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Medicare Surprise: Drug Plan Prices Change Mid-Year

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

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.

A 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.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Subscribe to KHN’s free Morning Briefing.

Why People Leave Medicare Advantage Plans

Why are so many people leaving Medicare Advantage Plans?
Studies show several reasons for the trend.

  1. Location

An article in Modern Healthcare found that people living in rural areas are more likely to leave Medicare Advantage and go back to Original Medicare. This is partially attributed to the lack of available in-network doctors, specialists, facilities, etc. 

  1. Cost

Along with being in a rural area, those with costly services are also more likely to disenroll from Medicare Advantage. One study warns that if Private Insurers start charging out-of-pocket costs for lifesaving COVID-19 care, people on Medicare Advantage could face hospital bills of $1000  or more. 

In this video, we discuss several studies that address why enrollees are choosing to leave Medicare Advantage. We also cover time frames and how to switch your Medicare Advantage plan or get back on to Original Medicare. There isn’t one plan best suited for everyone but we can help get you the knowledge needed to decide what plan best suits YOUR needs.

Diabetes and Medicare Advantage

Differences between Original Medicare vs. Medicare Advantage

If I have diabetes, should I choose Original Medicare or Medicare Advantage?

The answer to this question depends on how important individualized care is to you.

Medicare Advantage plans are typically bundled, all-in-one plans that are made as a ‘one size fits all’, with a prescription drug plan included.

However, Original Medicare is set up for you to choose a supplement plan along with a prescription drug plan tailored to your individual needs.

The American Journal of Managed Care published a study pertaining to the difference in treatment of diabetes between Original Medicare and Medicare Advantage.

In the study, they concluded that in order to achieve savings, Medicare Advantage enrollees are more likely to be treated with cheaper medications, such as Metformin and Sulfonylureas, rather than receive costly, newer medications, compared to Original Medicare. This means Original Medicare affords you the opportunity to have the drugs that might best suit you.

In this video, we review the study and explain some of the differences between Original Medicare and Medicare Advantage. We also discuss why this decision is so important if you or someone you know has diabetes and are searching for the best plan.

If you would like help finding the best Medicare plan for you, please reach out. Our help is 100% FREE to you.

How to Leave a Medicare Advantage Plan

In the first quarter of every year, seniors often discover that the plan they signed up for during the Annual Enrollment Period does not suit them.
Their doctors may have already left the network. Hospitals they thought participated might have dropped out already.

Still, some seniors have now had the time to review the Summary of Benefits and looked closely at how chemotherapy is covered by Medicare Advantage.

This is often quite a shock, when, not only must they use only network providers (in the case of the HMO), but the plans typically only pay 80% of the cancer treatment costs.

That’s the “Advantage” they’ve been sold for the often-zero premium.

Regardless of the reason, Medicare says that the first quarter is the opportunity to go back to original Medicare or change to a more-appropriate Medicare Advantage plan.

Steps to Cancel a Medicare Advantage Plan

From January 1 to March 31, Medicare now calls this the “Open Enrollment Period.”

A more appropriate name would be the “Disenrollment Period“. Those without a plan cannot obtain one, so it is not open by any stretch.

If you wish to go from Medicare Advantage to a Medicare Supplement, here are the steps:

  1. Apply for a Medicare Supplement
  2. Wait for the Underwriting Approval from the Supplement company
  3. When approved, make an application for a Part D plan.
  4. When the Part D plan starts, it automatically cancels the Advantage plan

This process ensures that you do not prematurely cancel the only insurance you may be able to qualify for. By using an independent Medicare broker, like the Senior Savings Network, you can find out what Medicare Supplement companies will likely approve your application and guarantee that you will not be paying too much for the same coverage that is offered by all of the Medicare Supplement companies.

Careful: Do Not Act in Haste!

Far too often, we get calls from seniors telling us that they became angry with the details of their Medicare Advantage plan and have already called their company and told them to cancel it. This is the wrong move.

In a worst-case scenario, that Advantage plan MAY be the only insurance you can have and, having something is better than nothing at all. So let an independent professional advise you on which plans are available in the market and which ones are most likely to approve you.

We would be happy to help with this process.


You can contact us securely here or by calling us at 1-800-729-9590.

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Medicare and You Book

The 2022 Medicare & You Guidebook is available and you can download it here.

When downloading the digital version, it will open in your Acrobat document reader, or in your browser. A tip for finding what you want, instantly, is to hit the Control and F button at the same time on your keyboard. This will bring up the FIND feature in your reader. 

Then, type in a word or phrase you are looking for. The reader should show you how many instances of that word or phrase exist in the entire book and you can click the down arrow to move from the first to the second, and so on.

This is how we zero in on things such as the Special Election Periods, Trial Right scenarios, Guarantee Issue Periods, and more. 

The 2022 Medicare & You book is slightly less controversial than those in the past.

 CMS (Center for Medicare and Medicaid Services) has been leaning more and more toward promoting Medicare Advantage plans and this bias has started to come through in their Medicare guide book.

In 2018, the non-profit Medicare Rights Center, in a joint letter with the Center for Medicare Advocacy and Justice in Aging, wrote a letter to the Administrator of CMS urging corrections in the proposed guidebook for 2019. 

They stated, “First, in several places, the Handbook suggests that Medicare Advantage is the less expensive alternative for beneficiaries. This is an overstatement. There are many variables determining whether enrollment in a Medicare Advantage plan may be more or less expensive for any particular Medicare beneficiary…. The repeated suggestion that Medicare Advantage can save beneficiaries money does not fairly represent these realities.”

The letter went on to point out that various descriptions throughout the book give the false impression that the benefits of Original Medicare are the same as the benefits in Medicare Advantage.

When the guidebook was first read by many of our clients, they found it to be confusing, contradictory, and inaccurate to their experience with Medicare. This again points to the benefit of using an independent Medicare professional who can interpret the realities of Medicare and how it works in the real world. This only comes from experience.

We are here to help and our service is always free.
1-800-729-9590

Does the Mayo Clinic Accept Medicare Supplement Plans?

Can you use your Medicare Supplement plan at the Mayo Clinic? Yes.
Depending on which Medicare Supplement plan letter you have, you may or may not be responsible for paying “Excess Charges”.

As of 2020, Mayo Clinic in Florida accepts full Medicare Assignment.
This means that they will not bill Excess Charges. Those on Medicare Supplement Plan N will not see an additional bill for Excess Charges when visiting the Mayo Clinic in Florida.

The Arizona Mayo Clinic facility does not (yet) accept Medicare Assignment, so those on Plan N might see an Excess Charge billed from Mayo in Arizona.

Medicare Supplement plans only supplement what is APPROVED by original Medicare. If Medicare approves the procedure and pays their 80%, the Supplement plan, also known as Medigap, will fill in the remaining portion, subject to your deductible and possible co-payment, depending again on which Medicare Supplement plan letter you signed up for.

In this video, we go over the details of how Medicare and Medicare Supplements are accepted at the Mayo Clinic. Also, for those on a Medicare Advantage plan, you must look very closely at your plan and communicate with Mayo on it, as these private plans are most often not accepted at centers of excellence like the Mayo Clinic.

See the video:

Need help with Medicare insurance?
Click here for our free help!

What are Excess Charges with Medicare?

Are you concerned with how excess charges might impact your Medicare plan? This video answers that:

Important to note, in addition to this video, that Medicare Advantage plans have nothing at all to do with these billing scenarios. The scenarios, including everything having to do with Excess Charges, only apply to original Medicare and/or Medicare with a Medicare Supplement policy. Medicare Advantage participants are not free to see any original Medicare provider and have restrictions, exclusions, co-pays, etc. in addition to original Medicare.

Mentioned in the video:
https://www.kff.org/medicare/issue-brief/paying-a-visit-to-the-doctor-current-financial-protections-for-medicare-patients-when-receiving-physician-services/

Physician Compare at Medicare:
https://www.medicare.gov/physiciancompare/

Getting the most out of Physician Compare tool:
https://www.youtube.com/watch?v=lI91Cp2Xwu4

We help folks with supplemental Medicare benefits, from coast to coast, and our service is completely free.

 To reach us for Medicare-related benefits help, call toll-free 1-800-729-9590

How to Sign up for MySocialSecurity Online

If you have been searching for the best information on how to sign up for a MySocialSecurity account online, this is the best place.

In the video below, it takes you through, step-by-step the entire process. It actually only takes a few minutes.

The site is more secure than ever and, the part the confuses folks the most, is the part where it actually pulls your credit report and verifies you are who you say you are. 

We have found that, often times, the information they show you, in order to verify things in your past, do not apply to you at all. In that case, just choose “None of the Above” and move on.

If you have any questions or need help signing up with your MySocial Security account, just call Social Security at their direct phone number at 1-800-772-1213.

The site to start the process, after you have seen the video is here:

https://www.ssa.gov/myaccount/create.html

See the video below. You will probably want to expand the video to full-screen, which you can do by clicking on the box inside the video playing window, on the lower right side.

The video:

We help seniors with their Medicare benefit choices. As you probably already know, Medicare covers roughly 80% of your costs, leaving a massive exposure – with no ceiling on how much you could pay during a health crisis.

Let us help! Our service is 100% NO COST to you.
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Senior Savings Network

Social Security Disability Income

How to get approved for Social Security Disability Benefits – this is one of the biggest questions on the internet.

In this in-depth video interview, we spoke with a former claims specialist form within Social Security that now works to help those applying for disability benefits. She has inside knowledge on what works and what does not work.

She loves to especially veterans to get Social Security Disability Income started as soon as possible and knows exactly what Social Security is looking for. 

See the interview:

After you have been on Social Security Disability for 24 months from the determined initial eligibility date, you are eligible for Medicare. 

The Senior Savings Network can help you, at no charge, to get the maximum value from your new Medicare benefits after you are newly eligible, following 24 months on Social Security Disability.

It is critically important that you not wait. You only have a very small window of “open enrollment” when newly eligible for Medicare. During this time frame, insurance carriers cannot reject you for Medicare Advantage or Medicare Supplement coverage. After this time expires, though, it becomes enormously difficult for someone on disability to qualify for supplemental benefits to Medicare.

The Senior Savings Network can be reached at 1-800-729-9590.