Health Care in the News: Keeping Down Costs

  1. Cost-Sharing Reductions: On Thursday, 10/12, the President announced the discontinuation of cost-sharing reduction payments (CSRs) for health insurers that sell plans in the state Health Insurance Marketplaces.
    • For those who choose to buy health insurance coverage through the marketplaces, they may be eligible for 2 types of financial assistance: 1) premium tax credits; and 2) cost-sharing reductions. Premium tax credits reduce your monthly premium payment for whichever plan you choose to buy in the marketplace. Cost-sharing reductions are a requirement in the ACA, that insurance companies lower the cost of deductibles, co-payments, and co-insurance amounts on silver level plans, based on your income level. The cost-sharing reductions are provided by the insurance company, but are reimbursed by the federal government.
    • Since taking office, the President has indicated that he might end the CSRs. His lack of a definitive decision creative uncertainty for insurance companies in determining their rates for plans sold in the marketplace for 2018. This uncertainty actually cause may insurers across the country to choose not to sell plans in the marketplace for 2018, which ultimately reduces competition and increases rates for the plans that are sold in the marketplace. Some companies decided to continue to sell their plans, but increased their rates, to cover the loss of the CSR payments from the federal government.
    • It now falls on Congress to fund the CSR payments for 2018 and beyond. There is currently a proposal being discussed in the Senate to fund the CSR payments for two years, but it includes other changes (see below).
    • On Wednesday, 10/18, eighteen states filed a temporary restraining order to force the President to continue funding the CSR payments.

Alexander-Murray-Keeping-Costs-Down

  1. Alexander-Murray Legislation: On Wednesday, 10/18, in response to the President’s decision to end the CSR payments, U.S. Senators Lamar Alexander (R-TN) and Patty Murray (D-WA) reached a bipartisan compromise that is an important first step to stabilize health insurance markets and provide states more flexibility, while maintaining important patient protections.
    • They have proposed bi-partisan legislation, which will likely keep health insurance costs lower for consumers. This legislation is supported by nearly 30 cancer organizations representing patients, physicians, nurses, and social workers, because cancer patients and survivors need access to quality, affordable health insurance. However, there are some political compromises included in this bill.
    • This bill funds the CSR payments through 2019 and restores some of the funding that was previously cut by the President, for outreach and education about open enrollment and health insurance options.
    • This bill also takes some steps to expand access to catastrophic health insurance plans, which could allow more people to afford health insurance, but there is also serious concern about the limited coverage included in these plans. It also allows states flexibility to waive some of the ACA requirements for plans sold through the marketplace. Again, while it may expand access, there are some questions about the coverage included in those plans.
    • At this time, it is unclear if there are enough votes to pass this legislation. If you would like to share your opinion or experience, you can contact your U.S. Senators by calling: 844-257-6227.
  1. Executive Order: On Thursday, 10/12, the President also signed an Executive Order, which allows insurance companies to sell policies across state lines and to sell cheaper policies with less coverage than currently required under the ACA. The challenge with this proposal is that:
    • It allows insurance companies to avoid state health consumer protections.
    • It also creates a situation where people can buy minimal health insurance coverage, but if they are diagnosed with a serious medical condition like cancer, then they find out that those policies don’t cover needed medical care, like chemotherapy.
    • The Executive Order requires federal agencies to draft regulations, share the draft for public comments, and then release final regulations on these changes.

As these events unfold, Triage Cancer will continue to provide updates on these changes and how they may have an impact on the cancer community. Stay tuned.

Medicare and Hospice Care

Hospice is a program of care and support for people who are terminally ill. The focus ofHospice Care hospice care is on ensuring patient comfort, and not on curing an illness. In hospice, a specially trained team of professionals and caregivers provide care for the “whole person,” including physical, emotional, social, and spiritual needs. There are hospice facilities, but hospice care is generally provided in the home. Medicare can help cover some of the hospice care costs.

Hospice care can be a blessing for those suffering from a terminal medical condition and can even include specialized care, such as reading to a patient, playing music, and companionship. Hospice care providers can also provide respite for caregivers.

Medicare recognizes the importance of hospice and covers it fully. Meaning even if you only get Medicare Part A (hospital coverage), which is the minimum Medicare coverage, you will be fully covered for hospice care. Once you start getting hospice care, your Medicare hospice benefit should cover everything you need related to your terminal illness if your care comes from a Medicare-approved hospice provider. If, while in hospice, you need care that is not associated with your terminal illness (for instance, you fall and break your arm), you would be covered by your regular Medicare or Medicare Advantage plan benefits.

If you have determined that you no longer want to pursue curative treatment for your medical condition, you should discuss your decision with your health care team. Your health care team can help you coordinate hospice care. You always have the right to stop hospice care, and seek a curative treatment, at any time.

However, while in care of a Medicare-approved hospice provider, Medicare will not cover any of the following:

  • Prescription drugs (except for symptom control or pain relief).
  • Care from any provider that wasn’t set up by the hospice medical team. You must get hospice care from the hospice provider you chose. All care that you get for your terminal illness and related conditions must be given by or arranged by the hospice team. You can’t get the same type of hospice care from a different hospice, unless you change your hospice provider. However, you can still see your regular doctor or nurse practitioner if you’ve chosen him or her to be the attending medical professional who helps supervise your hospice care.
  • Room and board. Medicare doesn’t cover room and board. However, if the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay.
  • Care you get as a hospital outpatient (like in an emergency room), care you get as a hospital inpatient, or ambulance transportation, unless it’s either arranged by your hospice team or is unrelated to your terminal illness and related conditions.

For more information on hospice care, please review: Hospice FAQs from the National Hospice and Palliative Care Organization.

For more information about Medicare’s coverage of hospice benefits, you can read: Medicare Hospice Benefits.

Did You Know? Medicare Covers Home Health Care

If you’ve ever been admitted to a hospital, you know it’s not the best place to rest up Home Health Careand recuperate from an illness. Medicare understands that, too. That is why Medicare covers home health care services for eligible individuals. Home health care can be less expensive, more convenient, and provide better quality of life for many patients.

If you have Medicare, you can use your home health benefits if you meet all of the following criteria:

  1. You are in the care of a doctor and being regularly seen by a doctor.
  2. A doctor certifies that you need any of the following:
  • Intermittent skilled nursing care (“intermittent” is defined as skilled nursing care that’s needed or given on fewer than 7 days each week or less than 8 hours each day over 21 days (or less) with some exceptions in special circumstances)
  • Physical therapy
  • Speech-language pathology services
  • Continued occupational therapy
  1. The home health agency caring for you is approved by Medicare (Medicare-certified).
  2. A doctor certifies that you are homebound.
  3. A doctor or nurse practitioner documents that they’ve seen you in person within the required timeframe and that the findings of that encounter support that you’re homebound and need skilled care.

If you think you or your loved one may be eligible for these benefits, you can learn more by reading this booklet: Medicare & Home Health Care, which includes information about choosing a home health care agency, how the payment for services works, guarding against fraud, and your rights as a recipient of home health care.

California, Other States To Extend Obamacare Sign-Up Beyond Federal Limit


California and several other states will exempt themselves this year from a new Trump administration rule that cuts in half the amount of time consumers have to buy individual 2018-enrollment_1170health insurance under the Affordable Care Act.

In California, lawmakers are contemplating legislation that would circumvent the rule in future years, too.

The Trump administration’s rule gives people shopping for 2018 coverage on the federal exchange 45 days to sign up, from Nov. 1 through Dec. 15.

But in California and some of the other states that run their own exchanges — Colorado, Minnesota, Washington and Massachusetts, as well as the District of Columbia — consumers purchasing insurance for themselves this year will have extra time to make decisions.

In Colorado, for example, the sign-up period is from Nov. 1 to Jan. 12. In Minnesota, it will start Nov. 1 and run through Jan. 14. In Washington state, it is Nov. 1 through Jan. 15.

Consumers shopping for coverage in California’s exchange, Covered California, will still have the full three months they’ve had in recent years, starting on Nov. 1 and ending Jan. 31. Californians shopping for individual market plans outside the exchange will have those same three months to make up their minds.

“We want to make sure our consumers have the time they need to find the best plan that fits their needs,” said James Scullary, a spokesman for Covered California.

The rule that truncated the enrollment period for the federal exchange, published in April by the Centers for Medicare & Medicaid Services (CMS), gives state-based exchanges the ability to extend the amount of time allowed by tacking a “special” enrollment period onto the 45 days set by the federal government.

California and several other states will exempt themselves this year from a new Trump administration rule that cuts in half the amount of time consumers have to buy individual health insurance under the Affordable Care Act.

In California, lawmakers are contemplating legislation that would circumvent the rule in future years, too.

The Trump administration’s rule gives people shopping for 2018 coverage on the federal exchange 45 days to sign up, from Nov. 1 through Dec. 15.

But in California and some of the other states that run their own exchanges — Colorado, Minnesota, Washington and Massachusetts, as well as the District of Columbia — consumers purchasing insurance for themselves this year will have extra time to make decisions.

In Colorado, for example, the sign-up period is from Nov. 1 to Jan. 12. In Minnesota, it will start Nov. 1 and run through Jan. 14. In Washington state, it is Nov. 1 through Jan. 15.

Consumers shopping for coverage in California’s exchange, Covered California, will still have the full three months they’ve had in recent years, starting on Nov. 1 and ending Jan. 31. Californians shopping for individual market plans outside the exchange will have those same three months to make up their minds.

“We want to make sure our consumers have the time they need to find the best plan that fits their needs,” said James Scullary, a spokesman for Covered California.

The rule that truncated the enrollment period for the federal exchange, published in April by the Centers for Medicare & Medicaid Services (CMS), gives state-based exchanges the ability to extend the amount of time allowed by tacking a “special” enrollment period onto the 45 days set by the federal government.

Because that flexibility is limited to 2018 coverage, California legislators are taking an extra step to keep the three-month enrollment period for 2019 and beyond. Assemblyman Jim Wood (D-Healdsburg) introduced legislation last week that would ensure a three-month enrollment window for consumers seeking coverage in 2019 and subsequent years.

“When the Trump administration issued its new … rules cutting the ACA’s open enrollment period in half, we knew we had to act,” Wood said. “Californians have enjoyed a three-month enrollment period for years, and this change could catch people off guard and not allow them to sign up in time. That would be a travesty.”

Health policy experts say the federal rule is a political attempt to undermine the viability of the Obamacare insurance exchanges.

“It’s no big secret that the Trump administration isn’t a big fan of the Affordable Care Act or the individual market that it created,” said Dylan Roby, associate professor of Health Services Administration at the University of Maryland. “There’s just this general intent of the administration to reduce enrollment, reduce … subsidies and make it a little bit harder for people to enroll.”

The shortened enrollment window was part of a so-called market stabilization rule rolled out by the Trump administration that also offers insurance companies concessions, including the flexibility to sell some health plans that cover less of the enrollees’ cost of care than currently required by the ACA.

California’s insurance commissioner, Dave Jones, expressed concern about the impact of a shortened enrollment period in a letter to the federal government in March, before the rule was finalized.

Jones’ letter cited research that shows younger people tend to sign up for health insurance toward the end of open enrollment, and that putting up barriers to their enrollment could reduce the number of healthy people in the insurance pool.

That would “needlessly destabilize the market” and would “result in increased premiums for those who do enroll in coverage,” the insurance commissioner said.

Shana Alex Charles, an assistant professor of health sciences at California State University-Fullerton, said the pushback by California lawmakers against federal attempts to shorten the enrollment period underscores the state’s commitment to having a marketplace that “actually makes sense.”

“If you want to maximize enrollment, you need to make sure people can get their paperwork together, and have the mindset and the time for people to complete the application,” she said.

Because that flexibility is limited to 2018 coverage, California legislators are taking an extra step to keep the three-month enrollment period for 2019 and beyond. Assemblyman Jim Wood (D-Healdsburg) introduced legislation last week that would ensure a three-month enrollment window for consumers seeking coverage in 2019 and subsequent years.

“When the Trump administration issued its new … rules cutting the ACA’s open enrollment period in half, we knew we had to act,” Wood said. “Californians have enjoyed a three-month enrollment period for years, and this change could catch people off guard and not allow them to sign up in time. That would be a travesty.”

Health policy experts say the federal rule is a political attempt to undermine the viability of the Obamacare insurance exchanges.

“It’s no big secret that the Trump administration isn’t a big fan of the Affordable Care Act or the individual market that it created,” said Dylan Roby, associate professor of Health Services Administration at the University of Maryland. “There’s just this general intent of the administration to reduce enrollment, reduce … subsidies and make it a little bit harder for people to enroll.”

The shortened enrollment window was part of a so-called market stabilization rule rolled out by the Trump administration that also offers insurance companies concessions, including the flexibility to sell some health plans that cover less of the enrollees’ cost of care than currently required by the ACA.

California’s insurance commissioner, Dave Jones, expressed concern about the impact of a shortened enrollment period in a letter to the federal government in March, before the rule was finalized.

Jones’ letter cited research that shows younger people tend to sign up for health insurance toward the end of open enrollment, and that putting up barriers to their enrollment could reduce the number of healthy people in the insurance pool.

That would “needlessly destabilize the market” and would “result in increased premiums for those who do enroll in coverage,” the insurance commissioner said.

Shana Alex Charles, an assistant professor of health sciences at California State University-Fullerton, said the pushback by California lawmakers against federal attempts to shorten the enrollment period underscores the state’s commitment to having a marketplace that “actually makes sense.”

“If you want to maximize enrollment, you need to make sure people can get their paperwork together, and have the mindset and the time for people to complete the application,” she said.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Do You Need a Medigap Policy? Your Ability to Get One May Depend on Where You Live.

Americans who receive their health insurance through Medicare may want to purchase Medigapextra coverage through a Medigap Policy.  However, one’s ability to purchase a Medigap policy may depend on where they live.

Medicare is a government funded and run health insurance program for eligible individuals. To be eligible for Medicare, you must be:

  • 65+ years old;
  • have collected SSDI more than 24 months; or
  • have been diagnosed with end stage renal disease (ESRD) or ALS.

Medicare coverage is divided into four parts:

  • Part A: Hospital Insurance. Includes hospital care, skilled nursing facilities, nursing homes, hospice, and home health services.
  • Part B: Medical Insurance. Includes services from doctors, preventive care, outpatient care, lab tests, mental health care, ambulance services, and durable medical equipment.
  • Part C: Advantage Plans. Part C is an alternative to Parts A & B and it includes the benefits and services covered under Parts A & B, and usually Part D. You can select a PPO or HMO plan that is run by a Medicare-approved private insurance company. Make sure to select a plan that covers your health care providers.
  • Part D: Prescription Drug Coverage. You have different plans to choose from depending on where you live, with different premiums and formularies. Make sure to select a plan that covers the drugs you take.

For more information about Medicare, you can read our Quick Guide on Medicare, or watch this webinar.

Parts A and B of Medicare are often called “original Medicare,” because that is the coverage that originally existed. Part B of Medicare has an 80/20 cost share, meaning that Medicare covers 80% and you are responsible for 20% of your medical expenses covered under Part B.  In order to help people pay for the 20% and for other things that Medicare does not cover, Medicare created an option to buy supplemental health insurance coverage, called Medigap. There are different Medigap plans, which are named by letters, which are offered by private health insurance companies. You must have Medicare Parts A and B to buy a Medigap plan.

Medicare’s website allows you to type in your zip code and whether or not you already own a Medigap policy, and it shows you the different Medigap policies available to you. . Medicare also provides a chart comparing Medigap plans A-N and their benefits. For example, Medigap plan A does not cover skilled nursing facility care coinsurance, while Medigap plan F does. Medigap plans K and L have an out-of-pocket limit, while the other 12 plans do not. It is important to note that three states – Massachusetts, Minnesota, and Wisconsin – offer different Medigap plans not available in other states. There are separate pages for the Medigap plans on Medicare’s website for these exceptions.

Medigap policies, however, are only available in certain states. According to Medicare, “each insurance company decides which Medigap policies it wants to sell, although state laws might affect which ones they offer.”

While Medigap policies seem like they would be welcomed and encouraged in each state, there are 22 states that are allowed to not sell Medigap policies to those under 65 years of age who qualify for Medicare because of a disability. Those states are: Alabama, Alaska, Arizona, Arkansas, Idaho, Indiana, Iowa, Kansas, Kentucky, Montana, Nebraska, Nevada, New Mexico, North Dakota, Ohio, Rhode Island, South Carolina, Utah, Virginia, Washington, West Virginia, and Wyoming. Simply put, if you live in one of these and are on Medicare but under 65, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65.

The remaining 28 states require insurance companies to offer people under 65 at least one Medigap plan: California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Vermont, and Wisconsin.

Click here for more information about Medigap plans and coverage.

Enrolling in Medicare Part B – What You need to Know!

Medicare is a government health insurance program for eligible individuals. To be Medicare Part Beligible you must be: 65+ years old; have collected SSDI benefits for more than 24 months; or have been diagnosed with end stage renal disease (ESRD) or ALS. Medicare coverage is broken up into “parts:”

  • Part A: Hospital Insurance – includes hospital care, skilled nursing facilities, nursing homes, hospice, and home health services.
  • Part B: Medical Insurance – includes services from doctors, preventive care, outpatient care, lab tests, mental health care, ambulance services, and durable medical equipment.
  • Part D: Prescription Drug Plan (PDP) – different plans to choose from depending on where you live, with different premiums and formularies.
  • Part C: Advantage Plans. Part C is an alternative to Parts A & B and it includes the benefits and services covered under Parts A & B, and usually Part D. You can select a PPO or HMO plan that is run by a Medicare approved private insurance company.

You can enroll in Medicare for the first time during Initial Enrollment Periods, when:

  • You’re newly eligible for Medicare because you turn 65. You get a 7-month period to pick your plans, which starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
  • You’re newly eligible for Medicare because you’re disabled and under 65.
  • You’re already eligible for Medicare because of a disability, and you turn 65.
  • You are working and receiving insurance through your work, you can enroll up to 8 months after you stop working.

If you fail to enroll during these windows, you can enroll during the General Enrollment Period (GEP), which is January 1st through March 31st, every year. However, if you sign up during the GEP, but were eligible earlier than that, you could be facing a Medicare Part B late enrollment penalty.

Most people receive their Part A coverage at no cost, but they do have pay for Part B coverage.  Since Part B is something you pay for, you have the right to refuse the coverage.  Refusing Part B coverage is an important decision to make, so please consider it wisely.

Consider these examples, to help you decide if you should keep Part B:

  • I’m still working and have coverage through my employer. Or, my spouse is still working and I’m covered by his or her employer. Ask your employer or union benefits administrator if they require you to sign up for Part B. If your employer doesn’t require you to sign up for Part B right away, you can usually sign up for Part B later during a Special Enrollment Period without a late enrollment penalty.
  • I’m retired and have coverage through a former employer, or I have COBRA or VA coverage. If you’re retired and have retiree health insurance from a former employer or union, or you have COBRA or U.S. Department of Veterans Affairs (VA) coverage, Medicare generally will become your primary health insurance. Medicare will pay its part of the costs for any health care services you get, and then any amount not covered by Medicare can be submitted to your non-Medicare plan. If you don’t keep Part B, your current coverage might not pay your medical costs during any period in which you were eligible for Medicare Part B, but didn’t sign up for it.
  • I have coverage through the Health Insurance Marketplace as an individual or through an employer. If you have a Marketplace plan for individuals or families, you should keep Part B and drop your Marketplace plan so it stops when your Medicare starts. You won’t be eligible for premium tax credits or other savings for a Marketplace plan once your Part A coverage starts and you if you miss your enrollment period you will end up paying a penalty for enrolling late.
  • I have TRICARE coverage (insurance for active-duty military, military retirees, and their families). You must have Part B to keep TRICARE coverage. However, if you’re an active duty service member or the spouse or dependent child of an active-duty service member, you may not have to get Part B right away.
  • I have CHAMPVA coverage. You must have Part B to keep your CHAMPVA coverage.
  • I have coverage through a private insurance plan. If you accept Medicare Part B, Medicare will pay its part of the costs for any health care services you get, and then any amount not covered by Medicare can be submitted to your private plan.
  • I don’t have other health insurance. If you don’t have other health insurance, you should accept Part B if you want coverage for things like doctors’ services or preventive services.

Before you make any decisions about opting out of Part B, speak to the Social Security Administration (and keep detailed notes of each conversation).

Resources

For a more information about Medicare please read the booklet entitled Welcome to Medicare.

You can also find more information on our Triage Cancer blog, by reading our Quick Guide to Medicare, or watching our webinar on “Making Sense of the Medicare Maze.”

Don’t Be Late! Medicare Part D Penalty

Within the alphabet soup that is Medicare, there are important deadlines of which to be Medicare Part D Penaltyaware.  If you are late to enroll you may be forced to pay a Medicare Part D penalty.

Medicare Part D is the prescription drug benefit of Medicare.  Like all of Medicare, there are specific and limited times that you can enroll in the program.  It is important to understand these enrollment periods, so you can avoid late enrollment penalties.

When can you enroll in Medicare Part D?

The Initial Enrollment Periods for Medicare include:

  • You’re newly eligible for Medicare because you turn 65. You get a 7-month period to pick your plans, which starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65.
  • You’re newly eligible for Medicare because you’re disabled and under 65.
  • You’re already eligible for Medicare because of a disability, and you turn 65.
  • You HAVE Medicare Part A coverage, and you get Medicare Part B for the first time by enrolling during the Part B General Enrollment Period (January 1–March 31).

The Penalty

You may owe a late enrollment penalty if at any time after your Initial Enrollment Period is over, there’s a period of 63 or more days in a row when you don’t have Part D or other creditable prescription drug coverage. Creditable prescription drug coverage is coverage (for example, from an employer or union) that’s expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.

The late enrollment penalty is an amount that’s added to your Part D premium each month. If you have a penalty, you may have to pay it each month for as long as you have Medicare drug coverage!  The Part D late enrollment penalty is calculated as 1% of the national base beneficiary premium for each full, uncovered month that you didn’t have Part D or creditable coverage.

For example, if there was a period of 14 months that you did not have Part D or creditable prescription drug coverage, this is how the penalty is calculated:

14 months x 1% = .14

.14 x $35.63 (2017 base beneficiary premium) = $4.98

$4.98 rounded to the nearest $.10 = $5

$5.00 would be added to your monthly Part D premium for as long as you have Medicare Part D (which is usually for the rest of your life).  So each year you would be paying an additional $60 in Part D penalties. Over 20 years that would be $1,200 in completely avoidable penalties.

For more information about Medicare, read our Quick Guide to Medicare, or watch our webinar on “Making Sense of the Medicare Maze.”

For more information on the Part D Late Enrollment Penalty, visit www.medicare.gov/Pubs/pdf/11219-Understanding-Medicare-Part-C-D.pdf  or https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/downloads/11222-P.pdf

Understanding Medicare Part D – Prescription Drug Coverage

Medicare is a government health insurance program for eligible individuals. To be Medicare Part Deligible you must be: 65+ years old; have collected SSDI benefits for more than 24 months; or have been diagnosed with end stage renal disease (ESRD) or ALS. There are currently about 56 million Americans enrolled in Medicare.

Medicare coverage is broken up into “parts:”

  • Part A: Hospital Insurance – includes hospital care, skilled nursing facilities, nursing homes, hospice, and home health services.
  • Part B: Medical Insurance – includes services from doctors, preventive care, outpatient care, lab tests, mental health care, ambulance services, and durable medical equipment.
  • Part D: Prescription Drug Plan (PDP) – different plans to choose from depending on where you live, with different premiums and formularies.
  • Part C: Advantage Plans. Part C is an alternative to Parts A & B and it includes the benefits and services covered under Parts A & B, and usually Part D. You can select a PPO or HMO plan that is run by a Medicare approved private insurance company.

For more information about Medicare, read our Quick Guide to Medicare, or watch our webinar on “Making Sense of the Medicare Maze.”

Medicare Part D is optional, but if you are taking prescription medication and do not have Part D, you may have to pay for medications out-of-pocket. If you decide later that you want Part D, but didn’t sign up when you were first eligible, you pay have to pay a late enrollment penalty.

How much you pay for Medicare Part D and out-of-pocket prescription drug costs depends on a number of factors, like which Part D plan you choose, how many prescriptions you take and how often, whether your pharmacy is in your plan’s network, whether your prescription drugs are on your Medicare Part D plan’s formulary, and more. To find which Medicare Part D plans are available where you live, click here.

Part D premiums generally range from $10-$100 per month (depending on the plans available in your area and on the specific plan you choose). The maximum deductible—the amount you must pay out-of-pocket before Medicare will contribute to your prescription costs—in 2017 is $400. After paying your deductible, then Medicare will pay 75% of your prescription drug costs and you will pay 25%, up to a total of $3,700.

What many refer to as the “donut hole” in Medicare Part D coverage is a gap in coverage when you have spent a certain total amount on covered prescriptions. In 2017, once you and your plan have spent $3,700 on covered drugs, you’re in the coverage gap. This amount may change each year. Also, people with Medicare who get Extra Help paying Part D costs won’t enter the coverage gap. For more information and examples of the coverage gap, visit Medicare.

Even with Part D coverage, prescription drugs can be expensive. Depending on your income level, you may qualify for financial assistance to help pay for your prescriptions drugs. A Low-Income Subsidy provides Medicare beneficiaries with assistance in paying their Part D monthly premium, annual deductible, coinsurance, and copayments. Some people may be eligible for Extra Help, a program aimed for those who do not automatically qualify for a Low-Income Subsidy. You may be entitled to Extra Help if you are entitled to Medicare and get full coverage from a state Medicaid program, you are enrolled in a Medicare Savings Program, or you get SSI disability benefits. The Medicare Savings Program pays for the Medicare Part A and the Medicare Part B premiums. It also pays Medicare cost-sharing expenses, including deductibles, coinsurance, and copayments.

For more information on how to reduce your prescription drug costs, visit the following link. Examples include switching to lower-cost medication if approved by your health care team, or switching to mail-order programs from your plan.

You can also visit CancerFinances.org to find other financial assistance resources.

For help with Medicare and making plan choices, you can visit Medicare.gov or call 1-800-MEDICARE. You can also speak to a local counselor through the State Health Insurance Assistance Program. Click here, then pick your state from the drop down menu on the right, under “Find someone to talk to,” and it will provide the local contact information.

Losing Your Health Insurance Coverage? Get the Details on Changes to Special Enrollment Periods.

You may qualify for a special enrollment period (SEP) to buy coverage through the Changes-to-Special-EnrollmentACA’s health insurance Marketplaces, if you experience a life-changing event that results in a loss of coverage, such as:

  • losing your employer based coverage,
  • aging out of your parent’s health insurance coverage, or
  • moving to a new state.

During a SEP you have 60 days to shop for, and buy, new health insurance coverage in the Marketplace. You may also add family members to your coverage during a SEP, if you get married, or give birth to or adopt a child.

Recently, the rules around special enrollment have changed by the Department of Health and Human Services (HHS) and there are a few extra steps that you now have to take.

On June 23, 2017, HealthCare.gov began requiring applicants to submit additional information to conduct a pre-enrollment verification of eligibility for a SEP. What this means, is that once you pick a plan the Marketplace will “pend” your enrollment and you will have 30 days to submit documents to confirm your SEP eligibility before you can begin using your coverage. When you submit an application on HealthCare.gov, you will get a notice with a list of documents you can send to provide this confirmation.

As soon as your SEP is verified, the Marketplace will send your information to the health insurance company you chose and your coverage will start based on when your SEP started and when you picked your plan. In some cases, this will be retroactive.

For more information and to see a copy of the various notices you may receive, visit the CMS Center for Consumer Information and Insurance Oversight website.

Uncertainty puts Marketplace Financial Assistance in Jeopardy

A recent study found that the average family in America spends 10.1% percent of the family’s income just on health insurance premiums and deductibles. So it’s no wonder Marketplace-Financial-Assistance-Jeopardythat many Americans need a little help purchasing health insurance coverage. The Patient Protection and Affordable Care Act (ACA) made financial assistance available for people who buy health insurance in the marketplaces, based on their income level. However, due to uncertainty in politics, as well as policy and legislative changes, that financial assistance may be in jeopardy.

There are two different types of financial assistance in the marketplaces:

  • Premium tax credits reduce the amount that people pay for their monthly premiums to have health insurance.
  • Cost-sharing subsidies, also known as cost-sharing reductions, help to lower deductibles, co-payments and co-insurance. The way that cost-sharing subsides work is that the insurance company reduces what they charge individuals and, in turn, the insurance companies are reimbursed by the federal government.

Since the beginning of the year, uncertainty has put these financial assistance options in jeopardy. The new presidential administration had suggested that they were going to eliminate the cost-sharing reductions and that they would repeal the ACA, which would eliminate the premium tax credits, as well.

While health insurance companies are accustomed to dealing with uncertainty, like not knowing how many people will get sick during a given year, it is unusual for politics to create such uncertainly in the health insurance market.

Specifically, the uncertainty that will have the greatest impact is the fact that there has not be a clear decision from the President or Congress on if they are going to continue funding the cost-sharing reduction payments to insurance companies, and whether the individual mandate will be strictly enforced. The individual mandate was designed to insure that individuals do not wait to purchase insurance once they are sick. The IRS has already indicated that they will not strictly enforce the mandate moving forward.

Oliver Wyman, an actuarial consultant, states that these sort of ambiguities are new to actuaries who are in charge of setting the rates, and actuaries are predicting that 2018 insurance premiums are expected to increase between 28 and 40%.

Ultimately, the uncertainty around cost-sharing reduction payments, and the lack of enforcement of the individual mandate is projected to be responsible for the bulk of premium increases for 2018 and has already led some insurers to pull out of the marketplaces in some states, to avoid having to deal with the uncertainty.

This uncertainly, along with the current proposals for health care reform being discussed in the U.S. Senate, have the potentially to significantly impact the cancer community.

Stay tuned to our blog for the latest updates on proposed changes to our health care system.