Will you get insulin-cost relief from the inflation bill? Not if you have private insurance

Will you get insulin-cost relief from the inflation bill? Not if you have private insurance

But an out-of-pocket cap identical to that for Medicare was stripped from the bill for those with private insurance because Democrats are trying to pass the bill by a simple majority through the reconciliation process. That requires Senate Parliamentarian Elizabeth MacDonough to vet the provisions. She said most of the health-related features were fine, but the insulin proposal for those who have private insurance, not Medicare, violated the Byrd provision, which says that issues “extraneous to the federal budget” cannot be passed by simple majority through reconciliation.

Out-of-pocket spending for those with Part D Medicare drug coverage will be capped at $2,000 a year.

In 2024, a 5% coinsurance payment that now kicks in after someone reaches the catastrophic drug spending level of $7,050 in Medicare will end. Because drug companies set their own prices, 5% on expensive drugs can be a lot of money.

Related:

Democrats are on a dangerous path with drug pricing (written by a lobbyist)

Proponents claim that enabling Medicare to negotiate prices will lower the cost of prescription drugs for the nearly 64 million Americans who are currently on Medicare*, and more specifically for the 1.4 million beneficiaries who spend more than $2,000 per year on their medications.

Regrettably, this is a misguided assessment that fails to consider how this policy will actually decrease both the affordability and accessibility of prescription drugs in the long run.

Democrats’ drug pricing policy won’t improve the problem that it is designed to address — making prescription drugs more affordable for Medicare beneficiaries — and it will end up limiting Medicare patients’ access to certain medications. Moreover, it will discourage pharmaceutical innovation, and worst of all will drive costs up for the 220 million Americans with private insurance.

Indeed, this policy will raise drug costs and health care premiums for the 220 million Americans with private health insurance. If drugmakers are forced to give Medicare significant discounts on certain drugs, these companies will make up for this lost revenue by raising prices in the commercial market, as “The Wall Street Journal’s” Editorial Board argued in their column earlier this week.

H/T Jimmy Dore:

One of the final healthcare actions made by the Trump Administration has been rescinded by the Biden Administration. On December 23, 2020, the Trump Administration finalized a rule that directed the Department of Health and Human Services (HHS) to take action to require that federally qualified health centers (FQHCs) make insulin and injectable epinephrine available to certain patients at 340B prices. The Biden Administration delayed the rule twice before it became effective on July 20, 2021, and the first opportunity for HHS to impose the requirements of the rule would have been through grants awarded in fiscal year 2022. So, while the rule has been in effect since July, it has yet to be implemented.

In the Federal Register notice rescinding the rule, HHS noted that the rule would have resulted in “excessive administrative costs and burdens” on health centers. Specifically, the agency took issue with the requirement that health centers would need to create and maintain new practices to determine patients’ eligibility to receive drugs at or below the discounted price paid by the health center, plus a minimal fee. HHS also noted its belief that the implementation of the Rule would have resulted in “reduced resources available to support critical services to health center patients – including those who use insulin and injectable epinephrine.

[10-2021] Biden Administration Rescinds Trump Administration Insulin Pricing Rule

Some Medicare Information, regarding prescription drug coverage:

When becoming eligible for Medicare, many Medicare beneficiaries make the mistake of thinking they automatically get prescription drug coverage. This is not the case. Original Medicare (Part A and Part B) does not cover prescription drugs. If you want prescription drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Medicare recipients can get prescription drug coverage one of two ways:

Medicare Advantage Plan (Part C)

Medicare Prescription Drug Plan (Part D)

Does Medicare Pay for Prescription Drugs?

Your [insulin] costs in Original Medicare:

You pay 100% for insulin (unless used with an insulin pump, then you pay 20% of the Medicare-Approved Amount after you meet the Part B deductible). You pay 100% for syringes, needles, alcohol swabs, and gauze, unless you have Part D.

Insulin savings through the Part D Senior Savings Model:

You may be able to get Medicare drug coverage that gives supplemental benefits specifically for insulin. You can get this savings on insulin if you join a Medicare drug plan or Medicare Advantage Plan with drug coverage that participates in the insulin savings model. Participating plans offer coverage choices that include multiple types of insulin at a maximum copayment of $35 for a month’s supply. (The $35 maximum copayment doesn’t apply during the catastrophic coverage phase of Medicare drug coverage.)

Medicare.gov

Most Medicare drug plans (Medicare drug plans and Medicare Advantage Plans with prescription drug coverage) have their own list of what drugs are covered, called a formulary. Plans include both brand-name prescription drugs and generic drug coverage. The formulary includes at least 2 drugs in the most commonly prescribed categories and classes. This helps make sure that people with different medical conditions can get the prescription drugs they need. All Medicare drug plans generally must cover at least 2 drugs per drug category, but plans can choose which drugs covered by Part D they will offer.

What Medicare Part D drug plans cover

Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. Most Medicare Advantage Plans include drug coverage (Part D). In most cases, you’ll need to use health care providers who participate in the plan’s network. These plans set a limit on what you’ll have to pay out-of-pocket each year for covered services. Some plans offer non-emergency coverage out of network, but typically at a higher cost. Remember, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. Keep your red, white, and blue Medicare card in a safe place because you may need to use your Medicare card for some services. Also, you’ll need it if you ever switch back to Original Medicare. Below are the most common types of Medicare Advantage Plans.

Medicare Advantage Plans

Sounds like it will benefit those Medicare beneficiaries, with Medicare Part D or a Medicare Advantage Plan, with high out-of-pocket costs (see catastrophic coverage). Otherwise, it seems like commonly prescribed insulin only costs $35, already. For me, Part D wasn’t worth it since the commonly prescribed prescriptions weren’t any that I was taking at the time (I take mostly herbal remedies, now).