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.

To find out if you are eligible to receive a vaccination, you can visit the California state site at Riverside County’s COVID website is Orange County’s site is and the San Diego County site is

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.

There are more options than ever before for you to consider when searching for a Medicare Advantage Plan. Beginning in January 2021, more benefits will be available, from savings on insulin costs to getting a portion of your Part B premium returned. Here are a few of the new features.

The Senior Savings Model was introduced to some 2021 Medicare Advantage plans and Part D drug plans to reduce the cost of insulin to their members.  The plans that participate vary by county for the Advantage Plans and are state-wide for certain stand-alone Part D drug plans.  The plans participating in the federal model cap insulin copays at $35, and some are even lower depending on the brand of insulin. 

New “Giveback” Advantage Plans give a portion or all of the Part B Premium “back” to you.  These plans also vary by county and are not available in all areas.  The insurance carrier pays the discount on the Part B premium.  For example, if you sign up for a plan that gives you $125 back on your $148.50 Part B premium, the carrier pays the $125 to Medicare, and you would pay the remaining $23.50.  If your Part B is paid out of your Social Security check, the portion of your Part B premium paid by the carrier will be added back to your monthly SS check.

There is also a new Special Needs Medicare Advantage (SNP) plan for people with End Stage Renal Disease.  People who have ESRD had not been allowed to purchase a Medicare Advantage Plan prior to 2021.  Plans with an effective date starting January 1, 2021 can enroll those with ERSD in a SNP Medicare plan.  These plans also vary by county and may not be available in all regions. Cost-sharing for outpatient dialysis or immunosuppressant drugs on these plans cannot be higher than what the beneficiary would pay under Original Medicare.

Under the Social Security Act, Medicare premiums are adjusted annually. For 2021, the Part B premium increased from $144.60 to $148.50. The annual deductible for the Part B premium went to $203 from $198, and the Part A deductible rose $76 to $1,484.

It is important to note, that in 2007, the Part B premium became subject to IRMAA or Income Related Monthly Adjustment Amount, which is a surcharge on high earners. In 2021, if you are a single earner with more than $88,000 reported income on your tax returns, you will pay $207.90 for your Part B premium instead of $148.50. If you file jointly with a spouse, the surcharge applies to incomes over $176, 000. The premium is increased in income increments to a high of $504.90 for a single earner making over $500,000 income per year or $750,000 for joint filers. Also, in 2011 as part of the Affordable Care Act, the IRMAA applies to Part D drug plans as well. The monthly amount added to the premium of your drug plan ranges from a low of $12.30 to a high of $77.10 depending on income. The surcharges collected for Parts B & D go directly to Medicare and not to the insurance companies.

Cost-sharing also increased under Part A for daily coinsurance rates for hospital stays. From day 61 to 90, the daily rate is $371, up from $352. From day 91 to 150, the rate goes up to $742 from $704 in 2020. For Skilled Nursing Facility care, the rate rose from day 21 to 100 to $185.50 per day, an increase of $9.50.

Most individuals will receive Medicare Part A at $0 premium because they have worked at least 40 quarters or a spouse can qualify through their husband or wife. For those who have at least 30 quarters, they may buy into Part A at $259, and those who have less than 30 quarters may buy in at the full rate of $471.

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.

Part D drug plans are how Medicare recipients receive their prescription drug coverage. Whether you have a Medicare Advantage plan or a Supplemental plan, your Part D works the same way with 4 levels of coverage. The 4 levels of coverage are:

Deductible Phase – If your plan has a deductible, you must pay the full amount of your medications until the deductible is met. Some plans exclude Tier 1 and Tier 2 drugs from the deductible.

Initial Coverage Phase – You pay a portion of your drug cost via a copayment or coinsurance until your total costs reach $4,130.00 (Initial Coverage Limit for 2021 plans). Once this is met, you move into the Coverage Gap.

Coverage Gap or Donut Hole – You pay 25% of drug costs for brand and generic drugs until total out-of-pocket (TROOP) costs reach $6,550.00 (TROOP for 2021 plans) at which time you move into Catastrophic Coverage.

Catastrophic Coverage Phase – You pay the greater amount of 5% of the drug costs on any tier or $3.60 copay for Tier 1 & 2 drugs and $8.95 copay for all other tiers.

Part D drug plans may have changes every year which might include, premium and deductible increases (or decreases), formulary changes (the drugs covered under the plan), tier changes (changes to tiers of covered medications) and changes in preferred pharmacies. You will receive an Annual Notice of Change every year from your drug plan. You should check to make sure your medications are still covered under the plan, the tiers haven’t changed and whether a deductible has increased or been added.

The Annual Enrollment Period starting on October 15 and lasting to December 7 is the time to switch coverage, with your new plan going into effect on January 2021.

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.