Medicare Surprise: Drug Plan Prices Touted During Open Enrollment Can Rise Within a Month

Something strange happened between the time Linda Griffith signed up for a new Medicare prescription drug plan during last fall’s enrollment period and when she tried to fill her first prescription in January.

She picked a Humana drug plan for its low prices, with help from her longtime insurance agent and Medicare’s Plan Finder, an online pricing tool for comparing a dizzying array of options. But instead of the $70.09 she expected to pay for her dextroamphetamine, used to treat attention-deficit/hyperactivity disorder, her pharmacist told her she owed $275.90.

“I didn’t pick it up because I thought something was wrong,” said Griffith, 73, a retired construction company accountant who lives in the Northern California town of Weaverville.

“To me, when you purchase a plan, you have an implied contract,” she said. “I say I will pay the premium on time for this plan. And they’re going to make sure I get the drug for a certain amount.”

But it often doesn’t work that way. As early as three weeks after Medicare’s drug plan enrollment period ends on Dec. 7, insurance plans can change what they charge members for drugs — and they can do it repeatedly. Griffith’s prescription out-of-pocket cost has varied each month, and through March, she has already paid $433 more than she expected to.

A recent analysis by AARP, which is lobbying Congress to pass legislation to control drug prices, compared drugmakers’ list prices between the end of December 2021 — shortly after the Dec. 7 sign-up deadline — and the end of January 2022, just a month after new Medicare drug plans began. Researchers found that the list prices for the 75 brand-name drugs most frequently prescribed to Medicare beneficiaries had risen as much as 8%.

Medicare officials acknowledge that manufacturers’ prices and the out-of-pocket costs charged by an insurer can fluctuate. “Your plan may raise the copayment or coinsurance you pay for a particular drug when the manufacturer raises their price, or when a plan starts to offer a generic form of a drug,” the Medicare website warns.

But no matter how high the prices go, most plan members can’t switch to cheaper plans after Jan. 1, said Fred Riccardi, president of the Medicare Rights Center, which helps seniors access Medicare benefits.

Drug manufacturers usually change the list price for drugs in January and occasionally again in July, “but they can increase prices more often,” said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University and a member of the Medicare Payment Advisory Commission. That’s true for any health insurance policy, not just Medicare drug plans.

Like a car’s sticker price, a drug’s list price is the starting point for negotiating discounts — in this case, between insurers or their pharmacy benefit managers and drug manufacturers. If the list price goes up, the amount the plan member pays may go up, too, she said.

The discounts that insurers or their pharmacy benefit managers receive “don’t typically translate into lower prices at the pharmacy counter,” she said. “Instead, these savings are used to reduce premiums or slow premium growth for all beneficiaries.”

Medicare’s prescription drug benefit, which began in 2006, was supposed to take the surprise out of filling a prescription. But even when seniors have insurance coverage for drugs, advocates said, many still can’t afford them.

“We hear consistently from people who just have absolute sticker shock when they see not only the full cost of the drug, but their cost sharing,” said Riccardi.

The potential for surprises is growing. More insurers have eliminated copayments — a set dollar amount for a prescription — and instead charge members a percentage of the drug price, or coinsurance, Chiquita Brooks-LaSure, the top official at the Centers for Medicare & Medicaid Services, said in a recent interview with KHN. The drug benefit is designed to give insurers the “flexibility” to make such changes. “And that is one of the reasons why we’re asking Congress to give us authority to negotiate drug prices,” she said.

CMS also is looking at ways to make drugs more affordable without waiting for Congress to act. “We are always trying to consider where it makes sense to be able to allow people to change plans,” said Dr. Meena Seshamani, CMS deputy administrator and director of the Center for Medicare, who joined Brooks-LaSure during the interview.

On April 22, CMS unveiled a proposal to streamline access to the Medicare Savings Program, which helps 10 million low-income enrollees pay Medicare premiums and reduce cost sharing. Enrollees also receive drug coverage with reduced premiums and out-of-pocket costs.

The subsidies make a difference. Low-income beneficiaries who have separate drug coverage plans and receive subsidies are nearly twice as likely to take their medications as those without financial assistance, according to a study Dusetzina co-authored for Health Affairs in April.

When CMS approves plans to be sold to beneficiaries, the only part of drug pricing it approves is the cost-sharing amount — or tier — applied to each drug. Some plans have as many as six drug tiers.

In addition to the drug tier, what patients pay can also depend on the pharmacy, their deductible, their copayment or coinsurance — and whether they opt to abandon their insurance and pay cash.

After Linda Griffith left the pharmacy without her medication, she spent a week making phone calls to her drug plan, pharmacy, Social Security, and Medicare but still couldn’t find out why the cost was so high. “I finally just had to give in and pay it because I need the meds — I can’t function without them,” she said.

But she didn’t give up. She appealed to her insurance company for a tier reduction, which was denied. The plan denied two more requests for price adjustments, despite assistance from Pam Smith, program manager for five California counties served by the Health Insurance Counseling and Advocacy Program. They are now appealing directly to CMS.

“It’s important to us to work with our members who have questions about any out-of-pocket costs that are higher than the member would expect,” said Lisa Dimond, a Humana spokesperson. She could not comment about Griffith’s situation because of privacy rules.

However, Griffith said she received a call from a Humana executive who said the company had received an inquiry from the media. After they discussed the problem, Griffith said, the woman told her, “The [Medicare] Plan Finder is an outside source and therefore not reliable information,” but assured Griffith that she would find out where the Plan Finder information had come from.

She won’t have to look far: CMS requires insurers to update their prices every two weeks.

“I want my money back, and I want to be charged the amount I agreed to pay for the drug,” said Griffith. “I think this needs to be fixed because other people are going to be cheated.”


3 States Limit Nursing Home Profits in Bid to Improve Care

Nursing homes receive billions of taxpayers’ dollars every year to care for chronically ill frail elders, but until now, there was no guarantee that’s how the money would be spent.

Massachusetts, New Jersey and New York are taking unprecedented steps to ensure they get what they pay for, after the devastating impact of covid-19 exposed problems with staffing and infection control in nursing homes. The states have set requirements for how much nursing homes must spend on residents’ direct care and imposed limits on what they can spend elsewhere, including administrative expenses, executive salaries and advertising and even how much they can pocket as profit. Facilities that exceed those limits will have to refund the difference to the state or the state will deduct that amount before paying the bill.

The states’ mandates mark the first time nursing homes have been told how to spend payments from the government programs and residents, according to Cindy Mann, who served as Medicaid chief in the Obama administration.

With this strategy, advocates believe, residents won’t be shortchanged on care, and violations of federal quality standards should decrease because money will be required to be spent on residents’ needs. At least that’s the theory.

“If they’re not able to pull so much money away from care and spend it on staffing and actual services, it should make a big difference,” said Charlene Harrington, professor emeritus at the University of California-San Francisco’s School of Nursing who has spent four decades studying nursing home reimbursement and regulation. “I would expect the quality of care would improve substantially.”

“The actual effect will be just the opposite,” said Andrew Aronson, president and CEO of the Health Care Association of New Jersey. “By trying to force providers to put more money into direct care, you’re creating a disincentive for people to invest in their buildings, which is going to drive the quality down.”

Next year, New York’s nursing facilities will have to spend at least 70% of their total revenue —including payments from Medicaid, Medicare and private insurers — on resident care and at least 40% of that direct-care spending must pay for staff members involved in hands-on care. In Massachusetts, Gov. Charlie Baker issued rules requiring nursing homes have to spend at least 75% of all revenue on residents’ care. New Jersey’s law requires its nursing homes to spend at least 90% of revenue on patient care. But its state regulators have proposed that the requirement apply only to Medicaid funding. No final determination has been made.

All three states promise a boost in Medicaid payments to facilities that comply with the laws.

Harrington and other advocates say the measures are well overdue, but they are watching how regulators in each state define direct care, who qualifies as a direct care worker, what counts as revenue and whether it is reported accurately.

Jim Clyne, president and CEO of LeadingAge New York, which represents nonprofit nursing facilities, questions the legality of some provisions in New York’s law. “I don’t think there’s any doubt that it will end up in court,” he said.

Aronson said the mandate is based on a misconception — that nursing homes could have kept covid-19 out of their facilities if they had only marshaled their resources properly. “As long as covid is in our communities, it will also find its way into our facilities,” he said.

But poor infection control practices resulting from inadequate staffing have been the most common violation cited by nursing home inspectors over the years, according to a study released last year by the federal Government Accountability Office. The pandemic did little to change that trend. In August 2020, a frustrated Seema Verma, then-administrator of the Centers for Medicare & Medicaid Services, warned nursing home operators that “significant deficiencies in infection control practices” were responsible for increases in covid deaths and pleaded with them “to really double down on those practices.”

“Philosophically, if a payer wants to tell the provider how to use their funds within certain parameters, I understand that, but that’s not what the [New York] law does,” said Clyne. “The law goes beyond that. The state is telling the provider how much of other people’s money they have to spend on care also, not just the state’s money.”

Bills paid by Medicare or individuals should be excluded from the state mandate, along with Medicaid funds earmarked for certain purposes such as mortgage expenses, he said.

Medicaid, funded under a state and federal government partnership, provides health insurance to low-income people and typically pays for about 60% of the nursing home care nationwide, usually for long-term residents with chronic health problems. Medicare, funded by federal dollars, insures older or disabled adults, and provides about 16% of facilities’ revenue. The rest comes from private Medicare Advantage and other health insurance companies, and individuals who pay for their own care.

“Nursing homes are primarily funded by public tax dollars, Medicaid or Medicare — and the public has a reason to care about how our dollars are being spent,” said Milly Silva, executive vice president of 1199SEIU, the union that represents 45,000 nursing home workers in New York and New Jersey, and backed the legislation in both states.

The spending mandates are not a new idea for health care. The Affordable Care Act directs health insurers to spend at least 80 cents of every dollar in premiums to pay for beneficiaries’ health care needs. What remains can be spent on administrative costs, executive salaries, advertising and profits. Companies that exceed the limit must refund the difference to beneficiaries.

Harrington disagrees with industry officials who want to exclude Medicare dollars from the calculation of how much nursing homes must spend on direct care. That would leave a large source of profits untouched, she said, and allow them to use that money “however you want.”

Medicare paid nursing homes $27.8 billion in fiscal year 2019, according to the Medicare Advisory Payment Commission, an independent panel appointed by Congress.

Even if only the Medicaid money is affected, though, there’s still a big problem in the direct care spending mandate, said Aronson. “Ninety percent of facilities are losing money,” he said, because Medicaid payments don’t cover the cost of care. In New Jersey, he added, the shortfall is $40 a day per resident.

But some state lawmakers are not convinced. “Medicaid payments may not fully cover the cost of care, but somehow for-profit nursing homes are making money,” said New York state lawmaker Richard Gottfried, who has chaired the Assembly health committee since 1987. More than two-thirds of the state’s nursing homes operate as for-profit businesses and have been able to hide some of those profits in associated businesses they also own and then hire, he said. They can “use real estate gimmicks and shell contracts to make it look like they’re spending money when what they are really doing is just siphoning income into their own pockets,” he said. The use of such “related parties” payments has occurred across the country for several years.

To uncover the facilities’ true income and expenses, the state mandates require accurate documentation. “If they file false documentation, that will be a felony,” said Gottfried.

The spending mandates come at a challenging time for the industry, which is still recovering from the worst of the pandemic and facing a staffing shortage and low occupancy. But New York Assembly member Ron Kim, whose uncle died in a nursing home from presumed covid, said lawmakers should be able to tell nursing home operators how to spend taxpayers’ money. “If they choose to rely on public dollars to deliver care, they take on a greater responsibility,” he said. “It’s not like running a hotel.”


Student Nurses Who Refuse Vaccination Struggle to Complete Degrees

Kaitlyn Hevner expects to complete a 15-month accelerated nursing program at the University of North Florida in Jacksonville in December. For her clinical training this fall, she’s working 12-hour shifts on weekends with medical-surgical patients at a hospital.

But Hevner and nursing students like her who refuse to get vaccinated against covid-19 are in an increasingly precarious position. Their stance may put their required clinical training and, eventually, their nursing careers at risk.

In early September, the Biden administration announced that workers at health care facilities, including hospitals and ambulatory surgery centers, would be required to receive covid vaccines. Although details of the federal rule won’t be released until October, some experts predict that student nurses doing clinical training at such sites will have to be vaccinated, too.

Groups representing the nursing profession say “students should be vaccinated when clinical facilities require it” to complete their clinical training. In a policy brief released Monday, the National Council of State Boards of Nursing and eight other nurse organizations suggested that students who refuse to be vaccinated and who don’t qualify for an exception because of their religious beliefs or medical issues may be disenrolled from their nursing program or be unable to graduate because they cannot fulfill the clinical requirements.

“We can’t have students in the workplace that can expose patients to a serious illness,” said Maryann Alexander, chief officer for nursing regulation at the national council. “Students can refuse the vaccine, but those who are not exempt maybe should be told that this is not the time to be in a nursing program.”

“You’re going to go into practice and you’re going to be very limited in your jobs if you’re not going to get that vaccine,” Alexander said.

Kaitlyn Hevner, a nursing student at the University of North Florida, has opted not to get vaccinated against covid even though many medical facilities require it. She questions whether “we give up our own religious rights and our own self-determination just because we work in a health care setting.” (Robert Working)

Hevner, 35, set to finish her clinical training in early October, said she doesn’t feel it’s acceptable to benefit from a vaccine that was developed using fetal cells obtained through abortion, which she opposes. (Development of the Johnson & Johnson covid vaccine involved a cell line from an abortion; the Pfizer-BioNTech and Moderna mRNA vaccines were not developed with fetal cell lines, but some testing of the vaccines reportedly involved fetal cells, researchers say. Many religious leaders, however, support vaccination against covid.)

With vaccines for nursing students still optional in many health care settings, nursing educators are scrambling to place unvaccinated students in health care facilities that will accept them.

Down the coast from Jacksonville in Fort Pierce, Florida, 329 students are in the two-year associate degree nursing program at Indian River State College, said Roseann Maresca, an assistant professor who teaches third-semester students and coordinates their clinical training. Only 150 of them are vaccinated against covid, she said.

Not all of the eight medical facilities that have contracts with the school require student nurses to be vaccinated.

“It’s been a nightmare trying to move students around this semester” to match them with facilities depending on their vaccination status, Maresca said.

Commonly, health care facilities have long required employees to be vaccinated against various illnesses such as influenza and hepatitis B. The pandemic has added new urgency to these requirements. According to a September tally by FierceHealthcare, more than 170 health systems mandate covid vaccines for their workforces.

In May, the federal Equal Employment Opportunity Commission made it clear that under federal law employers can mandate covid vaccinations as long as they allow workers to claim religious and medical exemptions.

Under the Biden administration’s covid plan, roughly 50,000 health care facilities that receive Medicare or Medicaid payments must require workers to be vaccinated. Until the administration releases its draft rule in October, it is unclear how nursing students assigned to health care sites for clinical training will be treated.

But the federal rule published in August that lays out regulations for government hospital payments in 2022 offers clues. It defined health care personnel that should be vaccinated as employees, licensed independent contractors and adult students/trainees and volunteers, said Colin Milligan, director of media relations at the American Hospital Association.

In addition to staff members, the Biden plan says mandates will apply to “individuals providing services under arrangements” at health care sites.

A spokesperson for the Centers for Medicare & Medicaid Services declined to clarify who would be covered by the Biden plan, noting the agency is still writing the rules.

Nonetheless, vaccination mandates threaten to derail the training of a relatively small proportion of nursing students. A recent survey by the National Student Nurses’ Association reported that 86% of nursing students and 85% of new nursing graduates who responded to an online survey said they had been or planned to be vaccinated against covid.

But the results varied widely by state, from 100% in New Hampshire and Vermont on the high end to 63% in Oklahoma, 74% in Kentucky and 76% in Florida on the low end. The survey had 7,501 respondents.

Students who don’t want to be vaccinated are asking schools to offer them alternatives to on-site clinical training. They suggest using life-size computer-controlled mannequins or computer-based simulations using avatars, said Marcia Gardner, dean of the nursing school at Molloy College in Rockville Centre, New York.

Last year, when the pandemic led hospitals to close their doors to students, many nursing programs increased simulated clinical training to give nursing students some sort of clinical experience.

But that’s no substitute for working with real patients in a health care setting, educators say. State nursing boards permit simulated clinical study to varying degrees, but none allow such instruction to exceed 50% of clinical training, said Alexander. A multisite study found that nursing students could do up to half their clinical training using simulation with no negative impact on competency.

The policy brief by the council of state nursing boards states that nursing education programs “are not obligated to provide substitute or alternate clinical experiences based on a student’s request or vaccine preference.”

As more nursing students become vaccinated, the issue will grow less acute. And if the Biden plan requires nursing students to be vaccinated to work in hospitals, the number of holdouts is likely to further shrink.

Hevner, the University of North Florida student, said she’s not opposed to vaccines in general and would consider getting a covid vaccine in the future if she could be assured it wasn’t created using aborted fetal cells. She filed paperwork with the college to get a religious exemption from vaccine requirements. It turned out she didn’t need one because Orange Park Medical Center, where she is doing her clinical training, doesn’t require staffers or nursing students to be vaccinated against covid “at this time,” said Carrie Turansky, director of public relations and communications for the medical center, in Orange Park, Florida.

Although Hevner opposes getting the vaccine, “I take protecting my patients and protecting myself very seriously,” she said. She gets tested weekly for covid and always wears an N95 mask in a clinical setting, among other precautions, she said. “But I would ask: Do we give up our own religious rights and our own self-determination just because we work in a health care setting?”

She hopes the profession can accommodate people like her.

“I’m concerned because we’re in such a divisive place,” she said. But she is eager to find a middle ground because, she said, “I think I would make a really great nurse.”