Proudly Serving all of PA & NJ
Health Insurance for Self-Employed
Flexible Plans
We offer a range of plans that can be customized to fit the unique needs of self-employed individuals.
Tax Benefits
Self-employed individuals may be eligible for tax benefits when purchasing health insurance through our plans.
No Networks
Our plans offer the flexibility to choose any doctor or hospital without being restricted to a network.
Prescription Drug Coverage
Our plans provide coverage for prescription drugs, including both brand-name and generic medications.
Easy Enrollment
Enroll in our self-employed health insurance plans easily online or by phone.
Site Content
How a default could affect Medicare, Medicaid
The CMS has said that if the debt ceiling isn't raised by June 1, "there would be significant consequences for Medicaid, Medicare and the Affordable Care Act Marketplaces." It's unclear how the federal government would prioritize payments for the programs, and without funding for the programs, health care providers would need to prepare to stop receiving Medicare reimbursements. A key issue in debt limit negotiations between the administration and House Republicans is adding work requirements to programs such as Medicaid and the Supplemental Nutrition Assistance Program. Full Story https://thehill.com/policy/healthcare/4009038-what-a-default-could-mean-for-medicaid-and-other-federal-benefits/
Study: 20% of older adults struggle to afford medications
About 20% of US adults ages 65 and older who responded to a national survey last year said cost concerns forced them to skip or postpone filling a prescription, take less medication than prescribed or take drugs prescribed to another person. The study, published in JAMA Network Open, found about 30% of more than 2,000 respondents used a coupon or copayment card to pay for medications and more than 8% skipped buying basic needs such as groceries and gas to afford their prescriptions. Full Story https://www.nbcnews.com/health/health-news/1-5-older-adults-skipped-delayed-medications-last-year-cost-rcna84750
Poll: Depression rates among US adults hit record high
A record 29% of respondents to a Gallup poll conducted in February said they had been diagnosed with depression at some point, up from 26.9% last year. The percentage of Americans who said they are currently depressed or receiving treatment for the condition also reached a record level, at 17.8%, with Black and Hispanic adults more likely to report receiving a depression diagnosis than white adults. Read more https://www.forbes.com/sites/brucejapsen/2023/05/17/gallup-poll-us-depression-hits-all-time-high-with-29-whove-been-diagnosed-at-some-point/?sh=6874a01c6c77
FDA approves first oral drug for Crohn's disease
AbbVie's oral JAK inhibitor Rinvoq, or upadacitinib, was approved by the FDA for treatment of moderately to severely active Crohn's disease among adults whose disease has not responded to or who cannot tolerate at least one tumor necrosis factor inhibitor medication. The approval makes Rinvoq the first oral treatment to receive FDA approval for Crohn's disease. Read more https://medcitynews.com/2023/05/abbvie-rinvoq-fda-approval-crohns-disease-pill/
AHIP's new campaign to hold Big Pharma accountable
AHIP has launched a major new advertising campaign that spotlights the role health insurance providers play in securing savings, promoting competition, and providing more choices than ever before for millions of Americans. The ads call out Big Pharma for spending millions pointing fingers at others in the health care system to distract Americans from manufacturers' soaring drug prices.
N.H. House votes for Medicaid expansion
The New Hampshire House voted 193-166 to advance a bill that would reauthorize the state's Medicaid expansion program and make it permanent. Supporters of the legislation said 70% of Medicaid beneficiaries in the state have full- or part-time jobs and the Granite Advantage program has contributed to a healthier and stronger workforce, while opponents say the program needs more time to demonstrate its value. Full story https://apnews.com/article/medicaid-expansion-new-hampshire-2018fcb999bc3cea03dc0323bb216a18
Site Content
How a default could affect Medicare, Medicaid
The CMS has said that if the debt ceiling isn't raised by June 1, "there would be significant consequences for Medicaid, Medicare and the Affordable Care Act Marketplaces." It's unclear how the federal government would prioritize payments for the programs, and without funding for the programs, health care providers would need to prepare to stop receiving Medicare reimbursements. A key issue in debt limit negotiations between the administration and House Republicans is adding work requirements to programs such as Medicaid and the Supplemental Nutrition Assistance Program. Full Story https://thehill.com/policy/healthcare/4009038-what-a-default-could-mean-for-medicaid-and-other-federal-benefits/
How a default could affect Medicare, Medicaid
The CMS has said that if the debt ceiling isn't raised by June 1, "there would be significant consequences for Medicaid, Medicare and the Affordable Care Act Marketplaces." It's unclear how the federal government would prioritize payments for the programs, and without funding for the programs, health care providers would need to prepare to stop receiving Medicare reimbursements. A key issue in debt limit negotiations between the administration and House Republicans is adding work requirements to programs such as Medicaid and the Supplemental Nutrition Assistance Program. Full Story https://thehill.com/policy/healthcare/4009038-what-a-default-could-mean-for-medicaid-and-other-federal-benefits/
Study: 20% of older adults struggle to afford medications
About 20% of US adults ages 65 and older who responded to a national survey last year said cost concerns forced them to skip or postpone filling a prescription, take less medication than prescribed or take drugs prescribed to another person. The study, published in JAMA Network Open, found about 30% of more than 2,000 respondents used a coupon or copayment card to pay for medications and more than 8% skipped buying basic needs such as groceries and gas to afford their prescriptions. Full Story https://www.nbcnews.com/health/health-news/1-5-older-adults-skipped-delayed-medications-last-year-cost-rcna84750
Poll: Depression rates among US adults hit record high
A record 29% of respondents to a Gallup poll conducted in February said they had been diagnosed with depression at some point, up from 26.9% last year. The percentage of Americans who said they are currently depressed or receiving treatment for the condition also reached a record level, at 17.8%, with Black and Hispanic adults more likely to report receiving a depression diagnosis than white adults. Read more https://www.forbes.com/sites/brucejapsen/2023/05/17/gallup-poll-us-depression-hits-all-time-high-with-29-whove-been-diagnosed-at-some-point/?sh=6874a01c6c77
FDA approves first oral drug for Crohn's disease
AbbVie's oral JAK inhibitor Rinvoq, or upadacitinib, was approved by the FDA for treatment of moderately to severely active Crohn's disease among adults whose disease has not responded to or who cannot tolerate at least one tumor necrosis factor inhibitor medication. The approval makes Rinvoq the first oral treatment to receive FDA approval for Crohn's disease. Read more https://medcitynews.com/2023/05/abbvie-rinvoq-fda-approval-crohns-disease-pill/
AHIP's new campaign to hold Big Pharma accountable
AHIP has launched a major new advertising campaign that spotlights the role health insurance providers play in securing savings, promoting competition, and providing more choices than ever before for millions of Americans. The ads call out Big Pharma for spending millions pointing fingers at others in the health care system to distract Americans from manufacturers' soaring drug prices.
N.H. House votes for Medicaid expansion
The New Hampshire House voted 193-166 to advance a bill that would reauthorize the state's Medicaid expansion program and make it permanent. Supporters of the legislation said 70% of Medicaid beneficiaries in the state have full- or part-time jobs and the Granite Advantage program has contributed to a healthier and stronger workforce, while opponents say the program needs more time to demonstrate its value. Full story https://apnews.com/article/medicaid-expansion-new-hampshire-2018fcb999bc3cea03dc0323bb216a18
Important medical plan benefit update: Federal public health emergency for COVID-19 to end May 11th
Upcoming changes to federal COVID coverage requirements may impact your clients’ medical plan benefits. On May 11, 2023, the federal public health emergency (“PHE”) for COVID-19 will end which means health plans and group plan sponsors will no longer be required to follow federal PHR requirements to cover certain COVID-19 testing, testing-related services and vaccines.
- Starting May 12, 2023, the amount members pay for covered COVID-19 testing, testing-related services and treatment may change
- COVID-19 vaccines will continue to be covered at no additional cost when members visit an in-network provider. Vaccines obtained out-of-network will be subject to plan cost-sharing.
- Employers will be notified by email on May 2
Members will be notified via email or letter prior to May 12
Hospitals face rough waters from high costs
The patients are back — but health systems are facing post-pandemic cost pressures driven by inflation and workforce shortages. These financial pressures are threatening the recovery of the industry, mainly the most vulnerable organizations, experts tell Axios. Full Story: https://www.axios.com/2023/05/01/hospitals-high-costs-financial-pressures
CMS proposes rate transparency rules for Medicaid
CMS proposed two new rules April 27 that would establish national standards of care provided through fee-for-service Medicaid/CHIP and managed care plans, along with a requirement to publicly disclose provider payment rates online. Full story
https://www.beckerspayer.com/policy-updates/cms-proposes-price-transparency-rules-for-medicaid.html
Mental health and substance use disorder coverage in Medicare Advantage plans
Mental health and substance abuse disorder services are needed by people of all ages, including older adults. In February 2023, 20% of adults 65 and older reported symptoms of anxiety and/or depression. Medicare covers a range of mental health and substance use disorder services, and Medicare Advantage plans are required to cover the same set of services as traditional Medicare. Full story https://www.kff.org/medicare/issue-brief/mental-health-and-substance-use-disorder-coverage-in-medicare-advantage-plans/
Half of all eligible medicare beneficiaries are now enrolled in private Medicare Advantage plans
According to recently released data from the Centers for Medicare & Medicaid Services, Medicare Advantage now provides Medicare coverage for just over half of eligible beneficiaries. In January 2023, 30.19 million of the 59.82 million people with both Medicare Part A and Part B were enrolled in a private plan.
Most who lose Medicaid will shift to employer plans
An AHIP-funded study estimates that 54% of Medicaid beneficiaries who lose coverage during the redetermination process will likely transition to health coverage through an employer, 21% will lose coverage entirely, 15% will transition to the Children's Health Insurance Program and the rest will either join nongroup coverage or shift to coverage through a different public program. Delaware is expected to have the highest percentage of Medicaid beneficiaries transferring to employer-based coverage after disenrollment at 57.1%, while seven states are expected to see uninsured rates ranging from 23.1% to 26.2%, according to the research. Read the full story https://healthpayerintelligence.com/news/americans-who-lose-medicaid-may-choose-employer-sponsored-coverage
Tripathi: Agencies working to support electronic prior authorization
National Coordinator for Health IT Micky Tripathi said the Biden administration is considering new certification requirements for health care provider EHRs to help improve the electronic prior authorization process. Speaking at AHIP's Medicare, Medicaid, Duals & Commercial Markets Forum on Wednesday, Tripathi said the ONC and the CMS are working together to ensure any electronic prior authorization requirements are aligned and to improve interoperability between health care providers and health insurance providers.
Research: Primary care is key to population health
Agency for Healthcare Research and Quality data show that 78% of US primary care physicians are practicing in urban regions, causing many patients in outlying areas to have trouble accessing care. Researchers said a higher density of primary care clinicians boosts detection and diagnosis of health conditions and narrows health disparities, while adding 10 primary care physicians per 100,000 residents correlates to a 51.5-day increase in patient life expectancy. US cities with the highest and lowest proportions of primary care clinicians are listed. Full story. https://www.beckershospitalreview.com/rankings-and-ratings/5-cities-with-the-most-fewest-primary-care-providers.html
United Concordia Dental Logo Gets Contemporary Look
United Concordia Dental’s logo is getting a more contemporary look in the coming weeks to signify its evolution and innovation as a company. Full story https://news.unitedconcordia.com/united-concordia-news-releases?item=122496
HHS: 27 Part B drugs subject to new Medicare rebates
HHS has released a list of Part B prescription drugs whose manufacturers will need to pay rebates to Medicare beginning April 1 because their price increases have exceeded the rate of inflation. The list of 27 drugs includes AbbVie's Humira, Pfizer's Fragmin and Kite Pharma's Tecartus.
How insurance companies use AI algorithms to cut health care for seniors on Medicare Advantage
Insurance companies are using algorithms to cut off healthcare to vulnerable seniors subscribed to Medicare Advantage, the taxpayer-funded alternative to traditional Medicare.
Here & Now's Robin Young hears more from Bob Herman, who covers the business of healthcare for STAT News, the health and medicine publication.
This segment aired on March 15, 2023..Listen to the Podcast https://www.wbur.org/hereandnow/2023/03/15/ai-algorithms-medicare-advantage
Why Medicare is suddenly under debate again
The White House released President Biden's $6.8 trillion proposed budget last week, listing his priorities for the upcoming fiscal year. Among other things, Biden singled out Medicare — the federal health insurance program for people aged 65 or older. Republican leaders insist they won't be threatening cuts to Medicare in upcoming budget negotiations, but others in the party have floated the idea of making changes over time to the program — including benefit cuts they say will be necessary to keep Medicare solvent. Listen to the podcast https://www.npr.org/sections/health-shots/2023/03/14/1163163234/why-medicare-is-suddenly-under-debate-again
Biden budget would raise taxes for some to bolster Medicare
Biden says his budget plan would extend Medicare to 2050 without adding to the deficit By Deepa Shi
President Biden is proposing a tax increase for people who make more than $400,000 to extend the life of Medicare for another 25 years, highlighting a major element of his budget proposal which the White House will release in full on Thursday.. Read the entire article https://www.npr.org/2023/03/07/1161582417/biden-budget-medicare
They could lose the house — to Medicaid
How seniors could lose in the Medicare political wars
Most with overdue medical bills carry hospital debt
A report from the Robert Wood Johnson Foundation and the Urban Institute found that 15.4% of Americans ages 18 to 64 live in families with past-due health care bills, and 72.9% of those cases involve money owed to a hospital. Researchers examined data from the Health Reform Monitoring Survey with 9,494 respondents, and they found that 60.9% of people who had past-due hospital bills had been contacted by a collections agency, 5.2% had been sued by a hospital, 3.9% said their salaries had been garnished, and 1.9% said their bank account funds had been seized.
Health care staff shortages affecting more Americans
A HealthDay/Harris Poll survey conducted last month found 35% of US adults ages 18 and older have noticed or have been affected by the shortage in health care workers, up from 25% in November, and 52% are concerned that staffing shortages will prevent them from getting necessary health care services. The poll, which included 2,048 respondents, also found that 84% have attempted to get medical care in the last six months, and almost 73% of them said their medical care was delayed or they encountered challenges in getting health care. Read More https://consumer.healthday.com/poll-shows-more-americans-worried-about-health-care-understaffing-2659571765.html
Medicaid stakeholders prioritize continuity of coverage
Roughly 15 million Medicaid enrollees are expected to lose coverage after eligibility redetermination begins next month, and some state Medicaid officials are leaning on health insurance providers to avert a substantial jump in uninsured rates. Officials say insurers offering Medicaid plans have the marketing resources needed and better access to enrollees to reach them with information about finding other coverage, such as through Affordable Care Act exchanges. Read More. https://khn.org/news/article/medicaid-disenrollment-public-health-emergency-insurance-revenue-increase/
Poll: 37% of US adults skip Rx fills because of costs
A survey of 1,500 Americans conducted this month found 37% of US adults have not filled a prescription due to cost, and women and people with less than $50,000 in annual family income were more likely to report doing so. A majority of respondents said they favor government efforts to limit the cost of prescription drugs such as insulin, cancer treatments, antidepressants and blood thinners
CDC: US adults should get hepatitis B test, vaccine
The CDC has issued a recommendation that all US adults should be tested for hepatitis B at least once during their lifetime, and all individuals between the ages of 19 and 59 years should get immunized against it. Officials wrote that up to 2.4 million US residents may have the infection, and it can cause "substantial morbidity and mortality," but two-thirds of those who are infected may be unaware of it. Read More. https://www.healio.com/news/infectious-disease/20230309/cdc-recommends-hepatitis-b-testing-for-all-adults
Some prostate cancer may not need treatment
A study of more than 1,600 UK men with localized prostate cancer found their risk of death was low regardless of whether they had surgery or were treated with radiation or actively monitored for up to 21 years after diagnosis. More aggressive treatment did not lower patients' mortality risk from prostate cancer, but it slowed the progression of the disease, researchers reported in the New England Journal of Medicine. Read More https://apnews.com/article/prostate-cancer-treatment-surgery-radiation-study-508ac3025e164ff629b180ebb6113df0
Women face high out-of-pocket costs for breast cancer treatment
Women with high deductible health plans or consumer driven health plans experienced higher out-of-pocket costs for breast cancer treatment than those with PPO or EPO plans.
Humana Will Leave Employer Group Insurance Business to Focus on Public Plans
Humana has announced plans to leave the employer group insurance business and direct its focus toward its government-funded health plan offerings. The payer’s employer group commercial medical. Read More https://healthpayerintelligence.com/news/humana-will-leave-employer-group-insurance-business-to-focus-on-public-plans
Hospice Enrollment from Community Setting More Common in Medicare Advantage
Medicare Advantage beneficiaries were more likely to enroll in hospice from a community setting rather than a hospital or nursing home setting compared to traditional Medicare beneficiaries,
How the Inflation Reduction Act Impacted Medicare Part D Benefit Design
Medicare Part D plan liability could lead to major changes in benefits and formulary design for beneficiaries in the coming years, according to an Avalere study that was funded by PhRMA
Employer-Sponsored Health Plans Pay More for Drugs than Medicare
Employer-sponsored health plans paid more than Medicare for most physician-administered drugs with the highest use and the highest spending, according to data published in JAMA Health Forum.
HHS Introduces Models for Lowering Prescription Drug Spending
The Department of Health and Human Services (HHS) has released three models intended to bring down prescription drug spending for consumers in Medicare and Medicaid. Read More https://healthpayerintelligence.com/news/hhs-introduces-models-for-lowering-prescription-drug-spending
Eli Lilly said it would cut the price of insulin, capping the monthly out-of-pocket cost of the life
The drugmaker Eli Lilly and Company said on Wednesday that it would significantly reduce the prices of several of its lifesaving insulin products that are used by diabetes patients and whose prices Lilly has repeatedly increased in the past.
Lilly also said it would cap at $35 a month what patients pay out of their own pockets for the company’s insulin.The move marks at least a partial retreat for a company that has been a primary contributor to soaring prices for an injection that millions of Americans rely on to keep their blood sugar levels in check. It comes at a time of mounting political pressure on drug companies to rein in what lawmakers and other critics view as the industry’s pattern of abusive profiteering.
Read the full article https://www.nytimes.com/2023/03/01/business/insulin-price-cap-eli-lilly.html?smid=tw-nytimes&smtyp=cur
More MA plans to offer supplemental services this year
An ATI Advisory analysis found the number of Medicare Advantage plans offering supplemental, non-medical benefits jumped to more than 2,200 this year from over 600 in 2020, the first year these benefits were allowed. A total of 1,091 MA plans will offer in-home support services this year, up more than fourfold since 2020, while 929 plans will offer food deliveries, up from 101 plans.
Full Story: Forbes (tiered subscription model)
Study links sweetener erythritol to increased CVD risks
Erythritol, a sugar alcohol often added to reduced-sugar products and sweeteners like stevia and monk fruit, has been linked to blood clotting and a heightened risk of cardiovascular events and mortality, according to a study published in the journal Nature Medicine. Researchers said people with existing heart disease risk factors, including diabetes, who had the highest levels of erythritol in their blood, had double the risk of a heart attack or stroke.
Full Story: CNN
People with insomnia, diabetes at higher heart attack risk
A study published in the journal Clinical Cardiology found that people with insomnia had 13% higher odds of experiencing a heart attack, with even greater risk seen in those with insomnia and diabetes. Researchers also found that older adults who had trouble staying or falling asleep had twice the risk of heart attacks compared with non-insomniac counterparts. Read the full story https://consumer.healthday.com/insomnia-2659454105.html
Getting Rehab at Home After Heart Attack Can Extend Lives
f you have had a heart attack, getting cardiac rehab at home could save your life
Patients who did rehab were 36% less likely to die of cardiac complications during a four-year study
But one barrier is lack of insurance coverage, experts say, although a bill before Congress would extend rehab coverage to Medicare and Medicaid patients Read the full article HealthDay https://consumer.healthday.com/cardiac-rehab-2659464316.html
Remote monitoring tech could enhance patient outcomes
The COVID-19 pandemic accelerated the adoption of wearable health trackers, which give clinicians a broader view of patients' health as well as baselines for individuals. Ambient sensors in homes that track biomechanics could help older people remain at home, and a combination of wearables and ambient technology could help patients actively participate in their own care as well as clinical trials and reduce inequalities, writes Brian Anthony, co-director of the Medical Electronic Device Realization Center at MIT. Read the full story https://medcitynews.com/2023/02/how-patient-monitoring-is-poised-to-revolutionize-healthcare/
MEDICARE IN THE NEWS
Humana to exit employer health plan market, focus on government programs
Humana Inc. will exit the employer-based insurance business over the next 18 to 24 months, to focus primarily on government-backed programs such as Medicare and its specialty businesses, the insurer announced Feb. 23, Reuters reports. In 2021, the last full year for which the company broke out revenues for its group and specialty segment, the Kentucky-based insurer’s group health business generated revenue of just under $7 billion, less than 10% of the total revenue of $83 billion.
Insurers: Medicare drug regulations could drive up costs
Medicare Advantage and Medicare drug plan insurers told the Centers for Medicaid and Medicare Services that too much regulation at once could drive up costs and result in increased premiums or fewer benefits, Axios reports. The public comment closed this week on a proposal to crack down on Medicare Advantage marketing practices, impose other standards on Medicare drug plans and create requirements to increase access to behavioral health and culturally competent care.
Value-based MA plans have better outcomes than Medicare: Optum
Value-based models in Medicare Advantage achieve better patient outcomes and more efficient care compared to traditional Medicare, according to a recent study from Optum, reports Fierce Healthcare. The researchers found that the MA model produced better outcomes and greater efficiency across all eight metrics studied, including admissions for certain diseases, avoidable emergency department visits and readmissions.
Hospitals may face reforms of high billing for outpatient services
Hospitals could be playing defense this year as bipartisan scrutiny builds in Congress over the way facilities charge more for outpatient services that can be done in less-expensive settings, like a private doctor's office, Axios reports. So-called site-neutral payment reforms could save Medicare upward of $100 billion over a decade, according to various projections, and those with private health insurance could see savings, too.
CMS pilot programs aim to lower prescription drug costs
The Centers for Medicare and Medicaid proposed on Feb. 14 three new pilot projects aimed at lowering prescription drug prices for people enrolled in government health insurance plans, including offering some essential generic drugs for $2 a month, Reuters reports. The CMS said it would test the models in the Medicare health program for people aged 65 or over and the disabled and the Medicaid program for the poor.
Denial of inpatient care claims up, especially for Medicare Advantage
Initial denials of inpatient claims filed by providers rose in 2022 with the highest denial rates coming from Medicare Advantage plans, according to a report from Crowe Revenue Cycle Analytics, reports Becker’s Payer Issues. Through November 2022, the dollar value of initial clinical denials by payers represented 3.2% of billed inpatient dollars, a rate that is 18.5% percent higher than in 2021
Physician lobby faces political headwinds for higher Medicare payments
The American Medical Association and nearly 100 other physician groups recently called for "long-term, substantive payment reforms," saying Medicare payments to clinicians have declined 22% from 2001 to 2021, when adjusted for inflation, Axios reports. The doctors want an inflation adjustment built into their rates, to help ensure they can make enough treating Medicare patients while costs rise.
Site Content
AHIP responds to Becerra's remarks on MA payment cuts
AHIP objected to recent statements made by HHS Secretary Xavier Becerra about the impact of the CMS' proposed 2024 Advance Rate Notice for Medicare Advantage and Part D plans, where Becerra said the administration is not proposing cuts to Medicare Advantage. AHIP says changes in the MA risk model, quality bonus payments and benchmarks proposed in the advanced notice will actually lead to a 2.27% cut to average MA rates instead of the 1.03% increase estimated by the CMS, and the rules "will have real-world consequences in 2024 for the more than 30 million seniors and people with disabilities who choose MA -- they will face increased costs and reduced benefits."
Study: Value-based MA models deliver better outcomes than FFS Medicare
A study in JAMA Network Open found value-based Medicare Advantage models deliver better outcomes and efficiency than traditional Medicare across eight metrics examined, including avoidable emergency department visits, readmissions and admissions for certain conditions. The findings, based on data from 316,000 individuals, found MA members in two-sided risk accountable care models had 18% lower odds of hospital admission, among other care metrics, compared with traditional Medicare beneficiaries.
70% of hospitals comply with price transparency rules
About 70% of US hospitals had both a consumer-friendly price display and a machine-readable price file by the end of last year, compared with only 27% in 2021, and 82% of hospitals had one or the other, according to an article in Health Affairs. However, side-by-side price comparisons are still difficult, and some private companies are devising ways to aggregate price information from different hospitals for easier shopping, says Lovisa Gustafsson with The Commonwealth Fund.
COVID-19 vaccines protect heart after breakthrough infection
People who are fully or partially vaccinated against COVID-19 have lower risks for heart attack, stroke and other cardiovascular issues if they subsequently develop COVID-19 than patients with COVID-19 who have not been vaccinated against the disease, researchers reported in the Journal of the American College of Cardiology. Researchers studied data from more than 1.9 million COVID-19 patients and found protection against cardiovascular events related to COVID-19 was associated with both mRNA vaccines and Johnson & Johnson's viral vector vaccine
20 minutes of physical activity may cut admission risk
Research published in JAMA Network Open found adults who increased their physical activity by 20 minutes more per day had lower hospitalization risk for various common illnesses such as stroke and venous thromboembolism. The study, based on data from 81,717 UK Biobank participants ages 42 years to 78 years, "provided evidence that increasing MVPA levels may help to lower hospital burdens
Have Questions on Medicare?
Call our office for a free consultation in person or over the phone
215-388-2158
medicare in the news
COVID as a pre-existing condition
Globally one-fifth of insurers are now treating long COVID as a pre-existing condition, potentially excluding coverage for individuals’ claims for the condition. This is most evident in Latin America, where 25% now exclude it.
CMS Proposes Benefit Expansion for Mobility Devices, Advancing Health Equity for People with Disabil
Proposal supports coverage of power seat elevation equipment for power wheelchairs
The Centers for Medicare & Medicaid Services (CMS) released a proposed National Coverage Determination (NCD) decision that would, for the first time, expand coverage for power seat elevation equipment on certain power wheelchairs toMedicare individuals. The proposed NCD is open for public comment for 30 days.
“Millions of people with Medicare rely on medically necessary assistive devices to perform daily tasks that directly impact their quality of life. CMS remains committed to ensuring persons with disabilities are receiving available benefits that improve their health,” said CMS Administrator Chiquita Brooks-LaSure. “Today’s proposal promotes a first of its kind benefit expansion providing people with Medicare additional tools to improve their lives.”
If finalized, power seat elevation equipment would be covered by Medicare for individuals with a Group 3 power wheelchair, which are designed to meet the needs of people with Medicare with severe disabilities, in order to improve their health as they transfer from the wheelchair to other surfaces. Transfers often strain shoulder and back muscles and constrain an individual’s daily mobility at home and other customary locations.
HHS Secretary Responds to the President’s Executive Order on Drug Prices
The Centers for Medicare & Medicaid Services (CMS) announced that the Secretary of the Department of Health and Human Services (HHS) has selected three new models for testing by the CMS Innovation Center to help lower the high cost of drugs, promote accessibility to life-changing drug therapies, and improve quality of care. The Secretary released a report describing these three models to respond to President Biden’s Executive Order 14087, “Lowering Prescription Drug Costs for Americans,” which complements the historic provisions in the Inflation Reduction Act of 2022 (IRA) that will lower prescription drug costs.
“HHS is using every tool available to us to lower health care costs and increase access to high-quality, affordable health care,” said HHS Secretary Xavier Becerra. “We are full steam ahead in delivering the cost savings from the President’s Inflation Reduction Act of 2022, and people on Medicare are already feeling the benefits. But as President Biden has made clear, we must build on the new prescription drug law with further action, which is why HHS is implementing these new projects to bring down prescription drug costs.”
AHIP strikes back against HHS claims over Medicare Advantage payments Three changes in the Advance
On February 1, the Centers for Medicare and Medicaid Services released the 2024 Advance Notice for the Medicare Advantage and Part D Prescription Drug Programs in which CMS said MA plans are expected to receive a 1.03% increase in revenue.
However, three changes in the rate notice would, on average, cut MA rates in 2024 by 2.27%, AHIP president and CEO Matt Eyles said by statement on Friday.
These three changes include: a 3.12% reduction due to the MA risk model that accounts for the health status and demographic characteristics of enrollees; 1.24% lower quality bonus payments under the Medicare Star Ratings program; and increase benchmarks used to set maximum payment rates on average by 2.09%, which is less than half the growth rate in 2023 (4.88%) and well below the projected growth in per enrollee Medicare costs (5%).
CMS takes big steps to fix prior authorization in Medicare Advantage
The AMA and nearly 120 physician organizations are strongly supporting proposed reforms of prior authorization in Medicare Advantage and the Medicare prescription drug benefit.
What’s the news: The AMA and nearly 120 physician organizations are strongly supporting proposed reforms of prior authorization in Medicare Advantage and the Medicare prescription drug benefit.
The AMA helps physicians build a better future for medicine, advocating in the courts and on the Hill to remove obstacles to patient care and confront today’s greatest health crises.
The physician organizations sent a letter (PDF) to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure thanking her and urging the agency to finalize proposed reforms that target the inappropriate use of prior-authorization requirements by Medicare Advantage plans to delay, deny and disrupt the provision of medically necessary care to patients.
“Physicians appreciate the efforts of CMS to address the significant and multifaceted challenges that prior authorization requirements pose to Medicare beneficiaries and physicians,” said AMA President Jack Resneck Jr, MD. “We applaud CMS for listening to physicians, patients, federal inspectors, and many other stakeholders, and recognizing a vital need to rein in Medicare Advantage plans from placing excessive and unnecessary administrative obstacles between patients and evidence-based treatments.”
Among other things, CMS should finalize provisions requiring that Medicare Advantage plans:
- Only use prior authorization to confirm diagnoses or other medical criteria and ensure the medical necessity of services. That is, prior authorization is not a tool to be used to delay or discourage care.
- Give their beneficiaries access to the same items and services as they would under traditional Medicare. When no applicable coverage rule exists under traditional Medicare, plans must use current evidence from widely used treatment guidelines or clinical literature for internal clinical coverage criteria, which must then be made publicly available.
- Establish a utilization-management committee to review their clinical coverage criteria and ensure consistency with traditional Medicare guidelines.
- Not be allowed to deny care ordered by a contracted physician based on a particular provider type or setting, unless medical necessity criteria are not met.
Government Lets Health Plans That Ripped Off Medicare Keep the Money
Medicare Advantage plans for seniors dodged a major financial bullet Monday as government officials gave them a reprieve for returning hundreds of millions of dollars or more in government overpayments — some dating back a decade or more.
The health insurance industry had long feared the Centers for Medicare & Medicaid Services would demand repayment of billions of dollars in overcharges the popular health plans received as far back as 2011.
But in a surprise action, CMS announced it would require next to nothing from insurers for any excess payments they received from 2011 through 2017. CMS will not impose major penalties until audits for payment years 2018 and beyond are conducted, which have yet to be started.
While the decision could cost Medicare plans billions of dollars in the future, it will take years before any penalty comes due. And health plans will be allowed to pocket hundreds of millions of dollars in overcharges and possibly much more for audits before 2018. Exactly how much is not clear because audits as far back as 2011 have yet to be completed.
MEdicarein the news
MA plan enrollment up by more than 7% this year
New federal data indicate that Medicare Advantage enrollment has grown from 29.1 million last year to nearly 31.2 million this year, an increase of 7.1%. The annual growth rate is at its lowest point in seven years, but the MA plans now cover about half the population of Medicare beneficiaries.
Majority of Medicaid enrollees unaware of eligibility renewals
About 64% of adults enrolled in Medicaid or those with a family member enrolled in the program were not aware that states will resume Medicaid eligibility renewals in April, and awareness was low across the US regardless of geographical location, according to a new survey from the Urban Institute and the Robert Wood Johnson Foundation. As of December 2022, around 16% had heard only a little, 13.9% had heard some, and 5.1% had heard a lot about the resumption of Medicaid renewals.
Study: Surgery prices far higher at hospitals in networks
A study in JAMA Network Open showed the median negotiated prices for certain surgical procedures are substantially higher at hospitals within networks compared with independent hospitals. An analysis of negotiated prices for 16 surgical procedures at 3,195 hospitals showed prices vary widely for each procedure, including prostatectomy, with a median price of $8,601 at independent facilities and $9,567 at facilities within hospital networks.
Medicare Advantage enrollees need less retirement savings for healthcare costs: Report
Medicare beneficiaries who enroll in a Medicare Advantage plan may need less retirement savings to cover their healthcare costs, an analysis published Feb. 9 by the Employee Benefits Research Institute found.
The study's authors note that healthcare costs are largely dependent on individual circumstance, but enrollees in Medicare Advantage have lower retirement savings targets than counterparts in traditional Medicare.
A couple enrolled in a Medigap plan with average premiums would need $212,000 in savings to have a 50 percent chance of affording all their healthcare expenses, and $318,000 saved to have a 90 percent chance of covering all these expenses.
Compared to counterparts in Medigap plans, MA enrollees would need less savings, on average, the study's authors found.
A couple in a MA plan would need $123,000 in savings to have a 50 percent chance of covering all their healthcare expenses and $184,000 for a 90 percent chance.
New Bill seeks harsher fines for hospitals lacking price transparency
A bill that would implement stricter penalties on hospitals that don't comply with the federal hospital price transparency rules was introduced by Sen. John Kennedy, R-La. The Hospital Transparency Compliance Enforcement Act would double the monetary penalties for noncompliant hospitals, block hospitals from shielding pricing data using webpage coding, require the CMS to release the names of noncompliant facilities and give noncompliant hospitals 60 days to pay their financial penalties after receiving notice of noncompliance
CBO warns of sharp uptick in Social Security, Medicare spending
Federal spending on Social Security and Medicare is projected to outpace revenues and the economy over the next decade, with combined spending projected to nearly double by 2033, according to the Congressional Budget Office. The CBO also said Social Security will face a funding gap by 2032, which is two years sooner than earlier forecasts.
Medicare In the news
Before you enroll in Medicare, what to know about new rules that eliminate coverage gaps
As of this year, people new to Medicare won’t face big delays in coverage — an unenviable situation that some beneficiaries used to find themselves in.
Thanks to legislation passed in late 2020, months-long delays in certain Medicare enrollment circumstances are now eliminated. Additionally, individuals who missed signing up when they were supposed to due to “exceptional circumstances” may qualify for a special enrollment period.
Signup rules for Medicare can be tricky
Medicare’s enrollment rules can be confusing. People who are already receiving Social Security benefits before the reach age 65 — which is when you become eligible for Medicare — are automatically enrolled in Part A (hospital coverage) and Part B (outpatient care coverage).
Otherwise, you are required to sign up during your “initial enrollment period” when you hit age 65 unless you meet an exception, such as having qualifying health insurance through a large employer (20 or more workers).
Initial enrollment period gap is eliminated
Your initial enrollment period starts three months before your 65th birthday and ends three months after it (seven months total). The new rule makes it so coverage takes effect the month after you sign up if you do so in the latter part of that enrollment window. In the past, some beneficiaries waited up to three months for coverage to take effect.
If you enroll before the month you turn 65, coverage starts the first of your birthday month (that hasn’t changed).
Cancer death rates fall steadily in the US, with more survivors than ever
Cancer is the second leading cause of death and even with recent clinical innovation, it remains costly and complex to treat. A steady decline in death rates is a significant milestone in the fight against this disease and shows that commitments to end smoking can have an impact.
Penalties may still apply for some late enrollment
If you miss your initial enrollment period and don’t qualify for a special enrollment period, you generally can only sign up during the first three months of the year during a “general enrollment period.”
Going that route also has meant waiting until July 1 for coverage to take effect. Starting this year, it will be effective the month after you sign up.
‘Exceptional’ situations may result in special enrollment
Starting this year, individuals may be able to sign up outside of current enrollment periods if they have “exceptional circumstances.” This is already a flexibility available with Part D, as well as Medicare Advantage Plans (which deliver Parts A and B and usually D), Schwarz said.
“It’s really designed to provide relief for people who are impacted by exceptional situations and need access to health insurance,” she said.
Additionally, beneficiaries who qualify for the special enrollment period will not face Part B late enrollment penalties. .
Medicare Advantage Plans Now Cover Close to Half of Beneficiaries
Soon more than half of Americans who get their hospital and medical coverage through Medicare are likely to be enrolled in Medicare Advantage (MA), the private insurance alternative to the government-run coverage, according to a new analysis by the Kaiser Family Foundation (KFF).
Of the nearly 59 million people who get their health care from both Medicare’s Part A, which covers hospital care, and Part B, which covers doctor visits and other outpatient services, 48 percent now get their coverage through a Medicare Advantage (MA) plan, according to the KFF findings.
Medigap Plans Help Bridge Gap of Original Medicare Costs
If you decide to enroll in original Medicare, one way you can help pay the extra costs the program doesn’t cover is to buy a supplemental — or Medigap — insurance policy.
Private insurers sell Medigap policies, but states and the federal government strictly regulate them. These plans are available for people enrolled in Medicare parts A and B, not for those who elect a Medicare Advantage plan. Medigap plans pay for costs such as deductibles and copays and other charges that Medicare doesn’t cover.
In 2010 the federal government standardized the types of Medigap plans, creating 10 options designated by A, B, C, D, F, G, K, L, M and N. In January 2020 two of the more comprehensive and popular plans, C and F, ceased to be available to people newly eligible for the program. That’s because in 2015, Congress decided to prohibit Medigap from covering the annual deductible for Part B, which pays for doctor visits and other outpatient services.
Choosing a Medigap Plan
Don’t get confused by the way these policies are named. The Medigap policies’ letter designations have nothing to do with which Medicare program you chose.
Because the Medigap plans are standardized, an A or F plan sold by one insurer covers the same things as an A or F plan from another insurer.
Medigap plans are consistent in all but three states: Massachusetts, Minnesota and Wisconsin have their own standard policies.
So how do the 10 policies differ? “Some are high deductible, some require higher cost-sharing, and some cover more costs,” says Mary Mealer, life and health manager at the Missouri Department of Insurance, Financial Institutions & Professional Registration. Consumers should “evaluate their individual situation as to what plan meets their needs and what they can afford.”
How to Find, Enroll in a Medicare Advantage Plan
If your 65th birthday is approaching, or if you are thinking of retiring it may be time to start thinking about what kind of Medicare coverage you’ll need.
You have two choices: original Medicare, the government-run program that includes Part A hospitalization coverage and Part B doctor and outpatient services; or a Medicare Advantage Plan. These plans bundles together Parts A and B and usually adds Part D prescription drug coverage.
Private insurers sell Medicare Advantage plans, also known as Part C. Some plans help pay for certain services that original Medicare doesn’t cover, such as routine dental, hearing and vision care.
CMA sets 2.09% rate increase for Medicare Advantage plans in 2024
Medicare Advantage plans are in line for a 2.09% rate increase in 2024, the Centers for Medicare & Medicaid Services said in a notice, Axios reports. The adjustment is driven by growth in Medicare fee-for-service costs. But analysts said the bump is offset by other policy changes that would translate into a net reduction of 2.27%.
Medicare In the news
Almost 40% of US households affected by tripledemic
About 40% of US households were affected by the tripledemic of COVID-19, influenza and respiratory syncytial virus during the holiday season, with at least one person in the household getting infected with one of the respiratory viruses, according to a Kaiser Family Foundation survey. Flu affected 27% of households, while COVID-19 and RSV affected 15% and 10% of households, respectively, during the holidays, but the tripledemic has since declined, with flu, COVID-19 and RSV cases all down recently.
Biden calls for permanent expansion of ACA tax credits
During his State of the Union address Tuesday, President Joe Biden called on Congress to permanently extend the enhanced Affordable Care Act tax credits and to expand the $35 monthly cap on insulin costs to all Americans and not just those on Medicare. Biden vowed to protect Medicare and Social Security by not allowing any spending cuts to either program as part of any deal to raise the debt ceiling, and he indicated he will unveil a provision to extend the Medicare Trust Fund by at least 20 years.
Study links extreme weather to risk of CV-related death
A study in the journal Circulation linked exposure to extreme hot or cold weather to an additional 11.3 cardiovascular-related deaths among patients with heart disease for every 1,000 incidents. Researchers said patients with heart failure had a higher risk of negative effects from extreme weather when compared with patients who had other types of heart disease. The study included data on more than 32 million cardiovascular deaths in 27 countries between 1979 and 2019.
Cancer death rates fall steadily in the US, with more survivors than ever
Cancer is the second leading cause of death and even with recent clinical innovation, it remains costly and complex to treat. A steady decline in death rates is a significant milestone in the fight against this disease and shows that commitments to end smoking can have an impact.
Social Security Increase 2023
Finally, some good news. Social Security is set to increase for next year! The most recent estimate is ~8.7% for 2023.
Like the Medicare Part B increases, the final amounts are just speculation for now and will be announced on October 13th. Everyone on Social Security will get the increase. It doesn’t matter what type of benefit you are getting, you will get the increase in your January check. Stay tuned for more.
AHIP blasts government plan to pursue Medicare Advantage overpayments
The America's Health Insurance Plans trade group blasted the Biden administration for finalizing a rule that seeks to claw back millions of dollars from health insurers through Medicare Advantage audits that will apply retroactively to payments beginning in 2018, Healthcare Dive reports. AHIP called the final rule “unlawful” and “fatally flawed” in a Jan. 30 statement following the its release by the Centers for Medicare & Medicaid Services. .
Biggest Medicare Changes for 2022
The biggest change Medicare's nearly 64 million beneficiaries will see in the new year is higher premiums and deductibles for the medical care they'll receive under the federal government's health care insurance program for individuals age 65 and older and people with disabilities.
Medicare's benefits will remain largely the same in 2022. As the new year begins, Congress is still debating several proposals that would change the face of Medicare, including adding a hearing benefit and several proposals to lower the price of prescription drugs, including capping out-of-pocket costs in Part D plans. But even if Congress adopts these changes, they wouldn't take effect this year.
Medicare Advantage Plans Now Cover Close to Half of Beneficiaries
Soon more than half of Americans who get their hospital and medical coverage through Medicare are likely to be enrolled in Medicare Advantage (MA), the private insurance alternative to the government-run coverage, according to a new analysis by the Kaiser Family Foundation (KFF).
Of the nearly 59 million people who get their health care from both Medicare’s Part A, which covers hospital care, and Part B, which covers doctor visits and other outpatient services, 48 percent now get their coverage through a Medicare Advantage (MA) plan, according to the KFF findings.
Medigap Plans Help Bridge Gap of Original Medicare Costs
If you decide to enroll in original Medicare, one way you can help pay the extra costs the program doesn’t cover is to buy a supplemental — or Medigap — insurance policy.
Private insurers sell Medigap policies, but states and the federal government strictly regulate them. These plans are available for people enrolled in Medicare parts A and B, not for those who elect a Medicare Advantage plan. Medigap plans pay for costs such as deductibles and copays and other charges that Medicare doesn’t cover.
In 2010 the federal government standardized the types of Medigap plans, creating 10 options designated by A, B, C, D, F, G, K, L, M and N. In January 2020 two of the more comprehensive and popular plans, C and F, ceased to be available to people newly eligible for the program. That’s because in 2015, Congress decided to prohibit Medigap from covering the annual deductible for Part B, which pays for doctor visits and other outpatient services.
Choosing a Medigap Plan
Don’t get confused by the way these policies are named. The Medigap policies’ letter designations have nothing to do with which Medicare program you chose.
Because the Medigap plans are standardized, an A or F plan sold by one insurer covers the same things as an A or F plan from another insurer.
Medigap plans are consistent in all but three states: Massachusetts, Minnesota and Wisconsin have their own standard policies.
So how do the 10 policies differ? “Some are high deductible, some require higher cost-sharing, and some cover more costs,” says Mary Mealer, life and health manager at the Missouri Department of Insurance, Financial Institutions & Professional Registration. Consumers should “evaluate their individual situation as to what plan meets their needs and what they can afford.”
How to Find, Enroll in a Medicare Advantage Plan
If your 65th birthday is approaching, or if you are thinking of retiring it may be time to start thinking about what kind of Medicare coverage you’ll need.
You have two choices: original Medicare, the government-run program that includes Part A hospitalization coverage and Part B doctor and outpatient services; or a Medicare Advantage Plan. These plans bundles together Parts A and B and usually adds Part D prescription drug coverage.
Private insurers sell Medicare Advantage plans, also known as Part C. Some plans help pay for certain services that original Medicare doesn’t cover, such as routine dental, hearing and vision care.
CMA sets 2.09% rate increase for Medicare Advantage plans in 2024
Medicare Advantage plans are in line for a 2.09% rate increase in 2024, the Centers for Medicare & Medicaid Services said in a notice, Axios reports. The adjustment is driven by growth in Medicare fee-for-service costs. But analysts said the bump is offset by other policy changes that would translate into a net reduction of 2.27%.
Medicare In the news
Medicare Advantage enrollment explodes in last 15 years
Enrollment in Medicare Advantage has exploded over the past 15 years, a new study shows, reports Fierce Healthcare. From 2006 to 2022, MA enrollment increased by 337% as enrollment in traditional Medicare declined by 2.9%, according to a study in Health Affairs. Meanwhile, the number of Medicare beneficiaries grew to about 63 million in 2022 from 41.8 million in 2006.
Employers pay more for top drugs than Medicare plans, report shows
Employer-sponsored health plans pay significantly more than Medicare for costly physician-administered drugs, threatening access to lifesaving treatments, according to a newly published analysis of claims data and Medicare files, reports Axios. Price markups increased between 2016 and 2020 for five of the top 10 drugs that account for the most spending and more than doubled for three: the white blood cell-booster pegfilgrastim and the cancer drugs trastuzumab and rituximab, according to a report by the Health Care Cost Institute published in JAMA Health Forum.
Study finds 6% of Medicare Advantage prior authorization requests denied
Medicare Advantage insurers denied or partially denied 2 million – or 6% -- of more than 35 million prior authorization requests in 2021, of which about 2 million, or 6%, according to an analysis by Kaiser Family Foundation, reports Axios. Medicare Advantage plans have previously come under fire for denying too many services which should have been paid for under Medicare coverage rules.
Audits show widespread overcharges by Medicare Advantage plans
Newly released federal audits reveal widespread overcharges and other errors in payments to Medicare Advantage health plans for seniors, with some plans overbilling the government more than $1,000 per patient a year on average, reports Fierce Healthcare. The government’s audits uncovered about $12 million in net overpayments for the care of 18,090 patients sampled, though the actual losses to taxpayers are likely much higher.
Cancer death rates fall steadily in the US, with more survivors than ever
Cancer is the second leading cause of death and even with recent clinical innovation, it remains costly and complex to treat. A steady decline in death rates is a significant milestone in the fight against this disease and shows that commitments to end smoking can have an impact.
Medicare Will Not Lower Part B Premium in 2022
Medicare's Part B $170.10 basic monthly premium will not be reduced this year, but instead any savings from lower spending will be passed on to beneficiaries in 2023.
U.S. Health and Human Services Secretary Xavier Becerra had ordered the Centers for Medicare and Medicaid Services (CMS) to reassess its record-high premium increase in 2022 for Part B, which covers doctor visits, diagnostic tests and other outpatient services. The $21.60 basic premium hike in 2022 was the largest dollar increase in the health insurance program’s history.
Among the reasons CMS gave for the outsize increase was that it needed to set aside money in its reserves in the event it decided to cover Aduhelm, the new Alzheimer’s drug approved in June by the U.S. Food the Drug Administration (FDA). At the time, Biogen, the medication’s manufacturer, estimated the drug’s price would be $56,000 a year. After considerable pushback, Biogen cut its price estimate roughly in half, saying the drug would cost $28,200 annually effective Jan. 1, 2022. Also, since the premium increase was announced, CMS decided that Medicare coverage of Aduhelm will be limited to beneficiaries enrolled in approved clinical trials.
Social Security Increase 2023
Finally, some good news. Social Security is set to increase for next year! The most recent estimate is ~8.7% for 2023.
Like the Medicare Part B increases, the final amounts are just speculation for now and will be announced on October 13th.
Everyone on Social Security will get the increase. It doesn’t matter what type of benefit you are getting, you will get the increase in your January check. Stay tuned for more.
Biggest Medicare Changes for 2022
The biggest change Medicare's nearly 64 million beneficiaries will see in the new year is higher premiums and deductibles for the medical care they'll receive under the federal government's health care insurance program for individuals age 65 and older and people with disabilities.
Medicare's benefits will remain largely the same in 2022. As the new year begins, Congress is still debating several proposals that would change the face of Medicare, including adding a hearing benefit and several proposals to lower the price of prescription drugs, including capping out-of-pocket costs in Part D plans. But even if Congress adopts these changes, they wouldn't take effect this year.
Medicare Advantage Plans Now Cover Close to Half of Beneficiaries
Soon more than half of Americans who get their hospital and medical coverage through Medicare are likely to be enrolled in Medicare Advantage (MA), the private insurance alternative to the government-run coverage, according to a new analysis by the Kaiser Family Foundation (KFF).
Of the nearly 59 million people who get their health care from both Medicare’s Part A, which covers hospital care, and Part B, which covers doctor visits and other outpatient services, 48 percent now get their coverage through a Medicare Advantage (MA) plan, according to the KFF findings.
Medigap Plans Help Bridge Gap of Original Medicare Costs
If you decide to enroll in original Medicare, one way you can help pay the extra costs the program doesn’t cover is to buy a supplemental — or Medigap — insurance policy.
Private insurers sell Medigap policies, but states and the federal government strictly regulate them. These plans are available for people enrolled in Medicare parts A and B, not for those who elect a Medicare Advantage plan. Medigap plans pay for costs such as deductibles and copays and other charges that Medicare doesn’t cover.
In 2010 the federal government standardized the types of Medigap plans, creating 10 options designated by A, B, C, D, F, G, K, L, M and N. In January 2020 two of the more comprehensive and popular plans, C and F, ceased to be available to people newly eligible for the program. That’s because in 2015, Congress decided to prohibit Medigap from covering the annual deductible for Part B, which pays for doctor visits and other outpatient services.
Choosing a Medigap Plan
Don’t get confused by the way these policies are named. The Medigap policies’ letter designations have nothing to do with which Medicare program you chose.
Because the Medigap plans are standardized, an A or F plan sold by one insurer covers the same things as an A or F plan from another insurer.
Medigap plans are consistent in all but three states: Massachusetts, Minnesota and Wisconsin have their own standard policies.
So how do the 10 policies differ? “Some are high deductible, some require higher cost-sharing, and some cover more costs,” says Mary Mealer, life and health manager at the Missouri Department of Insurance, Financial Institutions & Professional Registration. Consumers should “evaluate their individual situation as to what plan meets their needs and what they can afford.”
Arbitrator: NYC should shift to Medicare Advantage for retirees
An arbitrator is directing New York City to quickly move ahead with a plan to transfer some 250,000 municipal retirees from their current Medicare coverage to a Medicare Advantage plan operated by Aetna Inc. – despite ongoing and persistent efforts by some retirees to block the move, Gothamist reports. The switch was proposed in 2018 to save the city about $600 million annually thanks to federal subsidies available to Medicare Advantage plans, according to city estimates.
MEDICARE IN THE NEWS
Patina Health inks deals with insurers to provide senior home care
Patina Health, a startup providing in-home care for older adults, is expanding to serve members of Aetna Inc., UnitedHealth Group Inc. and Cigna Corp. Medicare Advantage plans, reports Becker’s Payer Issues. The startup, based in Bala Cynwyd, Pennsylvania, was previously only available to Independence Blue Cross Medicare Advantage members.
HHS Secretary Responds to the President’s Executive Order on Drug Prices
Action announces new models and supports access to $2 generic drugs
Today, the Centers for Medicare & Medicaid Services (CMS) announced that the Secretary of the Department of Health and Human Services (HHS) has selected three new models for testing by the CMS Innovation Center to help lower the high cost of drugs, promote accessibility to life-changing drug therapies, and improve quality of care. The Secretary released a report describing these three models to respond to President Biden’s Executive Order 14087, “Lowering Prescription Drug Costs for Americans,” which complements the historic provisions in the Inflation Reduction Act of 2022 (IRA) that will lower prescription drug costs.
New CMS rule strengthens various Medicare Advantage elements
A new Center for Medicare and Medicaid Services rule designed to strengthen Medicare Advantage is generating positive feedback for its proposal to streamline the prior authorization process, expand access to behavioral health care, make prescription drugs more affordable and stop misleading advertising, reports Healthcare Dive. Among other changes, the rule released Dec. 14 would revise prior authorization requirements to reduce disruption for enrollees, so that an approval would remain valid for a full course of treatment.
GAO urges faster background checks on providers in Medicare program
A government watchdog agency is urging federal health regulators to speed up checks on providers and conduct background checks after raising concerns about the risk for fraud during the coronavirus pandemic, reports Healthcare Dive. The Center for Medicare and Medicaid Services relaxed provider enrollment requirements during the pandemic to ensure continuity for both providers and enrollees during the public health emergency.
FCC OKs robocalls, texts to communicate Medicare eligibility changes
Managed care plans and states can now deliver robocalls and texts to Medicaid beneficiaries without fear of violating a federal law, a critical change as states face eligibility redeterminations in a few months, Fierce Healthcare reports. The Federal Communications Commission released new guidance Jan. 24 on the change after getting a letter from the Department of Health and Human Services back in April 2022.
Medicare Advantage audit rules could result in clawbacks from insurers
The nation's largest health insurers are gearing up for upcoming changes to Medicare Advantage risk adjustment rules that could collectively cost them up to $3 billion in returned payments, Bloomberg reported Jan. 24, according to Becker’s Payer Issues. To date, nearly every major insurer has been accused of exploiting the program through elaborate "upcoding" schemes that make patients appear sicker on medical records than they are – thereby leading to higher payments from the Centers for Medicare & Medicaid Service
