Part D Senior Savings Model: Will there be a plan with higher premiums for insulin at a lower cost?

The Part D Senior Savings Model allows drug manufacturers to offer their discounts in the coverage gap, even when a Part D plan enhances cost sharing. This allows plans to offer a fixed, consistent cost sharing on insulin. This structure is estimated to save enrollees who take insulin $446 in annual out-of-pocket costs. Part D sponsor plan premiums vary and beneficiaries should find a Part D plan that provides coverage they want at the lowest total annual cost, premiums and out-of-pocket costs combined. As always, please contact your Total Benefit Solutions Medicare health insurance specialists at (215)355-2121 with any questions or concerns.

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Inflation Reduction Act: Establishing the Negotiated “Maximum Fair Price” for Medicare

The upper limit for the negotiated price of a drug (the “maximum fair price”) is equal to the lower of: The drug’s enrollment-weighted negotiated price (net of all price concessions) for a Part D drug; The average sales price for a Part B drug; or A percentage of the non-federal average manufacturer price (i.e., the average price wholesalers pay manufactures for drugs distributed to non-federal purchasers), depending on FDA approval date: 75% for small-molecule drugs more than 9 years but less than 12 years beyond FDA approval; 65% for drugs between 12 and 16 years beyond FDA approval; and 40% for drugs more than 16 years beyond FDA approval Financial… Read More

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Blue KC: Members Can Soon Access Rx Savings Solutions and Find Care in One Place

In October, Rx Savings Solutions will integrate with the Find Care tool on MyBlueKC.com and the MyBlueKC mobile app. Rx Savings Solutions is a secure, online tool that helps eligible members find ways to save money on prescription drugs. Once integrated, the two tools will allow members to view medical and pharmacy in one place and better use both tools. The integration is one way we’re helping reduce the total cost of care for members, employers, and health plans. Eligible members can follow this path to Rx Savings Solutions: MyBlueKC.com Click Find Care in the left column Click Find Doctors, Specialists & Hospitals Click Medication Finder Have any questions regarding… Read More

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Part D Senior Savings Model: Will step therapy apply with insulin drugs?

Step therapy is when a Part D plan requires enrollees to first try certain drugs to treat a medical condition before the plan will cover another drug for that condition. The Model doesn’t change Part D sponsors’ formulary requirements. Enrollees can find out if the insulin or insulins they use have any additional step therapy requirements or limits by looking at the Part D plan’s formulary. Have any questions regarding this notice? Please contact your Total Benefit Solutions Medicare health insurance specialists at (215)355-2121.

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What Insulin Drugs are Covered Under the Part D Senior Savings Model?

Part D sponsors are required to include at least one vial and pen dosage form for each of the different types of Model insulins, where available – rapid acting, short-acting, intermediate-acting and long-acting – at a maximum $35 copay for a one-month supply through the deductible, initial coverage, and coverage gap phases of the benefit. Part D sponsors are encouraged to include additional insulin formulations, such as concentrated insulins, at the same $35 copay for a one-month supply. The Model doesn’t affect the cost sharing of insulin covered under Part B. For a full list of the insulin drugs covered by each plan, as well as which drugs are covered… Read More

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Health Insurer Ordered to Stop Selling in Washington

Medova Healthcare, which sold illegal insurance plans through chambers of commerce, has agreed to stop selling in Washington, according to the Office of the Insurance Commissioner. The company also agreed to a $310,000 suspended fine, according to the OIC. It operated in 38 states including Washington and served 35,000 employees nationwide. Medova sold health insurance plans to almost 140 small businesses in the state, covering 1,487 employees, through chambers of commerce. One of them mentioned in the OIC investigation was the Lakewood Chamber of Commerce. The chamber did not respond to inquiries. The health plans were marketed to small businesses as traditional insurance plans, but they were self-funded Employment Retirement… Read More

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Prescription Drug Provisions in the Inflation Reduction Act

For the first time, requires the federal government to negotiate prices for some top-selling drugs covered under Medicare Requires drug companies to pay rebates if prices rise faster than inflation for drugs used by Medicare beneficiaries Eliminates 5% coinsurance for catastrophic coverage in Medicare Part D in 2024, adds a $2,000 cap on Part D out-of-pocket spending in 2025, and limits annual increases in Part D premiums for 2024-2030 Limits monthly cost sharing for insulin products to $35 for people with Medicare Expands eligibility for Medicare Part D Low-Income Subsidy full benefits Eliminates cost sharing for adult vaccines covered under Medicare Part D and improves access to adult vaccines under… Read More

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Open Enrollment Tips!

As always, please contact your Total Benefit Solutions health insurance specialists at today at (215)355-2121.

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Understanding the Health Care Provisions in the Inflation Reduction Act

The Inflation Reduction Act includes several landmark health care provisions that would lower prescription drug costs for people with Medicare, reduce Medicare drug spending and extend enhanced subsidies for Affordable Care Act marketplace coverage. On Thursday, August 11, a panel of KFF experts held a web briefing to explain these provisions and how they would affect people and federal health spending, followed by a Question and Answer session. Click here to open article and view Web Event video. The legislation for the first time would require the U.S. Secretary of Health and Human Services to negotiate directly with drug manufacturers over the price of some high-cost drugs in the Medicare… Read More

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The Employer Shared Responsibility Provision Estimator

The Taxpayer Advocate Service developed the Employer Shared Responsibility Provision (ESRP) Estimator to help employers understand how the provision works and learns how the provision may apply to them. The provision applies to applicable large employers – generally, that means employers that had an average of at least 50 full-time employees (including full-time equivalent employees-FTEs), during the preceding calendar year. If you are an employer, you can use the estimator to determine: The number of your full-time employees, including FTEs, Whether you might be an applicable large employers, and If you are an applicable large employer, an estimate of the maximum amount of the potential liability for the employer shared… Read More

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When is the Part D Senior Saving Model expected to end? How many years is the model?

Since CMS is testing the Part D Senior Savings Model to lower costs and improve health care quality, it has a set period for when it’s available. Part D plans participating in the Model first became available on January 1, 2021. The Model extends until December 31, 2025, but the plans participating in the Model may change each year. Please contact your Total Benefit Solutions Medicare health insurance specialists at (215)355-2121, if you have any questions or concerns.

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Guaranteed Issue Rights

Guaranteed Issue (GI) rights are rights the beneficiary has in certain situations when insurance companies must offer certain Medigap policies. There are ONLY 7 situations where Guaranteed Issue Rights apply. Two of the most common are: Beneficiary is in a Medicare Advantage Plan, and the plan is leaving Medicare or stops giving care in their area, or the beneficiary moves out of the Medicare Advantage plan’s service area. Beneficiary has Original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending. Just like with the Medigap Open Enrollment Period, during a Guaranteed Issue: No eligibility… Read More

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What plans are part of the Part D Senior Savings Model?

The Centers for Medicare & Medicaid Services (also known as CMS, the federal agency that approves Medicare plans) announced Medicare Advantage plans with prescription drug coverage (MA-PD) and Part D prescription drug plans (PDPs) that are participating in the Model for Calendar Year (CY) 2022 in September 2021. You can call 1-800-MEDICARE to ask questions about enrollment, eligibility, and the Model, or visit Medicare Plan Finder at https://www.medicare.gov/plan-compare/ to search for coverage in your area and compare Part D plan options with the lowest prices for your prescriptions. You can also find a list of participating plans on the Model website at https://innovation.cms.gov/media/document/pdss-2022-model-landscape-file. If you have any questions, please contact… Read More

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What is a health insurance deductible?

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest. Many plans pay for certain services, like a checkup or disease management programs, before you’ve met your deductible. Check your plan details. All Marketplace health plans pay the full cost of certain preventive benefits even before you meet your deductible. Some plans have separate deductibles for certain services, like prescription drugs. Family plans often have both an… Read More

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Defined Contribution Plans

The Issue As one of our long-time group insurance customers grew over the years, their workforce became more diverse and the management team found it difficult to accommodate each employee’s unique insurance needs. As much as the team wanted to provide the necessary coverage for the employees, they also required some control over the employee benefits budget. They came to us for advice. The Solution We proposed that this employer consider a defined contribution strategy. Defined contribution plans build benefit portfolios around a specific dollar amount, rather than around a specific plan or plans. In this way, the management team could select an amount that the company would contribute toward… Read More

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Medicare Advantage (MA) Quick Facts

What is it? A Medicare Advantage Plan is a type of Medicare health plan offered by a private company, such as Independence Blue Cross, that contracts with Medicare to provide all Part A and Part B benefits. If enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Plan types offered: Medicare Advantage Plans include Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO), for example. Independence offers Keystone 65 HMO as well as Personal Choice 65 PPO. Medical Coverage: If enrolled in a HMO, members must choose a PCP (which also will coordinate referrals) and must stay In-Network. PPO… Read More

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What is copayment?

A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible. Let’s say your health insurance plan’s allowable cost for a doctor’s office visit is $100. Your copayment for a doctor visit is $20. If you’ve paid your deductible: You pay $20, usually at the time of the visit. If you haven’t met your deductible: You pay $100, the full allowable amount for the visit Copayments (sometimes called “copays”) can vary for different services within the same plan, like drugs, lab tests. and visits to specialists. Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have… Read More

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Medigap Quick Facts

What is it? A Medigap policy (also called “Medicare Supplement Insurance”) is private health insurance that’s designed to supplement Original Medicare. This means it helps pay some of the health care costs (“gaps”) that Original Medicare doesn’t cover, like copayments, coinsurance, and deductibles. Play types offered: Insurance companies can sell only a “standardized” policy identified in most states by letters. Independence Blue Cross offers Plans A, B, F, F-HD, G, G-HD, and N. Medical Coverage: No selection of a PCP is required; members are able to choose any doctor or hospital as long as they accept Original Medicare. This also allows for no referrals and no network. Prescription Drug Coverage:… Read More

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What is the Part D Senior Savings Model?

The Part D Senior Savings Model allows participating Part D prescription drug plans to offer a broad set of formulary insulins at a maximum $35.00 copayment per month’s supply, throughout the deductible, initial coverage, and coverage gap phases of their Part D drug coverage. This means that participating Part D plans offer enrollees predictable, stable copayments for insulin to help enrollees save money on their drug costs. If you have any questions, please contact your Total Benefit Solutions Inc Medicare specialists at (215)355-2121.

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New Prescription Drug Reporting Requirement

As previously reported in December 2021, Section 204 of the Consolidated Appropriations Act, 2021 (“CAA”) requires plan sponsors of group health plans to submit information annually about prescription drugs and health care spending to Centers for Medicare and Medicaid Services (“CMS”) on behalf of the departments of Health and Human Services (“HHS”), Labor (“DOL”), and the Treasury (collectively, the “Departments”). The first deadline is December 27, 2022. CMS recently updated guidance related to this reporting requirement that provides some helpful clarification. Employers with fully insured or self-funded (includes level funded) group health plans, including grandfathered plans, church plans subject to the Internal Revenue Code, and governmental plans. The term “group… Read More

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What are HDHPs & HSAs?

One way to manage your health care expenses is by enrolling in a High Deductible Health Plan (HDHP) in combination with opening a Health Savings Account (HSA). How High Deductible Health Plans and Health Savings Accounts can reduce your costs: If you enroll in an HDHP, you may pay a lower monthly premium but have a higher deductible (meaning you pay for more of your health care items and services before the insurance plan pays). If you combine your HDHP with an HSA, you can pay that deductible, plus other qualified medical expenses, using money you set aside in your tax-free HSA. So if you have an HDHP and don’t… Read More

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Delaware Enacts New Paid Family and Medical Leave Requirement

The Healthy Delaware Families Act was recently signed into law, which provides paid leave for three categories of leave: parental leave, medical leave and family caregiving leave. Employers with 10-24 employees are only subject to the parental leave provisions. Employers with 25 or more employees are subject to all leave provisions. Employers with fewer than 10 employees are not obligated to participate in the leave program, although an employer can opt-in for a 3-year participation period. Click here to download for more information. As always, please contact your Total Benefit Solutions Inc health insurance specialists with any questions or concerns at (215)355-2121.

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Support for your emotional health

Virtual care visits from MDLIVE® IBC members pay $0 cost-share* You have access to care from therapists, psychologists, and psychiatrists who can help with concerns likeanxiety, depression, and panic disorders. With telebehavioral health from MDLIVE, you pay $0 costshare* for a confidential visit in the comfort of yourhome, or wherever you are. Choose to have your virtual care visit by video chat, using the MDLIVE website or mobile app, or by phone.

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Additional Guidance Addresses ACA Preventive Care Mandate

As part of FAQ 51, the Departments of Labor, Health and Human Services, and the Treasury (together, the “Departments”) issued guidance clarifying severalAffordable Care Act (“ACA”) preventive care coverage issues applicable to non-grandfathered group health plans. As background, non-grandfathered group health plans must cover certain in-network preventive care items and services without cost-sharing. Click the link below to download the bulletin. As always contact your health insurance specialists at Total Benefit Solutions, Inc if you have any additional questions or concerns (215)355-2121 https://www.totalbenefits.net

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SHOP Rules Finalized, Enrollment Forms Simplified

The Small Business Health Options Program’s (SHOP) place along the Affordable Care Act’s (ACA) timeline. It’s now being packaged for mass consumption and soon will be stocked on store shelves across all 50 states. Click here to read more…

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