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Annual Election Period (AEP) News

Lance

The 2023 Annual Election Period

Hi Everyone,

The 2023 Annual Election Period (AEP) or also know as Medicare Open Enrollment is here. It runs from October 15 through December 7.

New Legislation

The recent “Inflation Reduction Act” legislation passed by Congress has two components that will affect Part D Prescription Drug plans or PDPs for short. This also includes Medicare advantage plans with an embedded prescription drug benefit or MAPDs for short.

1) Covered Insulins

The Senior Savings model has been in effect for a few years with some PDPs and some MAPDs. It will now be across the board with companies sponsoring PDPs or MAPDs. This doesn’t mean that every plan is covered. It does mean that if, for example, Acme Health offers three PDPs, one of them must include the Senior Savings Model for covered insulins.

The Senior Savings Model limits your cost-share to $35 per month for covered insulins. Note: this doesn’t mean that every insulin is covered. It means that the insulins on the plan’s formulary are covered. Your cost-sharing for non-covered insulins will likely be higher.

More details are as follows:

  • You won’t pay more than $35 for a one-month supply of each insulin prescription covered by your plan, no matter what cost-sharing tier it’s on, even if your plan has a deductible that hasn’t been met.
  • While some of you already have plans that offer $35 insulins, this legislation ensures that all seniors who use insulin will benefit from this out-of-pocket cost limit.
  • Anyone on Medicare’s Extra Help program will continue to pay the CMS statutory maximum cost share for insulin, which is less than $35.
  • Some PDPs will offer covered insulins at less than the $35 copay.

Please check with us for more information.

2) Covered vaccinations

PDPs will cover most Part D vaccines for a $0 cost share, even if a plan has a deductible that hasn’t been met. As of this writing we don’t know what most is.

Why You Can Benefit from an Annual PDP Check up Every Year

Over the years we’ve heard many people say, “I’m happy with my plan and don’t want to change.” Question: Would you still be happy if the copay for one of your expensive meds doubled?

One very popular plan moved the pricy blood thinner Eliquis from a tier 3 to a tier 4 drug. Your copay would literally double if you stayed with that plan. Not good for your pocketbook! We have seen other changes that makes it worthwhile to do a PDP checkup.

Here’s another example. Most PDPs still have the generic Zetia (Ezetimibe) as a tier 3 drug, which is subject to the deductible. We discovered one plan that ranks Zetia as a tier 2 drug, meaning that it has a  low copay and is NOT subject to the deductible.

PDP Helper

Contact us or use our convenient PDP Helper link to send us a list of your current prescriptions.

Medicare Advantage News

We have seen an expansion of Medicare advantage plans (MA) into counties that previously have had either none or every limited MA options. Other counties have even more plans added to their list.

Noteworthy examples:

Idaho: Benewah County (St. Maries), has a large, national company starting service in 2023.

Montana: Several rural counties such as Granite, Powell, Deer Lodge, Beaverhead, Jefferson, and others have gone from one carrier to three carriers.

Wyoming: The MA offerings in Wyoming have previously been very limited. They have expanded for 2023. Please ask us for more details.

Two Idaho Medicare Supplements Changes

Starting in March 2022, Idaho is now using a community rate structure for Medicare supplement plans. This means that there is one rate for all ages. Many people 75 and better have already switched to plans with lower rates. This only applies to newly issued polices. This does not affect your current plan, unless you make a change.

The new Idaho birthday rule creates a 63-day open enrollment period to change your Medicare supplement, even if you have a medical condition that normally would disqualify your application.

Please check with us to determine your eligibility for lower rates.

Do I Need to Renew my plan for 2023 if I’m Not Making Any Changes?

You do not. Your existing plan auto renews for 2023. The exception would be if your plan is being discontinued for 2023. As of this writing, we don’t know of any.

Northwest Senior News January 2021

Lance

Fat Heals—Sugar Kills: Chapter 4 – Part 1, Sugar Isn’t Always Sweet

We continue our review and digest this month of Fat Heals-Sugar Kills: The Cause of and Cure for Cardiovascular Disease, Diabetes, Obesity, and Other Metabolic Disorders by Dr. Bruce Fife. In the first part of Chapter 4 titled Sugar Isn’t Always Sweet, Dr. Fife stresses the point that sugar is sugar whether is be table sugar, fructose, agave, honey or any other of the myriad forms of sugar.

Click here to continue

Fat Heals—Sugar Kills: Chapter 4 – Part 2

Part 2: The key takeaway here is that the over consumption of sugar leads to excessively elevated blood sugar (glucose) levels. This, in turn, forces the pancreas to produce more insulin to deal with the high sugar load, and this leads to our body’s cells becoming resistant to the effects of insulin. This situation is known as insulin resistance, which is the pre-cursor to type 2 diabetes.

Click here to continue

Sugar Blues: Chapter 1

Seven years ago, we initiated our review and digest of William Dufty’s book, Sugar Blues. His account of his sugar addition is timeless as the problem of sugar addiction continues unabated. We have revised our original summary and digest of his Chapter 1 titled: It Is Necessary to be Personal.

 

Click here to continue

Gary Taubes, a well-known scientific journalist and author, published on YouTube a speech of his titled: The Case Against Sugar. We have republished our original transcription of the first segment of his speech with updated comments. His talk is just as appropriate today as it was a few years ago.

 

Click here to continue

Fat Heals—Sugar Kills: Chapter 4 – Part 2, Sugar Isn’t Always Sweet

Lance

by Dr. Bruce Fife

Chapter 4, Part 2

Glucose—Blood Sugar and Insulin Resistance: continued

Where we left off is Dr. Fife explaining to us that insulin resistance is the hallmark feature and first step towards developing diabetes. We’ll concern ourselves here only with type 2 diabetes and not juvenile diabetes.

In type 2 diabetes, the pancreas may be able to produce enough insulin, but the cells of the body have become unresponsive to the hormone insulin. This is called insulin resistance. Over 90% of diabetics are of this type.

In the initial course of this disease, the pancreas usually can produce enough insulin to overcome the insulin resistance of the cells. However, the demand placed on the pancreas takes its toll, and insulin production eventually begins to decline. Eventually the pancreas can burn itself out and stop producing the insulin needed.

When this happens, type 2 diabetics will require supplemental insulin.

More than half of all those with type 2 diabetes eventually require insulin to control their blood sugar levels as they get older.

My Comments: I hope Dr. Fife’s words will serve as a dire warning to those who consume lots of refined carbs but have yet to be diagnosed as having pre-diabetes. I would hope that it also serves as a wake-up call to those that have been diagnosed as pre-diabetic and have been prescribed metformin. I also hope that the readers that are diabetic and taking metformin and/or other diabetic pills will hear the alarm bells going on as to the path they are headed on if they insist on continuing to abuse their bodies by consuming too many refined carbohydrates.

Dr. Fife warns that half of those will end up requiring insulin if the disease continues to progress. The progression continues with assorted diabetic complications:

  • Skin complications
  • Eye complications: Retinopathy, glaucoma, cataracts
  • Neuropathy: Nerve damage from diabetes is called diabetic neuropathy
  • Foot complications
  • DKA (ketoacidosis) & ketones
  • Kidney disease (nephropathy)
  • High blood pressure—also called hypertension—raises your risk for heart attack, stroke, eye problems and kidney disease.
  • Stroke

Folks, this is serious stuff. The obvious answer is to quit consuming or severely reduce “foods” made from refined carbohydrates. The problem, of course, just as with other addictive substances, refined carbs and particularly sugar in its various forms, are highly addictive.

William Dufty in Chapter 1 of his book, Sugar Blues, had this to say when he quit sugar cold turkey:

In about forty-eight hours I was in total agony, overcome with nausea, with a crashing migraine.

Continuing: Dr. Fife explains that diabetes is diagnosed when fasting blood sugar is 126mg/dL or higher. As insulin resistance increases, so do blood sugar levels. Fife also warns that you are not in the clear if you are at 125mg/dL. He explains that insulin resistance begins when fasting levels rise over 90 mg/dL.

Fife points out the correlations between increased sugar consumption and the increase of diabetes. He also states the reverse:

Eating a low-sugar or low-carb diet significantly reduces the risk [of developing diabetes].

He says that the scientific evidence linking excess sugar consumption with an increased risk of diabetes is strong.

My Comments: The problem here is what is “low” and what is “excess?” In Part 1 of Chapter 4, I quoted some dietary experts’ recommendations of consuming no more than 100 calories of sugar per day. If you are a regular consumer of processed foods, you’ll likely exceed this many times over. Keep in mind that 100 calories worth of sugar is 25 grams or slightly under an ounce or about six teaspoons.

Continuing:

Glycemic Index

The glycemic index (GI) is a measure of how quickly certain foods raise blood sugar levels. The GI is on a scale of 0 to 100. Glucose is given a GI of 100, and all other foods are rated in comparison.

A banana has a rating of 51, but a slice of white bread, by comparison, has a GI rating of 75. While the banana tastes sweeter, its fiber slows down the absorption process. The white bread is pure starch and quickly dumps a high load of glucose into the bloodstream once it’s digested.

Chronic Inflammation

Dr. Fife explains that high glycemic foods tend to increase inflammation.

When blood sugar levels rise, the sugar in your bloodstream tends to latch onto certain proteins in the blood vessel wall, causing injury and inflammation. When you eat high glycemic index foods repeatedly, your blood glucose levels are continually elevated, leading to chronic injury and inflammation.

It is inflammation that causes cholesterol to become trapped in the artery wall. Without inflammation being present in the body, there is no way that cholesterol would accumulate in the wall of the blood vessel. Without inflammation, cholesterol would move freely throughout the body as nature intended.

This chronic inflammation of the arteries is one of the distinguishing features of atherosclerosis and coronary heart disease. In fact, chronic inflammation is associated with diabetes, obesity, Alzheimer’s disease, and just about every other chronic degenerative disease. Ed: My emphasis

My Comments: When certain events happen, the cause-and-effect relationship can be immediate and painful. Accidentally placing your hand on a hot burner will give you immediate and painful feedback to the degree that you minimize your injury and avoid such behavior in the future. The effects of a bee or wasp sting is immediate and painful, and deadly for some. Those that have suffered painful stings take precautions to avoid getting stung again.

If I eat a candy bar, woof down half a bag of Oreos, or splurge on three bowls of my favorite chocolate chip ice cream, do I have a heart attack, have kidney failure, or go into a diabetic coma? Not yet and maybe not for decades. Nothing happens in the immediacy to the toxic load that I have subjected my body to. However, if I persist in this behavior, the effects will accumulate and eventually catch up with me.

The dilemma here for any addiction is that the pleasure derived by tickling the dopamine part of our brain outweighs any concerns of potential long term side effects. And just think, the psycho-physicists that Dr. Fife referenced earlier in this chapter understand this physiological response to pleasure and addiction better than we do. It is their job to ensure that we will really like the manufactured food or beverage they create to the point where we become lifetime consumers. That is their bliss point.

Continuing: Dr Fife states that inflammation can be determined by measuring a marker in the blood called C-reactive protein (CRP); the higher the CRP the more inflammation is present.

He succinctly explains the problem:

In the absence of infection, a primary cause of inflammation is eating excessive amounts of sugar. Sugar causes inflammation and exponentially* increases your chances of developing chronic diseases. Ed: My emphasis

My Comments: What if you made a nicely printed sign that you prominently posted in your kitchen that reads as follows.

EATING TOO MUCH SUGAR IS THE MAIN CAUSE OF INFLAMMATION IN MY BODY AND DRAMATICALLY INCREASES MY CHANCE OF DEVELOPING A MYRIAD OF CHRONIC ILLNESSES.

We can assume that the processed food industry will not be handing such signs out.

*Why does Dr. Fife use the word “exponentially” in his text?  Exponentially means more rapidly and that the speed of the rapidness keeps increasing.

Let’s say Person A consumes no sugar and no refined carbs and has a virtually zero percent chance of developing diabetes.

Person B consumes 500 calories per day of sugar/refined carbs and has 10 times more likelihood of developing type 2 diabetes compared to Person A.

Person C consumes 1,000 calories per day of refined carbs and has 10 times more chance of developing type 2 diabetes compared to Person B or 100 times more chance compared to Person A.

The above figures are hypothetical only, but Dr. Fife’s point by using the word exponentially is that the chances of contracting a chronic illness becomes increasingly higher with the increased consumption of sugar.

Continuing: Dr Fife further discusses chronic inflammation and arterial disease. He makes this key point:

The relationship between chronic arterial inflammation and heart disease is a much better indicator of heart disease risk then blood cholesterol levels.

My Comments: Assuming that Dr. Fife’s above comment is medically correct, then why are so many doctors pre-occupied with blood cholesterol levels? Over the years I have heard many, many people tell me that their doctor said that they have to get their cholesterol levels lower. The remedy is usually to prescribe a statin drug. With one possible exception, I have never heard anyone report to me that their doctor was just as hell-bent to get their blood sugar levels lowered by restricting their consumption of sugar and other refined carbs.

Continuing: Dr. Fife further explains the correlation of C-reactive protein and inflammation to heart disease.

Dr. Paul Ridker of Brigham and Women’s hospital in Boston evaluated blood samples from more than 28,000 healthy nurses. Those with the highest levels of C-reactive protein had more than four times the risk of having heart trouble. “We were able to find that the C-reactive protein is a stronger predictor of risk than were the regular cholesterol levels, and that’s very important because almost half of all heart attacks occur among people who have normal cholesterol levels,” he said.

Dr. Fife suggests that inflammation may explain why people have heart disease without other known risk factors. These are people with normal cholesterol, who are not diabetic, and appear to be in good physical condition. They make up about a third of all heart attack cases.

My comments: To learn more about C-reactive protein (CRP) here is what the Mayo Clinic has to say:

The level of C-reactive protein (CRP), which can be measured in your blood, increases when there’s inflammation in your body. Your doctor might check your C-reactive protein level for infections or for other medical conditions.

Healthline has this to say:

High CRP levels can also indicate that there’s inflammation in the arteries of the heart, which can mean a higher risk of heart attack. However, the CRP test is an extremely nonspecific test, and CRP levels can be elevated in any inflammatory condition.

I looked at other websites, and the information they offered about the link to diet, nutrition, and particularly sugar was scant. One suggested that a Mediterranean diet was beneficial. Another suggested that an unhealthy diet was one contributory factor towards CRP.

Dr. Fife cuts to the chase and lays the blame on high-glycemic foods. And what are high-glycemic foods? Yep, it’s refined carbohydrates which includes white flour and sugar in its various forms. End

 

Items of Interest Response Form

Lance

Note: If you would like us to shop for a prescription drug plan for you, please use our PDP Helper page and submit a list of your prescriptions to us there.




Note: Enrolling in a new MA-PD will disenroll you from your existing PDP or MA-PD plan.


Medicare Advantage Funding and the Causes of Non-Renewal Notices

Lance

by Lance D. Reedy

For those of you that have received a non-renewal notice from your Medicare advantage company, we encourage you to review our companion article, I Received a Disenrollment Letter: What Now?  It will explain your choices.

Note: In the discussion that follows, I have simplified some concepts for brevity.

History

The concept of Medicare Advantage (MA) plans began with the 1982 Tax Equity and Fiscal Responsibility Act (TEFRA). This act allowed privatized Health Maintenance Organization (HMO) plans to contract with Medicare to deliver a form of privatized Medicare. Health insurance companies later exited this privatized Medicare marketplace because the funding from Medicare wasn’t keeping up with rising costs.

The Balanced Budget Act of 1997 established the Medicare+Choice program. This was renamed Medicare Advantage by one of the provisions of the 2003 Medicare Modernization Act (MMA). It was this act that also stepped up the controversial capitation rate for the MA plans.

Medicare Advantage Funding

MA plans are privatized in that Medicare sends a certain amount of money per person per month to the sponsor, usually a large health insurance company, of the MA plan. This is called the capitation rate. This means that, for example, the base rate that the MA plan sponsor receives from Medicare is about $700 per month for every member enrolled in the sponsor’s plan. Simply put, they get so much per head per month. That’s the capitation rate.

Example: Betty Smith enrolls in the Medicare Deluxe plan from Acme Insurance Co. Her premium is $65 per month. Her plan also includes prescription coverage. Here is the revenue that Acme receives for enrolling Betty as a member:

Medicare Funding for the MA health plan: $700 per month (Note: this can be much higher for people with more health issues.), Medicare Funding for a prescription plan: $53 per month, Betty’s Premium: $65 per month. The breakdown is as follows: $30 is her contribution to the health plan, and $35 is for her prescription part of the plan.

Total: $818 per month

Remember, These Plans are Privatized

Let’s say that Betty has a knee replacement surgery with a total bill of $30,000. Her hospital stay is for three days.  Her plan has a hospital copay of $300 per day with a five-day cap. Acme pays for all days that exceed five.

Here’s how it looks:

Total bill: $30,000

Betty pays $300 per day x 3 days or $900 to the hospital. The hospital bills the balance of $29,100 to Acme, not Medicare. Remember, as far as claims go, Medicare is out of the picture.

Let’s say the Betty had physical therapy after her surgery, some labs, doctor visits and other miscellaneous medical events that cost Acme an additional $4,000 during the course of the year.

Annual Revenue that Acme Received

  • Funding from Medicare = $8,400 ($700/month x 12 months.)
  • Of Jane’s $65 monthly premium, $30 is for her health plan. $30/month x 12 months = $360
  • Total revenue = $8,400 + $360 = $8,760

Claims paid out for Betty Smith

  • Knee surgery: $29,100
  • Miscellaneous other medical services: $4,000
  • Total claims (losses) for covering Betty: $29,100 + $4,000 = $33,100. (Note: To keep this example simpler, we’re ignoring any prescription costs.)

A Losing Proposition

In this example, we can see that Acme losses were almost four times more on Betty’s behalf compared to the revenue they received from Medicare and Betty. Just to break even, Acme Insurance needs three other members’ (Alice #1, Alice #2 and Alice #3) revenue and little or no claims from those members.

As long as Acme only has a few Bettys and lots of Alices, they will be okay. They can maintain their $65 per month premium for 2018, keep their copays about the same, and maintain their extras such as a vision, dental, or health club benefit.

How Acme Insurance Gets in Trouble

In this example, we have the fictitious state of West Mountain. West Mountain has forty counties, and Acme has their MA plans in twenty of them. Acme’s bean counters have observed that they are consistently losing money in Wolf, Grizzly, Coyote, Rattlesnake, and Scorpion counties. These are low population, rural counties. To aggravate this problem, Medicare’s capitation rate in these counties is lower compared to the more urban ones. Worse yet, Acme is having difficulty finding enough specialists to serve on an “in network” basis in those counties.

To stem these losses and maintain the integrity of their Medicare Deluxe plan, Acme has decided to cut loose those five losing counties. They file their plan with Medicare, and they send non-renewal letters to their members in those five counties in early October. Simply put, they had too many Bettys and not enough Alices.

This is exactly what the now defunct New West Medicare did in Montana a few years ago. They had substantial losses in ten counties, so they non-renewed their members in those counties. Medicare advantage plan sponsors cannot drop an individual high claims member, but they can drop a high claims county.

In one rural county that New West dropped, I had one client that had a hip replacement surgery and another that was in the hospital in Billings for two and a half months. There couldn’t have been enough Alices to make up for those two Bettys. Also, there could have been more Bettys that I didn’t know about.

It Gets Worse

Exiting some counties can be a stop gap measure that buys time for a year or two. What happens if the losses begin to mount statewide? That’s what happened to New West in 2016. The decision makers looked at the numbers, and they weren’t good. In October of 2016, all New West MA members received their non-renewal notices.* While there were other factors in New West’s demise, the bottom line is that they lost enough money that they pulled their plans and exited the market. *Important. Be sure to keep your non-renewal notice. You may need it!

The Insurance Company has Another Option

Let’s say that Acme has lost money in most of West Mountain, but they want to stay in the game. Here’s their strategy.

  1. Drop their high loss counties.
  2. Drop their plans in the counties they wish to remain in, but come out with new plans. These new plans will have a combination of higher premiums and/or higher
  3. They also could trim some of their extras such as their vision or dental benefit. Your higher premiums and higher copays will generate more revenue for Acme. If it all works, they will continue to offer their plans.

Things to Remember About Medicare Advantage plans.

  1. Medicare advantage plans are privatized.
  2. The providers bill the plan sponsor (generally insurance companies) and not Medicare.
  3. The insurance company can’t operate at a loss, or it will go out of business.
  4. The company can decide which counties it desires to sponsor MA plans in any given state.
  5. Low population counties may not have any MA plans.
  6. MA plans are subject to premium and copay increases. (In a few instances these have slightly decreased.)

Conclusion

Receiving non-renewal notices for most people is an unsettling hassle. It involves change, and many people, including me, don’t like it. Now your Medicare plan needs to be redone.

I believe that having a basic understanding of how Medicare advantage funding works, can be a useful tool in your decision-making process.

Please click here to consult our companion article, I Received a Disenrollment Letter: What Now?

End

 

PDP Helper

Lance

Welcome to the PDP Helper page for Northwest Senior Insurance!

Please follow the instructions below to submit a list of your prescriptions to us so we can help you select a Prescription Drug Plan for the next year.

If you would like some additional guidance on how to use PDP Helper, please check out our PDPHelper Tips article.

Step 1 of 4

Contact Information

Please enter in your contact information so we will be able to get in touch with you.
Not required, but highly recommended so we have an alternate means of communication.

Pharmacy Information

Please enter your pharmacy of choice and, if applicable, any alternate pharmacies you might consider using. Then answer the following two questions.
Some plans offer substantially lower copays with specific retail pharmacies or mail order.

Benefits of a Medicare Supplement Plan

Lance

Introduction

The following table lists all of the possible benefits of a Medicare supplement plan. Plan F is the only plan that contains all of these benefits.

Basic Benefits

  1. Part A coinsurance. The Medicare supplement will pay the $315 per day coinsurance for days 61-90 of a hospital stay. The Medicare supplement will pay the $630 per day coinsurance for the 60 lifetime reserve days. The Medicare supplement will pay for 365 additional days of hospitalization after Medicare hospitalization benefits are exhausted.
  2. Medical expenses Part B: The Part B coinsurance is generally 20% of Medicare approved expenses. This includes the coinsurance for outpatient services and surgery. Plans K, L, and N require the Medicare beneficiary to pay a portion for the Part B coinsurance. ***Details below.
  3. Blood: The first three pints of blood.
  4. Hospice: The Medicare supplement pays the hospice coinsurance.

 

Skilled Nursing Facility coinsurance

  1. Medicare pays 100% for the first 20 days for an approved stay for skilled nursing facility care.
  2. For days 21-100 Medicare will pay for an approved stay. There is a $157.50 per day coinsurance that the Medicare supplement pays. ***See below for Plans K and L.

 

Part “A” Deductible

  1. For 2015 the Medicare Part “A” deductible is $1,260 per hospital benefit period. The benefit period is for 60 days and begins after one’s discharge. The Medicare supplement could pay this benefit more than one time per year. .***See below for Plans K and L

 

Part “B” Deductible

  1. 1. The Medicare Part “B” deductible is an annual $147 in 2015.

 

Part “B” Excess (100%)

  1. 1. In general, if a Medicare Part “B” provider charges an excess above the Medicare approved amount, this benefit will pay that amount. Physicians may charge a maximum of 115% of the Medicare approved amount. These are known as non-participating physicians or physicians that do not accept Medicare assignment.

 

Foreign Travel Emergency

  1. In general, Medicare does not pay in foreign countries. One will pay the first $250 for Medical services. After that, the Medicare supplement will pay 80%, and the insured will have a 20% coinsurance. Usually one must pay his/her bill upfront and then bring the bills back to submit a claim.

 

Out-of-pocket limit

  1. 1. For Plan K there is a maximum annual out-of-pocket limit of $4,940. The Medicare supplement will pay 100% after that limit is reached.
  2. 2. For Plan L there is a maximum annual out-of-pocket limit of $2,470. The Medicare supplement will pay 100% after that limit is reached.

 

High-deductible Plan F

  1. High-deductible Plan F pays the same benefits as Plan F after one has paid a calendar year deductible of $2,180. This deductible is for what the Medicare supplement would have paid. Medicare still pays its part when one has high-deductible Plan F. After one has met the deductible, then the plan pays just like a regular Plan F.

 

***Details for Plans K, L, and N

  1. Plan K: Hospitalization and preventative care paid at 100%. Other basic benefits are paid at 50%. Pays 50% of the skilled nursing coinsurance. Pays 50% of the Part A deductible.
  2. Plan L: Hospitalization and preventative care paid at 100%. Other basic benefits are paid at 75%. Pays 75% of the skilled nursing coinsurance. Pays 75% of the Part A deductible.
  3. Plan N: The insured pays a maximum $20 copay for a doctor’s office visit and a maximum $50 copay for an emergency room visit.