Matt Suter Health Insurance Specialist

04/08/2022

THis hits home for me as my mom and her father (my grandfather) both have/had Alzheimer's.

Medicare limits payments for new Alzheimer’s drug to clinical trials

The federal government on Thursday affirmed its plan to limit coverage for a costly new medication for Alzheimer’s disease, restricting it to Medicare patients enrolled in clinical trials.

Despite the Food and Drug Administration’s accelerated approval of the drug, Aduhelm, last June, the Centers for Medicare and Medicaid Services said it would limit payments for the drug to people in carefully controlled tests of the medication’s effectiveness for the progressive neurological disease.

Those trials could be approved by the FDA itself or by the National Institutes of Health, and would not have to be sanctioned by CMS, as originally proposed.

In a small victory for Alzheimer’s patients, CMS said if the FDA approves future drugs through a more traditional process, it would allow wider access to coverage for those medications. Those drugs also would target the amyloid plaques suspected of causing the devastating effects of Alzheimer’s.

The decision means Aduhelm will remain unavailable for now to some of the nation’s 6.2 million people with Alzheimer’s who had hoped to try it for mild cognitive impairment or dementia that results from the disease. The population with milder Alzheimer’s disease, the target group for the drug, is estimated at 1 million to 2 million people.

Aduhelm is the first Alzheimer’s treatment intended to slow cognitive decline.

Lee A. Fleisher, chief medical officer and director of CMS’s Center for Clinical Standards and Quality, said in a briefing for news media Thursday that “there is not currently enough evidence of clinical benefit to say [Aduhelm] is reasonable and necessary for people with Medicare.”

The decision reflects a wide spectrum of opinion on whether Aduhelm is effective enough to warrant greater distribution. A monoclonal antibody taken as a monthly infusion, the drug is the first new treatment for Alzheimer’s approved by the FDA since 2003. Its cost — $28,200 per patient, per year — also has raised concerns.

Medicare coverage for a costly, but controversial, new Alzheimer's drug will go only to people enrolled in approved clinical trials despite FDA endorsement of the medication.

03/14/2022

Top Medicare Supplement Declines - If you decide to go with a Medicare Supplement, you made a great choice. It's important to pick a reputable carrier with a good track record of longevity and market share. When you're first eligible for a plan, you are likely in an open enrollment period that guarantees coverage without any health questions asked.

After that window closes, you have a few options to change plans and carriers. In most cases, you can change a Medicare Supplement plan anytime (unlike Medicare Advantage Plans). However, you must answer health questions and a carrier has the option to accept or decline you as a customer. There are a few states that provide guarantee issue options every year on your birthday. If you're in one of those states, these top declination reasons wouldn't pertain to you.

Here are a few of the health reasons why one might be declined:
- Injections & infusions in a physician’s office
- Cardiac/Circulatory issues – heart attack, stents, bypass surgery, TIA or strokes
- Diabetes with 3 or more blood pressure medications (combo medications are being overlooked as 2 independent medications)
- Diabetes with complications – A1cs over 7.0 & neuropathy
- Respiratory issues with and without a history of to***co use – COPD, Asthma with a history of to***co use, MAC lung disease, Chronic bronchitis
- Blood pressure taking more than 3 BP meds (combo medications are being overlooked as 2 independent medications)
- Internal cancer
- Spinal Stenosis

Every insurance carrier has their own underwriting risk appetite, but these are pretty common among all the carriers. If you have been in the same plan for over 5 years and these conditions don't pertain to you, it's a good idea to compare rates with a new carrier. You may be able to get the same plan and save a fair amount. If you happen to still have Plan F, you definitely should look at Plan G.

If you choose the same plan, the coverage will be identical as plans are standardized across the country. You could receive some additional Add On's such as a dental, vision, hearing discount plan along with a gym membership. Most do not offer these, but a few carriers do.

02/03/2022

Medicare Income Related Monthly Adjustments to Part B & D
February 1, 2022|Matt Suter medicare, Medicare Part B, Medicare Part D, Part B, Part D, turning 65

When you're turning 65 or enrolling in Part B for the first time, most people get Part A free and must pay for Part B. While most individuals will pay the lowest amount (see charts below), you could be charged an Income Related Monthly Adjustment (IRMA) on Part B & Part D. If you take Part B in 2022, your Part B & D premiums are calculated on your 2020 income. If you take Part B in 2023, they look back at 2021, so forth and so on.

There is a good chance that your retirement income is lower than what it was 2 years ago due to work stoppage, retirement or some other circumstance. If that's the case, you can file an appeal and likely have it adjusted to your 2022 income or current income year if reading this in the future.

If you need to file an appeal, here are the steps you need to take.

You will need form SSA-44. Once you print the form, follow the instructions below for pages 1-3.

You will need supporting documentation. A summary letter of estimated income from you, your tax advisor or some other method you feel is sufficient. A signed statement from you is binding and all you need under perjury or penalty of law (this is stated on page 8). However, any supporting documentation can always help like a letter from your employer stating your retirement, 1099 or tax estimate from CPA. Make a copy of whatever you send for your records.

Mailing documents to social security is the best route for delivery. USPS Priority, UPS or FedEx is the safest as you get a confirmation of delivery. You can fax or use the drop box at a local office if you don't care to track the info you sent and have faith it will be found. Last, do not do this as a couple if you're married. Each person needs to file their own adjustment.

Form Instructions: (You only need to fill out pages 1-3)

Page 1: Full Name and Social Security is all you need.

Page 2:

Step 1: Choose Life Changing Event and Date of it.

Step 2: Enter 2022 Income and Tax Filing Status

Step 3: Usually answer No, but if yes, put the lower amount of the two years. Again, most of the time it's No. You will likely need to appeal this one more time the following year, if the two years look back puts you in a higher income bracket. IE: 2023 income is lower than 2021.

Page 3:

Step 4: It reiterates the supporting documentation to be attached that I mentioned above.

Step 5: Name, address and signature. You are finished, just remember to make a copy of everything you're sending.

Mail, fax or drop everything off at your local social security office. Being able to receive a confirmation is important and mail is the easiest way to get a confirmation. However, if you have faith in faxing or dropping off, go for it. You can find your local social security office using this link.

Allow 30-60 days for processing after delivering. I would follow up in 30 days by phone if you don't hear anything. If you are denied for some reason, you can ask to speak with a manager and explain your case. Sometimes an inexperienced representative may be confused. Last, if a higher amount is taken or you are billed the higher amount before this is approved, pay the higher amount. Social Security will adjust future payments accordingly.

Please reach out if you have any questions (513.807.0820)

Thanks - Matt Suter

11/17/2021

Wow!!! Part B Premiums are going up from $148.50 to $170.10 in 2022 for the majority of Americans. It could be higher depending on your income. It's the biggest increase in many years. Additionally, the Part B Deductible also increased significantly for 2022, $203 to $233. The only positive, a 5.9% COLA increase on social security income.

10/19/2021

Article from WSJ yesterday. Very good points about MAPD plans.

The choices can be confusing, and the fine print is important. But it’s crucial to choose wisely, because it may be hard to change your mind.

10/18/2021

Medicare Advantage turns 25 and why they are so popular.

As the law that created MA turns 25, about 42 percent of Medicare recipients are enrolled in MA plans, which can offer dental, vision and hearing care.

10/07/2021

Medicare Annual Election Period 2022

10/15 - 12/7 is the annual election period for people on Medicare. If you have a Medicare Advantage or Prescription drug plan, you should have received your annual notice of change (ANOC) by 10/15, likely a few weeks earlier. These are the most common actions you can take during this period.

1. Nothing, most people are happy with their plan and don't have to do anything. Your plan will automatically renew 1/1/2022 and your benefits start over for the calendar year.

Although, I encourage you to at least review every few years. Hundreds to thousands of dollars could be saved simply because of a medication you take or your max out of pocket changes. Many plans have added a lot of exciting value added benefits and lowered the max out of pocket. If you have a premium, many plans are $0 premium now. Last, networks can change annually.

2. You have a Medicare Advantage Plan and you're not happy with a certain aspect of it.

Shop a new Medicare Advantage Plan: No health questions asked and guarantee issue.

Drop your Medicare Advantage Plan > Go to Original Medicare > Get a Medicare Supplement (Must Answer Health Questions) > Get a Stand Alone Prescription Drug Plan.

3. I have a Medicare Supplement

Again, do nothing if you're happy with rates and benefits. If you aren't happy with the rates then drop your Medicare Supplement and get a Medicare Advantage Plan.

This is a good time of year to shop rates and apply for a new plan. Never cancel current plan until your new plan is active.

4. I have a Stand Alone Prescription Drug Plan

Even if happy with your plan, I encourage you to shop this every few years at a minimum. It's guarantee issue and no health questions asked. Plans vary significantly by insurance companies, formularies, pricing and pharmacy networks.

I encourage you to work with an independent agency that can shop at least 5 or more insurance carriers for you at a time. They can enter your medications, perform a network search of doctors and hospitals you need and break down those costs for you.

If you have any questions, please reach out.

Best, Matt

06/18/2021

Original Medicare is the term used when you enroll in Medicare at age 65 or before 65 due to disability. Most people pay into Medicare their entire working career and see a Medicare deduction on their paycheck. Once you have enough working hours (40 credits or approximately 10 years), you automatically qualify for Medicare Parts A (no charge) & B (optional with a premium). Your payroll deductions cover your Part A premium. If you don't have enough credits, you may qualify to purchase Part A. In most cases, you will be automatically enrolled in Part B. Most Americans pay $148.50 monthly in 2021 for Part B. However, Part B premium is determined by income.

If you're still working and have creditable coverage, it may not be necessary to get Part B. If you're not taking social security, but need Part B you will have to apply for it. If your birthday is 4/7, you would apply for Part B in January. Do not procrastinate this step. Not enrolling at the proper time could result in penalties and delayed coverage. Here is a turning 65 checklist you can use. Not signing up for Part B when first eligible will likely result in a penalty and a special enrollment window.

Let's assume it's a perfect world for this blog. You are turning 65 this year, you have all the necessary credits, you're taking social security and your birthday is in July. Your Original Medicare will start 7/1. At this time, people typically will choose a Medicare Supplement with a Prescription Drug Plan (Part D) or Medicare Advantage (Part C) Plans. Both plans are designed to mitigate risks with Original Medicare. However, you are not obligated to do either and you don't even have to pay for Part B. I believe getting one of the options is the wise choice, but you don't have to.

Medicare Part A Covers:

In Patient Care in a Hospital
Skilled Nursing Care Facility
Nursing Home Care
Hospice Care
Home Health care

Patient Care in a hospital will have a $1408 deductible each benefit period up until day 60, $0 coinsurance. Day 61-90 it's $352 per day. Day 90 and beyond, its $704 a day up to a lifetime reserve of 60 days. While unlikely, it could be very costly without a plan if you have an extended stay. Skilled Nursing Care facility will cover the first 20 days, then it's $185.50 per day up until day 100. You pay 100% after day 100 if you don't have a long term care policy. You may click on the link above for more details on the coverage.

Medicare Part B Covers:

Doctors
Preventive Services
Ambulance Services
Durable Medical equipment
Mental Health
Limited Outpatient Prescription Drugs

Part B has an annual $203 deductible in 2021. After you meet the deductible, Medicare pays 80% and you pay 20%.

Claims & Examples

It's important to note, Medicare has an approved rate and they negotiate very well with all aspects of Part A & B. You will see why a select few decide to simply choose original Medicare. You can use this tool to get an idea what a procedure might cost you.

Claim 1: You hurt your knee and have not been to any doctor yet this year. So you go see your favorite Orthopedic specialist. He looks at your knee and determines that it needs an MRI and it eventually leads to a meniscus surgery.

Doctor Visit: The doctor's rate for that visit might be $250.00. The Medicare Approved rate is $100. Since you haven't met your deductible, you pay $100. You now have $103 left on your $203 Part B annual deductible.

MRI: You get an MRI at any facility that accepts Medicare. The facility charges $1200 and the Medicare approved rate is $300. You will pay $103 of the $300 and you will owe $8 - $15 depending on where it's performed.

Meniscus Surgery: Using Medicare's Procedure cost look up, this would be anywhere from $401 - $691.

Claim 2: Simple Colonoscopy

This will cost you after the Part B deductible approximately $142-$241 depending on where it's done.

Claim 3: Hospital Stay (not including any Part B costs in the hospital)

Less than a day: Likely less than the $1408 deductible

5 Days: $1408

10 Days: $1408

59 Days: $1408

69 Days: $1408, plus 9 days at $352 each day.

Summary:

The point of this article is definitely NOT talk you out of getting a Medicare Supplement or Medicare Advantage plan. They can potentially mitigate large losses. However, Original Medicare on it's own does very well in terms of negotiating costs for you.

With Original Medicare and Medicare Supplements, you can go to any doctor or hospital that accepts it. If you choose a Medicare Advantage Plan, you will not have these freedoms, but they still make great options. I have provided many links above that take you to my website, blogs, Medicare's official site (Bible) along with their cost tool where you can learn more about everything Medicare.

If you choose to risk Original Medicare by itself, you can also get a stand alone prescription drug plan. If you do not get a drug plan when first eligible, there is a penalty for late enrollment that lasts a lifetime. If you have a specific question, please reach out.