Author: Dan

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Medicare Part D Prescription Drug

The New Law and Medicare Part D

Well, just as we are finishing up the annual federal and carrier Medicare Advantage and Part D certifications for 2023, the US House and Senate passed a bill (H.R. 5376 titled Inflation Reduction Act of 2022) which includes some important changes to the Medicare Part D prescription drug coverage.

Some of these changes take effect next year and others over the next several years. I have looked over the text, studied several analysis and have summarized below the 4 changes most likely to Medicare beneficiaries:

  1. Insulin – Effective 2023
  2. Adult Vaccines – Effective 2023
  3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
  4. Medicare to Negotiate Part D and Part B Drug Prices – Effective 2026

Please note: If you are receiving Part D financial assistance through state Medicaid or the Social Security Extra Help program, your benefits may already exceed what is becoming effective in this new bill. Also, if your medications are covered through your VA benefits, you may want to compare these new benefits to what VA covers and compare your options in the years ahead.

1. Insulin – Effective 2023 Beginning in 2023, for Medicare Part D beneficiaries who need insulin, monthly out-of-pocket costs will be capped at $35, and starting in 2026, the cap would be $35 or 25% of the negotiated price if that is lower. And insulin products will no longer subject to a Part D deductible.

2. Adult Vaccines – Effective 2023
Beginning in 2023, Medicare Part D cost-sharing will be eliminated for adult vaccines that are recommended by the Advisory Committee on Immunization Practices. For most clients, the most significant change will be the new $0 Part D copay for the two shot Shingles vaccine, previously covered through Part D however frequently subject to a deductible and higher Tier copay.

3. Cap on Out of Pocket Drug Costs – Effective in 2024 and 2025
For clients with drug costs placing them in the “Coverage Gap” (aka Donut Hole) and Catastrophic Coverage Phase, this change will be very welcomed although phased in over time.

In 2024, that 5% coinsurance payment that now kicks in after someone reaches the catastrophic drug spending level in Medicare will end. As you may imagine, 5% on some of those expensive drugs that cost thousands monthly can be a lot of money. That ends in 2024.

And in 2025 your Medicare Part D out-of-pocket spending will be capped at $2,000 a year.

4. Medicare to Negotiate Part D and Part B Drug Prices
CMS (Centers for Medicare & Medicaid Services) will be authorized and required to negotiate maximum prices for brand-name drugs that do not have other generic equivalents and that account for the greatest Medicare spending.

There is not yet an official, publicly available list of drugs that Medicare plans to target for negotiations. However Kaiser Family Foundation reports how just a handful of drugs represent the lion’s share of Medicare drug costs. Some likely candidates, based on how much Medicare spent on them in 2020: Eliquis, Xarelto and Januvia.

Today, those brand name drugs that do not have generic equivalents and represent the greatest cost are typically listed as Tier 4 or Tier 5 specialty medications under Medicare Part D coverage.

CMS will begin by negotiating the prices of 10 drugs in 2026, 15 drugs in 2027 and 2028, and 20 drugs in 2029 and each year thereafter. The negotiations would apply first to drugs people get at the pharmacy (Part D), but in the later two years, drugs administered in doctors’ offices (Part B) could also be covered.

If you have any questions or would like for me to review with you your plan benefits please schedule a telephone or Zoom conference convenient for you and direct to my calendar, call us at (518) 346-2115 or send a note to one of our licensed and carrier certified agents closest to you:

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Part D Prescription Drug Uncategorized

Part D Late Enrollment Penalty

Q: “Dan, I just received a letter stating I will have to pay a Part D late enrollment penalty next year for not having a drug plan during the months of February through December, 2017. What’s this all about?”

A: “Sam, after you turned 65 in October 2016 you had individual coverage with prescription drug benefits through January 2017. Now you’re enrolling in a Medicare Advantage plan with Part D coverage, effective January 2018. For those 11 months, February through December, that you went without drug coverage Medicare will impose a penalty for the late enrollment.”

Again, why do I owe a late enrollment penalty?

If, for any continuous period of 63 days or more after your Initial Enrollment Period is over you go without one of the following, you will have a penalty added to your Medicare Part D premium:

  • A Medicare Prescription Drug Plan (Part D)
  • A Medicare Advantage Plan (Part C) (HMO or PPO) with prescription drug coverage.
  • Creditable prescription drug coverage (a drug plan that pays at least as much as the Medicare standard – most often provided through an employer or the individual insurance exchange.)

 

How does Medicare calculate the late enrollment penalty?

The penalty is based on multiplying two factors.

  1. Medicare calculates 1% of the “national base beneficiary premium” ($35.63 in 2017; $35.02 in 2018) which for 2018 will be $.35
  2. Medicare determines the number of full, uncovered months you didn’t have Part D or creditable coverage. In the above instance, that was 11 months.
  3. The $.35 is then multiplied by the number of months. In our example of 11, that equals $3.85
  4. The monthly penalty is rounded to the nearest $.10 (the example would then be rounded to $3.90) and added to your monthly Part D premium.

Will the late enrollment penalty change?

Yes, annually.  When Medicare determines the national base beneficiary premium has changed, as in $35.63 in 2017 to $35.02 in 2018, the late enrollment penalty amount will be recalculated.

Do I pay the late enrollment penalty through Social Security?

No.  The penalty, rounded to the nearest $.10 is added to your Part D premium and collected by your private insurance company

 

Source: https://www.medicare.gov/part-d/costs/penalty/part-d-late-enrollment-penalty.html

Categories
Case Studies Part D Prescription Drug

“Having this EPIC plan was a miracle; an absolute miracle.”

Only a fraction of the nearly 3 million New York State residents aged 65 and older are enrolled in the state’s pharmaceutical assistance program known as New York EPIC.

When I meet with New York Medicare Part D clients, I ask if their individual income is below the $75,000 threshold, $100,000 if married. If so, I advise enrolling in EPIC even if they don’t take any or have only inexpensive medication.  Because, as Schenectady County, New York resident Beth says, “You never know.”

Beth shares her story. The $20,000 per dose medication.

In this 16 minute interview Beth shares her story of how she originally enrolled in EPIC and didn’t use it. She explains how her doctor prescribed a specialty medication. And how that medication was not included on her Medicare Part D plan formulary, its list of covered medications. And when she learned the drug would require a special exception approval from her Medicare Part D plan and costs $20,000 per dose, she was relieved to hear that EPIC would help. Listen in as Beth explains how affordable this $20,000 medication became after EPIC’s help.

Beth: “To me, having this EPIC plan was miracle, an absolute miracle. Because I wouldn’t have been able to get that drug and I would still remain very ill.”

If you reside in New York State, are age 65 or above, and have questions about how EPIC and your Medicare Part D plan can work together, please call (518) 346-2115.

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Categories
Case Studies Medicare supplement

A conversation: Focus the fight against cancer instead of the HMO

Medicare Supplement Plan

In this nearly 16 minute conversation Greensboro North Carolina residents, Bob and Signe Foxworth, talk about their frustration and anxiety of trying, unsuccesfully, to obtain HMO approval for Bob’s preferred out of network prostate cancer treatment. Listen as Bob and Signe explain how peace of mind came when Dan counseled them to revert to Original Medicare and enroll in Medicare Supplement Plan N.
Signe: “As I recall, it was tremendous anxiety at the time. Because not being able to get the treatment sooner rather than later could have had fatal consequences … We had more anxiety fighting the (HMO) insurance company than we did about his illness… We were kind of at our wits end.”
Bob: “I got $20,000 worth of treatment for $20 … Everything was covered.”
Signe: “In this whole thing, the most precious thing is that peace of mind knowing that you are covered. Yes, you strain a little on your monthly budget But things happen unexpectedly and you are covered. It’s really beautiful.”

For a personal consultation regarding your Medicare choices, call Dan at (518) 346-2115
Categories
Case Studies Part D Prescription Drug

Medicare Extra Help: “The savings are a godsend…”

Medicare Supplement Testimonial

Medicare Extra Help

I was delighted to assist this New York based beneficiary who is on a limited income and was not aware of the Medicare Savings Program available through a New York State program for Medicare Part B premium or that Social Security offers “Extra Help” with Part D premium and prescription drug co-pay.

Call 518-346-2115 for a confidential review of your Medicare Part B or Part D costs.

Extra Help for Medicare Part B and Medicare Part D
Extra Help for Medicare Part B and Medicare Part D
Categories
Medicare A & B

Switching Medicare Supplement (Medigap) policies

Medicare Supplement Plan

Reasons Why New Yorkers Switch Their Medicare Supplement (Medigap) Policies:

As a reminder, Medicare Supplement, also known as Medigap, are policies designed primarily to supplement (or fill the gap) Medicare benefits. You simply present your red, white and blue Medicare card to the provider or facility along with the Supplement / Medigap card to help with out-of-pocket costs; such as deductible and co-insurance amounts with Original Medicare Part A and Part B.

Currently, there are 10 standardized Medigap plans, each represented by a letter (A, B, C, D, F, G, K, L, M, N; both Plans F and G offer a high-deductible version). These plans are available in most states. While premiums will vary from state to state the standardized benefits of each lettered plan remain the same despite the insurance company or location. For example, Plan F benefits are the same in Florida as they are in New York.

Q: Is there an Annual / Open Enrollment Period?

Most people buy their Medicare Supplement / Medigap policy during the six month period after they first enroll in Medicare. After that, in many states, Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application and how much to charge you for the Medigap policy.

Q: So How Do New York State Residents Have More Protection?

New York State laws and regulations continue this open enrollment period. A person enrolled in Medicare Parts A and B may purchase a Medigap policy at any time. Insurers may not consider an applicant’s health status, claims experience, or age. Laws in New York also prohibit insurers from basing Medigap premiums on age and charging a higher premium as they grow older. Also,

Q: But What About Pre-Existing Conditions; Are They Covered?

Medigap insurers may impose up to a six-month waiting period to be covered for any preexisting conditions a person may have. Federal law and New York State regulation define a preexisting condition as any condition for which medical advice was given or treatment was recommended by or received from a physician within six months before the effective date of coverage.
Under New York State regulation, the waiting period may be either reduced or waived entirely, depending upon whether an individual has had previous health insurance coverage. Medigap insurers are required to reduce the preexisting condition waiting period by the number of days an individual was covered under some form of “creditable” coverage so long as there were no breaks in coverage of more than 63 calendar days. Translation: If you are switching from a “creditable” plan that you have held consecutively for six months, New York regulation requires the new Medicare Supplement / Medigap plan to reduce or waive the six month pre-existing condition waiting period.

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Categories
Case Studies

A Medicare Supplement Testimonial

Medicare Supplement Testimonial
A Medicare Supplement Testimonial

…. it’s great to hear results.

Continue reading “A Medicare Supplement Testimonial”
Categories
Case Studies Part D Prescription Drug

“Thank you again for giving me my life back.”

Medicare Supplement Testimonial

…. it’s great to hear results.

Just before Thanksgiving I met with a recently widowed woman who was reeling from her loss and struggling to make sense of her health plan costs and dramatically reduced monthly income.

When she disclosed her assets and monthly income, I explained to her some programs she was likely eligible for and provided assistance with the enrollment process.

For starters, the easy one. I enrolled this client in the New York State Elderly Pharmaceutical Insurance Coverage (EPIC) program. EPIC helps with Medicare Part D premiums, prescriptions co-pays and the Part D “donut hole.”

Then, we confirmed she was eligible for Social Security Extra Help – available to Medicare participants with limited resources.

Third, New York State offers Part B premium assistance to Medicare participants with limited income and resources.

I love what I do.

When I received this note with the closing “Thank you again for giving me my life back” it reminds me of why we serve – to add some value to another’s life.  This is fulfilling and rewarding in its own way.

2016 0215 Thank you note