May29

Three Medicare Part D Companies Own Half The Market: What You Should Know

United Health Group, Humana, and CVS Health own 55% of the market in the Medicare Part D arena. Here is a great article by the Kaiser Foundation on what you should know about Your part D provider and how they stack up.

Medicare Part D in 2018: The Latest on Enrollment, Premiums, and Cost Sharing

By: Juliette Cubanski, Tricia Neuman, and Anthony Damico
Published: May 17, 2018

Summary

This analysis presents findings on Medicare Part D enrollment, premiums, and cost sharing in 2018 and key trends over time, based on data from the Centers for Medicare & Medicaid Services (CMS).

Enrollment: In 2018, 43 million of the 60 million people with Medicare have prescription drug coverage under a Medicare Part D plan; most (58%) are covered under a stand-alone prescription drug plan (PDP) but a growing share (42% in 2018) are in Medicare Advantage prescription drug plans (MA-PDs), which also provide other Medicare-covered benefits. More than 12 million Part D enrollees receive premium and cost-sharing assistance through the Part D Low-Income Subsidy (LIS) program.
- Three firms—UnitedHealth, Humana, and CVS Health—account for over half (55%) of all Part D (PDP and MA-PD) enrollees in 2018 (Figure 1).

Figure 1: Three firms—UnitedHealth, Humana, and CVS Health—cover over half of all Medicare Part D enrollees in 2018

Premiums: Monthly Part D PDP premiums average $41 in 2018, but premiums vary widely among the most popular PDPs, ranging from $20 per month for Humana Walmart Rx to $84 per month for AARP Medicare Rx Preferred. Overall, average monthly PDP premiums increased by a modest 2 percent in 2018.
Deductibles: More than 4 in 10 PDP and MA-PD enrollees are in plans that charge no Part D deductible, but a larger share of PDP enrollees than MA-PD enrollees are in plans that charge the standard deductible amount of $405 in 2018.
Cost sharing for generics and brands: Most Part D enrollees face modest cost-sharing amounts for generic drugs but can face much higher cost sharing for brands and non-preferred drugs, and a mix of copayments and coinsurance for different formulary tiers. For example, for PDP enrollees, median cost sharing ranges from $1 for preferred generics to $37 for preferred brands, and a 40% coinsurance rate for non-preferred drugs.
Specialty drugs: More than 4 in 10 Part D enrollees are in plans that charge 33 percent coinsurance for specialty tier drugs, defined by CMS as drugs that cost at least $670.

Findings

Enrollment

More than 43 million Medicare beneficiaries, or 72 percent of all Medicare beneficiaries nationwide, are enrolled in Part D plans.

This total includes plans open to everyone and employer-only group plans for retirees of a former employer or union (Figure 2). Most Part D enrollees (58 percent) are in stand-alone prescription drug plans (PDPs), but a rising share (42 percent in 2018, up from 28 percent in 2006) are in Medicare Advantage prescription drug plans (MA-PDs), reflecting overall enrollment growth in Medicare Advantage.

Figure 2: Medicare Part D enrollment has grown steadily since the program started in 2006 and now totals 43.4 million beneficiaries in 2018

In 2018, three Part D sponsors account for more than half of all Part D enrollees and two-thirds of all PDP enrollees.

UnitedHealth, Humana, and CVS Health cover more than half (55%) of all beneficiaries enrolled in Part D in 2018, and two-thirds (67%) of all stand-alone PDP enrollees (Table 1). UnitedHealth and Humana have had large market shares since the program began, while enrollment in CVS Health has grown over time through acquisition of other plan sponsors (Figure 3).

Figure 3: Humana, CVS Health, and UnitedHealth have the most stand-alone PDP enrollees in 2018; enrollment in CVS-sponsored PDPs has grown through consolidations

The proposed mergers of CVS Health and Aetna, and Cigna and Express Scripts would result in further consolidation of the Part D marketplace. If these mergers go through, four firms—the two merged firms plus UnitedHealth and Humana—would cover 71 percent of all Part D enrollees and 86 percent of stand-alone drug plan enrollees, based on 2018 enrollment.

The ten largest sponsors of Part D plans account for nearly 90 percent of all enrollment.

UnitedHealth has maintained the top position since the Part D program started, and in 2018 provides coverage to nearly one quarter of Part D enrollees, when PDP and MA-PD enrollment is combined (Table 1). Among all plan sponsors, UnitedHealth has the most MA-PD enrollees in 2018, while CVS Health has the most PDP enrollees.

At the state level, UnitedHealth is the top firm in terms of 2018 Part D enrollment in 26 states and territories, and is one of the top 3 firms in 44 states/territories (Figure 4, Table 2). Humana is the top firm in 17 states/territories, and is one of the top 3 firms in 41 states/territories.

Figure 4: UnitedHealth, Humana, and CVS Health are one of the top 3 Part D firms by enrollment in many states/territories

CVS Health, which sponsors PDPs but not MA-PDs, is the top Part D firm in only 6 states/territories, but is among the top 3 firms in 35. Together, three firms—UnitedHealth, Humana, and CVS Health—occupy all of the top 3 spots in terms of Part D 2018 enrollment in 19 states and territories (in varying orders).

Among PDPs, at the plan level, SilverScript Choice PDP (sponsored by CVS Health) has the most enrollees in 2018, covering more than 1 in 10 Part D enrollees, or 4.6 million (Table 3). This total is nearly double that of the second most popular plan, AARP MedicareRx Preferred (sponsored by UnitedHealth), with 2.6 million enrollees.

PREMIUMS

PDP premiums have risen modestly in recent years; for 2018, the average PDP premium is $41 per month.

PDP enrollees are in plans with an average monthly premium of $41 in 2018, a modest 2 percent increase over 2017 but up by 11 percent since 2015 (Figure 5). The combined average Part D premium for PDP and MA-PD enrollees is $32 in 2018. This is lower than the average for PDPs due in part to the ability of MA-PD sponsors to use rebate dollars from Medicare payments for benefits covered under Parts A and B to lower their Part D premiums. The average MA-PD premium is $34 in 2018, which includes Part D and other benefits.

Figure 5: The average monthly premium for stand-alone PDPs increased by a modest 2% in 2018 to $41, but has risen 11% since 2015

Premiums for 7 of the 10 most popular PDPs increased in 2018, and continue to vary widely across plans.

Monthly premiums for 2 of the 10 largest PDPs–AARP MedicareRx Preferred and Humana Enhanced—increased by more than $10 in 2018 (Figure 6). Premium decreases among the top PDPs were generally of a smaller magnitude; for example, the average monthly premium for SilverScript Choice, the PDP with the most enrollees, fell by $3.

Figure 6: Average monthly premiums for 7 of the 10 most popular stand-alone PDPs increased for 2018

Monthly premiums in 2018 vary widely among the most popular PDPs. Premiums range from $20 per month for Humana Walmart Rx to four times more—$84 per month—for AARP Medicare Rx Preferred.

Among the top 5 PDPs, those plans with lower premiums in 2018 than in 2017 generally have higher enrollment in 2018 than in 2017, and vice versa.

Among several of the top PDPs, there appears to be an inverse relationship between premium changes from 2017 to 2018 and the year-to-year change in voluntary enrollment among enrollees who are not receiving low-income subsidies (LIS). (Low-income enrollees may be reassigned automatically in response to premium increases under certain circumstances.)

For example, the monthly premium for SilverScript Choice fell by $3 for 2018 (from $29 to $26), and its non-LIS enrollment increased by 12 percent between 2017 and 2018 (Figure 7). By contrast, the premium for AARP MedicareRx Preferred increased by $12 for 2018 (from $72 to $84), and its non-LIS enrollment decreased by 10 percent between 2017 and 2018. These enrollment changes take into account both enrollment of new Part D enrollees and plan changes by current enrollees.

Figure 7: Among the top 5 PDPs, those plans with lower premiums in 2018 than in 2017 generally have higher enrollment in 2018 than in 2017, and vice versa

The one exception to this inverse relationship among the top 5 PDPs was Humana Walmart Rx, which experienced a 6 percent increase in enrollment despite a $3 premium increase for 2018 (from $17 to $20). This could be related to the fact that, despite its premium increase for 2018, the Humana Walmart Rx PDP is among the lowest-premium PDPs available in almost all regions in 2018; while some PDPs have lower premiums, they are not available nationwide.

DEDUCTIBLES AND COST SHARING

In 2018, more than 4 in 10 Part D enrollees are in plans that charge no deductible for drug coverage.

While more than 4 in 10 PDP and MA-PD enrollees (45%) are in plans that charge no deductible, a larger share of PDP enrollees than MA-PD enrollees are in plans charging the standard deductible amount of $405 in 2018 (46% and 3%, respectively), while a larger share of MA-PD enrollees than PDP enrollees face a partial deductible amount (Table 4). As a result, the weighted average Part D deductible is higher among PDP enrollees than MA-PD enrollees in 2018 ($213 and $129, respectively).

Cost Sharing for Generic Drugs

Around 2 in 10 Part D enrollees have a $0 copayment for preferred generics, but many pay $10 or more for other (non-preferred) generics.

In 2018, 19 percent of PDP enrollees and 24 percent of MA-PD enrollees have a $0 copayment for preferred generics (Figure 8). Median cost sharing for preferred generics is $1 for PDP enrollees and $3 for MA-PD enrollees in 2018, a reduction from earlier years (Table 5).

Figure 8: Around 2 in 10 Part D enrollees have a $0 copayment for preferred generics, but many pay $10 or more for other (non-preferred) generics

For drugs on the second (non-preferred) generic tier—a tier that became common in 2012—median cost sharing is $6 for PDPs and $12 for MA-PDs. Nearly 4 in 10 PDP enrollees (37%) and 70 percent of MA-PD enrollees pay between $10 and $20 for generics on this tier.

Cost Sharing for Brand-Name Drugs

For preferred brands, most PDP enrollees pay copayments less than $40; most MA-PD enrollees pay $45 to $47.

The vast majority of Part D plans (both PDPs and MA-PDs) charge copayments for preferred brand-name drugs rather than coinsurance. Among Part D enrollees in plans that use copayments for preferred brands, enrollees typically face lower copayments in PDPs than MA-PDs (Figure 9). Nearly two-thirds of PDP enrollees (62%) are in plans charging less than $40 for these drugs, while a similar share of MA-PD enrollees (63%) are in plans charging at least $45. Median cost sharing for preferred brands in 2018 is $37 for PDP enrollees and $45 for MA-PD enrollees.

Figure 9: For preferred brands, most PDP enrollees pay copayments less than $40; most MA-PD enrollees pay $45 to $47

For non-preferred drugs, half of PDP enrollees pay coinsurance between 40% and 50%; most MA-PD enrollees pay copayments between $90 and $100.

For non-preferred drugs (or non-preferred brands; 5-tier plans use one or the other), nearly all PDP enrollees pay a coinsurance rate, whereas most MA-PD enrollees pay a copayment amount. Half of PDP enrollees pay coinsurance of 40 percent or more for non-preferred drugs, while among MA-PD enrollees in plans charging copayments for non-preferred drugs, most (89%) pay between $90-$100 (Figure 10).

Figure 10: For non-preferred drugs, half of PDP enrollees pay coinsurance between 40% and 50%; most MA-PD enrollees pay copayments between $90 and $100

Whether one group of enrollees faces higher average out-of-pocket costs than the other for non-preferred drugs cannot be assessed because of the different approaches to cost sharing that each plan type uses; in particular, the actual out-of-pocket cost that PDP enrollees face who pay coinsurance for non-preferred drugs depends on the list price of the drug.

Cost Sharing for Specialty Drugs

More than 4 in 10 Part D enrollees are in plans charging 33 percent coinsurance for specialty tier drugs.

Close to half of PDP enrollees (45%) and more than 4 in 10 MA-PD enrollees (42%) are in plans that charge the maximum 33 percent coinsurance rate for specialty drugs, defined by CMS as those that cost at least $670 per month (Table 4). Only those plans that waive some or all of the standard deductible are permitted to set the specialty tier coinsurance rate above 25 percent.

LOW-INCOME SUBSIDIES

Three in 10 Part D enrollees receive additional subsidies for Part D coverage through the Low-Income Subsidy program.

More than 12 million Part D enrollees (29%) receive low-income subsidies (Figure 11). These additional financial subsidies, also called “Extra Help,” pay Part D premiums for eligible beneficiaries, as long as they enroll in PDPs designated as premium-free “benchmark” plans, and also reduces cost sharing. Six in 10 low-income subsidy (LIS) enrollees (61%, or 7.6 million) are enrolled in stand-alone PDPs. The other 4.9 million LIS enrollees are in standard MA-PDs, Medicare Advantage Special Needs Plans (SNPs), Medicare-Medicaid plans participating in financial alignment demonstrations, cost plans, or PACE plans.

Figure 11: In 2018, 6 in 10 Part D enrollees receiving Low-Income Subsidies are enrolled in stand-alone PDPs, while more than one-third are in MA-PDs

More than 1 million LIS beneficiaries pay premiums for Part D coverage, even though they may be able to obtain coverage with no premium, either through a benchmark PDP or through a zero-premium MA-PD.

In 2018, 1.2 million LIS beneficiaries (10% of all LIS beneficiaries) pay a premium for Part D coverage, even though they may be able to obtain coverage without paying a premium. This total includes 0.9 million PDP enrollees who are not enrolled in benchmark PDPs, and more than 0.3 million MA-PD enrollees who are enrolled in MA-PDs that charge a premium. MA-PDs are not designated as benchmark plans by CMS, although most of the LIS enrollees in MA-PDs are currently enrolled in zero-premium plans.

CMS reassigns some LIS beneficiaries in PDPs to a premium-free PDP during open enrollment if their previous PDP loses benchmark status and charges a premium. But other LIS enrollees are not reassigned by CMS because they have actively selected the plan they are in, whether it is a PDP or an MA-PD.

On average, the 1.2 million LIS beneficiaries paying Part D premiums in 2018 pay $26 per month, or more than $300 per year (Figure 12). This amount is up 13 percent from 2017 and is nearly three times the amount in 2006.

Figure 12: In 2018, 1 in 10 Low-Income Subsidy enrollees pay an average of $26 per month for Part D coverage, even though they might be able to obtain coverage with no premium

Methodology

This analysis focuses on the Medicare Part D marketplace in 2018 and trends over time. Data on Part D plan availability, enrollment, and premiums were collected primarily from a set of data files released by the CMS on a regular basis:

Part D plan landscape files, released each fall prior to the annual enrollment period. These files include basic plan characteristics, such as plan names, premiums, deductibles, gap coverage, and benchmark plan status.
Part D plan and premium files, released each fall. These files include more detail on plan characteristics, including premiums charged to LIS beneficiaries, the portions of the premiums allocated to the basic and enhanced benefits, and the separate drug premiums for MA-PDs.
Part D plan crosswalk files, released each fall. These files identify which plans are matched up when a plan sponsor changes its plan offerings from one year to the next.
Part D contract/plan/state/county level enrollment files, released on a monthly basis. These files include total enrollment by contract and plan at the state and county level. We use March enrollment counts for enrollment-weighted analysis in this report. Enrollment files suppress totals for plans with 10 or fewer enrollees.
Part D Low-Income Subsidy enrollment files, released once annually (in March for 2018). These files include total enrollment counts for LIS enrollees. As with the other enrollment files, we exclude plans with small enrollment counts in estimates that are plan-enrollment weighted.
Medicare plan benefit package files, released each fall. These files supply detailed information on the benefits offered by plans, including cost-sharing amounts for each formulary tier, tier labels, and the different cost-sharing amounts for standard and preferred cost-sharing pharmacies, where applicable.
Medicare penetration files, released on a monthly basis. These files are used to estimate average counts of plans available per beneficiary.

For analysis of changes in premiums for the top 5 PDPs and changes in non-LIS enrollment, we calculated the percentage change in premiums and enrollment between March 2017 and March 2018. We did not measure the change in non-LIS enrollment that occurred during the open enrollment period specifically.

For analysis of cost sharing for formulary tiers in PDPs and MA-PDs, we did not analyze which drugs are on what tier under each type of plan and whether this has changed over time, factors which would also influence enrollees’ out-of-pocket costs

May17

President Trump’s Plan to Help Lower Cost For Medicare Part D Recipients

By Tom Matteson - blog

This is a great article by Roy Avik from Forbes, outlining how the Trump Administration is trying to help with Medicare Part D drug costs

Avik Roy , Forbes Staff

05-14-2018

WASHINGTON, DC – MAY 11: U.S. President Donald Trump listens to Health and Human Services Secretary Alex Azar deliver remarks during an announcement about drug prices in the Rose Garden at the White House May 11, 2018 in Washington, DC. Trump announced a ‘blueprint’ for lowering the cost of perscription medications. (Photo by Chip Somodevilla/Getty Images)

On Friday, in the White House Rose Garden, President Trump announced a comprehensive new effort to lower drug prices. The hot take is that the new plan will achieve little, because it doesn’t ask Medicare to directly negotiate drug prices. But the hot take is badly misinformed. The Trump plan, if enacted, represents a sea change in pharmaceutical pricing policy, one that will have a significant effect on drug prices in the future.

Medicare already negotiates drug prices

There’s long been a myth out there that within the Medicare prescription drug program, also known as “Part D,” Medicare doesn’t negotiate drug prices. But Medicare does negotiate drug prices, and has done so since the program was created in 2003.

As the Congressional Budget Office put it in a 2014 report, “The competitive structure of Part D gives plan sponsors significant incentive to hold down spending…sponsors use three main approaches: They encourage the use of less-expensive brand-name drugs, they negotiate lower prices for brand-name drugs, and they encourage the use of generic drugs.” (Emphasis added.)

This negotiating process is why Part D spending has come in massively under budget, representing the most successful cost-control experiment in Medicare’s history.

Medicare Part D spending has come in massively under budget.

Recommended by Forbes

When Medicare Part D was enacted in 2003, people on the left complained that it administered the program through private insurers and PBMs. They wanted Part D to be a government-run, single-payer program, and have long agitated for Part D to be changed in this way. That’s what people mean when they talk about Medicare directly negotiating drug prices. But the Congressional Budget Office has repeatedly evaluated this idea, and concluded that the effect would be “limited” and “modest,” because Part D plans already negotiate on Medicare’s behalf.

Congressional action on drug pricing

The Trump plan involves two categories of reform: things the administration can do unilaterally, and things that it will call on Congress to enact. Friday’s release focused mainly on unilateral actions, but the Congressional piece is arguably more important, and has gone underappreciated by many observers. As the President put it, “These [unilateral] reforms are just the beginning. In the coming weeks, we will work with Congress to pass legislation that will save Americans even more money at the pharmacy. For that, we need the help of Congress, and we think it will be forthcoming.”

In particular, the Trump administration has proposed limiting the growth of Medicare payments for drugs administered in the doctors’ office—under Medicare Part B—to consumer inflation (CPI). This simple change could save taxpayers tens of billions of dollars over time, and curb the ability of drug companies to exploit the system by instituting double-digit price increases every year for old drugs.

Similarly, the administration is proposing shifting some, if not all, drugs out of Part B into Part D, in order to increase the number of drugs that fall under Part D’s negotiating process. And the administration is considering rolling back mandates that force Medicare to keep costly drugs on its formularies, regardless of their value.

Ideally, the Trump administration will also persuade Congress to revisit two laws that have driven up the cost of prescription drugs: the Orphan Drug Act of 1983, which allows companies with no intellectual property to charge exorbitant prices for drugs meant to treat rare diseases; and the Biologics Price, Competition, and Innovation Act of 2009, which has not done enough to encourage competition for off-patent biotech drugs.

What the Trump administration will do on its own

On Friday, the administration released a 44-page blueprint for executive action on drug pricing entitled “American Patients First.” The blueprint represents the most comprehensive, serious, and thorough effort by any presidential administration to address the problem of high prescription drug prices.

That doesn’t mean it’s perfect. There are plenty of areas where the blueprint can improve. But it considers many good ideas for addressing the problem of high prices, including:

Reforming the FDA’s internal procedures in order to reduce artificial barriers to generic competition.
Promoting the use of biosimilars (i.e., generic biotechnology drugs) and reducing barriers to their take-up.
Preventing branded drug manufacturers from gaming FDA risk management strategies and 180-day generic launch rules to forestall generic competition.
Providing avenues for Medicare to bulk-purchase costly drugs so as to limit the pricing power of monopolies.
Requiring drug rebates negotiated by PBMs to be passed directly on to the patients using those drugs, instead of being used to reduce premiums for all policyholders. This should incentivize more and wider use of rebates, because price-sensitive consumers will benefit from lower prices on the drugs they themselves use.
Requiring drug companies to disclose list prices for their drugs in television ads, just as they do for side effects and other drug risks. This should make companies think twice about charging egregious prices, knowing that there will be a PR blowback.

Where the Trump administration has the wrong idea

The HHS blueprint justly recognizes the key factor in bringing drug prices down: increasing competition. But it gets distracted with other, more political goals that won’t do anything to make medicines more affordable to taxpayers.

The blueprint complains a lot about “high list prices for drugs”; that is to say, the “sticker price” that drug companies charge. But the sticker price isn’t what matters. What matters is the actual price, net of rebates and wholesaler discounts, that Americans pay. Getting that net price down should have been a greater focus of HHS’ efforts.

On a related note, the blueprint complains about “high and rising out-of-pocket costs for consumers.” Consumer costs are indeed rising, but not just for out-of-pocket payments. Spending on insurance premiums is also rising. The HHS blueprint engages in some faulty actuarial math by advocating measures that will cap out-of-pocket costs for seniors, in ways that actually incentivize the use of costlier drugs, thereby driving up Part D premiums and taxpayer spending on Medicare drugs.

Finally, the blueprint wastes several pages complaining about “foreign governments free-riding off of American investment in innovation.” This is a nationalist canard, perhaps meant to help drug companies feel better about the blueprint’s other, tougher measures. The problem is not that other countries underpay for branded drugs; the problem is that the U.S. overpays. Pharmaceutical manufacturers are free to not do business with any country that is paying an unattractive price. The drug companies accept those prices because they still make money at those rates.

Where Trump should do more: Tackling monopolies

As I mentioned above, the Trump administration is doing a lot of good things to open up competition in the drug sector. Competition is the one thing that has been reliably proven to reduce drug prices.

But there are lots of diseases—particularly rare ones–in which there is only one drug approved by the FDA for treatment. If that one drug is patented, its manufacturer often exploits that fact to charge prices that would never fly in a true market. It is in these situations where more aggressive action is needed.

Capping growth of Part B drug prices at consumer inflation is a good first step. Rolling back formulary mandates, so that Medicare isn’t forced to pay for low-value drugs, is a second one. Here are some other ideas:

Borrowing the Swiss idea of creating a safe harbor for private insurers to jointly negotiate drug prices with a monopoly manufacturer in a given state.
Eliminating requirements that force Medicare to pay for all FDA-approved drugs (i.e., open formularies).
Allowing the FDA to fast-track drugs that would compete with established monopolies.
Allowing pharmacies to import a drug from other countries if the manufacturer of an off-patent, monopoly drug takes a double-digit price increase (i.e., a price increase greater than 10 percent).

President Trump and HHS Secretary Alex Azar promise that they’re only just getting started. The proof will be in the pudding.

May14

CMS is Protecting Access to Durable Medical Equipment in Rural Areas

By Tom Matteson - blog

CMS safeguards patient access to certain medical equipment and services in rural and other non-contiguous communities

Date: 2018-05-09
Title: CMS safeguards patient access to certain medical equipment and services in rural and other non-contiguous communities
Contact: press@cms.hhs.gov

CMS safeguards patient access to certain medical equipment and services in rural and other non-contiguous communities
Interim final rule delivers relief to providers through increased fee schedule rates throughout 2018

On the heels of the Rural Health Strategy released yesterday, the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule with comment period (IFC) to increase the fee schedule rates from June 1, 2018, through December 31, 2018, for certain durable medical equipment (DME) items and services and enteral nutrition furnished in rural and non-contiguous areas (Alaska, Hawaii, and U.S. territories) of the country not subject to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP).

Today’s action aims to protect access to needed durable medical equipment in rural and non-contiguous areas that are not subject to the DMEPOS CBP, helping beneficiaries to maintain their health, mobility, and overall quality of life. Stakeholders have raised concerns about significant financial challenges the current adjusted DME fee schedule rates pose for suppliers, including many small businesses, and that the number of suppliers in certain areas continues to decline.

“This action will help Medicare beneficiaries in rural areas continue to access life-sustaining durable medical equipment, like oxygen equipment,” said CMS Administrator Seema Verma.

In 2016 and 2017, information from the DMEPOS CBP was used to adjust Medicare payments for certain DME and enteral nutrition in certain areas of the county where the CBP did not occur (“non-bid areas”). The CBP has not been implemented in rural areas comprising about half the volume of the volume of items and services furnished in non-bid areas subject to the adjustments. Beginning January 1, 2017, the fully adjusted fee schedule rates were on average 50 percent lower than the unadjusted rates in these non-bid areas based on the average reduction in payment for all of the items and services subject to the adjustments, weighted by volume.

In 2016, prior to the fully adjusted fee schedule rates going into effect, blended rates of 50 percent of the amount based on the competitive bid rates and 50 percent of the traditional fee schedule amounts were implemented for the transitional year period. Today’s action resumes these blended rates from June 1, 2018, to December 31, 2018, in rural and non-contiguous areas not subject to the CBP.

CMS is continuing to engage with stakeholders regarding the CBP, including the national mail-order program, and payment for items and services furnished in non-bid areas. Going forward, CMS will continue to review data and information about rates for DMEPOS items and services, as required under section 16008 of the 21^st Century Cures Act. CMS intends to undertake subsequent notice-and-comment rulemaking to address the rates for durable medical equipment and enteral nutrition furnished in 2019 and beyond.

For more information on Durable Medical Equipment Fee Schedule, Adjustments to Resume the Transitional 50/50 Blended Rates to Provide Relief in Rural Areas and Non-Contiguous Areas (CMS-1687-IFC) or to submit a comment on or before July 9, 2018, please visit: http://www.regulations.gov.

May8

New Medicare Cards Are On The Way: How To Avoid Being Scammed

By Tom Matteson - blog

The federal government is delaying the mailing of new Medicare cards as it beefs up security measures. (Contributed photo/CMS)

Medicare officials are mailing out new identification cards as they beef up security measures while warning of possible scams.

Beneficiaries living in Delaware, Washington, D.C., Maryland, Pennsylvania, Virginia and West Virginia were scheduled to begin receiving their new Medicare ID cards in April. Instead, the new schedule has pushed the delivery date back to May.

“We are working on making our processes even better by using the highest levels of fraud protection when we mail new cards to current Medicare beneficiaries,” the Centers for Medicare and Medicaid Services said.

New Medicare enrollees will automatically receive the new card, regardless of where they live.

The change comes as Medicare officials are working to crack down on fraud. Previously, Medicare cards contained the holder’s Social Security numbers. The new cards remove the Social Security number and replace it with a new 11-digit randomly assigned number called a Medicare Beneficiary Identifier or MBI.

Medicare card scams

The planned mailout of new Medicare cards has scammers looking to cash in.

Here’s what to be looking out for, according to CMS:

Medicare will never call you uninvited and ask for personal or private information and you do not have to provide this information to receive a new card. The new Medicare card will be mailed automatically to beneficiaries.

Do not give out your Social Security number or new MBI to anyone who contacts you about your card. If someone asks you for your information, for money, or threatens to cancel your health benefits if you don’t share your personal information, hang up and call us at 1-800-MEDICARE (1-800-633-4227).

You can go here to sign up for an alert letting you know when your new card is mailed.

Once you get your new Medicare card, destroy your old Medicare card and start using your new card right away.

May2

Great Job Morgan!

By Tom Matteson - blog

MIC would like to congratulate Morgan Novak for qualifying for the 69th annual Future Masters Tournament in Dothan Alabama. Great Job Morgan!

May1

Medicare trying to combat opioid use.

By Tom Matteson - blog

Opioid is not just impacting the younger generation it is also impacting the senior community. Here is a great article written by the New York Times that dives into the subject

Written By

Jan Hoffman

March 27, 2018

Medicare officials thought they had finally figured out how to do their part to fix the troubling problem of opioids being overprescribed to the old and disabled: In 2016, a staggering one in three of the 43.6 million beneficiaries of the program’s drug plan had been prescribed the painkillers.

Medicare, they decided, would now refuse to pay for long-term, high-dose prescriptions; a rule to that effect is expected to be approved on April 2. Some medical experts have praised the regulation as a check on addiction.

But the proposal has also drawn a broad and clamorous blowback from many people who would be directly affected by it, including patients with chronic pain, primary care doctors and experts in pain management and addiction medicine.

Critics say the rule would inject the government into the doctor-patient relationship and could throw patients who lost access to the drugs into withdrawal or even provoke them to buy dangerous street drugs. Although the number of opioid prescriptions has been declining since 2011, they noted, the rate of overdoses attributed to the painkillers and, increasingly, illegal fentanyl and heroin, has escalated.

“The decision to taper opioids should be based on whether the benefits for pain and function outweigh the harm for that patient,” said Dr. Joanna L. Starrels, an opioid researcher and associate professor at Albert Einstein College of Medicine. “That takes a lot of clinical judgment. It’s individualized and nuanced. We can’t codify it with an arbitrary threshold.”

Mr. Zobrosky’s medication regimen is strictly monitored at home. He submits to random urine tests and brings his pills to his doctor to be counted.CreditEamon Queeney for The New York Times

Underlying the debate is a fundamental dilemma: how to curb access to the addictive drugs while ensuring that patients who need them can continue treatment.

The rule means Medicare would deny coverage for more than seven days of prescriptions equivalent to 90 milligrams or more of morphine daily, except for patients with cancer or in hospice. (Morphine equivalent is a standard way of measuring opioid potency.)

According to Demetrios Kouzoukas, the principal deputy administrator for Medicare, it aims to further reduce the risk of participants “becoming addicted to or overdosing on opioids while still maintaining their access to important treatment options.”

The Centers for Medicare and Medicaid Services estimates that about 1.6 million patients currently have prescriptions at or above those levels. The rule, if approved as expected at the end of a required comment and review period, would take effect on Jan. 1, 2019.

Dr. Stefan G. Kertesz, who teaches addiction medicine at the University of Alabama at Birmingham, submitted a letter in opposition, signed by 220 professors in academic medicine, experts in addiction treatment and pain management, and patient advocacy groups.

His patients include formerly homeless veterans, many of whom have a constellation of physical and mental health challenges, and struggle with opioid dependence. For them, he said, tapering opioids does not equate with health improvement; on the contrary, he said, some patients contemplate suicide at the prospect of suddenly being plunged into withdrawal.

“A lot of the opioid dose escalation between 2006 and 2011 was terribly ill advised,” Dr. Kertesz said. “But every week I’m trying to mitigate the trauma that results when patients are taken off opioids by clinicians who feel scared. There are superb doctors who taper as part of a consensual process that involves setting up a true care plan. But this isn’t it.”

Some two dozen states and a host of private insurers have already put limits on opioids, and Medicare has been under pressure to do something, too. Last July, a report by the inspector general at the Department of Health and Human Services raised concerns about “extreme use and questionable prescribing” of opioids to Medicare recipients. In November, a report from the Government Accountability Office took Medicare to task, urging greater oversight of opioid prescriptions.

If the rule takes effect, Mark Zobrosky’s experience could be a harbinger for many patients. Mr. Zobrosky, 63, who lives in the North Carolina Piedmont, takes opioids for back pain, which persists despite five surgeries and innumerable alternative treatments. He has an implanted spinal cord stimulator that sandpapers the edge off agony, and has broken four molars from grinding because of pain, he said. He receives Medicare as a result of his disability, including a private plan that pays for his drugs.

He submits to random urine tests and brings his opioids to his doctor to be counted every month. To prepare for mandatory reductions, his doctor has tapered him down to a daily dose equivalent of about 200 milligrams of morphine. (Mr. Zobrosky has a large frame; doctors say that opioid tolerance depends on many factors — one person’s 30 milligrams is another person’s 90.)

In February, Mr. Zobrosky’s pharmacist told him that his insurance would no longer cover oxymorphone. His out-of-pocket cost for a month’s supply jumped to $1,000 from $225, medical records show. “I can’t afford this for very long and I’m nervous,” he said.

A Medicare official who would speak only on background said that the limit for monthly high doses was intended not only to catch doctors who overprescribe, but also to monitor patients who, wittingly or not, accumulate opioid prescriptions from several doctors. When the dose is flagged, the pharmacist or patient alerts the doctor.

But it falls to pharmacists to be the bad-news messengers. James DeMicco, a pharmacist in Hackensack, N.J. who specializes in pain medications, said that negotiating opioid insurance rejections for patients was already “beyond frustrating.” He spends hours shuttling between doctors and insurers. “My heart goes out to patients because they feel stigmatized,” he said.

Dr. Anna Lembke, an addiction medicine expert at Stanford, sees merit in the intent of the proposed rule, if not its design.

“The C.D.C. declared a drug epidemic in 2011, which they unequivocally and rightly attributed to overprescribing,” she said. “Without external limits, I do not believe that prescribers will be able to limit their prescribing to the extent necessary to address this public health crisis.”

But, she added, Medicare also needed to establish a reasonable grace period to allow patients on high doses to taper down safely.

According to a draft of the rule, when a high-dose prescription is rejected, a doctor can appeal, asserting medical necessity — although there is no guarantee that the secondary insurer covering the drugs under Medicare would relent. A pharmacist may fill a one-time, emergency seven-day supply.

Opponents of the new limit say that doctors are already overwhelmed with time-consuming paperwork and that many will simply throw up their hands and stop prescribing the drugs altogether.

A delay or denial would put chronic pain patients — or those with inflammatory joint diseases, complex shrapnel injuries or sickle cell disease — at risk of precipitous withdrawal and resurgence of pain, doctors said.

The Medicare proposal relies on guidelines from the Centers for Disease Control and Prevention that say doctors should not increase an opioid to a dose that is the equivalent of 90 milligrams of morphine.

But experts say that Medicare misread the recommendations — that the C.D.C.’s 90-milligram red flag is for patients in acute pain who are just starting opioid therapy, not patients with chronic pain who have been taking opioids long-term. The acute pain patient, the guidelines say, should first be offered treatments like acetaminophen or ibuprofen. A short course of a low-dose opioid should be a last resort.

“We didn’t take a specific position on people who were already on high doses,” said Dr. Lewis S. Nelson, the chairman of emergency medicine at Rutgers New Jersey Medical School and University Hospital, who worked on the guidelines.

“We did say that established, high-dose patients might consider dosage reduction to be anxiety-provoking, but that these patients should be offered counseling to re-evaluate,” he added. “There is a difference between a C.D.C. guideline for doctors and a C.M.S. hard stop for insurers and pharmacists.”

Dr. Erin E. Krebs recently released a comprehensive study showing that patients with severe knee pain and back pain who took opioid alternatives did just as well, if not better than, those who took opioids. Nonetheless, she and seven others who worked on the C.D.C. guidelines signed the letter opposing the Medicare rule.

“My concern is that our results could be used to justify aggressive tapering or immediate discontinuation in patients, and that could harm people — even if opioids have no benefit for their pain,” said Dr. Krebs, an associate professor of medicine at the University of Minnesota.

“Even if we walk away from using opioids for back and knee pain, we can’t walk away from patients who have been treated with opioids for years or even decades now,” she added. “We have created a double tragedy for these people.”

Apr30

Changes to Medicare in 2018

By MedicareIC - blog

There are a few changes that have happened in 2018 to Medicare. It is important to understand how they may impact you, now and going forward. Below is a great article by Forbes that highlights all of the changes:

Article Written By

David Haass

04/14/2018

So far, 2018 has brought many new changes for Medicare patients. If you’re a Medicare agent or have a Medicare plan, you should be aware of these changes. Here are some of the biggest changes that you will see this year, including information and resources regarding new Medicare cards that will begin to be mailed out in April.

Medicare Part A

Deductibles have increased to $1,340 per benefit period. The deductible for 2017 was $1,316.

Hospital coinsurance has also undergone a $6 per day increase for days 61-90 of hospitalization. Beneficiaries are covered for shared costs for the first 60 days. Beneficiaries in a skilled nursing facility sawan increase in their daily coinsurance for days 21-100 of $3 from 2017. Lifetime reserve days have increased from $658 to $670 per day.

Medicare Part B

The annual deductible for Medicare Part B has stayed the same for 2018, as have the standard premiums. However, there are a few major changes to take note of.

Hold Harmless

Those who are protected by the “hold harmless” provision saw an increase. The hold harmless rule applies if you collect Social Security benefits and your Medicare Part B premium is deducted from those benefits each month. Most Medicare beneficiaries are covered by this.

IRMAA

If you have a higher income and therefore pay the Income Related Monthly Adjustment Amount (IRMAA), you may have also seen your premium increase.

IRMAA works in tiered income patterns. The first two tiers remained the same as far as premium surcharges. However, those who fall into higher tiers may be seeing higher premium surcharges in 2018 as a result of the Medicare Access and CHIP Reauthorization Act (MACRA). The income levels in tiers three through five were changed this year, meaning you may have gone from paying 50% of Part B costs to 65% or even 80%.

Medicare Part D

The Part D deductible for Medicare patients will increase slightly in 2018 from $400 to $405. Beneficiaries should be happy to see a $50 increase in their initial coverage limit for Medicare Part D. The new limit for 2018 is $3750. The out-of-pocket threshold for Medicare in 2018 is $5,000, which is $50 more than in 2017. The maximum copay for 2018 is $3.35 for generic drugs and $8.35 for other drugs.

New Medicare Cards

In order to protect Medicare beneficiaries from medical identity theft, the centers of Medicare & Medicaid Services (CMS) are removing social security numbers from Medicare cards and replacing them with unique Medicare Beneficiary Identifier (MBI) numbers.

Starting in April 2018, the new Medicare cards with MBIs will begin the process of being mailed out in phases by geographic location. This process is expected to be completed by April 2019. Beginning January 1, 2020, only new cards will be usable.

10 Things Medicare Beneficiaries Should Know About Their New Medicare Cards

1. Your card is being mailed out based on geographic location, but your card could arrive at a different time from your neighbor’s.

2. Once you receive your new Medicare card, destroy the old one.

3. Only give your new Medicare card number to people you trust to handle your Medicare on your behalf.

4. Know that your new Medicare number is unique to you.

5. Your new card is paper, so if you ever need a replacement card, you can print one.

6. Always keep your new card with you.

7. Your healthcare facilities and providers will be asking for your new card at your next visit.

8. If you forgot your new card at home, don’t worry. Your healthcare provider or doctor can look it up online.

9. If you’re on Medicare Advantage, your plan ID card is still your main card for Medicare. Make sure to carry your ID card as well as your new Medicare card on you.

10. If you don’t receive your new Medicare card by April 2019, call 1-800-MEDICARE.

How Medicare Agents Can Prepare For New Medicare Cards

While CMS is trying to make the new Medicare card transition as smooth as possible, there are a few steps Medicare agents should take and resources to use to prepare.

1. Prior to April 1, 2018, update your business and system processes so that they can accept the new MBI numbers.

2. Become familiar with the preferred language and termswhen talking about the new Medicare cards.

3. Understand the Medicare Beneficiary Identifier (MBI) format.

4. Add widgets to your website with a link to go.medicare.gov/newcard.

5. Begin social media outreach using the Partner Social Media Toolkit provided by CMS.

6. Download and review the 2018 partner update slides.

Thankfully, CMS has provided many resources for Medicare agencies and agents to use in order to help educate and bring awareness to people with Medicare. Make sure to check CMS partners and employers overview page regarding the new Medicare cards often for new information and resources.

Page 4 of 41 2 34

Blog

Three Medicare Part D Companies Own Half The Market: What You Should Know

United Health Group, Humana, and CVS Health own 55% of the market in the Medicare Part D arena. Here is a great article by the Kaiser Foundation on what you should know about Your part D provider and how they stack up.

Medicare Part D in 2018: The Latest on Enrollment, Premiums, and Cost Sharing

Summary

Findings

Enrollment

More than 43 million Medicare beneficiaries, or 72 percent of all Medicare beneficiaries nationwide, are enrolled in Part D plans.

In 2018, three Part D sponsors account for more than half of all Part D enrollees and two-thirds of all PDP enrollees.

The ten largest sponsors of Part D plans account for nearly 90 percent of all enrollment.

PREMIUMS

PDP premiums have risen modestly in recent years; for 2018, the average PDP premium is $41 per month.

Premiums for 7 of the 10 most popular PDPs increased in 2018, and continue to vary widely across plans.

Among the top 5 PDPs, those plans with lower premiums in 2018 than in 2017 generally have higher enrollment in 2018 than in 2017, and vice versa.

DEDUCTIBLES AND COST SHARING

In 2018, more than 4 in 10 Part D enrollees are in plans that charge no deductible for drug coverage.

Cost Sharing for Generic Drugs

Around 2 in 10 Part D enrollees have a $0 copayment for preferred generics, but many pay $10 or more for other (non-preferred) generics.

Cost Sharing for Brand-Name Drugs

For preferred brands, most PDP enrollees pay copayments less than $40; most MA-PD enrollees pay $45 to $47.

For non-preferred drugs, half of PDP enrollees pay coinsurance between 40% and 50%; most MA-PD enrollees pay copayments between $90 and $100.

Cost Sharing for Specialty Drugs

More than 4 in 10 Part D enrollees are in plans charging 33 percent coinsurance for specialty tier drugs.

LOW-INCOME SUBSIDIES

Three in 10 Part D enrollees receive additional subsidies for Part D coverage through the Low-Income Subsidy program.

More than 1 million LIS beneficiaries pay premiums for Part D coverage, even though they may be able to obtain coverage with no premium, either through a benchmark PDP or through a zero-premium MA-PD.

Methodology

President Trump’s Plan to Help Lower Cost For Medicare Part D Recipients

This is a great article by Roy Avik from Forbes, outlining how the Trump Administration is trying to help with Medicare Part D drug costs

Recommended by Forbes

CMS is Protecting Access to Durable Medical Equipment in Rural Areas

CMS safeguards patient access to certain medical equipment and services in rural and other non-contiguous communities

New Medicare Cards Are On The Way: How To Avoid Being Scammed

Great Job Morgan!

MIC would like to congratulate Morgan Novak for qualifying for the 69th annual Future Masters Tournament in Dothan Alabama. Great Job Morgan!

Medicare trying to combat opioid use.

Opioid is not just impacting the younger generation it is also impacting the senior community. Here is a great article written by the New York Times that dives into the subject

Changes to Medicare in 2018

There are a few changes that have happened in 2018 to Medicare. It is important to understand how they may impact you, now and going forward. Below is a great article by Forbes that highlights all of the changes:

Article Written By

Medicare Part A

Deductibles have increased to $1,340 per benefit period. The deductible for 2017 was $1,316.

Medicare Part B

The annual deductible for Medicare Part B has stayed the same for 2018, as have the standard premiums. However, there are a few major changes to take note of.

Hold Harmless

Those who are protected by the “hold harmless” provision saw an increase. The hold harmless rule applies if you collect Social Security benefits and your Medicare Part B premium is deducted from those benefits each month. Most Medicare beneficiaries are covered by this.

IRMAA

If you have a higher income and therefore pay the Income Related Monthly Adjustment Amount (IRMAA), you may have also seen your premium increase.

Medicare Part D

New Medicare Cards

In order to protect Medicare beneficiaries from medical identity theft, the centers of Medicare & Medicaid Services (CMS) are removing social security numbers from Medicare cards and replacing them with unique Medicare Beneficiary Identifier (MBI) numbers.

Starting in April 2018, the new Medicare cards with MBIs will begin the process of being mailed out in phases by geographic location. This process is expected to be completed by April 2019. Beginning January 1, 2020, only new cards will be usable.

10 Things Medicare Beneficiaries Should Know About Their New Medicare Cards

1. Your card is being mailed out based on geographic location, but your card could arrive at a different time from your neighbor’s.

2. Once you receive your new Medicare card, destroy the old one.

3. Only give your new Medicare card number to people you trust to handle your Medicare on your behalf.

4. Know that your new Medicare number is unique to you.

5. Your new card is paper, so if you ever need a replacement card, you can print one.

6. Always keep your new card with you.

7. Your healthcare facilities and providers will be asking for your new card at your next visit.

8. If you forgot your new card at home, don’t worry. Your healthcare provider or doctor can look it up online.

9. If you’re on Medicare Advantage, your plan ID card is still your main card for Medicare. Make sure to carry your ID card as well as your new Medicare card on you.

10. If you don’t receive your new Medicare card by April 2019, call 1-800-MEDICARE.

How Medicare Agents Can Prepare For New Medicare Cards

While CMS is trying to make the new Medicare card transition as smooth as possible, there are a few steps Medicare agents should take and resources to use to prepare.

1. Prior to April 1, 2018, update your business and system processes so that they can accept the new MBI numbers.

2. Become familiar with the preferred language and termswhen talking about the new Medicare cards.

3. Understand the Medicare Beneficiary Identifier (MBI) format.

4. Add widgets to your website with a link to go.medicare.gov/newcard.

5. Begin social media outreach using the Partner Social Media Toolkit provided by CMS.

6. Download and review the 2018 partner update slides.

Thankfully, CMS has provided many resources for Medicare agencies and agents to use in order to help educate and bring awareness to people with Medicare. Make sure to check CMS partners and employers overview page regarding the new Medicare cards often for new information and resources.