Below is a summary of recent events to help you stay current on the healthcare and Medicare news that impacts you. This page is updated frequently, so check back regularly to keep up with changes in the healthcare industry.
Healthcare Reform News Update for September 22, 2022
OIG warns of fraud for Medicare telehealth services
More Medicare beneficiaries are using telehealth services to access care.
Data shows that telehealth services for Medicare beneficiaries rose from 840,000 visits per year to more than 52 million (an increase of 6,000%) from 2019 to 2020.
However, in a recent study, the Office of Inspector General identified a rise in fraud, waste, and abuse related to telehealth services for Medicare beneficiaries.
In the study, the OIG found that:
- 1,714 providers out of 742,000 that billed for Medicare-related telehealth services pose a high risk for fraud, waste, and abuse.
- Medicare paid an estimated $128 million for telehealth services to providers that “warrant further scrutiny” for fraud, waste, and abuse.
- Fraudulent activity and risk factors for Medicare telehealth providers included
- Billing for services not medically necessary
- Connections to providers already identified as a high risk to Medicare
- Difficulty identifying associations with established telehealth companies
Recommendations to reduce Medicare telehealth fraud, waste and abuse include:
- Increase monitoring and oversight for telehealth providers that serve Medicare beneficiaries
- Educate telehealth providers on appropriate billing practices
- Require telehealth providers to include detailed information about services provided
- Identify telehealth companies that bill for Medicare
- Follow-up with Medicare providers that meet risk factors for fraud, waste, and abuse
Healthcare Reform News Update for September 16, 2022
Medicare changes cap insulin costs beginning in 2023
Changes to prescription drug costs outlined in the Inflation Reduction Act will cap insulin costs at $35 per month for Medicare Part D plans beginning January 1, 2023.
3.3 million Medicare beneficiaries have diabetes
For the estimated 3.3 million Medicare beneficiaries who have diabetes and use insulin, it’s a cost-saving measure designed to help control rising drug costs.
In a Yale University study published in the journal Health Affairs, researchers found that 14% of people who require insulin to manage diabetes spend 40% or more of their income after covering basic needs on insulin.
IRA rules help control prescription drug costs
Capping insulin costs at $35 per month for Medicare beneficiaries is the first in a series of rules outlined in the IRA to help control prescription drug costs over the next 7 years.
Beginning in January 2023 the IRA:
- Limits insulin copays to $35 per month for Medicare Part D plans
- Requires drug companies to pay rebates if drug prices rise faster than inflation
- Lowers vaccine costs for Medicare beneficiaries
Additional IRA rules designed to help control prescription drug costs include:
- Cap out-of-pocket prescription drug costs for Medicare beneficiaries to $4,000 or less.
- Eliminate 5% coinsurance for Medicare Part D for catastrophic coverage
- Limit Medicare Part D premium increase to no more than 6% per year through 2029.
- Require drug companies to pay rebates if drug prices rise faster than inflation.
- Require the federal government to negotiate rates for 60+ Medicare Part B and Medicare Part D drugs.
- Cap out-of-pocket prescription drug costs for Medicare beneficiaries at $2,000 or less.
Healthcare Reform News Update for September 7, 2022
New rules for marketing Medicare Advantage beginning Oct. 1
Third-party marketing organizations that market Medicare Advantage plans must comply with new rules established by the Centers for Medicare and Medicare Services beginning Oct. 1.
CMS took a hard look at third-party marketing practices for Medicare plans after consumer complaints surged by 165% over the previous year. Complaints included:
- Misinformation in celebrity endorsement advertising
- Perks and promises like free meals, free transportation to medical appointments, and cash payments for enrolling
- Forged signatures and fraudulent enrollments
- Misleading information about in-network and out-of-network providers
Some of the new Medicare marketing rules effective Oct. 1 include:
- Recording all calls where plans are discussed with beneficiaries and storing for 10 years.
- Stating a scripted disclaimer within the first minute of a call or electronic communications which says: “I/We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.”
- Notify beneficiaries their information will be shared with a licensed insurance agent for verbal, written, or digital communication.
- For more information, see the final rule on CMS Medicare marketing.
Healthcare Reform News Update for August 18, 2022
Poll: Majority of Medicare Beneficiaries Support At-Home Health Care Services
Approximately 97% of Medicare beneficiaries believe the U.S. government should continue policies that provide coverage for home health services , according to a new poll conducted by Morning Consult. Additionally, 88% of Medicare beneficiaries advocate for Congress to pass legislation that would stop the Centers for Medicare & Medicaid Services (CMS) from cutting these services.
The findings also included:
- 91% of Medicare beneficiaries prefer to receive short-term recovery or rehabilitation health care at home.
- 94% of Democrats and 93% of Republicans support the Medicare home health program.
- 65% of registered voters oppose CMS cutting Medicare home health services.
Healthcare Reform News Update for August 17, 2022
President Biden Signs Inflation Reduction Act
President Joe Biden signed the Inflation Reduction Act into law on Tuesday. The legislation will impact U.S. healthcare in a number of ways.
- The federal government will be able to negotiate prices for some Medicare prescription drugs. In 2026, Medicare will negotiate the price of 10 drugs; in 2027, 15 more drugs will be added; in 2029, 20 additional drugs will be a part of the process. The negotiations will first apply to drugs covered under Medicare Part D, and later expand to Medicare Part B.
- The cost of insulin will be capped at $35/month for people on Medicare starting in 2023.
- Out-of-pocket spending on prescription drugs will be capped at $2,000 for people on Medicare Part D starting in 2025.
- Affordable Care Act (ACA) enhanced premium subsidies will be extended until 2025.
- If drug companies increase their prices faster than the rate of inflation, they will be penalized starting in 2024.
FDA Expands Access to Hearing Aids
Some hearing aids will be available for purchase over-the-counter (OTC), according to a final rule issued by the U.S. Food and Drug Administration (FDA) on Tuesday.
The rule creates a new category for OTC hearing aids, and it will apply to air-conduction devices intended for people age 18 or older with mild or moderate hearing loss. Consumers will be able to buy them without a medical exam, prescription, or fitting by an audiologist.
The final rule is scheduled to take effect October 15, 2022.
Healthcare Reform News Update for July 12, 2022
Report: Consumers Confused by Medicare Enrollment Process
A majority of Medicare-eligible older adults are overwhelmed by Medicare enrollment and experience confusion, according to a new report by Sage Growth Partners. The study determined that many Medicare beneficiaries don’t have the right support to find the right plan for their needs.
The findings also included:
- 20% of Medicare-eligible individuals say they have a good understanding of Original Medicare
- 31% of Medicare-eligible individuals say they have a good understanding of Medicare Advantage
- 63% of Medicare-eligible individuals say they’re overwhelmed by Medicare advertising
- 58% of respondents stay in their current Medicare plan each year instead of reviewing their options
Healthcare Reform News Update for June 28, 2022
CMS Testing New Payment Model To Improve Medicare Cancer Care
The Centers for Medicare and Medicaid Services (CMS) will launch the Enhancing Oncology Model (EOM), a voluntary payment model intended to help Medicare beneficiaries who are cancer patients, in July of 2023. Participants in the EOM will include oncology practices.
Medicare beneficiaries will not be responsible for the new EOM payment, the full amount will be covered by Medicare.
Services provided by EOM participants may include:
- 24/7 access to a clinician with real-time access to your medical records
- Patient navigation services
- A detailed care plan
- Screening for needs related to food, transportation, and housing
- Questions regarding your overall cancer care experience and health outcomes
The program will run for a five-year testing period.
Healthcare Reform News Update for June 24, 2022
Supreme Court Upholds HHS Statutory Interpretation
In a 5-4 decision, the Supreme Court ruled in favor of the U.S. Department of Health and Human Services (HHS) and against the hospital industry in Becerra v. Empire Health Foundation.
The case involved a challenge to the way HHS understands the phrase “Medicare fraction,” which is used to calculate reimbursement rates for hospitals that provide treatment for a lot of low-income patients. HHS interpreted the regulation to mean that individuals “entitled to Medicare Part A benefits” consist of those who qualify for Medicare, even if Medicare doesn’t pay for all or part of a patient’s hospital stay.
The Court decided that HHS’s interpretation was correct, which means some providers may be unable to get back some of their expenses when providing healthcare for low-income patients.
Healthcare Reform News Update for June 21, 2022
Study: Medicare Could Save Billions on Generic Drugs
If Medicare purchased generic drugs at the prices offered by Dallas billionaire Mark Cuban’s newly launched digital pharmacy in 2020, it could have saved the government program approximately $4 billion, according to a study published in Annals of Internal Medicine.
The report compared the cost of 89 generic drugs at Cuban’s company in 2022 with the price Medicare Part D plans paid for the same drugs in 2020. After adjusting for changes in drug costs between 2020 and 2022, the researchers found that Medicare paid more for 77 generic drugs.
Cuban recently announced on Twitter that his pharmacy plans to add more than 1,000 additional drugs in the next year.
Healthcare Reform News Update for June 16, 2022
Report: Medicare Advantage Enrollment Surpasses 50% in 123 Congressional Districts
Medicare Advantage enrollment has overtaken 50% of Medicare beneficiaries in more than 120 Congressional districts, which is an increase of 37% (90 districts) over last year, according to new data from the Better Medicare Alliance. Eighty-three of the districts are represented by Democratic members of Congress, while 40 are represented by Republicans.
The top 3 districts are:
- FL-24 – 76% Medicare Advantage enrollment.
- NY-15 – 73% Medicare Advantage enrollment.
- NY-25 –71% Medicare Advantage enrollment.
Healthcare Reform News Update for June 15, 2022
Supreme Court Rules Against HHS
In a unanimous decision, the Supreme Court ruled against the Department of Health and Human Services (HHS) and in favor of a nonprofit hospital group in American Hospital Association v. Becerra.
The case involved whether HHS had the discretion to alter the group’s annual Medicare reimbursement rates for outpatient drugs. The Court ruled that they did not and had acted unlawfully by reducing them, overturning a lower court’s 2020 decision.
Healthcare Reform News Update for June 3, 2022
Medicare Part A Trust Fund to Be Depleted by 2028
The projected date for when Medicare’s hospital trust fund will run out of money has been pushed back two years, from 2026 to 2028, according to the annual Social Security and Medicare trustees report. The trust fund pays for services like Medicare Part A inpatient care.
The report also projects that Social Security’s trust fund reserves will be depleted by the end of 2034, one year later than previously estimated.
Healthcare Reform News Update for April 20, 2022
Analysis: Medicare Advantage Beneficiaries Save Almost $2K Over FFS Medicare
Beneficiaries enrolled in Medicare Advantage spend $1,965 less on out-of-pocket costs and premiums than fee-for-service (FFS) Medicare beneficiaries, according to a new study by Better Medicare Alliance.
The study also found:
- More than 52% of beneficiaries with Medicare Advantage live under 200% of the Federal Poverty Level (FPL).
- 38.3% of beneficiaries with FFS Medicare live under 200% of the FPL.
- 94.9% of Medicare Advantage beneficiaries and 96% of FFS Medicare beneficiaries report being “satisfied” or “very satisfied” with the quality of health care they received in the past year.
Healthcare Reform News Update for April 8, 2022
U.S. Postal Service Reform Bill Signed Into Law
President Biden signed the Postal Service Reform Act of 2022 into law on Wednesday. The legislation creates the Postal Service Health Benefits Program starting in January 2025 and addresses financial issues with the agency.
The bill performs the following functions:
- Eliminates a 2006 Congressional mandate that the Postal Service fund future retiree health benefits.
- Requires retired Postal Service employees to enroll in Medicare Parts B and D.
- Saves $50 billion over the next decade.
CMS Updates Medicare’s Alzheimer’s Drug Coverage Guidelines
The Centers for Medicare & Medicaid Services (CMS) finalized a rule on Thursday limiting coverage for the Alzheimer’s drug Aduhelm. Going forward, Medicare will only cover the cost of the prescription for those participating in clinical trials.
In making this final decision, CMS allowed flexibility for approving future medications for the treatment of Alzheimer’s. If the prescriptions show that they can benefit patients, they could potentially be covered by Medicare.
Healthcare Reform News Update for February 14, 2022
Medicare Increases Access to Lung Cancer Screening Tool
Low dose computed tomography (LDCT), a tool used to detect lung cancer, will now be available to more people on Medicare, according to a new Centers for Medicare & Medicaid Services (CMS) final decision.
CMS expanded eligibility requirements in an effort to help people determine if they have lung cancer sooner.
- The eligibility age for LDCT has decreased from 55 to 50 years.
- Tobacco smoking history eligibility has decreased from 30 packs a year to 20.
- A requirement for radiologist documentation has been eliminated.
- A requirement for radiology facilities to use a “standardized lung nodule identification, classification, and reporting system” has been added back.
Healthcare Reform News Update for February 3, 2022
Medicare to Provide Coverage for At-Home COVID-19 Tests
Medicare will provide coverage for over-the-counter COVID-19 rapid tests, according to a Centers for Medicare and Medicaid Services (CMS) statement.
Tests will be available at no cost to beneficiaries beginning in spring 2022. People with Medicare Part B, whether enrolled in a Medicare Advantage plan or not, will be able to visit their local pharmacy and retrieve the COVID-19 tests. Up to eight tests per person per month will be covered.
Healthcare Reform News Update for January 19, 2022
Report: Medicare Advantage Enrollment Increased in 2021
Federal data has revealed that Medicare Advantage enrollment increased 8.8% year-over-year, according to a new independent analysis.
From January 1, 2021 – January 1, 2022, more than 28.5 million seniors and people with disabilities enrolled in a Medicare Advantage plan.
Healthcare Reform News Update for December 29, 2021
CMS Expands Medicare Part B Durable Medical Equipment Coverage
Adjunctive continuous glucose monitors (CGMs) for diabetes treatment will now be classified as Durable Medical Equipment (DME) under Medicare Part B coverage, according to a final rule issued by the Centers for Medicare & Medicaid Services (CMS).
The rule also finalizes DME payment provisions that were previously included in 2018 and 2020 interim final rules.
The new classification will go into effect on February 28, 2022.
Healthcare Reform News Update for November 23, 2021
Original Medicare Premiums & Deductibles to Increase in 2022
Premiums and deductibles for Medicare Parts A and B will rise in 2022, according to the Centers for Medicare & Medicaid Services (CMS).
New rates for 2022:
- The Medicare Part B standard monthly premium will be $170.10, an increase of $21.60..
- The Medicare Part B annual deductible will be $233, an increase of $30.
- The Medicare Part A inpatient hospital deductible will be $1,556, an increase of $72.
- Medicare Part A coinsurance will be $389 per day for days 61-90, an increase of $18.
CMS has attributed the rise in costs to increased healthcare system use, the effort to keep Medicare Part B premiums lower in 2021, and the uncertainty of whether Medicare will cover the expensive Alzheimer’s drug, Aduhulelm™, in the future.
Medicare Open Enrollment is currently underway but will end on December 7, 2021.
Healthcare Reform News Update for September 30, 2021
2022 Medicare Advantage & Part D Premium Information Released
The Centers for Medicare and Medicaid Services (CMS) has released average premiums for 2022 Medicare Advantage and Part D plans. The average 2022 Medicare Advantage premium has decreased to $19/month from $21.22/month in 2021. For Medicare Part D, the average 2022 premium has increased slightly to $33/month, up from $31.47 in 2021.
Medicare Open Enrollment will run from October 15 through December 7.
Healthcare Reform News Update for September 2, 2021
CMS Names First Chief Dental Officer
The Centers for Medicare and Medicaid Services (CMS) has announced that Dr. Natalia Chalmers will be its first-ever Chief Dental Officer. The primary focus of the position will be “commitment to care for the whole person, a key to reducing health disparities and advancing health equity.”
Chalmers previously served as a dental officer at the U.S. Food and Drug Administration.
Healthcare Reform News Update for August 24, 2021
Price Transparency Rule Enforcement Delayed Until July 2022
The Centers for Medicare & Medicaid Services (CMS) will be delaying the enforcement of a new Transparency in Coverage final rule for group health insurance plans and companies until July 1, 2022.
The rule, issued in October 2020, requires group health insurance policies and insurance carriers to make public in-network rates, out-of-network amounts and billed charges, and prescription drug prices.
Previously, the rule was scheduled to be implemented on January 1, 2022.
Healthcare Reform News Update for July 12, 2021
President Biden Signs Executive Order Promoting Competition
President Joe Biden signed an executive order on Friday that directs the U.S. Department of Health and Human Services (HHS), among others, to strengthen and promote competition in the American economy.
As HHS Secretary, Xavier Becerra was ordered to “ensure that Americans can choose health insurance plans that meet their needs and compare plan offerings, implement standardized options in the national Health Insurance Marketplace and any other appropriate mechanisms to improve competition and consumer choice.”
The order also declared that it is the policy of the current administration to support the enactment of a public health insurance option.
Healthcare Reform News Update for July 7, 2021
The Director of Center for Medicare Announced by CMS
The Centers for Medicare and Medicaid Services (CMS) has announced that Dr. Meena Seshamani will be the Deputy Administrator and Director of the Center for Medicare.
Seshamani previously served as Vice President of Clinical Care Transformation at MedStar Health and as Director of the Office of Health Reform at the U.S. Department of Health and Human Services (HHS).
Healthcare Reform News Update for May 26, 2021
Senate Confirms Brooks-LaSure to Lead CMS
The Senate on Tuesday confirmed Chiquita Brooks-LaSure as head of the Centers for Medicare and Medicaid Services (CMS). The department oversees health insurance programs for more than 130 million Americans, including the Affordable Care Act (ACA) and children’s health coverage.
Brooks-LaSure previously served at CMS under Barack Obama and in the White House budget office during George W. Bush’s presidency.
Healthcare Reform News Update for May 19, 2021
Study: Dual-Eligible Enrollees May Have Had Better Access to Care Under Medicare Advantage Plans than Original Medicare During Past Year
Low-income Americans enrolled in dual-eligible Medicare Advantage plans throughout the pandemic were less likely to experience difficulties accessing medical care than those with Original Medicare, according to a new study from NORC at the University of Chicago.
The analysis shows that, even though enrollees with dual-eligible plans are older, sicker, and more racially diverse than those in traditional plans, they had better access to healthcare.
Other findings from the analysis include:
- 51% of dual-eligible enrollees with Original Medicare were unable to receive a regular checkup compared to 35% of those with Medicare Advantage.
- 23.1 % of dual eligibles felt socially isolated compared to 32.8% of Original Medicare enrollees.
- 63% of dual eligibles had access to telemedicine visits compared to 52% of Original Medicare enrollees.
Healthcare Reform News Update for April 13, 2021
Study: Medicare Advantage Users Spend 40% Less
People with Medicare Advantage plans spend 40% less per year than people enrolled in Original Medicare, according to resources used in a recent UnitedHealth Group publication.
The analysis found that average spending for annual out-of-pocket costs and premiums for Medicare Advantage beneficiaries is $3,558. That compares to $5,361 for people with Original Medicare and a Part D plan and $5,992 for those with Original Medicare, a Part D plan, and Medicare Supplement Plan G.
Other findings in the study:
- Annual cost sharing for Medicare Advantage Prescription Drug (MA-PD) users is 10.7% compared to 16.3% for Original Medicare beneficiaries.
- Medicare Advantage Prescription Drug (MA-PD) users spend between $64,321 and $98,878 less in lifetime costs than those with Original Medicare and Medigap Plan G, respectively.
Healthcare Reform News Update for April 7, 2021
New Medicare Advantage Plan Created for Older Beneficiaries in VT, NY
MVP Health Care and the University of Vermont Health Network have partnered to launch a new Medicare Advantage plan in 2022 for older residents in Vermont and northern New York. Details of plan benefits will be available this fall.
Healthcare Reform News Update for February 8, 2021
Medicare Advantage Extra Benefits Enrollment Triples in 2021
Enrollment in Medicare Advantage plans that offer special supplemental benefits for the chronically ill (SSBCI) increased from 1 million in 2020 to 3 million in 2021, according to research from Avalere Health.
Beginning last year, Medicare Advantage plans were allowed to offer non-primary health-related benefits to people with conditions such as diabetes and asthma. These plans represent 16% of all 2021 Medicare Advantage plans that were analyzed.
The most commonly offered SSBCI are meals, food and produce, and pest control.
The analysis found that 86% of Medicare beneficiaries live in a county with at least one plan that offers an SSBCI benefit. Overall, 15% of 2021 Medicare Advantage enrollees are enrolled in plans offering SSBCI, compared to 6% in 2020.
Healthcare Reform News Update for January 19, 2021
CMS Oks New Medicare Part D Drug Tier
The Centers for Medicare & Medicaid Services (CMS) finalized a rule that will allow insurance companies to create a second “preferred” specialty tier for some high-cost Medicare Part D specialty drugs.
The new preferred tier will have lower out-of-pocket costs for Medicare patients than the current “specialty” tier. Currently, all drugs on a Part D plan’s specialty tier have the same level of cost sharing.
Healthcare Reform News Update for January 13, 2021
Medicare Rule Allows Faster Coverage for Innovative Technologies
The Centers for Medicare and Medicaid Services (CMS) issued a final rule that will allow innovative medical devices to be covered more quickly by Medicare.
The rule approves devices designated as “breakthrough” to be covered as soon as the same day the device is authorized by the Food and Drug Administration (FDA). Devices will receive an initial four years of Medicare coverage.
Healthcare Reform News Update for December 22, 2020
Congress Passes Spending Package That Includes a Ban on Surprise Billing
Congress on Monday passed a $900 billion economic relief package including legislation that eliminates the practice of “surprise billing” beginning in 2022.
Surprise bills result from insured patients unexpectedly using out-of-network providers, most commonly in emergency settings.
The bill applies to doctors, hospitals, and air ambulances. Ground ambulances are unaffected. An exception is made if a patient gives consent prior to visiting an out-of-network physician.
Instead of charging patients, non-network providers will work directly with insurance companies regarding payment. Disagreements will be sent to outside mediators to negotiate.
Healthcare Reform News Update for December 10, 2020
New Study Claims Medicare Advantage Better for High-Need Beneficiaries
Americans with Medicare Advantage (MA) plans who have high needs and high costs achieve better outcomes than those with Original Medicare, according to a new study by the Better Medicare Alliance, a Medicare Advantage advocacy group.
High-need, high-cost beneficiaries, as defined by the study, include those individuals underage 65 who are disabled, the frail elderly, and those with major complex chronic conditions. The analysis compared MA to Original Medicare on a host of quality measures including preventative screenings, prescription drug use, and hospitalizations.
The study found that high-need, high-cost beneficiaries with MA plans:
- Had prescription drug costs 41% lower than Original Medicare; and had combined medical and prescription drug costs that were 15% lower.
- Had a 57% lower rate of avoidable hospitalizations for acute conditions when dealing with a major complex chronic condition.
- Had a 66% higher rate of outpatient visits if the enrollee was frail, and a 46 percent higher visit rate if the enrollee was under 65 and disabled.
- Received 49% more pneumonia vaccines and 11% more flu vaccines.
- Received more screenings for depression, breast cancer, and prostate cancer.
- Had a 16% lower rate of skilled nursing facility stays if the enrollee had a major complex chronic condition.
Healthcare Reform News Update for November 23, 2020
Trump Administration Finalizes Rules to Lower Medicare Prescription Drug Costs
The Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) finalized two new rules last week that could lower Medicare prescription drug costs for beneficiaries.
The first rule announced a Most Favored Nation (MFN) Model for Medicare Part B drugs. Drug payments will be based on the lowest price that drug manufacturers obtain in similar countries and will go into effect January 1, 2021.
The second rule eliminates Medicare Part D prescription drug rebates for insurance companies, which could provide patients up to 30% in savings and will go into effect January 1, 2022. Instead, the rebates would go directly to the beneficiaries.
Healthcare Reform News Update for November 19, 2020
Anthem Medicare Advantage Virtual Visits Increase Greatly in 2020
The number of virtual healthcare visits made by Anthem Medicare Advantage beneficiaries between March and May of 2020 was 136 times greater than during the same period last year, according to a new report from the company’s Public Policy Institute.
The coronavirus (COVID-19) pandemic and stay at home orders are attributed with increasing the number of virtual visits from 4,400 in 2019 to 600,000 in 2020.
Some of the findings of how the company’s Medicare Advantage members used virtual healthcare include:
- Care delivered by providers with existing relationships to the patient accounted for 98% of virtual visits.
- Mental health conditions and substance abuse were the most common diagnoses treated virtually, with an increase of 5,000% over last year.
- Cardiovascular problems were the most commonly addressed physical conditions, followed by musculoskeletal ailments and endocrine and metabolic conditions.
Healthcare Reform News Update for November 12, 2020
Medicare to Cover COVID-19 Antibody Treatment for Beneficiaries
A new coronavirus (COVID-19) monoclonal antibody treatment will be available with no cost-sharing to people on Medicare, the Centers for Medicare & Medicaid Services said Tuesday.
The drug, called bamlanivimab, was approved by the U.S. Food and Drug Administration (FDA) this week and can be administered via infusion by a variety of providers, including hospitals, infusion centers, home health agencies, and nursing homes.
Healthcare Reform News Update for October 29, 2020
Medicare Will Pay for Future COVID-19 Vaccine
Medicare will cover all costs for government-approved coronavirus (COVID-19) vaccines under a new rule announced Wednesday by the Trump administration.
The plan ensures that Medicare beneficiaries will receive any and all doses at no charge once they are available.
Healthcare Reform News Update for October 23, 2020
Blue Cross Blue Shield of North Dakota Launches New Medicare Advantage Provider
Blue Cross Blue Shield of North Dakota (BCBSND) has debuted NextBlue, its new Medicare Advantage health insurance affiliate.
NextBlue is initially offering Medicare Advantage products for the 2021 plan year to Medicare-eligible residents in Burleigh, Cass, Morton, Richland and Stutsman counties, with the intent to expand in the future.
Healthcare Reform News Update for October 6, 2020
Aetna Broadens Medicare Advantage Plan Availability
Aetna announced its 2021 Medicare Advantage plans will be available in 115 new counties, making the plans accessible to 1.9 additional people.
Benefits under the company’s 2021 Medicare Advantage (non-special needs) plans include:
- $0 coronavirus (COVID-19) testing and expanded coverage of virtual mental health services while the public health emergency is in effect (all plans).
- Virtual primary and urgent care visits, including after hours or weekend care, sick visits and prescription refills (all plans).
- An annual $0 in-home visit from a clinician that includes a comprehensive health risk assessment and non-invasive physical exam (all plans).
- The Aetna Resources for Living program, which connects enrollees to community resources such as transportation, housing, food programs, caregiver support and utility assistance (all plans).
- Access to MinuteClinic walk-in and telehealth services for the same copay as a regular primary care physician visit (select PPO and HMO plans).
- Fitness memberships though Aetna’s SilverSneakers program (all plans).
The company will also offer its Dual Eligible Special Needs plans to select counties in nine new states: California, Connecticut, Kentucky, Maine, Michigan, Mississippi, Nevada, New Jersey, and New York.
In addition, Aetna will offer a new standalone Medicare Part D plan, SilverScript SmartRx. At an average of $7.15, the plan will have the lowest PDP premium available in the country.
Clover Health & Walmart Launch New Medicare Advantage Plans in Georgia
Clover Health has partnered with Walmart to offer two new Medicare Advantage plans in eight Georgia counties (Bartow, Bibb, Cherokee, Cobb, Gwinnett, Henry, Paulding, and Rockdale).
Benefits of the LiveHealthy: Clover Powered, Walmart Enhanced and the LiveHealthy LI: Clover Powered, Walmart Enhanced plans include:
- $0 copays on primary care visits, lab tests, preventative dental exams, and annual physicals.
- In-network access to 31 hospitals and over 8,000 providers.
- Access to select Walmart Health centers.
Healthcare Reform News Update for October 5, 2020
UnitedHealthcare to Offer 2021 Medicare Advantage Plans in Nearly 300 New Counties
UnitedHealthcare announced its Medicare Advantage plans will be available to nearly an additional 3.2 million people in close to 300 counties in 2021, signaling the company’s largest expansion in five years.
Benefits that will be available for the company’s 2021 Medicare Advantage (non-special needs) plans include:
- $0 copays for telehealth visits (all plans).
- $0 copays for medical and behavioral telehealth visits, labs, routine vision and hearing exams, colonoscopies, mammograms, and cardiac rehab (most plans).
- $0 copays for tier 1 and tier drugs when ordered via OptumRX home delivery pharmacy (most plans).
- HouseCalls, a program that provides a yearly home visit with a licensed clinician to help coordinate needed care (most plans).
- Navigate4Me, which offers a dedicated support representative to those with complex healthcare needs such as surgery, cancer treatments, or chronic illnesses (all plans).
- A $35 per month cap on out-of-pocket insulin costs (some plans).
- Renew Active™ Fitness Program, which includes gyms, classes, and events to stay healthy (most plans).
Healthcare Reform News Update for October 2, 2020
Humana Adds New Counties and Benefits for 2021 Medicare Advantage Plans
Humana’s Medicare Advantage HMO plans will expand into 125 new counties for the 2021 plan year, and its Medicare Advantage PPO plans will be available in 98 new counties, according to a press release.
New benefits for the company’s 2021 Medicare Advantage and prescription drug plans include:
- $0 copays for telehealth visits and coronavirus (COVID-19) testing.
- A Health Essentials Kit including items to help prevent the spread of COVID-19.
- $0 copay for COVID-19 treatment and 14 days of home-delivered meals (up to 28) for patients with the virus.
- An Insulin Savings Program (ISP) for select plans with out-of-pocket costs for insulin capped at $35 per month.
- A Healthy Foods Card for Dual Eligible Special Needs Plan (D-SNP) members with a monthly food allowance of up to $75 per month.
Healthcare Reform News Update for October 1, 2020
Cigna Adds 5 States to 2021 Medicare Advantage Plans
Cigna’s Medicare Advantage offerings are expanding by 22% in 2021 with the addition of five new states and 67 new counties. In total, Cigna will offer plans across 369 counties in 23 states for the 2021 plan year.
According to a press release, the company will now offer Medicare Advantage plans in select regions of the following states:
- New Mexico – Albuquerque area,
- Ohio – Cleveland area,
- Oklahoma – Oklahoma City area,
- Utah – Salt Lake City area, and
- Virginia (Tri-Cities area in the southwest part of the state).
Cigna also announced new virtual physical therapy services to all Medicare Advantage enrollees and, in select areas, a program that provides an allowance of up to $30 per month for fresh fruits and vegetables.
Healthcare Reform News Update for September 25, 2020
Trump Signs Executive Order on ‘Surprise’ Medical Billing
President Donald Trump on Thursday signed two executive healthcare orders, one of which focuses on ending “surprise” medical billing.
The second of the two executive orders addresses “surprise” medical billing for out-of-pocket expenses not covered by a patient’s health insurance. Often, these medical bills are a result of patients receiving care from an out-of-network provider in emergency situations or through nonsurgical hospital stays – instances in which patients cannot choose their healthcare provider.
The order instructs Congress to work with Health and Human Services (HHS) Secretary Alex Azar to develop a legislative solution to this issue by December 31. If Congress fails to act by that date, HHS will have the authority to pursue a regulatory approach. Azar did not offer specific details.
The first order declares it a U.S. policy to “ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates” – despite the future of the Affordable Care Act (ACA).
Healthcare Reform News Update for September 15, 2020
New Jersey Healthcare Leaders Team Up to Launch New Medicare Advantage Plan
Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) and health network Hackensack Meridian Health have partnered to launch Braven Health, a new Medicare Advantage plan. RWJBarnabas Health will also join the plan, pending state regulatory approval.
These plans will be offered for the 2021 plan year to Medicare-eligible residents in eight New Jersey counties: Bergen, Essex, Hudson, Middlesex, Monmouth, Ocean, Passaic, and Union.
Healthcare Reform News Update for September 1, 2020
CMS Proposes Faster Medicare Coverage for New ‘Breakthrough’ Devices
The Centers for Medicare and Medicaid Services (CMS) has proposed a rule that will shorten the time between when new medical devices are approved for use by the Food and Drug Administration (FDA) and when they are covered by Medicare.
The rule will help fast-track devices designated by the FDA as “breakthrough” technology that treats unmet medical needs.
In the current process, manufacturers receive Medicare approval on a regional basis. The Medicare Coverage of Innovative Technology pathway would enable devices to receive national Medicare coverage approval concurrently with FDA approval.
Healthcare Reform News Update for August 24, 2020
Oscar Partners with South Florida Health Groups For New Medicare Advantage Offering
Health insurance company Oscar has partnered with Holy Cross Health and Memorial Healthcare System to provide a new Medicare Advantage plan for residents of Broward County, Florida.
The plan will provide enrollees access to Holy Cross Health’s and Memorial Healthcare System’s network of healthcare providers, dedicated care guides, and $0 unlimited virtual visits beginning January 2021.
The plan will be available during this fall’s Medicare annual election period pending approval from state regulators.
Healthcare Reform News Update for August 5, 2020
CMS Proposes Policies to Expand Medicare Coverage
The Centers for Medicare & Medicaid Services (CMS) on Tuesday proposed several new policies that could affect Medicare beneficiaries.
The proposals include:
- Expanding the amount of procedures that Medicare would pay for in the hospital outpatient setting to more than 1,700 services, including around 300 musculoskeletal services (e.g. specific joint-replacement procedures).
- Covering 11 additional surgical services performed in ambulatory surgical center (ASC) settings.
- Reducing the payment rate for hospital outpatient drugs.
CMS will accept public comments until Monday, October 5.
Healthcare Reform News Update for August 4, 2020
Trump Expands Medicare Telehealth Services
President Donald Trump issued an executive order August 3 that permanently expands Medicare telehealth services in rural communities throughout the United States, prompting the Centers for Medicare & Medicaid Services (CMS) to propose changes to the current system.
CMS previously expanded the availability of telehealth services because of the coronavirus (COVID-19); this executive order builds upon those efforts. Over the past several months, Medicare telehealth visits have grown to over 1 million per week – a significant increase from the previous thousands per week.
The executive order directs the following actions:
- Strategic investments in rural communications infrastructure.
- New “payment model testing innovations” for rural hospitals.
- The launch of a joint initiative to improve healthcare communication infrastructure.
Healthcare Reform News Update for July 30, 2020
Medicare Drug Premiums to Rise Slightly in 2021
The Centers for Medicare & Medicaid Services (CMS) announced that Medicare Part D prescription premiums will only slightly increase in 2021. The average premiums will be $30.50, compared to $30 this year.
Part D premium prices continue a trend of lower costs with a 12% decline since 2017.
Healthcare Reform News Update for July 21, 2020
Clover Health to Triple Medicare Advantage Availability
Clover Health plans to expand its 2021 Medicare Advantage plan offerings to 74 additional counties, tripling its current reach.
The company’s expansion adds 69 counties to states it already serves, which includes Arizona, Georgia, New Jersey, Pennsylvania, South Carolina, Tennessee, and Texas. It will also expand into five counties in Mississippi, a new market for the company.
Healthcare Reform News Update for July 13, 2020
Medigap Enrollees Prefer the Most Comprehensive Coverage
The majority of Medicare Supplement enrollees choose more comprehensive coverage, according to a new study from America’s Health Insurance Plans (AHIP).
Around 9.3 million people were enrolled in a Medicare Supplement Plans F and G, in 2018, accounting for 70 percent of all enrollment. Plans F and G are two of the most comprehensive plans, but Plan F was discontinued to new enrollees as of January of this year.
Other finding from the study include:
- In 2018, total enrollment in Medicare Supplement plans was 14 million, an increase of 3.7 percent compared to 2017.
- Only 5 percent of Medicare Supplement plan enrollees reported having difficulty paying medical bills in the last year, compared to 12 percent of people with Original Medicare who do not have Medicare Supplement plans.
- Plan F has the largest enrollment with 7,043,000 enrollees.
Healthcare Reform News Update for June 30, 2020
House Democrats Pass Bill to Extend ACA Provisions
The House voted to expand the Affordable Care Act on Monday. The measure is the first significant ACA bill to pass since the law was enacted.
The legislation passed primarily along party lines, with Democrats in support and Republicans opposing. The bill is not expected to pass in the Republican-controlled senate, and the White House announced that the president would veto the measure if it comes before him.
Some of the provisions in the bill include:
- Capping premiums for benchmark silver plans at 8.5% of income for all enrollees, instead of only offering ACA premium tax subsidies to those earning under 400 percent of the federal poverty level.
- Increasing funding for ACA outreach and enrollment to $100 million per year.
- Allowing federal health officials to negotiate the price of prescription drugs under Medicare.
- Reestablishing the 3-month duration limit for short-term health insurance.
- Reducing Medicaid funding for states that have not expanded Medicaid, but also allowing the federal government to pay the entire initial cost for expansion.
Healthcare Reform News Update for June 9, 2020
Molina Waives Coronavirus Cost-Sharing Through 2020
Molina Healthcare will continue to waive customer out-of-pocket costs for coronavirus (COVID-19) testing and treatment for the remainder of the year. The initiative applies to all of its Affordable Care Act, Medicare, and Medicaid plans.
Healthcare Reform News Update for June 2, 2020
Cigna Eliminates Cost-Sharing for All Plans and Increases MA Meal Benefits
Cigna announced that it is expanding and extending its cost-sharing relief initiatives for all enrollees with individual, family and Medicare Advantage plans.
Effective immediately, the company will:
- Waive all copays, deductibles and coinsurance for in-person and telehealth visits for in-network primary care physicians and specialists, including behavioral health.
- Extend coronavirus (COVID-19) cost-sharing elimination, which includes testing and treatment.
- Increase the Medicare Advantage meal benefit to 28 home-delivered meals available for 14 days after a hospital stay.
These new measures will be in effect for Medicare Advantage through the end of this year. For individual and family plans, the changes will apply until the end of applicable federal and state public health emergencies.
Healthcare Reform News Update for May 27, 2020
CMS: 1,750 Medicare Advantage & Part D Plans Will Cap Insulin Costs
Beginning in 2021, more than 1,750 standalone Medicare Advantage and Medicare Part D prescription drug plans will cap monthly out-of-pocket costs for insulin at $35, according to the Centers for Medicare & Medicaid Services (CMS).
Plans in all 50 states, the District of Columbia, and Puerto Rico will participate in the program, called the Part D Senior Savings Model. The pricing will be available for a range of insulins, including pen and vial dosage forms for rapid-acting, short-acting, intermediate-acting, and long-acting insulins.
CMS projects that the average savings for consumers will be $446 per year.
Healthcare Reform News Update for May 26, 2020
CMS Expands Telehealth Benefits for 2021 Medicare Advantage Plans
The Centers for Medicare & Medicaid Services (CMS) released final rules for 2021 Medicare Advantage (MA) plans that allow increased flexibility to offer and discount telehealth services for specialty care.
Other finalized changes/enhancements include:
- People with End Stage Renal Disease (ESRD) will be eligible to enroll in MA plans. Currently, individuals with ESRD can enroll in an MA plan only if they develop ESRD after enrolling in an MA plan, receive benefits through the same organization that offers MA plans (such as an employer-sponsored plan), or have had a successful kidney transplant.
- Member feedback will be weighted more heavily in determining MA and Part D Star Ratings.
- “Look-alike” Dual Eligible Special Needs Plans (D-SNPs) will be phased out. Look-alike plans have similar levels of enrollment qualifications as D-SNPs but do not have the federal regulatory and state-contracting requirements applicable to D-SNPs.
Healthcare Reform News Update for May 7, 2020
UnitedHealth Group, Cigna Offer Discounts, Relief in Response to COVID-19
Two of country’s largest health insurers, UnitedHealth Group and Cigna, have announced new measures in response to the coronavirus (COVID-19) pandemic.
UnitedHealth Group’s assistance includes:
- Employer and individual health plans. The company will issue premium credits ranging from 5% to 20% in June.
- Medicare Advantage plans. All cost-sharing for specialist and primary care will be waived through September.
- AARP Medicare Supplement plans. The company will provide both new and renewal premium price stability and support.
UnitedHealth is also expanding its Housing+Health and homeless support programs.
Express Scripts, a Cigna company, is offering its Parachute RxSM discount program to any American who has lost coverage due to COVID-19 for a limited time. The program provides generic drugs capped at $25 for a 30-day supply and brand-name drugs capped at $75 for a 30-day supply.
The Parachute RxSM program covers over 40 brand-name drugs and thousands of generic medication used mostly commonly to treat conditions such as asthma, diabetes, glaucoma, heart disease, migraine, non-opioid pain management, reproductive health, seizures, and thyroid conditions. Users can have drugs delivered from the Express Scripts Pharmacy or pick up at them up one of the 50,000 participating retail pharmacy locations.
Medicare Allows Special Enrollment Period for Those Affected by COVID-19
The Centers for Medicare & Medicaid Services (CMS) announced that Medicare beneficiaries can sign up for new coverage until June 30 if they were unable to sign up previously due to the coronavirus (COVID-19) pandemic.
This Special Enrollment Period (SEP) is available to residents of all states, tribes, territories, and the District of Columbia. Beneficiaries do not have to provide proof that they were affected by the pandemic-related emergency.
Healthcare Reform News Update for May 6, 2020
Humana Waives Medicare Advantage Cost-sharing for 2020
Humana is waiving all copays, coinsurance, and deductibles for all in-network primary care, behavioral health, and telehealth visits for its Medicare Advantage customers for the remainder of 2020.
In addition, the company is sending a safety kit that includes masks and health advice information to its Medicare Advantage members to help them see their healthcare providers safely.
Last month, Humana waived all out-of-pocket expenses for coronavirus (COVID-19) treatments. The company says that this latest measure is intended to help ease financial burdens, support member safety, reopen the healthcare system, and boost the economy.
Healthcare Reform News Update for April 29, 2020
COVID-19 Is Causing Medicare Part B Enrollment Delays
Seniors transitioning from employer coverage to Medicare Part B medical insurance are likely to encounter wait times more than twice as long as normal due to coronavirus (COVID-19) office closures.
With many workers furloughed or laid off, Social Security has seen an increase in applications for Medicare Part B, which covers outpatient services such as lab tests, from workers who continued working past age 65. Many Medicare issues can be handled online. But moving from employer coverage to Medicare Part B requires contacting Social Security personnel, who are currently working from home.
Most recently, the increase in Part B applications has led to average hold times of 45 minutes. However, wait times could be up to 90 minutes for the agency’s national 800 number, according to the Social Security Administration’s website. Previously, the average was 20 minutes.
Acknowledging the delays, Social Security teamed up with the Centers for Medicare and Medicaid Services (CMS) to streamline the application process by temporarily waiving some signature requirements and creating a dedicated fax number for applications.
Healthcare Reform News Update for April 13, 2020
CMS: Insurers Must Provide Free COVID-19 Antibody Tests
Insurance companies are required to provide antibody tests for the coronavirus (COVID-19) to policyholders with no out-of-pocket costs, according to new guidance released by the Trump administration on Saturday.
The free antibody tests will be used to detect those with immunity against the virus and help determine how many Americans were infected with the virus but experienced little or no symptoms.
Health experts believe that extensive antibody testing is integral to easing social distancing protocols and will enable employees to go back to their workplaces faster.
It’s not clear whether uninsured Americans will be eligible for free antibody tests.
Healthcare Reform News Update for April 10, 2020
Trump Administration Bans Surprise Bills for COVID-19 Patients
Hospitals and doctors that accept funding from the $2 trillion stimulus bill are barred from charging insured patients for out-of-network costs incurred while receiving treatment for the coronavirus (COVID-19), according to the Trump administration.
Individuals covered by individual plans, employer plans, and government programs will not receive these “surprise” medical bills. Plans for how costs for uninsured COVID-19 patients will be handled have not yet been announced.
Previously, co-pays and deductibles for testing were waived, and many insurance companies have also waived out-of-pocket costs for in-network treatment.
Healthcare Reform News Update for April 2, 2020
Health Care Services Corp Opens Special Enrollment for Fully Insured Group Plans
Due to the coronavirus (COVID-19) outbreak, Health Care Services Corporation announced a Special Enrollment Period for its fully insured group plans through April 30.
The company, which runs Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma, and Texas, is allowing employees who did not opt in to their group plans to enroll themselves and dependents in coverage. Currently enrolled employees may also add eligible dependents and spouses to their existing plans.
The special enrollment is for medical/pharmacy and dental coverage only and will be effective April 1.
UnitedHealthcare, Anthem Waive COVID-19 Treatment Cost-Sharing
UnitedHealthcare, Anthem, and two regional insurance companies have announced that they will waive cost-sharing for coronavirus (COVID-19) treatment.
UnitedHealthcare will waive out-of-pocket costs for its Medicare Advantage, fully insured group plans and Medicaid plans. The company is also working with self-funded employers who would like to offer the benefit.
Anthem will cover out-of-pocket costs through May 31 for individuals, Medicare Advantage and Medicaid enrollees, and fully insured employer plans. The company has also encouraged its self-funded plans to offer the benefit.
Healthcare Reform News Update for March 31, 2020
Federal Ruling Allows Medicare Patients to Challenge Hospital Observation Status
Medicare patients can now appeal hospital-mandated status changes that characterize them under “observation” status instead of “inpatient,” according to a March 24 ruling by a federal judge.
The decision, part of a class action lawsuit, is important because it could protect some Medicare beneficiaries from large out-of-pocket costs. Medicare Part A does not pay for costs associated with hospitalization or post-acute skilled nursing stays unless the patient has been admitted as an inpatient.
U.S. District Judge Michael Shea said patients should be allowed to challenge decisions that essentially strip them of their Medicare Part A benefits. His decision applies to Medicare beneficiaries from 2009 forward.
The ruling does not apply to patients who were initially placed into hospital “observation” status and were never admitted as inpatients.
The Centers for Medicare and Medicaid Services (CMS) is reviewing the ruling; the Department of Health and Human Services (HHS) has until late May to appeal the decision.
Healthcare Reform News Update for March 30, 2020
Cigna, Humana Waive Out-of-Pocket Costs for COVID-19 Treatment
Health insurers Cigna and Humana will not require policyholders to make out-of-pocket payments for treatment related to the coronavirus (COVID-19).
The companies’ decision will affect all fully insured health policies for employer-sponsored, individual, and Medicare Advantage customers. Self-insured employers are encouraged to waive deductibles and copays but can opt out if they choose.
Cigna’s waived payments are in effect through May 31. Humana has not set an end date and will evaluate the policy as needed.
Healthcare Reform News Update for March 23, 2020
George Forbids Health Insurers From Cancelling Policies During Coronavirus Outbreak
Georgia Insurance Commissioner John King has banned insurance companies from cancelling health insurance policies for nonpayment during the coronavirus pandemic. The directive is in effect until further notice.
Healthcare Reform News Update for March 19, 2020
Blue Shield of California to Provide Digital COVID-19 Triage Tool to Hospitals
A new digital tool from Blue Shield of California will allow its in-network hospitals to provide patients up-to-date COVID-19 triage and advice from their websites.
The result of a partnership with GYANT, the COVID-19 Screener and Emergency Response Assistant (SERA) tool will enable participating providers to manage patient demand by:
- asking basic questions,
- directing users to the appropriate site for care,
- and providing the latest guidance from the Centers for Disease Control and Prevention and the World Health Organization.
For hospitals that may not have the capacity to create an online patient tool, SERA can be deployed and customized within 48 hours to meet a facility’s needs. It will be offered to hospitals free of charge for three months.
CMS Advises Delay of Non-Essential Procedures
The Centers for Medicare & Medicaid Services recommended Wednesday that all elective surgeries and non-essential medical, surgical, and dental procedures be delayed during the COVID-19 pandemic.
CMS Administrator Seema Verma said personal protective equipment, beds, ventilators, and the healthcare workforce should be preserved for COVID-19 care during this critical time.
The final decision about proceeding with non-essential procedures will be given at the local level by clinicians, patients, hospitals, and state and local health departments.
Healthcare Reform News Update for March 18, 2020
CMS Expands Medicare Telehealth Services Amid COVID-19 Spread
The Trump administration is temporarily expanding Medicare telehealth services to limit the vulnerable senior population’s exposure to–or spreading of–the coronavirus.
All Medicare beneficiaries may use services such as FaceTime or Skype to connect with a healthcare professional by phone or video conference for treatment or diagnosing purposes. This also includes cases unrelated to COVID-19, said Seema Verma, administrator of the Centers for Medicare and Medicaid Services. Previously, only seniors living in rural areas had access to telehealth.
The service will be available for Medicare patients to connect with physicians, nurse practitioners, clinical psychologists and social workers in a variety of settings–including nursing homes and hospital outpatient departments–at no additional cost.
Healthcare Reform News Update for March 12, 2020
CMS Pilot Program to Lower Medicare Part D Insulin Costs by 66%
The CMS’ Center for Medicare & Medicaid Innovation will test a program for Medicare Part D enhanced plans that will cap out-of-pocket costs for insulin at $35 a month.
The Part D Senior Savings Model could potentially save beneficiaries in participating plans an average of $446 per year. The savings would apply to a broad set of formulary insulins, including rapid-acting, short-acting, intermediate-acting, and long-acting insulins.
The goal of the Part D Senior Savings Model is to enable consistent, predictable access to medications to help improve the total cost of care for those with diabetes. The department predicts that the program could save the government more than $250 million during a five-year period, in large part due to drug companies paying additional discounts.
The pilot program will begin January 1, 2021, with participating insurers.
MA & Part D Plans Encouraged to Waive Costs for Coronavirus
The Centers for Medicare and Medicaid Services (CMS) has issued guidance to insurance companies on the out-of-pocket costs of coronavirus testing and treatment for seniors with Medicare Advantage or Medicare Part D plans.
CMS outlined some of the options available to insurance providers, including:
- Waiving cost-sharing for COVID-19 testing
- Waiving cost-sharing for COVID-19 treatment received in doctors’ offices, emergency rooms, and telehealth services
- Eliminating prior authorization requirements
- Waiving drug refill limits
- Lifting drug delivery restrictions
- Expanding telehealth access
The Trump administration has previously said that Medicare would cover a COVID-19 vaccine if it is developed.
Healthcare Reform News Update for March 11, 2020
Insurers & Lawmakers Address Free Coronavirus Testing for Self-Funded Employers
Insurers and Congress moved this week to extend free conoravirus testing to those on self-funded employer plans. Most large insurance companies have previously announced that they will waive out-of-pocket costs for fully insured employer, Medicare Advantage, Medicaid, and ACA plans.
Cigna automatically signed up all its self-funded clients for the benefit this week, giving them 10 days to opt out if they choose to. Meanwhile, House Reps. Diana DeGette (D-CO) and Donna Shalala (D-FL) introduced legislation that would require insurers to cover 100 percent of coronavirus testing costs.
Until now, the Centers for Disease Control and Prevention has conducted and covered most testing. As more tests become available, private labs are expected to start billing insurance companies.
Healthcare Reform News Update for March 10, 2020
Trump Administration Rules Will Allow More Electronic Access to Health Records
Federal officials announced finalized rules that will make it easier for patients to retrieve their health records electronically from healthcare providers and insurance companies.
The new rules would require health providers to make data available free of charge to patients in a standardized format, which could then be downloaded onto smartphones. Standardized data could help public health agencies more efficiently analyze the safety and effectiveness of medications or the spread of contagions such as coronavirus. It could also make it easier for technology companies to use the data to develop artificial intelligence and other software tools.
To address concerns over privacy and security, the rules require developers to verify to plans to protect medical data. Consumers must be warned about programs that do not meet privacy standards and will be provided with clear information about how their information will be used by third parties.
The new rules also prevent hospitals, health insurers, and vendors of electronic health records from blocking access to patient data. Most of the new data provisions will go into effect by 2022.
Healthcare Reform News Update for February 6, 2020
CMS Proposes Changes for Medicare Advantage & Part D Plans
The Centers for Medicare and Medicaid Services released proposed rule changes for Medicare Advantage and Medicare Part D prescription drug plans on Wednesday. Some of the proposals include:
- Increasing Medicare Advantage rates by 0.93% for 2021
- Allowing those with end-stage renal disease on dialysis to enroll in Medicare Advantage
- Enabling consumers to view real-time direct drug price comparisons between formulary options
- Adding a second specialty drug tier to formularies for “preferred” medications
- Revising the star ratings system to account for patient feedback.
CMS will accept comments on the proposed changes until Friday, March 6.
Healthcare Reform News Update for February 4, 2020
Humana and Private Equity Firm to Develop More Medicare-centric Primary Care Centers
Health insurer Humana and private equity firm Welsh, Carson, Anderson & Stow have formed a joint venture to develop payor-agnostic primary care centers that focus on treating seniors.
The clinics will be managed by Humana’s Partners in Primary Care and will more than double the number of its care centers over the next three years. Currently, it runs 47 facilities in Florida, Kansas, Missouri, North Carolina, South Carolina, and Texas.
Healthcare Reform News Update for January 28, 2020
Medicare Approves Coverage of Next Generation Sequencing Tests for Cancer Patients
Medicare will now cover diagnostic laboratory tests that use next-generation sequencing (NGS) for enrollees with inherited ovarian and breast cancers, The Centers for Medicare & Medicaid Services announced. The new tests will help determine the most effective treatments for patients with advanced cancers and their candidacy for clinical trials.
Healthcare Reform News Update for January 22, 2020
Medicare to Cover Acupuncture for Chronic Low Back Pain
Medicare will now pay for acupuncture treatments for beneficiaries with chronic low back pain, CMS announced on Tuesday. Coverage includes up to 12 sessions over three months and an additional 8 sessions if symptoms improve.
The decision is part of an effort to increase the number options for non-opioid pain management.
Healthcare Reform News Update for January 2, 2020
Costs for over 200 Prescriptions Drugs Expected to Rise in 2020
Pharmaceutical companies are expected to increase the cost of over 200 medications in the U.S. beginning in 2020. These include treatments for cancer, rheumatoid arthritis, respiratory issues, and more. The price increases are expected to all stay below 10%, most likely due to pressure from politicians and patients.
Healthcare Reform News Update for December 19, 2019
Medicare Suspends Data Sharing Tool Over Technical Error
The Centers for Medicare and Medicaid announced that it has temporarily shut down access to Blue Button 2.0 due to a coding error that may have exposed beneficiaries’ data.
The Blue Button data sharing tool allows Medicare enrollees to share claims data with third-party applications. The error may have unintentionally sent protected health information to the wrong user or to the wrong Blue Button 2.0 app. Any data exposure was limited to Blue Button beneficiaries or developers; the information was not compromised by outside entities.
CMS said that the issue has affected fewer than 10,000 users and 30 authorized apps.
Access to Blue Button 2.0 will remain closed until the issue is resolved.
Healthcare Reform News Update for December 10, 2019
Poll: Medical Costs Are Causing Americans to Delay Care for ‘Serious’ Conditions
One in four Americans say they or a family member decided to postpone treatment for a serious medical condition in 2019 because of the cost, according to a new Gallup poll. The percentage is the highest recorded since Gallup began asking the question in 1991.
Other findings from the poll include:
- 8% of respondents said they or a family member delayed treatment for less serious conditions because of cost.
- 36% of households with less than $40,000 in annual income reported delaying treatment because of cost–an increase of 13% compared to 2018.
- Delaying care for those with pre-existing conditions rose 13% compared to last year.
- Throughout the past 18 years, there has been a 50% increase in the percentage of respondents who have delayed care due to cost.
- The increase in delaying care did not appear to be caused by changes in insurance status, as the percentage of those uninsured remained steady.
Healthcare Reform News Update for December 5, 2019
Hospital Groups Sue Trump Administration Over Price Transparency Rule
Four hospital groups have filed a lawsuit over a Trump administration rule that requires hospitals to publish the rates they negotiate with insurers.
The groups argue that the rule violates the First Amendment, would cause confusion with consumers regarding their out-of-pocket costs, and would be an administrative burden. They also claim that the Department of Health and Human Services does not have the legal authority to enforce the rule.
The suit was filed Wednesday by the American Hospital Association, Association of American Medical Colleges, the Children’s Hospital Association, and the Federation of American Hospitals.
Healthcare Reform News Update for December 4, 2019
Humana Will Offer Remote Monitoring Services to At-Risk Medicare Advantage Enrollees
Humana is partnering with health technology company Philips on two programs that will offer remote monitoring services to Medicare Advantage members who are at high risk of hospital readmissions.
Humana will offer Philips’ Lifeline medical alert service to members who are at risk for falls and a suite of remote monitoring tools to members with severe congestive heart failure.
The initiatives are intended to provide at-risk members with 24/7 access to care, increase support after a hospital stay, and encourage prevention.
Healthcare Reform News Update for December 3, 2019
Study: Most Medicare Beneficiaries Are Keeping Their Current Plans
Most Medicare Beneficiaries with Medicare Advantage prescription drug plans (MA-PDs) and Part D stand-alone prescription plans (PDPs) do not switch to different plans during the Open Enrollment Period, according to a new analysis from the Kaiser Family Foundation.
The study shows that during Open Enrollment in 2016, 8% of MA-PD enrollees switched to new 2017 plans and 10% of PDP enrollees switched to new 2017 plans.
For all the Open Enrollment periods between 2007 and 2016, enrollees who switched to new plans ranged from 6% to 11% for MA-PD enrollees and 10% to 13% for PDP enrollees.
The reluctance to change plans could be attributed to several factors. But previous analysis showed that 45% of Medicare beneficiaries never review or compare their options, and 35% said it is “very difficult” or “somewhat difficult” to compare plans.
Healthcare Reform News Update for December 2, 2019
UnitedHealthcare Opens Medicare Service Centers in Walgreens Stores
UnitedHealthcare will open service centers for Medicare beneficiaries in Walgreens stores in Las Vegas, Phoenix, Cleveland, Denver, and Memphis beginning in January.
The service centers will provide information about Medicare coverage options and the ability for enrollees of the company’s Medicare Advantage plans to schedule their annual wellness visits.
Healthcare Reform News Update for November 22, 2019
Medicare Plan Finder Tool Can Misdirect Consumers to Higher-Cost Plans
A feature in the new plan finder tool on the Medicare.gov website may be causing some beneficiaries to unintentionally choose higher-cost coverage.
The tool, used by 60 million Medicare recipients, automatically displays the lowest-premium plan at the top of the page. However, the tool does not take into consideration other out-of-pocket expenses such as copays and prescription drug costs. If a user doesn’t take extra steps to filter the results, the plan with the lowest total annual cost may not be the first one shown.
Critics of the new tool say that the wrong choice could cost beneficiaries thousands of dollars per year.
Medicare is testing different methods, such as a pop-up, to direct consumers’ attention to total costs.
Healthcare Reform News Update for November 18, 2019
Trump Administration Proposes New Insurance Price Transparency Rules
The Trump administration on Friday released a new proposal that would require insurance companies to provide price and cost-sharing information to consumers before services are performed.
The Transparency in Coverage proposal would enable participants, beneficiaries and enrollees to:
- Access personalized out-of-pocket cost information for all covered services through an online tool or a printed copy, if requested.
- See the rates their insurance company has negotiated with in-network providers and the allowed amounts for out-of-network providers.
- Share the cost savings received by their insurance company.
The proposal builds on its newly finalized transparency rules for hospitals “to ensure consumers are empowered with the information they need to make informed health care decisions,” according to a statement by the Centers for Medicare and Medicaid Services.
Healthcare Reform News Update for November 14, 2019
Google Healthcare Data Project Incites Federal Investigation
The Department of Health and Human Services’ Office for Civil Rights has opened an investigation regarding the healthcare data collection partnership between Google and Ascension.
The federal probe will investigate whether the initiative is compliant with federal patient privacy laws.
Both companies have stated that the mass collection of patient data meets all HIPAA regulations regarding data privacy, security, and usage.
“We are happy to cooperate with any questions about the project,” said Tariq Shaukat, Google Cloud’s president of industry products and solutions.
Healthcare Reform News Update for November 12, 2019
Google to Store & Analyze Healthcare Records for Millions of Patients
Google’s deal with medical system Ascension allows the tech company to collect and analyze the medical data, such as lab results, doctor diagnoses, and hospitalization records, of millions of Americans.
Google said in a blog post that patient data would not be combined with any of its consumer information.
The companies are in “early testing” for optimizing Ascension’s data. Ascension claims its goal for the partnership is to use artificial intelligence to help improve clinical effectiveness and patient safety.
Ascension operates 150 hospitals and more than 50 senior living facilities in 21 states.
Healthcare Reform News Update for November 11, 2019
Original Medicare Premiums and Deductibles to Increase in 2020
Original Medicare monthly premiums, deductibles, and copayments will in increase in 2020, the Centers for Medicare and Medicaid announced on Friday.
Medicare Part B premiums will rise nearly 7 percent, increasing from $135.50 to $144.60 for beneficiaries who earn up to $87,000 per year. The Part B outpatient deductible will rise from $185 to $198.
Medicare Part A rates will also increases. Inpatient hospital deductibles will jump from $1,364 to $1,408, an increase of $44. Coinsurance for the 61st through the 90th day in the hospital will rise from $341 per day to $352.
Healthcare Reform News Update for November 7, 2019
Federal Judge Voids Trump Administration Conscience Rule
A federal court on Wednesday struck down a Trump administration rule that allowed healthcare providers to refuse to cover or perform services on religious or moral grounds.
U.S. District Judge Paul Engelmayer said the “conscience” rule was “arbitrary and capricious,” conflicted with federal laws, and would threaten funding for noncompliant providers including hospitals, clinics, and universities.
The law was scheduled to go into effect November 22.
Healthcare Reform News Update for November 6, 2019
Report: Number of MA Plans With Supplemental Benefits Increases Significantly
Medicare Advantage plans offering expanded supplemental benefits grew from 102 in 2019 to 364 in 2020, according to a new study from Milliman and the Better Medicare Alliance.
Some of the benefits that will become more available in 2020 are therapeutic massage, in-home support services, adult day health services, home-based palliative care, and support for caregivers of beneficiaries. In 2019, no plans offered more than one of these services; in 2020, 116 plans include more than one.
Healthcare Reform News Update for November 5, 2019
Survey: Majority of Seriously Ill Medicare Beneficiaries Incur Financial Difficulties
Over half of all Medicare enrollees who are seriously ill face financial hardships as a result of medical bills, according to a new survey published in “Health Affairs.”
Drug costs are the leading cause of financial exposure, with hospital bills, ambulance rides, and emergency visits also cited.
Other findings include:
- More than a third said they used all or most of their savings to pay medical bills.
- 30% said prescription drugs were their major hardship.
- 27% were contacted by a collection agency.
- 25% said the costs were a major burden on their families.
- 23% could not pay for basics, including housing, food, and utilities.
The study describes seriously ill patients as those who have conditions that require two or more hospital stays and have visited more than three doctors. Heart disease, cancer, and diabetes were the most common illnesses.
Healthcare Reform News Update for October 28, 2019
Medicare Advantage Choices Reach Highest Level in a Decade
The average Medicare beneficiary will be able to choose from 28 Medicare Advantage plans offered by seven different insurance carriers in 2020, according to new analysis by the Kaiser Family Foundation. Availability varies by location.
In total, there will be 3,148 Medicare Advantage plans available nationwide, up from 2,734 in 2019. HMOs account for 64% of all plans offered.
Other findings include:
- More special needs plan will be available in 2020 than in any other year.
- Twenty-four percent of Medicare users will be able to choose between plans offered by 10 or more companies, while 4% will only be able to choose from plans offered by two or fewer.
- Metropolitan counties will average 31 plans per beneficiary, whereas non-metropolitan counties will average 16 plans.
- Ninety-seven percent of beneficiaries have access to extra benefits, like dental, vision, fitness, and hearing.
- There are 13 new insurers entering the market in 2020 and one insurer leaving, with a total of over 100 companies offering Medicare Advantage plans.
Healthcare Reform News Update for October 14, 2019
More 2020 Medicare Plans Receive Higher Star Ratings
The Centers for Medicare & Medicaid Services (CMS) released Medicare star ratings for 2020, which shows an increase in the number of plans rated four stars or higher.
Some of the star-rating results:
- 52.4% of 2020 Medicare Advantage plans with drug coverage received at least four stars, a 6.7% increase over 2019 plans.
- The average star rating for 2020 Medicare Advantage plans with prescription drug coverage is 4.16 (compared to 4.06 in 2019).
- Higher-rated plans get a larger share of enrollments; MA-PD plans rated 4 stars or higher are on track to have 81.1% of members (compared to 75.3% in 2019).
- Enrollment in Medicare Part D plans that received at least four stars is estimated to grow from 5.6% in 2019 to 27.6 in 2020.
- 2020 Part D plans received an average star rating of 3.5 (compared to 3.34 in 2019).
CMS awarded five stars to 23 individual plans, including offerings from CVS Health, Humana, UnitedHealth Group, and Kaiser Foundation Health Plan.
Healthcare Reform News Update for October 4, 2019
Trump Signs Executive Order to Expand Medicare Advantage Plans
President Donald Trump issued an executive order Thursday that directs the Department of Health and Human Services (HHS) to develop regulations that will encourage Medicare Advantage plans to offer innovative services and benefits.
Medicare Advantage plans are offered by private insurance companies and serve as an alternative to Original Medicare, which is managed by the federal government.
The order asks HHS to develop proposals that will:
- Expand access to Medicare medical savings accounts.
- Ensure that Original Medicare is not promoted over Medicare Advantage plans
- Allow plans to offer access to telehealth services.
- Change the payment model that will allow beneficiaries receive savings or rebates for seeking high-quality care.
- Modify Original Medicare fee-for-service payments to more closely reflect prices paid for Medicare Advantage and private plans.
- Allow nurse practitioners and medical assistants to practice at the top of their licenses.
- Streamline approval, coverage, and coding processes for medical devices.
Healthcare Reform News Update for October 2, 2019
Cigna Rolls out Its Largest Medicare Advantage Expansion to Date
Cigna is launching its first Medicare Advantage PPO plans in 43 counties and expanding HMO plans into 37 new counties for 2020 plan year. The company is also offering both types of Medicare Advantage plans in Colorado for the first time.
Cigna’s new Medicare Advantage PPO plans will be available in select counties in Alabama, Colorado, Delaware, Georgia, Illinois, North Carolina, Pennsylvania, and Tennessee.
The company’s Medicare Advantage HMO plans are expanding into new counties in Arkansas, Colorado, Florida, Illinois, Kansas, Missouri, New Jersey, North Carolina, and South Carolina.
According to Cigna, most plans will include vision and dental benefits, access to fitness centers and remote access to doctors. In addition, select plans will offer additional benefits that target the social determinants of health, such as:
- an adult day care allowance,
- acupuncture allowance,
- transportation, and
- fall prevention programs.
Healthcare Reform News Update for October 1, 2019
Alignment Healthcare Expands California Medicare Advantage Offerings
Alignment Healthcare announced that it will double its Medicare Advantage coverage in California for 2020.
The company will offer plans in eight new counties in Sacramento and the Bay area. If approved by regulators, the expansion
Healthcare Reform News Update for September 25, 2019
Medicare Advantage Rates Hit Lowest Point in 13 Years
Premiums for 2020 Medicare Advantage plans will be the lowest since 2007, according to the Centers for Medicare and Medicaid Services.
Plan premiums for 2020 will be 14.4% lower than those for 2019, with the average monthly premium set for $23 per month compared to last year’s $26.87.
In addition, the average number of Medicare Advantage plans available per county will increase from 33 to 39. CMS also expects enrollment in Medicare Advantage plans to increase 9.9% for a total of 24.4 million enrollees.
Healthcare Reform News Update for September 24, 2019
Medicare Double Bills 411,000 Part B Direct Payments
Due to a processing error, the Centers for Medicare and Medicaid Services deducted Medicare Part B premiums twice for approximately 411,0000 beneficiaries who pay through the department’s Easy Pay system.
CMS says that “approximately 20% of the duplicated transactions have been returned by financial institutions, and if the remaining duplications are not returned by Wednesday, Sept. 25, Treasury’s Bureau of Fiscal Service will begin to reverse the remaining transactions to complete the reimbursement.”
Any overdraft of fees resulting from the error should be waived by the financial institution.
Healthcare Reform News Update for September 11, 2019
Report: Number of Privately Insured Americans Held Steady in 2018
The percentage of people covered by private health insurance remained statistically the same between 2017 and 2018, according to a new report from the U.S. Census Bureau.
In 2018, 67.3% of Americans purchased private health insurance plans through employers, directly from insurance companies, or through TRICARE. This is a 0.4% decrease from 2017.
The overall uninsured rate increased slightly from 7.9% to 8.5%, mostly due to a decrease in Medicaid participants.
Other findings include:
- The percentage of people with Medicare coverage grew from 17.4% to 17.8%.
- The percentage of uninsured children increased from 4.9% to 5.5%.
- States with the largest percentage of uninsured residents were Texas (17.7%), Oklahoma (14.2%), Georgia (13.7%) and Florida (13%).
Healthcare Reform News Update for August 21, 2019
New Medicare Advantage Plan Launched for Chicago Area
Health2047 is launching a new Medicare Advantage plan in 2020 geared toward helping traditionally underserved seniors.
Zing Health, available in Cook County, will use local teams to coordinate with physicians and hospitals in order to help improve access to care.
Healthcare Reform News Update for August 20, 2019
CMS Announces Updates to Hospital Star Ratings for 2021
The way hospital star ratings are determined will change beginning in 2021, according to the Centers for Medicare and Medicaid Services.
The agency will finalize the changes after a public listening session and the formation of a technical expert panel.
In the meantime, CMS will refresh the ratings on the Hospital Compare website in early 2020 using the current methodology.
Alignment Healthcare to Expand Presence in California
Alignment Healthcare announced that its Medicare Advantage plans will be available in more California counties in 2020, doubling from eight to 16.
The company will increase its offerings from 10 health maintenance organization (HMO) plan to 22 HMO and preferred provider organization (PPO) plans.
Healthcare Reform News Update for August 8, 2019
Medicare Will Cover CAR T-cell Cancer Therapy
Medicare will now cover CAR T-cell gene therapy when it is provided in healthcare facilities enrolled in the FDA risk evaluation and mitigation strategies program, according the Centers for Medicare & Medicaid Services.
These types of therapies use a patient’s own immune system to combat certain types of lymphoma and leukemia. CMS said it will also approve the therapy for additional uses when recommended by CMS-approved medical guidelines.
Healthcare Reform News Update for August 7, 2019
New Survey Shows Consumer Neutrality on Medicare for All Plans
Close to half of adults surveyed neither support nor oppose Medicare for All and other healthcare expansion proposals, according to a new study on consumer attitudes.
Urban Institute surveyed respondents on their opinions regarding access to care, costs, and other factors. The survey differs from other recent polls in that it offered respondents the option to remain neutral, instead of being forced into giving an opinion.
Some of the findings include:
- 40.7% of respondents neither support nor oppose Medicare for All.
- 45% of respondents neither support nor oppose a public option plan.
- Young adults, nonwhite and Hispanic adults and those with low incomes were more likely to support than oppose Medicare for All. Those with higher incomes were more likely to oppose.
- 29.8% of all respondents support Medicare for All.
- 27.8% of all respondents oppose Medicare for All.
- Medicare for All Supporters list universal coverage and affordability as important factors influencing their support. Opponents list higher taxes, wait times, and quality of care as their top concerns.
Healthcare Reform News Update for July 31, 2019
2020 Medicare Part D Premiums Expected to Decrease
The Centers for Medicare & Medicaid Services has projected that premiums for 2020 Medicare Part D prescription drug plans will decline for the third year in a row.
The average Part D premiums will be $30 per month, which is 13.5% less than in 2017, according to a CMS press release issued Tuesday. The price reduction will save enrollees roughly $1.9 billion in premium costs.
CMS attributed several cost-cutting measures for the price reduction, including:
- elimination of the “gag clause,”
- reducing out-of-pocket costs for biosimilar products, and
- requiring explanation of benefit notices to include price increases and lower-cost therapeutic alternatives.
Pilot Program Enables Medicare Providers Access to Patient Claims Data
The Centers for Medicare & Medicaid Services is launching a new pilot program called Data at the Point of Care that gives healthcare providers direct access to claims data for their Medicare patients.
CMS’s Blue Button computer interface will help physicians and clinicians easily access and assess a patient’s medical history.
“This data gives them more information about their patients, so they are better able to impact their care, and it allows them to do the analysis about their patient population,” said CMS Administrator Seema Verma.
The pilot program is scheduled to begin in September. Medicare beneficiaries will be automatically included in the program unless they contact Medicare to opt out.
Healthcare Reform News Update for July 30, 2019
Latest Kaiser Poll Shows Bipartisan Support for ACA Provisions
A majority of Americans prefer that the Affordable Care Act’s provisions remain in place and that future healthcare measures build on the existing law, rather than be replaced with a Medicare for All plan, according to a new Kaiser Family Foundation poll.
A majority of both Republican and Democratic respondents believed that it’s “very important” to maintain key provisions of the ACA, including protections for people with pre-existing conditions and pregnant women, no-cost preventive services, no annual or lifetime limits, and keeping young adults on their parents’ plan up to age 26.
Among Democrats, 55% favor expanding the ACA, and 39% prefer a Medicare for All approach.
Support for Medicare for All plans decreased from April, with Democratic support slipping from 80% to 72%, and Republican support dropping from 27% to 15%.
Among Democrats, 55% favor expanding the ACA, and 39% prefer a Medicare for All approach.
Other findings include:
- 65% favor a public option plan that would compete with private health insurance plans. However, views shifted when presented with arguments both for and against the approach.
- 83% have a favorable opinion of Medicare.
- 76% have a favorable opinion of employer health plans.
- Medicare, Medicaid, and employer coverage are viewed more favorably than individual health plans. But a majority rate their own coverage positively, whether they have private or public coverage.
Healthcare Reform News Update for July 25, 2019
Bright Health Expands Into 13 New Markets for 2020
Bright Health announced that it will double its locations in 2020 by expanding into 13 new markets in seven states for Affordable Care Act health plans and Medicare Advantage plans.
If approved by regulators, the new markets will increase the company’s availability to a total of 22 markets in 12 states.
New Bright Health plan locations for ACA plans include:
- Colorado: Summit County
- Florida: Jacksonville, Orlando, Palm Beach, Tampa
- North Carolina: Charlotte, Winston-Salem
- Nebraska: Statewide
- Oklahoma: Oklahoma City
- South Carolina: Greenville
New Bright Health plan locations for Medicare Advantage plans include:
- Florida: Orlando, Palm Beach
- Illinois: Chicago
- Nebraska: Omaha
- Ohio: Cleveland
- South Carolina: Greenville
- Tennessee: Memphis
Report: Medicare Could Save $57M By Providing Free Home-Delivered Meals
Medicare could save about $57 million per year by providing free meals to recently hospitalized seniors, according to a new report from the Bipartisan Policy Center.
By analyzing data from seniors with multiple chronic conditions, the study found that providing meals for one week after a hospitalization could prevent nearly 10,000 hospital readmissions every year.
The meals would cost approximately $101 million, but Medicare would save more than $158 million in payments for return hospital stays.
Currently, some Medicare Advantage plans cover meal-service delivery. The report recommends that lawmakers add the benefit to Original Medicare in limited circumstances.
Healthcare Reform News Update for July 24, 2019
Senate Committee Announces Plan to Overhaul Medicare Part D
The Senate Finance Committee announced its bipartisan legislation designed to lower drug costs.
The proposal, called The Prescription Drug Pricing Reduction Act, would overhaul Medicare Part D in significant ways, including:
- Putting a cap on drug prices, which would keep drug makers from raising prices above the rate of inflation.
- Lowering the threshold that activates the catastrophic phase for Medicare Part D users from more than $8,000 to $3,100 by 2022.
- Revising the catastrophic coverage drug payment model so that insurance companies pay 60 percent of the costs, and the government and drug makers each pay 20 percent.
The proposal is projected to save Medicare beneficiaries $27 billion in out-of-pocket costs and $5 billion in premiums over 10 years.
Committee leaders Senators Chuck Grassley (R-IA) and Ron Wyden (D-OR) said that the committee plans to vote on the legislation on Thursday.
Healthcare Reform News Update for July 18, 2019
Oscar Health Will Offer Medicare Advantage Plans
Oscar Health announced Wednesday that it will enter the Medicare Advantage market in 2020 with plans available in New York City and Houston.
In New York, the company is offering plans in partnership with Montefiore Health System. In Houston, the company is pairing with several regional providers including Houston Methodist, HCA Houston Healthcare, and St. Joseph Medical Center.
Pending approval by regulators, the plans will be available during Open Enrollment this fall.
Healthcare Reform News Update for July 16, 2019
Medicare Considering Covering Acupuncture for Back Pain
A new Medicare proposal would cover acupuncture for beneficiaries with chronic low-back pain as an alternative to opioid treatments, which can become addictive.
Health and Human Services Secretary Alex Azar announced Monday that the coverage would apply only to patients enrolled in clinical trials or other CMS-approved studies. The agency would then use results of those trials to determine further acupuncture coverage options.
CMS is gathering public input before finalizing the proposal.
Healthcare Reform News Update for July 12, 2019
Cancer Patients Face Substantial Financial Burden
A recent study from the Centers for Disease Control and Prevention shows that the annual out-of-pocket expenses for cancer survivors is increasing with 25 percent experiencing problems paying their bills and 34 percent worried about their costs.
Average out-of-pocket spending for cancer survivors is $1,000 per year compared to $622 per year for people who’ve never had cancer. And those costs are growing. Even with health insurance in place, cancer patients incur an additional financial burden from things such as traveling to treatment and being away from work.
Other findings from the study:
- Out-of-pocket expenses were highest among cancer survivors ages 18-64 and those who were unemployed.
- Cancer survivors ages 40-49 reported the highest percentage of “material or psychological financial hardship.”
- A higher percentage of minority racial/ethnic cancer survivors reported “material or psychological financial hardship.”
- “Cancer survivors [are] more likely to be older, female, non-Hispanic white, married, privately insured,” full-time employees, more educated, and have more chronic conditions compared to people who’ve never had cancer.
Narrow Medicare Advantage Networks Limit Access for Some Enrollees
Finding a doctor in a Medicare Advantage (MA) plan network can be difficult for many enrollees, especially if they live in rural areas.
Government audits have found that nearly half of the entries in MA directories had incorrect addresses, phone numbers, or doctors who were not accepting new patients. The American Journal of Managed Care found that a Google search for participating doctors could be more accurate than using a plan’s directory.
A Kaiser Family Foundation study from 2017 found that MA plans included “46 percent of all physicians in a county, on average.” Access to psychiatrists is the most restricted, with 23 percent in a county’s plan on average, followed by cardiothoracic surgeons, neurosurgeons, plastic surgeons, and radiation oncologists.
Rural beneficiaries can be especially burdened by narrow MA networks. A study of California MA plans showed that some enrollees in rural areas lived over 100 miles from in-network specialists.
Healthcare Reform News Update for July 9, 2019
Connecticut Enacts Mental Health Parity Bill
Connecticut Governor Ned Lamont signed a bill into law that will require insurance providers to submit annual reports to state insurance commissioners, detailing their coverage of mental health and substance abuse services.
The new law intends to hold insurers accountable for complying with state and federal laws that mandate equal access to mental and physical health services.
Healthcare Reform News Update for July 8, 2019
Medicare Coverage Expanded for Blood Pressure Monitoring Devices
The Centers for Medicare & Medicaid Services (CMS) has extended coverage of Ambulatory Blood Pressure Monitoring (ABPM) devices to Medicare beneficiaries who have suspected abnormal low blood pressure readings while in a doctor’s office.
Previously, Medicare covered ABPM devices only for patients with suspected “white coat hypertension,” which occurs when a patient’s blood pressure is elevated due to anxiety associated with a clinical setting. The 24-hour monitoring device is now also approved for “masked hypertension,” the inverse of “white coat hypertension,” which causes patients to have lower-than-normal blood pressure readings while in a clinical setting.
The new rule also lowers the definition of hypertension from a reading of 140/90 to 130/80 “to align with the latest society recommendations regarding the diagnostic criteria.”
Healthcare Reform News Update for July 3, 2019
Poll: Majority Support Medicare for All if Healthcare Providers Remain
A majority of voters would back a Medicare for All plan if they could keep their preferred doctors and hospitals, according to a new Morning Consult/Politico survey.
Of those surveyed, 55% of respondents backed a single-payer system that would reduce the role of private insurance companies but allow them to keep their healthcare providers.
But 46% were in favor when told the role of private insurers would be reduced, and 53% approved when not given any specifics about insurers or doctors.
The poll found that general support for a Medicare for All system comes from 77% of Democrats, 27% of Republicans and 50% of Independents.
Healthcare Reform News Update for June 26, 2019
New Study Shows 14% Increase in Out-of-Pocket Healthcare Costs
In 2018, out-of-pocket costs for inpatient services increased 14% over the previous year, according to a report from TransUnion Healthcare.
TransUnion tracked deductible and co-pay costs for patients with commercial insurance, Medicare Advantage, Traditional Medicare, and those who self-pay to find the annual averages.
2018 Average Out-of-Pocket Cost
2017 Average Out-of-Pocket Cost
In addition, the study found that 59% of patients had out-of-pocket expenses between $501 and $1,000, compared to 39% in 2017. Patients with expenses of $500 or less drop from 49% in 2017 to 36% in 2018.
Healthcare Reform News Update for June 25, 2019
President Signs Executive Order on Healthcare Pricing Transparency
President Trump signed an executive order on Monday that will require hospitals and insurance companies to publicly disclose their negotiated pricing.
The order is meant to increase price transparency through five policies:
- Providers must disclose the prices for insurers and patients in an easy-to-read format.
- Providers and insurance must provide patients with the estimated out-of-pocket costs before they receive care.
- Agencies must propose ways to simplify and improve quality measures across all healthcare programs.
- Researchers must gain increased access to healthcare claims information, stripped of individual details.
- The Treasury Department must look for ways to expand how health savings accounts can be used.
Before the changes can be implemented, government agencies, including Health and Human Services and the Treasury Department, must determine a rule-making process and work out the details of how the president’s plan will be executed.
Healthcare Reform News Update for June 13, 2019
House Committee Debates Medicare for All Proposals
For the first time, the House Ways and Means Committee held a hearing on the various Democratic proposals for universal healthcare.
The discussion, held Wednesday with a panel of healthcare experts and advocates, primarily served as a platform for partisan debate. Republicans were united in the belief that Medicare for All measures would cost too much, raise taxes and dilute the quality of healthcare. Democrats remain split on what type of public plans to support and whether the Affordable Care Act could be used to move those proposals forward.
Lawmakers from both parties agreed that the current healthcare system needs to be revised so that more people can have access to quality care and affordable coverage.
Healthcare Reform News Update for June 7, 2019
250K Medicare Beneficiaries Could Be Impacted by Error
At least 250,000 Medicare beneficiaries enrolled in Medicare Advantage and Medicare Part D plans could receive bills for five months of coverage due to a “processing error” within the Social Security Administration.
This error has caused some beneficiaries to be dropped from their coverage due to nonpayment.
In a notice to beneficiaries, the Department of Health and Human Services disclosed that some enrollees have not had premiums deducted from their Social Security benefit checks since February. The error has been corrected and payments will be resumed beginning this month or in July.
Insurance companies will bill customers for any shortfalls. Members will have at least two months to pay the premiums that were missed. Payment plans can be set up for beneficiaries who need them.
Neither the SSA or Medicare have said how the glitch occurred, which plans were affected, or the total amount of premiums that will need to be paid retroactively.
Healthcare Reform News Update for June 5, 2019
Medicare for All Hearing Set for Next Week
The House Ways and Means Committee has scheduled a Medicare for All hearing for June 12. It will be the first time the measure is examined by a panel that oversees healthcare issues.
The House version of the proposal is sponsored by Rep. Pramila Jayapal (D-WA) and currently has 110 Democratic cosponsors.
This hearing could encourage the House Energy and Commerce Committee, which also has control over healthcare issues, to consider the Medicare for All proposal.
Healthcare Reform News Update for June 4, 2019
Committee Starts Talks to Expand Long-Term Care in MedSupp Plans
The House Ways and Means Committee has reached out to the National Association of Insurance Commissioners for recommendations on how to expand long-term care benefits for Medicare Supplement plans.
Committee Chair Richard Neal (D-MA) wrote to NAIC President Eric Cioppa asking for ideas on how a federal policy could be crafted to “provide some relief” to families without causing adverse selection. Neal requested suggestions on lifetime and daily caps, waiting periods, eligibility requirements, and enrollment forecasts.
Healthcare Reform News Update for May 17, 2019
Trump Administration Releases Final Rule for Medicare Drug Pricing
The Centers for Medicare and Medicaid Services (CMS) released a final rule Thursday aimed at lowering costs and improving price transparency for prescription drugs.
Stipulations in the rule include:
- Medicare Part D plans will continue to cover drugs in six “protected classes,” including antidepressants and immunosuppressants.
- Medicare Advantage plans are allowed to use “step therapy” for Part B drugs, which requires the use of a lower-cost medication before trying a more expensive one.
- Pharmacists may disclose when Part D drugs can be purchased at a lower cost out-of-pocket than through their insurance.
Also, beginning in 2021:
- The Part D explanation of benefits beneficiaries receive will include a notice of price hikes and any low-cost therapeutic alternatives.
- Each Part D plan will use at least one electronic benefit tool that works with electronic health records.
CMS did not implement some rules it had proposed last fall, including allowing insurance companies to drop a medication from its formulary if the price soared or was a new formulation of an existing single-source drug.
Healthcare Reform News Update for May 14, 2019
Washington Creates Country’s First State-Run, Long-Term Care Benefit Program
A first-of-its-kind program that will help state residents offset the costs of long-term care became a law on Monday when Washington Governor Jay Inslee signed the new bill.
Beginning in 2025, participants will receive a $100-per-day allowance that can be used for nursing home fees, in-home assistance, and reimbursement for family caretakers, up to a lifetime maximum of $36,500, indexed to inflation. To receive the funds, residents must need help with at least three “activities of daily living,” such as bathing, eating, and dressing.
The program will be funded through a payroll tax that starts in 2022. Employees will pay 0.58 percent of their income into a state fund. Workers will have to pay the premium for at least 500 hours per year for three of the previous six years, or for a total of 10 years (with at least five of those paid without interruption), in order to be eligible for the benefit.
Residents who have long-term care insurance policies are exempt from paying the tax. Those who are self-employed can opt to pay into the program, but it’s not required.
Healthcare Reform News Update for May 13, 2019
Washington to Become First State With a Public Healthcare Option
Washington will establish the country’s first universally available public insurance option when Governor Jay Inslee signs the legislation today.
The public option, called Cascade Care, is a hybrid insurance model: the state will create the terms of the plans and private insurance companies will administer the day-to-day operations, such as enrollment and claims payments.
Premiums are expected to be up to 10 percent lower than comparable private insurance coverage. The reduced costs are made possible by capping payments to healthcare providers at 160 percent of federal Medicare rates.
The set of tiered plans will available by 2021 and will be offered to all Washington residents, regardless of income.
Healthcare Reform News Update for May 10, 2019
Study: Employer Plans Pay 241% More Than Medicare
Hospitals charged private employer-sponsored plans 240% more on average than what they billed Medicare, according to a new RAND Corp. study on healthcare pricing.
Researchers compared payment rates for 1,600 hospitals in 25 states. The charges represent the negotiated allowed amounts between hospitals and health plans.
Some of the findings include:
- The price disparity has increased from 2015, when it was 236%.
- The difference between Medicare and employer plans ranged from 150% to over 400%.
- If employer plans were charged the same as Medicare during the study period. It would have reduced health spending by $7.7 billion.
- The price difference was higher for outpatient care (293%) than for inpatient care (204%).
The study also recommends measures that employers could take to help reduce the disparity, including:
- pressuring their health plan to base pricing on Medicare rates
- encouraging state or federal policy intervention as a way to readjust “negotiating leverage between hospitals and employer health plans”
Healthcare Reform News Update for May 7, 2019
Study: Medicare Advantage Beneficiaries Spend Less
People who switch to Medicare Advantage plans spend less on average and use fewer services than traditional Medicare beneficiaries—even before they enroll in Medicare Advantage, according to a new study from the Kaiser Family.
In the study, researchers compared the “average traditional Medicare spending and use of services in 2015 among beneficiaries who switched to Medicare Advantage plans in 2016 with those who remained in traditional Medicare that year, after adjusting for health risk.”
Those who switched spent $1,253 less on average in 2015, according to the analysis.
The spending difference remained, regardless of age, gender, or health condition. Medicare Advantage users with dual-eligibility also spent less prior to their switch to Medicare Advantage.
The findings suggest that the Centers for Medicare and Medicaid Services (CMS) could be overpaying MA plans by billions of dollars per year because the department bases its payments on spending by those on traditional Medicare.
In addition, the results question whether the care management strategies of Medicare Advantage plans are responsible for the lower spending of enrollees.
Healthcare Reform News Update for May 2, 2019
CBO Report Highlights Complexities of a Medicare for All System
The Congressional Budget Office released a report on Wednesday that analyzes the “opportunities and risks” of creating a Medicare for All type of healthcare system like those proposed by some Democratic lawmakers and presidential candidates.
Instead of cost estimates, “Key Design Components and Considerations for Establishing a Single-Payer Health Care System” lays out the positive and negative outcomes that lawmakers and consumers could face if current system were revised.
The report outlines ways in which Congress could address issues that may arise with a single-payer system, such as:
- Funding the system
- Plan oversight
- The role of private insurance providers
- Management of provider rates and prescription drugs
The analysis suggests drawbacks of single-payer healthcare could include longer wait times and decreased access to care. New taxes would also have to be established for income, payroll, or consumption to help pay for the system.
Benefits of a single-payer system, according to the report, include costs savings from administrative streamlining, and a greater focus on preventive care and increasing the nation’s health as a whole.
Other considerations for legislators include whether or not to pay for undocumented immigrants and long-term care services, and what strategies should be used to maintain costs.
Democrats Reintroduce Compromise Medicare Expansion Proposal
Democratic Representatives Rosa DeLaura of Connecticut and Jan Schakowsky of Illinois presented their plan for expanding healthcare coverage on Wednesday. The Medicare for America Act is considered a more moderate approach than a single-payer models like Medicare for All.
The plan debuted last year, but now has 16 cosponsors.
The proposal would maintain employer-based health plans, but employees would have the option to enroll in Medicare coverage. Consumers who have coverage though Affordable Care Act plans, Medicaid, Medicare and CHIP would all transition to the newly expanded Medicare plans.
Premiums for the plans would be based on income, but cost would be capped at 8 percent of monthly pay. Tax subsidies would be provided to those with low-incomes. There would be no deductibles to be met before coverage begins.
Healthcare Reform News Update for May 1, 2019
Medicare for All Bill Receives First Congressional Hearing
The first public congressional discussion on Medicare for All was held on Wednesday in front of the House Rules Committee. The hearing centered on a bill from Representative Pramila Jayapal (D-WA), which has over 100 Democratic co-sponsors.
Speakers included healthcare providers, a conservative economist, liberal activists with disparate opinions on how a single-payer system would operate, and Ady Barkan, a supporter with Lou Gehrig’s disease who described his struggles with exorbitant out-of-pocket costs.
Jayapal’s bill currently lacks support from centrist Democrats and would not be able to pass in the Republican-controlled Senate. However, she and other advocates were positive about gaining a hearing. “This was the first step, it’s a big step, but we’re on our way. Medicare for All is possible. It is reasonable. It can move forward, and I think it should,” said the Chairman of the Rules Committee Jim McGovern (D-MA.).
Republicans remained skeptical about Medicare for All efforts. Representative Tom Cole (R-OK), the ranking Republican on the committee, said that supporters have “not told us how much this massive new program would cost, who would pay for it and how much taxes would have to go up.”
Additional hearings on Medicare for All were confirmed during Wednesday’s discussion: one for The House Budget Committee and another for the House Ways and Means Committee.
Healthcare Reform News Update for April 23, 2019
CMS Announces New Medicare Payment Models for Primary Care Practices
Health and Human Services Secretary Alex Azar on Monday announced two new voluntary Medicare programs for primary care physicians that will reward practices based on their patients’ health improvements instead of the traditional fee-for-service payments.
The initiative will “move [the nation] toward a system where providers are paid for outcomes rather than procedures, and free up doctors to focus on the patients in front of them, rather than the paperwork we send them,” Azar said.
The CMS Primary Cares initiative, set to launch in 2020, contains new payment models where physicians and hospitals assume varying levels of financial responsibility for reducing costs and improving services.
The first model, aimed at small, primary-care practices, gives two payment options that include a flat monthly fee per patient, with bonuses and penalties based on patients’ health.
Larger practices and health systems have three payment options within this initiative:
- The “Professional Option:” Providers would receive a fixed monthly payment and assume 50% of the financial risk.
- The “Global Option:” Providers would assume the full risk of the cost of caring for patients.
- The “Geographic Option:” Health systems or insurance plans take on the full risk for the primary care cost for communities within a specific region.
CMS Primary Cares was designed to promote new technologies such as telehealth and remote patient monitoring. “Providers will have greater flexibility to spend these resources how they want, allowing them to come up with innovative ways to care for patients — and receive significant savings if they keep patients healthier than expected,” Azar said.
Azar said he expects around one-fourth of primary care practices to sign up for CMS Primary Cares.
Medicare and Social Security Funds Face Uncertainty
A new report from the board of trustees for Medicare forecast that the Medicare Supplementary hospital insurance fund will be depleted by 2026, which is the same date projected last year.
In addition, costs for the Medicare Supplementary Medical Insurance (SMI) fund, which covers drug cost in Part B and D, are expected to grow gradually from 2.1 percent of gross domestic product in 2018 to about 3.7 percent of GDP in 2038. However, trustees report that the fund will be sufficiently financed by general revenues and beneficiary premiums.
Social Security also faces an uncertain financial future, as its total cost is predicted to exceed its total income in 2020, which will be the first time it’s happened since 1982.
The report requests that legislators “take action sooner rather than later to address these shortfalls, so that a broader range of solutions can be considered and more time will be available to phase in changes while giving the public adequate time to prepare.”
Healthcare Reform News Update for April 11, 2019
Bernie Sanders Debuts Revamped Medicare for All Bill
Senator Bernie Sanders (I-VT) debuted an updated version of his Medicare for All bill on Wednesday with the support of 14 Democratic cosponsors.
In his proposal, Sanders calls for replacing private insurance with a single-payer, government-run system with no premiums or deductibles. Certain services would come with small copays, and copays for brand-name prescription would be capped at $200. This new version of the proposal adds coverage for long-term care.
“The American people are increasingly clear: They want a health care system which guarantees healthcare to all Americans as a right,” said Sanders.
Sanders did not outline how the program would be funded, but did offer general suggestions.
In response, White House press secretary Sarah Huckabee Sanders called the plan a “total government takeover of health care that would actually hurt seniors, eliminate private health insurance for 180 million Americans, and cripple our economy and future generations with unprecedented debt.”
Healthcare Reform News Update for April 1, 2019
Senators to Debut Revised “Medicare X” Plan
Democratic Senators Tim Kaine (VA) and Michael Bennet (CO) will introduce a new “Medicare X” healthcare plan next week, which would create a public health insurance option.
The proposal retains employer health plans, but also allows consumers to purchase Medicare plans through the individual or small-business ACA exchanges.
“180 million people in America get their insurance through an employer-based plan and Medicare X gives people the opportunity to decide whether they want to stay on that plan,” said Bennet.
Features of the Medicare X plan include:
- access to the Medicare network of doctors,
- the ACA’s essential benefits, such as maternity and newborn care,
- the establishment of a federal reinsurance program to keep premiums down, and
- tax credits for higher-income Americans.
The plan would be gradually phased in over a five-year period, beginning in rural areas, then nationwide, and lastly to small businesses.
The proposal has no Republican cosponsors, although Bennet and Kaine are optimistic about the idea catching on.