#medicaresupplements – Page 2 – Total Benefit Solutions Inc

Additional Guidance on New Prescription Drug Reporting Requirement

October 18, 2022September 20, 2022Ed MacConnell

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.

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

October 17, 2022September 7, 2022Ed MacConnell

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

Get ready for the Medicare Annual Enrollment Period with our centralized guide to AEP.

October 15, 2022October 15, 2022Ed MacConnell

Every year, the AEP is your opportunity to enroll in or switch to a Medicare plan that fits your ever evolving health care needs. This special enrollment window only runs October 15 to December 7, so it’s important to be prepared to accomplish anything you’d like to during that time. If reviewing or changing your coverage seems a little daunting with all the different plans and benefits on the market and decisions to make, don’t worry! You don’t have to go it alone. Get Your Guide to the Medicare Annual Enrollment Period and Get ready for the Medicare Annual Enrollment Period with our centralized guide to AEP. Click here to… Read More

Does an MSA Health Insurance Plan (Medical Savings Account) cover prescription drugs?

October 15, 2022October 11, 2022Ed MacConnell

Does an MSA health insurance plan cover drugs? No. You A Medicare MSA Plan cannot cover prescription drugs. To cover prescription drugs when you have an MSA you must enroll in a separate policy with prescription drug coverage. You can also join a Medicare Prescription Drug Plan to help with your drug costs. As always please ask your Total Benefit Solutions, Inc health insurance expert about your Medicare prescription drug plan options at (215)355-2121 or you can shop and compare online by clicking here.

3 Types of Medigap Rating Structure

October 12, 2022August 2, 2022Ed MacConnell

Attained-Aged: Premium based on current age when policy is issued. Premium goes up as you get older AND may go up due to a rate increase. All Medigap Freedom plans are Attained-Aged rated. Issued-Aged: Premium based on the age you are when you buy (are issued) the Medigap policy. Premium DOES NOT go up as you get older AND may go up due to a rate increase. Community: Same premium is charged to everyone who has the Medigap policy, regardless of age. Premium DOES NOT go up as you get older AND may go up due to a rate increase. Call your Total Benefit Solutions, Inc Medicare health insurance specialists… Read More

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

October 11, 2022September 7, 2022Ed MacConnell

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

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

October 7, 2022August 22, 2022Ed MacConnell

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.

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

October 5, 2022August 24, 2022Ed MacConnell

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

Key Differences: Medigap Open Enrollment, AEP, and ICEP

October 4, 2022July 28, 2022Ed MacConnell

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.

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

October 3, 2022August 22, 2022Ed MacConnell

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.

How is the Part D Late Enrollment Penalty Calculated?

October 1, 2022September 29, 2022Ed MacConnell

learn more about the Medicare Part D Late Enrollment Penalty.

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

September 30, 2022August 31, 2022Ed MacConnell

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

How to File a Medicare Appeal

September 30, 2022September 29, 2022Ed MacConnell

Medicare beneficiaries have the right to file an appeal when they or their physicians disagree with a treatment or claim denial. Luckily Medicare provides a step by step instruction guide to filing those appeals. Please click the link below to downlead the Medicare appeals guide. As always please contact your Total Benefit Solutions Inc Medicare health insurance specialist at (215)355-2121 if you have any additional questions or concerns.

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

September 29, 2022August 19, 2022Ed MacConnell

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.

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

September 23, 2022August 18, 2022Ed MacConnell

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

Prescription Drug Provisions in the Inflation Reduction Act

September 21, 2022August 17, 2022Ed MacConnell

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

Understanding the Health Care Provisions in the Inflation Reduction Act

September 19, 2022August 16, 2022Ed MacConnell

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

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

September 14, 2022August 10, 2022Ed MacConnell

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.

Medigap Open Enrollment Period

September 13, 2022July 28, 2022Ed MacConnell

Most beneficiaries get ONE Medigap Open Enrollment Period. The Medigap Open Enrollment Period cannot be changed or repeated. Under 65 Medicare beneficiaries get another Medigap Open Enrollment Period when they turn 65. As always, please contact your Total Benefit Solutions, Inc health insurance specialists with any questions or concerns at (215)355-2121.

What is a Medicare Coverage Gap?

September 8, 2022August 11, 2022Ed MacConnell

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.

Over-the-Counter Hearing Aids May Help People with Medicare

September 8, 2022Ed MacConnell

The Food and Drug Administration (FDA) recently finalized a rule that will permit people with Medicare, and others, to purchase hearing aids online or in stores, at lower costs, and without a prescription. The long-awaited rule, which will go into effect in October, may make hearing aids more affordable for as many as 30 million adults who believe they have mild to moderate hearing loss, even if they have not had a hearing exam. Last week, the Food and Drug Administration (FDA) finalized a rule that will permit people with Medicare, and others, to purchase hearing aids online or in stores, at lower costs, and without a prescription. The long-awaited rule, which will go into effect in October, may… Read More

What employers or plans are subject to TEFRA and MSP ( Medicare as Secondary Payor) rules?

September 8, 2022September 8, 2022Ed MacConnell

Employers with 20 or more employees for each working day in each of 20 or more work weeks in the preceding or current calendar year are subject to TEFRA and MSP rules. Full-time, part-time, union, and non-union employees are counted as one employee each. For the purpose of group size, employees are counted regardless of whether they are eligible or enrolled in the employer plan. Changing from non-TEFRA to TEFRA status occurs on the date that the employer has 20 or more employees for each working day in each of 20 or more work weeks in the preceding or current calendar year. Whereas changing from TEFRA to non-TEFRA can only… Read More

Guaranteed Issue Rights

September 7, 2022July 29, 2022Ed MacConnell

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

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

September 2, 2022August 10, 2022Ed MacConnell

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

Celebrity Medicare Sales Pitches Are Toned Down After Scrutiny

August 31, 2022Ed MacConnell

Soaring complaints and aggressive sales efforts result in tighter rules from regulators From WSJ.COM: If it’s football season, you can count on seeing Joe Namath on television, along with William Shatner and Jimmie “J J” Walker. They are the most prominent pitchmen for what has become an annual fall selling frenzy for Medicare Advantage policies. After a surge in consumer complaints, and stiffer government rules, the sales pitches will likely be tamer this year. If there is confusion, “we’ll change things so it satisfies everybody and eliminates the confusion,” said Mr. Shatner, best known for his role as Captain Kirk in the “Star Trek” franchise The federal Centers for Medicare and Medicaid Services toughened its… Read More

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