Health Insurance Matters: New Year, New Laws

New Year, New Laws

There are many new laws and rules that went into effect on January 1 concerning health care. Several will impact many residents of the valley.

Schedule II Drug Prescriptions: This new law went into effect this past July, but one section of the law just began. The intent of the law (AB1048) authorizes a pharmacist to dispense a Schedule II controlled substance as a partial fill if requested by the patient or the provider. Beginning January 1, the bill requires health care service plans and insurers to prorate the member’s cost-sharing for a partial fill of a prescription of an oral, solid dosage form prescription drug. Several clients have reported that their health plan (insurance company) is only authorizing a 7 day refill, and then they must return to the pharmacy after the seven days for the balance of the pain medication prescription. Once they have filled the seven days, and then the remaining 30 day prescription, they then may refill as prescribed, typically 30 days at a time.

Hospital Price Transparency: CMS clarified that all hospitals required by the IPPS/LTCH PPS final rule for the 2015 fiscal year (FY) to make public a list of the hospital’s standard charges for items and services provided by the organization are also required to make that list public via the Internet in FY 2019.

Hospitals can choose how to make the standard charges public on the Internet, CMS added in the FAQs. Hospitals can use whatever format “as long as the information represents the hospital’s current standard charges as reflected in its chargemaster.”

The information must also include the standard charges for all items and services provided by the organization. Apparently there is no penalty for non-compliance, and many advocates are saying that the “standard price” is seldom the actual price, and that the chargemaster list is to complex for the consumer to use.

Medicare “donut hole” goes away for brand name drugs. Many people are under the illusion that the cost of prescriptions will be eliminated as the donut hole is gone for brand name drugs. Not true. You will be responsible for 25 percent of the cost of the drug as negotiated by your insurance plan. The donut hole for generic drugs goes away in 2020. Until then, you will pay 37 percent of the cost of generics.

Medicare Open Enrollment Period. 2019 ushers in a new law that will allow people in a Medicare Advantage plan (typically an HMO plan in Kern County) to change to another plan or return to “Original Medicare” between January 1 and March 31 of each year. Persons returning to Original Medicare will have the opportunity to enroll in a Medicare prescription drug plan (PDP). People who would like to change from a HMO to a Medicare supplement should be aware that the supplement may ask medical questions, and therefore is not required to accept you. Early application to the Supplement is recommended BEFORE the HMO is dropped. Good news, insurance companies are not allowed to advertise this change opportunity, so you should not receive annoying phone calls and a mail box stuffed with solicitations.

Medicare HMO plans for Dual Eligibles (also referred to as Medi-Medi) as they are receiving Medicare and Medi-Cal benefits will no longer be allowed to change plans on a monthly basis. As of January 1, they will only be allowed to change once for the first three quarters of the year, with no changes allowed in the forth quarter.

Obamacare and Individual Plan Enrollment is still open. If an individual or family applies between January 1 and January 15, they will have a February 1 effective date. If they apply between January 16 and the 31, a March 1 effective date. Enrollment in either Covered California or direct with the health plans ends February 28 for the year.

Social Security and SSI Increases. More than 67 million Americans will see a 2.8 percent increase in their Social Security and SSI benefits in 2019. For some, this may be a problem. A small increase in income for those people receiving benefits from Medi-Cal could put them over the threshold and could kick them out of the Medi-Cal program, or subject them to a high “share of cost.”

This will open a special enrollment period which allows them to change their health plans. Please feel free to call Harry if this happens to you or a loved one.

Harry P. Thal, MA, is a licensed insurance broker in California (0621106) and 27 other states. His offices are in Kernville. He is a member of the Society of Certified Senior Advisors and Past-President of the Kern Association of Health Underwriters. He may be reached at 760-376-2100, e-mail or visit him on the web at