessary standard, the standards for deciding appeals of coverage decisions, and the prioritization and timeline for each National Coverage Determination process in light of changes made to local coverage determination processes; and

(iii)  identifying challenges to the use of parallel FDA and CMS review and proposing changes to address those challenges; and

(b)  modifying the Value-Based Insurance Design payment model to remove any disincentives for MA plans to cover items and services that make use of new technologies that are not covered by FFS Medicare when those items and services can save money and improve the quality of care.

Sec. 7.  Rewarding Care Through Site Neutrality.  The Secretary shall ensure that Medicare payments and policies encourage competition and a diversity of sites for patients to access care.

Sec. 8.  Empowering Patients, Caregivers, and Health Providers.  (a)  Within 1 year of the date of this order, the Secretary shall propose a regulation that would provide seniors with better quality care and cost data, improving their ability to make decisions about their healthcare that work best for them and to hold providers and plans accountable.

(b)  Within 1 year of the date of this order, the Secretary shall use Medicare claims data to give health providers additional information regarding practice patterns for services that may pose undue risks to patients, and to inform health providers about practice patterns that are outliers or that are outside recommended standards of care.

Sec. 9.  Eliminating Waste, Fraud, and Abuse to Protect Beneficiaries and Taxpayers.  (a)  The Secretary shall propose regulatory or sub-regulatory changes to the Medicare program, to take effect by January 1, 2021, and shall propose such changes annually thereafter, to combat fraud, waste, and abuse in the Medicare program.  The Secretary shall undertake all appropriate efforts to direct public and private resources toward detecting and preventing fraud, waste, and abuse, including through the use of the latest technologies such as artificial intelligence.

(b)  The Secretary shall study and, within 180 days of the date of this order, recommend approaches to transition toward true market-based pricing in the FFS Medicare program.  The Secretary shall submit the results of this study to the President through the Assistants to the President for Domestic and Economic Policy.  Approaches studied shall include:

(i)    shared savings and competitive bidding in FFS Medicare;

(ii)   use of MA-negotiated rates to set FFS Medicare rates; and

(iii)  novel approaches to information development and sharing that may enable markets to lower cost and improve quality for FFS Medicare beneficiaries.

Sec. 10.  Reducing Obstacles to Improved Patient Care.  Within 1 year of the date of this order, the Secretary shall propose regulatory changes to the Medicare program to reduce the burden on providers and eliminate regulations that create inefficiencies or otherwise undermine patient outcomes.

Sec. 11.  Maximizing Freedom for Medicare Patients and Providers.  (a)  Within 180 days of the date of this order, the Secretary, in coordination with the Commissioner of Social Security, shall revise current rules or policies to preserve the Social Security retirement insurance benefits of seniors who choose not to receive benefits under Medicare Part A, and propose other administrative improvements to Medicare enrollment processes for beneficiaries.

(b)  Within 1 year of the date of this order, the Secretary shall identify and remove unnecessary barriers to private contracts that allow Medicare beneficiaries to obtain the care of their choice and facilitate the development of market-driven prices.

Sec. 12.  General Provisions.  (a)  Nothing in this order shall be construed to impair or otherwise affect:

(i)   the authority granted by law to an executive department or agency, or the head thereof; or

(ii)  the functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.

(b)  This order shall be implemented consistent with applicable law and subject to the availability of appropriations.

(c)  This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.


October 3, 2019.


Additional Updates:

Tags: Medicare Advantage, Medicare

Medicare Pays for 1/3 of U.S. Prescription

Posted by www.psmbrokerage.com Admin on Tue, Oct 08, 2019 @ 03:02 PM

Medicare Pays for 1/3 of U.S. Prescription

The majority of Medicare voluminous prescription drug spending is for drugs covered under Part D, although Part B also covers medicine; this spending accounts for 30 percent of national retail spending on drugs, and nearly $1 out of every $5 in total Medicare spending. 

medicare drug spending chart

Prescription drugs are an important component of health care for Medicare beneficiaries, which includes more than 60 million older adults and people with long-term disabilities.

The majority of Medicare prescription drug spending is for drugs covered under Part D, the outpatient prescription drug benefit. Medicare Part B also covers drugs that are administered to patients in physician offices and other outpatient settings.

A majority of Americans favors allowing the federal government to negotiate prescription drug prices on behalf of Part D beneficiaries;
the practice is prohibited under current law.

View Full Article


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Tags: Medicare Advantage, Medicare, Medicare Supplement, Medicare Part D

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