On Friday August 5 2022, The U.S. House of Representatives passed a comprehensive climate, tax, and healthcare bill. It includes significant measures to lower prescription drug prices within Medicare. This allows the government to negotiate drug prices and caps seniors' out-of pocket drug costs at up to $2,000 per year. President Biden will sign the Inflation Reduction Act of 20,22 which was passed by party lines in a 220-207 vote.
The Senate passed the package which also extends premium subsidies under the enhanced Affordable Care Act and expands and adds clean energy tax credits.
The bill will allow for the government to negotiate prices on certain medications, limit seniors' out of pocket spending on drugs at $2,000 per year, penalize drug manufacturers that raise their prices more than the Medicare inflation rate, and cap the Medicare beneficiary's out-of–pocket insulin cost at $35 per month.
The 2003 Part D drug program was established by legislation that was heavily influenced from the pharmaceutical industry. It prohibits the government from directly negotiating with pharmaceutical companies. Part D insurance companies can negotiate with each other, but not with the same bargaining power as the federal government. According to estimates by the Congressional Budget Office, allowing the government to negotiate directly will save approximately $100 billion over 2031.
Juliette Cubanski (deputy director, Program on Medicare Policy, Kaiser Family Foundation) stated that "the pharmaceutical industry has largely avoided this level of legislation"
Although the bill is a major policy change, its negotiating clauses will be gradually implemented over several years and will only affect a few medications. Experts say that the bill's greatest impact will be felt immediately by seniors with high prescription drug prices.
According to the Senior Citizens League, about one quarter of current Part D beneficiaries (or more than 16,000,000 people in 2022) are at risk of spending $2,000 per year on prescription drugs. Mary Johnson, the Senior Citizens League's Medicare and Social Security policy analyst, said that there are "some really expensive drugs." She helped a neighbor to research Part D plans several years ago before she became eligible for Medicare. The neighbor found that her co-pay for Humira (a drug used in rheumatoid joint pain) was about $1,000 per month. To afford treatment, the neighbor researched alternative therapies and pharmacy assistance programs.
Part D currently does not cap out-of-pocket drug costs. In 2022 beneficiaries will have to spend $7,050 on medications. Once they reach this point, they will be responsible for 5%.
Even these small payments can add up for patients who need expensive prescriptions such as those that treat multiple sclerosis, rheumatoid and cancer. A beneficiary might reach catastrophic coverage in August if they have a $1,000 monthly co-pay. The remaining five months of the year will be covered by $50, which is a total of $250. It's only a rough example, because Part D rules are more complex and older adults often take multiple medications.
In 2025, the $2,000 annual cap will take effect. It will be indexed to inflation. Anyone enrolled in Part D drug plans, including stand-alone or Medicare Advantage plans that cover drugs, is subject to the cap. This includes co-pays as well as deductibles and coinsurance, but does not include the monthly premium cost. In 2024, the beneficiary responsibility for catastrophic coverage will be reduced to zero.
Negotiations will begin in 2026 with a maximum of 10 drugs, rising to 15 drugs in 2027, 2028 and 2029, and then to 20 drugs in 2029. Negotiated drugs include Part D and Part A medications. This includes drugs that are administered in the doctor's office (e.g., infusions) and not taken at home.
The drugs subject to negotiation are still unknown. Drugs with generic equivalents would also be exempted from consideration. Eylea, which is a drug for macular damage from Regeneron Pharmas is one possible candidate, as well as Keytruda from Merck. According to Karen Andersen (Healthcare strategist at Morningstar), there are many other candidates.
Beginning in 2023, any drug maker who raises their prices at a higher rate than inflation will be subject to a Medicare program fine. In addition, Medicare beneficiaries will have a $35 per month limit on insulin, and will receive free vaccines under Part D.
The Inflation Reduction Act also lowers the premiums on health insurance for millions of Affordable Care Act participants through 2025. The Affordable Care Act's income caps were temporarily lifted by the American Rescue Plan of 2021, which capped silver-tier insurance's cost at 8.5% of the enrollees' annual income. Consumers who earned more than 400% of federal poverty, or $54,360 per person in 2022, were not eligible for government assistance to pay their premiums. The bill extends the premium subsidies to 2025.
View the original version of this article by Elizabeth O'Brien of Barron's here:
For assistance with any questions related to how these Medicare changes will affect your coverage, contact Ted Czabanowski now at: 401-885-7467.
Medicare beneficiaries will see a reduction in their premiums, but not until next year
This recent article at abcnews.go.com explains how Medicare beneficiaries will receive a reduction in their premiums, but not before next year. This is due to what Health and Human Services Secretary Xavier Becerra recently stated as an overestimate of the cost of coverage for an expensive and controversial new Alzheimer's medication.
Becerra explained that the premium for 2022 should be reduced, but officials were prevented by legal and operational obstacles from making this happen in the middle of the calendar year. The amount of the reduction is unclear at this point. Medicare Part B premiums rose by $22 per month to $170.10 for 2022. This was partly due to the high cost of the controversial prescription drug Aduhelm, which showed only limited evidence that it can slow the progression of Alzheimer’s. Aduhelm is only covered by the Centers for Medicare (CMS) and Medicaid Services for use in approved clinical trials. Under pressure from Congress and consumers, CMS began to reevaluate the premium rise. Biogen, a Cambridge, Massachusetts-based drug manufacturer, has reduced the price of the drug by half to $28,000 per year.
CMS pointed out the dramatic reduction in drug prices and limitations on coverage to conclude that Medicare beneficiaries could result in cost savings to the program. According to a report by Becerra, CMS stated that the premium recommendation for 2022 would be $160.40 per month if the coverage determination and price reduction had been in place at the time officials calculated the figure. In the fall, the agency will announce the premium for 2023 Medicare's 56 million beneficiaries.
Becerra also stated that while they had hoped to get there sooner, CMS was not able to deliver the premium reduction in 2022. "CMS, HHS are committed lowering health care cost -- so we look forward seeing this Medicare premium adjustment through the finish line to ensure seniors receive their cost-savings by 2023."
The following Q & A was written by:
Karin Price Mueller | NJMoneyHelp.com for NJ.com
It's an excellent synopsis of what you need to know about what happens to your SSDI benefits when you reach full retirement age.
Q. I was placed on permanent SSDI due to medical concerns. I was paid retroactively to the date of my medical disability and have been collecting monthly SSDI for years. I am now 65. Do I have to sign up for Medicare or will it be adjusted to SSI at 66 years and seven months of age?
— Almost there
A. There’s plenty to know about how your benefits will change over time.
Before we start, remember that it’s always a smart choice to contact Social Security so it can advise based on your specific situation. Its number is (800) 772-1213.
Because you’re currently receiving Social Security disability benefits (SSDI), your disability benefits automatically convert to Social Security retirement benefits at your full retirement age, said Jeanne Kane, a certified financial planner with JFL Total Wealth Management in Boonton.
She said full retirement age (FRA) ranges between age 66 and 67, depending on your age. As you noted, yours is 66 years and seven months.
“In most cases, the benefit amount will remain the same,” she said. “You don’t need to do anything.”
You only get one benefit — Social Security retirement benefits — when you reach full retirement age, she said.
“Everyone eligible for Social Security disability insurance benefits is also eligible for Medicare after a 24-month qualifying period,” she said. “At that time, you would have been automatically enrolled in both Medicare Parts A & B at the start of your twenty-fifth month.”
At that time, you would have had the option to decline or delay Medicare Part
B, she said. Some people choose to do that if they want to remain on a spouse’s employer-based plan, she said.
“If you currently have Medicare parts A and B, you don’t need to do anything because you are already participating in Medicare,” she said. “The Medicare Part B premium is paid from your SSDI today and will be paid from your SSI when you reach full retirement age.”
If you declined Medicare Part B at the time you became Medicare-eligible through SSDI, you can continue using the company-based plan until there is a change of circumstances, such as your spouse retiring, she said.
“At change in circumstance, you have an eight-month special enrollment period to sign up for Medicare Part B,” she said. “You’ll need to call the Social Security Administration to obtain the specific forms to complete with your Part B application.”
“If you don’t, you may pay a penalty of up to 10% for each 12-month period you could have had Medicare part B but didn’t sign up,” she said.
For any specific questions, contact Ted Czabanowski for a complimentary review of your current health and long term care insurance plan(s).
Some Medicare beneficiaries will be hit with late-enrollment fees in 2022. These charges would be warned of by Congress before they occur, per this recent CNBC article. Here is a summary of the article:
The latest feedback on how to best navigate the Medicare system if you return to the work force can be found in a recent article from CNBC.
The CNBC article explains that if the company you work for employs fewer than 20 people, and you wish to enroll in the Medicare health plan, you will need to stay on Parts A or B. If you go to work for a larger company, different rules apply, but there are some things to consider before you sign up for an employer health plan.
There will be new rules and deadlines for you to re-enroll in Medicare.
Read the full article here:
When is open enrollment for Medicare Advantage? How does it work?
How long is open enrollment for Medicare?
Every year from January 1 through March 31 current policyholders of Medicare Advantage (MA) plans are eligible to enroll in a different MA plan.
How does open enrollment work?
MA, or Medicare C, plans can be changed once a year. Those who currently have this type of managed-care alternative to Original Medicare can choose to keep the same plan, to opt into a different Advantage plan, or to enroll in Medicare A, or Original Medicare.
If you decide to drop your MA plan in favor of Medicare A you may not be able to buy a supplemental Medigap plan.
Who is eligible for open enrollment?
This open enrollment period is only for people who already have an Advantage plan.
What are Medicare parts A, B, C, and D?
Medicare A is hospital insurance. Premium-free Part A is available to people who meet the criteria.
To qualify for premium-free Part A:
Whether or not you have a monthly premium, the benefits are the same, including deductibles and coinsurance. If you choose Part A, you must also:
Medicare Part B
Part B is optional medical insurance with a monthly premium. After the deductible is met, you’ll typically pay 20% for most doctor services. Included are inpatient hospital stays, outpatient therapies, and durable medical equipment (DME). Enrolling in Part B when you’re eligible for Medicare will save you a late enrollment penalty.
Medicare Part C
Medicare Advantage plans, (MA or Medicare Part C), is Managed Care, very much like most employer-offered insurance. MA plans combine parts A and B, and 90% of MA plans include drug coverage (Part D). Medigap plans insurance can’t be used for MA plans, as they’re unnecessary. Talk about one-stop shopping!
Medicare Part D
Medicare Part D is available as a separate policy for prescriptions only. Choosing a drug plan at the time you enroll in Medicare, even if you don't currently take medications, will avoid a possible late enrollment penalty if you do eventually need drug coverage; late enrollment penalties will increase your monthly premium.
The pros and cons
Medicare Advantage Plans may have rules that are different from Original Medicare. However, in keeping with CMS rules, your plan must give you at least the same coverage as Original Medicare. Some services may only be covered in a particular facility or for patients with certain conditions. Some MAs offer more comprehensive plans to fit your needs: many cover over-the-counter medications or gym memberships.
Carefully research your options; compare your needs to each plan’s offerings before enrolling. Very rare circumstances will permit a change before the open enrollment period begin.