<![CDATA[Wisconsin Individual & Small Business Health Insurance - WIHIA - Blog]]>Wed, 15 Jan 2025 12:35:13 -0600Weebly<![CDATA[Medicare's new $2,000 cap on Rx spending]]>Wed, 15 Jan 2025 16:51:37 GMThttp://wihealthinsuranceadvocate.com/blog/medicares-new-2000-cap-on-rx-spendingThe Inflation Reduction Act (IRA), signed into law in August 2022, marked a historic milestone in healthcare policy by introducing significant cost-saving measures for Medicare beneficiaries. Among its most notable provisions is the cap on out-of-pocket prescription drug costs, ensuring that no Medicare beneficiary pays more than $2,000 annually for their medications. This change took effect in 2025, transforming the financial landscape for millions of older Americans and individuals with disabilities.
Before the IRA, Medicare beneficiaries often faced daunting expenses for prescription medications, particularly those requiring high-cost treatments for chronic or life-threatening conditions. Although Medicare Part D provided prescription drug coverage, its out-of-pocket expenses could be overwhelming, with no upper limit to protect against catastrophic costs. This left many seniors choosing between essential medications and other basic needs, a dilemma that underscored the urgent need for reform.
The $2,000 cap on out-of-pocket costs is a game-changer, offering substantial financial relief. It applies to Medicare Part D enrollees and ensures that once beneficiaries reach the cap, they will no longer have to pay for additional prescriptions for the remainder of the year. This measure not only shields individuals from unexpected and crippling expenses but also promotes better medication adherence by removing a significant financial barrier.
In addition to the out-of-pocket cap, the IRA includes several complementary measures aimed at reducing prescription drug costs for Medicare beneficiaries. For example, the legislation allows Medicare to negotiate prices for certain high-cost drugs, a provision long advocated by healthcare reformers. The Center for Medicare and Medicaid Services (CMS) will choose a list of specific drugs set for negotiation every year. The most up to date list can be found here: https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation
The IRA also limits annual premium increases for Medicare Part D to no more than 6% per year, ensuring that beneficiaries are not burdened with steep, unpredictable cost hikes. Moreover, it includes a provision requiring pharmaceutical companies to pay rebates to Medicare if drug prices rise faster than inflation, disincentivizing excessive price increases.
The implementation of these changes represents a collaborative effort involving Medicare administrators, healthcare providers, and insurers. Policymakers have emphasized the importance of educating beneficiaries about these new benefits, ensuring that they are fully informed and able to maximize their savings.
Critics of the IRA’s prescription drug provisions have expressed concerns about potential impacts on pharmaceutical innovation and market dynamics. However, proponents argue that the benefits to consumers far outweigh the drawbacks, noting that the legislation strikes a balance between cost containment and encouraging innovation.
The $2,000 cap is particularly impactful for individuals with complex health conditions such as cancer, multiple sclerosis, or rheumatoid arthritis, who often rely on expensive specialty drugs. For these patients, the cap provides not just financial relief but also peace of mind, enabling them to focus on their health rather than worrying about mounting medical bills.
In conclusion, the Inflation Reduction Act’s cap on Medicare prescription drug costs at $2,000 annually is a landmark achievement in healthcare reform. By alleviating financial strain and fostering greater access to necessary medications, this provision enhances the quality of life for millions of Medicare beneficiaries. 


]]><![CDATA[New recording requirements punish the wrong people]]>Wed, 28 Sep 2022 15:59:21 GMThttp://wihealthinsuranceadvocate.com/blog/september-28th-2022Just recently, the Center for Medicare and Medicaid Services (CMS - and I'm not sure about you but the fact that it's not CMMS is unsettling to my orderly brain!) created new requirements for all agents and brokers selling Medicare plans. Unfortunately, these new administrative requirements take up a lot of our time without any compensation. We now have to record and store calls at our expense, and we all had to scramble to figure out a way to do this, costing us hundreds of hours of time and several thousand dollars per year.  

But, what I'm concerned about is the wider impact and who this rule is punishing and who is really guilty but getting off scotfree. Because of the cost to our time and resources, this means is that we will have to shorten our appointments. This means we will know our clients less well and will be more focused on the clock than we had to be before. And while we will do everything we can to continue to provide best-in-class service, our response times will be longer as our administrative burden has increased. In sort, we are being punished.

Why (do we think) this rule was created? Every year, millions are spent by call centers with "independent agents" (meaning they don't work for an insurer) who telemarket plans. These call centers are everything we aim not to be--they are churning mills who will do anything for a sale, who have no sense of the local plans, networks, or customer service, and who call people on repeat. They aren't scammers in the legal definition, but by all ethical standards they are scammers. And they get big celebrities like Joe Namath to sell their services. 

Much like all of the commercials this time of year, the commercials are massively misleading. They mention only the perks and not the costs. They provide no advice about making sure your doctors or medications are covered. They make everything sound like it won't cost you anything, or give you money back. There's a grain of truth, but it's no where near the full picture. 

Last year, there were hundreds of thousands of complaints against these call centers--who actually already have to record calls. The complaints against local brokers are statistically tiny in comparison to these call centers. But, these big corporations have huge sway. So, instead of more closely monitoring the claims in their ads or making requirements that they ethically assist with plan selection, CMS decided to respond by making local agents/brokers record all conversations. And while I have nothing to hide, I also have to pay for that recording capability, storage space, and the administrative time to save and file all those calls. It is not a cheap or easy task. 

And these hucksters are still out there with no check on their power. They are calling confused older folks without insurance experience and moving them into plans that are terrible fits. This isn't a made-up story, I talk to dozens of people every year who have had this happen. One fellow was actually sold a plan with copays that did not cover his doctors, when he had full coverage under a different type of plan.  

I'm sure there are unscrupulous local brokers, too, but by and large we have accountability--you know our names and can find us, you can make a complaint if there is a problem, and so on. We are available year round to help with problems or questions.  Call center agents are called "churn and burn" agents by industry insiders. 

This just isn't right, and it's not fair to the beneficiaries because they are also going to suffer as local help dries up and only the biggest dogs are left in the fight. 

We're going to do all we can to make sure our clients are taken care of right, but I also had to speak out about what's happening on the back end and the pressures, both time and financial, that we are having to deal with for no good reason. 

​]]><![CDATA[The $800 Preventive Lab Work Bill]]>Mon, 21 Feb 2022 22:43:43 GMThttp://wihealthinsuranceadvocate.com/blog/the-800-preventive-lab-work-billI cannot overstate the importance of carefully reading your medical bills and comparing them to your Explanation of Benefits document from your insurance. 

In September, I visited my primary care doctor at Froedtert for an annual physical, which is supposed to be covered at 100% by all full insurance plans. She ran some regular lab work typical with any physical. I was pretty shocked to then get a $800 bill for the lab work portion of my visit. 

I contacted my insurance company right away, because I know my insurance plan inside and out (of course!) and know something went seriously wrong. Turns out, from their end, some of the labs that were sent in are not considered as part of the preventive work by Allstate (my insurer) because of their different interpretation of the Affordable Care Act mandates. 

Now, this is not particularly unique. Two weeks ago, I helped a client with the same issue with United Health Care. A month before that, Molina. All ACA-compliant carriers. This is, in a word, typical. And almost always a struggle. Insurance blames the hospital system, the hospital system blames insurance. In my experience, the blame is equally divided. 

So, what can be done? First, DO NOT WAIT. Insurance always has time limitations on when appeals can be filed, and when they will look at claims. Hospitals typically wait only 90 days before they start nudging toward collections.  You need to take action right away. 

The first thing you should do is get a written appeal in to your insurance company within their appeal timelines. Write a short letter that contains your full contact information, your ID number, and information about the claim like the date of the service, amount charged, name of doctor. Keep a copy of that appeal and a note about when you mailed it. 

The second thing you can do is contact your doctor about properly coding the claims. Most hospital systems have outsourced insurance billing, so there is a disconnect between your doctor who ordered the service and the person who typed it up and sent it in to insurance. This can lead to wrong codes being used and services being denied. Contact your doctor directly for help. They can often request internally that billing use a better code. 

If you lose your appeal with insurance, follow your next step appeal rights. You can request a reconsideration, or some kinds of insurance even allow for an outside oversight organization (sometimes called an Ombudsman) to review the appeal. 

If that still doesn't work, you can file a complaint with your state department of insurance. In Wisconsin, that's the Office of the Commissioner of Insurance. 

If insurance says that your hospital is simply refusing to bill the right code, or they are still trying to collect, you can try filing a complaint against them with your state's Department of Consumer Protection. 

Generally speaking, as long as you take action quickly you won't yet be at the collections stage. It's critical to take swift action, because once you're in the collections stage it can be hard to impossible to resolve the issue, even if you're right. Please consider connecting with your state lawmakers to encourage them to pass real protections for consumers when it comes to medical billing practices. 

​]]><![CDATA[COVID19 At Home Test Kit Coverage]]>Thu, 10 Feb 2022 18:41:18 GMThttp://wihealthinsuranceadvocate.com/blog/covid19-at-home-test-kit-coverageA new rule went into effect on January 15th requiring commercial insurance plans (group plans and individual Marketplace/off-Market plans) to cover up to 8 at-home COVID19 tests kits per month. Find out more about how it's been working in this short video. 
]]><![CDATA[​The No Surprises Act: AT LAST!]]>Thu, 06 Jan 2022 18:46:36 GMThttp://wihealthinsuranceadvocate.com/blog/the-no-surprises-act-at-lastBy Sadie Tuescher
 
As of January 1st, 2022 an incredibly important piece of legislation went into effect that is long overdue. The No Surprises Act has many components, and while we are disappointed in some that create extra reporting without pay to agents like ourselves, we are also very happy about the main provision: the end to emergency services balance billing for patients who have an ACA-compliant plan.
 
Before this rule went into effect, patients who had an ACA-compliant plan—that’s most insurance, commercial, employer, individual, with the exception of short term plans—had guaranteed coverage for emergency services out of network. However, almost all insurance companies found a loophole in how the ACA worded this provision: the insurers determined that while they had to cover emergency care out of network, they only had to pick up the portion of the bill that they would have paid if the person went in network. That led to gigantic balance bills for patients.
 
In a real case, a client of mine sought emergency care out of state while travelling. The ER bill totaled more than $30,000. His insurer, a prominent health insurance marketplace carrier in Wisconsin, applied $7,000 toward his deductible saying the amount was what they would have allowed had he stayed in network, and they paid $0 of that bill. At the time, I helped negotiate that bill in half—something that none of our major hospital systems will do anymore. Insurance paid nothing. Under the No Surprises Act, his insurer in 2022 would still be allowed to apply his $7,000 deductible, but they would have to pay the remaining amount to the hospital.
 
And while we are thrilled, this act is merely another bandage to our already bleeding health care system. Rather than checking the amount hospitals can charge for services, the act merely passes the cost on to insurance companies—which then passes the cost on to consumers through higher premiums and bigger deductibles. There is no check whatsoever on what hospitals are allowed to charge for services, and how much they can balance bill individuals when they are out of network with the patient’s insurance. I worry this will only intensify the perverse incentives hospitals have to keep costs high. See our prior blog post for more information. 
 
In the immediate sense, we are happy for patients. We’ve been calling for federal balance billing rules for nearly a decade and are glad to see this change.
 
If you seek emergency care out of network, your insurance company will now have a specific appeal process to follow. Do not pay the balance bill, contact your agent and/or insurance company immediately. Wisconsin Health Insurance Advocate brokers provide assistance at no cost to clients, and can provide assistance for a fee to non-clients. ]]><![CDATA[The American Recovery Act of 2021 and Changes to Health Insurance]]>Fri, 19 Mar 2021 21:12:57 GMThttp://wihealthinsuranceadvocate.com/blog/the-american-recovery-act-of-2021-and-changes-to-health-insuranceLast week, Congress passed a new stimulus package and it was signed into law by President Biden. This sweeping legislation will have a major effect on health care access for people who buy their own coverage or have taken COBRA coverage from lost employment. There are many important changes in the bill, many of them temporary.

While the implementation will take some time, here’s what we do know:
  • Advanced Premium Tax Credits (APTC) will be extended to anyone eligible for a subsidy whose income is under 400% of the Federal Poverty Level (about $51,000 for a single person, about $70,000 for a couple). The rates premier on April 1st, so we are not yet sure of the potential impact.
  • APTCs for people under 150% of the Federal Poverty Level (about $19,300 for a single person, about $26,100 for a couple) will make it so the benchmark Silver plan has a $0 premium. People may not necessarily want to choose the benchmark Silver plan as networks of doctors vary by plan, but we are hopeful this means that all plans will be more affordable through these subsidies.
  • People who are over 400% of the Federal Poverty Level (about $51,000 for a single person, about $70,000 for a couple) will be eligible for an APTC if the benchmark Silver premium is more than 8.5% of their household Modified Adjusted Gross income. The APTC will make it so the lowest cost plan’s premium will be no more than 8.5% of income. This will largely affect people over 50, because premiums are higher based on age. Some younger people will benefit too, depending on how close they are to the income limits.
  • People receiving Unemployment Compensation will be treated as if they had income at 130% of the Federal Poverty level and therefore receive the fullest cost-sharing subsidies on the Marketplace. This means that a Silver plan will have a small deductible and out of pocket maximum, making the plan quite affordable.
However, for all of the above, a person must not be eligible for (or have a spouse who is eligible for) any employer-based health insurance in order to get a subsidy. Oftentimes this particularly hurts families when one spouse has a job that offers a group plan to just the employee, or when the premiums are very expensive (this is often called the Family Gap, and it is truly a travesty of justice that Congress continues to have no interest in resolving).

All of these monumental changes are only valid for 2021 and 2022. Hopefully Congress will act before they expire to continue some of the new subsidies.

One other item of interest is a change to COBRA rules. COBRA applies to all large employers and any small employer with a fully-insured plan (most plans). COBRA premiums will be covered from April 1st to September 30th, 2021. Employers will have to pay the full price of the premiums and then will be able to apply for subsidies from the federal government. This will undoubtedly ruffle many feathers and put a high burden on small businesses. Exactly how this is going to be carried out is unclear.

We’re here to help. Call us at 414-797-3408 to set up an appointment to talk about your options. ]]><![CDATA[Just Announced! The Marketplace is Opening for a Special Enrollment Period]]>Tue, 02 Feb 2021 15:46:28 GMThttp://wihealthinsuranceadvocate.com/blog/just-announced-the-marketplace-is-opening-for-a-special-enrollment-periodThe White House announced last week that President Biden has signed an executive order to open the Marketplace (healthcare.gov and off-market carriers) from February 15th to May 15th for anyone eligible who is currently uninsured or wishes to switch plans. 

This is a unique and unprecedented opportunity for people who missed the Open Enrollment Period (November 1st-December 15th)  to enroll in health coverage. 

In part, this action is meant to help educate the American people about their access to health insurance with advertising campaigns, since ads have been cut over the past few years. Regardless of politics, it's important to get covered during these strange pandemic times. 

If you're trying to navigate health insurance on your own, my advise is don't be fooled by plans that look too good to be true. Read the small print, non-Marketplace plans are known as short term plans and they don't cover much. 

We offer assistance with quoting, enrollment, and understanding your health insurance options for no-cost. Call us at 414-797-3408 for help, or submit a contact form (we do our best to respond to all form submissions within 1 business day)

]]><![CDATA[Secure Your Family's Financial Future With Three Simple Steps]]>Mon, 05 Oct 2020 17:40:48 GMThttp://wihealthinsuranceadvocate.com/blog/secure-your-familys-financial-future-with-three-simple-stepsBy Sara Bailey of thewidow.net
 
Parenting comes with a host of responsibilities—sometimes, more than you think you can handle. Not the least of which is your financial obligations. Yet with the right mindset and no shortage of motivation, it might just be simpler than you think. So without further ado, here are some of the best things you can do to kickstart your financial goals as a parent.
 
Get insured.
 
When it comes to financial planning, with a family to think about or otherwise, insurance is undoubtedly the smart place to start. Indeed, much is known about the myriad benefits of life insurance, and RocketLawyer notes there’s little question that the pros far outweigh the cons (if any).
 
Life insurance can single-handedly safeguard your family’s financial security in the future in the event something happens to you. It’s also a smart investment that can be utilized in many different ways. Moreover, it also plays a crucial role in estate planning—to protect your dependents and cover debt and tax liabilities, as well as ensure the fair distribution of your estate at the time of your death.
 
Needless to say, life insurance is a real must-have in your financial portfolio. But do note that not all life insurance policies are created equal. So before you buy coverage, make sure to shop around and compare offerings from multiple providers. Reach out to Wisconsin Health Insurance Advocate, LLC to help make this process easy for you!
 
Build an emergency fund.
 
No doubt, another thing you should establish in your financial groundwork is an emergency fund. This pertains to cash that you put away and can tap into in the event of, yes, emergencies. While it’s been said that at least six months’ worth of your household income is the ideal amount in your emergency fund, there are those that argue that nine to 12 months is more ideal in this day, age, and economy.
 
Regardless, there’s no doubt that everyone needs an emergency fund. Such a fund is then best ‘forgotten’ to avoid the temptation of unnecessary use. Rather, it should only be tapped in case of bona fide emergencies like losing one’s job or acquiring a non-insurance-covered injury.
 
If you tend to dip too low into your cash to have a solid safety net, set up a separate account and add a budgeting app like GoodBudget or Mint to your phone. That way, keeping tabs on spending is a breeze.
 
Save for the future.
 
Lastly, it’s never too early to save for the future, both for yourself and your children. If you're planning to become a first-time homeowner, know that it's best to start saving for the down payment now. If you make a higher down payment, you'll reduce the interest rates and decrease the amount of your monthly payments. Low down payments require private mortgage insurance, so you'll actually be paying more monthly. Therefore, you should begin looking at your budget now and decide what needs adjusting. For example, you might benefit from getting a side job or cutting down on certain areas of your spending that aren't necessary for survival.
 
While your kids may be too young for their future college education to be forefront in your mind, the truth is you can get ahead by starting now. Not only that, Education Planner explains that having a healthy college fund makes it possible for your kids to attend the schools of their choice, which, in turn, allows you to offer them a great platform from which to realize their dreams.
 
Your inevitable retirement is also one event that you should start saving for early in life. In fact, CNN says that as a rule of thumb, you should put away as much as 10 to 15 percent of your income for retirement in your 20s. But of course, there’s more than one way to save for retirement without relying on your 401(k), so explore your options and make it a key part of your financial planning efforts.
 
It goes without saying that financial concerns are bound to rear their ugly heads at any point in life. But with adequate foresight and financial planning, you will find yourself better equipped to handle whatever comes your way. What’s more, you can take comfort in knowing that your family is financially secure in the event of your absence.
 
Remember: If you need insurance assistance, contact Wisconsin Health Insurance Advocate, LLC by visiting our website or calling 414-797-3408.

Learn more about Sara's story and her upcoming book at thewidow.net
  
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Photo via Unsplash.com
]]><![CDATA[COVID19 Changes to Small Group Rules]]>Wed, 01 Apr 2020 21:03:32 GMThttp://wihealthinsuranceadvocate.com/blog/covid19-changes-to-small-group-rulesBy Sadie Tuescher

​In response to the Governor's request for insurance companies to be more lenient with their rules for small groups, insurance companies have made some interesting (and mostly) helpful changes to their policies. 

Many insurance companies are waiving the waiting periods for new hires and rehires. Most insurance companies are allowing employees to stay on insurance during layoff as long as they are still considered active employees by the employer (intent to return to work, still active in the employer’s system). This is giving employees access to insurance while on unemployment when under normal condition rules they would be cut off. 

Paying premiums is still required. Insurance companies won’t waive costs unless required to by law. This is the biggest challenge for most employers, how do they make those payments without income? They will also have to collect from employees their portion of the premium since payroll is not running. It’s a weird situation.

It’s great that Wisconsin and the Small Business Administration are offering some loan assistance, but the reality is that a loan is a liability many businesses cannot recoup with sales because they are closed indefinitely. Wisconsin initially announced funding but has since walked back the offer and said Wisconsin will make loans to businesses affected. https://wedc.org/programs-and-resources/covid-19-response/

The best advice I can give at this time is if you, the employer, need to end coverage with your group, give your employees enough notice so they can move into individual plans with no gap. We can help at no cost with those enrollments. ]]><![CDATA[Laid off? We can help you get covered.]]>Tue, 31 Mar 2020 05:00:00 GMThttp://wihealthinsuranceadvocate.com/blog/laid-off-we-can-help-you-get-coveredBy Mary Fenner

Recently, many of you have lost your jobs, or gotten laid off and with that you may have lost your health
care coverage. There are choices for you and your families that can be quite affordable, but the time to
act is now! 

Marketplace Insurance
You only have 60 days from the time you lost coverage to apply for Marketplace (Obama Care
Insurance). Also, the sooner you apply the sooner your policy will go into effect. The plans only start on
the 1 st of the Month, so to get a April 1 st start date you would have to apply before March 31 st .

Short Term Plans
Short term plans can fill in the gaps between coverage. They can be purely catastrophic, or include
supplements to help cover hospital stays and other medical needs.

BadgerCare
If you make below $12,760 in a single household you can apply for Badger Care which is state insurance.
They do ask income questions and unemployment is included as income.

COBRA
Is offered through your employer so you can keep the same insurance you had when you were
employed, but can be very expensive as you will have to pay full price. After you are let go the employer
does not have to contribute to your premium coverage.

Please call us if you have any questions need help or advice at: 414-797-3408
Wisconsin Health Insurance Advocates LLC]]>