Anfuso Benefit Consulting, LLC

Are you, or do you know a DACA recipient? They are now eligible to apply for Marketplace health insurance.

CMS rule extends Marketplace coverage to DACA recipients | AHA News The Centers for Medicare & Medicaid Services May 3 released a final rule that would allow DACA recipients, young undocumented immigrants authorized to work in the U.S., to purchase coverage through the Health Insurance Marketplace, qualify for Marketplace subsidies based on income, and apply for the...

Are you familiar with GA Pathways? Are you NOT eligible for a Marketplace plan? Do you make to much to qualify for Medicaid. This may be the plan for you.

More than 100,000 applied, but only 4,200 people are in Georgia Pathways to Coverage program For Georgians to qualify for Pathways, single people need to be making roughly $15,000 per year or less. Members of a family of three need to have a household income of less than $26,000.

Is this as good as it sounds? It will benefit those who take numerous and/or expensive medications but hurt those that do not. Your drug card is going to cost more, your formulary is going to be more limited, many drugs will not be covered and you will have to get more pre authorizations for drugs you are already taking. Insurance carriers are already talking about cancelling certain plans.

HHS Announces Cost Savings for 64 Prescription Drugs Thanks to the Medicare Rebate Program Established by the Biden-Harris Administration’s Lower Cost Prescription Drug Law Some people with Medicare will pay less for some Part B drugs if the drug’s price increased faster than the rate of inflation.

The Inflation Reduction Act1requires drug companies to:
Negotiate prices with drug companies for certain single-source brand-name drugs or biologics without generic or biosimilar competitors covered under Medicare Part D (starting in 2026) and Part B (starting in 2028)12.
Pay rebates to Medicare if drug prices increase faster than the rate of inflation for certain drugs34.
Calculate and invoice these rebates to Medicare4.
Potentially save Medicare beneficiaries between $1 and $3,575 per average dose depending on their individual coverage

There are going to be lots of health insurance changes for the 2025 open enrollment period. This will be one of them.

Georgia to moving health insurance enrollment to state-run marketplace in November Georgia is switching to a state-run portal to shop for and enroll in health insurance plans.

What is Medicare?
Medicare is federal health insurance for people 65 or older, (some younger people with disabilities).

To qualify for Medicare, you must meet certain requirements, including age, citizenship, and work history:
• Age: You must be 65 or older. However, you may be eligible earlier if you have a disability, End-Stage Renal Disease (ESRD), or ALS (Lou Gehrig's disease).
• Citizenship: You must be a U.S. citizen or permanent legal resident.
Work history: You or your spouse must have worked for at least 10 years (or 40 quarters) in Medicare-covered employment. You may also qualify if you receive Social Security or railroad retirement benefits, or if you've worked long enough to be eligible for those benefits but aren't yet collecting them.

Medicare Part B premiums will start at $180 in 2025.Medicare Part B premiums are based on income and can range from 35% to 85% of the total cost2.
You can sign up for Medicare during your Initial Enrollment Period, which begins three months before your 65th birthday and ends three months after. If you apply for Social Security three months before you turn 65, you can sign up for Medicare at the same time.
Types of Medicare:
• Original Medicare – Part A & B Part A provides hospital coverage, while Part B covers doctor's visits and other aspects of outpatient medical care. These plans aren't competitors but are intended to complement each other. The annual deductible for all Medicare Part B beneficiaries will be $263 in 2025 then Part B will pay approximately 20% of all Medicare approved fees
• Medicare Supplement - You must generally have Medicare Part A and Part B These costs include deductibles, copayments, and coinsurance. Medigap plans vary in what they cover, so you can choose one that fits your needs. Out of pocket costs are limited
• Medicare Advantage - A Medicare Advantage (MA) plan, also known as a Part C plan, is a health plan that provides Medicare Part A and Part B coverage through a private company that has been approved by Medicare. MA plans can include additional services like wellness programs, hearing aids, and vision services. They can also have lower monthly premiums, lower out-of-pocket costs, and a maximum amount that you have to pay out-of-pocket each year. However, MA plans may have more restrictive provider networks, and you may need to get referrals to see specialists.
• In 2025, Medicare beneficiaries will pay no more than $2,000 out of pocket for prescription drugs covered under Part D12. This spending cap will apply to original Medicare enrollees who have a Part D prescription drug plan and beneficiaries with a Medicare Advantage plan that includes prescription drug coverage. This could mean more prior authorizations to get prescriptions, additional restrictions on which medications the plans cover, and hikes in Part D premiums and co-pays. Or some combination of these.

ANFUSO BENEFIT CONSULTING, 510 WINDER TRAIL, CANTON, GA 404-276-7554

Medicare Part D is changing in 2025

Saving money with the prescription drug law Saving money with the prescription drug law A new prescription drug law that went into effect January 1, 2023, will help save money for people with Medicare. This law improves access to affordable treatments and strengthens the Medicare program. Here’s what the law means for you: More vaccines cov...

great article

Prior Authorizations: Your Doctor-Recommended Care Denied - Glaucomflecken You’re denied care, and your doctor is burned out. Why? Prior authorizations and claim denials.

In a Medicare Advantage Plan?

You can still make a change!
From Jan 1 – March 31, if you’re in a Medicare Advantage Plan, you can switch plans or return to Original Medicare and join a separate Medicare drug plan.

Are you receiving a subsidy?

Have you received your Form 1095-A – Health Insurance Marketplace Statement in the mail? If so, make sure to keep it with your other important tax records, like the W-2 you get from your employer. If not, keep an eye on the mail as it should arrive by mid-February.

Did you know -

VantageScore® is removing medical debt from its credit-scoring model
If you have medical debt, changes may be coming to your credit score in the near future.
Here’s what you need to know
• As of July 2022, paid medical debt no longer appears on consumer credit reports.
• Starting in 2023, medical debt under $500 won’t be included on consumer credit reports.
• Beginning January 2023, VantageScore® 3.0—which is monitored by CreditWise—will no longer include medical debt in credit score calculations.

Happy New Year! The below article is from UHC but has some good interesting trends for 2023.

5 health care trends impacting employers in 2023
Behavioral health challenges, the end of the public health emergency and rising health care costs are all going to be top of mind for employers in 2023.

Jan. 4, 2023
All states

As the new year begins, employers have their hands full. Not only is a looming recession top-of-mind,1 the competitive labor market is forcing many employers to do more with less. The demand for higher salaries and better benefits are making it increasingly difficult to attract and retain talent, and other dynamics within the health care industry are adding to the challenge.

1. The concern around health care costs amid economic uncertainty
Health care costs continue to rise, and the economy isn’t helping. A 2022 report found that health care costs increased 3.2% in 2022, and employers are bracing for an even bigger increase at 5.4%.2 Another survey revealed that 7 in 10 employers expect their health care costs to rise moderately or significantly over the next 3 years, which likely contributes to the fact that more than 50% of respondents expect their costs to be over-budget in 2023.3

What does this mean for an employer’s health care strategy? Today’s competitive labor market, coupled with economic uncertainty, has many employers looking for ways to contain their costs without having to sacrifice the quality of coverage they offer their employees.
As we enter this time of heightened economic uncertainty, the ability to control costs from a health care perspective is going to become more and more important.

— Craig Kurtzweil, Vice President of the Center for Advanced Analytics at UnitedHealthcare
2. The “return to health” phenomenon
During the pandemic, some Americans put off preventive care appointments and procedures. But 2022 UnitedHealthcare claims data shows that members are making a “return to health,” as many are back to scheduling appointments with their primary care providers and getting routine tests like colonoscopies and mammographies at levels in line with pre-pandemic years.4

What does this mean for an employer’s health care strategy? While the “return to health” could initially mean higher medical costs, the long-term benefits of preventive care may result in better health outcomes and lower overall costs. For instance, routine appointments and screenings may help catch conditions early that could be treated in a more successful and cost-effective way.

3. The need for more behavioral health support
It pays to have happy employees, but recent research finds that frequent mental distress has increased among adults.5 In fact, according to America’s Health Rankings 2022 Annual Report, the prevalence of frequent mental distress increased 11% among adults between 2020 and 2021.5 That’s concerning in more ways than one. Employees with unresolved depression may experience a reduction in productivity, which may also affect their employers’ profitability and the wider economy. On the other hand, a 2019 study from Oxford University found that happy workers are 13% more productive.6

What does this mean for an employer’s health care strategy? More employers will be looking for benefits that integrate medical with behavioral and give their employees improved access to behavioral health services. For example, UnitedHealthcare is focused on expanding its network of behavioral health care providers and enhancing its virtual behavioral health support. Discover the ways UnitedHealthcare is advancing behavioral health.

4. The (continued) rise of specialty drugs
Enormous investments continue to be made in pharmaceutical research and development. From 2014 to 2022, the industry has seen a 78% increase in the number of available drugs.7 But the cost of specialty drugs has continued to grow with it. In 2021, the total cost of specialty drugs amounted to $301 billion, an increase of 43% since 2016.8

What does this mean for an employer’s health care strategy? Employers are looking for strategies that can help them better manage their pharmacy care costs. One way UnitedHealthcare does this is by putting the data and tools into the hands of employees and their providers to help steer them to more cost-effective drug alternatives, when applicable. Learn how UnitedHealthcare is working to make pharmacy and specialty drugs more affordable, such as by eliminating out-of-pocket costs on certain, vital prescription drugs.

High prices are a significant barrier to prescription drugs for many people, so we are using our unique capabilities to deliver savings for consumers. We are doing what we can to shield people from the prices set by pharmaceutical companies and hope all stakeholders also will act to make prescription drugs more affordable.

— Brian Thompson, Chief Executive Officer of UnitedHealthcare
5. The potential end of the public health emergency (PHE)
Another trend employers are keeping an eye on is the end of the PHE, which was established by the federal government in January 2020 due to the 2019 novel coronavirus outbreak. When the PHE is lifted, about 18 million Americans9 who received Medicaid coverage during the pandemic will be reevaluated or “redetermined” – over a 14-month period on a state-by-state basis – as to whether they’re still eligible for Medicaid or whether they will need to seek health care coverage through their employer or on the individual exchange. Early industry research shows that about 40% will become eligible for employer-sponsored coverage.10

What does this mean for employers? Since more employees may be seeking another insurance option, employers should prepare for 1) an influx of questions about “redetermination” from their employees and 2) the financial impact of enrolling more employees in their benefits.

Tomorrow, December 15th is the last day to enroll for a 1/1/23 effective date. If you enroll after the 15th you will have a 2/1/23 effective date.

Hmm, I wonder about this one. Not completely sold on the third party.

The unsung middlemen between patients and drug prices Pharmacy Benefit Managers add $145 billion in value to society annually, while the 10 largest drug manufacturers made over $700 billion in 2021 alone.

https://thehill.com/opinion/healthcare/3747077-stop-hospital-consolidations-to-lower-health-care-prices-for-all-americans/

Stop hospital consolidations to lower health care prices for all Americans With 2023 bringing divided government and inflation at levels not seen in decades, lowering the cost of health care is a political and moral necessity. Over the years, Americans have found that ins…

Medicare beneficiaries' access to a physician may be in jeopardy due a planned 8.42% cut in Medicare reimbursements in 2023. If these cuts go into effect, it will severely impede patient access to care due to the forced closure of physician practices and put further strain on those that remained open during the pandemic.
Tell Congress to protect America's Medicare patients and stop the cuts!
It's clear that Congress must work with the patient and physician communities to develop long-term solutions to the systemic problems with the Medicare physician payment system and preserve patient access by passing legislation. In the meantime, policymakers need to address the immediate problem before the end of the year.
Recently, Representatives Ami Bera, MD (D-CA) and Larry Bucshon, MD (R-IN) introduced H.R. 8800 the "Supporting Medicare Providers Act" to help address the flawed payment system and provide relief from the devastating cuts.
With only a handful of days before the election, now is the time to build on the momentum from H.R. 8800 and demand that Congress take action to stop these devastating Medicare cuts in the "lame duck" session. Please take a moment and contact your Senators and Representative to tell them to protect America's Medicare patients access to care by canceling these cuts!
________________________________________

What is the timeline for COBRA?

The federal COBRA law requires employers to maintain a timeline of notifications. Employers have a total of 44 days from the date of the qualifying event to notify the employee of their right to COBRA benefits

An employee who’s eligible for Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage must elect it within 60 days of their insurance termination date, or the date that the employee recieved their COBRA

What is the difference between copay & coinsurance?

Copay is a fixed expense. Example, $30 office visit copay

Coinsurance is a percentage of the cost. Example, you are responsible for 20% of $1,000 claim. You owe $200

Medicare Open Enrollment begins tomorrow October 15th. If you have any questions feel free to contact me at 770-704-0321 @ Anfuso Benefit Consulting

Medicare Advantage -
These are the plans you see advertised on TV. They are a great fit for many, but you need to realize that these plans are supposed to help subsidize your healthcare costs.

DO NOT get caught up in the "perks" offered that are not medically related. There are going to be additional perks this open enrollment that will look appealing but your first priority must be how your medical and prescription claims are paid.

Did you know - Medicare Advantage is an alternative to traditional Medicare in which health care coverage is provided by private insurance companies, which are reimbursed by the federal government. Medicare Advantage is funded by Medicare and by people who sign up for the plans. With the exception of hospice care, Medicare Advantage must offer at least the same hospital and medical coverage as original Medicare. In return, Medicare pays a fixed amount to the insurance companies every month to help finance this coverage. If you choose an Advantage plan, you'll also help pay for its costs through premiums and other charges.

Again, Advantage plans are a great fit for many people. Be sure you understand your benefits.

Medicare open enrollment begins 10/15/22.

Open enrollment is only a few months away

Anfuso Benefit Consulting, LLC If you are a Benefits Manager searching for answers to confusing legal changes and updates under the

Healthcare has become a consumer driven product. Vision, dental and pharmacy benefits. Those on Medicare really need to shop their pharmacy costs. There can be a significant price difference between pharmacies. You want to stay out of the donut hole for as long as possible.

Aging out dependents age 26+ are eligible to sign up for Individual & Family plans

Whether you're enrolling in an individual health plan for the first time or looking to switch your current benefit, choosing an individual health insurance policy on your own can be difficult. Many individual health insurance plans are available on the market, but how do you know which one is right for you?
Choosing a health insurance plan doesn't have to be complicated or time-consuming. Please call us for a free consultation.

March 14, 2022

We are committed to making sure your client's have access to high quality, affordable healthcare. One way we do this is by negotiating the rates we pay doctors and hospitals for the care they provide.

We've worked closely with Northside Hospital for several months. If we don't reach an agreement by April 15, 2022, Northside Hospital will no longer be in your client's plans' network on April 16, 2022.

Members can continue to use Northside facilities and doctors through April 15, 2022, as we continue our efforts to reach a new agreement. Starting April 16, 2022, your clients' employees will pay more if they receive care from Northside doctors or facilities. They will save money if they choose a doctor or hospital in their plan's network. Members can find doctors in their plan's network on the SydneySM Health mobile app or by logging in to anthem.com.

Members' benefits may continue to cover care from Northside Hospital for a limited time on or after April 16, 2022, if they're receiving ongoing treatments, have a procedure scheduled, or are admitted to Northside Hospital due to an emergency. They can call the Member Services number on their ID card for more information.

We'll keep you updated about our continued negotiations with Northside Hospital. Our goal is to improve our members' access to affordable healthcare in Georgia.

If you have questions, please visit anthem.com/northside or contact your sales representative.

An update regarding UnitedHealthcare’s negotiation with Wellstar Health System
Thank you for your patience and support as we continue to work diligently to restore network access to Wellstar Health System at an affordable cost. We understand that Wellstar recently distributed a communication once again containing misinformation regarding our negotiation. You deserve the truth, so we’re reaching out today to provide you an update on our negotiation and ensure you have all the facts.
In addition to the information below, you can also view the fact sheets linked below, which provide a comprehensive and transparent overview of where things currently stand in our negotiation and correct some the inaccuracies Wellstar has flooded the market with over the past several months:
• Wellstar’s transparency data (pdf)
• The impact of Wellstar’s 40% price hike demands for Atlanta residents and employers (pdf)
Wellstar recently responded to our Dec. 17 proposal with essentially the same demands it had previously proposed.
We were hopeful Wellstar would accept our latest proposal, which met all of Wellstar’s demands with the exception of the health system’s unreasonable 40% price hike it continues to seek for its hospitals, which are already the highest cost in Atlanta. Unfortunately, with the exception of changing some of the effective dates of the contract, Wellstar responded with the same exact proposal it had previously delivered to us. Each of Wellstar’s last four proposals dating back to September have maintained its request for a 40% price hike for its hospitals, which would inflate health care costs by $90 million. These continued exorbitant demands make it apparent that Wellstar has no interest in making health care affordable for Georgia residents and employers.
Contrary to what Wellstar communicated, we responded to the health system’s proposal.

We’ve met all of Wellstar’s demands except the egregious 40% price hike for its hospitals
As we have previously shared, we have made significant movement in an effort to get a deal done following Wellstar’s decision to end the contract we had just renewed in the summer of 2020.
From the onset of our negotiation, Wellstar communicated that one of its top priorities was to update our contract to more fully recognize Wellstar Clinical Partners (WCP) as a clinically integrated network. We have done just that, offering to bring the WCP physicians under one clinically integrated contract while providing WCP the rate increase Wellstar sought.
Our proposals to Wellstar have also included meaningful, annual rate increases for its hospitals, despite the fact that they were already the highest cost in Atlanta. While the rate increases we have proposed are more than the market demands, we did this in the spirit of compromise and to end the disruption the communities we serve have experienced.
Unfortunately, only one side has compromised in this negotiation. While we’ve been focused on getting a deal done, Wellstar has spent its time maintaining its same demand for egregious rate increases while spreading false narratives to the market.
Publicly available transparency data from Wellstar illustrates we were reimbursing Wellstar at rates consistent with other health insurance plans
Wellstar has repeatedly stated that the contract it is seeking would result in reimbursement similar to those from other health insurance providers. Look no further than the health plan transparency rates that were previously published on Wellstar’s website and are available by clicking here (pdf) to draw the simple conclusion that this message from Wellstar is false.
According to Wellstar’s transparency data, which lists the reimbursement it receives from each of the five major health plans for 267 services, UnitedHealthcare ranked at parity or near the higher end of reimbursement for the majority of the services listed. For a more comprehensive breakdown of Wellstar’s transparency data, please click here.
Soon after we pointed Wellstar back to the transparency data on its own website as additional proof we were reimbursing the health system at rates consistent with other insurers, the health system removed all information related to what we were reimbursing the health system. We believe Wellstar is attempting to hide the truth after realizing information it was sharing publicly countered the misinformation it was spreading in an effort to paint us in a negative light during this negotiation.
Our latest proposal remains on the table. We once again ask that Wellstar either work with us to finalize our offer or come to the negotiating table with a realistic proposal that’s affordable for the people and businesses we serve.
We understand this continues to be a challenging process for our employer group customers and members who rely on Wellstar for their health care needs. We assure you we do not take this type of disruption in the market lightly. It remains our top priority to restore access to Wellstar but at a cost that is affordable and sustainable to the people and employers we serve. We urge Wellstar to work work with us to accomplish this goal.
Thank you again for your patience and partnership as we work to reach an agreement with Wellstar.

Looking for a plan that includes Anthem/BCBS, Let us provide a quote for you. This will effect all individual/group/advantage plans.
https://www.11alive.com/article/news/health/northside-hospital-anthem-blue-cross-blue-shield-negotiations/85-c404fe92-cedc-438c-bc69-769bf442334a

400,000 patients in Georgia may have to find new doctors by end of month Anthem BlueCross BlueShield and Northside Hospital are negotiating right now with a deadline of Dec. 31.

Anfuso Benefit Consulting, LLC updated their address.