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Yahoo
09-07-2025
- Health
- Yahoo
Trump's big, beautiful bill is downright ugly for health insurers
For America's private health insurers, President Donald Trump's 'big, beautiful bill' is turning out to be not so the many Sign in to access your portfolio
Health Line
09-07-2025
- Business
- Health Line
The Medicare Prescription Cap
Prescription cap for 2025 Prescription cap changes Other spending caps In Medicare, two types of plans cover prescription drugs: stand-alone Medicare Part D plans or Medicare Advantage prescription drug (MAPD) plans. Private insurers manage both types of plans, which means the plans have different deductibles, premiums, and coinsurances. But due to the Inflation Reduction Act of 2022, once coverage kicks in, you don't need to pay more than a fixed amount out of pocket per year. What is the Medicare prescription cap for 2025? In 2025, you don't need to pay more than $2,000 per year out of pocket once your drug coverage kicks in. Once you reach this amount, you enter catastrophic coverage. This means your plan must fully cover any further costs. You can also use any contributions you make toward Extra Help toward this limit. This annual cap applies to stand-alone Part D and Medicare Advantage (Part C) plans offering drug coverage, also known as MAPD plans. Does the Medicare prescription cap change annually? As of 2025, the Medicare prescription cap is significantly lower than in previous years. Before the new law took effect in 2024, you had to spend $8,000 before reaching catastrophic coverage. You were in the donut hole once you reached $5,030 until you reached $8,000. That said, the new annual cap eliminated this donut hole. However, it isn't static and changes each year. It may rise to $2,100 in 2026. What other spending caps does Medicare have? Medicare spending caps are generally called maximum out-of-pocket (MOOP) limits. While MOOP limits don't apply to Original Medicare (parts A and B), they do apply to Part C and D plans in other ways besides your overall, annual spending on prescription drugs. For example, under the Inflation Reduction Act, any Medicare drug plan enrollees who need insulin may never pay more than $35 per month. Your plan may have two MOOP limits: one for in-network services and another for out-of-network services. In 2025, you may not spend more than $9,350 for in-network services and no more than $14,000 for out-of-network services.
Health Line
02-07-2025
- Health
- Health Line
What Are Some Drawbacks of Medicare Advantage for Doctors?
Although Medicare Advantage plans offer beneficiaries a variety of attractive features, there are some aspects of these private plans that healthcare professionals may dislike. Medicare Advantage (Part C) plans offer eligible individuals an alternative to Original Medicare (parts A and B). These plans, which are offered by Medicare-approved private insurance companies, combine the hospital and medical insurance of Original Medicare with various other benefits, like dental, vision, and hearing care. Medicare Advantage overview People who join Medicare Advantage plans may do so for reasons including: Customization: There are many plan options from numerous insurers, allowing you to find a plan that meets your specific healthcare needs. Convenience: These plans allow you to bundle all your health insurance coverage under a single plan. Affordability: Medicare Advantage plans often have low (or no) monthly premiums, out-of-pocket maximums, and low deductibles. While enrollees value these benefits, doctors may find some of the administrative hurdles associated with these plans to be challenging. Potential issues with Medicare Advantage plans include: requiring prior authorization for procedures that Original Medicare does not denying coverage for certain services limiting members to strict provider networks Prior authorization requirements Medicare Advantage plans commonly require beneficiaries to get prior authorization before receiving services or equipment. Original Medicare, on the other hand, generally does not require prior authorization. The health policy research nonprofit KFF reports that 99% of people enrolled in Medicare Advantage plans in 2023 required prior authorization for some services. While these requirements can help prevent wasteful procedures and allow insurers to keep costs low, they can also lead to delays in care and administrative headaches for healthcare professionals. A 2024 survey from the American Medical Association found that doctors and their staff spend 13 hours per week on average completing prior authorization requests. And a 2023 article notes that these administrative burdens can be a source of 'frustration and clinician burnout' for staff. Denials of service One possible outcome of the process of requesting prior authorization is that you receive a denial of service. In cases where a healthcare professional considers a procedure medically necessary, this can lead to a potentially drawn-out appeals process that increases a physician's workload. Further, it has the potential to negatively affect patient care and disrupt treatment. KFF reports that in 2023, 3.2 million prior authorization requests were fully or partially denied. This represents about 6.4% of all requests. Of the denials that were appealed, 81.7% were overturned. Network restrictions Medicare Advantage plans impose strict network restrictions on their members. These restrictions may create issues when doctors are making specialist referrals or sending patients to other facilities for care. Some people enrolled in Medicare Advantage plans report having trouble finding the necessary care within their plan's network. This can be a particular issue for people living in rural areas where provider access is already limited. Other issues Complexity is another factor that some healthcare professionals may face with Medicare Advantage plans. There are many plans from many carriers, and these plans can have a range of different coverage rules. Managing this complexity on a case-by-case basis can take a lot of time, adding to the administrative burden discussed above. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
Malay Mail
02-07-2025
- Health
- Malay Mail
Cancer Diaries: Please don't take my EPF for insurance, learn from other countries instead
JULY 2 — There are things that irk me about Malaysia sometimes but I'm grateful our public healthcare exists. If it hadn't, faced with charges like RM4,000 for a biopsy and nearly RM3,000 for a PET scan, the alternate choice of flying somewhere with snow and dying from exposure on a wintery mountainside would seem far more appealing. Remembering the anguish I felt seeing just how much scans and cancer drugs cost when I started my cancer journey, I do not wish it on anyone else. Public healthcare and the generosity of friends and supporters is literally saving my life so why wouldn't I want that same healthcare available for everyone? Instead some guy in a suit is telling me no, we need to make everyone buy insurance and go to private hospitals instead. I support the notion of a national health insurance scheme but only if it's used for public healthcare. Let's call a cangkul a cangkul: the idea of extracting funds from people's EPF accounts to pay for private insurance benefits not the average Malaysian but private insurers and hospitals. Just look at their financial reporting for the last few years. They make enough money already; we don't need to give them the keys to our retirement funds. My recent dealings with the EPF was a preview of how things will be if this proposal goes through — making health withdrawals will be likely near-impossible because the funds will be frozen to pay your insurance. There are so many things that aren't taken into account with this new idea. It would only work if insurance premiums stayed low and only rose to keep pace with inflation, when in reality the older you get the more costly your premiums become. Insurance companies also usually have an age cutoff not to mention exclusions for pre-existing conditions. Will the rules for medical withdrawals instead follow insurance guidelines — with only specific procedures allowed, generic medications permitted and EPF getting to decide patients' treatment plans? We could learn instead from countries with national health insurance schemes such as China, Japan and South Korea or from Singapore's dedication to preventative healthcare. Singapore starts early by taking a more serious approach to physical education in schools while also encouraging as well as facilitating healthy lifestyle choices among its populace. Meanwhile in Malaysia, we keep hearing of school canteen operators selling slop at expensive prices to our children who are now shorter than ever thanks to an increase in stunting. Why must we constantly shame Malaysians for 'personal choices' when we never make the healthier choice the easier one? I would love for diamonds to be taxed but apparently precious gems and metals will not be included in the SST expansion but dried mushrooms, a very common ingredient in Chinese cookIng, is. Make it make sense. Public healthcare, not private insurance, has been a lifeline for many Malaysians — but proposed changes risk shifting the burden onto individuals and their retirement savings. — Picture by Raymond Manuel I could live with a tweak of tax brackets if it meant that I won't see my oncology nurse be close to tears because there are too many patients and not enough staff to handle them all. Money should never be what decides who lives or who dies. I want more doctors, more nurses, more health interventions for lower income earners and more health resources spread around the country so cancer patients in Pahang and the East Coast don't have to travel all the way to the Klang Valley to be seen. Do not tell me that is not possible or practical when more has been spent on far less important endeavours such as our version of National Service. Perhaps bean counters see the cost of public healthcare as just an expense and not an investment. What do I see? I see women far older than me, frail-looking and tiny, resolutely showing up to their appointments. I watched a bow-legged man walk hand-in-hand with his wife as she hobbled along with a cane along a hospital corridor. On Threads I read the stories of a woman with Stage 4 cancer resolutely trying to live for her children despite the money running out for her drugs, who comes in for treatment on the same days that I do. (You can donate to her here) At the hospital I see people who want to live or at the very least, are doing their best not to die. They deserve better than a system that considers withholding treatment for lack of payment a cost-savings. * This is the personal opinion of the columnist.
Medical News Today
02-06-2025
- Business
- Medical News Today
Medicare and preexisting condition waiting periods
Original Medicare and Part C plans cannot deny coverage based on preexisting conditions. However, a waiting period for enrolling in Medicare due to preexisting conditions can apply to a Medigap plan. Due to the Affordable Care Act (ACA), Original Medicare (parts A and B), Medicare Advantage (Part C), and Part D drug plans cannot impose waiting periods for preexisting conditions or deny coverage based on such conditions. However, Medicare supplement (Medigap) plans are not subject to the ACA. For this reason, people who wish to sign up for a Medigap plan should be aware of enrollment and waiting periods where preexisting conditions might be applicable. Medigap initial enrollment period Private companies approved by Medicare offer Medigap plans, which are also called Medicare supplement plans. These plans cover costs that Original Medicare does not cover, such as deductibles, coinsurance, and copayments. Since Medigap plans do not provide direct medical coverage and do not meet the ACA's minimum essential coverage requirements, insurers can deny coverage due to preexisting conditions. However, other federal laws impose certain restrictions, one of which applies during the initial enrollment period. When a person turns 65 and enrolls in Medicare Part B, they enter a six-month Medigap open enrollment period. During this time, they can choose any Medigap policy without undergoing medical underwriting. Insurers cannot deny them coverage based on preexisting conditions, allowing the person to select the plan that best fits their needs. If a person misses this enrollment period, they may face higher costs or experience coverage denial. Additionally, those under 65 who qualify for Medicare due to a disability might have to wait until they reach 65 before Medigap insurers must legally offer them coverage. » Learn moreDoes Medicare cover preexisting conditions? Insurance companies can refuse to enroll a person in a Medigap plan based on preexisting conditions if the person applies outside the initial 6-month enrollment window. However, exceptions exist in which a person can get protection from coverage denial even after this period ends. These exceptions, called 'guaranteed issue rights,' apply in the following specific circumstances: A Medicare Advantage Plan either changes, becomes unavailable in the person's area, or the person moves outside its service zone. A person with Original Medicare and an employer or union plan that offers coverage after Medicare, including the Consolidated Omnibus Budget Reconciliation Act (COBRA), loses that coverage. A person with Original Medicare and a Medicare SELECT policy moves out of the policy's service area. A person who initially joined a Medicare Advantage Plan or Programs of All-Inclusive Care for the Elderly (PACE) when they first became eligible for Medicare decides to switch to Original Medicare within the first year. A person who switched to a Medicare Advantage Plan (or Medicare SELECT) within the past year now wants to switch again. A person's Medigap insurance provider goes bankrupt or cancels a person's policy through no fault. A person changes or cancels their Medicare Advantage plan or Medigap policy due to a violation or misleading information from the provider. Additionally, some states may have additional 'guaranteed rights' beyond what federal regulations require. » Learn more:What to know about Guaranteed Issue in Medicare Ten Medigap plans offer different levels of coverage. A person who has held their current Medigap policy for more than 6 months and wants to switch to the same Medigap plan offered by another insurance plan cannot experience coverage denial based on preexisting conditions, nor do they have to wait for coverage. But if a person wants to switch between different Medigap plans, they may have to wait 6 months for coverage. This is known as the preexisting condition waiting period. However, their new insurer should account for the period when the person has had coverage from their existing Medigap plan. For example, if a person has had 2 months of coverage before switching, their new policy should only impose an additional 4-month wait. Medicare Advantage trial period Medicare Advantage (Part C) plans must offer coverage equivalent to Original Medicare (parts A and B). According to the ACA, insurers providing Part C plans cannot deny coverage based on preexisting conditions. However, since a person can only have Medigap for Original Medicare expenses, they must discontinue their Medigap plan if they choose a Part C plan. For this reason, Medicare grants a 12-month trial period to allow a person to test a Part C plan without losing their Medigap coverage. The person may leave the Part C plan and return to Original Medicare within this period. In that case, they can rejoin their previous Medigap plan or select a new one without medical underwriting. Original Medicare (parts A and B), Medicare Advantage (Part C), and Part D prescription plans have no preexisting conditions waiting periods. This means these plans cannot deny coverage because of preexisting conditions. However, specific enrollment and waiting periods for preexisting conditions might apply to a Medicare supplement (Medigap) plan. These include a 6-month initial enrollment period, guaranteed issue rights, and a 12-month trial period to test a Part C plan. The information on this website may assist you in making personal decisions about insurance, but it is not intended to provide advice regarding the purchase or use of any insurance or insurance products. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance.
