NAHU CEO: ‘Medicare For All’ Moves From Congress To The States

NAHU CEO: 'Medicare For All' Moves From Congress To The States –  InsuranceNewsNet

Source: InsuranceNewsNet

Congress has backed off “Medicare for All” for the time being. But legislators in several states are now taking up the charge.

In California, Democrats call for “a universal, single-payer health care system” as part of their party platform. A bid to install such a system failed in the California Assembly at the end of January, but the Golden State’s leaders have promised to make another run at it.

At least a dozen other states are considering bills that would ban private health insurance and establish single-payer health care. That’s bad news for ordinary Americans. It makes little sense to force nine in 10 Americans off their current health plans as part of a drive to bring about universal coverage.

About two-thirds of insured Americans currently depend on private health insurance plans. About 177 million people receive coverage through an employer, and about 34 million people purchase private coverage directly.

A single-payer system could do away with all those plans.

Moreover, Americans like their private plans. In a recent study of people with employer-sponsored coverage, more than two-thirds said they were satisfied with their insurance. More than three-quarters felt confident it would protect them during a medical emergency.

Research by the Kaiser Family Foundation found that what support there is for single-payer declines when people consider its attendant consequences like higher taxes and treatment delays.

Analyses of specific state single-payer plans suggest the downsides would be severe.

The New York Health Act, for instance, would reduce employment in the Empire State by 315,000, according to research published last year by the Foundation for Research on Equal Opportunity. Another report found that if the bill became law, New York residents would have to pay some $250 billion in new taxes.

 

Further, single-payer will lead to lower-quality care. That’s because government payers rely on lower payments to hospitals and doctors to keep costs in check. Look no further than Medicare. The American Hospital Association says hospitals receive just 87 cents for every dollar they spend treating Medicare beneficiaries.

That’s obviously not sustainable. If a single-payer system — and its low payment rates — were adopted widely, doctors and hospitals would respond by reducing the supply of care they’re willing to provide.

That diminution of supply, combined with unlimited demand stoked by making health care free at the point of service, could lead to long waits.

Just ask the Congressional Budget Office. According to a recent CBO analysis, a single-payer system would result in more “unmet demand” for health care services, “greater congestion in the health care system” and “lower payment rates.”

Lawmakers in several states have responded to concerns like these by championing a supposedly more moderate public option — a government-run insurance plan that would supposedly compete against private options.

But any public option would also reimburse providers at lower rates than private plans do. The public plan would use that pricing power to set premiums and deductibles below those of private insurers. As people gravitated toward the cheaper public option, private insurers would gradually leave the market, until only the public plan remained.

A public option is just a slower way of introducing single-payer. And single-payer health care is a cure worse than the disease.

Janet Trautwein is CEO of the National Association of Health Underwriters. This piece originally ran in the Boston Herald.

A Reduction In Medicare Part B Premiums Remains In Play. Here’s Where Things Stand

A possible reduction for Medicare Part B premiums is still in playSource: CNBC, by Sarah O’Brien

For Medicare beneficiaries wondering whether their Part B premiums could be reduced, the waiting continues.

More than three months after Health and Human Services Secretary Xavier Becerra ordered a reassessment of this year’s $170.10 standard monthly premium — a bigger-than-expected jump from $148.50 in 2021 — it remains uncertain when a determination will come and whether it would affect what beneficiaries pay this year.

 

“A mid-course reduction in premiums would be unprecedented,” said Tricia Neuman, executive director of the Medicare policy program at the Kaiser Family Foundation.

A spokesperson for the Centers for Medicare & Medicaid Services said the agency continues to reexamine the premium and will announce further information when it’s available.

About half of the larger-than-expected 2022 premium increase, set last fall, was attributed to the potential cost of covering Aduhelm — a drug that battles Alzheimer’s disease — despite actuaries not yet knowing the particulars of how it would be covered because Medicare officials were still determining that.

By law, CMS is required to set each year’s Part B premium at 25% of the estimated costs that will be incurred by that part of the program. So in its calculation for 2022, the agency had to account for the possibility of broadly covering Aduhelm.

Things have changed, however.

Several weeks ago, CMS officials announced that the program will only cover Aduhelm for beneficiaries who receive it as part of a clinical trial. Additionally, the per-patient price tag that actuaries had used in their calculation last year was cut in half, effective Jan. 1, by manufacturer Biogen — to $28,000 annually from $56,000.

“Certainly the rationale for an increase that high is gone,” said Paul Ginsburg, a nonresident senior fellow at the Brookings Institution and a health care policy expert.  “The question would be what’s administratively feasible.”

If a premium reduction occurs, there’s also the chance it could be applied for 2023 instead of 2022. There have been year-to-year drops in the Part B premium in the past for various reasons, including legislative changes to how the premium is calculated.

“If I were administering this, I’d be concerned about setting a precedent for making changes in the middle of the year,” Ginsburg said.

It’s also possible that lower-than-projected spending on Aduhelm could be at least partially offset by increased costs in other areas of Part B coverage, which includes outpatient care and medical equipment. While Medicare Part D provides prescription drug coverage, some medicines are administered in a doctor’s office — as with Aduhelm, which is delivered intravenously — and therefore covered under Part B.

“Even if fewer people are using Aduhelm than originally projected and at a lower price than assumed, the actuaries may be inclined to take into account other changes that could moderate that amount,” Neuman said.

Roughly 6 million Americans suffer from Alzheimer’s, a degenerative neurological disease that slowly destroys memory and thinking skills, and has no known cure. It also can destroy the lives of families and friends of those with the disease.

Most of these patients are age 65 or older and generally enrolled in Medicare, which covers more than 63 million individuals. In 2017, about 2 million beneficiaries used one or more of the then-available Alzheimer’s treatments covered under Part D, according to the Kaiser Family Foundation.

Medicare At 60 Would Have Harmful Unintended Consequences

Unintended Consequences Of Medicare-for-All

Source: STAT News, by Tom Church and Daniel L. Heil

In an era of rising inflation and trillion-dollar deficits, there appears to be growing bipartisan support for fiscal restraint. President Biden’s recent budget proposal featured more than $1 trillion in deficit-reducing policies. And his administration is now promising that the proposals once comprising the president’s Build Back Better agenda will be, at worst, deficit neutral.

But despite the changing fiscal environment, many in Congress are still eager to enact a costly and risky expansion of Medicare.

This idea seems simple: lower the eligibility age of Medicare from 65 to 60 to make out-of-pocket health care costs and premiums more affordable for millions of Americans. Supporters of the idea point to Medicare’s popularity among the elderly and argue that the policy would extend coverage at the stage of life when health care costs begin to rise.

This seemingly simple idea, however, would come with significant downsides and unintentional consequences. With support from the Partnership for America’s Health Care Future, we scored the distributional and fiscal impacts of lowering Medicare’s eligibility age on both the newly eligible population and on health care providers.

Expanding coverage wouldn’t be cheap. We estimate that the federal deficit would rise by as much as $42.6 billion in the first year of the program and $452 billion over its first 10 years — not counting increased interest costs to the federal government.

But the fiscal costs are only part of the story. Medicare at 60 poorly targets those in need and relies on cost-shifting to hide its true cost.

One of the justifications for lowering the eligibility age for Medicare is to help those in need of purchasing health insurance. Yet our analysis finds that compared to the 18- to 59-year-olds who would remain ineligible, the newly eligible population would be less likely to be uninsured and more likely to have incomes above 400% of the federal poverty line.

And even among the newly eligible, it is far from clear whether the policy would help low-income Americans. Many of these individuals are already receiving health care subsidies through the Affordable Care Act, so shifting them to Medicare could mean higher premiums and increased out-of-pocket spending. We estimate that 36% of Affordable Care Act enrollees would see their combined premiums plus out-of-pocket spending rise under Medicare at 60. Even worse, the group most likely to see their combined costs rise are those with incomes between 150% to 250% of the federal poverty line. Conversely, 90% of ACA recipients with incomes above 400% of the poverty line would see their combined costs fall under Medicare at 60.

There’s one other group that would be financially affected by Medicare at 60: doctors, hospitals, and other health care providers. Previous efforts to rein in growing costs have focused on paying physicians and hospitals less for their services, and Medicare at 60 is no different.

The issue is that physicians and hospitals receive less for providing the exact services to patients covered by Medicare or Medicaid than they receive for those who are privately insured. Medicare at 60 would shift more reimbursements from private rates to government-mandated Medicare rates, resulting in revenue cuts for health care providers.

Actuaries at the Centers for Medicare & Medicaid Services project that, under current law, reimbursement rates for Medicare services relative to private insurers will continue to fall. In the absence of cost-cutting measures or large increases in utilizations, reductions in inpatient hospital service payments from Medicare at 60 would reduce annual profits by about 25% for the median hospital and by even larger amounts for hospitals with below-average margins. Physicians would be less affected in the short term, but face steeper growth in cuts in the long term.

These cuts would have significant financial effects on hospitals and providers. Congress’s past behavior suggests these cuts may not come to fruition. From 2003 to 2014, Congress repeatedly overrode scheduled cuts to providers as part of the near-annual legislation that came to be known as the “doc fix.” But if Congress succumbs to political pressures and prevents reimbursement rates from falling any further, we estimate the fiscal cost of Medicare at 60 would rise by $72 billion during the 10-year budget window. The trade-off is inevitable: either Medicare at 60 will mean steep revenue cuts for physicians and hospitals, or much higher costs for taxpayers.

Lawmakers are now admitting that the federal government faces a genuine budget constraint. That makes it an odd time to think about expanding Medicare to 60-to 64-year-olds. Even under optimistic fiscal assumptions, the proposal would add billions to federal deficits, while poorly targeting those in need and straining the finances of hospitals and physicians.

Medicare Surprise: Drug Plan Prices Touted During Open Enrollment Can Rise Within a Month

Medicare Surprise: Drug Plan Prices Touted During Open Enrollment Can Rise  Within a Month | Kaiser Health NewsSource: Kaiser Health News, by Susan Jaffe

Something strange happened between the time Linda Griffith signed up for a new Medicare prescription drug plan during last fall’s enrollment period and when she tried to fill her first prescription in January.

She picked a Humana drug plan for its low prices, with help from her longtime insurance agent and Medicare’s Plan Finder, an online pricing tool for comparing a dizzying array of options. But instead of the $70.09 she expected to pay for her dextroamphetamine, used to treat attention-deficit/hyperactivity disorder, her pharmacist told her she owed $275.90.

“I didn’t pick it up because I thought something was wrong,” said Griffith, 73, a retired construction company accountant who lives in the Northern California town of Weaverville.

“To me, when you purchase a plan, you have an implied contract,” she said. “I say I will pay the premium on time for this plan. And they’re going to make sure I get the drug for a certain amount.”

But it often doesn’t work that way. As early as three weeks after Medicare’s drug plan enrollment period ends on Dec. 7, insurance plans can change what they charge members for drugs — and they can do it repeatedly. Griffith’s prescription out-of-pocket cost has varied each month, and through March, she has already paid $433 more than she expected to.

recent analysis by AARP, which is lobbying Congress to pass legislation to control drug prices, compared drugmakers’ list prices between the end of December 2021 — shortly after the Dec. 7 sign-up deadline — and the end of January 2022, just a month after new Medicare drug plans began. Researchers found that the list prices for the 75 brand-name drugs most frequently prescribed to Medicare beneficiaries had risen as much as 8%.

Medicare officials acknowledge that manufacturers’ prices and the out-of-pocket costs charged by an insurer can fluctuate. “Your plan may raise the copayment or coinsurance you pay for a particular drug when the manufacturer raises their price, or when a plan starts to offer a generic form of a drug,” the Medicare website warns.

But no matter how high the prices go, most plan members can’t switch to cheaper plans after Jan. 1, said Fred Riccardi, president of the Medicare Rights Center, which helps seniors access Medicare benefits.

Drug manufacturers usually change the list price for drugs in January and occasionally again in July, “but they can increase prices more often,” said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University and a member of the Medicare Payment Advisory Commission. That’s true for any health insurance policy, not just Medicare drug plans.

Like a car’s sticker price, a drug’s list price is the starting point for negotiating discounts — in this case, between insurers or their pharmacy benefit managers and drug manufacturers. If the list price goes up, the amount the plan member pays may go up, too, she said.

The discounts that insurers or their pharmacy benefit managers receive “don’t typically translate into lower prices at the pharmacy counter,” she said. “Instead, these savings are used to reduce premiums or slow premium growth for all beneficiaries.”

Medicare’s prescription drug benefit, which began in 2006, was supposed to take the surprise out of filling a prescription. But even when seniors have insurance coverage for drugs, advocates said, many still can’t afford them.

“We hear consistently from people who just have absolute sticker shock when they see not only the full cost of the drug, but their cost sharing,” said Riccardi.

The potential for surprises is growing. More insurers have eliminated copayments — a set dollar amount for a prescription — and instead charge members a percentage of the drug price, or coinsurance, Chiquita Brooks-LaSure, the top official at the Centers for Medicare & Medicaid Services, said in a recent interview with KHN. The drug benefit is designed to give insurers the “flexibility” to make such changes. “And that is one of the reasons why we’re asking Congress to give us authority to negotiate drug prices,” she said.

CMS also is looking at ways to make drugs more affordable without waiting for Congress to act. “We are always trying to consider where it makes sense to be able to allow people to change plans,” said Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, who joined Brooks-LaSure during the interview.

On April 22, CMS unveiled a proposal to streamline access to the Medicare Savings Program, which helps 10 million low-income enrollees pay Medicare premiums and reduce cost sharing. Enrollees also receive drug coverage with reduced premiums and out-of-pocket costs.

The subsidies make a difference. Low-income beneficiaries who have separate drug coverage plans and receive subsidies are nearly twice as likely to take their medications as those without financial assistance, according to a study Dusetzina co-authored for Health Affairs in April.

When CMS approves plans to be sold to beneficiaries, the only part of drug pricing it approves is the cost-sharing amount — or tier — applied to each drug. Some plans have as many as six drug tiers.

In addition to the drug tier, what patients pay can also depend on the pharmacy, their deductible, their copayment or coinsurance — and whether they opt to abandon their insurance and pay cash.

After Linda Griffith left the pharmacy without her medication, she spent a week making phone calls to her drug plan, pharmacy, Social Security, and Medicare but still couldn’t find out why the cost was so high. “I finally just had to give in and pay it because I need the meds — I can’t function without them,” she said.

But she didn’t give up. She appealed to her insurance company for a tier reduction, which was denied. The plan denied two more requests for price adjustments, despite assistance from Pam Smith, program manager for five California counties served by the Health Insurance Counseling and Advocacy Program. They are now appealing directly to CMS.

“It’s important to us to work with our members who have questions about any out-of-pocket costs that are higher than the member would expect,” said Lisa Dimond, a Humana spokesperson. She could not comment about Griffith’s situation because of privacy rules.

However, Griffith said she received a call from a Humana executive who said the company had received an inquiry from the media. After they discussed the problem, Griffith said, the woman told her, “The [Medicare] Plan Finder is an outside source and therefore not reliable information,” but assured Griffith that she would find out where the Plan Finder information had come from.

She won’t have to look far: CMS requires insurers to update their prices every two weeks.

“I want my money back, and I want to be charged the amount I agreed to pay for the drug,” said Griffith. “I think this needs to be fixed because other people are going to be cheated.”

Small Businesses Owe Billions In Unforgiven PPP Loans

Small Businesses Owe Billions in Unforgiven PPP Loans | Word & Brown

Source: Word & Brown, by Alex Strautman

The Paycheck Protection Program (PPP), launched as part of the federal government’s Coronavirus Aid, Relief, and Economic Security (CARES) Act to aid to small businesses coping with the impact of COVID-19, ended on May 31, 2021. However, nearly 350,000 small businesses that received a PPP loan have not had their loans forgiven. Another 380,000 loans have been only partially forgiven.

A recent analysis by Bloomberg News says total PPP debt amounts to $28 billion, with most loans for less than $25,000. During 2021, the Small Business Administration (SBA) reported distributing more than $400 billion to more than six million businesses through the PPP, Restaurant Revitalization Fund, Shuttered Venue Operators Grant, COVID Economic Injury Disaster Loan (EIDL), and targeted and supplemental advance programs.

Employers receiving a PPP loan during the first funding round had until August 30, 2021, to apply for loan forgiveness. However, advocacy groups, community leaders, and business owners say the process for seeking forgiveness is burdensome for businesses. Indeed, the loan forgiveness application, SBA Form 3508S (07/21), is seven pages and requires considerable documentation regarding how PPP funds were used.

The SBA boasted in 2021 that it had streamlined its forgiveness application processes. In a press release, the SBA said, “a borrower of a participating lender can now complete most or all of a forgiveness application using a computer or, for the first time, their smartphone. On average, users are able to complete and submit directly to the SBA their applications in just six minutes, and most receive their forgiveness decisions within a week from the date of submission.“

More than six months after the forgiveness application deadline, 50+ business and advocacy groups are still pushing the SBA, Treasury Department, and Congress to forgive automatically PPP loans of $25,000 and less. They argue that many sole proprietors face challenges with income, payroll, and expense documentation. They are also seeking rescission of a rule that denied forgiveness to businesses making a good-faith effort to comply with forgives rules.

In other PPP-related news, the Justice Department continues to go after individuals and businesses that have misused funds related to CARES assistance. In March, charges were filed in Louisiana against an Amtrak employee who sought approximately $89,000 in PPP funds, even while working full-time.

Sentencing also took place last month for two Michigan residents who obtained nearly $1.5 million in PPP funds. Authorities have recovered more than $1.123 million traced to the fraudulently obtained funds through a parallel civil asset forfeiture action. California convictions include seven individuals in Los Angeles sentenced in November for PPP and EIDL fraud in excess of $20 million, as well as a separate action last year against a Temecula business owner who sought and obtained $7.25 million in federal assistance.

CMS Proposes 5 Medicare Special Enrollment Periods

CMS proposes 5 Medicare special enrollment periods | Modern Healthcare

Source: Modern Healthcare, by Maya Goldman

Arbiters To Expand Surprise Billing Dispute Resolution Reviews, CMS Says

Surprise Medical Bills: New Protections for Consumers Take Effect in 2022 |  KFFSource: Modern Healthcare, by Maya Goldman

DMHC Guidance Confirms that California Law, Not the Federal No Surprises Act, Governs Payment and Dispute Resolution Processes for Certain Out-of-Network Services Provided in California

What the Federal 'No Surprises Act' Means in California | California  Healthline

Source: JD Supra, by Sheppard Mullin Richter & Hampton LLP

Executive Summary

The California Department of Managed Health Care (“DMHC”) issued a recent guidance interpreting the application of the No Surprises Act (“NSA”)—a new federal law prohibiting out-of-network healthcare providers from balance-billing patients for certain emergency and non-emergency services—in California.  Significantly, when determining which payment and dispute resolution processes will apply in a dispute regarding the value of non-contracted emergency and non-emergency services, the NSA expressly defers to existing state law which already protects patients from receiving “surprise” medical bills, as long as such state laws conform to certain requirements set forth in the NSA.  The NSA refers to such qualifying laws as “specified State law[s]”.  However, the NSA does not explicitly indicate which states’ existing balance billing laws qualify as “specified State law[s]”—rather, each state must independently review the provisions of the NSA to determine if its existing balance billing laws qualify.

The DMHC recently issued an All-Plan Letter (“APL”) confirming that California law governing health care service plans, as set forth in the Knox-Keene Health Care Service Plan Act of 1975 and its implementing regulations, constitutes “specified State law” and will continue to govern out-of-network disputes for certain emergency and non-emergency services provided in California, rather than the payment and dispute resolution provisions of the NSA.  However, in all states, the NSA governs disputes relating to air ambulance services, not state law.

Background of the NSA

The NSA, which went into effect on January 1, 2022, limits the amount an out-of-network provider can charge for emergency services, nonemergency services provided at in-network facilities, and air ambulance services.  When a patient receives services covered by the NSA from an out-of-network provider, the NSA generally caps the patient’s cost sharing obligation at the median in-network contracted rate that the health plan agreed to pay for similar services from in-network providers for the same services in the same geographic region.  In addition, the NSA also creates a dispute resolution process for out-of-network payment disputes.  Under the NSA’s “baseball style” dispute resolution process, when providers and payors cannot come to an agreement, each side submits an offer that an approved Independent Dispute Resolution Entity must select between as the final payment amount.  The payment and dispute resolution processes of the NSA do not apply to every dispute, however.  Before the enactment of the NSA, many states already had surprise billing laws in place, and the NSA does not fully preempt state payment standards.  Instead, it expressly defers to the requirements of qualifying “specified State law[s]”—e.g., a qualifying balance billing law as specified by the NSA.  The NSA also envisions that states may revise their balance billing laws to qualify as “specified State law” in response to the passage of the NSA and its implementing regulations.  See 86 Fed. Reg. 36,925 (July 13, 2021).

The DMHC’s APL Confirms the Application of the NSA in California

On March 21, 2022, the DMHC issued an APL confirming that California law qualifies as “specified State law” for: (i) non-emergency, noncontracted services at an in-network facility by a noncontracted provider; and (ii) out-of-network emergency services.  Federal law governs disputes relating to out-of-network services provided by air ambulance providers.

  • * The DMHC confirmed that the anti-balance billing laws enacted by California’s AB 72 are “specified State law[s]”, which apply when a non-contracted provider provides non-emergency services at an in-network facility: The DMHC concluded that California’s AB 72 is a “specified State law” governing the provision of out-of-contract non-emergency services at a contracted facility, which therefore continues to apply rather than the provisions of the NSA.  Under AB 72, the out-of-network reimbursement rate for out-of-network providers must be greater than the plan’s average contracted rate or 125% of Medicare.  AB 72 also limits the enrollee’s cost-sharing amount to the enrollee’s in-network rate.  And, as the DMHC recognized, AB 72’s definition of in-network facilities is broader than the NSA’s definition, because it encompasses not only hospitals and ambulatory surgery centers, but also laboratories, radiology, imaging centers, and other outpatient centers.  In its APL, the DMHC concluded that disputes governing these services must be resolved using the DMHC’s Independent Dispute Resolution Process, not the NSA dispute resolution mechanism.
  • * The DMHC confirmed that California law, including Knox-Keene Act provisions governing balance billing of enrollees for out-of-network emergency services and related case law, are “specified State law: As for out-of-network emergency services, the DMHC concluded that California’s complex legal framework (including the Knox-Keene Act, its implementing regulations, and related case law interpreting the same) adequately prohibits providers from balance billing enrollees for out-of-network emergency services, including certain post-stabilization care.  Thus, the DMHC confirmed, this legal framework qualifies as “specified State law” under the NSA.  As a result, for out-of-network emergency services, DMHC-licensed health plans must continue to comply with California law regarding enrollee cost-sharing, provider reimbursement, and the resolution of disputes between plans and providers/facilities for out-of-network emergency services.
  • * The DMHC recognized that the NSA applies to disputes relating to air ambulance services: Under the NSA, a plan that provides or covers air ambulance services must impose the same cost-sharing requirements for an out-of-network air ambulance provider that would apply if the services were provided by an in-network air ambulance provider. The Knox-Keene Act likewise prohibits balance billing for out-of-network air ambulance services.  However, because federal law (particularly the  Airline Deregulation Act of 1978) preempts state law on the “rates, routes and services of any air carrier,” including air ambulance providers, the DMHC concluded that California law does not govern air ambulance disputes.  Instead, the DMHC concluded, plans must follow the NSA and its implementing regulations when calculating reimbursement amounts for noncontracted air ambulance providers.

The DMHC stated that it expects CMS to issue an updated letter consistent with its interpretation of California’s balance billing laws.

Last Updated 05/25/2022

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