How the States are Handling Health Insurance

There are many proposed and approved changes to our health care system at both the state update health insurancefederal and state levels, which may impact the cancer community. If you don’t live in one of these states, it’s important to know that these changes could come to your state next.

Health Insurance Marketplace Data:

We have heard a lot in the news about how the plans in the Health Insurance Marketplace are more expensive this year. The final enrollment report just came out and it showed that 7.5 million people qualified for financial assistance to purchase their plan. The average monthly premium for those plans was $89. This is actually less than the average from 2017, which was $107. Also, more people were able to get better coverage for less money, choosing more gold plans than last year. For example, in Wyoming, in 2018, 46% of plans chosen were gold, compared to 3% in 2017.

Other National News:

  1. The IRS has made some changes to Health Savings Accounts (HSAs). If you have an HSA, read more hereabout the changes to avoid any penalties and other IRS news.
  2. A new survey finds that 44% of people surveyed said they didn’t go to a doctor when they were sick or injured last year because of cost. 30% of people said that they had to choose between medical care and paying for basic necessities (food, heating, housing, etc.). And, 39% of people didn’t go to a dentist last year when they needed treatment. Read more here.
  3. Nearly 1 in 5 Americans has crippling medical debt. Medical debt is still the leading cause of personal bankruptcy in the United States. RIP Medical Debt is an organization that uses donations to purchase debt portfolios from collection agencies, to help people who need it the most. While you cannot apply to have your debt forgiven through RIP Medical Debt, there is an opportunity to add your name to their Debt Forgiveness Registry. If RIP Medical Debt is able to have your debt forgiven, they will notify you. Read more here.

Hawaii:

The Governor of Hawaii signed a bill that would allow physicians to prescribe life-ending medication to terminally ill patients. Adult patients who are terminally ill have to meet strict guidelines to get the medication, including:

  • Meeting with a counselor who must determine that the patient isn’t suffering from conditions that may interfere with decision-making, such as a lack of treatment for depression;
  • Making two oral requests for the medication, with a 20-day waiting period in between, and sign a written request witnessed by two people, one of whom can’t be a relative; and
  • Two doctors have to confirm the patient’s diagnosis, prognosis, ability to make decisions, and that the request is voluntary. They must also agree that the patent has less than six months to live.

Hawaii joins California, Colorado, Oregon, Vermont, Washington, and the District of Columbia, which have death with dignity laws. Click herefor more information about state laws. Hawaii’s bill takes effect January 1, 2019.

Maine:

In November, voters in Maine passed a proposition to expand Medicaid coverage in Maine, under the ACA.  The state legislature has actually passed Medicaid expansion laws 5 times since the ACA was signed into law on March 23, 2010. Each time, the Governor of Maine, Paul LePage, vetoed the expansion. When the voters approved Medicaid expansion, the Governor immediately said he would not implement it, unless lawmakers in Maine came up with the money to pay for Medicaid expansion without raising any taxes. The Governor had a deadline of April 3, 2018. to submit an expansion proposal to the federal government for approval.  But April 3rdhas come and gone and there has been no action. It is now up to legislature to figure out how to handle the funding. Expansion is supposed to begin July 2, 2018. Read more about Medicaid in Maine here.

Massachusetts:

Read this articleabout the paid family and medical leave proposal currently being discussed by the state legislature.  If the legislature doesn’t approve a plan, then advocacy groups are working to get a voter proposition on the November ballot.

Paid Family leave programs are also being discussed in Connecticut and New Hampshire.

 Iowa:

Governor Kim Reynolds has signed a bill to let the Iowa Farm Bureau Federation and Wellmark Blue Cross & Blue Shield sell health insurance plans. These “health benefit plans” would not be deemed “insurance,” so they are able to deny coverage or charge more for people with pre-existing conditions and would not be subject to regulation by the Iowa Insurance Division. With the change of a word, consumers lose access to many protections, especially those with serious medical conditions.

Many states are looking at this as an option. Tennesseewas actually the first state to allow farm bureau plans to be carved out of insurance protections.  These plans can ask people about their pre-existing conditions on the application, and reject people it expects to have high medical costs.

Utah:

Governor Gary Herbert signed a bill to give more than 70,000 Utahans access to Medicaid. Now the state waits for the Trump administration to sign off on their partial Medicaid expansion plan. If approved, it will likely be at least a year, before people will be able to sign up. This partial expansion covers adults making up to 100% of the federal poverty level (FPL), or $12,140 a year for an individual. The ACA’s Medicaid expansion covered adults up to 138% of the FPL, or $16,753 for an individual. It also includes a work requirement.

There are also advocacy efforts to collect signatures to put an initiative on the November ballot, which would expand coverage to adults with a household income up to 138% of the FPL. The deadline for collecting signatures was April 15.  We will see if this proposal gets on to the November ballot.

Stay tuned for the latest news  . . .

An Update From the States

An Update from the States

In an ongoing effort to keep you up to date on the many proposed and approved changes to our health care system and how they might impact the cancer community, this week, we bring you updates from around the country. If you don’t live in one of these states, be aware, these changes could come to your state next. 

Medicaid News:

Do you have Medicaid coverage? You can now access the services included in Amazon Prime for a discounted fee of $5.99 a month, less than half the regular cost of $12.99 a month. Access to Prime services, including free expedited shipping, can be particularly useful for someone who is treatment. Instead of having to go grocery shopping or running other errands for household items, Amazon Prime can deliver those items to your doorstep for free. Amazon also now offers electronic benefit transfer (EBT) cards, which are used for food stamp benefits.

Other National News:

In the recent Bipartisan Budget Act of 2018, passed by Congress on February 9th, there were several changes made to our health care system that may be helpful and challenging for the cancer community:

  1. It provided two additional years of funding to State Health Insurance Assistance Programs (SHIP) and Area Agencies on Aging, which are two valuable resources that help seniors manage their Medicare coverage and get access to other programs and services.
  2. It eliminated the Medicare cap on access to outpatient physical, occupational, and speech therapy services as of January 1, 2018.
  3. It closed the Medicare Part D donut hole one year earlier in 2019, lowering the cost of prescription drugs for people with Medicare.
  4. It also changed the way that Medicare pays for home health services beginning in 2020. The home health coverage will be reduced from 60 days to 30 days and therapy thresholds will be eliminated. Beginning in 2019, Medicare will be allowed to base eligibility for home health services on a review of a patient’s medical record, including a home health agency’s record.

Hawaii:

The Hawaii House has approved a bill that would allow physicians to prescribe life-ending medication to terminally ill patients. The bill now moves to the Senate, which approved a similar bill laws year. If approved, Hawaii would join California, Colorado, Oregon, Vermont, Washington, and the District of Columbia, which have death with dignity laws. Click here for more information about state laws.

Idaho:

A few weeks ago we shared that the Idaho Governor announced that he will allow insurance companies to sell plans in violation of the Patient Protection and Affordable Care Act (ACA). The ACA required health insurance plans to meet certain minimum requirements in order to protect consumers from pre-existing condition exclusions and annual and lifetime limits, while ensuring coverage of essential health benefits.

This past week, the Trump Administration did reject Idaho’s plan to sell plans in violation of the ACA.  Many other states had been closely watching this decision, as they also were looking at allowing plans without the ACA consumer protections. The cancer advocacy community was pleased to see that these consumer protections wouldn’t be ignored. However, the Administration did suggest to Idaho that they instead promote the sale of short-term insurance plans. Click here for more information on these plans.

Iowa:

The Iowa Senate voted last week to let the Iowa Farm Bureau Federation and Wellmark Blue Cross & Blue Shield sell health insurance plans that don’t comply with the ACA, allowing people with pre-existing conditions to be denied or charged more for coverage.  Given the Administration’s rejection of Idaho’s plans, it is likely that Iowa will not be able to move forward with the sale of these plans.

Arkansas:

There was a question as to whether or not Arkansas’ legislature was going to keep their expanded Medicaid program. However, lawmakers did vote to keep the program that covers 285,000 people in Arkansas another year.

In addition, the Trump Administration has approved Arkansas’ request to add a work requirement to their Medicaid program, joining Indiana and Kentucky as states that have added this new requirement. There are seven other states that have submitted applications for a Medicaid work requirement and 14 other states that are considering it.

Stay tuned for the latest news  . . .

Medicare Enrollment Periods – Do You Know the Difference?

More than 58 million people in the United States are enrolled in Medicare. But there is still medicare
a significant amount of confusion about how and when to make Medicare coverage choices. For information about the basics of Medicare and its different parts of coverage, read our Quick Guide to Medicare.

There are 4 separate enrollment periods that are important to getting access to Medicare coverage.

  1. The initial enrollment period happens once – when you are first eligible for
    Medicare. And, generally, it lasts 7 months (the 3 months before your 65th birthday, the month of your 65th birthday, and 3 months after your 65th birthday). If you are eligible for Medicare because you have received SSDI benefits for 24 months, your Medicare will begin in your 25th month of receiving SSDI benefits.
  1. And, each year, from October 15 to December 7, you can make changes to your Medicare coverage, which will begin on January 1. This is called the open enrollment period.
  1. If you are over the age of 65, but are still working, you have a special enrollment period of 8 months after your employer-sponsor group health plan or your retirement plan coverage ends.
  1. And finally, if you do not sign up for Medicare when you are first eligible during your initial enrollment period or your special enrollment period, then you can still enroll in Medicare, but you have to wait until the general enrollment period. The general enrollment period occurs each year from January 1 to March 31. Individuals can sign up for Part A and B during this time frame. Once enrolled in Part A and Part B, between April 1 and June 30, individuals can add a Part D plan or move to a Part C plan. However, even if you sign up for coverage on the first day of the general enrollment period, you still have to wait until July 1, for your coverage to begin.

medicare2

And, because you didn’t sign up for Medicare when you were first eligible, you will likely have to pay a late enrollment penalty:

  • Part A: you must pay a 10% penalty for twice the number of years you were eligible, but didn’t sign up.
  • Part B: you must pay a 10% penalty for each full 12-month period you were eligible, but didn’t sign up. You must pay this penalty on your Part B premium for life!
  • Part D: you must pay a penalty of 1% of the national base monthly premium, times the number of full months you were eligible, but didn’t sign up. You must pay this penalty on your Part D premium for life!

Part B Penalty Example:

David’s initial enrollment period ended August 31, 2015, but waited to sign up for Part B until the general enrollment period in February 2018. David waited 30 months to sign up, but this only included 2 full 12-month periods. (2 full 12-month periods x 10% = 20% penalty). David will pay a 20% penalty, in addition to his monthly Part B premium, for life!

Waiting to enroll in Medicare coverage can cost you a lot over time, so it is important to understand your options. For more information about Medicare enrollment and penalties, visit www.medicare.gov

Is Short-Term Insurance the Solution?

Last week, we shared a number of changes that states are looking to make to our health Short term health insurance policy on a table. care system. This week, we bring you a major change that has been proposed nationally.

Short-Term Insurance Plans

First, the U.S. Department of Health and Human Services (HHS) has released a proposed rule to allow the sale of short-term health insurance plans with coverage for any period less than 12 months.

Short-term health insurance plans are plans that only provide coverage for a certain period of time, less than a year. These plans were only intended to provide coverage for people who were between jobs or needed temporary coverage for other reasons.

These plans are not required to comply with the ACA’s consumer protections, which means that they can deny people with pre-existing conditions, can require people to complete medical questionnaires on the application, can charge people more because of an individual’s health history, and do not have to cover essential health benefits.  For example, a plan could exclude mental health care, preventive care, substance abuse treatment, or maternity care. They also are not required to have an out-of-pocket maximum, which means that people with serious medical conditions like a cancer, will pay significantly more for their medical expenses.

Because they don’t have to comply with these consumer protections, these plans are often referred to as “junk insurance.” These plans generally appear cheaper than other individual health insurance plans. The lower monthly premiums make them attractive for people who are healthier.  However, cancer is unpredictable.

The other challenge with these short-term plans, is that when they end, they do not have ‘guaranteed renewability.’  This means that an insurance company does not have to offer an individual a new policy when the term of coverage ends.  Furthermore, because these plans do not comply with the ACA, they are not creditable coverage. So when they end, it does not trigger a special enrollment period to buy a plan in the Health Insurance Marketplace. If no other coverage is available (e.g., going on a parent’s plan if they are under 26 years old), someone who has been diagnosed with cancer may have to wait for coverage until the next open enrollment period.

HHS’s previous rule from 2016, limited these short-term insurance plans to a maximum of three months. HHS is now allowing these plans to last for any time period up to 12 months, meaning that they can last up to 364 days.

Advocates have three main concerns about this change:

  1. Unsuspecting consumers who are healthier will leave the Marketplace to buy these cheaper plans, which will drive up the costs of plans in the Marketplace
  2. If these healthier individuals are diagnosed with serious medical conditions, they may find they are not adequately covered by their short-term plan and may lose access to insurance when their term ends
  3. People with pre-existing conditions won’t be able to purchase these cheaper short-term plans, which means they will be stuck in the marketplace with more expensive plans

While expanding access to these short-term plans does increase the number of options available to consumers, there is a concern that the expansion of these plans allows insurance companies to do another end run around the consumer protections laid out in the ACA, ultimately leaving consumers with less coverage and more cost.

People have until April 23, 2018, to comment on this proposed rule, and then HHS will release a final rule at some point after that. We will keep you posted. Stay tuned.

How States are Changing Health Insurance Rules

In an ongoing effort to keep you up to date on the many proposed and approvedhealth insurance
changes to our health care system and how they might impact the cancer community, this week, we bring you updates from around the country. If you don’t live in one of these states, be aware, these changes could come to your state next.

National News:

Two weeks ago, we reported that 11 states have applied for waivers to make some individuals work, in order to get access to health care through Medicaid. Since then, Kentucky and Indiana’s waivers have already been approved by the Center for Medicare and Medicaid Services and those states are moving forward with implementing plans for a Medicaid work requirement. Click here to learn more about the impact of the Medicaid waivers and to see what the states are asking for in their waivers.

In addition to work requirements, five states have also asked the U.S. Department of Health & Human Services if they can place a lifetime cap on how long an individual can receive Medicaid coverage. For example, Arizona, would like to place a 5-year lifetime cap on coverage. Kansas, Utah, Maine and Wisconsin are also seeking to impose lifetime caps.

This would be a substantial change to the Medicaid program, since signed into law under President Truman in 1965.  More than 68 million people receive Medicaid coverage, including children, seniors, and people with disabilities.  HHS has not released any guidance on this issue, to date.

Ohio:

Ohio has now joined Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, Mississippi (still in process), New Hampshire, North Carolina, Utah, and Wisconsin, in asking for permission to add a work requirement to their Medicaid program. The work requirement would begin July 1, 2018, if approved in time.

Ohio has also asked the federal government for permission to not comply with the individual mandate. This will likely have no actual impact, as Congress reduced the penalty for not purchasing health insurance to $0, in the latest tax bill. The $0 penalty will begin in 2019, which means that those who don’t have health insurance in 2018 will still be responsible for the penalty!

Rhode Island:

Rhode Island is also making cuts to its Medicaid program, which covers more than 300,000 people. Individuals will be required to pay co-pays when receiving health care services or prescription drugs.  However, there will be an annual cap on co-pays equal to 6% of an individual’s income.

Idaho:

Idaho announced last week that they will allow insurance companies to sell plans in violation of the Patient Protection and Affordable Care Act (ACA). The ACA required health insurance plans to meet certain minimum requirements in order to protect consumers from pre-existing condition exclusions and annual and lifetime limits, while ensuring coverage of essential health benefits. Insurers argue that providing this quality coverage is more expensive and that is why plans sold in the Health Insurance Marketplace can be more expensive.

Idaho’s approach to bring down the cost of insurance is to allow plans to offer less coverage and to exclude people with pre-existing conditions. This directly violate the law. It will be up to HHS to enforce the law or allow Idaho to continue offering these illegal plans. There are many other states waiting to see how HHS will react.

Blue Cross of Idaho has already unveiled five new plans that don’t comply with the ACA, including having annual caps on coverage and pre-existing condition exclusions for up to 12 months.

Advocates have three concerns about this approach:

  1. People who are healthier will leave the Marketplace to buy these cheaper plans, which will drive up the costs of plans in the Marketplace
  2. If these healthier individuals are diagnosed with serious medical conditions, they will find they have inadequate coverage
  3. People with pre-existing conditions won’t be able to purchase these cheaper plans, which means they will be stuck in the marketplace with more expensive plans

This turn of events is very concerning for the cancer community, as it allows insurance companies to do an end run around the ACAs protections for people with pre-existing conditions.

Medicaid Work Requirements & the Cancer Community

There has been discussion in the news over the last few weeks about the President’s decision to allow states to require that people “work” in order to receive Medicaid. This is referred to as the Medicaid work requirement. We want to break down these changes for you and how this might impact the cancer community.

If you live in one of the states that is about to make changes to its Medicaid program, you should definitely keep reading.

What is Medicaid?

Medicaid is the federal health insurance program that covers more than 74 million individuals who have a low income, low resources, and meet some other category of eligibility, such as being a senior, a minor child, or having a disability (receiving Supplemental Security Income (SSI)). In 2014, the Affordable Care Act expanded access to Medicaid to all adults with an income level up to 138% of the federal poverty level ($16,753 for an individual in 2018).  Eliminating the low resource requirement and the requirement to be receiving Supplemental Security Income, made it much easier for someone with a cancer diagnosis to get access to Medicaid coverage, and ultimately get access to care.

While Medicaid is a federal program, it is administered by both the federal government and states. Since 2014, 32 states have expanded access to their Medicaid program under the ACA.

There is a lot of discussion about the number of people who receive Medicaid, but don’t work, and whether or not that is fair. Those who are in favor of work requirements for Medicaid believe that “able-bodied” adults should be working if the federal government is going to pay for their health insurance coverage.

Those who are opposed to work requirements are concerned how they might impact people who are unable to work for a variety of reasons or who live in communities where work is difficult to find. Advocates are concerned that the additional administrative requirements will cause people to lose vital coverage, that people will be discouraged from applying for coverage, and that the number of uninsured people will start to rise again.  One of the many benefits of lower numbers of uninsured individuals was that it decreases the amount of uncompensated care that hospitals provide. When hospitals have high levels of uncompensated care, they are more likely to close, which impacts access to care for everyone.

Who Receives Medicaid?

According to an analysis by the Kaiser Family Foundation, most Medicaid and CHIP enrollees would be actually be automatically exempt from the requirement because of their age or disability status.

Medicaid Work Requirements & the Cancer Community

What are the New Medicaid Rules?

In January, the Trump Administration announced its decision to make significant changes to the Medicaid program, by allowing states to apply for waivers to impose work requirements on Medicaid enrollees in their state. The Centers for Medicare and Medicaid Services (CMS) released rules for the states who want to apply for those waivers.

The rules forbids states from imposing work requirements on certain populations, such as the elderly, minor children, individuals who are pregnant, and those receiving SSI.

CMS also requires states to exempt individuals who are “medically-frail.” CMS defines “medically frail” as those who have “disabling mental disorders; chronic substance abuse disorders; serious and complex medical conditions; physical, intellectual, or developmental disabilities that significantly impact the ability to perform one or more activities of daily living; and those who meet Social Security disability criteria.”

While CMS does remind states to consider how some communities have high unemployment rates due to economic factors, it gives states significant flexibility to design their own requirements. CMS also suggested that states could allow for “community engagement” alternatives to work, such as job search, job training, volunteering, community service, or education.

Work requirements are likely to have an impact on everyone receiving Medicaid in a particular state, because everyone will have to document that they meet the requirements. And, the CMS rules allow for states to ask enrollees to certify they are still eligible as often as monthly.

Which States Want Medicaid Work Requirements?

These eleven states have already applied for waivers to add work requirements: Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, Mississippi (still in process), New Hampshire, North Carolina, Utah, and Wisconsin.  Additional states are considering submitting requests.

Medicaid Work Requirements

Since the CMS announcement, Kentucky and Indiana’s waivers have already been approved and those states are moving forward with implementing plans for a Medicaid work requirement.

Click here to learn more about the impact of the Medicaid waivers and to see what the states are asking for in their waivers.

What is in Kentucky’s Waiver?

Kentucky’s waiver requires people to work 80 hours a month, or alternatively to engage in job searching, job training, community service, or education. Drug treatment and caregiving for a non-dependent relative or another person with a disabling medical condition are also considered work activities.

Kentucky Medicaid enrollees can obtain an exception to the work requirement if they can verify one of the following during their month of noncompliance with the work requirement:

  • Disability, hospitalization, or serious illness of enrollee or immediate family member in the home;
  • Birth or death of a family member living with the enrollee;
  • Severe inclement weather including natural disaster; or
  • Family emergency or other life-changing event such as divorce or domestic violence.

A primary caregiver of a dependent minor child or adult with disabilities per household is also exempt.

In addition to the medicaid work requirements, the waiver also establishes premiums, deductibles, benefit restrictions, and six-month coverage lock-outs, while eliminating non-emergency medical transportation.

Also included in Kentucky’s waiver is the elimination of the 3-month retroactive coverage for most adults, including those who are medically frail. This was very useful for someone diagnosed with cancer, so that they could start receiving care while their Medicaid application was being processed.

To read a breakdown of Kentucky’s waiver, click here. These changes are set to begin being phased in on April 1, 2018.

However, advocacy groups in Kentucky have filed a lawsuit to stop the implementation of Kentucky’s waiver. Kentucky Governor Matt Bevin has signed an executive order stating that if the court does stop the work requirements, that the Governor will eliminate the expanded access to Medicaid in Kentucky entirely. This would result in 48,000 people in Kentucky losing access to their health insurance coverage.

What is in Indiana’s Waiver?

Indiana’s waiver was approved on February 2, and requires adult enrollees to work an average of 20 hours a month and it is phased in over time. It also has a long list of exemptions and alternatives to employment. In addition to the work requirement, Indiana will also implement a “lockout” provision.  Medicaid enrollees who fail to submit their paperwork showing that they still qualify for the program, will be blocked from coverage for three months. Click here to read Indiana’s Medicaid waiver.

More Information

Triage Cancer will continue to follow the changes to state programs and how those changes might impact the cancer community and share that information on our blog.  Stay tuned.

Changes Coming to Medicare

There are a number of changes coming to Medicare. Individuals who are already enrolled and new enrollees should both be aware of these Medicare changes.

A New Medicare Card

Sometime between April 2018 and April 2019, you will be receiving a new Medicare card that will not have your Social Security number on it. The cards will have Medicare Changesa new Medicare Number on them, which will be unique to you. This change will keep your Social Security number more secure, and help protect your identity.

The Social Security Administration is asking you to make sure that your mailing address is up to date.  If you do need to update your address, you can do so by calling 1-800-772-1213 or at http://www.ssa.gov/myaccount. They are also warning you to be aware of anyone contacting you about your new card.  The Social Security Administration will never call you and ask you for private information to get your card.  And finally, don’t worry if your neighbor gets their card before you do.  It will take some time to mail our cards to every Medicare member.

2018 Medicare Costs

For 2018, the Medicare Part B Deductible will be $183.  The Part B Standard Premium will be $134 or higher, depending on your income (see chart).  However, most people who get Social Security benefits pay less than this amount ($130 on average). You pay the standard premium amount of $134 (or higher based on the chart below) if:

  • You enroll in Part B for the first time in 2018.
  • You don’t get Social Security benefits.
  • You’re directly billed for your Part B premiums.
  • You have Medicare and Medicaid, and Medicaid pays your premiums.
  • Your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount.
If your yearly income in 2016 was You pay (in 2018)
File individual tax return File joint tax return File married & separate tax return
$85,000 or less $170,000 or less $85,000 or less Your plan premium
Above $85,000 up to $107,000 Above $170,00 up to $214,00 Not applicable $13 + your plan premium
Above $107,000 up to $133,500 Above $214,000 up to $267,000 Not applicable $33.60 + your plan premium
Above $133,500 up to $160,000 Above $267,000 up to $320,000 Not applicable $54.20 + your plan premium
Above $160,000 Above $320,000 Not applicable $74.00 + your plan premium

 

The 2018 standard Medicare Part D (the prescription drug benefit) Deductible is $405. Once that deductible is met, your costs break out as follows:

Deductible: $0-$405 100% paid by Participant until the deductible is met
Initial Coverage Limit $3,750 in total drug costs 75% Paid by Medicare 25% paid by Participant
 

 

Between $3,750 and $7,508.75 in total drug costs

Brand Name Drugs:

50% Manufacturer Discount

15% Paid by Medicare

 

Generic Drugs:

56% Paid by Medicare

 

35% Paid by Participant

 

 

 

44% Paid by Participant

 

Above $7,508.75 in total drug costs 95% Paid by Medicare 5% Paid by Participant

 

Medigap Plans C and F

One useful way to reduce your out-of-pocket Medicare expenses is to buy a Medigap Plan. These are supplemental Medicare plans that cover some of the costs that Medicare Parts A & B don’t cover, deductibles, and co-insurance amounts.  There are 10 different Medigap plans, each labeled with a different letter, each having a different level of coverage.  One of the most comprehensive plans is Medigap Plan F, which includes coverage of:

  • Part A hospital and coinsurance costs up to an additional 356 days after Medicare benefits are exhausted
  • Medicare Part A hospice care copayment or coinsurance
  • Medicare Part B coinsurance
  • Medicare Part B excess charges
  • Medicare Part A deductible
  • Medicare Part B deductible
  • First three pints of blood used in an approved medical procedure (annually)
  • Skilled nursing facility coinsurance
  • Foreign travel emergency coverage (80%, up to plan limits)

Another popular plan is Medigap Plan C.  Plan C covers almost everything Plan F covers.  The one difference is that Part C doesn’t cover something called “Part B excess charge”.  The www.medicare.gov definition of that is “If you have Original Medicare, and the amount a doctor or other health care provider is legally permitted to charge is higher than the Medicare-approved amount, the difference is called the excess charge.”

You can see why these 2 plans are so popular.  In 2015, Congress voted to close these plans to new people in 2020.  Meaning, if you are new to Medicare in 2020, you won’t have the option of choosing these plans or if you are a current Medicare recipient looking to change Medigap plans, these plans won’t be available.

Between now and 2020, seniors and people with disabilities need to think about this carefully.  Right now, people turning 65 or just switching to Medicare from an employer plan can be accepted into any Medigap plan they choose, regardless of their health.  If they want to switch Medigap plans later on, insurance companies can look at their health, and either turn them down for that reason, or charge them a hefty premium for a pre-existing health condition. So, your first choice is important.

That said, should you just jump and buy Plan F while you can?  Maybe not.  Experts expect the premiums on Plan F to rise after they close the plans because there won’t be any new, relatively healthy 65 years olds to offset the costs of the aging people already in Plan F.  So choosing a Medigap Plan F now could lock you into a very expensive plan in the future.

Experts are recommending people look at Plan G.  This is a plan that is almost as comprehensive as Plans F and C, but it does require you to pay the Medicare Part B annual deductible.

Will Medicare Plan F premiums go up too much?  Will you develop a medical condition that makes moving from Plan F to another Medigap plan too expensive? These are things to consider.  Medicare offers a really helpful grid comparison of the different Medigap plans at https://www.medicare.gov/supplement-other-insurance/compare-medigap/compare-medigap.html#1319. Without a crystal ball, these choices are really hard, but know this, the clock is ticking.

How Medicare Covers Chemotherapy

Throughout our lifetimes, we enroll in health insurance for a variety of reasons. Medicare-ChemotherapyIt gives us access to doctors and provides preventive care and screenings for early detection of medical conditions. There’s no question, however, that the main reason we buy health insurance is to help us pay for major treatment if we are diagnosed with a serious illness such as cancer.

Many people who are new to Medicare or have been recently diagnosed wonder how Medicare covers various cancer treatments, such as chemotherapy. The good news is that Medicare provides extensive coverage of cancer treatment and cancer-related services.

Medigap supplemental coverage is also available to round out that coverage, help pay for your deductibles, and protect you from catastrophic out-of-pocket medical spending. Let’s look at how Medicare’s coverage of chemotherapy and other cancer treatments works:

The Parts of Medicare

Original Medicare has two parts. Part A is your inpatient hospital coverage, and this provides for your hospital room and some skilled nursing care. Part B is your outpatient coverage, which includes physician services, lab work, diagnostic imaging, preventive care, durable medical equipment, and much more. Part D provides prescription drug coverage. Click here for an explanation of Part C.

Although chemotherapy is often administered in a hospital or clinic setting, it generally falls under Part B, since chemotherapy is a treatment administered by a physician. Radiation treatment and some anti-nausea medications are covered under Part B as well, if the doctor prescribes them to you within 48 hours of a chemotherapy session. Otherwise, these would be covered under a Part D drug plan. Click here for a complete chart comparing drugs covered by Parts B vs. Part D.  In terms of chemotherapy coverage, this is how it breaks out:

  Covered by Part B Covered by Part D
Infusion drugs Drugs administered by an implantable infusion pump

 

or

 

Drugs administered by an external infusion pump that you use at home and your local DME contractor covers them under Part B.

Drugs administered by an external infusion pump outside of the home (i.e., in a skilled nursing facility or hospital) and your stay is not being covered by Part A or you do not have Part A.

 

Drugs administered by an external infusion pump that you use in the home, but your Durable Medical Equipment contractor does not cover them under Part B for use in the home.

 

Infusion drugs administered at home without an infusion pump at home. One example of this is an IV push.

Injectable Drugs The drug generally cannot usually be self-administered and your doctor provides and administers the drug to you. You can buy the drug at the pharmacy and it is either administered by your doctor or you administer the drug yourself.
Oral Anti- Cancer Drugs It is an oral anti-cancer drug that was once available only in an injectable form that was covered by Medicare. You or your doctor can administer the drug. It must be used to treat cancer. You use the drug to treat a condition other than cancer.
Oral Anti-Nausea Drugs (antiemetics) Must be related to cancer, used as a full replacement for intravenous treatment, and administered within 48 hours of cancer treatment. It can be administered by yourself or by a doctor. The drug is used for conditions other than cancer.

 

It is used more than 48 hours after cancer treatment or is not a full replacement for intravenous treatment.

Part B has a small annual deductible that you must pay. That deductible is $183 in 2018. Then, Part B pays for 80% of covered services that you receive. You are responsible for the other 20%. This is called your Part B co-insurance. There is no out-of-pocket maximum for Part B, so your expenses could be high.

That is why a Medigap plan can be helpful to pay for that co-insurance and other Medicare-related out-of-pocket costs, such as deductibles and copays. You can find out more information about Medigap plans here.  You may also find a Medicare Advantage plan helpful to lower your out-of-pocket costs.  For more about Medicare Advantage, click here.

Creating A Sanctuary At Home For Your Loved Ones

By Jane Jenkins, a freelance writer

More than 1.6 million new cases of cancer are diagnosed every year. When cancer Home-Sanctuarypatients hear their diagnosis, they know that a potential struggle lies ahead of them including surgery, treatment, and a change in lifestyle habits. If you’re living with a loved one who’s going through cancer, you can ensure that your home is a sanctuary for them. Research has found that one’s environment can have a large impact on mood, but a happy home environment is about more than having bright colors on the walls. Your loved one who’s been diagnosed with cancer will need privacy when they want to be left alone with their thoughts and a stress-free space where they can rest between treatments, for instance. Here are other things you can do to make them comfortable and happy.

Keep It Clean

Cleanliness is important for cancer patients, whose treatments can lower their immune systems. Clean floors, counters, and pay special attention to the bedroom. If your loved one spends lots of time in there, it should be spotless to prevent infection. Bedding should be washed in hot water once a week to kill dust mites. Mop the floor and make sure you use antibacterial household cleaners to kill germs.

It could also be a good idea for your loved one to get into the habit of kicking off shoes before entering the bedroom as any germs or pollen collected from the garden could end up in this room, where they can cause allergies. Allergic reactions are commonly reported with most chemotherapy medicines, so you want to avoid any triggers, such as dust and pollen.

Keep It Quiet

Many people who undergo cancer treatment experience sleep problems such as insomnia. It’s important to ensure quietness in the home as noise can create further stress by increasing one’s heart rate and blood pressure. Make sure your loved one’s bedroom is in an area of the house where there’s not a lot of noise from the road or neighbors as this will help them to relax. Cancer patients require lots of rest between radiation or chemotherapy treatments to regain their strength.

Make It Safe

You will need some important features to make your home safe and user-friendly for your loved one. Toilet grab bars that are mounted to the wall can make it easier for your loved one to lower and lift themselves up when they’re feeling weak or fatigued. Chairs in the shower can also prevent falls. Weakness and fatigue are common during cancer treatments, so you want to be sure that your loved one will be safe when walking around the house. Make sure that there aren’t any snags in the carpet that can trip them up. Place some chairs in risky spots, such as on the staircase landing or in the middle of a long passage, so that they can rest if they need to.

If your loved one is struggling with treatment side effects such as fatigue, having a resting place on or moving their bedroom to the ground floor of your home can help them avoid having to use staircases multiple times a day, which can be exhausting.

Boost Their Interaction With Nature

A lot of research has shown that just a few minutes of being in nature can decrease stress, anger and fear, while boosting one’s mood. If you don’t have a garden in which your loved one can walk and sit, make sure you bring more pictures of nature into the home. Even these have been shown to alleviate stress and boost feelings of wellness.

Pictures of nature can be good replacements for real plants if you don’t have a garden, or your loved one is receiving chemotherapy. Research has found that patients undergoing chemotherapy shouldn’t be around plants in the house. This is because indoor plants and flowers release mold into the air, which can cause infection.

Fill The Space With Love

It’s important that people feel that they can do the things they love in a space that allows them to enjoy this activity. For instance, if your loved one enjoys reading, a room with good lighting and a comfortable sofa can be a relaxing retreat for them. On the other hand, if they love to fix things, a workspace can be invaluable. Time to do what they love can provide a good distraction while providing a sense of normalcy.

Turning your home into a safe and comfortable sanctuary is important way to support your loved ones and allow them feel that they can relax, do things they love, and regain their energy in a healing place.

Understanding Health Insurance: Self-funded Plans vs. Funded Plans

Self-Funded Plans

Do you get coverage through your employer? Do you know which type of plan you have? You should.

But, the truth is, most people don’t.

For most people, this is a totally foreign concept.  We are more familiar with different premiums, different levels of coverage, different insurance company names, but whether or not your plan is self-funded or funded may be a new concept.

These are two ways in which employers provide health insurance benefits for their employees:

  • Funded plan: also called fully insured, these plans are when an employer contracts with a state-regulated insurance company, and the insurance company assumes the risk of your medical expenses. So, an employer buys coverage for its employees from an insurance company.
  • Self-funded plan: also called a self-insured plan, these plans are set up by the employer to pay the medical bills of their employees directly.

Though self-funded plans are most common among large companies, smaller businesses are beginning to self-fund. The big reason for this is cost.  It is cheaper to self-fund a plan because self-funded plans and are often exempt from state-mandated benefits. This means that in most cases, the only consumer protections for the people in these plans is whatever the federal law provides.

For instance, in California and 20 other states, there are laws related to surprise medical bills. These laws protect consumers from surprise bills from out-of-network doctors like anesthesiologists or emergency room doctors. There is no federal law regarding surprise medical billing.

How do I know if my plan is self-funded?

This is a question for your HR representative or whomever administers your employee benefits.  You probably won’t be able to tell from your insurance card, because most companies that self-fund still contract with an insurance company to administer the plan (pay claims, mail out EOB’s, etc.).  So whether you in a self-funded plan or funded plan, you may still have a typical insurance card from a company (e.g., Aetna, Humana, etc.). But keep in mind, if you work for a large company, with thousands of employees, there is a strong likelihood that you are in a self-funded plan.

What do I do if I am unhappy with a coverage decision in a self-funded plan?

  1. Contact the customer service number listed on your card.
  2. If your situation is not resolved, call the Employee Benefits Security Administration (EBSA) through the Department of Labor at 866-444-3272 or contact them online.
  3. If EBSA doesn’t help in a timely manner, many states have consumer assistance programs to help you navigate insurance problems. They can assist you in filing an appeal and be an advocate. Visit http://TriageCancer.org/StateResources for information in your state.

Don’t be too concerned if you are in a self-funded plan.  Large companies want happy employees, so they often write protections right into their plans.  Just be aware, because there is a difference in which laws may or may not apply to your plan.