No Votes on Health Care or Social Security Issues This Week
After having come back in session after a two-week break, the House of Representatives is out of session again this week for a district work period. That means the members of the House are back in their districts meeting with constituents. It is a good time for you to call one of their district offices and try to arrange a meeting with your Representatives to express your concerns.
The Senate is in session this week but there are no votes schedules on health care or Social Security issues.
* * * *
Biden Administration Issues New Rule to Help Lower Drug Costs
With the legislation to lower drug costs stalled in Congress and its fate uncertain, last week the Biden Administration took action that it hopes will lower drug costs for many seniors.
Under a final rule issued last Friday, seniors enrolled in Medicare Advantage plans and Medicare Part D prescription drug plans can expect improved transparency and lower out-of-pocket costs for medications by requiring Medicare prescription drug plans to pass certain savings on to customers.
More Medicare Part D drug plans are entering “price concession” arrangements in which they pay reduced costs to some pharmacies for certain dispensed drugs. But these arrangements are not publicly disclosed, and the drug plans do not pass the savings along to Medicare patients who purchase the drugs.
The new rule requires Part D plans to give all price reductions they receive from network pharmacies to the person buying the drug, which should reduce the out-of-pocket cost charged to the customer. The policy will take effect on Jan. 1, 2024.
The delay in the starting date of the new rule is to give the Part D plans time to adjust their pharmacy contracting and avoid any possible disruptions.
However, the insurance companies that offer the Part D plans are not happy. They say that only pharmacists will benefit from this requirement, with seniors and taxpayers paying the price through higher premiums.
The final rule also requires, among other things, private Medicare Advantage plans to streamline the grievance and appeals processes in certain cases for those who are “dual-eligibles,” who are seniors who qualify for both Medicare and Medicaid. The rule makes a change in Medicare Advantage plans’ co-payment rules that would result in more equitable payments to health-care providers who serve dual-eligibles.
The rule also includes a new maximum out-of-pocket policy for dual-eligible beneficiaries for Medicare Part A hospital services and for Part B outpatient services.
* * * *
Inspector General Report Reveals Some Seniors Enrolled in Medicare Advantage Plans Denied Medically Necessary Care
Medicare Advantage Plans that have become popular among many seniors are offered by private insurance companies. They are advertised as alternatives to traditional Medicare that can be less expensive and provide a wider array of benefits than the traditional government-run program offers.
More than 27 million seniors are covered through private Medicare Advantage plans, which receive a set amount to cover each enrollee’s projected cost of care. The plans receive higher “risk-adjusted” payments for sicker individuals with more projected medical costs.
Those plans are offered because they are very profitable for the companies. However, a new report from the Office of the Inspector General (IG) of the Department of Health and Human Services raises troubling questions about how some companies are trying to increase their profits.
According to the report, some companies have denied access to medically necessary care by denying prior authorization and payment requests that, in fact, met Medicare coverage rules. They have done that by:
- using clinical criteria that are not contained in Medicare coverage rules;
- requesting unnecessary documentation; and
- making manual review errors and system errors.
They have also sometimes denied payments to providers for some services that met both Medicare coverage rules and the companies’ own billing rules. Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers.
Under traditional Medicare, there may be an incentive for hospitals and doctors to over treat patients because they are paid for each service and test performed. But the fixed payment given to private plans provides “the potential incentive for insurers to deny access to services and payment in an attempt to increase their profits,” the report concluded.
According to one health care lawyer, people signing up for Medicare Advantage are surrendering their right to have a doctor determine what is medically necessary, he said, rather than have the insurer decide.
The investigators urged Medicare officials to beef up oversight of Advantage plans and provide consumers “with clear, easily accessible information about serious violations.”
Medicare officials said in a statement that they are reviewing the findings to determine the appropriate next steps, and that plans found to have repeated violations will be subject to increasing penalties.
The agency “is committed to ensuring that people with Medicare Advantage have timely access to medically necessary care,” officials said.
* * * *
The Windfall Elimination Provision and the Government Pension Offset
The Windfall Elimination Provision and the Government Pension Offset are two provisions that unfairly reduce or even eliminate the Social Security benefits of millions of Americans who have devoted their careers to public service, as well as having worked other jobs that withheld payroll taxes from their wages for Social Security benefits.
In January of 2021, bipartisan legislation, the Social Security Fairness Act (H.R. 82) which would eliminate the WEP and the GPO was introduced by Rep. Rodney Davis (IL) and Abigail Spanberger (VA). To date the bill has 270 co-sponsors including BOTH Democrats and Republicans. TSCL strongly endorses this legislation, and we are asking that you contact your Member of Congress and ask them to support the legislation too! If they already do, say thank you! If they do not, remind them that an election is coming up and you’ll be taking this issue into consideration when you cast your ballot.
As we continue dealing with the Covid 19 pandemic, TSCL remains constant in our fight for you to protect your Social Security, Medicare, and Medicaid benefits. We’ve 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 our website at www.SeniorsLeague.org or follow TSCL Facebook or on Twitter.