65 Plus Health Plans LLC

10/05/2024

CMS is proposing a 2.8% cut, which opens in a new tab or window in the Medicare fee schedule for the 2025 fiscal year. If approved by Congress, this would be on top of a 1.69% cut in 2024.

Doctors' groups such as the American Medical Association argue that CMS should adopt an inflation-adjusted reimbursement model instead of cutting doctor pay. "When the cost of living goes up, there should be some [similar] adjustment in the physician reimbursement model. That will provide sustainability, especially for private practice.

Helping private practices stay in business, rather than forcing doctors to close their private practices and work for hospital systems, "will actually eventually lower the cost of care ... because reimbursement in private practice is relatively lower than hospital-based [reimbursement], so there's a cost saving for health insurers," including Medicare.

This needs to be fixed once and for all. The Medicare payment system needs to be significantly revamped because this creates a lot of stress on healthcare provision for seniors. There's nothing about this that is right."

09/28/2024

One of President Joe Biden’s signature domestic achievements is set to cause a significant spike in Medicare premiums for millions of Americans just before the November election. Now, his administration is preparing to dole out billions of dollars to private insurance companies to blunt the impact of the increase.

The jump in premiums results from efforts to reduce what older Americans pay for prescription drugs, part of the 2022 Inflation Reduction Act. Insurance companies are on the hook for what patients used to pay and are raising drug plan premiums to make up the difference. The government is giving health insurers an extra $15 per member a month to stabilize premium increases.

09/25/2024

Tuesday, the Senate Health, Education, Labor, and Pensions (HELP) Committee's hearing on Ozempic and Wegovy prices, which featured Novo Nordisk's CEO Lars Fruergaard Jørgensen as the sole witness, was no different.

Cigna Group, CVS Health, and UnitedHealth, which comprise most of the commercial insurance market, each confirmed that lowering prices would not adversely affect patient access through their programs. The insurers each operate large PBM divisions.

As it stands, PBMs receive more significant rebates on drugs with higher costs, a dynamic that can result in lower-priced drugs being placed lower on formularies or dropped altogether from the coverage lists. Last year, the HELP committee proposed a bipartisan PBM reform bill that has yet to pass the Senate floor.

At the hearing, Jorgenson expressed "a bit of concern" for how Ozempic and Wegovy price cuts could play out on the PBM side, citing prior experience with Novo's insulin Levemir being removed from formularies after a price cut. But the CEO said he'd "be happy to" sit down with the PBMs and discuss options.

08/16/2024

For the first time ever, Medicare negotiated directly with drug companies and the American people are better off for it,” said U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra.

Fiasp and NovoLog insulins (Novo Nordisk): Reduced the cost of a 30-day supply from $495 to $119, a decrease of 76%.
Farxiga (AstraZeneca): List price for a 30-day supply decreased from $556 to $178.50, or 68%.
Enbrel (Immunex Corporation): Cut the list price for a 30-day supply by 67% from $7,106 to $2,355.
Jardiance (Boehringer Ingelheim): Reduced the cost of a 30-day supply by 66%, or from $573 to $197.
Stelara (Janssen): The list price for a 30-day supply dropped from $13,836 to $4,695 or by 66%.
Xarelto (Janssen): Lowered the cost for a 30-day supply by 62%, or from $517 to $197.
Eliquis (Bristol Myers Squibb): The cost for a 30-day supply decreased from $521 to $231, or by 56%.
Entresto (Novartis): Reduced the list price for a 30-day supply by 53%, or from $628 to $295.
Imbruvica (Pharmacyclics): Decreased the cost for a 30-day supply from $14,934 to $9,319, or by 28%.

07/25/2024

Medicare Advantage provides health coverage to over half of the nation's older adults. Still, some hospitals and health systems are opting to end their contracts with MA plans over administrative challenges.

Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers.

In 2023, Becker's began reporting on hospitals and health systems nationwide that dropped some or all of their Medicare Advantage contracts.

In January, the Healthcare Financial Management Association released a survey of 135 health system CFOs, which found that 16% of systems plan to stop accepting one or more MA plans in the next two years. Another 45% said they are considering the same but have yet to make a final decision. The report also found that 62% of CFOs believe collecting from MA is "significantly more difficult" than it was two years ago.

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07/12/2024

A recent Kaiser Family Foundation article states that 5 million Medicare Part D prescription drug enrollees had out-of-pocket drug costs of $2,000 or more in at least one year during the 10 years between 2012 and 2021, and more than 6 million enrollees have paid $2,000 or more out of pocket in at least one year since 2007.

07/09/2024

Millions of Americans likely to develop and die from heart disease live in cardiology deserts — areas of the country without a single heart specialist to care for them. New research published Monday in the Journal of the American College of Cardiology finds that nearly half of all counties in the U.S. lack a practicing cardiologist.

Most of those counties are rural, with residents who tend to be sicker in general with complex medical problems. Though heart disease is the nation's No. 1 killer, people living in rural areas are dying earlier and more often from heart disease that could've been prevented, according to a Centers for Disease Control and Prevention report published in May.

07/03/2024

Attorney General Merrick Garland announced Thursday a two-week operation in which 193 people across the country, including 76 licensed healthcare providers, were charged for their alleged participation in healthcare fraud schemes.

Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure also stated that her agency “took 127 administrative actions in the last six months separately against providers for their alleged involvement in healthcare fraud schemes.”

Top of law enforcement’s list was a $900 million-plus fraud scheme in which four defendants allegedly targeted elderly Medicare patients for pricey amniotic grafts. These treatments were applied to the patients’ superficial wounds “indiscriminately, without coordination with the patient’s treating physicians and without proper treatment for infection,” DOJ said in a statement. DOJ said two of those defendants received over $600 million from Medicare within just a 16-month period.

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06/28/2024

The Centers for Medicare & Medicaid Services (CMS) announced Wednesday that Medicare enrollees will pay less for 64 prescription drugs from July through the end of September because drug companies raised prices faster than the rate of inflation.

The drugs discounted for seniors treat conditions like osteoporosis, cancer, and infections, according to a news release.

06/27/2024

A leading Democrat and health legislator is urging the Centers for Medicare & Medicaid Services (CMS) to better enforce Medicare Part D program requirements for pharmacy benefit managers.

Senate Finance Committee Chair Ron Wyden, D-Oregon, wrote to the agency in a letter that PBMs are threatening the financial health of the country's smaller pharmacies by evading such requirements.

Over 300 independent pharmacies closed last year, including 35 in Wyden's home state of Oregon. The inflated drug prices that Americans pay, the barriers to pharmacy and medication access that they face, and the impossible terms forced on pharmacies—at the hands of the pharmaceutical middlemen—cannot be allowed to stand,

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06/26/2024

Arkansas Attorney General Tim Griffin revealed the state is filing a lawsuit against pharmacy benefit managers (PBMs) Optum and Express Scripts for their role in the state's ongoing opioid epidemic.

In the lawsuit (PDF), the state argues the PBMs negotiated deals with opioid manufacturers and exploited rebates, all while failing to protect consumers as they financially benefited.

06/20/2024

Amazon Pharmacy is expanding its prescription drug subscription program, RxPass, to Prime members on Medicare insurance.
The RxPass program, launched in January 2023, provides unlimited access to 60 eligible generic medications and will ship the medications to customers' homes for a flat monthly fee of $5, along with 24/7 access to a pharmacist, according to the company.

A Medicare beneficiary who takes at least one medication available through RxPass could save approximately $70 per year, and a beneficiary who takes two or more medications could save even more, John Love, vice president of Amazon Pharmacy, said in an interview.