Balance billing is a common practice in healthcare where a patient is billed for payments not covered by their insurance because they received treatment from out-of-network providers. Assemblyman David Chiu (D-San Francisco) pulled a bill he introduced to the state Senate that would have prohibited out-of-network hospitals to bill insured patients for emergency services. It would also have put limits on charges for each service.
In a continuing effort to lower health-care expenses for Californians, Governor Newsom is proposing that the state manufacture generic drugs, leveraging the huge market of its residents to increase competition and lower pricing.
Along with asking the drug manufacturers to make available more rebates and establishing a health-care affordability office, Newsom maintains that the reforms would “put consumers back in the driver seat.”
According to the Kaiser Family Foundation, six in ten Americans take a prescription medication and nearly 80% worry about the cost. Also, three in ten don’t take their medications because they are too expensive.
Amid allegations of price-fixing by big pharma, Newsom signed a bill in 2019 to deter “pay-to-delay” agreements between drug companies and competing manufacturers of generic drugs that serve to delay release of the cheaper off-brands. According to a study by the Federal Trade Commission, these deals to stifle competition cost consumers as much as $3.5 billion in higher drug costs every year.
While the federal mandate to have health insurance was repealed in January 2019, California has imposed its own state mandate for individuals to have insurance coverage that goes into effect January 2020. Those who fail to have a qualified health insurance plan could pay a penalty of
$695 when filing their 2020 state income tax return.
Dependent children pay half that amount or $347.50.
Families or individuals whose health-care coverage costs exceed a certain percentage of their income will not have to pay the penalty. In 2020, it is 8.24 percent of household income to be eligible for an exemption.
California has also expanded the criteria to be eligible for subsidies based on income up to 600% of FPL (Federal Poverty Level). What that means is that more people will qualify for premium assistance who may not have qualified in the past. For example, a family of four with a household income of $154,500 could qualify for help based on the new parameters.
Annual changes for those on Medicare occur in January 2020 with new deductibles and copays applying for Parts A & B. The Part A deductible (Hospital Coverage) goes from $1,364.00 to $1,408.00. The Part B deductible (Medical Services) increases to $198.00. Daily hospital copays increase to $352.00 for days 61-90 and $704.00 for days 91 and up. Skilled Nursing Facility copays go from $170.50 to $176.00.
While most peoples’ health insurance costs go down when they sign up for Medicare, many are surprised that Medicare doesn’t pay 100% of their medical expenses. There are deductibles, co-pays, and coinsurance which can add up to hundreds, if not thousands, of dollars per year of out-of-pocket costs if you have Medicare alone.
So how can you bridge the gap and keep more money in your pocket? There are basically two ways you can go. Below is an explanation of each:
Medicare Supplemental Plans – You remain in Original Medicare and can go to any doctor who takes Medicare throughout the United States. Your plan travels with you, and you do not have to get a new plan if you move out of State, and you don’t need to get referrals to see a specialist. If you want prescription drug coverage, you would have to purchase a stand-alone Part D plan to go with your Supplemental Plan.
Medicare Advantage Plans – You opt out of Original Medicare and go with a private company that combines Parts A, B and D into one plan (which is also called Medicare Part C). Most plans require you to see Network Doctors and get referrals to see a specialist. Some plans exclude Part D if you have other drug coverage such as VA Medicare benefits. Advantage Plans include Special Needs Plans for people with certain chronic conditions and Medi-Medi plans for those who qualify for both Medicare and Medical.
If you’re approaching Medicare eligibility, it is important to know the various times to sign up for this important milestone. Here are the enrollment periods that might help you determine what your eligibility is and whether you need to sign up for Medicare at all.
Initial Enrollment Period – Period three months before your 65th birthday month, your birthday month, and three months following your birthday month. You are guaranteed issue (no underwriting) for the plan you select.
Annual Enrollment Period – Period every year between October 15 and December 7 when you can change your Medicare Advantage Plan or Prescription Drug Plan.
Open Enrollment Period – Additional period of time from January 1 through March 31 when you can change your Medicare Advantage Plan. You can also return to Original Medicare with or without a drug plan.
Retirement/Loss of Group Health Insurance – Period of time once you retire or lose creditable group coverage to sign up for Medicare and a Supplemental, Advantage Plan and/or Part D Drug plan.
Supplemental Plan Birthday Rule – Period that allows you to change your Supplemental plan that begins 30 days before your birthday up to 30 days after your birthday.
Special Enrollment Period – Period of time to change your Medicare Advantage plan or Part D drug plan because of a life event, i.e., moving out of service area, qualifying for Low Income Subsidy.
If you are still actively working and have a creditable (as good as Medicare) group employee health insurance plan, you may be able to keep the plan until you retire and delay signing up for Medicare without incurring penalties. Check with your benefit’s administrator to see if this is a viable option for you.
Jan Emerson-Shea, spokeswoman for the California Hospital Association, said that health plans would be less inclined to negotiate contracts with hospitals if the state imposed set prices for services. She maintained that if this provision were eliminated, the hospital association would support the bill. “That provision doesn’t need to be in the bill if the bill is really about protecting patients,” she said.
Chiu does not agree, fearing that without the provision, insurers would raise premiums to recoup their costs. “It is useless to protect patients from receiving a bill on the front end if hospitals can turn around and price gouge consumers on the back end. It’s like closing your front door and leaving the back door wide open,” he said.
To avoid these “surprise” bills, always check in advance with your health insurance carrier to make sure all the doctors involved with your surgery are in-network. Even though your hospital is in-network, it may contract with doctors who are not. Also, make sure any lab work you have done is with a facility that is in-network.
If you do receive one of these unexpected bills, there are still steps you can take to avoid or lower the payment. Many insurers will negotiate if you appeal the questionable charges. There are also billing or patient advocates who will step in to help you if you have questions concerning your bill. These advocates look for things such as duplicate or unusually high charges.
IRMAA stands for Income-Related Monthly Adjustment Amount, and what it means is that you are being charged more on your Medicare Part B premium and your Medicare Part D Drug Planpremium. How much more depends on your income. If your Modified Adjusted Gross Income, or MAGI, is over $85,000 as a single person or over $170,000 as a couple, you will have this surcharge added to your monthly premiums.
It goes up incrementally as your income rises to a high of an additional $325.00 on Part B and $77.40 for Part D if you are in the highest brackets (above $500,000 for individuals or $750,000 for couples). The amount is added to the standard premium, $135.50 for 2019. The good news is that it doesn’t affect what you pay for a supplemental or advantage plan.
Only about 5% of people on Medicare pay the extra charge which was implemented on Part B in 2003 and on Part D in 2011 as a way to save the federal government money on the burgeoning cost of the Medicare program.
What can be even more frustrating is that Medicare looks at income tax records from two years prior. That means if you sign up for Medicare in 2019, your IRMAA will be based your 2017 tax records.
Most people are making less money once they retire and go on Medicare, so what can you do if you are in this situation? You can appeal the extra charges to Medicare directly. By filing form SSA-44, Medicare may adjust the amount you owe to reflect your current income levels. If you don’t appeal, your income is re-evaluated yearly, so you won’t be paying the higher premiums forever if your income does decrease.
With nearly 30 million Americans still without Healthcare, it is one of the most pressing topics in Washington as the 2020 election approaches. While President Trump plans to delay any action on replacing Obamacare until after the election, Democrats have come up with several proposals to deal with the issue.
Probably the most well-known plan is Bernie Sanders’ (I-Vt.) Medicare For All. It is the most sweeping and the most costly with estimates around $32 trillion. It would end private insurance and replace it with a single-payer system much like Medicare with comprehensive coverage for all Americans. The huge bill could be paid, according to Sanders, by using money currently spent on federal health programs and by raising taxes on the wealthy or taxing employees and employers. It would also have no cost-sharing, i.e., premiums, deductibles, co-insurance.
Medicare for America is sponsored by Democratic Representatives Rosa DeLaur (D-Conn.) and Jan Schakowsky (D-Ill.) This plan offers Americans universal coverage but gives them the option of keeping their employer-sponsored plans. Premiums and deductibles would be based on income. The projected cost of this proposal (although there are no estimates at this time) could be paid by eliminating the tax cuts Congress passed in 2017, raising taxes on the wealthy, and increasing the Medicare payroll tax along with contributions from State governments.
The Medicare-X Choice Act is sponsored by Senators Michael Bennet (D-Colo.) and Tim Kaine (D-Va.). This plan leaves the current system in place with a Medicare-administered public option for individuals and small businesses (similar to Obamacare). It would offer tax credits for those with lower incomes to purchase Medicare-X plans.
The Medicare at 50 Act is sponsored by Senator Debbie Stabenow (D-Mich.) and Representative Brian Higgins (D-NY). This bill lowers the age to buy Medicare from 65 to 50. Obamacare subsidies could be used to purchase plans.
“Our legislation will give millions of older Americans another choice for more affordable, quality health insurance coverage,” cosponsor Senator Tammy Baldwin (D-WI) said in a press release. “For people between the ages of 50 and 64, this is a high quality option that can help reduce health care costs and increase competition in the marketplace.”
One has to ask how realistic these proposals are when the federal trust that funds Medicare is projected to run out in 2026 in the latest forecast of the program’s financial stability.
“At a time when some are calling for a complete government takeover of the American health-care system, the Medicare trustees have delivered a dose of reality,” Seema Verma, administrator of the Centers for Medicare and Medicaid Services, said in a statement after the report was released.
Beginning in January, hospitals were required to provide an online list of pricing for procedures, services and anything dispensed for your care be it a bandage, pill or blood test. Critics have touted that all this information will be of little use to the consumer because the prices are inflated and negotiated down by insurance companies. Furthermore, navigating through the convoluted list of procedures and medical codes can be a daunting task.
I decided to see for myself how hard it would be to find pricing for a surgical procedure. I chose an appendectomy, and after an hour of searching on three hospital websites, I was only able to find pricing on one site. I had to go online to look up information on the medical terminology and coding for the procedure to attempt to find it in the long, confusing lists. On two of the sites, I couldn’t find it at all.
While this new law attempts to require hospitals to provide information for consumers to comparison shop, it is of little use until something is done to make it more user-friendly. Hospital pricing has long been guarded as proprietary information, and until the hospital administrators make a commitment to true transparency, patients will continue to be on their own navigating the convoluted billing practices in place.
Open enrollment for Covered California begins October 15 and ends January 15, 2019. This is the time to change your current plan or sign up for new coverage.
Despite rising premiums, the uninsured rate remained at 8.8 percent last year with nearly 28.5million Americans without insurance. Uninsured rates are expected to rise next year when the individual mandate is lifted.
In 2018, under new guidance from the Trump administration, the Centers for Medicare and Medicaid will allow individuals to claim hardship exemptions without providing supporting documentation. A hardship might be classified as a bankruptcy, fire, flood or homelessness or other circumstance that made it impossible to get insurance. Without an exemption, an individual would pay either $695 or 2.5 percent of income, whichever is higher.
“Although the tax cuts signed by the President earlier this year eliminate the mandate penalty starting in 2019, Americans are still under threat of the penalty for this tax year of 2018,” CMS Administrator Seema Verma said in a statement clarifying the rules for this year.
Covered California has announced a projected 8.7% rate increase on 2019 health plans despite recent court rulings in New Mexico and Massachusetts. The rulings suspended $10 billion in “risk adjustment” payments meant to
stabilize the insurance market.
The program transfers money from insurers with healthier enrollees to those with enrollees who are more at risk in order to avoid “cherry-picking” by companies who take only the healthiest people.
Despite Congress’s failed attempt last year to repeal and replace the ACA, the Trump administration has been able to weaken the health law by halting subsidies covering some out-of-pocket costs and eliminating the mandate to have insurance.
Critics said that the suspension of payments will drive up costs and further undermine the ACA. Dave Jones, California Insurance Commissioner, maintained that the “Trump administration has just taken another step to sabotage the nation’s health insurance market.”