Valenzano Insurance Services

09/30/2024

Avoid big medical bills while traveling

You can find travel/trip insurance on my website at www.yourinsurancebroker.com

Here is a short article from Consumer Reports:

BATON ROUGE, La. (WAFB) - Many Americans enjoy traveling abroad, but an unexpected health issue can quickly turn a dream vacation into a costly nightmare. Consumer Reports explains how to avoid big medical bills while traveling internationally.

A 2022 survey found that nearly 1 in 4 Americans have faced health issues while traveling abroad.

It can be difficult to get quick help from your health insurance back home, and your policy might not even cover you abroad.

Most U.S. insurance providers, including Medicare, offer little to no medical coverage outside the country, which can lead to hefty medical bills if you need care.

To protect yourself, consider a travel medical insurance policy. These plans can cost less than $100 per trip, depending on the provider and what’s covered.

Be sure to shop around. Websites like InsureMyTrip and Squaremouth make it easy to compare different policies. Pick a provider with strong ratings from the Better Business Bureau and A.M. Best, a credit rating agency for insurance companies.

Before buying, check for exclusions, coverage limits, and deductibles. Verify that the plan includes any pre-existing conditions and prescriptions.

It’s also a good idea to have a policy that covers medical evacuation, especially if you’re heading to remote areas with limited access to major hospitals.

This article taken from CONSUMER REPORTS: Avoid big medical bills while traveling
By WAFB Staff
Published: Sep. 27, 2024 at 4:29 AM PDT|Updated: Sep. 27, 2024 at 4:56 AM PDT

Valenzano Insurance Services, offering Californians Individual Health, Group Health, Life Insurance . We work with most Major Insurance Carriers. Call us today at 800-531-4448!

09/10/2024

Why this year’s Medicare Annual Notice of Change will be vital reading for beneficiaries

Fortune· Getty Images
Richard Eisenberg
Updated Mon, Aug 26, 20247 min read

If you’re on Medicare, you’ll be getting one or two Annual Notice of Change letters in your mail or email this September about your 2025 coverage and costs. You may be tempted to ignore what looks like junk, as nearly a third of recipients do, according to an eHealth survey.

Don’t!!!!!

“So often, a person who is quite happy with their plan and doesn’t bother to look at their Annual Notice of Change then gets a nasty surprise in January” when the plan’s new costs and coverage kick in, says Danielle Roberts, author of 10 Costly Medicare Mistakes You Can’t Afford to Make and founding partner of Boomer Benefits, which sells Medicare policies.

What is an Annual Notice of Change?
An Annual Notice of Change from your Medicare Part D prescription drug plan or a private insurer’s Medicare Advantage plan lays out how much your premiums, deductibles, and co-pays will differ in the year ahead and whether the plan will even be offered. (Medigap plans don’t send these notices because they don’t change much year to year.)

An Annual Notice of Change from your Part D plan also says whether your prescriptions will be covered and, if so, how much you’ll pay. A Medicare Advantage Notice of Change will tell you if your doctors and hospitals will remain in the plan’s network.

While this information is always essential to make smart choices during Medicare’s eight-week open enrollment period (Oct. 15 – Dec. 7), experts say reading your Annual Notice of Change is especially important in 2024.

“There is an excellent chance that something is changing on your plan,” says Roberts. “This year, more than ever, we can expect big changes in the plans.”

Surprising effect of the $2,000 prescription drug cap
That’s largely due to a major Medicare change coming in 2025: the new $2,000 cap on out-of-pocket costs for prescriptions covered by a Part D plan.

Since Part D health insurers will be on the hook for more prescription costs due to the cap, they’ll be looking for ways to compensate.

That could mean higher premiums (currently $43 a month for stand-alone plans, on average, according to KFF), deductibles, and co-pays—possibly substantially higher than in 2024.

“I have been very, very concerned about what the $2,000 cap was going to do to Part D premiums,” says Roberts.

The prescription drug change in 2025 could also lead to your Part D plan no longer covering certain medications you take or raising prices of ones it will.

Medicare Advantage plans—some facing profit squeezes currently—often include Part D coverage, so they may respond to the $2,000 cap by trimming or eliminating benefits to keep their popular $0 premiums intact, experts expect.

As a result, your Medicare Advantage benefits that original Medicare can’t offer—such as dental, vision, hearing, and gym memberships—could be less attractive than in 2024, or possibly gone entirely.

“It really will be important to understand what’s changing in the coming year in my current plan and does the plan still fit?” says eHealth CEO Fran Soistman. “Does it still provide the value that it did when I elected to go in it in the first place?”

Reading and understanding the Notice of Change
Your Annual Notice of Change will tell you—if you can understand it.

Only 36% of Medicare beneficiaries surveyed by eHealth said their Annual Notice of Change letter is “readily understandable.”

Figure on spending about 30 minutes closely reading your Annual Notice of Change to see exactly what will be different in 2025 and whether you’ll want to switch plans or coverage next year as a result.

During open enrollment, you can switch from your current Part D plan to another, from your Medicare Advantage plan to another, from Medicare Advantage to original Medicare as well as from original Medicare to a Medicare Advantage plan.

But don’t feel compelled to switch plans just because your Annual Notice of Change says your premium will go up a little or a benefit will be trimmed slightly.

“If there’s a modest benefit decrease or premium increase, but they’re satisfied with what the carrier is providing, people shouldn’t make a change,” Soistman says.

However, he added, if a medication you take will no longer be covered or your physician or hospital won’t be in network, that’s an important change that may persuade you to switch coverage.

The Medicare Plan Finder on Medicare’s site (Medicare.gov) will let you compare Part D and Medicare Advantage plans for 2025.

And, as Philip Moeller writes in the forthcoming revised edition of his book, Get What’s Yours for Medicare, if your Medicare Advantage plan won’t include your favorite doctor or hospital in its network in the year ahead, it’s legally obligated to work with you to identify other physicians or hospitals in its network that you’d like.

A new program to help avoid big premium hikes
To help prevent drastic Part D premium increases, the government’s Centers for Medicare and Medicaid Services recently threw a bone to health insurers with a premium-stabilization plan.

Medicare will provide a special subsidy to those insurers for 2025 in exchange for avoiding slapping members with exorbitant premium hikes.

“It should take what might have been a 40%, 50%, or higher premium increase down to probably 25%,” says Soistman. “It’s still going to be a bit of sticker shock when some people see how their premiums changed.”

Roberts says, “I’m still somewhat concerned about premiums, but I feel a little better after the stabilization program announcement.”

Getting help if your Medicare plan will change
After reading your Annual Notice of Change, you may want to get help deciding on the right Medicare plans for 2025 and to understand the implications of coming changes to your plans.

You can ask a Medicare broker or agent for assistance; there’s a directory at the National Association of Benefits and Insurance Professionals site. The sooner you do, the better, since agents and brokers will be swamped near the end of open enrollment.

“At Boomer Benefits, we have to stop taking new requests after Thanksgiving,” says Roberts.

If one of your prescriptions won’t be covered by your Part D plan in 2025, call your doctor to see if another covered medication would be okay or if you should find a new plan that includes it, Roberts advises.

For information about Part D and Medicare Advantage plans without purchase recommendations, try your State Health Insurance Assistance Program or visit Medicare’s site or call Medicare’s toll-free number, 800-633-4227.

More time for open enrollment?
Soistman believes all the changes coming to Part D and Medicare Advantage plans for 2025 will push back the arrival of the Annual Notice of Change documents to the last two weeks of September.

If so, this will give people with the plans less time than normal to read the notices before open enrollment.

The eHealth agency has asked the Centers for Medicare and Medicaid Services to extend open enrollment by about five days to give beneficiaries, insurers, and Medicare brokers more time. Boomer Benefits favors the extension, too.

So far, the government hasn’t responded to eHealth’s proposal.

Could the 2025 open enrollment become Medicare’s equivalent of the Department of Education’s FAFSA financial-aid form fiasco of chaos and confusion?

“I don’t think it will be quite as drastic. I think it is going to be a year of change, though,” says Soistman. “And change is hard for people.”

This story was originally featured on Fortune.com

08/30/2024

Weight loss injections not covered in health insurance, here's the new price

The question is will this market competition now put pressure on the makers of Wegovy to do the same?

METAIRIE, La. — With a 40 percent obesity rate in Louisiana, access to affordable treatment is critical.

It took decades, but beginning in January, health insurance will have to cover weight loss surgeries.

Still, those weight loss injections are not covered.

Now there’s a new price update.

GLP-1 injections have changed the health of people who have difficulty losing weight. That excess weight can lead to chronic health problems. The medication regulates a disrupted metabolism and helps get rid of the food noise in the brain.

The medication works, but the cost doesn't.

“The state of Louisiana is considered a low-access state from an obesity standpoint," said bariatric surgeon Dr. Shuna Levy, Medical Director of the Tulane Weight Loss Center. "So, there are many, many people who do not have insurance coverage for obesity treatments, including anti-obesity medications,”.

Since insurance doesn't pay the monthly cost of more than $1,000 for injections like Wegovy or Zepbound, people are turning to compounding pharmacies, paying only $200 to $300 a month.

There is no convenient preloaded pen. It's a vial and syringe you fill and inject with a tiny needle. Well now, drugmaker Eli Lilly is significantly lowering the prices of the two lowest doses of Zepbound by giving patients the option of getting it in vials without the pen.

“So, I would say it's about time they move to the vials, truly, because access and affordability are such huge barriers for patients and getting these medications,” said Dr. Levy.

You won't be able to go to your pharmacy now to get these vials and syringes.

There's a catch. You'll have to go through Lilly's telehealth platform, LillyDirect, and pay out-of-pocket prices in the $400 to $550 a month range. You can't use the manufacturer's discount coupons, and it will be shipped to you.

“They're still expensive, but to me, this signals the beginning of market competition in terms of them ultimately lowering the price and really improving access to care for these medications.”

The question is will this market competition now put pressure on the makers of Wegovy to do the same?

In some cases, it's still less costly to pay out-of-pocket for prescription injections at a compounding pharmacy.

Author: Meg Farris / WWL Louisiana Medical Reporter (WWL)
Published: 5:26 PM CDT August 28, 2024
Updated: 5:26 PM CDT August 28, 2024
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08/08/2024

Goodbye Medicare Part D Donut Hole; Hello $2,000 Cap

The Medicare Part D "donut hole" has gone away.getty
Just about any Medicare beneficiary who takes prescription medications has heard about the donut hole. It has had quite an interesting history.

When Part D prescription drug coverage began in 2006, those who landed in the donut hole had to pay 100% of the cost for every drug. That’s likely the reason that the official name of this Part D drug payment stage is the Coverage Gap. Insurance companies didn’t pay anything in this stage. Some beneficiaries could not afford this, so they quit taking their medications.
Beginning in 2012, once in the donut hole, there were discounts for drugs. These discounts started at 50% for brand-name medications and 14% for generics.
Every year after that, discounts gradually increased until the donut hole closed completely in 2020. That didn’t make drugs free; it just made the cost sharing 25% of the drug’s cost, the same as in Initial Coverage. Some beneficiaries were paying $3,500, $4,000, or more in the donut hole.
But things are changing. The Inflation Reduction Act is taking steps to provide financial relief for beneficiaries by lowering drug costs. As of January 1, 2024, the 5% coinsurance in the Catastrophic Coverage payment stage is gone, essentially capping drug costs at $3,300-$3,500. No longer do some beneficiaries face unlimited drug costs. Then, starting in January 2025, the maximum amount anyone with Part D drug coverage will pay for medications will be $2,000. That’s only four months away so this is a good time to get to know the Part D cap.

Seven Facts About The Part D $2,000 Cap
1. The cap will apply automatically; you do not have to do anything.
That’s probably a good thing because, according to KFF, 75% of seniors don’t know or aren’t sure there is such a law that caps drug costs.

2. Costs will be capped for anyone with Part D coverage.
That coverage can be provided through a stand-alone Part D plan or Part D coverage incorporated into another plan, such as a Medicare Advantage or Federal Employee Health Benefits (FEHB) plan.

3. The cap will apply only to covered medications, meaning those that are included in a plan’s formulary.
Briefly, covered drugs must be approved by the FDA and not excluded by the Social Security Act. Drug plans must cover every drug in six protected classes: immunosuppressants, antiretrovirals, antidepressants, antipsychotics, anticonvulsants and antineoplastics, and at least two drugs from every other class. The individual will pay full retail price for any noncovered drug.

4. The cap does not apply to Part B drugs.
These drugs are provided as part of a physician’s service or for use with durable medical equipment and generally not self-administered.

It is important to note that a separate IRA initiative is working on the cost of Part B drugs. The Inflation Rebate Program will lower the price of a Part B drug that increases faster than the rate of inflation. According to a Health and Human Services press release, some beneficiaries can save between $1 and $4593 a day, depending on the type of coverage they have.

5. The cap is starting at $2,000 but it will be indexed annually for inflation.

6. This initiative has spawned a new program, the Medicare Prescription Payment Plan.
Those who reach the limit likely will get hit with $2,000 in the first or second month. This program is similar to an installment payment plan that allows one to pay off bills in consecutive payments over time. The Centers for Medicare and Medicaid Services is working on the final details and who will qualify. Once that is finalized, all stand-alone Part D plans and Medicare Advantage plans with Part D coverage must offer eligible enrollees the option to pay the out-of-pocket prescription drug costs in monthly payments.

This payment plan is optional; a person must sign up for it. Drug insurers will start sending information to those who qualify in the next few months.

7. The donut hole has vanished.
With this new $2,000 limit, there will be three Part D drug payment stages.

The deductible: This will be $590 in 2025. Plans can charge from nothing up to that limit.
Initial Coverage: Drug plan members are responsible for 25% of the cost of drugs. The plans will likely continue to charge a copayment or coinsurance until the member reaches the threshold, $2,000.
Catastrophic Coverage: Once the cap is reached, the plan member pays nothing for the rest of the calendar year.

If It Sounds Too Good To Be True…
A KFF analysis shows that the $2,000 Part D cap could reduce drug costs for over one million beneficiaries; however, many others likely will pay more. We are living that now, with the elimination of the 5% coinsurance in Catastrophic Coverage. Drug plans must pick up a bigger share of the drug costs. In response, plans changed many copayments to coinsurance and raised drug plan premiums. And, with the new cap, plans may place more restrictions on drugs or choose not to cover costly ones. When 2025 plan information becomes available this fall, we’ll all learn more.

Excuse the broken record. Please pay attention to your drug coverage during the Open Enrollment Period, October 15-December 7.

Credit article to:
Diane Omdahl
Diane Omdahl is a nationally acclaimed Medicare expert, registered nurse, and serial entrepreneur. With extensive experience, she has served as a technical... Read More

07/30/2024

What are the differences between Medicare Parts A, B, C, D?

Medicare includes four different segments that each insure a wide variety of services and supplies for enrollees.

Source: Getty Images

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July 29, 2024 - Medicare covers 67.2 million Americans, making it one of the largest payers in the US.

However, Medicare is not a monolith. It is divided into multiple parts, each covering a different range of services. Understanding the unique attributes of each Part can help payers improve member education and illuminate the Medicare population’s needs.

Medicare includes Part A, Part B, Part C—more commonly referred to as “Medicare Advantage”—and Part D. “Original Medicare” covers Parts A and B. Additionally, those who enroll in Original Medicare can buy a Medicare Supplement or Medigap policy. Although 41.4 percent of fee-for-service Medicare beneficiaries have Medigap policies, these are not considered Medicare plans.

In this article, HealthPayerIntelligence explores the differences between the various parts of Medicare and what they do and do not cover.

Medicare Part A
What it covers
This Part of Medicare addresses hospital coverage. When Medicare beneficiaries receive inpatient care, their Medicare Part A benefits cover the cost of semi-private rooms, drugs, nursing, meals, and certain other services.

Part A can also cover care received at skilled nursing facilities, hospice sites, nursing homes, and some at-home care. The program pays for a fixed number of inpatient mental health days. In skilled nursing facilities, Medicare will cover certain drug costs. Covered home health services include wound care, injections, physical therapy, medical social services, at-home medical supplies, and more.

Under Medicare Part A, beneficiaries can receive coverage for inpatient hospital care if they have a physician’s order and if the hospital accepts Medicare coverage. Beneficiaries pay a fixed amount based on the number of days that they stay in the hospital and Medicare covers the rest.

Beneficiaries must require more than just custodial care—for example, assistance with bathing or dressing—in order to qualify for nursing home coverage.

What it does not cover
Part A does not cover private nursing, personal care items, a private room (with exceptions), or a room’s television or phone costs.

In hospice care, Medicare Part A does not cover treatments or drugs to cure illnesses because this part of the program primarily covers palliative hospice care. Unless a hospice team arranges it, it also does not cover outpatient hospital treatment, including ambulance transportation, or room and board if you live in a hospice facility or if you are receiving hospice care at home.

Home health needs that extend beyond part-time or intermittent care—up to 8 hours a day or 28 hours a week—will not be covered under Medicare. All-day care, meal deliveries, and homemaker or custodial services are not covered.

Medicare Part B
What it covers
Part B covers medical needs that happen outside the hospital. This encompasses any services or equipment that have been approved to treat a condition. For example, outpatient care and durable medical equipment such as wheelchairs or walkers are all covered under this segment of Medicare.

Part B also includes preventive care coverage. Beneficiaries may receive coverage for an extensive list of preventive and screening services, from cervical cancer screenings and COVID-19 vaccines to yearly wellness visits and medical nutrition therapy services.

Both Parts A and B may cover home health services if the need is part-time or if you only need intermittent skill services. For example, a beneficiary who cannot leave home without assistance may be eligible for home health services coverage.

Certain hospital-related benefits are covered under Part B instead of Part A. Specifically, in emergencies, Medicare Part B covers ambulance services to hospitals and skilled nursing facilities. Airplane or helicopter transportation may be covered if deemed medically necessary.

Under this segment of Medicare, certain benefits have a price cap. Insulin cannot cost more than $35 under Medicare Advantage or when using a pump covered through Part B.

Part B has the most benefits related to mental health and substance abuse care services. These include inpatient mental healthcare from a doctor or provider, outpatient mental health or substance abuse care services that occur outside a hospital, intensive outpatient mental health and substance abuse care programs at specific facilities, partial hospitalization services (under certain conditions), and behavioral health integration services.

What it does not cover
Medicare Part B covers certain drugs, but the list is less extensive than its Part D counterpart. Generally, drugs that cannot be self-administered are covered through Part B. However, there are exceptions like the injectable blood clotting factors which beneficiaries can inject personally.

Many mental health services are covered under Part B. But this segment does not cover outpatient prescription drugs related to mental health conditions or general or psychiatric hospital care for mental or substance use disorders.

Oxygen equipment for air travel is not covered under Medicare Part B, although the segment does insure other oxygen supplies.

Medicare Part C or Medicare Advantage
What it covers
Although it is considered a “Part” of the large public payer program, Medicare Advantage is really a combination of Parts A and B and sometimes Part D along with extra benefits. Medicare-approved health insurers can offer Medicare Advantage plans privately.

One major difference in Part A coverage through Original Medicare compared as opposed to Medicare Advantage’s Part A benefits is that in Original Medicare beneficiaries are covered by any hospital or provider that takes Medicare. Only 1.1% of physicians opted out of Medicare in 2023. As a result, beneficiaries have a large hospital network.

In contrast, under Medicare Advantage, beneficiaries must go to a hospital within the payer’s network. This difference has been a major challenge for Medicare Advantage plans in recent years as hospitals have started dropping their Medicare Advantage contracts due to administrative and financial issues.

Medicare Advantage plans typically include benefits that go beyond traditional Medicare’s offerings. Most beneficiaries are in plans that offer vision, hearing, dental, fitness, and telehealth benefits. Less common Medicare Advantage benefits include over-the-counter benefits, acupuncture, transportation, and Part B rebates.

What it does not cover
Since these plans are privately-run and can offer extra coverage beyond Original Medicare’s parameters, they vary in their benefits. Medicare Advantage plans may not cover clinical research studies or kidney transplants. Hospice care is covered under Original Medicare, not Medicare Advantage.

Medicare Part D
What it covers
Part D covers prescription drugs. Beneficiaries with Original Medicare coverage have to enroll in Medicare Part D separately. In contrast, Medicare Advantage beneficiaries receive Part D coverage as part of their enrollment.

Part D shares some organizational similarities to Medicare Advantage in that private companies run Part D plans under Medicare regulations. As a result, there is some variation from plan to plan regarding what Part D may cover. Additionally, the list of covered drugs may change from year to year.

Each plan has its own formulary, incorporating brand-name and generic prescriptions. Payers offer two drugs for the most popular categories and classes to give beneficiaries options, and they must cover two drugs in each of the six drug categories.

What it does not cover
Part D plans will not cover every brand name and generic drug, so beneficiaries will find they might not have insurance for their preferred prescription. However, if a provider believes that the beneficiary needs a specific drug for her condition not included in her Part D plan’s formulary, the provider may appeal for an exception.

07/26/2024

HEALTH REPORTING IN THE STATES
California tries but fails to fix a major Medicare loophole for seniors
JULY 25, 20249:19 AM ET
By

Kate Wolffe

Judith Dambowic, a multiple myeloma patient, on her porch in Oakland, CA, right before shaving her head in preparation for a stem cell transplant in May. Dambowic wanted California to pass a law regulating Medigap insurance policies. The reform, which ultimately failed, would have made it easier for her to switch her coverage from Medicare Advantage to traditional Medicare.
Judith Dambowic, a multiple myeloma patient, on her porch in Oakland, CA, right before shaving her head in preparation for a stem cell transplant in May. Dambowic wanted California to pass a law regulating Medigap insurance policies. The reform, which ultimately failed, would have made it easier for her to switch her coverage from Medicare Advantage to traditional Medicare.
Judith Dambowic
Many seniors are grateful when they turn 65 and become eligible for Medicare. But to get enrolled they first have to make a big decision — choosing a Medicare plan.

The initial choice is whether to go with traditional Medicare or Medicare Advantage.

This story was produced in partnership with KFF Health News.

Traditional Medicare has deductibles, co-pays, and co-insurance, and the extra costs can add up. To fill in the gaps, people often buy a private supplemental plan, called Medigap insurance.

“One of the main benefits of Medigap is that it provides people on Medicare predictable expenses, because people pay monthly premiums to avoid unpredictable expenses if they get sick,” said Tricia Neuman, Executive Director for KFF’s Program on Medicare Policy.

This combination also gives people the most options in choosing doctors, because most accept traditional Medicare.

The other option a newly-eligible senior can choose is Medicare Advantage. This plan, sold by a private insurance company, streamlines the upfront costs, making a separate Medigap plan unnecessary.

Insurance companies often heavily market their Medicare Advantage plans, and offer extra benefits like dental and vision insurance.

Because of the initial appeal of Medicare Advantage plans, over half of people eligible for Medicare opted for a Medicare Advantage plan in 2023.

But there’s a major drawback to Medicare Advantage plans: they lock patients into a preferred network of doctors and hospitals, narrowing options for treatment.

“They might be, 65, 66, 67 — in the scheme of things, they’re at their healthiest, but it could be that over the course of several years, they develop a serious illness,” said Neuman.

The limited nature of the Advantage plans, Neuman added, means seniors might not be able to go to the specialists they want.

Sometimes seniors decide they’d rather have the flexibility and choice of providers available under traditional Medicare, and try to switch back.

But they might be stuck. If they try to switch back after the first 6 months of enrollment in Medicare, there’s no guarantee they can get a Medigap policy to pair with traditional Medicare.

That’s because private insurers who issue Medigap policies have the power to refuse coverage or set a high price, once the six-month window is closed.

“People can be denied a policy because they have a pre-existing condition, or they can be charged more, or they can get the policy — but not for the particular condition that will require medical attention,” Neuman said.

These coverage denials and price hikes were common in the individual health insurance market before reforms under the Affordable Care Act. But the ACA’s regulations don’t apply to seniors seeking Medigap plans after the six-month window.

California takes a stab at opening Medigap enrollment

A bill that would have changed that was introduced in the California legislature this year.

Driving the effort was concern among legislators that California seniors on Medicare Advantage plans were facing fewer and fewer choices in their networks.

In 2023, Scripps Health, a major San Diego hospital system, stopped accepting Medicare Advantage plans, saying the plans paid less than other insurers for the same treatments, and required doctors to navigate prior authorization protocols that were burdensome and time-consuming.

The move sent seniors in the San Diego region scrambling to sign up for traditional Medicare, supplemented by Medigap plans. The high numbers of people who found Medigap plans unaffordable drew the attention of State Senator Catherine Blakespear, who put forward a Medigap reform bill.

Four states reformed Medigap in the 1990s — Connecticut, Maine, Massachusetts, and New York. The rest, including California, allow Medigap insurers wide leeway in setting prices and issuing denials.

California’s bill would have created a 90-day open enrollment period for Medigap, every single year. That would allow seniors to opt-in or out each year and not be denied — or face exorbitant premiums due to pre-existing conditions.

Insurance industry representative Steffanie Watkins testifies April 24 before the Senate Standing Committee on Health, in opposition to a bill that would have created an annual open enrollment period for Medigap insurance. This could have allowed seniors greater flexibility in switching from Medicare Advantage plans to traditional Medicare.
Insurance industry representative Steffanie Watkins testifies April 24 before the Senate Standing Committee on Health, in opposition to a bill that would have created an annual open enrollment period for Medigap insurance. This could have allowed seniors greater flexibility in switching from Medicare Advantage plans to traditional Medicare.
Senate of the State of California
The Leukemia and Lymphoma Society became a major supporter of the effort to pass the bill.

“Cancer or any chronic illness is very, very expensive, and that's why having supplemental coverage is important,” said Adam Zarrin, a policy analyst for the Society. “The second part is about making sure that patients have access to the best health care available.”

Zarrin says leukemia and other blood cancers are more commonly diagnosed in older adults, after age 55.

That was the case for Oakland resident Judith Dambowic.

Dambowic was 58 and working as a physical therapist when she found out her swollen and painful eye was a symptom of multiple myeloma, a cancer of the bone marrow.

Ten years after being diagnosed, Dambowic has become a patient advocate in the effort to reform Medigap in California.

“It's the options. It's the choice that matters,” she said.

Dambowic has a Medicare Advantage plan, and for the moment, she is satisfied with her network choices. But with her cancer, traditional treatment options often stop working to manage the disease.

Dambowic wants flexibility in the future to seek out different clinicians, or even experimental trials.

“These slots are highly coveted and it's very hard to get in from an Advantage plan. And the Advantage plans aren't really running these cutting edge clinical trials,” Dambowic said.

But unless the regulations change, Dambowic will have to stay in Medicare Advantage. She thinks it’s unlikely she could get a Medigap policy that would allow her to return to traditional Medicare.

There’s some evidence that indicates cancer patients may have fewer options in Medicare Advantage.

A recent study in the Journal of Clinical Oncology found “[Medicare Advantage] beneficiaries have significant barriers in accessing optimal surgical cancer care,” when compared to people with traditional Medicare.

Insurance rates would increase, industry fights back

As the bill was being debated in the state Capitol this spring, Steffanie Watkins spoke to lawmakers on behalf of the insurance lobby.

If more sick Californians are able to move onto Medigap plans, Watkins argued, insurance companies would have to raise premiums for everyone.

“We are concerned with the potential devastating impacts this bill could have on the 1.1 million seniors who, by no fault of their own, would experience significant rate increases if this bill were to pass,” she said.

A state budget analysis of the proposed bill found the average Medigap premium would increase by 33 percent, about 80 dollars a month.

That’s a valid concern, according to KFF’s Tricia Neuman.

“For people with modest incomes, people [on]of the sort of lower end of the income scale who have Medigap, they might feel priced out of the market,” she said.

In the end, the bill failed to make it out of the appropriations committee to advance to a full vote in the Senate.

Zarrin blamed legislators for siding with the insurance companies, but said his group will keep pushing for this reform in future sessions.

Judith Dambowic was also disappointed.

For now, she’ll continue to focus on educating friends and other cancer patients about their Medicare options, so they know what they’re signing up for from the start — and how difficult it might be to change.

This story comes from NPR's health reporting partnership with CapRadio and KFF Health News.