Senior Healthcare Reform News Updates
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 Update for October 6, 2023
Drug companies agree to proceed with price negotiations
Pharmaceutical companies that manufacture 10 drugs selected for the Medicare Drug Price Negotiation Program recently notified the Centers for Medicare and Medicaid Services they plan to participate.
It’s the first time Medicare will directly negotiate drug prices with manufacturers based on requirements outlined in the Inflation Reduction Act.
“We look forward to engaging with the drug manufacturers of the selected drugs that have decided to participate in the Medicare Drug Price Negotiation Program,” says CMS Administrator Chiquita Brooks-LaSure.
Pharmaceutical companies participating in the Medicare Drug Price Negotiation Program include:
- Bristol Myers Squibb
- Boehringer Ingelheim
- Janssen Pharms
- Merck Sharp Dohme
- AstraZeneca AB
- Novartis Pharms Corp
- Immunex Corporation
- Pharmacyclics LLC
- Janssen Biotech, Inc.
- Novo Nordisk Inc.
“Our goal is to ensure access to innovative treatments and therapies for people that need them when they need them,” says Brooks-LaSure. “Medicare will negotiate in good faith consistent with the requirements of the law on behalf of people with Medicare.”
The first 10 prescription medications that will be part of the Medicare Drug Price Negotiation Program include:
- Eliquis (treats and prevent blood clots)
- Jardiance (treats diabetes, heart failure)
- Xarelto (prevents blood clots, reduces risk for coronary or peripheral artery disease)
- Januvia (controls blood sugar levels)
- Farxiga (treats diabetes, heart failure, chronic kidney disease)
- Entresto (treats heart failure)
- Enbrel (reduces symptoms of rheumatoid arthritis, psoriasis, psoriatic arthritis)
- Imbruvica (treats certain types of blood cancers)
- Stelara (treats psoriasis, psoriatic arthritis, Crohn’s disease, ulcerative colitis)
- Fiasp (controls blood sugar levels). This also includes: Fiasp FlexTouch; Fiasp PenFill; NovoLog; NovoLog FlexPen; NovoLog PenFill
- CMS will begin drug price negotiations with pharmaceutical companies this year.
- Any agreed-upon negotiated prices for the selected drugs will be published by CMS by September 1, 2024.
- Those prices will be effective starting January 1, 2026.
- CMS will select for negotiation up to 15 more drugs covered under Part D for 2027, up to 15 more drugs for 2028 (including drugs covered under Part B and Part D), and up to 20 more drugs for each year after that.
Healthcare Reform Update for September 27, 2023
CMS: Medicare rates to remain stable in 2024
In 2024, rates for Medicare Advantage and the Medicare Part D prescription drug program will remain stable, according to the Centers for Medicare and Medicaid Services.
This impacts an estimated:
- 31.6 million people who enroll in Medicare Advantage plans
- 50.5 million who enroll in the Medicare Part D prescription drug program
“Today’s release shows that, as expected, people with Medicare will continue to have robust options and stable benefit offerings in the Medicare Advantage market,” says CMS Deputy Administrator and Director of the Center for Medicare Meena Seshamani, MD, Ph.D.
Medicare Advantage rates in 2024
- The average monthly plan premium for all Medicare Advantage plans (including prescription drug plans) is projected to change from $17.86 in 2023 to $18.50 in 2024 (an increase of $0.64).
Medicare Part D rates in 2024
- The total monthly premium for Medicare Part D coverage is projected to be approximately $55.50 in 2024. This expected amount is a decrease of 1.8% from $56.49 in 2023.
Medicare Open Enrollment begins October 15, 2023
CMS released the 2024 rates for Medicare Advantage Plans and Medicare Part D prescription drug plans ahead of the Medicare Open Enrollment Period, which begins on October 15, 2023.
“It is important for people with Medicare to review their health care coverage and explore their Medicare options during Open Enrollment,” says CMS Administrator Chiquita Brooks-LaSure.
Healthcare Reform Update for September 21, 2023
CMS: New rule improves Medicare Savings Program enrollment for 10 million people
A new rule finalized by the Centers for Medicare and Medicaid Services will streamline the Medicare enrollment process in the Medicare Savings Program for an estimated 10 million people.
According to the Federal Register, this final rule:
- Simplifies processes for eligible individuals to enroll and retain eligibility in the Medicare Savings Program
- Better aligns enrollment into the Medicare Savings Program with requirements and processes for other public programs.
- Reduces the complexity of applications and re-enrollment for eligible individuals
Only about half of people eligible for the Medicare Savings Program actually enroll, often because of a complicated enrollment and verification process, according to CMS.
- This final rule makes it easier for people to enroll in, retain, and afford health coverage and care through Medicare.
“CMS’ new rule will further protect and strengthen health care coverage for older adults and people with disabilities,” says CMS Administrator Chiquita Brooks-LaSure. “This final rule will help hundreds of thousands of people access health care…”
Healthcare Reform Update for September 12, 2023
40 percent of psychiatrists opt out of Medicare
For Medicare enrollees in need of a psychiatrist to evaluate, diagnose, and treat psychological disorders, finding a doctor may be getting harder.
According to a recent report published by the Centers for Medicare and Medicaid Services, an estimated 40 percent of psychiatrists opted out of Medicare in 2023.
“Psychiatrists have the highest opt-out rates and are disproportionately represented among physicians who have opted out of Medicare in 2023,” according to a report published by the Kaiser Family Foundation.
When a physician or practitioner opts out of Medicare, the provider no longer submits a bill to Medicare. Instead, the patient pays the physician out-of-pocket and neither party can receive a payment from Medicare.
2 reasons psychiatrists opt out of Medicare
Based on Kaiser Family Foundation research, psychiatrists appear to prefer to be paid directly from the patient instead of from Medicare or private insurance to:
- Minimize the administrative burden of billing and waiting for payments
- Have the flexibility to charge higher fees for care
While a significant number of psychiatrists have opted out of Medicare, on average less than two percent of physicians opted out of Medicare in 2023 in all but four states.
Healthcare Reform Update for September 5, 2023
HHS selects 10 drugs for Medicare Drug Price Negotiation Program
The U.S. Department of Health and Human Services recently selected the first 10 prescription medications to be part of the Medicare Drug Price Negotiation Program.
The first 10 drugs selected for price negotiations with pharmaceutical companies are widely used by Medicare Part D enrollees.
- Last year, Medicare enrollees spent an estimated $3.4 billion out-of-pocket on these 10 drugs.
- These selected drugs accounted for $50.5 billion in total Part D gross covered prescription drug costs in a one-year period.
“For far too long, pharmaceutical companies have made record profits while American families were saddled with record prices and unable to afford life-saving prescription drugs,” says HHS Secretary Xavier Becerra.
“But thanks to the landmark Inflation Reduction Act, we are closer to reaching President Biden’s goal of increasing availability and lowering prescription drug costs for all Americans.”
- Eliquis (treats and prevent blood clots)
- Jardiance (controls blood sugar levels)
- Xarelto (lowers risk of stroke and blood clots)
- Januvia (controls blood sugar levels)
- Farxiga (controls blood sugar levels & lowers risk for heart disease)
- Entresto (treats heart failure)
- Enbrel (reduces symptoms of rheumatoid arthritis)
- Imbruvica (treats certain types of cancer)
- Stelara (treats plaque psoriasis, psoriatic arthritis, Crohn’s disease and ulcerative colitis)
- Fiasp (controls blood sugar levels). This also includes: Fiasp FlexTouch; Fiasp PenFill; NovoLog; NovoLog FlexPen; NovoLog PenFill
Medicare Drug Price Negotiations: What happens next…
The Centers for Medicare & Medicaid Services will begin price negotiations this year with pharmaceutical companies for the 10 selected drugs.
- The selected drug’s clinical benefit
- The extent to which it fulfills an unmet medical need
- The drug’s impact on people who rely on Medicare
- Costs associated with research and development
- Production and distribution for selected drugs
- And other factors
- CMS will begin drug price negotiations with pharmaceutical companies this year.
- Any agreed-upon negotiated prices for the selected drugs will be published by CMS by September 1, 2024.
- Those prices will be effective starting January 1, 2026.
- CMS will select for negotiation up to 15 more drugs covered under Part D for 2027, up to 15 more drugs for 2028 (including drugs covered under Part B and Part D), and up to 20 more drugs for each year after that.
Healthcare Reform Update for August, 25, 2023
Medicare ACO care model saves $1.8 billion
Medicare’s accountable care organization saved an estimated $1.8 billion in 2022 and improved quality of care for millions of seniors, according to the Centers for Medicare and Medicaid Services.
It’s the sixth consecutive year the Medicare Shared Savings Program saved money, and the second highest annual savings in more than a decade.
“The Medicare Shared Savings Program helps millions of people with Medicare experience coordinated health care while also reducing costs for the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure.
“CMS will continue to improve the program, and it is exciting to see that Accountable Care Organizations are continuing to be successful in delivering coordinated, high-quality, affordable, equitable, person-centered care,” Brooks-LaSure said.
How it works…
- Medicare’s ACO includes groups of doctors, hospitals, and other health care providers.
- They collaborate to provide coordinated, high-quality care to people with Medicare.
- This helps avoid unnecessary services, reduce medical errors, and saves money.
- It also lowers healthcare costs for Medicare beneficiaries and reduces emergency-room visits.
- 573,000. Over 573,000 clinicians currently participate in the Medicare Shared Savings Program.
- 11 million. These clinicians provide care to about 11 million Medicare beneficiaries.
- 8 key health issues. Clinicians excel at helping patients with 8 key health issues: Diabetes, blood pressure control, breast cancer and colorectal cancer screening, tobacco screening, smoking cessation, depression screening and follow-up.
- 63% earn performance payments. About 63% of ACOs that participate in the Medicare Shared Savings Program earned payments for performance in 2022.
Healthcare Reform Update for August 18, 2023
Inflation Reduction Act reduces Medicare program costs
Medicare beneficiaries are spending less on prescription drugs, health plan premiums, and out-of-pocket costs because of the Inflation Reduction Act of 2022, which was signed into law one year ago.
The Inflation Reduction Act includes specific provisions to help reduce Medicare costs, including:
- Capping the cost for a one-month supply of insulin for Medicare beneficiaries to no more than $35
- Lowering the costs of Medicare Part D prescription drugs
- Providing recommended adult vaccines at no cost for Medicare beneficiaries
- Allowing Medicare to negotiate the price of prescription medications with drug companies
- Requiring drug companies to pay Medicare a rebate if they raise the price of drugs faster than the rate of inflation
“The new law provides meaningful financial relief for millions of people with Medicare by improving access to affordable treatments and strengthening the Medicare Program both now and in the long run,” CMS said in a press release published on August 16, 2023.
The Inflation Reduction Act of 2022 also extends enhanced financial help for purchasing health insurance through HealthCare.gov or state-based marketplaces.
Healthcare Reform Update for August 11, 2023
HHS report: National uninsured rate reaches all-time low
Analysts looked at enrollment data from the National Health Interview Survey for the first quarter of 2023. They found that an estimated 6.3 million people gained health insurance since 2020, reducing the uninsured rate to a record low.
“The Inflation Reduction Act has played a critical role in helping more Americans afford coverage through the Affordable Care Act,” says HHS Secretary Xavier Becerra.
Key factors that helped lower the uninsured rate include:
- American Rescue Plan’s enhance Affordable Care Act subsidies to help lower health insurance costs
- Fixing the “family glitch” in the ACA to lower health insurance costs for an estimated 5 million people with access to employer-sponsored coverage
- Extended subsidies from The Inflation Reduction Act
- State Medicare expansions
“This year, the nation’s uninsured rate reached an all-time low, even breaking last year’s record,” says Becerra. “HHS will continue to do everything we can to help Americans keep or get coverage and have access to quality, affordable health care.”
Healthcare Reform Update for August 4, 2023
GUIDE created to improve care & quality of life for Alzheimer’s patients
With an estimated 6.7 million Americans over age 65 living with Alzheimer’s dementia in the United States, the U.S. Department of Health and Human Services and other partners recently announced a new guide to improve care and quality of life for seniors with Alzheimer’s and their unpaid caregivers.
The Guiding an Improved Dementia Experience Model (GUIDE) was developed through a partnership between HHS, the Centers for Disease Control and Prevention, and the Centers for Medicare & Medicaid Services.
“HHS continues to innovate to help Americans living with dementia and their unpaid caregivers,” says HHS Secretary Xavier Becerra.
“Our new GUIDE Model has the potential to improve the quality of life for people with dementia and alleviate the significant strain on our families,” Becerra added.
The GUIDE Model has FOUR main objectives:
- Improve quality of life for people living with dementia
- Reduce strain on unpaid caregivers
- Help people remain in their homes and communities
- Improve care coordination and management, caregiver education and support, and respite services
Seniors with Alzheimer’s and their unpaid caregivers will also be assigned a care navigator to help them access:
- Clinical care services
- Non-clinical services such as meals and transportation through community-based organizations
“As millions of Americans already know, dementia can devastate people and their families in many ways,” says CMS Deputy Administrator and Innovation Center Director Liz Fowler.
For more information about the GUIDE Model, see: https://innovation.cms.gov/innovation-models/guide
Healthcare Reform Update for July 28, 2023
Data security breach impacts 612,000 Medicare beneficiaries
A Medicare contractor recently experienced a data security breach that exposed personal data and health information of an estimated 612,000 Medicare beneficiaries.
The data breach occurred between May 27 through May 31, 2023, on the corporate network of Maximus Federal Services, Inc., when a third-party application obtained access through Progress Software’s MOVEit Transfer software.
The MOVEit hack is part of a larger data security breach that accessed private-personal data from an estimated 15 million people and impacted 130-plus organizations, including Medicare.
“The incident involved a security vulnerability in the MOVEit software, a third-party application which allows for the transfer of files during the Medicare appeals process,” according to a letter Medicare sent to beneficiaries.
Notification + free credit monitoring
- Medicare beneficiaries impacted by the data security breach will receive a letter from CMS and Maximus Federal Services, with details about the data breach.
- Maximus is also offering impacted beneficiaries 24 months of free credit monitoring.
Healthcare Reform Update for July 20, 2023
Two men plead guilty in $67 million Medicare fraud scheme
Two Florida men recently pled guilty to submitting $67 million in false claims to Medicare between January 2020 and July 2021.
Daniel M. Carver and his brother Louis “Gino” Carver targeted Medicare beneficiaries in a telemarketing scam for genetic testing and durable medical equipment.
According to the U.S. Department of Justice, court documents show that the Carver brothers paid bribes and kickbacks to telemedicine companies for:
- Forging signatures from doctors and patients on medical documents
- Creating falsified doctors’ orders
- Ordering medically-unnecessary genetic tests
- Ordering medically-unnecessary durable medical equipment
Daniel Carver faces up to 25 years in prison for conspiracy to:
- Commit health care fraud
- Commit wire fraud
- Defraud the United States
- Pay and receive kickbacks
Lois Carver faces up to 10 years in prison for conspiracy to:
- Commit health care fraud
The Carver brothers will be sentenced on December 5, 2023 in a federal district court.
Five more people involved in this $67 million Medicare fraud scam have already pled guilty, and are awaiting sentencing.
Healthcare Reform Update for July 13, 2023
Medicare Part D changes will save beneficiaries $7.4 billion annually
Medicare Part D changes outlined in the Inflation Reduction Act will save beneficiaries an estimated $7.4 billion annually by 2025, according to a recent report published by the U.S. Department of Health and Human Services.
- An annual cap of $2,000 on out-of-pocket costs for prescription drugs
- An average savings of $400 per year on prescription drugs for 18.7 million enrollees
- An estimated 1.9 million enrollees will save at least $1,000 annually on prescription drug costs, beginning in 2025
- An out-of-pocket cost savings on prescription drugs for seniors of about $7.4 billion annually
“The Biden-Harris Administration is committed to helping seniors and people with disabilities save money on the medications they need and ensuring hardworking families have insurance when they need it,” said HHS Secretary Xavier Becerra.
Healthcare Reform News Update for June 30, 2023
CMS releases revisions & timeline for Medicare drug price negotiations
The Centers for Medicare & Medicaid Services will announce the first 10 drugs selected to be part of the Medicare Drug Price Negotiation Program by September 1, 2023.
To clarify the drug selection and negotiation process, CMS recently published revised guidelines and key dates:
CMS will choose the first 10 drugs for the Medicare Drug Price Negotiation Program based on the drug’s:
- Clinical benefit
- Potential to fulfill an unmet medical need
- Impact on Medicare beneficiaries
- Costs associated with research and development, production and distribution
“Medicare drug price negotiation allows CMS to better protect the health of people with Medicare by ensuring they can afford the prescription drugs they need,” say CMS Administrator Chiquita Brooks-LaSure.
“Negotiating with manufacturers on drug prices will improve access to lifesaving drugs for millions of people with Medicare while driving market competition and scientific innovation.”
Key dates for the Medicare Drug Price Negotiation Program include:
- September 1, 2023: CMS will announce the first 10 drugs selected to part of the Medicare Drug Price Negotiation Program
- October 1, 2023: Deadline for drug companies that manufacture the drugs selected to sign agreement to participate in negotiations
- February 1, 2024: Deadline for CMS to send negotiated drug price offers to participating drug companies
- March 2, 2024: Deadline for participating drug companies to accept, reject or proposed a counter offer for negotiated drug price
- September 1, 2024: CMS will publish negotiated maximum fair prices for first 10 drugs chosen for the program
- January 1, 2026: Negotiated drug prices become effective
Healthcare Reform Update for June 27, 2023
FBI investigation leads to guilty verdict in $10 million Medicare fraud
A physician assistant based in Charlotte, N.C., was found guilty of $10 million in Medicare fraud in federal court on June 13, 2023, following an investigation by the Federal Bureau of Investigation.
Colby Edward Joyner, 35 of Monroe, N.C., was convicted of one count of healthcare fraud and six counts of making false statements relating to health care matters.
- Signed documents for fraudulent prescriptions and genetic tests for hundreds of Medicare beneficiaries from 2018 to 2019, while working as a contractor for a telemedicine company.
- Was paid $12 to $15 by the telemedicine company for every fraudulent prescription or genetic test he signed and submitted.
- Falsified medical records so he wasn’t listed as the treating physician and so they did not reveal failed to conduct medical evaluations or examinations for the beneficiaries.
- Submitted $10 million in fraudulent Medicare claims and received more than $3.6 million in payments.
“Joyner exploited telemedicine technology to siphon off money from Medicare,” said Dena J. King, U.S. Attorney for the Western District of North Carolina.
“As the telehealth field continues to grow, federal prosecutors and investigators are keeping a watchful eye for scammers who seek to exploit this platform for their own benefit.”
Joyner faces a maximum prison term of 10 years and a $250,000 fine for healthcare fraud. He also faces a maximum sentence of five years in prison and a $250,000 fine for each count of making false statements related to healthcare matters.
Healthcare Reform News Update for June 21, 2023
Drug makers sue over Medicare drug price negotiations
A lobby group for the pharmaceutical industry filed a lawsuit in federal court this week challenging details in the Inflation Reduction Act that allows Medicare to negotiate drug prices.
The joint lawsuit filed by Pharmaceutical Research and Manufacturers of America (PhRMA), National Infusion Center Association and the Global Colon Cancer Association aims to overturn Medicare’s ability to negotiate and set drug prices as outlined in the Inflation Reduction Act.
“The price setting scheme in the Inflation Reduction Act is bad policy that threatens continued research and development and patients’ access to medicines,” says PhRMA President and CEO Stephen J. Ubl.
“We hope the court recognizes the serious concerns raised and declares the price setting provisions unconstitutional.”
President Joe Biden signed the Inflation Reduction Act into law August 16, 2022. It includes provisions to control prescription drug costs for Medicare beneficiaries such as:
- Capping costs for insulin at $35 per month
- Allowing Medicare to negotiate directly with drug manufacturers to lower Medicare Part B and Medicare Part D prescription drug costs
- Limiting annual pharmacy costs for Medicare beneficiaries to no more than $2,000 per year beginning in 2025.
- Requiring drug companies to pay Medicare a rebate if they raise drug prices faster than the rate of inflation
It’s the fourth lawsuit filed in less than a year challenging Medicare’s ability to negotiate and control prescription drug costs. Similar lawsuits have been filed by pharmaceutical companies Merck & Co and Bristol Myers Squibb. The U.S. Chamber of Commerce has also filed a lawsuit challenging Medicare’s ability to control prescription drug costs.
“We’ll vigorously defend the President’s drug price negotiation law, which is already lowering health care costs for seniors and people with disabilities,” U.S. Department of Health and Human Services Secretary Xavier Becerra said.
Healthcare Reform News Update for June 15, 2023
Inflation Reduction Act lowers some Medicare drug costs beginning July 1
Beginning July 1, the Inflation Reduction Act may lower the cost of 43 prescription drugs for Medicare beneficiaries.
This could save Medicare beneficiaries who depend on these medications an estimated $1 to $149 per average dose, according to the Centers for Medicare & Medicaid Services.
“Under this provision, people with Medicare will no longer have to worry about sudden out-of-pocket price increases when drug companies raise prices faster than the rate of inflation,” says Dr. Meena Seshamani, Deputy Administrator and Director of the Center for Medicare.
“This is just one of the many ways we are helping people with Medicare realize the impact of this law as CMS continues its thoughtful implementation.”
- The Inflation Reduction Act was signed into law by President Joe Biden in August 2022, and included a provision to help control rising costs of prescription drugs due to inflation.
- Earlier this year, the Inflation Reduction Act capped prescription insulin costs at $35 per month for Medicare Part D enrollees.
- A cap on 43 more prescription drugs for Medicare Part B begins July 1, 2023.
“The Medicare Prescription Drug Inflation Rebate Program is a critical way to address long-term price increases by drug companies,” says Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure.
The lower Part B coinsurance for the 43 drugs included in the Medicare Prescription Drug Inflation Rebate Program will be in effect from July 1, 2023 to September 30, 2023.
Healthcare Reform News Update for June 8, 2023
CMS launches pilot program to improve primary care
The Centers for Medicare & Medicaid Services is testing a pilot program in eight states to improve primary care, called the Making Care Primary Model.
It’s part of a 10-year goal to help 100% of Medicare beneficiaries:
- Enroll in a plan and receive essential health care services
- Improve health outcomes, follow-up and accountability
- Expand care-provider networks to improve access to care
“This model focuses on improving care management and care coordination,” says CMS Administrator Chiquita Brooks-LaSure.
“Equipping primary care clinicians with tools to form partnerships with health care specialists, and partnering with community-based organizations will help the people we serve with better managing their health conditions and reaching their health goals.”
The states participating in the Making Care Primary Model pilot program include:
- New Jersey
- New Mexico
- New York
- North Carolina
“Ensuring stability, resiliency, and access to primary care will only improve the health care system,” said CMS Deputy Administrator and CMS Innovation Director Liz Fowler.
“The Making Care Primary Model represents an unprecedented investment in our nation’s primary care network and brings us closer to our goal of reaching 100% of Traditional Medicare beneficiaries and the vast majority of Medicaid beneficiaries in accountable care arrangements, including advanced primary care, by 2030.”
CMS will review applications from primary care organizations in participating states for the pilot program later this year. The program will begin July 1, 2024.
Healthcare Reform News Update for June 2, 2023
CMS seeks FDA approval to cover Alzheimer’s drugs
The Centers for Medicare & Medicaid Services is seeking U.S. Food and Drug Administration approval to cover the costs of medications used to treat Alzheimer’s disease in certain cases.
An estimated 6 million people in the U.S. have been diagnosed with Alzheimer’s disease, and that’s expected to double over the next 30 years, according to the Alzheimer’s Association.
- Alzheimer’s is a progressive disease that damages memory and brain function, and there is no cure. However, several drugs appear to help slow the progression of the disease.
“CMS has always been committed to helping people obtain timely access to innovative treatments that meaningfully improve care and outcomes for this disease,” CMS Administrator Chiquita Brooks-LaSure said.
“If the FDA grants traditional approval, CMS is prepared to ensure anyone with Medicare Part B who meets the criteria is covered.”
Healthcare Reform News Update for May 30, 2023
HHS makes permanent changes to Medicare telehealth services
The U.S. Department of Health and Human Services recently made permanent changes to Medicare telehealth services to improve access to behavioral and mental health services.
The permanent changes allow:
- Qualified health centers and clinics to provide telehealth services for behavioral and mental health to Medicare beneficiaries.
- Medicare beneficiaries to receive telehealth services for behavioral and mental health care from home.
- Any qualified health center or clinic to provide Medicare telehealth services for behavioral and mental health remotely, regardless of geographic location.
- Telehealth services to be delivered via audio-only via phone or other communication platforms.
Temporary changes to telehealth services for Medicare beneficiaries began during the COVID-19 public health emergency.
However, the U.S. Department of Health and Human Services chose to make some of these changes permanent following the end of the COVID-19 Public Health Emergency announced on May 11, 2023.
Healthcare Reform News Update for May 19, 2023
Feds charge 18 suspects in $490 million Medicare COVID-19 scams
The U.S. Department of Justice recently filed charges against 18 suspects for fraudulently billing the Centers for Medicare & Medicaid Services and other federal programs an estimated $490 million for COVID-19 testing kits and services.
Federal investigators found that the schemes included:
- Purchasing Medicare beneficiary numbers and personal information to commit fraud.
- Billing CMS for COVID-19-related services not wanted, not rendered, and not medically necessary
- Shipping unwanted COVID-19 testing kits to Medicare beneficiaries, and even deceased persons in some cases
- Producing fake COVID-19 vaccination cards
- Destroying vials of the COVID-19 vaccine intended for patients
“The Justice Department will not tolerate those who exploited the pandemic for personal gain and stole taxpayer dollars,” said Attorney General Merrick B. Garland.
“This unprecedented enforcement action against defendants across the country makes clear that the Department is using every available resource to combat and prevent COVID-19 related fraud and safeguard the integrity of taxpayer-funded programs.”
Medicare fraud tip line: People with Medicare or private Medicare Advantage plans who receive COVID-19 testing kids or medical supplies they didn’t order can contact the Senior Medicare Patrol Resource Center at 1-877-808-2468.
Healthcare Reform News Update for May 12, 2023
CMS extends virtual services for Diabetes Program through 2023
Medicare beneficiaries with diabetes will be able to receive virtual services through the end of 2023 as part of the Medicare Diabetes Prevention Program, according to the Centers for Medicare & Medicaid Services.
When COVID-19 restrictions limited in-person care, CMS granted diabetes-care providers for Medicare beneficiaries the ability to provide virtual services. However, those services were set to expire on May 11, 2023.
In a CMS rule published in May 2, 2023, virtual services currently provided through the Medicare Diabetes Prevention Program will now be allowed to continue through December 31, 2023.
This allows Medicare providers to provide services and collect data without in-person visits to Medicare beneficiaries with diabetes. These virtual services to support weight management and diabetes include:
- Health education
- Wellness coaching in a group environment
- Weight management strategies
- Collection of bodyweight measurements
The Medicare Diabetes Prevention Program is aimed to help prevent type 2 diabetes for people with prediabetes. The primary goal is to help Medicare beneficiaries with prediabetes lose 5 percent body weight or more and learn to adopt healthier lifestyle habits.
Healthcare Reform News Update for May 11, 2023
Report: Half of all Medicare beneficiaries enrolled in Medicare Advantage plans
A new report published by the Centers for Medicare & Medicaid Services shows that half of all Medicare beneficiaries are enrolled in Medicare Advantage plans by private health insurance providers.
Medicare Advantage enrollment data
Current Medicare enrollment data shows that 30.19 million people of the 59.82 million enrolled in Medicare are enrolled in Medicare Advantage plans through private insurance companies.
Medicare Advantage plans, also called Medicare Part C, combines Medicare Parts A and B (Original Medicare). These plans are offered by private insurance companies that contract with Medicare, providing patients with an additional way to receive Medicare benefits.
Since 2018, Medicare advantage enrollment has increased by 13%. The rise in Medicare Advantage enrollment has also increased Federal Trade Commission scrutiny for advertising practices that target seniors.
Healthcare Reform News Update for May 5, 2023
HHS releases data on 17,000 Medicare-certified hospice & home-health agencies
Consumers have a new way of evaluating Medicare-certified hospice and home health agencies, according the U.S. Department of Health and Human Services.
Last month, HHS released ownership data for 6,000 hospices and 11,000 home-health agencies certified to participate in the Medicare program.
Consumers can search the Medicare-certified databased of hospices and home-health care agencies for enrollment information including:
- Organization name
- Type of organization
- Practice location address
- National Provider Identification
- CMS certification number
- Ownership status (organization, individual, direct/indirect owner)
- Data on mergers, acquisitions, consolidations and any ownership changes since 2016
“Transitioning to hospice care is often an emotionally overwhelming time for many families,” says Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure.
“Making this data public increases transparency, giving families the information needed to help them identify the best care for their loved one.”
Healthcare Reform News Update for March 7, 2023
Biden outlines plan to protect Medicare through 2050
President Joe Biden recently outlined budget plans to extend Medicare benefits through 2050.
“The budget I am releasing this week will make the Medicare trust fund solvent beyond 2050 without cutting a penny in benefits,” Biden wrote.
In addition to savings outlined in the American Rescue Plan and the Inflation Reduction Act, budget changes to protect Medicare through 2050 will include:
- Extending Medicare’s ability to negotiate lower drug prices with pharmaceutical companies
- Capping out-of-pocket drug costs for Medicare beneficiaries at no more than $2,000 a year
- Investing cost savings from lower drug prices back into the Medicare trust fund
- Increasing Medicare taxes to 5% for people earning more than $400,000 a year
“Add all that up, and my budget will extend the Medicare trust fund for more than another generation, an additional 25 years or more of solvency beyond 2050,” Biden wrote.
Healthcare Reform News Update for March 3, 2023
Medicare: COVID-19 services after public health emergency ends
When the COVID-19 Public Health Emergency ends, some changes will be made to Medicare benefits for vaccines, testing, and treatment, according to the Centers for Medicare & Medicaid Services.
Last month President Joe Biden proposed ending the COVID-19 Public Health Emergency later this year.
“I anticipate terminating the national emergency concerning the COVID-19 pandemic on May 11, 2023,” Biden said.
Based on that plan going forward, the CMS recently outlined changes to COVID-19 services for Medicare beneficiaries when the Public Health Emergency officially ends.
This will include the following:
- Vaccines. People with Medicare coverage will still be able to get COVID-19 vaccinations without additional costs.
- COVID-19 Testing. Tests for COVID-19 will still be covered by Medicare when ordered by a healthcare provider. Beneficiaries enrolled in a Medicare Advantage may pay part of the cost for COVID-19 testing, when ordered by a healthcare professional. Free over-the-counter COVID-19 tests covered by Medicare will no longer be available.
- Treatment. Medicare benefits to treat COVID-19 (including access to oral antivirals) after the public health emergency ends will remain the same.
- Telehealth. Broad telehealth services will still be available to Medicare beneficiaries to treat COVID-19, in addition to other healthcare needs. Medicare Advantage beneficiaries should check with their plan about telehealth services.
Healthcare Reform News Update for February 28, 2023
CMS programs aim to improve Medicare services in rural areas
Among the 63 million Americans covered by Medicare, 1 in 3 live in rural areas. However, many rural areas lack access to care.
“These communities often experience significant health inequities,” according to a blog post published on February 10, 2023, by the Centers for Medicare & Medicaid Services.
According to the National Institutes of Health, compared to people living in urban areas, adults in rural areas are more likely to have a higher risk for:
- Heart disease
- Lung disease
- Fatal car accidents
- Drug overdoses
To improve healthcare in rural areas, CMS created a framework based on a three-pronged approach, which includes:
1. Financial support for rural providers
- Pay designated Rural Emergency Hospitals 5 percent more for most services
- Financial support for REHs will also include a monthly payment that increases with inflation.
2. Expanded access to care in rural areas
- Provide funding for telehealth services to increase access to behavioral health clinicians
- Assess Medicare beneficiaries for health literacy, and provide digital health education for those who need it
- Expand provider networks of Medicare Advantage with behavioral health and drug-treatment clinicians
3. Partnering with ACOs to transform rural healthcare
- Work with more Accountable Care Organizations that include doctors, hospitals and health care providers to improve care for Medicare beneficiaries
Healthcare Reform News Update for February 17, 2023
CMS testing three models to control prescription drug costs
The CMS Innovation Center will begin testing three different models to control prescription drug costs, improve access to drug therapies, and improve quality of care.
The U.S. Department of Health and Human Services selected the three models in response to the Inflation Reduction Act of 2022 to lower prescription drug costs.
The three new models will help:
- Lower prescription drug costs to just $2 for some generic drugs
- Improve access to life-changing drug therapies
- Improve quality of care
“HHS is using every tool available to us to lower health care costs and increase access to high-quality, affordable health care,” says HHS Secretary Xavier Becerra.
“We are full steam ahead in delivering the cost savings from the President’s Inflation Reduction Act of 2022, and people on Medicare are already feeling the benefits.”
- The Medicare $2 Drug List: Identify generic drugs for chronic conditions like high blood pressure, high cholesterol, and others that can be capped at $2 per month per drug for Medicare Part D plans.
- The Cell and Gene Therapy Access Model: Under this model, state Medicaid agencies will assign CMS to coordinate and administer multi-state, outcomes-based agreements with manufacturers for certain cell and gene therapies to improve access and control costs to treat conditions like sickle cell disease and cancer.
- The Accelerating Clinical Evidence Model: CMS will develop payment methods for drugs approved under accelerated approval to complete clinical trials faster, and improve access to post-market safety and efficacy data.
Healthcare Reform News Update for February 14, 2023
ACA health plans deny 17% of in-network claims
In a new report published by the Centers for Medicaid & Medicare Serves, data shows that ACA health plans deny an estimated 17% of in-network claims per year.
- In 2021, an estimated 291.6 million in-network claims were submitted to ACA health plans.
- About 48.3 million of those claims were denied for various reasons
Health plans available through the ACA are required to disclose the reason for a denial. Claims are typically denied for one of several reasons, including:
- Excluded services
- Lack of pre-authorization or referral
- Medical necessity
- Other reasons
Claim denials by ACA health plans ranged from 2% to 49% in 2021.
The appeal process when a claim is denied by an ACA health plan
While there is an appeal process, most consumers covered by an ACA health plan don’t appeal when a claim is denied.
According to the report:
- Less than two-tenths of 1% of consumers who are denied services by an ACA health plan for an in-network claim appeal the decision.
- However, of the small number of claims that are appealed, ACA health plans uphold the original denial decision 59% of the time.
In a review of the CMS report, the Kaiser Family Foundation found that:
“Consumers are not provided any information about how reliably marketplace plan options pay claims and plans reporting high claims denial rates do not appear to face any consequences.”
Healthcare Reform News Update for February 10, 2023
Study: Dental care declines for beneficiaries after 65
Even for adults age 65with dental insurance through a Medicare Advantage plan, it’s not enough to provide adequate dental care, according to a recent study published in the journal Health Affairs.
In the study, researchers found that:
- Half of all older adults don’t have dental insurance
- The chance of losing all your teeth at age 65 or older increased by nearly 5% during a 10-year period
- Restorative dental care among older adults dropped nearly 9% during a 10-year period
- An estimated 1 in 20 adults age 65 and older will lose all their teeth
- Even for older adults enrolled in a Medicare Advantage plan with dental insurance, the findings were similar
“Older adults have the lowest rates of dental insurance in the U.S. and cost is a major barrier for many in seeking dental care,” says corresponding author of the study Dr. Lisa Simon.
“We know that Medicare, by covering medical services, improves health outcomes and reduces racial health inequities among older adults, but it has the exact opposite effect for dental care.”
Some Medicare Advantage plans offer dental coverage, but qualifying dental services and coverage amounts vary.
Healthcare Reform News Update for February 7, 2023
Ohio Department of Insurance warns seniors of Medicare Card Scam
Just a month into 2023 and the start of a new year for health insurance, the Ohio Department of Insurance is warning seniors of the Medicare Card Scam.
Here’s what the Medicare Card Scam looks like, according to Ohio Department of Insurance Director Judith L. French:
- Phone call. The scammer calls a senior claiming to be from a government agency such as the Social Security Administration, Medicare, and even the Ohio Department of Insurance
- Medicare card. The scammer tells their intended victim they need a new Medicare card or need to turn in their paper card for a plastic card.
- Personal information. If the scammer hooks their intended victim, they ask for personal information (Social Security Number, Medicare number, birth date, and more) to steal their identify.
“Government agencies, such as the Social Security Administration, Medicare, and the Ohio Department of Insurance do no cold call Ohioans on Medicare,” French said in a press release.
To avoid being a victim of the Medicare Card Scam:
- Never give personal information to anyone who contacts you unsolicited by telephone, email, text, or in person.
- Know that Medicare will never call you to sell anything, visit your home, or enroll you over the phone unless you called first.
- Medicare or Medicare health plans will only call and request personal information if you are a plan member or you called and left a message.
Healthcare Reform News Update for February 2, 2023
Telehealth services extended to treat opioid disorders for Medicare beneficiaries
Telehealth services for Medicare beneficiaries who need treatment for opioid use disorders were recently extended through 2024.
- Telehealth services to treat Medicare beneficiaries with opioid use disorder
- The prescription drug buprenorphine used to treat opioid use disorders
- Reimbursements to federally qualified providers that use telehealth services to treat opioid use disorder and other mental health issues
In 2020, about 1 million Medicare beneficiaries were addicted to opioids, less than 16% received medication to treat opioid use disorders.
Study: Telehealth services improve opioid treatment
A recent study published in the journal JAMA Psychiatry found that telehealth services help people stay in treatment longer and prevent medically-treated overdoses.
“The results of this study add to the growing research documenting the benefits of expanding the use of telehealth services for people with opioid use disorder,” said lead author Dr. Christopher M. Jones, acting director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention.
- Need to see their provider in person once every 12 months.
- New patients will need to see their provider in person within six months, and every 12 months after that.
Healthcare Reform News Update for January 31, 2023
CMS seeks $4.7 billion from Medicare Advantage insurers
The Centers for Medicare & Medicaid Services will seek $4.7 billion in repayments from Medicare Advantage insurers over the next 10 years.
A new rule finalized in the Medicare Advantage Risk Adjustment Data Validation program, will allow CMS to recover overpayments made to Medicare Advantage insurers for medical diagnoses not supported by a beneficiary’s medical record.
“Today we are taking some long overdue steps to move us in a direction of accountability,” U.S. Department of Health and Human Services Secretary Xavier Becerra said.
“Protecting Medicare is one of my highest responsibilities as Secretary, and this commonsense rule is a critical accountability measure that strengthens the Medicare Advantage program. CMS has a responsibility to recover overpayments across all of its programs, and improper payments made to Medicare Advantage plans are no exception.”
Auditing periods for Medicare Advantage insurance overpayments
- CMS will audit specific Medicare Advantage insurance payments from 2011 to 2017 to identify diagnostic errors and collect overpayments.
- Beginning with 2018, CMS will use extrapolation to identify trends in Medicare Advantage overpayments, and seek repayment from insurers.
“CMS is committed to protecting people with Medicare and being a responsible steward of taxpayer dollars,” Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure said.
“By establishing our approach to RADV audits through this regulation, we are protecting access to Medicare both now and for future generations.”
Healthcare Reform News Update for January 26, 2023
16.3 million sign up for ACA health plans during Open Enrollment
During the 2023 Affordable Care Act Open Enrollment period beginning November 1, 2022, 16.3 million people signed up for health insurance through the federal Marketplace or State-based marketplaces.
- This includes 3.6 million people new to the Marketplace for 2023, and 12.7 million people who were enrolled in a Marketplace health plan in 2022.
- Nearly 50% more people enrolled in a health plan through the Marketplace during this enrollment period compared to 2021.
- The 2023 Marketplace enrollment data also represents a 13% increase over enrollment in 2022.
“The Biden-Harris Administration has made lowering health care costs and expanding access to health insurance a top priority,” says U.S. Department of Health and Human Services Secretary Xavier Becerra.
“These record-breaking numbers show we are delivering results for the American people. We will keep doing everything we can to ensure more people have the peace of mind that comes with high-quality, affordable health care.”
- 33 states used the federal Marketplace platform for Open Enrollment
- 17 states used State-based marketplace platforms for Open Enrollment
- The District of Columbia used its own eligibility and enrollment platform for Open Enrollment
- Three states with the most enrollments include California: 1.7 million; Florida: 3.2 million; and Texas: 2.4 million.
- California offered health plans through a State-based marketplace. Florida and Texas offered health plans through the federal Marketplace.
Healthcare Reform News Update for January 24, 2023
Insulin savings begins for Medicare Part D enrollees
Medicare Part D enrollees began paying less for insulin beginning January 1, 2023, based on provisions outlined in the Inflation Reduction Act.
The Inflation Reduction Act caps prescription insulin costs at $35 per month for Medicare Part D enrollees. A similar cap takes effect for Medicare Part B on July 1, 2023.
“Thanks to this historic law, people who get their insulin through Medicare won’t have to pay more than $35 for a month’s supply,” says U.S. Department of Health and Human Services Secretary Xavier Becerra. “No one should have to skip or ration their insulin because they can’t afford it.”
The savings cuts the monthly cost of insulin significantly for an estimated 3.3 million Medicare beneficiaries who use one or more common forms of insulin.
A recently published report, Insulin Affordability and the Inflation Reduction Act: Medicare Beneficiary Savings by State and Demographics, shows that in 2019:
- The national average out-of-pocket cost for insulin was $58 per month
- Patients with Medicare and private insurance paid an average of $63 per month for insulin. Some paid as much as $70 per month for insulin.
- States with the highest out-of-pocket insulin costs for Medicare beneficiaries included North Dakota ($67 per month), Iowa and South Dakota ($60 per month).
- States with the largest population of Medicare beneficiaries that would benefit from lower insulin costs include Texas (114,000 beneficiaries), California (108,000 beneficiaries), and Florida (90,000 beneficiaries).
Healthcare Reform News Update for January 20, 2023
Report: Uninsured rate reaches all-time low
A recent report released by the U.S. Department of Health and Humans Services shows that the number of Americans without health insurance dropped from 11.1% in 2019 to 10.5% in 2021, reaching an all-time low.
According to the report, the drop in uninsured rates is a result of increased access to health plans and lower premiums from:
- Stated-based expansions to Medicaid
- A change in the Affordable Care Act that fixed a “family glitch,” giving about 1 million more families access to health insurance through the marketplace
- Subsidies from the American Rescue Plan and the Inflation Reduction Act that lowered health insurance costs for more people
“The Biden-Harris Administration has worked tirelessly to expand access to health insurance and lower costs for America’s families,” U.S. Department Health and Human Services Secretary Xavier Becerra said.
“We know that access to quality, affordable health care is key to healthier lives, economic security, and peace of mind.”
The uninsured rate declined the most among the following groups:
- Younger adults
- Latino, American Indian, and Alaska Native individuals
- Non-English speaking adults
- People living in states that expanded access to Medicaid
Healthcare Reform News Update for January 19, 2023
ACO initiatives to improve care for 13.2 million Medicare beneficiaries
Three new Accountable Care Organization initiatives will improve access to healthcare providers and treatment for more than 13.2 million Medicare beneficiaries beginning in 2023, according to the Centers for Medicare & Medicaid Services.
Accountable Care Organizations are groups of doctors, hospitals, and other health care providers, who collaborate to provide coordinated, high-quality care to Medicare patients.
Beginning in 2023, the three new ACO initiatives that will help improve patient care include the:
- Medicare Share Savings Program
- Accountable Care Organization Realizing Equity, Access, and Community Health
- Kidney Care Choices Model
These ACO initiatives will help:
- Provide access to care and treatment in rural and underserved areas
- Improve equity and access to healthcare across all demographics
- Increase participation in Medicare plans
- Support Medicare beneficiaries with kidney and renal disease, delay dialysis, and increase access to kidney transplants.
“Through the CMS accountable care initiatives and working with our partners, we have made significant progress in addressing our greatest health care challenges,” says Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure.
“Health care providers coming together as Accountable Care Organizations provide high quality and equitable care to people with Medicare while improving the sustainability of the Medicare program.”
Healthcare Reform News Update for January 10, 2023
Medicare responds to subcontractor data breach
The Centers for Medicare & Medicaid Services recently sent a letter to an estimated 254,000 beneficiaries after discovering a subcontractor data breach that potentially exposed personally identifiable information and protected health information.
“The safeguarding and security of beneficiary information is of the utmost importance to this agency,” said CMS Administrator Chiquita Brooks-LaSure.
“We continue to assess the impact of the breach involving the subcontractor, facilitate support to individuals potentially affected by the incident, and will take all necessary actions needed to safeguard the information entrusted to CMS.”
In October 2022, CMS learned that Healthcare Management Solutions, a subcontractor of ASRC Federal Data Solutions, was subjected to a series of cyber security attacks that exposed personal information for some Medicare enrollees, which may have included:
- Date of birth
- Phone Number
- Social Security Number
- Medicare Beneficiary Identifier
- Banking information, including routing and account numbers
- Medicare entitlement, enrollment, and premium Information
In December 2022, CMS sent beneficiaries potentially impacted by this data breach a letter explaining the circumstances and investigation, along with a new Medicare card, and new Medicare number.
While CMS has yet to confirm if banking information of Medicare beneficiaries was compromised, free credit monitoring is also available to all those affected by the data breach.
Healthcare Reform News Update for December 8, 2022
North Carolina extends Medicare enrollment deadline after power outage
Residents eligible for Medicare in Moore County North Carolina will have an additional two months to enroll or make changes to existing plans, according to the North Carolina Insurance Commission.
The Special Enrollment Period was granted after a widespread power outage beginning December 3, 2022, caused 45,000 homes and businesses to lose power, just days before the December 7, 2022 Medicare enrollment deadline.
The Federal Bureau of Investigation is currently seeking information related to the shooting of two electrical substations managed by Duke Energy that caused the power outage.
“Medicare beneficiaries that were impacted by the mass power outage can enroll in or make changes to their Medicare health or prescription drug plan through February 8, 2023,” said North Carolina Insurance Commissioner Mike Causey.
Healthcare Reform News Update for November 18, 2022
FTC warns of Medicare scams during open enrollment
The FTC recently warned consumers shopping for Medicare plans that scammers are actively trying to steal:
- Medicare information
The most common method Medicare scammers use
Is the phone ringing? Before you answer it, the FTC wants you to know it’s the most common method Medicare scammers use to steal money and information.
“Scammers may sound professional, say they’re from Medicare, and have your personal details,” according to the FTC. “But in reality, they’re trying to steal your money, Medicare information, or your identity.”
For people shopping for a Medicare plan, the FTC recommends the following:
- Don’t trust Caller ID. Scammers can use software to display familiar names and phone numbers to get you to answer.
- Hang up if you’re asked for your Medicare number, Social Security number, bank information, or credit card number.
- Take your time. You have until December 7, 2023 to enroll in a Medicare plan.
- Beware of threats & promises. Scammers may threaten to take away your benefits if you don’t enroll right away. Some promise gifts, cash rewards, gift cards, and services that they never intend to provide.
- The buzzword “preferred Medicare provider” is a lie. Medicare doesn’t endorse a specific plan.
- Contact the FTC to report Medicare scams. Call (800) 633-4227 or visit ReportFraud.ftc.gov
Healthcare Reform News Update for November 10, 2022
New Medicare rules reduce gaps in coverage
A final rule recently issued by the Centers for Medicare & Medicaid Services will reduce gaps in coverage and simplify the enrollment process for beneficiaries.
Based on the Consolidated Appropriations Act, the changes will help eliminate gaps and delays in coverage in several ways:
- When a beneficiary enrolls in a Medicare plan, the coverage will begin the month immediately after enrollment.
- Special enrollment periods will give eligible beneficiaries access to Medicare coverage without late enrollment fees.
- Immunosuppressive drug coverage will be extended for Medicare beneficiaries who have had a kidney transplant.
“For the first time, special enrollment periods will be available in traditional Medicare for individuals who were unable to enroll due to exceptional conditions, and individuals who have had a kidney transplant will now be able to receive extended Medicare coverage for immunosuppressive drugs,” says CMS Administrator Chiquita Brooks-LaSure.
Changes to improve access to Medicare begin January 1, 2023. Medicare Open Enrollment ends December 7, 2022.
Healthcare Reform News Update for October 13, 2022
CMS releases annual Star Rating data to compare Medicare plans
For consumers age 65 or older, comparing Medicare plans can help people make the right buying decision to promote health, prevent disease, and control healthcare costs.
CMS recently released annual Star Ratings data to help people review and compare plans for Medicare Advantage (Medicare Part C) and Medicare Part D prescription drug coverage.
Before buying a product or service, it’s common for consumers to read reviews and compare options, including Medicare options.
- One recent survey found that 95% of consumers read reviews before making a purchasing decision.
- 58% said they would even pay more for a product or service based on positive reviews
“The Star Ratings system supports CMS’ efforts to empower people to make healthcare decisions that are best for them,” according to a CMS press release published October 6, 2022.
Star Ratings: How it works
Medicare plans are rated on a 1 to 5 scale. One star represents poor performance and 5 stars represents excellent performance.
Health plan ratings are based on performance metrics for:
- Staying healthy: screenings, tests, & vaccines
- Managing chronic (long term) conditions
- Member experience with health plan
- Member complaints & changes in the health plan’s performance
- Health plan customer service
Drug plan ratings are based on performance metrics for:
- Drug plan customer service
- Member complaints & changes in the drug plan’s performance
- Member experience with the drug plan
- Drug safety & accuracy of drug pricing
Annual Star Ratings data
Star Ratings are released annually based on data provided by people enrolled in Medicare Advantage and Part D prescription drug plans.
- 72% of people currently in Medicare Advantage plans that offer prescription drug coverage are enrolled in a plan that earned four or more stars in 2023.
- 51% of Medicare Advantage plans that offer prescription drug coverage will have an overall rating of four stars or higher in 2023.
Healthcare Reform News Update for October 1, 2022
Medicare beneficiaries will pay lower premiums in 2023
Medicare Part B premiums will drop by 3% in 2023, according to the Centers for Medicare and Medicaid Services.
CMS announced the reduction in Medicare Part B premiums last week, ahead of Medicare Open Enrollment, which begins October 15.
It’s the first time in more than a decade Medicare premiums haven’t increased.
- Premiums: $164.90 per month, a decrease of $5.20 per month compared to 2022
- Deductible: $226 annual deductible, a decrease of $7 compared to 2022.
Savings on Alzheimer’s drug helps lower Medicare premiums
Last year, CMS estimated a significant increase in cost for the drug Aduhelm used to treat Alzheimer’s disease made by the pharmaceutical company Biogen. This was expected to drive up Medicare premiums, according to U.S. Department of Health and Human Services Secretary Xavier Becerra.
However, after Biogen lowered the price of the drug and CMS announced limited coverage of the drug, the savings were used to lower Medicare premiums.
“…I’m instructing the Centers for Medicare and Medicaid Services to reassess the recommendation for the 2022 Medicare Part B premium, given the dramatic price change of the Alzheimer’s drug, Aduhelm,” Becerra said. “With the 50% price drop of Aduhelm on January 1, there is a compelling basis for CMS to reexamine the previous recommendation.”
- The 2022 premium included a contingency margin to cover projected Part B spending for…Aduhelm, according to a CMS press release published September 27.
- Lower-than-projected spending on both Aduhelm and other Part B items and services resulted in much larger reserves…which can be used to limit future Part B premium increases.
Other costs savings for seniors in 2023 will include:
- A $35 cost-sharing limit on insulin products, outlined in the Inflation Reduction Act.
- No-cost adult vaccines recommended by the Advisory Committee on Immunization Practices
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.