Tagged Medicare

Must-Reads Of The Week From Brianna Labuskes

The next time I even hint that we’re drifting into a slow news period, feel free to remind me not to jinx things: This week was bursting with industry moves, health law attacks, midterm strategizing, and, oh yeah — an indictment.

A quick programming note before we dive into all that: The Breeze is going on hiatus as I breeze out of town for a bit. But I’ll be back Aug. 31, just as we really start heading into midterm season, so look for me again then.

Now for the news you may have missed:

This week’s swipe at the health law focused on accountable care organizations (shorthand explanation: a program that took a carrot-and-stick approach to getting hospitals, doctors and other providers to coordinate, with the end result of higher-quality, more efficient care). They were supposed to save the government billions of dollars, but data show they’ve failed to measure up to the promise, so the program is being overhauled.

The Washington Post: Trump Administration Proposes Further Dismantling of Affordable Care Act Through Medicare

Rep. Chris Collins (R-N.Y.) was charged with fraud in connection to alleged insider trading after an investigation into his ties with Innate Immunotherapeutics, an Australian biotech firm.

Politico: GOP Rep. Chris Collins Charged With Securities Fraud

If that all sounded vaguely familiar, it’s because back when then-HHS secretary nominee Tom Price was being vetted for any possible ethics violations, his connection to both Innate and Collins was put in the spotlight. And just a small plug: KHN did deep reporting on this, and you can read the stories here.

Medicare Advantage got some leverage to curb drug costs this week by way of “step therapy” (or, as it’s known to critics, “fail first”). Essentially, the private plans will be able to require that patients try cheaper versions of drugs before moving on to more expensive ones. To be clear: This is a pretty distant cry from campaign promises to let Medicare negotiate drug prices, and there’s no guarantee patients will actually see any savings from this move.

Stat: Private Medicare Plans Will Be Able to Use a New Tool to Lower Drug Costs

Would a Netflix model work for drugs? That’s what Louisiana wants to find out. Under the proposal, the state would pay a subscription-type fee to be able to cover all of its Medicaid patients who need hepatitis C treatment. Beyond the click-baity notion, though, experts warn that because drug prices are such a moving target (with some costs coming down quickly) the state may not actually save money.

Stat: Louisiana Explores a ‘Netflix’ Subscription Model for Buying Hepatitis C Drugs

For even some moderate Democrats, “Medicare-for-all” is a pipe dream involving all sorts of politically unpopular complications like trillions of dollars in government spending (the current point of contention). But on the trail, it’s a rallying cry. Gubernatorial candidates, especially, are embracing it, suggesting their states become early testing grounds for universal coverage plans that have been more rhetoric than action so far.

The Washington Post: Tossing Aside Skepticism, Democratic Candidates for Governor Push for State-Based Universal Health Care

The Hill: Ocasio-Cortez: ‘Medicare for All’ Is ‘Not a Pipe Dream’

Apart from “Medicare-for-all,” Democrats could have a winning health issue with drug prices. The problem? They can’t really coalesce behind a plan, all these “concessions” as of late are making it harder to attack the administration, and, uh, there may be a lack of interest in cutting off campaign cash this close to the elections.

Stat: Drug Prices Could Be a Winning Issue for Democrats — If Only They Had a Plan

The idea to penalize legal immigrants’ use of Medicaid has been rumbling around for a bit now, but it picked up some speed in recent days. Though it could be a winning issue for Republicans on the trail, the argument isn’t really backed up by the data. It turns out that legal immigrants are likely subsidizing native-born Americans’ health care.

The New York Times: Plan to Punish Immigrants for Using Welfare Could Boost G.O.P. Candidates

The Hill: Study: Immigrants Have Lower Health-Care Costs Than People Born in US

Buckle up, there were industry moves galore this week. I’ll try to keep it quick:  Billionaire Carl Icahn came out against Cigna’s attempts to acquire Express Scripts, saying it is (in my favorite vocab usage of the week) a “$60 billion folly”;  Rite Aid called off its (unpopular) merger with Albertsons; the American Medical Association came out against CVS’ deal with Aetna; and GM signed an exclusive deal with a health system to provide care for its workers.

The Wall Street Journal: Carl Icahn Publicly Opposes $54 Billion Cigna-Express Scripts Deal

The Wall Street Journal: Rite Aid, Albertsons Call Off Merger Amid Investor Opposition

Reuters: American Medical Association Opposes Merger of CVS and Aetna

The Wall Street Journal: GM Cuts Different Type of Health-Care Deal

If that wasn’t enough news for you, here’s my miscellaneous file: A billionaire and his PTSD clinics have become entangled in the fierce debate over VA privatization; a look at how Zika babies are faring as they grow up is sobering in the breadth of damage the virus has done; an app can warn those recovering from addiction when they’re in neighborhoods or with acquaintances that could trigger a relapse; and a medical examiner is writing to doctors personally each time one of their patients dies from an overdose — and it’s working.

ProPublica: Steve Cohen Is Spending Millions to Help Veterans. Why Are People Angry?

The Washington Post: 1 In 7 Babies Exposed to Zika in U.S. Territories Have Birth Defects, Nervous System Problems

Stat: Can An App’s Warnings to Avoid Triggers Prevent Opioid Addiction Relapses?

Los Angeles Times: Coroner Sent Letters to Doctors Whose Patients Died of Opioid Overdoses. Doctors’ Habits Quickly Changed

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And don’t miss one of my favorite long reads of the week (which I got sucked into while on deadline, thank you very much) about an Appalachian odyssey and a hunt for ALS genes.

Stat: Appalachian Odyssey: Hunting for ALS Genes Along a Sprawling Family Tree

Have a great weekend, all!

Trump Administration Sinks Teeth Into Paring Down Drug Prices, On 5 Key Points

Three months after President Donald Trump announced his blueprint to bring down drug prices, administration officials have begun putting some teeth behind the rhetoric.

Many details have yet to be announced. But experts who pay close attention to federal drug policy and Medicare rules say the administration is preparing to incrementally roll out a multipronged plan that tasks the Centers for Medicare & Medicaid Services (CMS) and the Food and Drug Administration with promoting competition, attacking the complicated drug rebate system and introducing tactics to lower what the government pays for drugs.

Mark McClellan, director of the Duke-Margolis Center for Health Policy in Durham, N.C., and a former CMS administrator, said that although none of the initial steps has “fundamentally transformed drug prices,” there is “a lot going on inside the administration.”

Two HHS officials who are rolling out the plan, Dan Best and John O’Brien, described their efforts to Kaiser Health News not as a public relations strategy but a push to reform the system.

“This administration is trying to go after root causes” of high drug prices, said Wells Fargo analyst David Maris.

But others are not so optimistic.

Ameet Sarpatwari, an instructor in medicine at Harvard Medical School in Boston, said policies the administration has rolled out thus far “alone will not translate into meaningful cost savings for most Americans.”

Broadly, the strategy falls under a handful of steps:

1. Attacking The Rebates

Health and Human Services Secretary Alex Azar has said Americans “do not have a real market for prescription drugs” because drug middlemen and insurers get a wide range of hidden rebates from drugmakers, but those savings may not be passed on to consumers or Medicare. In July, the administration submitted a proposed rule that could change the way rebates are handled.

Details of the proposal have not been made public. But O’Brien, a deputy assistant secretary at HHS, explained during a recent conference on federal drug spending sponsored by the Pew Charitable Trust: “You don’t have to use market power to get rebates, you can use market power to obtain discounts, to actually lower the price of the drug on the front end.”

Umer Raffat, an investment analyst with EverCore ISI, said “it’s not clear [that drug prices are going down]” but the “rebate structure is changing.”

2. Bringing More Negotiation To Medicare

This week, CMS Administrator Seema Verma announced that Medicare Advantage insurers can use a step-therapy approach to negotiate better prices for Part B drugs — those administered in hospitals and doctors’ offices. These private plans will be allowed to require patients to first select the least expensive drug before stepping up to more costly drugs if the original medications aren’t working.

The administration is also looking at ways to introduce more competition into Part B drug purchasing. That idea was mentioned deep inside the annual Medicare outpatient payment rule released last month.

Peter Bach, director of Memorial Sloan Kettering’s Center for Health Policy and Outcomes in New York, pointed to the possible introduction of a competitive purchasing program in which a firm negotiates with drugmakers to buy their drugs and then sells them to the doctors and hospitals that will administer the medications. Bach said that helps ensure that hospitals and doctors can’t make more money by prescribing more expensive drugs.

Currently, Medicare pays the average sales price plus 6 percent to doctors or hospitals when they purchase drugs, a pricing mechanism that can benefit the providers if the drug costs go up. If there were a third party buying the drugs, it would “have a huge effect,” Bach said.

3. Paying For Value

Trump’s blueprint calls for CMS to encourage “value-based care” to lower drug prices, shifting from paying a set fee for drugs to basing payments on how well the patient does on them.

Louisiana’s Medicaid program could show the way. The state is working with CMS to explore a subscription-based model to pay for hepatitis C medicines. Louisiana would pay a fixed price to a drug manufacturer that would then get unlimited access to treat patients enrolled in Louisiana’s Medicaid program or in prison.

The program would move “from a big payment upfront to paying less over time based on actual outcomes,” said McClellan, who also serves on the boards of health care giant Johnson & Johnson and insurer Cigna.

CMS also approved a Medicaid waiver from Oklahoma in June. Medicaid programs are allowed to negotiate drug prices. Oklahoma’s plan would expand that to negotiate additional prescription price reductions based on value-based purchasing agreements.

Still, CMS’ recent rejection of a related Massachusetts proposal makes it difficult to believe negotiating drug prices will really happen, said Sara Rosenbaum, a professor of health law and policy at George Washington University.

That proposal would have allowed Massachusetts’ Medicaid program to choose drugs based on cost and how well the medicines work.

“They have been very good and quite careful with their [Medicaid] program and so why not let them try this?” Rosenbaum said.

4. Tackling Foreign Drug Costs

Pharmaceutical makers often sell their drugs at substantially lower prices in many foreign countries than they do in the United States. Trump emphasized in May that “it’s time to end the global freeloading once and for all,” saying U.S. consumers were paying part of the cost of the medicines that patients in other countries use.

He directed U.S. Trade Representative Robert Lighthizer to address the situation. Lighthizer’s office declined to comment.

When Sen. Todd Young (R-Ind.) asked during a Senate health committee hearing in June whether trade agreements with other countries should be used to “level the playing field,” Azar’s response was swift: “We absolutely believe we should be using our trade agreements to get them to pay more even as we have our job to pay less.”

Avalere Health President Matt Brow, who has been involved in talks with the administration, said it’s clear the focus on overseas pricing isn’t going away and the administration is “talking a lot about how to get the president what he wants.”

5. Increasing Competition

FDA Commissioner Scott Gottlieb has become the Trump administration’s lead proponent for increasing competition among drugmakers.

Competition resonates with Americans “because people see it every day in their experience in Costco and other places,” said Rena Conti, an assistant professor at the University of Chicago.

Gottlieb has announced plans to bolster the use of generic drugs and an “action plan” to encourage the development of biosimilars, which are copycat versions of expensive biologic drugs made from living organisms.

And to combat anti-competitive behavior in the market, Gottlieb said the FDA has passed along information to the Federal Trade Commission and hinted at potential action to come: “I think we’ve handed them some pretty good facts.”


KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Medicare To Overhaul ACOs But Critics Fear Fewer Participants

Accountable care organizations were among the key initiatives of the Affordable Care Act, designed to help control soaring Medicare costs.

ACOs were expected to save the government nearly $5 billion by 2019, according to the Congressional Budget Office.

It hasn’t come anywhere close.

On Thursday, the Trump administration proposed an overhaul to the program, which was designed to encourage doctors and hospitals to work together to coordinate care by reducing unnecessary tests, procedures and hospitalizations. The move could dramatically scale back the number of participating health providers.

Administration officials say ACOs have led to higher Medicare spending.

The announcement was just the latest in a steady drumbeat of moves by Trump administration officials to unwind health policies set in place by the Obama administration.

Medicare ACOs began in 2012 and today enroll more than 10 million beneficiaries. If they provide care for less than certain cost targets — while meeting quality of care standards — then they get to share in any of the savings. Commercial insurers and Medicaid have also adopted ACOs in the past decade.

About 82 percent of the 561 Medicare ACOs are set up so that they are not at risk of losing money from Medicare. They can share in any savings they achieve. The rest are in a model where they can gain a higher share of savings, but also risk paying back money to Medicare if they do not meet their savings targets. Those ACOs have been more successful in saving money, Medicare officials said.

The Medicare program said it would phase out its no-risk model beginning in 2020.

A recent industry-sponsored survey showed 70 percent of ACOs would rather quit than assume such financial risk.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said it’s wrong to have ACOs that can only make profits but not risk any losses. “We want to put the accountability back into Accountable Care Organizations,” she said during a briefing with reporters.

Existing ACOs will have one year to switch to a model accepting financial risk. New ACOs will have two years.

Currently, ACOs have up to six years to shift to a model where they share in financial risk.

These and other proposed changes would save Medicare $2.2 billion over the next decade, Verma said.

The proposal drew rare praise from a former Obama administration official. Andy Slavitt, who once headed CMS, tweeted: “CMS is proposing changes to Medicare pay for value (ACO) models. … At first look, they look positive to me.”

CMS estimated that its new policy would lead to a drop of about 100 ACOs by 2027.

Industry observers say that prediction seems modest at best.

“That does not seem too realistic,” said Ross White, manager of the Center for Health Care Regulatory Insight at KPMG, a large consulting firm. “This is going to come as quite a shock to a lot of current participants, although the administration has been sending these signals for several months. … It definitely seems like they are trying to ratchet down and squeeze the dollar savings out and not have participants in it for the wrong reasons.”

Clif Gaus, the CEO of the National Association of ACOs, blasted the proposal, saying it will “upend the ACO movement” and introduces “many untested and troubling policies.”

CMS is “pulling the rug out from ACOs by redoing the program in a short timeframe,” he said.

He added that the “likely outcome will be that many ACOs quit the program, divest their care coordination resources and return to payment models that emphasize volume over value.”

Tom Nickels, executive vice president of the American Hospital Association, also criticized the new ACO rules. “The proposed rule fails to account for the fact that building a successful ACO, let alone one that is able to take on financial risk, is no small task; it requires significant investments of time, effort and finances.”

Under the new plan, CMS also wants to require doctors in ACOs to inform their patients that they are in an ACO. That has not occurred previously, because unlike HMOs, ACOs do not restrict which providers they can see.

Verma, who has repeatedly said unleashing the free market principles will help control costs and improve quality, said ACOs are driving more hospitals and doctors into mergers, which leads to higher costs.

“We want to work with ACOS that are serious about delivering value. We can no longer run a program that is losing money for taxpayers,” she said.

Podcast: KHN’s ‘What The Health?’ Coming Soon: ‘Long-Term Short-Term’ Plans

The Trump administration’s new rule allowing “short-term” insurance plans to be used for up to three years has touched off a big reaction in health policy circles. Supporters of the change say those who can no longer afford comprehensive health insurance will have the ability to purchase lesser but cheaper plans. But opponents worry that consumers who fail to read the fine print will end up with plans that won’t cover care they need.

Reaction is similarly divided over an administration rule change that will make it easier for managed-care plans participating in Medicare to negotiate the price of drugs provided in doctors’ offices or hospitals. Insurance groups call it a small but positive step; patient groups worry it will make it harder for those with serious medical problems to get the medication their doctors recommend.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Margot Sanger-Katz of The New York Times and Kimberly Leonard of the Washington Examiner.

Among the takeaways from this week’s podcast:

  • The Trump administration says its promotion of short-term health plans is designed to help people who don’t get government subsidies find more affordable health coverage and will provide some help to people who are not going to buy a plan on the federal health insurance marketplaces anyway. But the policies tend to limit many types of care, such as maternity expenses, prescription drugs and mental health issues.
  • In addition to concerns that these plans will destabilize the Affordable Care Act marketplaces, some consumer advocates say people looking at the plans don’t realize the extent to which they lack patient protections. For example, one may not cover hospital expenses if a patient is admitted over a weekend or pay for care needed for injuries if the patient was drunk.
  • As part of the administration’s effort to meet President Donald Trump’s promise to curb prescription costs, federal officials announced this week that private Medicare Advantage plans can require patients being prescribed drugs from a doctor or in a hospital to first try the cheapest drug options. But some patient advocates object, saying consumers and their doctors should be able to decide what is the best therapy.
  • The federal indictment announced this week against Rep. Chris Collins (R-N.Y.) renews questions about why a member of Congress with a large role in a biotech company was allowed to be a member of a House committee that oversees health issues. After the indictment, House Speaker Paul Ryan stripped Collins of his seat on the Energy and Commerce Committee.
  • New York Gov. Andrew Cuomo, a Democrat, surprised many people with his announcement that insurers would not be able to factor in to premium prices the expectation that fewer people will buy marketplace plans because the health law’s coverage penalties expire in 2019.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too:

Julie Rovner: NPR’s “Doctors With Disabilities Push For Culture Change In Medicine,” by Elana Gordon

Anna Edney: The Atlantic’s “Women More Likely to Survive Heart Attacks If Treated by Female Doctors,” by Ed Yong

Margot Sanger-Katz: ProPublica’s “The Shadow Rulers of the VA,” by Isaac Arnsdorf

Kimberly Leonard: The Washington Post’s “A Huge Clinical Trial Collapses, and Research on Alcohol Remains Befuddling,” by Joel Achenbach

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Pharmacy-Made Pain Creams Flagged On Fears Of Medicare Fraud And Risk

Medicare pays hundreds of millions of dollars each year for prescription creams, gels and lotions made-to-order by pharmacies — mainly as pain treatments. But a new report finds that officials are concerned about possible fraud and patient safety risks from products made at nearly a quarter of the pharmacies that fill the bulk of those prescriptions.

“Although some of this billing may be legitimate, all of these pharmacies warrant further scrutiny,” concludes the report from the Office of the Inspector General for the Department of Health and Human Services.

In total, 547 pharmacies — nearly 23 percent of those that submit most of the bills to Medicare for making these creams — hit one or more of five red-flag markers set by investigators. Those included what the researchers called “extremely high” prices; large percentages of Medicare members getting identical drugs — 16 of the pharmacies billed for identical drugs for 200 or more customers; “greatly increased” year-over-year billing — 20 pharmacies increased their billing by more than 10,000 percent; or having a single medical provider writing more than 131 prescriptions. More than half of those pharmacies hit two or more measures — and 10 hit all five.

One Oregon pharmacy, for example, submitted claims for 91 percent of its customers. A pharmacy in New York submitted 5,342 prescriptions ordered by one podiatrist, while a Florida pharmacy saw its Medicare billing for such treatments go from $7,468 in 2015 to $1.8 million the following year.

Many of the pharmacies are clustered in four cities: Detroit, Houston, Los Angeles and New York.

The report comes amid ongoing concern by Medicare officials about these custom-made — or compounded — drugs. In addition to questions like those raised in the report about overuse and pricing, safety has been a key issue in recent years. A meningitis outbreak in 2012 was linked to a Massachusetts pharmacy that did not maintain sterile conditions and sold tainted made-to-order injections that killed 64 Americans.

When done safely, pharmacy-made compounded drugs provide a legitimate option for patients whose medical needs can’t be met by commercially available products mass-produced by pharmaceutical companies. For example, a patient who can’t swallow a commercially available prescription pill might get a liquid version of a drug.

State boards of pharmacy generally oversee compounding pharmacies, and the drugs they produce are not considered approved by the Food and Drug Administration.

The new report focuses on concerns with compounded topical medications.

Medicare spending for such treatments has skyrocketed, rising more than 2,350 percent, from $13.2 million in 2010 to $323.5 million in 2016. Price hikes and an increase in the number of prescriptions written drove the increase, the report said.

It is not the first time the inspector general has looked at compounded drugs. A 2016 report found that overall spending on all types of compounded drugs — not just topical medications — rose sharply. The U.S. Postal Service inspector general and the Department of Defense also have raised concerns about rising spending and possible fraud for compounded drugs.

In response to those previous reports, the International Academy of Compounding Pharmacists, the industry’s trade group, has said that legitimately compounded drugs “can dramatically improve a patient’s quality of life,” noting that proper billing controls need to be in place. The inspector general’s report in 2016, it added, found that “such controls are not in place.”

This report, which the compounding trade group has not yet reviewed, focuses on topical drugs and a subset of the 15,290 pharmacies that provide at least one such prescription each year. It looked at billing records from the 2,388 pharmacies that do at least 10 such prescriptions a year — providing 93 percent of all compounded topical drugs paid for by Medicare.

Most of the prescriptions were for pain treatment, made from ingredients such as lidocaine, an anesthetic, or diclofenac sodium, an anti-inflammatory drug.

On average, those compounds were more expensive than non-compounded drugs with the same ingredients.

For example, Medicare paid an average of $751 per tube of compounded lidocaine, and $1,506 for the diclofenac, according to the inspector general’s report. Non-compounded tubes of those drugs averaged $445 and $128, respectively.

FDA Commissioner Scott Gottlieb recently outlined new efforts his agency is taking to oversee compounded drugs in the wake of legislation passed by Congress following the meningitis outbreak.

“The FDA is inspecting compounding facilities to assess whether drugs that are essentially copies of FDA-approved drugs are being compounded for patients” who could otherwise take a product sold commercially, he said in a statement issued on June 28.

Gottlieb also said the FDA plans to make more information available to patients and their doctors about compounded topical pain creams, including information about their effectiveness and any potential safety risks.

Not being effective is a safety risk, noted Miriam Anderson, a researcher with the inspector general’s office who helped write the report.

The report urged the Centers for Medicare & Medicaid Services to clarify some of its policies to emphasize that insurers can limit the use of compounded drugs by requiring prior authorization or other steps. The agency concurred with the recommendations, according to the report, including the need to “follow up on pharmacies with questionable Part D billing and the prescribers associated with these pharmacies.”

Anderson said the inspector general’s office is continuing to probe the issue.

“We will investigate a number of leads on specific pharmacies and prescribers who were identified as having these questionable patterns,” she said. “Whenever we see that kind of increase in spending, it raises concern about fraud, waste and abuse.”


KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

How Genetic Tests Muddy Your Odds Of Getting A Long-Term-Care Policy

This week, I answer questions from readers who are concerned about Medicare and insurance for long-term care.

Q: Can getting a genetic test interfere with being able to buy long-term-care insurance in the future? If you do get a plan, can the insurer drop you after you find out the results of a genetic test?

In general, long-term-care insurers can indeed use genetic test results when they decide whether to offer you coverage. The federal Genetic Information Nondiscrimination Act prohibits health insurers from asking for or using your genetic information to make decisions about whether to sell you health insurance or how much to charge. But those rules don’t apply to long-term-care, life or disability insurance.

When you apply for long-term-care insurance, the insurer may review your medical records and ask you questions about your health history and that of your family. It’s all part of the underwriting process to determine whether to offer you a policy and how much to charge.

If the insurer asks you whether you’ve undergone genetic testing, you generally have to disclose it, even if the testing was performed through a direct-to-consumer site like 23andMe, said Catherine Theroux, a spokeswoman for LIMRA, an insurance industry trade group.

“You need to release any medically relevant information,” she said.

Some states provide extra consumer protections related to genetic testing and long-term-care insurance, said Sonia Mateu Suter, a law professor at George Washington University who specializes in genetics and the law. But most follow federal law.

If you get genetic testing after you have a policy, the results can’t affect your coverage.

“Once the policy has been underwritten and issued, the insurer doesn’t revoke the policy if new medical information comes to light,” Theroux said.

Q: Can I switch Medigap insurance companies midway through the year? I found a less expensive policy.

It depends. Under federal law, when people turn 65 and first enroll in Medicare Part B they have a six-month window to sign up for a Medigap plan. Medigap plans pick up some of beneficiaries’ out-of-pocket costs for services under Medicare Part A, which covers hospitalization, and Medicare Part B, which covers outpatient services. During that six-month period, insurers have to accept people even if they have health problems.

If you’re still in that six-month period now and you want to switch plans, go right ahead.

But if you’re past the six-month window, under federal law insurers are required to sell you a plan only in certain circumstances, such as if you lose your retiree coverage or Medicare Advantage plan. If you don’t meet the criteria, insurers can decline to cover you or charge you more for preexisting medical conditions.

Many states have provided more robust protections, however. Three states — Connecticut, Massachusetts and New York — have year-round open enrollment and require insurers to offer coverage. And Maine requires a one-month “guaranteed issue” open-enrollment period every year.

Some states guarantee current policyholders a chance to switch Medigap plans at certain points during the year. Other states have additional qualifying events that allow people to switch Medigap plans, according to data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“The first thing the person should do is check with her state insurance department to find out her rights related to buying a Medigap plan,” said Brandy Bauer, associate director at the Center for Benefits Access at the National Council on Aging. If someone decides to go ahead and switch, it is wise to sign up for a new plan before terminating your current policy, she said.

Q: I did not enroll in Medicare Part B when I turned 65 because I already have a regular plan that covers everything. I was told that the insurer would keep paying as usual, but now the company says it will pay only part and that I have to buy Medicare Part B. I didn’t want to pay for two policies. Is there anything I can do to avoid that?

From your description, it’s hard to know exactly what’s going on, but we can make educated guesses. Typically, when people turn 65, it makes sense to sign up for Medicare unless they or their spouse are working and getting health insurance from an employer. For others, at age 65, Medicare typically becomes their primary insurer and any other coverage they have becomes secondary, filling in gaps in Medicare coverage.

That’s how it generally works with retiree coverage, said Tricia Neuman, director of the Program on Medicare Policy at the Kaiser Family Foundation.

If you have an individual policy that you bought on the health insurance exchange and decide to hang on to it instead of signing up for Medicare, your premiums and other costs could be higher than they would be on Medicare, depending on your income.

But if you’re not receiving employee coverage and you don’t enroll in Medicare Part B, you could be subject to a permanent premium penalty of 10 percent for every 12 months that you could have signed up for Part B but didn’t. You could also owe a premium penalty for not signing up for a Part D prescription drug plan. (Most people don’t owe any premium for Medicare Part A, so there’s no penalty for late sign-up.)

“Without knowing more, it sounds like she should drop the [current] plan and sign up for Part B and D,” Neuman said. “But we need more information to know for sure.”

Your best move now may be to call 800-Medicare or visit your local state health insurance assistance program (SHIP) to help sort out your coverage issues.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

One Of Nation’s Largest Hospital Systems Agrees To $65M Settlement Over Medicare Overbilling Allegations

Prosecutors had alleged that Prime Healthcare Services unnecessarily admitted Medicare patients who were being treated at the emergency rooms of several hospitals in its system. Medicare pays more for patients who are admitted to hospitals than those who are treated as outpatients.

Must-Reads Of The Week From Brianna Labuskes

A slow health news week wrapped up with a flurry of movement over the Affordable Care Act in the past few days. As we drift into August, there are definitely a few stories to keep an eye on.

Here’s what you might have missed:

The Trump administration issued a final rule on short-term plans. (The highlights: Coverage can go for 12 months and be renewed for a max of 36 months; it doesn’t have to cover essential benefits; and there aren’t preexisting conditions protections.) Officials were surprisingly candid (“We make no representation that it’s equivalent coverage”) in acknowledging the skimpiness of these plans — which were only ever supposed to act as three-month stopgaps for people between jobs.

The New York Times: ‘Short Term’ Health Insurance? Up to 3 Years Under New Trump Policy

For Democrats in the Senate, there’s a silver lining: The move gives them an opportunity to try to force Republicans — just months before midterm elections, mind you — to go on record voting against those popular provisions that short-term plans strip away. There’s no chance such a measure would pass the House (much less be signed by President Donald Trump), but it puts their colleagues across the aisle in a tough spot.

The Associated Press: Dems Will Try Forcing Senate Vote Against Trump Health Plan

The latest attempt to unmoor the ACA is just one in a series of grenades the administration has lobbed at the health law. But premiums aren’t spiking as much this year, insurers are joining the marketplace instead of fleeing it, and public support for Obamacare is skyrocketing. Has the war been already won?

Politico: Trump’s Losing Fight Against Obamacare

And, that wasn’t the only hubbub over the health law this week. Four major cities are suing Trump, saying his multiple attempts to “sabotage” the legislation is a failure of his constitutional duty to enforce the laws of the land. (Spoiler: They’re unlikely to be successful.)

Reuters: Four U.S. Cities Sue Over Trump ‘Sabotage’ of Obamacare

Passion over HHS’ decision to separate children at the border continues to boil. The government is now making the argument that the burden of reuniting deported parents with their children should actually fall on the American Civil Liberties Union. The ACLU fired back saying that the government is the one that made the mess, and officials shouldn’t be able to foist it off now that it needs cleaning up.

Politico: Trump Administration Tells ACLU to Find Deported Parents

An eye-popping price tag for a “Medicare-for-all” proposal dominated headlines early this week, but experts are saying there’s more to that $32.6 trillion than it might seem. Essentially, the plan would actually save money in overall national health care spending, but shift it over to the government — which means higher taxes.

Modern Healthcare: Libertarian Think Tank: Providers Would Pay for Medicare for All

Rebates are being painted as the new villain in the blame game that is the conversation around lowering high drug prices. Here’s a primer on what they are — but don’t get too attached, they might not be around for long.

The New York Times: Meet the Rebate, the New Villain of High Drug Prices

Bloomberg: Secret Drug Price Rebates Will Go Away, Pfizer CEO Predicts

If that’s not enough news for you, my miscellaneous file is chock-full: New VA Secretary Robert Wilkie is planning on reassigning the officials who have been at the heart of the morale crisis plaguing the agency; Medicare could save nearly $3 billion in a single year if it were able to negotiate drug prices as other agencies can; the FDA put the companies that were selling a dangerous class of opioids in charge of monitoring abuse of said opioids — and then did little to intervene over poor prescribing practices; and the drug industry is pumping millions in charity money into those very towns that are suing the companies over their role in the opioid crisis.

The Washington Post: New Veterans Affairs Chief Plans to Reassign, Sideline Trump Loyalists Now in Power

Stat: Medicare Could Save $2.8 Billion in a Single Year if Prices Could Be Negotiated

The New York Times: F.D.A. Did Not Intervene to Curb Risky Fentanyl Prescriptions

Bloomberg: Facing Wave of Opioid Lawsuits, Drug Companies Sprinkle Charity on Hard-Hit Areas

And as if childbirth wasn’t hard enough, this woman says she had to have a C-section without anesthesia.

Have a great weekend!

Podcast: KHN’s ‘What The Health?’ Let’s Talk Politics

It seems increasingly likely that health care politics will play an important role in the midterm elections come November. But unlike every election since 2010, this year finds the Democrats playing offense and the Republicans back on their heels.

There is one health proposal most Democrats and Republicans agree is a good idea — providing “reinsurance” to help insurers pay for their sickest patients, thus enabling them to lower premiums for everyone. This week, the Trump administration approved reinsurance plans requested by Maine and Wisconsin. But legislation in Congress that would extend those programs nationwide failed to get a vote in either the House or Senate earlier this year — another casualty in the partisan fight over health care.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Alice Ollstein of Talking Points Memo and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Congressional Democrats are making preexisting conditions a key debating point, including Senate candidates running in deep-red states, such as Missouri and West Virginia. The guarantee of coverage even when a person has a medical problem is one of the most popular provisions in the Affordable Care Act. Democrats are playing up the Trump administration’s contention in a lawsuit that since the Congress got rid of the penalty for people who don’t get health coverage, insurers don’t need to cover preexisting conditions.
  • Republicans are seeking to prove that they care about health care too, by pointing to their efforts to cut taxes on health care industries and to expand health savings accounts that allow consumers to set aside money for medical bills in tax-free accounts. But the GOP is in a bind because often if people don’t feel the direct benefits of a policy — such as the industry savings from the tax changes — politicians may not reap much benefit.
  • A growing number of Democrats in the House and Senate are also expressing support for a “Medicare-for-all” health care system. Although some may be more interested in skirting the complex details of such a transition in favor of backing a policy that appeals to Democratic voters.

Rovner also interviews KHN’s Emmarie Huetteman, who wrote the latest Bill of the Month. It features a very expensive surgical bill and a very persistent patient. You can read it here.

If you have a medical bill you’d like NPR and KHN to investigate, you can submit it here.

And if you have a question for the podcast, you can send it to whatthehealth@kff.org.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too:

Julie Rovner: The New York Times’ “Meet the Rebate, the New Villain of High Drug Prices,” by Katie Thomas

Anna Edney: USA Today’s “Hospitals Know How to Protect Mothers. They Just Aren’t Doing It,” by Alison Young

Alice Ollstein: Politico’s “Trump Policy Shop Filters Facts to Fit His Message,” by Dan Diamond

Rebecca Adams: The Atlantic’s “Being Black in America Can Be Hazardous to Your Health,” by Olga Khazan

To hear all our podcasts, click here.

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