High Cost Meds and ACA

[kgmom219]

I set up a bronze plan yesterday for a family with the medication covered at 100% percent when the deductible is met.. This spouse has 6000 dollars pharmaceutical drug costs. Most like the good ole' HSA plan.

I'm LOVING this plan. And am selling it about 90% of the time I'm with an individual. Sold it today. A retired couple with $10K in after tax income really doesn't need copays. And its perfect for "sick" people. They are always going to meet their deductible, so why not do it faster and save the cash spent on copays and take advantage of the 40% lower premium costs.

I didn't mention that BCBS doesn't know how to get the deductibles to feed between the systems. I'm hoping that is fixed prior to the 4/1 effective date

 

[yorkriver1]

I sold something similar to a client who was just glad to have insurance finally with a limit on their share of costs. Has big bills from an ongoing problem, multiple surgeries.
Not always easy sell on high deductibles, but those who "get" how fast $6K mounts up can see the value in lower premiums.
This one has subsidy, pays almost $0 for plan for self/spouse.

 

[Ann H]

Rumor has it that part of ACA is that the drug companies are required to help with the EXTRA expensive medication. I've heard it mentioned a couple of times from clients (and really wondered what they were smoking), but today I heard about it from a Chemo pharmacy. My client is on chemo and the pharmacy told her to call Merck (who makes her chemo) because they are supposed to pay for some of it, due to ACA. Client called Merck, who said "yes, you qualify and it takes 3 days to process". Client is not on the exchange.

So...that's what I've got. Any thoughts?

I saw this on a Kaiser web page about Medicare Part D. Perhaps this is what they were referring to?

The majority of plans offered in 2014 will offer no gap coverage beyond that which is required by the Affordable Care Act (ACA) of 2010, which phases out the coverage gap by 2020. Under current law, for 2014, manufacturer prices for brand-name drugs purchased in the gap will be discounted by 50 percent (with plans paying 2.5 percent and enrollees paying the other 47.5 percent), and plans will pay 28 percent of the cost for generic drugs in the gap (with enrollees paying 72 percent).

Medicare Part D: A First Look at Plan Offerings in 2014 | The Henry J. Kaiser Family Foundation​

 

[kgmom219]

That's interesting, because this is what I got today from CMS...

Lower Out-of-Pocket Drug Spending: Beneficiaries in the Part D prescription drug coverage gap, or “donut hole,” will benefit from greater savings on prescription drugs. As a result of the Affordable Care Act, in 2015, enrollees with liability in the donut hole will receive coverage and discounts of 55 percent on covered brand name drugs and 35 percent on covered generic drugs, an increase from 52.5 percent and 28 percent, respectively, in 2014. The Affordable Care Act’s Coverage Gap Discount Program has provided discounts to more than 7 million Medicare beneficiaries, an average of $1,200 each

I should note that this is "proposed guidance" not final decision language

 

[somarco]

Big print, OBAMACARE CLOSES DONUT HOLE IN MEDICARE PART D

Small print, your premiums, copays and out of pocket will increase as the hole closes.

 

[AllenChicago]

Big print, OBAMACARE CLOSES DONUT HOLE IN MEDICARE PART D

Small print, your premiums, copays and out of pocket will increase as the hole closes.

How True! Part-D clients tell me that as the "donut hole" closes, their prescription prices are increasing by the exact same proportion. This means that the pharmacist and/or the drug manufacturers are double-dipping. Taking money from the government and also from the patient. A Republican Administration would launch a probe into this kind of gouging, the way they did with gasoline price abuse.

 

[somarco]

Yet only 6% of seniors ever reach the donut hole

 

[AllenChicago]

Wednesday 4-9-2014

As new ObamaCare enrollees start to use their insurance, it's becoming clear that the earliest to sign up were those with the most expensive medical needs.

Story: http://www.nytimes.com/2014/04/09/b...t_tnt_20140409&nlid=58462464&tntemail0=y&_r=0

It's a good thing the 3 R's were added to the ACA (Risk Adjustment, Reinsurance, Risk Corridors), because it doesn't look like enough healthy people enrolled to offset the expenses of the non-healthy.
ac

 

[yorkriver1]

I just talked to someone who has an early 20's age family member receiving an injectable twice a month, $1,000 per dose. Insurance pays some, drug company pays some, client pays their OOP for that level drug, probably a percentage llike 30%. Not sure if that's an income based situation.

 

[RayNY]

I like the closing comment: "The plans knew what they were getting into,” he said. “They understood that this population was going to look really different.”

They knew, but the gov't dictated the risk profiles, age makeup, experience, etc. Carriers had to base premiums on estimates from the gov't that assumed a best-case scenario (40% young and healthy, same drug usage, etc.)

Keep in mind, carriers have to submit next year's rates very soon. This data, this experience, is going to be what they are forced to use. Expect to see some higher rates next year.