How does Original Medicare work?

Original Medicare covers most, but not all of the costs for approved health care services and supplies. After you meet your deductible, you pay your share of costs for services and supplies as you get them. There’s no limit on what you’ll pay out-of-pocket in a year unless you have other coverage (like Medigap, Medicaid, or employee or union coverage). Services covered by Medicare must be medically necessary. Medicare also covers many preventive services, like shots and screenings. If you go to a doctor or other health care provider that accepts the Medicare-approved amount, your share of costs may be less. If you get a service that Medicare doesn’t cover,… Read More

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Four Key Changes in the Biden Administration’s Final Rule on Medicare Enrollment and Eligibility

The Centers for Medicare & Medicaid Services (CMS) issued a final rule on October 28, 2022, to implement several changes in Medicare enrollment and eligibility that were included in the Consolidated Appropriations Act of 2021 (CAA). These changes are designed to minimize gaps in coverage for people who sign up for Medicare and improve access to care by shortening the gap between Medicare enrollment and coverage; creating new Special Enrollment Periods for individuals whose coverage would otherwise be delayed due to challenging circumstances, such as a natural disaster; and extending coverage of immunosuppressive drugs for certain beneficiaries with end-stage renal disease (ESRD) who would otherwise lose coverage for these drugs… Read More

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Medicare Savings Programs

Get help from your state paying your Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) premiums through a Medicare Savings Program. If you qualify, Medicare Savings Programs might also pay your Part A and Part B deductibles, coinsurance, and copayments. You’ll apply for Medicare Savings Programs through your state. When you apply, your state determines which program(s) you qualify for. Even if you don’t think you qualify, you should still apply. For more information about the Medicare Savings Programs, click here. Have any questions regarding this notice? Please contact your Total Benefit Solutions Medicare health insurance specialists today at (215)355-2121.

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Medicare Part D: A First Look at Medicare Drug Plans in 2023

During the Medicare open enrollment period from October 15 to December 7 each year, beneficiaries can enroll in a plan that provides Part D prescription drug coverage, either a stand-alone prescription drug plan (PDP) for people in traditional Medicare, or a Medicare Advantage plan that covers all Medicare benefits, including prescription drugs (MA-PD). Highlights for 2023: For more information regarding Part D Plan Availability and Part D Premiums, click here. Have any questions regarding this notice? Don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.

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What is a Medicare Medical Savings Account (MSA) Plan?

Medicare works with private insurance companies to offer you ways to get your health care coverage. These companies can choose to offer a consumer-directed Medicare Advantage Plan, called a Medicare MSA Plan. These plans are similar to Health Savings Accounts Plans available outside of Medicare. You can choose your health care services and providers (MSA plans usually don’t have a network of doctors, other health care providers, or hospitals). Medicare MSA Plans combine a high-deductible insurance plan with a medical savings account that you can use to pay for your health care costs. High-deductible health plan: The first part is a special type of high-deductible Medicare Advantage Plan (Part C).… Read More

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What are Qualified Medical Expenses?

Qualified Medical Expenses are generally the same types of services and products that otherwise could be deducted as medical expenses on your yearly income tax return. Some Qualified Medical Expenses, like doctors’ visits, lab tests, and hospital stays, are also Medicare-covered services. Services like dental and vision care are Qualified Medical Expenses, but aren’t covered by Medicare. Qualified Medical Expenses could count toward your Medicare MSA Plan deductible only if the expenses are for Medicare-covered Part A and Part B services. Each year, you should get a 1099-SA form from your bank that includes all of the withdrawals from your account. You’ll need to show that you’ve had Qualified Medical… Read More

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Prescription Drug Reporting Reminder

As previously reported, plan sponsors of group health plans must submit information annually about prescription drugs and health care spending to the Centers for Medicare and Medicaid Services (“CMS”). The first deadline is December 27, 2022, for reporting on calendar years 2020 and 2021. Additionally: To learn more, click here to download the document. Have any questions regarding this notice? Please call your Total Benefit Solutions health insurance experts today at (215)355-2121.

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10 Steps to Use a Medicare MSA Plan

Choose and join a high-deductible Medicare MSA Plan. You set up an MSA with a bank the plan selects. Medicare gives the plan an amount of money each year for your health care. The plan deposits some money into your account. You can use the money in your account to pay your health care costs, including health care costs that aren’t covered by Medicare. When you use account money for Medicare-covered Part A and Part B services, it counts towards your plan’s deductible. If you use all of the money in your account and you have additional health care costs, you’ll have to pay for your Medicare-covered services out0of-pocket until… Read More

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Inflation Reduction Act: Eliminates Cost Sharing for Adult Vaccines in Medicare Part D and Improves Access to Adult Vaccines in Medicaid & CHIP

Medicare Part D: Eliminates cost sharing for adult vaccines covered under Medicare Part D that are recommended by the Advisory Committee on Immunization Practices (ACIP), such as for shingles Medicaid and CHIP: Requires state Medicaid and CHIP programs to cover all approved vaccines recommended by ACIP and vaccine administration, without cost sharing Have any questions regarding this notice? Don’t hesitate to contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.

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Inflation Reduction Act: Expands Eligibility for Full Benefits Under the Medicare Part D Low-Income Subsidy Program

The Part D Low-Income Subsidy (LIS) Program helps beneficiaries with their Part D premiums, deductibles, and cost sharing. Beneficiaries qualify for full or partial benefits depending on their income and resources. Current law: Beneficiaries qualify for full LIS benefits if they have income up to 135% of poverty and lower resources (up to $9,900 individual, $15,600 couple in 2022) Beneficiaries qualify for partial LIS benefits if they have income between 135-150% of poverty and higher resources (up to $15,510 individual, $30,950 couple in 2022) Inflation Reduction Act: Expands eligibility for full LIS benefits to individuals with incomes between 135% and 150% of poverty and higher resources (at or below the… Read More

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Inflation Reduction Act: Limits Monthly Copayments for Insulin in Medicare

Beginning in 2023, limits copayments to $35 per month per prescription for covered insulin products in Medicare Part D plans and for insulin furnished through durable medical equipment under Medicare Part B, with no deductible. For 2026 and beyond, limits monthly Part D copayments for insulin to the lesser of: $35 25% of the maximum fair price (in cases where the insulin product has been selected for negotiation) 25% of the negotiated price in Part D plans Please call your Total Benefit Solutions Medicare health insurance specialists with any questions or concerns at (215)355-2121.

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Additional Guidance on New Prescription Drug Reporting Requirement

As previously reported in 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 requirements that proves some helpful clarification. Have any questions regarding this notice? Please contact your Total Benefit Solutions health insurance specialists today at (215)355-2121.

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Inflation Reduction Act: Capping Medicare Part D Out-of-Pocket Spending and Other Part D Benefit Changes

Changes would lower beneficiary spending, reduce Medicare’s liability for high drug costs, and increase Part D plan and manufacturer liability for high drug costs. Beneficiaries: Eliminates 5% coinsurance for catastrophic coverage in 2024 Caps out-of-pocket drug spending at $2,000 beginning in 2025 Allows spreading out of out-of-pocket costs over the year Limits premium growth to no more than 6% per year for 2024-2030 Medicare: Lowers share of costs above the out-of-pocket spending cap (“reinsurance”) Part D Plans: Increases share of costs above the out-of-pocket spending cap Modifies share of costs below the out-of-pocket spending cap Drug Companies: Requires a price discount on brand-name drugs above the out-of-pocket spending cap Modifies… Read More

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Inflation Reduction Act: Requires Drug Manufacturers to Pay Rebates for Drug Price Increases Above Inflation

Requires drug manufacturers to pay a rebate if drug prices increase faster than the rate of inflation (CPI-U) for: Single-source drugs and biologicals covered under Medicare Part B All covered drugs under Medicare Part D except those where average annual cost is <$100 2021 is the base year for measuring cumulative price changes relative to inflation The rebate amount is based on units sold in Medicare multiplied by the amount that a drug’s price in a give year exceeds the inflation-adjusted price Price changes are measured based on the average sales price (for Part B drugs) or the average manufacturer price (for Part D); these measures include prices charged in… Read More

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Part D Senior Savings Model: Is there a cap on the number of units monthly to get the $35 copay?

Generally, the maximum $35.00 copayment under the Model applies to one month’s supply of insulin. This may be limited by a physician’s prescription or by plan rules on drug dosage to ensure patient safety. Please note that if an enrollee uses multiple types of insulin or has multiple prescriptions for select insulins covered under the Model, each prescription would have a copayment of a maximum $35.00 for a one month’s supply. Have any questions or concerns regarding this notice? Don’t hesitate to call your Total Benefit Solutions Medicare specialists today at (215)355-2121.

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Inflation Reduction Act Requires the Secretary of HHS to Negotiate Medicare Drug Prices

Modifies the current law “non-interference” clause to require the HHS Secretary to negotiate drug price with manufacturers for some drugs covered under Medicare Part B and Part D. Which drugs qualify for negotiation? The Secretary selects drugs to be negotiated from the 50 “negotiation-eligible” drugs with the highest total Medicare Part D spending and the 50 “negotiation-eligible” drugs with the highest total Medicare Part B spending. Which drugs are excluded from negotiation? “Negotiation eligible drugs” include brand-name drugs or biologics and exclude the following drugs: Drugs that have a generic or biosimilar available Drugs less than 9 years (for small-molecule drugs) or 13 years (for biological products) from their FDA-approval… Read More

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Key Differences: Medigap Open Enrollment, AEP, and ICEP

Medigap Open Enrollment Period: six (6) month period starting the first of the month a beneficiary turns 65 or enrolls into Part B, whichever is later. Once in a lifetime EXCEPT for Guaranteed Issue situation or beneficiaries under 65. Annual Election Period (AEP): Medicare Advantage or PDP ONLY. Every year from October 15th to December 7th. Initial Coverage Election Period (ICEP): Medicare Advantage Only. With most ICEPs, occurs 3 months prior, the month of and 3 months after a beneficiary’s 65th birthday. The professionals at Total Benefit Solutions, Inc are here to help you understand your Medicare health insurance choices. Call us today at (215)355-2121.

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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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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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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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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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What is a Medicare Coverage Gap?

Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again. As always, please contact your Total Benefit Solutions Medicare health insurance specialists today at (215)355-2121.

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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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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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