OTL Benefits - Medicare Questions Answered

02/02/2026

Excellent Wall Street Journal article about the scapegoating of Medicare Advantage plans in our nation’s capital. The article lays out the facts about the performance of these plans, and the projected impact of freezing Federal payments in 2026. Congress is punishing Medicare Advantage plans instead of dealing with the real problems in financing healthcare.

Politicians make the program a scapegoat for runaway entitlements.

08/05/2025

Good overview of financial health of the major Medicare Advantage insurers. Some have shored up their finances, others will need to make changes in their 2026 plans. The bottom line - major carriers are committed to Medicare Advantage for the long term, but some of them will be trimming extra benefits, like dental and OTC, for 2026.

Watch for your Annual Notice of Changes (ANOC) at the end of September.

Insurers are planning to scale back benefits, trim plans and exit from markets. Investors are cheering.

07/29/2025

Headwinds for Medicare Advantage plans in upcoming Annual Enrollment Period

Premiums for stand alone Medicare drug plans are predicted to go up a lot in 2026, due to rising costs, regulatory changes and reduced subsidies coming out of recent legislation.

This will also have a negative financial impact on Medicare Advantage plans that include prescription drug coverage. Additionally, Medicare Advantage carriers are reporting higher than anticipated medical costs in their 2025. Combine these facts, and there may be a lot of changes for Medicare Advantage plans in 2026. Stay tuned for more updates about Annual Enrollment Period - 10/15/2025 - 12/7-2025.

Trump administration aims to soften the blow by negotiating with insurers.

06/05/2025

Good progress between major Medicare Advantage insurers and the federal government regarding reimbursements based on diagnosis’ during home visits. Home visits are a key component of quality care for those recently discharged from the hospital, or those who are shut in. But home visits should not be used to increase reimbursements to the insurers.

The changes would limit how insurers add patient diagnoses that trigger lucrative extra payments.

04/12/2025

Physician payment is a very complicated subject, but the bottom line for seniors is – does my physician participate in Medicare? Here is some good news - Physicians are not required to take Medicare patients, but most do; virtually all (98%) of non-pediatric physicians accept Medicare’s standard payment rate for all Medicare covered services, and just 1% opted out of the program in 2024. The article below is very in-depth, and here are a few take-aways:

1. CMS is focused on keeping physician payment levels at a level that will incentivize them to continue to participate in Medicare.
2. CMS recognizes that Primary Care Physicians are underpaid, and they are looking for solutions, albeit in a very difficult budgeting environment.

In November 2024, CMS finalized a 2.83% decrease in the physician fee schedule conversion factor, a key aspect of payment rates under the Medicare program, resulting in a 2.93% decrease in overall payments to physicians and other clinicians. Congress has not yet enacted legislation to address this p...

04/09/2025

Good news for those of us enrolled in Medicare Advantage plans, or considering to do so. Payments from the Federal government to MAPD plans will increase on average just above 5% in 2026. This is a larger than anticipated increase, and a big reversal from a small reduction in 2024. There are a number of moving parts, so it is worth reading this press release from CMS. The bottom line is that the Federal government believes that MAPD plans can offer critical services in an efficient, accountable manner, and this reimbursement increase will support the plans.

Today, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2026 Rate Announcement for the Medicare Advantage (MA) and Medicare Part D Prescription Drug Programs that finalizes the payment policies for these programs. This release — combined with the CY 2026 MA and Pa...

12/21/2024

Why is that other countries use private health insurance companies as part of their overall strategy, and do not have all the problems that we have here? This WSJ article boils it down, and offers some simple solutions.

The UnitedHealthcare CEO shooting has sharpened the public’s focus on the role of private insurers, a necessary evil in the U.S. healthcare system.

11/27/2024

Two of my favorite Millwright retirees - Stanley Clark Sr. and Stanley Clark Jr. Senior has been a dues paying union member since 1967, and Junior since 1990. Everyone is seeking help with all the prescription plan changes. We sorted things out, and changed them to better plans for 2025.

08/15/2024

More Good News On Prescription Drugs Costs. The Federal Government (Health and Human Services) announced today that negotiations with prescription drug manufacturers have resulted in huge discounts for the ten drugs targeted for negotiations. If you are a senior struggling with prescriptions costs, you will recognized these over-priced prescriptions - Eliquis, Xarelto, Jardiance are near th top of the list. The article below provides a good summary of this great news.

Next target for lowering prescription costs should be Prescription Benefits Managers - PBMs!

The negotiations with drugmakers are projected to save older adults $1.5 billion in out-of-pocket costs when the new prices go into effect in 2026.

07/26/2024

Big changes in Medicare Advantage Prescription Plans in 2025 for seniors who are burdened with high out of pocket costs. The following flyer summarizes the prescription coverage enhancements of the INFLATION REDUCTION ACT (IRA).

06/18/2024

Looming large over 2025 benefit and premium decisions by the Medicare insurers is the growing use and coverage of weight loss drugs. These prescriptions are expensive, and, to date, coverage has been limited to individuals who have diabetes. A recently published study at Brigham and Women’s Hospital showed that patients with overweight or obesity who have a history of heart disease, but no diabetes, had a clear benefit from taking weight loss drugs. This research will probably require the insurers to expand coverage of the drugs. This may be a breakthrough for many people suffering from obesity and related diseases. The other side of the coin is- how will this expanded coverage be paid for?

06/14/2024

KATIE PORTER AND HER FAMOUS WHITEBOARD

The Federal government is continuing price negotiations with drug manufacturers, targeting ten widely used expensive drugs. Many believe that this type of negotiation with the drug manufacturers will benefit consumers, but there are those who argue that squeezing the drug manufacturers will suppress research and development of new drugs.

Let’s look at the argument that price negotiations will suppress drug company research and development. Katie Porter is an American politician and lawyer who has been the U.S. representative from California. Katie is no slouch – raised on a farm in Iowa, graduated from Yale University and Harvard Law School. She uses her famous Whiteboard to grill Pharma CEO’s, and hits the Research and Development issue directly. Check out this video:

Using her signature whiteboard, Democratic Rep. Katie Porter laid into AbbVie CEO Richard Gonzalez on Tuesday about the disproportionate amount of money his ...