Medicare Part D requires clients to buy plans from a private insurance company. That means that each insurer offering Part D has its own list of covered drugs, the plan formulary.
In order for each insurance company to be able to provide information to potential and existing clients, they break the drugs into various tiers with differing costs. Thus, the drugs in the lowest tier generally have a lower co-insurance or co-payment cost and vice versa — higher-cost drugs usually have a higher co-insurance or co-payment price. There is an exception to this rule, however, if a doctor wants a patient to take a drug in a higher tier, it is possible for patients to obtain the drugs at an affordable price.
The formulary usually stays the same during the year, but it is possible for a plan to change coverage providing it follows Medicare’s rules and regulations. Patients affected by such a change must have at least 60 days’ notice before changes go into effect. Additionally, a refill request must be honored, plus the patient is offered a 60-day supply under the previous plan before changing to the new plan.
Interested in finding out what drugs are covered in your area? Check out Medicare’s plan finder tool at: https://www.medicare.gov/find-a-plan/questions/home.aspx
Posted on Friday, April 7th, 2017. Filed under
Medicare.
Until Congress passes the proposed American Health Care Act, the current rules and regulation regarding the ACA remain in place. This means that the following aspects of the ACA must still be complied with for the duration.
Some of the rules and regulations that must still be followed include, but are not limited to:
- Anti-discrimination rules related to transgender benefit protections and their enforcement
- Individual and employer mandates and fines/taxes for non-compliance
- Market reform mandates and IRS tax enforcement from large employers whose self-insured group plans do not satisfy market reform rules
- Reporting obligations/IRS tax enforcement of dues from large companies failing to accurately and in a timely manner report coverage offered to workers/dependents
The rising opposition to the proposed American Health Care Act, is likely going to cause a delay in the ability for the Act to pass through the House and Senate. Many voices of opposition are voicing their concerns that rushing through this healthcare act and not allowing it to be properly vetted will have the potential to adversely affect many Americans.
The next few months or years are likely to be confusing and frustrating. Insurance agents, brokers and carriers are going to be doing their best to stay on top of the latest changes.
Late January, President Trump signed a healthcare executive order that could impact employers, even if it did not specifically mention them.
The executive order instructed federal agencies to, “waive, defer, grant exemptions from, or delay the implementation of any provision or requirement that would impose a fiscal burden,” on states, health care providers or individuals. The order can undo individual mandates to purchase insurance and other mandates placed on employers, like providing full-time employees with coverage.
The employer mandates may be regarded as a fiscal burden, according to the wording of the executive order. The employer mandate may become questionable if there is no tax on individuals who do not have minimum essential health insurance.
Nonetheless, it is advisable for all employers to continue complying with the established rules by the ACA until the GOP proposed American Health Care Act (or another act) is implemented.
The transition from the ACA to the proposed American Healthcare Act may be painful and prolonged. Stay on top of what is happening in the industry and understand your existing health coverage to be able to evaluate what may replace it.
Late January, President Trump signed an executive order that urges his administration to repeal and replace the Affordable Care Act (ACA). The order allows legislators to fight the current health care system by adding new rules and regulations. The executive order points the administration to allow states to decide the changes in healthcare policy.
This order sends a signal to the American people that health care laws are coming. The order itself, however, does not affect the ACA directly. In fact, the executive order is broad in scope and it raises a number of questions such as:
- How will changes impact employers offering group health care plans?
- How does the order affect what is currently in place under the ACA rules and regulations?
- If the mandate for individuals to have minimum essential health insurance or pay a penalty is suspended, how does that affect employers?
With so many questions to be answered, the plan to replace ACA is not going to be immediate. Given the nature of the legislative process, checks and balances, public input on various issues, various legal issues and political agendas, it may be several years before the ACA is replaced.
President Trump and his administration are actively engaged in negotiations about legislation meant to repeal and replace the Affordable Care Act (ACA). In late January, Trump signed an executive order that urges the current administration to fight the ACA.
In order to try and understand the executive order, here is a quick look at what the order contains:
- The new administration’s policy is to seek a prompt repeal of the ACA
- The order intends to efficiently maintain the ACA until repeal efforts are concluded
- The order minimizes regulatory and economic burdens to the states
- The order provides the states with greater flexibility to implement a free marketplace in the health care insurance industry
The full text of the order is far more revealing and it directs the Secretary of the Department of Health and Human Services (HHS) and other agencies with authority under the ACA to: “exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the [ACA] that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.”
It is clear that Trump intends to follow up on his campaign promise, and repeal and replace the ACA. In the months and years to come, a number of significant changes to the health care industry are expected. How this will impact on consumers is another question. Therefore, it is advisable that you check your existing health care insurance, understand fully what it covers and when any changes will be made to your coverage. Staying current on any healthcare news will allow you to transition into the future health care plan with ease.
One of the first executive orders President Trump signed was to pave the way for Congress to repeal and replace the Affordable Care Act (ACA). That order came one week after the House of Representatives passed a Senate budget resolution bill opening the door for the first step in a three step process to repeal the ACA.
A “reconciliation directive” in the budget resolution bill instructs four committees that oversee the federal healthcare program to draft legislation to repeal the ACA. The four committees involved include: the Energy and Commerce Committee in the House; the Health, Education, Labor and Pensions Committee in the Senate; the Finance Committee and the Ways and Means Committee.
The resolution bill gave instructions to complete a draft of repeal legislation by January 27, 2017. This deadline was unrealistic, as discussion about which parts of the ACA to repeal took more than only a couple of weeks. It is not clear what parts of the ACA, if any, are to be preserved.
The next step in the complete repeal and replacement of the ACA, is for the four committees to send their plan, also known as budget reconciliation, to the budget committee. Following this, both houses of Congress will take a vote, and a simple majority is necessary for the reconciliation to pass. Only after the vote, will parts of the ACA be repealed.
The last step in the process of ACA repeal and replacement is a comprehensive healthcare plan to replace the ACA. Following the release of the American Health Care Act, the Republican plan to replace and repeal the ACA a debate erupted between the Democrats and Republicans regarding the protection of coverage for low-income people.
The growing opposition to the proposed Republican healthcare program will likely affect the timeline of the repeal and replacement of the ACA.
Medicare Part A and Part B does not cover every medical procedure. If you find that some of the services you need are not covered under Medicare, you will need to cover the remainder yourself. If you have supplemental insurance or additional Medicare plans, they may offer the necessary coverage.
Medicare Part A and Part B cover hospital stays, outpatient care, medical supplies and more. However, even if Medicare Part A and Part B covers medical procedures, the plans still require a co-payment, a deductible or co-insurance.
Some of the services that Medicare Part A and Part B do not cover are:
- Routine foot care
- Hearing aids
- Exams for fitting hearing aids
-
Eye exams for prescribing glasses
- Dentures
- Long-term care/custodial care
- Cosmetic surgery
- Acupuncture
- Most dental care
- Treatment not medically necessary
-
Vaccinations/Immunizations
- Prescription drugs taken at home
- Non-prescription drugs
Posted on Friday, March 17th, 2017. Filed under
Medicare.
Many Americans are hoping for a reform in the health insurance system. They are hoping that the Trump administration delivers on its promises regarding health care. People want choices and perhaps that is what the incoming administration is planning to accomplish. It is not clear what changes may be made yet.
What most do no know is that in many states people only had one choice for their health insurance. What is worse is that in other states people had no choice in health insurance. Moreover, many of those who did sign up for insurance through the ACA, were unable to pay their premiums. Many people who qualified for the ACA, did not qualify for government subsidies.
The idea of the ACA was to get the young and healthy people to sign up to provide a cushion for those older Americans who do need health insurance more often. This, however, was not very successful. Young people were priced out of the market, as current wages do not keep up with the rising cost of living.
Obviously the health care system is incredibly imbalanced and a ponderously expensive entity that needs work to make it function well. Much like immigration reform, a replacement for the ACA is going to take some foresight and careful consideration.
Before the Affordable Care Act (ACA) came into being there was a four tier co-pay plan in place. When the ACA was passed people had to know their insurance plan very well, in order to make the most informed decision about switching healthcare.
While there is a great deal of speculation as to what may or may not replace the ACA, it is clear that it was challenging for many people who were used to the previous health care system. Before it was implemented, the four tier co-pay plan was clear: a set price for Tier 1 (preferred generic) and another price for Tier 2 (non-preferred generic).
When the ACA arrived, Americans had to pay close attention to their insurance plans. Many plans stated generic drugs were at no cost; Tier 2 through Tier 4 did not have a co-pay (only after the deductible is reached). Bronze and Silver plans use a major medical deductible before you get the co-pay for brand name drugs. Many of these changes, however, are proving to be costly for individuals and families.
Tier 3 had a certain dollar amount for preferred brand name drugs and Tier 4 may have had a higher set price or an option of paying 25 percent of a drugs listed price. Some individuals may have had a separate deductible for brand name drugs. Health Savings Accounts were in effect prior to the ACA’s arrival, but there was not separate deductible for brand name drugs.
In or out of network was a hard choice due to the costs. An example would be a woman who chose to go out of network on a Preferred Provider Organization plan (PPO). Once out of the network, out-of-pocket expenses and deductibles double. Put another way, going out of the network not only significantly hiked costs but some services are not covered. This means you pay thousands of dollars for medical care and none of it would be applied toward your out-of-pocket maximum.
All ACA plans must have ten health benefits compared to the “other” system which included seven benefits.
ACA Must Have Benefits:
- Outpatient care
- Emergency room care
- Hospital care
-
Prescription drugs
- Recovery services
- Lab work, blood work
- Preventative care
Private (Individual Market) Plan Benefits:
- Outpatient care
- Emergency room care
- Hospital care
-
Prescription drugs
- Recovery services
- Lab work, blood work
- Preventative care (a moving target in terms of what is/is not covered)
- Mental health (optional)
- Maternity (optional)
- Pediatric dental (optional)
Many Americans wondered why their costs soared instead of dropped. The answer lies in the way the ACA reform was funded. To fund such changes, there were multiple federally mandated fees (five to be exact) that began to show up on premiums in 2014. The fees were billed to insurance companies and in turn were passed along to the healthcare user.
Will the private, individual market plans return? Would a return to the old system benefit Americans? Would a blend of the old and new systems work best? Only time will tell.
With the United States facing significant changes in many areas, including health care, trying to understand what the Patient Protection Affordable Care Act (ACA) may evolve into is an unknown.
According to many industry watchers, since the ACA was enacted, over five millions people saw their health insurance policies discontinued because they did not meet ACA standards. Those plans were labeled as being unsatisfactory. However many scrapped plans offered more and were more valuable to customers than what was being sold under the auspices of the ACA.
What are the possible differences between the ACA and what may happen if it is repealed?
- The ACA plans are focused on preventive care
- According to the law, many of the services are covered without co-pay
- Many of the services are not subject to co-insurance
- Many of the services do not have a deductible
- These services are supposedly free, but as benefits, they add to premium costs
- Added premium costs are paid for by policy holders on the front end
- Health Savings Account-like plans are in the Bronze category under the ACA with a family deductible of over $12,000
The number of claims an insurance carrier gets determines premium costs. There is no underwriting under the ACA, which increases an insurance company’s claim expenses. Increased costs for the increased risks translate into higher premiums. To bring costs down many carriers have restricted their networks of hospitals and doctors — a turn of events that means Americans may have to change doctors or change insurance carriers.
If the ACA is repealed and a different kind of health care system comes into play, such as the system in existence before the ACA was passed into law, the following may be implemented:
- Insurance plans would focus on major medical
- Health Savings Accounts with a High Deductible Health Plan or plans similar in nature may return
- Prescription drug coverage and doctor visit co-pays were applied to the deductible
-
Monies in the savings account could pay for drugs and doctor visits
- Many people can pay $100 to $200 to visit a doctor
The possible repeal of the ACA and what would replace it is unknown. If the old system is revitalized, consumers may well see more choices and competitive rates and plans.
While the repeal of ACA is ongoing, the prospect for more fair insurance rates and a return to better plans may be hovering on the horizon.
