The LatestCouncil passes anti-K2 bills With video: Armed men rob Maspeth deliHomeEditionsCentral/Mid Queens NewsSENIOR LIVING GUIDE: Fall 2015Medicare Part D: a successStoryCommentsImage (2)PrintCreate a hardcopy of this pageFont Size:Default font sizeLarger font size1Previous Next Larry HausnerPosted: Thursday, October 1, 2015 10:30 am | Updated: 11:30 am, Fri Oct 2, 2015.by Larry Hausner | 0 commentsTaxpayers are being raked over the coals by high prescription drug prices — or so says Sen. Ron Wyden (D-Ore.). Claiming that the Medicare prescription drug insurance program, known as Medicare Part D, is “unsustainable,” he called for federal intervention to curb “skyrocketing drug costs.”The senator is potentially overstating the case. A new report from the agency that oversees Medicare shows that Part D premiums have not substantially changed in the last five years. Lawmakers should seek to protect the program — not undermine it. In this there is no dispute with Sen. Wyden.Established in 2006, Part D provides insurance to 37 million seniors, enabling them to afford the life-saving drugs that keep chronic diseases at bay, thus reducing the number of costly hospitalizations and surgeries. The program has cost $350 billion less than initially projected and about 90 percent of beneficiaries rate it positively.That satisfaction is largely due to stable premiums. Next year’s average monthly Part D premium will be just $32.50 — virtually the same as this year’s rate.Seniors aren’t the only ones benefiting from affordable premiums — taxpayers save money too. Again, by increasing access to medicines, Part D keeps people healthier and out of the hospital.
The Consumer Reports article published in the Aug. 18 Health & Science section, “Poll shows drug prices moving higher,” stated “when people covered by Medicare Part D plans reach the ‘doughnut hole’ — the situation where, after you and the plan pay $2,960 together, you have to pay fully for medications until the total reaches $3,310.” This is inaccurate for several reasons.
This year, once a Medicare beneficiary who is enrolled in a Medicare Part D Plan reaches the doughnut hole ($2,960), he does not pay full price for medications. Rather, he pays 45 percent of the plan’s cost for his covered brand-name prescription drugs and 65 percent of the plan’s cost for generic drugs. Once the beneficiary has spent $4,700 out of pocket for the year, his coverage gap ends, and he will pay a small coinsurance or co-payment for each covered drug until the end of the year.
WHAT IS THE DIFFERENCE BETWEEN MEDICARE SUPPLEMENTAL INSURANCE AND MEDIGAP INSURANCEThe two terms are synonymous. Medicare Supplemental Insurance is also called Medigap Insurance. It got this nickname because the insurance fills the gaps left by Medicare alone.HOW CAN I APPLY FOR MEDICARE SUPPLEMENTAL INSURANCE?The application process for Medicare Supplemental Insurance is very easy and can be done over the phone or in person. The process takes about 30 minutes and most times the policy can be issued within a week. You can call my office today at (239) 288 – 0880 , fill out the form on this webpage and I will be in contact shortly or send me an email at V.Reed.Speas@gmail.comDO I HAVE TO QUALIFY AND ANSWER HEALTH RELATED QUESTIONS FOR MEDICARE SUPPLEMENTAL INSURANCE?If you are turning 65 you are in a Guaranteed Issue period for the 7 months surrounding your 65 birthday. This means you will not have to answer any health questions and cannot be denied coverage for health reasons. There are other Guaranteed issue periods for Medicare Supplemental insurance some of them are: leaving a employer sponsored health plan, being dropped by a Medicare Advantage Plan or a Medicare Advantage plan you are enrolled in going out of business, or leaving a Medicare Advantage Plan after your first year.
Switching Your Medicare Advantage PlanUnder certain circumstances, you can change Medicare Advantage plans mid-year. Otherwise, you’ll have to wait for the open enrollment period for the year ahead.By Kimberly Lankford, September 4, 2015I haven’t been too happy with my Medicare Advantage plan this year—I started taking a drug with expensive out-of-pocket costs, and some of the doctors I want to see aren’t included in the plan’s network. Is it too late to switch plans?SEE OUR SLIDE SHOW: 11 Common Medicare Mistakes to AvoidProbably. In most cases, you can only switch plans during open enrollment in the fall, which runs from October 15 to December 7, 2015, for coverage to begin on January 1. But there are a few exceptions. For instance, you can switch into a Medicare Advantage plan with a five-star quality rating anytime during the year—if you have access to one. Only 11 Medicare Advantage plans with prescription-drug coverage earned five-star ratings for 2015. These plans are in certain counties in California, Colorado, Florida, Hawaii, Iowa, Maine, Maryland, New Hampshire, Ohio, Oregon, Virginia, Washington and Wisconsin, and in Washington, D.C. Five-star Medicare Advantage plans without prescription-drug coverage are in certain counties in Illinois, Iowa and Wisconsin. Use the Medicare Plan Finder tool to see if there are any five-star plans in your zip code. See this fact sheet from Medicare Interactive for more information about the star ratings.You can also switch plans outside of open enrollment if you move to an address that isn’t in your plan’s service area. There are a few other, less likely situations in which you can switch plans throughout the year; for details, see the Special Circumstances fact sheet at Medicare.gov for more information about situations where you can switch plans outside of open enrollment.
Q: I have a retiree medical plan sponsored by my former employer. It is a PPO with a $400 deductible per person and 20% co-insurance. The plan’s costs are reasonable, and it covers a wide range of drugs. There’s a $1,000 annual out-of-pocket maximum and one month of free maintenance drugs when you buy a 90-day supply from the preferred pharmacy. I will be Medicare eligible in 2016, and I do not think that my former employer will continue to offer a retiree health plan. Is there any insurer that will offer similar drug coverage to what I have now with no penalty for pre-existing conditions? How can I find such a plan, regardless of annual cost? Is there any way to avoid the $5,000 per year out-of-pocket cost that I hear is standard with Medicare Part D plans? Thank you. — Gary, N.Y.A: Gary’s question is a great opportunity to talk about the challenges that more and more retirees face as they shift from employer-sponsored group health plans to Medicare.As retiree health benefits have become increasingly expensive, many companies are dropping this coverage. In the best case scenario, the employer gives these retirees a lump sum, which is deposited into a health reimbursement account (HRA). The retiree can use the HRA funds to help buy an individual Medicare policy. But all too often, the employer may simply end the retiree health plan and provide no further support.Still, there is some good news. Gary won’t face pre-existing condition limitations as long as he signs up for Medicare on a timely basis. If he meets the enrollment deadlines, any pre-existing conditions he has will not affect him when purchasing Part D, or when signing up for Original Medicare (Parts A and B) or Medicare Advantage (Part C).If Gary chooses Original Medicare, he may want to buy a Medicare supplement policy, which also is called Medigap. Original Medicare pays only 80% of insured expenses, after beneficiaries pay annual deductibles and co-pays; policyholders must pay the other 20%. Medigap policies will pay that 20% plus other services that Medicare does not cover. If you purchase Medigap coverage at the time you become eligible for Medicare, you have guaranteed issue rights—you cannot be penalized for pre-existing conditions.
Small, regional nonprofit insurers are feeling a negative impact from the Medicare Advantage program that could force them to raise premiums, cut benefits or even leave the market, Politico New York reported.Nonprofit insurers in New York reported tens of millions of dollars in underwriting losses last year. EmblemHealth suffered a net underwriting loss of more than $167 million from Medicare, Excellus Blue Cross Blue Shield and HealthNow New York reported losses of $31.91 million and $78.97 million, respectively. They largely attribute those losses to three elements–reimbursement reductions, taxes and fees–plus the rising cost of care and prescription drugs.
Understanding Your Health Insurance – Aug. 9, 2015: What is the Medicare Part D late enrollment penalty?AUGUST 9, 2015 LAST UPDATED: MONDAY, AUGUST 10, 2015, 12:16 AMBY IRENE & BETSY CARDSUBURBAN TRENDS PrintMedicare Part D is the prescription drug component to Medicare. If you enroll in a Part D plan after your 65th birthday, as you have been covered by group health insurance up to that time, you have a very good chance of receiving a letter stating that you will have a late enrollment penalty.What is the late enrollment penalty? It is an amount of money added to your Medicare Part D monthly premium. You may owe a late enrollment penalty if you go without Part D or creditable prescription drug coverage for any continuous period of 63 days or more after your initial enrollment period is over. Creditable coverage is coverage that is equal to or better than the benefits offered under Medicare Part D. If you have employer-sponsored coverage, it may or may not be creditable coverage. It is the employer’s responsibility to inform you each year if your coverage if considered creditable or not.
Secret Medicare Advantage Audits Reveal Significant Billing Errors Comment Email Print RSS News Widget ShareThisJohn Castelluccio, for HealthLeaders Media , July 29, 2015Just-released audits on Medicare risk adjustments by HHS and the Department of Justice in 2008 show significant problems with billing-related risk score calculations that were used for beneficiaries of plans operated by Aetna Health, Independence Blue Cross of Pennsylvania, and Care Plus, a division of Humana.This article originally appeared in Physician Practice InsiderThe release earlier this month of secret Medicare Advantage audits CMS conducted on several major health insurers revealed the insurers were overpaid by more than $3.3 million in 2007. It may have been solely due to inadvertent billing errors and inflated risk scores as opposed to intentional fraud, but it’s unclear because the regulators aren’t talking.The audits, which were conducted in 2008 on at least five insurers across the country as part of a larger investigation on Medicare risk adjustments by HHS and the Department of Justice, showed significant problems with billing-related risk score calculations that were used for beneficiaries who joined a Medicare Advantage plan.
The reports, released Tuesday by HHS’ Office of Inspector General, come days after federal officials announced charges against 44 people across the country for fraud in Medicare Part D, which is Medicare’s drug benefit program. Those charges represented the first large-scale, federal effort to focus on Medicare Part D fraud—an effort many say is likely to continue.
One of the reports (PDF) released Tuesday shows that more than 1,400 pharmacies had questionable billings for opioid drugs, and a number of cities had higher than average billings for certain medications last year. The second report (PDF) calls on the CMS to implement more of the OIG’s recommendations for fighting fraud and abuse in Part D.
Medicare Advantage, a managed care program created to save the government money, is losing anywhere from $2 billion to $10 billion a year from overbilling.That’s the staggering conclusion by the National Bureau of Economic Research (NBER), which recently published a report analyzing how private insurance companies that run Medicare Advantage health plans may be gaming the system to inflate so-called “risk adjustment” payments they receive from the government.Medicare Advantage was supposed to realize cost savings by shifting government healthcare spending from a “fee-for-service” model to a capitated managed care approach. More than 17 million people are enrolled in Medicare Advantage plans — about a third of those eligible for Medicare.The capitation payments to private insurers are based, in part, on the enrollees’ health risks. Payments to Medicare Advantage plans are influenced by “risk scores” that take into account differences in patients’ medical diagnoses and health outcomes. The sicker the patient, the higher the “risk score” assigned. For example, a depression diagnosis that is reclassified as a “major” depression would receive a higher risk score. Higher risk scores, in turn, generate increased risk adjustment payments by the federal government to the Medicare Advantage insurance plans.