Debate about controlling drug pricing is on the legislative agenda as Democrats weigh whether to include it in the new infrastructure package. The debate about allowing the government to negotiate drug prices, which was largely derailed by the pandemic, was brought back to life by one of Big Pharma’s most vocal critics, Senator Bernie Sanders. Senator Sanders scheduled a hearing in the new Congress on drug pricing, which got the attention of Pharma industry lobbyists who oppose the measure.
Democrats are looking at H.R. 3, the bill introduced by Elijah E. Cummings that passed the house in late 2019 but never made it to the Senate. The Lower Drug Cost Now Act, as the bill was called, would have allowed the Secretary of Health and Human Services to negotiate the price on expensive medications that don’t have generic alternatives. It would also have capped out-of-pocket cost Part D beneficiaries would pay yearly for prescription medications at $2,000.00. Further measures would have mandated rebates by drug manufacturers that raised prices more than the rate of inflation.
With the Democratic majority in both houses, there is a chance the bill, or one similar to it, could be passed despite the pharmaceutical industry’s opposition to what they see as price controls that would limit future research and development.
One of the largest relief packages in U.S. history, the American Rescue Plan Act of 2021, gives about $34 billion to aid Americans in buying health insurance. The provisions in the bill do expire in two years, however, there may be a push by Democrats down the road to make them permanent.
Among the biggest winners in President Biden’s $1.9 trillion COVID relief package are those who buy health insurance on the federal marketplace exchanges, which in California is Covered California. The bill includes a provision that caps what an insured would pay for premiums on the exchange to 8.5 percent of income. It also provides for those who find themselves unemployed due the pandemic, allowing them to buy health insurance on the exchanges even though they are receiving unemployment benefits, which typically excludes them from getting subsidies.
Another key aspect of the bill addresses those who are on COBRA, the program that allows workers to buy coverage offered by their former employer. The bill would pay 100 percent of the COBRA premiums from April 1, 2021 to September 30, 2021. The bill also includes incentives for states that did not expand Medicaid to do so, allowing more people to qualify for help from the federal aid program.
Medicare can be very confusing for those newly eligible, and often I see the same issues coming up for those who are trying to navigate the Medicare maze. Here are few points to try and help clarify the process.
Many confuse the Parts of Medicare with the various Supplemental Plans available to them to fill the gaps in Medicare. The reason is that some of the Supplemental Plans have the same letter name as parts of Medicare. You have Parts A, B, and C with Medicare, but these are also names of Supplemental Plans that go with Medicare. Basically, Medicare has Part A – Hospital Coverage, Part B – Medical or Doctors’ Coverage, Part C – Medicare Advantage Plans, and Part D – Prescription Drug Coverage. You also have Plans A, B and C which are Supplemental Plans that cover the gaps in Medicare. A Medicare Advantage Plan is not the same as a Medicare Supplemental Plan. When you sign up for a Medicare Advantage Plan, you are signing up for Part C with Medicare, even though these plans are administered through private insurance companies. The insurance companies handle all costs associated with your care, but are subsidized by the Medicare program. These plans are usually HMO’s that require referrals to see specialists, and you must use Network providers in your service area to be covered. Supplemental Plans are PPO’s with no Network restrictions. However, you must use providers that take Medicare. Cobra is not considered creditable coverage for Medicare. If you lose your job and are Medicare-eligible, if you go on Cobra, it is not considered creditable coverage, which means you could be charged a penalty on your Medicare Part B and Part D premiums once you do sign up for Medicare. If your employer has 20 or more employees, you can remain on your employee group plan (as well as your dependents) if you are actively working, even though you are eligible for Medicare. The prominent word here is actively working, which means you cannot be on Cobra or laid-off from work. Higher earners pay more for their Medicare Part B premium and their Medicare Part D premium. If you make over $88,000 (as a single person) or over $176,000 (as a couple), you will pay more for your Part B and Part D premiums. It is called IRMMA (Income-Related Monthly Adjusted Amount), and it increases in increments based on income level.
As the Biden Administration works with FEMA to open 100 COVID vaccination sites across the United States, there is still much confusion over who is eligible to get the vaccine and where they go to schedule an appointment. The two federal sites in California that have already opened are located at Oakland-Alameda Colosseum in the Bay area and California State University in Los Angeles.
As well as these county sites, appointments can be made at certain Albertsons, Rite Aid, Ralphs and Pavilions pharmacies. Blue Shield and Kaiser Permanente have been contracted with the state to help manage the vaccine rollout. Those who are eligible currently, according to state guidelines, are those in phase 1A (healthcare workers and long-term care residents) and 1B (those 65 and older, agricultural and food workers, educators and emergency service personnel). The next phase, which includes those 16 to 64 with high-risk underlying conditions is scheduled to open on March 15.
The Biden Administration recently signed an Executive Order to extend Open Enrollment on the Federal Health Insurance Exchanges for Americans to sign up for health insurance during the pandemic. Covered California has announced the Open Enrollment period will be from February 1 through May 15 of this year.
“The pandemic and recession continue to be a painful reality, and Covered California is doing whatever it can to make sure people have every opportunity to sign up for health care coverage,” said Peter V. Lee, executive director of Covered California. “There are millions of Californians out there without the peace of mind and protection of health care coverage, and now is not the time to be uninsured.”
California expanded its parameters last year to offer more residents subsidy assistant. A family of four earning a household income of up to $157, 200 could get help to lower their health insurance premium. An individual with earnings of up to $76,560 could also be eligible for financial assistance through the state health insurance marketplace.
If you are among the nearly 68 million Americans covered under Medicare, the federal government has provided access to the COVID-19 vaccine at no cost under the CARES Act implemented in March. The vaccine will be covered under Medicare Part B, and the annual Part B deductible will not be applied. This will be the case under Original Medicare, Medicare Advantage Plans and Medicare Cost Plans.
If you have an employer-sponsored or individual plan, in most cases, the vaccine will be covered with no additional copays or coinsurance required of the insured under Section 3203 of the CARES Act. It will fall into the category of “Preventive Services” as outlined in the Affordable Care Act (ACA) and applies to all non-grandfathered plans.
Grandfathered plans (health plans in effect prior to March 23, 2010 when the ACA was signed into law) may have some or no cost-sharing depending on the plan, however, individual states may mandate these plans to cover the full cost of the vaccine and its administration. Other health plans, like short-term and healthcare-sharing ministry plans, may not cover the costs of the COVID-19 vaccine.
If you are on Medicaid, the federal government has provided extra funding to states to cover the vaccine to Medicaid recipients, without requiring them to pay a share of cost. This will be the case as long as the public health emergency is in effect. Once it has expired, cost-sharing may be determined based on eligibility level.
With the cost of insulin nearly tripling over the past decade, many Americans with diabetes face difficult decisions when it comes to their health – whether to limit or stop taking their insulin because of the staggering cost. Seniors on fixed incomes may be even more vulnerable to the dire consequences of not being able to afford their medications.
In an effort to address the growing problem, the Centers for Medicare and Medicaid have implemented the Senior Savings Model for Part D Drug plans starting in January 2021. This new model limits copays in the deductible, initial and coverage gap phases for certain brands of insulin to a maximum of $35 per 30-day supply. The cost could even be less, depending on the medication. These rules apply to both stand-alone Part D drug plans and those imbedded in Advantage plans. Plans do not have to participate in the new model, and there are a limited number of plans that have opted into the new program.
In California, the stand-alone Part D plans that have agreed to participate are as follows: AARP Medicare Rx Preferred, Cigna Secure-Extra Rx, Express Scripts Medicare Choice, Express Scripts Medicare Saver, Humana Premier Rx, Mutual of Omaha Rx Premier, WellCare Medicare Rx Value Plus, WellCare Value Script, WellCare Wellness Rx. Advantage plans participating in the Senior Savings Model vary by county.
A Medi-Medi plan, also often referred to as a dual-special-needs plan or “look alike” plan, is a type of Medicare Advantage plan for people who qualify for both Medicare and Medicaid or Medi-Cal in California. Medicare is the primary payer on these types of plans with Medi-Cal being the secondary payer. You must go to doctors who accept both Medicare and Medi-Cal, and your share of cost is determined by your asset level. In California, to qualify in 2020 as a single person, your asset level is at $2,000 or below ($3,000 or below for couples). There are many things that are not included in your asset level like your primary residence, household items, pre-paid burial expenses and your car.
The advantages of having a Medi-Medi plan are that they coordinate your care with a provider network and often include extra benefits such as vision, dental and transportation services. You do, however, have to use the doctors and specialists in the plan’s network to be covered (except in cases of emergency). These plans are provided by private insurance companies, and the benefits and costs can vary from company to company. Prescription drugs are included in the plan with copays at no more than $1.30 for generic drugs and no more than $8.95 for brand drugs. If you pay no share of cost, your copays would be $0 for your medications.
You will automatically be enrolled in Medi-Cal if you qualify and sign up for Supplemental Security Income (SSI) through Social Security. You may qualify, as well, if you don’t get SSI, but you must contact your Medi-Cal county office to see if you meet eligibility requirements. If you are considering a Medi-Medi plan, be sure and check that your current doctors are in the plan’s network (if you wish to remain with them), and that your medications are in the plan’s formulary. You can also apply for one of these plans if you become newly eligible for assistance or during the Annual Enrollment Period from October 15 to December 7.
Seven companies have won grants from the National Institutes of Health (NIH) to develop better and faster testing to help fight the spread of the Coronavirus. Six of the seven companies are here in California.
“This is a very substantial investment to try to speed up the availability of COVID-19 testing to try to deal with this pandemic,” said Francis Collins, NIH Director, during a virtual briefing to reporters.
Mammoth Biosciences, Inc. and Fluidigm Corp. are two San Francisco-based companies that will get a portion of the $1.5 billion in emergency funding provided by Congress back in April. Mammoth will base its testing using CRISPR, DNA editing technology that can pinpoint a specific location in a genetic code. Fluidigm has developed a saliva test that could be a game-changer for ease and rapid testing.
Quidell Corp. and Mesa Biotech, headquartered in San Diego, also received funding. Quidell’s new antigen test can get a result in as little as 15 minutes, and Mesa’s hand-held device can produce results in as little as 30 minutes.
Helix OpCo LLC is located in San Mateo and plans to ramp up processing to up to 100,000 nasal swabs by year’s end using next generation sequencing, and Ginko Bioworks in Boston is scaling up to do the the same. The final company, Talis Biomedical located in Melo Park, California has a test which uses a multiplexed cartridge to detect the virus with results in 30 minutes.
Trump recently signed four executive orders in hopes of curbing high drug prices in the United States. One of the orders targets how Medicare reimburses physicians for the administration of medications in hospital or office settings which is covered under Medicare Part B. The standing rule is that doctors can charge up to an additional 6% of the average sales price of a medication, which would incentivize physicians to use higher cost drugs. Trump’s order reduces the amount that can be charged to the lowest price paid by industrialized nations under an International Pricing Index.
Another executive order revamps the rebate rule which allows pharmacy benefit managers to pocket these payments instead of passing these discounts to the consumer. Under the order, patients would receive the savings instead of these middlemen, who would receive a fixed dollar amount instead of a percentage of the price of the medications.
Obtaining low-cost drugs from other countries is addressed in an order which allows FDA-approved medications to be imported, and the final order targets lowering the cost of insulin and epinephrine. Insulin prices have more than doubled in the last five years and the average cost of a two-pack EpiPen continues to soar. The order would require Federally Qualified Health Centers who serve low-income patients to pass on savings to their consumers instead of pocketing the discounts made available to them under the federal drug discount program or 340B.