u/OleLadyThinker

Jul 02, 2026 CMS Acts to Strengthen Care Quality, Cut Drug Costs, and Slash Out-of-Pocket Expenses for Medicare Beneficiaries

from the link ~

Medicare beneficiaries deserve a program that pays for the right care, in the right setting, at the right time,” . . . “This proposed rule focuses squarely on patient affordability by strengthening our utilization management tools, aligning drug payments with actual acquisition costs, and removing site-of-care disparities that have unnecessarily driven up costs for millions of seniors. We are committed to ensuring that Medicare resources are directed toward clinically appropriate, affordable high-value care for every patient we serve.”

end copy paste -

If they can make these thing fly, it will be beneficial to the Medicare program and beneficiaries alike.

Reserving judgement to see if they can make these things fly - other administrations have tried it before only to be shot down somehow and nothing changed - maybe this time they can get it done - saving money for the Medicare program and beneficiaries alike.

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Questions as to how it works -

Employee or their spouse has primary coverage under their Employer Group plan and Medicare as Secondary - so they both have Parts A, B, D or A, B, C

1. Do medical provders have to bill both or is there a crossover plan for the employer coverage to send it on to Medicare for secondary coverage processing?

2. What about pharmacies, mail order or preferred, can this be correlated between the Employer plan and the Part D plan? If so, what do they need to consider when picking a plan other than the med is covered. Is this even possible? How are claims filed and by whom?

3. What would happen if the primary employer group plan insurer and the Medicare Part D or perhaps even Part C insurers are the SAME - ?

4. Last but not lease - If a person with this sort of coordination of benefits - has already signed up for Medicare (including Part B) what happens when they stop working and want to get a Medigap plan? Do they still get a Medigap special enrollment even thought they have already signed up for Part B long ago?

Thank YOu

So people have to have an assigned or picked PCP for some MA plans now? Which plans have this stipulation - all / some - which type?

Are new Medicare beneficiaries experiencing this phenomenon? Providers, especially of the primary care variety, that accept Medicare assignment, are limiting the number of Medicare beneficiaries they are taking into their practice until others move on.

I have seen this complaint on many senior board recently - this one and the amount of time it takes to see a specialist - from appointment, with or without a referral, to the actual initial visit.

I know there are lots of baby boomers and a shortage of primary care providers -should we be making plans for this to get worse? Is this a regional thing or not?

Just wondering - Do any experts brokers or insurers themselves go to high schools or colleges or other educational arenas to teach about at least the basics of health insurance in America?

I just check the 1st flair on coverage to post this but it could be more - HIPPA, Employer coverages -

Even the very basics would help I think

I just wonder what the experts here think will be the likelihood of even more PPO MA plans biting the dust in 2027? I know some Union and probably Federal employee special plans and maybe some others that are more group plans than individual will probably last at increasing prices - but what about the Medicare individual who is going it without a group ? Are PPO plans gonna be a dying breed in Medicare Advantage plans?

Why don’t state Medicaid programs for those who also have Medicare as a dual eligible - just buy them a Medigap policy and let Medicare and the Supplemental plan cover all their medical needs??? May save the state some money - but then again, maybe not - same decision those Medicare beneficiaries has to make about those Medigap plans?

Thanks for humoring me

Location: GA

Synopsis - my area is watershed protected to keep down impervious ground we restrict residential growth so it is pretty rural with suburban all around it. So the roads are busy going hither and yon but the homes are rather sparse considering it is so close to Atlanta.

I understand that sometimes trees fall that are healthy especially with lots of rain but many times they are not and are just not taken care of and thus fall when weather may prove too much for an old dead BIG tree - wind and water. They fall on the road, they fall on the power lines, they fall on home - so a dangerous situation. And now it seems they don’t even have to have occurring wind and water, they just fall.

The county and the state try to keep the power lines clear of trees on the easement but sometimes they don’t do it effectively. Then there are the property owners who have these dead / diseased trees on their property side and they just let them be -

I am getting really tired of the numerous power outages which we are incurring due to fallen trees. It could be worse - it could have fallen on a family occupied car or or a home. But my inconvenience is getting intollerable for me. Yes, I will be putting in a Generac w/propane or solar ASAP. But I still want some action. Lots of people could not afford to do that and many are elderly or disabled - the economic level of the area overall is probably pretty low. They do things for themselves or have a family member do it many times and that is fine by me.

Can I sue for damages like lost food in small claims court. What about if I have hired contractors to do work and they can’t work because of the power outage - I still get charged something. Again can I sue for this? Anyway to build in something just for inconvenience? I was gonna stream my granddaughters game today but missed it ALL. last Sunday, out all day - about 9 hours and today about 5 hours. Really kills the day‘s plans. Know what I mean.

Now this is what I want: To sue I would need the power company to identify the place where it happened so that I can discern if it is county, state or property owner if the tree is in a bad place for the power lines or is diseased or dead. Then I will take it upon myself and maybe some other neighbors who have had enough is enough to bring the suit.

OR I would settle for an ordinance to force the county, state, utility who owns the easement or property owner to clear away all trees over a certain height from the power lines and their route OR they can pay to bury the power/utility lines if that is what they would rather do to preserve the trees.

This is not a small problem - a friend of mine was driving down the state highway in her RV on her way to a fun weekend and an overhanging branch on a large tree took off the top of her RV - she was insured but that is not the point here - the tree should have been cut down or at least pruned back from overhanging the right-a-way.

I see these trees, BIG, BIG, BIG ones, just as I am driving down the road - they are not a secret. I believe in responsibility and stopping problems before a disaster occurs which could even involve loss of life.

Any standing or am I just griping to the wind?

Will a free standing Part D plan (and their pharmacy designate) cover a med that has been prescribed by a provider that has opted out of Medicare?

Would the drug coverage in a MAPD cover it too? (just asking on this one)

Med should be readily available on formulary.

Edited to add: yes, the drug is on formulary - can use Plan’s preferred pharmacy or even mail order - but initial order thought it would be quicker to get it filled more local but in-network.

I just didn’t know it the Medicare standing of the provider had anything to do with their prescribing and filing in Part D plans or even in a MAPD. I mean other providers can prescribe in MAPD plans, right?

The opt out provider is a psychiatrist and yes he has an opt-out affidavit on file with Medicare (CMS data) .

Higher income government employees and widowers who are affected by the SSFA may become exposed to IRMAA assessments, or perhaps higher ones - ongoing too.

Lower income government employees and widowers who are affected by the SSFA may lose eligiblity for the Medicare Savings Programs or lose dual eligibility.

More income does bring consequences even if it is just in taxation. So I guess some will experience some consequences. I have heard some complaining - but hey, it is what it is.

Wonder how wide spread this might be?

Are there any mental health conditions that are on the Compassionate Allowance listing? Just asking -

All the other changes that were made to Plan G was because Medicare was picking up those benefits for everybody like preventive care and hospice cost. All they added was full coverage for excess charges - 100% covered instead of 80%. I don’t think this was an even type switch.

I am finding that nobody knows that this benefit is still there if the Plan G was purchased prior to June 1, 2010 - and thus claims are not even filed even if the recovery meets the definition of coverage. I do not see that there is any difference in premium assessment for the different types of Plan G’s - pre and post June 1, 2010 - It is like a benefit that is there but nobody knows about it - it is the forgotten benefit because those with coverage for it are all pretty old -

Why do we buy a Medigap plan when government years later can change the benefits like this especially when it removes something that is not replaced with something else for everybody.

They should have just given the newer plans a different letter designation.

Insurers have shown State Insurance Commissioners that they are paying out higher and more Medicare claims in their Medigap plans - so insurance commissioners have little else they can do but to approve this rate increases.

The NAIC (National Association of Insurance Commissioners) does a report on Medigap plans, I believe yearly - this is the last one Issued that I found  - 2024, issued in 2025.

NAIC - NAIC NATIONAL ASSOCIATION OF INSURANCE COMMISSIONERS 2024 Medicare Supplement Loss Ratios  

For Medigap (Medicare Supplement) plans, a higher Medical Loss Ratio (MLR) means a larger percentage of your premium dollars is going directly toward paying medical claims rather than into the insurer's administrative costs or profits

 Look at page 5 - a TEN Year Summary Comparison of all plans -

85% is what is legislated for ACA plans to pay out in coverage or they have to send a premium refund; I assume that is still within the ACA law, I haven’t kept up to date on any changes.  Of course, there is no such rule for Medigap plans and since this is private gap (financial protection) insurance. From what I have ready, Medigap insurers have tried to keep the MLR close to 75% or lower to maximize their profits (after their administrative cost has been covered).

Now they are paying out more and more in (medical) benefits compared to the premiums they have received.  So the increase was due and they probably had no problem getting it approved by the state insurance commissioner in your state.

Of course the actual increases are by insurers - but if you want to digest more of this long report you will see that some plans are really paying out the benefits in comparison to the premiums they are reaping.  I saw several over the 100% mark -

Would ECT treatments have to be pre-approved? Anybody know?

I am just wondering since there seems to be so many people coming here asking just the basics on signing up and what they should do or if working, what they have to do.

So no more info going to those who are turning 65 and are not already getting any Social Security benefits?

Just askin

CMS.gov-News Release 05/13/2026 - CMS Announces Aggressive Nationwide Crackdown on Fraud with Six-Month Hospice and Home Health Agency Enrollment Moratoria

from the link ~

This follows a declaration earlier this year of a similar moratorium to prevent fraudulent Medicare billing by certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) companies. With three separate moratoria now in place, CMS has taken some of the most significant fraud prevention actions in the agency’s history.

• Home Health Agencies (HHAs): Nationwide temporary moratorium on new Medicare enrollment, effective May 13, 2026.
• Hospice Providers: Nationwide temporary moratorium on new Medicare enrollment, effective May 13, 2026.
• **DMEPOS Suppliers (Medical Supply Companies):**Nationwide temporary moratorium on new Medicare enrollment for specific types of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers, effective February 27,2026

Hopefully the beginning of a new era -

I watched all three - I liked them all but definitely there was the good, better, best.

PD gets my good rating -

MED gets my better rating -

And by FAR, FIRE gets the BEST - and I have even gotten away from liking Fire all that much

Why - it got me so involved that now I cannot wait to find out what happened in the next opening season - just the way they did it at the end made one think now WHO might not be coming back because they met their maker?!?