Anthem Insurance Carrier Face Becoming Out-Of-Network with Reid

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Posted February 5, 2024 at 6:11am by Jeff Lane

Ref: https://kicks96.com/local-news/727456

(Richmond, IN)–Tens of thousands of area residents who have Anthem health insurance are set to be impacted if Reid Health becomes out-of-network for Anthem.  Kicks 96 and 101.7 The Point News was informed last week by a source close to the situation that patients of Reid Health and its providers would soon receive a letter stating that Reid has been unsuccessful in reaching an agreement with Anthem and will terminate the relationship with Anthem to stand up for its healthcare providers.  The letter has now been sent and states that Reid will be out-of-network for Anthem beginning March 18 unless an agreement is reached.  More than 44,000 area patients stand to be impacted.  A website has been created to give more information.  It’s reidhealthaccess.org.

CSM’s Employee Spotlight Featuring: Jaime Lebrón

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Congratulations Jaime Lebrón for 7 years of service with Cornerstone Senior Marketing!

Jaime is paving the way for Medicare agents up in the Northeast corner of Ohio, as 2024 marks his 30th year in the insurance industry. Jaime plays a vital role with developing relationships with brokers and understands the value of a true partnership. He is constantly out in front of brokers educating and helping the independent agent or agency learn more on how to grow their business organically.

Cornerstone Senior Marketing wants to thank Jaime for his excellent service to our agents!

Brokers International Adds AuguStar Life to Carrier Line-Up

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Brokers International is pleased to announce a dynamic addition to our carrier line-up with the partnership of A-rated AuguStarSM Life. This means you have access to a suite of life insurance choices right for a wide range of individual family needs and crucial business protection.

Our new relationship with AuguStar Life (formerly Ohio National Financial Services) is now being offered to BI’s network of agencies and financial professionals.

AuguStar is focusing on further expanding the role of life insurance in protecting the financial health of individuals, families, and businesses through life’s predictable and unpredictable events. Products include:
  • Indexed universal life—to protect loved ones, grow wealth, and create tax advantages
  • Indexed whole life—life-long insurance protection, level premiums and death benefits, and tax-smart cash value that earns interest based on an investment index
  • Term life—for death benefits guaranteed throughout a specific period, premiums based on insured’s age, health, and life expectancy, and possible renewal and conversion

Reach out to your Cornerstone Senior Marketing Sales Rep to receive more information to help you assess your existing clients’ needs and consider new market segments and people who may need your financial expertise.  614-763-2255

Medical Mutual Signs Agreement to Acquire Paramount Health

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MMO Broker Update 1/29/2024:

Today, Medical Mutual announced its intent to purchase Paramount Health, a Northwest Ohio-based health insurance company. Paramount, which offers Medicare Advantage, Individual ACA, commercial group and short-term insurance plans, is headquartered in Toledo and does business primarily in Ohio and Michigan.

FULL DETAILS HERE…

Prepare for a potential shift in the Medicare Agent/FMO distribution model

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Exclusively from our partners at Deft Research:

The Value of the Health Insurance Agent/FMO Model

DEFT RESEARCH SPECIAL EXECUTIVE RESEARCH BRIEF

 

CLICK HERE TO READ FULL BRIEF 

CMS Releases Revised Guidance for Medicare Prescription Drug Inflation Rebate Program

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December 14, 2023

Contact: CMS Media Relations
CMS Media Inquiries

FOR IMMEDIATE RELEASE
December 14, 2023Contact: CMS Media Relations
CMS Media Inquiries

 

CMS Releases Revised Guidance for Medicare Prescription Drug Inflation Rebate Program 

Under President Biden’s lower-cost prescription drug law, drug companies will pay rebates to Medicare for raising prescription drug prices faster than the rate of inflation

 

As a result of President Biden’s historic prescription drug law, the Inflation Reduction Act, drug companies will pay rebates to Medicare when prices of certain prescription drugs administered or dispensed to people with Medicare increase faster than the rate of inflation. In addition, people with Medicare may pay a lower coinsurance for some Part B drugs if the drugs’ prices increase faster than the rate of inflation.

Today, the Centers for Medicare & Medicaid Services (CMS) released revised guidance detailing key requirements and procedures for calculating rebates and invoicing manufacturers that owe rebates to Medicare under the Medicare Prescription Drug Inflation Rebate Program for certain drugs covered under Medicare Part B and Part D. CMS also released the list of 48 prescription drugs for which Part B beneficiary coinsurances may be lower between January 1, 2024 – March 31, 2024. Some people with Medicare who take these drugs may save between $1 and $2,786 per average dose starting January 1, 2024, depending on their individual coverage.

“The Inflation Reduction Act is making health care and prescription drugs more affordable while improving the sustainability of the Medicare program,” said CMS Administrator Chiquita Brooks-LaSure. “The Medicare Prescription Drug Inflation Rebate Program is an important tool to discourage excessive price increases and protect people with Medicare, and today’s revised guidance for the Inflation Rebate Program finalizes key requirements and outlines the process by which CMS will calculate and invoice inflation rebates beginning in 2025.”

When drug companies of certain drugs covered under Medicare Part B and Part D raise prices at a rate that exceeds the rate of inflation, these drug companies will pay rebates to the Medicare Trust Fund under the Medicare Prescription Drug Inflation Rebate Program. CMS will issue invoices to drug companies for these rebates starting in 2025, including for years 2022, 2023, and 2024. The Part D inflation rebate period began on October 1, 2022, and the Part B inflation rebate period began on January 1, 2023. In addition, CMS will continue to apply lower beneficiary coinsurances for certain Part B drugs if prices increase faster than inflation. Including the drugs announced today, CMS has lowered coinsurance for 64 drugs and biologicals.

CMS issued initial guidance on the Medicare Prescription Drug Inflation Rebate Program in February 2023 and voluntarily sought public comment on key topics. The agency received and analyzed more than 90 comments on the initial guidance from consumer and patient groups, drug companies, and other interested parties.

CMS gathered feedback on how best to address challenges drug companies are facing due to likely or actual drug shortages and severe supply chain disruptions, particularly for events outside of their control, and provides for appropriate reduced rebate amounts consistent with the Inflation Reduction Act. The revised guidance also includes guardrails to minimize incentives for drug companies to remain on a shortage list, delay resolving a severe supply chain disruption, or maintain a situation in which a generic drug would be at risk of shortage in order to avoid paying an inflation rebate. While the inflation rebates do not apply to multi-source generic drugs, which are the drugs most likely to be in shortage, the revised guidance provides a greater rebate reduction for Part D sole-source generic drugs as well as Part B and Part D plasma-derived products in shortage.

“Today’s guidance strikes a balance between discouraging large price increases by drug companies and providing appropriate relief to drug companies experiencing shortages or severe supply chain disruptions,” said Dr. Meena Seshamani, M.D., Ph.D., CMS Deputy Administrator and the Director of the Center for Medicare. “Our goal at CMS is to make sure drugs are more affordable and accessible, which includes helping to safeguard and ensure that the pharmaceutical supply chain can deliver critical medicines to providers and patients.”

Key dates for implementing the Medicare Prescription Drug Inflation Rebate Program include:

  • October 1, 2022: Began the first 12-month period for which drug companies will be required to pay rebates to Medicare for raising prices that outpace inflation on certain Part D drugs.
  • January 1, 2023: Began the first quarterly period for which drug companies will be required to pay rebates for raising prices that outpace inflation on certain Part B drugs.
  • April 1, 2023: Some people with Traditional Medicare and Medicare Advantage started paying a lower coinsurance for certain Part B drugs with prices increasing at a rate faster than inflation.
  • 2025: CMS intends to send the first invoices to drug companies for the rebates owed.

View a fact sheet on the Medicare Prescription Drug Inflation Rebate Program revised guidance.

Read the Medicare Part B Prescription Drug Inflation Rebate revised guidance.

Read the Medicare Part D Prescription Drug Inflation Rebate revised guidance.

The lower Part B coinsurance on the list of drugs will be in effect from January 1, 2024, to March 31, 2024. This coinsurance adjustment applies to certain drugs and biologicals paid under Medicare Part B. The Part B drugs impacted by this coinsurance adjustment may change quarterly.

More information about these 48 Part B drugs and biological products can be found in the quarterly Average Sales Price (ASP) public files, available here. A fact sheet is available here.

View an ASPE fact sheet on prescription drugs with reduced coinsurances in 2023.

 

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Inflation Reduction Act raises Medicare Part D prescription costs by 42-57%

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Inflation Reduction Act raises Medicare Part D prescription costs by 42-57%
by Julia SpencerWed, December 6th 2023, 8:30 AM EST

L PASO, Texas (KFOX14/CBS4)

Medicare will be increasing the cost of prescription drugs in Part D of their plans.

People enrolled in the Medicare Part D plan will see a 42% to 57% increase in price of their prescription drug medication, according to Healthview Services.

The increase is a result of the new Inflation Reduction Act that pans to lower out of pocket costs to $2,000 dollars in 2025 compared to $7,000 in 2023.

If a patient is enrolled in the premium Medicare plan, also known as Medicare Advantage, they will not be seeing an increase in their prescription drug plan because prescription drug costs are already embedded into the plan.

Read full article here

CMS Newsroom: Biden-Harris Administration Proposes to Protect People with Medicare Advantage and Prescription Drug Coverage from Predatory Marketing…

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FOR IMMEDIATE RELEASE
November 6, 2023

Biden-Harris Administration Proposes to Protect People with Medicare Advantage and Prescription Drug Coverage from Predatory Marketing, Promote Healthy Competition, and Increase Access to Behavioral Health Care in the Medicare Advantage Program

Today, the Biden-Harris Administration is proposing important steps to strengthen Medicare Advantage and the Medicare Prescription Drug Benefit Program (Part D). As part of his Bidenomics agenda, President Biden has worked to increase competition in the health care industry and other sectors, lower costs for families, and make sure every American has access to affordable, high-quality health care.

The Centers for Medicare & Medicaid Services’ (CMS’) proposed rule will help people with Medicare select and enroll in coverage options that best meet their health care needs by preventing plans from engaging in anti-competitive steering of prospective enrollees based on excessive compensation to agents and brokers, rather than the enrollee’s best interests. The proposed guardrails protect people with Medicare and promote a competitive marketplace in Medicare Advantage, consistent with the goals of President Biden’s historic Executive Order on Promoting Competition in the American Economy.

The proposed rule will also improve access to behavioral health care by adding a new facility type that includes several behavioral health provider types to Medicare Advantage network adequacy requirements. CMS is also proposing policies to increase the utilization and appropriateness of supplemental benefits to ensure taxpayer dollars actually provide meaningful benefits to enrollees. Additionally, the proposed rule would improve transparency on the effects of prior authorization on underserved communities and proposes more flexibility for Part D plans to more quickly substitute lower cost biosimilar biological products for their reference products.

“The Biden-Harris Administration remains committed to making health care more affordable and accessible for all Americans. By ensuring Medicare recipients have the information they need to make critical decisions about their health care coverage, we are doing just that,” said U.S. Department of Health and Human Services Secretary Xavier Becerra. “Promoting competition in the marketplace helps to lower costs and protect access to care while making the whole process more transparent and accountable.”

“CMS continues to improve the Medicare Advantage and Part D prescription drug programs and maintain high-quality health care coverage choices for all Medicare enrollees,” said CMS Administrator Chiquita Brooks-LaSure. “People with Medicare deserve to have accurate and unbiased information when they make important decisions about their health coverage. Today’s proposals further our efforts to curb predatory marketing and inappropriate steering that distorts healthy competition among plans.”

CMS has previously taken unprecedented steps to address predatory marketing of Medicare Advantage plans, such as banning misleading TV ads. Many people on Medicare rely on agents and brokers to help navigate Medicare choices. CMS is concerned that some Medicare Advantage plans are compensating agents and brokers in a way that may circumvent existing payment rules, inappropriately steer individuals to enroll in plans that do not best meet their health care needs, and lead to further consolidation in the Medicare Advantage market. To further protect people with Medicare through stronger marketing policies and to promote a competitive marketplace in Medicare Advantage, CMS is proposing added guardrails to plan compensation for agents and brokers, including standardization. These proposals are consistent with the statutory requirement that CMS develop guidelines to ensure that the use of compensation creates incentives for agents and brokers to enroll individuals in the Medicare Advantage plan that is intended to best meet their health care needs.

CMS also proposes to strengthen and improve access to behavioral health care by adding a new facility type, which includes marriage and family therapists, mental health counselors, addiction medicine clinicians, opioid treatment providers, and others, to CMS’ Medicare Advantage network adequacy requirements. This proposed addition builds on changes finalized last year to strengthen these requirements and would ensure people with Medicare Advantage can access vital mental health and substance use disorder treatment.

“The people we serve are at the center of the Medicare program, and we work each day to make sure the program works for them. Agents and brokers play an important role in guiding people with Medicare to the option that is tuned in to their medical needs. Our proposals on how plans compensate agents and brokers seek to support a competitive marketplace that best serves people with Medicare,” said Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare.

Currently, 99% of Medicare Advantage plans offer at least one supplemental benefit. Over time, the benefits offered have become broader in scope and variety, with more rebate dollars directed toward these benefits. CMS is committed to ensuring these offerings are effectively reaching enrollees and actually meeting their needs, and not just used for attracting enrollees. In today’s rule, CMS proposes requiring Medicare Advantage plans to send a personalized notification to their enrollees mid-year of the unused supplemental benefits available to them to encourage higher utilization. Furthermore, CMS is proposing additional requirements designed to help ensure that benefits offered as special supplemental benefits for the chronically ill (SSBCI) are backed by evidence. CMS is also proposing new marketing and transparency guardrails around these benefits. These proposals will help ensure a robust and competitive Medicare Advantage marketplace made up of plan options with meaningful benefits.

Additionally, CMS is concerned that certain prior authorization policies may disproportionately inhibit access to needed care for underserved enrollees. To provide additional safeguards, CMS is proposing to require that Medicare Advantage plans include an expert in health equity on their utilization management committees and that the committees conduct an annual health equity analysis of the plans’ prior authorization policies and procedures. This analysis would examine the impact of prior authorization on enrollees with one or more of the following social risk factors—eligibility for Part D low-income subsidies, dual eligibility for Medicare and Medicaid, or having a disability—compared to enrollees without these risk factors. These analyses would have to be posted publicly to improve transparency into the effects of prior authorization on underserved populations. To further promote health equity, CMS is also proposing to streamline enrollment options for individuals with both Medicare and Medicaid, providing more opportunities for integrated care.

To support competition in the prescription drug marketplace, CMS is also proposing to provide more flexibility to substitute biosimilar biological products other than interchangeable biological products for their reference products to give people with Medicare more timely access to lower-cost biosimilar drugs. This proposal would permit Part D plans to treat such substitutions as maintenance changes so that the substitutions apply to all enrollees, not only those who begin the therapy after the effective date of the change, following a 30-day notice.

There will be a 60-day comment period for the notice of proposed rulemaking, and comments must be submitted at one of the addresses provided in the Federal Register no later than January 5, 2024. The proposed rule can be accessed at the Federal Register at https://www.federalregister.gov/public-inspection/2023-24118/medicare-program-contract-year-2025-policy-and-technical-changes-to-the-medicare-advantage-program

View a fact sheet on the proposed rule at cms.gov/newsroom.

View the CMS Blog Important New Changes to Improve Access to Behavioral Health in Medicare at https://www.cms.gov/blog/important-new-changes-improve-access-behavioral-health-medicare-0

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Protect Your Clients: Ohioans on Medicare Urged to Protect Against Scams During Open Enrollment

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For Immediate Release
October 26, 2023

Don’t Get Scammed! Ohioans on Medicare Urged to Protect Against Scams During Open Enrollment

COLUMBUS — Ohio Department of Insurance Director Judith L. French is urging Ohioans on Medicare to protect themselves against scams to take their personal information during Medicare’s Oct. 15 to Dec. 7 open enrollment period to select coverage for 2024.

“With the barrage of plan options and marketing pitches, it can be difficult to discern if something is legitimate or fraudulent,” French said. “Be wary of any Medicare communication seeking personal information or money in exchange for help with Medicare enrollment or services.”

How to protect yourself:

  • Never give personal information, including Medicare, Social Security, bank account, and credit card numbers, to anyone who contacts you unsolicited by telephone, email, text, or in person, such as door-to-door sales.
  • Medicare will never call you to sell anything, visit your home, or enroll you over the phone unless you called first.
  • Medicare or Medicare health plans will only call and request personal information if you’re a plan member or you called and left a message.
  • Only give certain personal information to your doctors, insurance companies acting on your behalf, or trusted people in the community officially working with Medicare such as the Ohio Senior Health Insurance Information Program (OSHIIP), which is a program of the Ohio Department of Insurance.
  • Never purchase gift cards as payment for anything.

Report fraud and predatory sales practices:

  • OSHIIP partners with Ohio’s Senior Medicare Patrol (SMP) to detect and report wrongdoing. The SMP provides education and response to reported Medicare fraud, waste, and abuse. Contact SMP at 800-488-6070 and proseniors.org/ohio-smp.
  • If you feel an insurance agent is using high-pressure, fraudulent, or dishonest sales practices, contact the Ohio Department of Insurance Fraud and Enforcement Division at 800-686-1527 or the SMP.

Medicare has implemented new marketing guidelines for representatives of Medicare plans, including prohibiting asking for personal information, such as bank account or credit card numbers over the phone, unless it is needed to process an enrollment request.

OSHIIP Director Chris Reeg recently testified before the United States Senate Finance Committee in Washington, D.C. on the topic of cracking down on deceptive practices and improving senior experiences.

OSHIIP representatives are available at 800-686-1578, or by email, oshiipmail@insurance.ohio.gov, and insurance.ohio.gov to answer Medicare questions.

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Overall Satisfaction with Medicare is High, But Beneficiaries Under Age 65 With Disabilities Experience More Insurance Problems Than Older Beneficiaries

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Juliette Cubanski, Maiss Mohamed, Tricia Neuman, and Gary Claxton
Published: 

While most people with Medicare are adults age 65 or older, Medicare also covers millions of younger people who qualify for Medicare based on having a long-term disability, or diagnosis with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS, also known as Lou Gehrig’s disease). In 2022, 7.7 million people under age 65 with disabilities were covered by Medicare, representing 12% of all Medicare beneficiaries. Younger beneficiaries who qualify for Medicare because of disability are more likely than those who qualify based on age to have lower incomes and education levels, to be Black or Hispanic, and to be in worse health.

Medicare covers the same benefits for people of all ages, regardless of how they qualified for Medicare, and Medicare coverage options and financial assistance programs are generally the same – the main exception being that people under age 65 with disabilities do not have a guaranteed issue right to purchase Medigap supplemental policies. However, perhaps related to their different pathways to Medicare eligibility and because the program was originally designed to cover older adults, with coverage for younger people with disabilities added later, Medicare generally does not work as well for people under age 65 with disabilities. This conclusion is based on KFF analysis of surveys dating back to 2008 but not more recent than 2019. According to previous analysis, beneficiaries under age 65 with disabilities have reported worse access to care, more cost concerns, and lower satisfaction with care than those age 65 or older.

To get a more current understanding of how Medicare is working for older adults and younger people with disabilities, this brief analyzes data from the 2023 KFF Survey of Consumer Experiences with Health Insurance, a nationally representative survey of 3,605 U.S. adults with health insurance. This brief focuses specifically on the 885 adults with Medicare, including 165 adults under the age of 65 with disabilities.

This analysis provides a window into the challenges facing people with disabilities as they navigate the health insurance system by focusing on the experiences of younger adults on Medicare who qualify for the program due to having a long-term disability. The analysis highlights the ways in which beneficiaries under age 65 with disabilities may be less well served by the Medicare program than older beneficiaries. (While people with disabilities are also included among the population of Medicare beneficiaries age 65 or older, the survey sample is insufficient to focus on this group specifically.) People with disabilities who are covered by private insurance or Medicaid are likely to face similar challenges using their coverage. Insights from this analysis could help to inform efforts to strengthen the Medicare program, particularly for younger adults with disabilities.

Key Takeaways

  • Overall, people with Medicare are more satisfied with their health insurance coverage than adults with other types of insurance, but among people with Medicare, those under age 65 with disabilities are less likely than those age 65 or older to give positive ratings to the overall performance of their insurance coverage (79% vs. 92%) and some features of it, such as the quality and availability of providers.
  • Overall, a majority of Medicare beneficiaries under age 65 with disabilities say they experienced a problem with their health insurance in the last year (70%), compared to half (49%) of those age 65 or older. This includes a larger share of those under age 65 with disabilities who say they experienced denials or delays in getting prior approval (27% vs. 9%) or insurance not paying for care they received that they thought was covered (24% vs. 8%).
  • A relatively small share of all Medicare beneficiaries who said they had a problem with health insurance in the past year reported difficulty accessing care as a direct result of these problems, but access problems were more likely to be reported by Medicare beneficiaries under age 65 with disabilities than those 65 or older. At least one in five Medicare beneficiaries under age 65 with disabilities who reported problems say they were unable to receive recommended treatment (24%) or experienced significant delays in receiving medical care or treatment (21%), compared to very small shares of those 65 or older who said the same (6% for both).
  • Medicare beneficiaries under 65 with disabilities were more likely to experience difficulty with the health insurance enrollment process and comparing insurance options compared to beneficiaries age 65 or older, including figuring out if their income qualifies them for financial assistance (30% vs. 11%).
  • Cost concerns related to insurance are an issue for Medicare beneficiaries of all ages, particularly when it comes to monthly premiums and out-of-pocket costs for prescription drugs, but a larger share of people with Medicare under age 65 with disabilities than those age 65 or older report certain problems. More than one in three people with Medicare under age 65 with disabilities report they had a problem paying a medical bill in the past 12 months (35%), compared to one in ten (9%) of those 65 or older. People with Medicare under age 65 with disabilities were also more likely to report delaying or going without specific health care services due to cost, such as dental care (42% vs. 24%), prescription drugs (18% vs. 10%), and doctor visits (14% vs. 4%).
  • About half of people with Medicare under age 65 with disabilities self-report fair or poor physical health, compared to 19% of those age 65 or older, since, by definition, people under age 65 qualify for Medicare based on having a long-term disability. The higher rate of poorer self-reported health among beneficiaries under age 65 could contribute to a higher rate of health insurance problems.
  • Three in 10 people with Medicare under age 65 with disabilities self-report fair or poor mental health status, compared to 1 in 10 (9%) of those age 65 or older, and a larger share also report problems related to mental health care availability and access, including reporting that there was a mental health therapist or treatment they needed that wasn’t covered by insurance (27% vs. 7%), and being unable to receive mental health services or medication in the past year they thought they needed (18% vs. 5%).

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