Medicare Part D beneficiaries can look forward to increases in deductibles come 2009 for standard benefit plans, i.e., the minimum plan that may be offered by insurers.

Participating Part D plans must offer beneficiaries a statutorily defined standard benefit or an alternative actuarial equivalent.

The Medicare Modernization Act (MMA) directs the Centers for Medicare and Medicaid Services (CMS) to update the statutory elements for the standard Part D drug benefit each year.

These elements include the standard deductible, initial coverage limit, and catastrophic coverage threshold, along with other related factors.

The 2008 standard benefits generally had a $275 deductible and coinsurance of 25 percent after the deductible to the coverage limit of $2,510.

This is followed by a coverage gap in which beneficiaries pay 100 percent — up to an out-of-pocket spending limit of $4,050.

Once the out-of-pocket spending reaches this level, the plan pays 95 percent of drug costs for catastrophic coverage.

The graphs on the right show highlights from standard benefit plans for 2006 to 2009. Of note, for 2008 to 2009:

  • The initial deductible will increase from $275 to $295
  • Initial coverage limit increases from $2,510 to $2,700
  • Out-of-pocket threshold increases from $4,050 to $4,350
  • Minimum cost sharing in the catastrophic coverage portion of the benefits increases from $2.25 for generic or preferred drug that is a multisource drug and $5.60 for all other drugs in 2008 to $2.40 for generics and $6 for other drugs in 2009

Source: Centers for Medicare and Medicaid Services and

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.