Update for April 24, 2021

Update for April 24, 2021

Fight Over Surprise Billing Regulations in Washington

Last year TSCL joined the fight to end “surprise billing,” a practice that generally refers to expensive, unexpected medical bills that patients receive from hospitals and doctors’ offices even when they have health insurance that they expect will cover the majority of the costs of treatment.

It can happen because the patient got treated by a doctor not on the list of providers that contract with that person’s health plan to provide care at negotiated rates. This can happen on visits to a hospital emergency room, when there’s no option of which doctor to see, for example.

Even when patients do seek treatment at a hospital mainly staffed by doctors in their insurance plans, they might wind up being treated by an out-of-network specialist. Worsening the problem, insurers have narrowed their networks of preferred doctors over the years in hopes of steering patients away from hospitals to lower-cost outpatient facilities and doctors.

Another issue known as “balance billing” arises when patients are billed the difference between what a doctor charges for a service and what an insurer is willing to pay for it.

Even patients on Medicare have faced this problem because not all health care providers accept Medicare or some Medicare supplement policies.

Congress passed legislation to end the practice at the end of the year, but as with so much other legislation Congress passes, it gave an outline of new policy but it left a great deal up to the President to work out the specifics.

Now, a new fight over the practice has emerged as Health groups and consumer advocates are mounting a lobbying campaign to shape forthcoming federal rules around the ban.  These are the same health groups that fought bitterly during the law’s drafting about who would pick up the costs they could no longer bill to patients.

The groups that have begun lobbying the administration include large hospital systems and health insurers, major trade associations, air ambulance companies and private equity-backed physician staffing firms.

They have already spent heavily on lobbying and are expected to soon intensify their efforts, and TSCL’s concern is that the new protections could be watered down during the rulemaking process and leave consumers still vulnerable to unexpectedly large bills.

The task for the Administration is to figure out how to ensure patients don’t unknowingly sign away their new protections, monitor and punish providers who violate the ban, and establish a process for settling disputes, among other complicated considerations. The ban is due to take effect in January.

This is an issue TSCL will continue to monitor as the year progresses to make sure the legislation is implemented as Congress intended.

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Will Biden Address Prescription Drug Prices This Week?

Although Democrats now hold the reigns of power in Washington, if only by the slimmest of margins, they are far from unanimous agreement on many of the issues facing our nation.  Included among those are the cost of health care and access to it.

This week President Biden will speak to the nation about his economic plan called the “American Family Plan.”  There is real concern among some Democrats that Biden will not include major health care policies in the plan, especially a plan to lower prescription drug costs.

House Speaker Nancy Pelosi (D- Calif.) is among those Democrats who are concerned that Biden will not address drug prices and because of that, last week House Democrats reintroduced their signature legislation to lower drug prices, known as H.R. 3.

Speaker Pelosi pointedly noted in a statement that including it in Biden's proposal is important for Democratic lawmakers. The measure would allow the secretary of Health and Human Services to negotiate lower drug prices, a long-held Democratic goal.

Democrats are also divided about how to spend the roughly $500 billion in savings that their drug pricing measure is estimated to generate.  Democratic progressives are pushing to lower the eligibility age for Medicare, and to expand Medicare to include dental, hearing and vision benefits.

However, Speaker Pelosi wants to spend the savings on making permanent an increase in ObamaCare subsidies that help people afford premiums.

Whether or not President Biden includes health care measures in his American Family Plan, it is possible that House Democrats will put the drug pricing measure and other health provisions back in the bill even if the White House leaves them out of the initial package.

Speaker Pelosi said she wants infrastructure to be bipartisan, but Republicans oppose Medicare price negotiation.  So if the Democrats are split among themselves, passing legislation will be a real up-hill climb.

Legislation to lower drug prices is one of TSCL’s top legislative goals this year so we are watching this development with great interest and we will be working hard to get some kind of legislation passed to fix the problem.

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Be Cautious When Selecting a Medicare Advantage or Supplement Plan

We have all seen the seemingly endless ads on TV by former football players, actors and fake talk show hosts that promote Medicare Advantage and Medicare supplement plans.  They all promote the long list of additional benefits that are available at (supposedly) no extra cost.

They also include an 800 number you can call to get more information and talk to an “agent” who can help guide you.  Of course, they hide that fact that the “agent” is a licensed insurance agent in the small print that you can barely read.

Now there’s a new study containing an analysis of three large, online broker insurance plan selection tools that found, on average, each included less than half of the available Medicare Advantage products and fewer than two-thirds of the applicable Part D plans.

It turns out that only 43% of available Medicare Advantage products, and 65% of Part D plans, were showcased on broker plan selection tools.

And when researchers searched online for health coverage options, they found that web results primarily showcased information directly from health plans — not from neutral government, or third-party, sources.

The report, released by the Commonwealth Fund last week, also said that in addition to the need for more transparency, continued support for existing public and not-for-profit outlets that focus on educating consumers about how Medicare works, and helping them navigate the marketplace could be helpful in smoothing seniors' transition into Medicare.

The current agent model focuses primarily on helping a patient choose a plan, rather than decide what type of Medicare is right for them. This presents a real problem for those who don't have access to tools for understanding the differences and trade-offs between plan types.

TSCL advises that when searching for a Medicare Advantage plan or Medicare supplement plan, you try to find a local or state government agency that can help you understand what the plans provide and which plan would be best for you.

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Medicare Spends Most of its Money on Only 10% of Drugs

A Kaiser Family Foundation study has found that ten percent of prescription drugs make up the majority of Medicare drug spending.

According to the study, the 250 top selling drugs, each with one manufacturer and no competitive products on the market, account for 60% of net total Medicare Part D spending. The top 50 selling drugs, also with one manufacturer each and no competitors, account for 80% of total Medicare Part B spending.

This new data strengthens the argument that focusing on negotiating prices for the relatively small number of drugs that make up a disproportionately large amount of Medicare spending could help reduce the costs of prescription drugs to Medicare and the patients who use them.

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Despite the coronavirus emergency, TSCL is continuing its fight for you to protect your Social Security, Medicare, and Medicaid benefits.  We have had to make some adjustments in the way we carry on our work, but we have not, and will not stop our work on your behalf.

For progress updates or for more information about these and other bills that would strengthen Social Security and Medicare programs, visit the our website at www.SeniorsLeague.org, follow TSCL on Twitter or Facebook.