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Where Your Coverage Counts

don trudeau

Healthcare services are notoriously opaque and that’s why you want someone on your side, like Benistar, presided over by healthcare expert Don Trudeau, who will help explain what you are covered for and will help you fight for your own coverage. But do you know what procedures you will need included in your healthcare plan? This is a hard thing to anticipate as a lot of health care costs don’t entail maintenance/prevention, they often entail accidents or previously unforeseen conditions. Well, in the case, you’ll want to consider the most popular and most important procedures/offerings your healthcare should cover. This is where your health care coverage really counts and where your dollars are put into action. In order to best understand where your coverage counts and what procedures are essential to be covered for, we’ll delve into what the healthcare industry considers essential.

In the healthcare marketplace, the following procedures/types of care are considered essential and are covered by most major, high-quality providers: outpatient care, emergency room trips, inpatient care in the hospital, care for infant delivery (both before and after), mental health and substance abuse treatment (this is relatively new, so some providers cover inpatient treatment, whereas covers behavioral health treatment, counseling and psychotherapy), prescription drugs, physical therapy and occupational therapy, tests completed in a laboratory, preventive measures (screenings, vaccines, maintenance for chronic diseases and counseling) and pediatric services (aka treatment for children). It is important to realize that plans vary from state to state as specific states have guidelines regarding health care coverage, plans and costs. Furthermore, health care coverage may vary slightly within different locations in the same state. However, the ten essentials are pretty steadfast, as they were initiated under the Affordable Healthcare Act. The act mandated that all individual and small group plans (available to companies that have under 50 employees) must cover the aforementioned essentials.

Though the ten essentials do comprise a lot of procedures and therapies you’ll need, there are some things healthcare providers may not cover because they are not included in the ten essentials. You will want to know what they are, as if they are important to you, you may want to consider contacting healthcare professionals at Benistar to talk you through and to the plan that’s perfect for you, your needs and probably the needs of your family, too. Benistar and their President Don Trudeau are committed to making sure you get the coverage you need.

Things not covered via the ten essentials include: travel vaccines, alternative treatments such as acupuncture, cosmetic surgery, nursing home care (of particular importance to those in the winter of their life), dental, vision and hearing, weight loss therapies and surgery, preventative tests, a lot of medications (though prescriptions are listed as part of the ten essentials, healthcare providers do not often provide all prescriptions, instead choosing one prescription of each varying class- you’ll want to connect with Benistar for optimum prescription benefits) and a few less important therapies. Benistar and their President Don Trudeau will make sure you are covered for the care you need, and will work with you even if the treatment is not listed under the ten essentials.

Healthcare and your subsequent coverage may seem incomprehensible, but with the help of Don Trudeau and Benistar, you’ll find you have coverage where it counts.

The Flexibility of the EGWP

benistar egwp

The Flexibility of the Employer Group Waiver Plan

There are several ways Benistar can help employers provide prescription drug benefits to their Medicare-eligible retirees. One way we do this is by providing flexibility in the plans that we offer, doing our best to reduce member disruption and noise for the employer. By attempting to match plan designs as closely as possible, we are able to provide a smoothest transition to both employer and retiree.

Subsidies and Discounts

The EGWP is particularly competitive in the marketplace because it offers government subsidies and discounts that are built into the premium. Two notable components are the Coverage Gap Discount Program and Catastrophic Reinsurance. CMS requires companies that wish to sell Part D drugs to give a 50% discount to Part D members inside the coverage gap. Catastrophic reinsurance is an 80% subsidy provided by CMS once the member hits a specific out-of-pocket expenditure.

The Coverage Gap

One of the most problematic issues with Part D is the coverage gap (often called “the donut hole”). The coverage gap is when a retiree has reached their initial coverage limit and has to start paying an increased out of pocket for his or her prescription drug costs. This is when the 50% discount from manufacturers kicks in. While the discount may help offset a significant portion of the expenditures from that point on, drug costs involving members who make it to this point are often-times becoming a serious financial issue for the member. With drugs costs always rising, these additional expenditures can be substantial.

A plan that exposes members to this additional out of pocket cost is known as a base plan. Benistar offers solutions that can help to keep the out of pocket costs low for retirees during this period by offering full-coverage and generic-only options. Full-coverage plans allow members to continue paying their initial coverage copay’s throughout the donut hole. Generic-only plans provide similar benefit to generic drugs while in the donut hole. Both types of plans work to both keep member cost low and keep patients healthy.


The standard open formulary for Benistar’s Part D program is among the broadest Medicare formularies. Benistar’s ability to offer such generous plans stems from our excellent partnerships with carriers and large book of business.

Employer Contribution

The EGWP allows plan sponsors the freedom to choose how much they contribute to the cost of the premium. Plan sponsors can either pay for the full premium, for a portion of the premium or they may choose to have retirees enter the plan on a voluntary non-contributory basis. Unlike with the Retiree Drug Subsidy, the EGWP contribution level does not impact savings from subsidies and discounts. This means that regardless of how the premium is split between employer and member, premiums are still eligible for the cost savings and subsidies under the EGWP.

NEW rules for Medicare Shared Savings Program

Benistar shares announcement from the website released June 5, 2015

The CMS finalizes rules for Medicare Shared Savings Program

Continued Growth in ACO Program is a Core Component of Delivery System Reform

The Centers for Medicare & Medicaid Services (CMS) today released a final rule updating the Medicare Shared Savings Program to encourage the delivery of high-quality care for Medicare beneficiaries and build on the early successes of the program and of the Pioneer Accountable Care Organization (ACO) Model.  This final rule is an effort to provide support for the care provider community in creating a delivery system with better care, smarter spending, and healthier people.

The Medicare Shared Savings Program final rule will both enhance the focus on primary care services and provide additional flexibility in the program, which should grow participation.  CMS is making these modifications to the proposed regulations after considering comments received from the December 2014 Notice of Proposed Rulemaking.

“Accountable Care Organizations have shown early but exciting progress in improving quality of care, while providing more patient-centered care at a lower cost,” said CMS Acting Administrator Andy Slavitt.  “The ACO rules today strengthen our ability to reward better care and lay the groundwork for more providers to become successful ACOs.”

The final rule issued today improves the program over the proposed rule in a number of areas, including but not limited to:

  • Creates a new Track 3, based on some of the successful features of the Pioneer ACO Model, which includes higher rates of shared savings, the prospective assignment of beneficiaries, and the opportunity to use new care coordination tools;
  • Streamlines the data sharing between CMS and ACOs, helping ACOs more easily access data on their patients in a secure way for quality improvement and care coordination that can drive critical improvements in beneficiaries’ care;
  • Establishes a waiver of the 3-day stay Skilled Nursing Facility (SNF) rule for beneficiaries that are prospectively assigned to ACOs under Track 3; and
  • Refines the policies for resetting ACO benchmarks to help ensure that the program continues to provide strong incentives for ACOs to improve patient care and generate cost savings, and announces CMS’ intent to propose further improvements to the benchmarking methodology later this year.

The Medicare Shared Savings Program was created by Section 3022 of the Affordable Care Act to promote better health for Medicare fee-for-service beneficiaries by encouraging physicians, hospitals, and other health care providers to improve patient health and experience of care and to reduce growth in costs.  The program is voluntary and accepts applications on an annual basis in which organizations agree to participate for three years.

Over 400 ACOs are participating in the Medicare Shared Savings Program, serving over 7 million beneficiaries. Early results released last November indicated the Medicare Shared Savings Program ACOs starting in the first two years of the program improved quality of care for beneficiaries, as ACOs improved performance in 30 of 33 quality measures.

According to an independent evaluation report released by CMS earlier this month, the Pioneer Accountable Care Organization (ACO) Model generated over $384 million in savings to Medicare over its first two years – an average of approximately $300 per participating beneficiary per year – while continuing to deliver high-quality patient care.  The Pioneer ACO Model is the first that meets the tests to have its elements incorporated into other Medicare programs.

ACOs are a part of the Department’s broader initiative to create a health care system that results in better care, smarter spending, and healthier people. The Administration earlier this year announced the goal of tying 30 percent of Medicare payments to quality and value through alternative payment models, such as ACOs, by 2016 and 50 percent of payments by 2018.

For more information on the Medicare Shared Savings Program, please visit:



Senior Star 2nd Quarter 2011

Aon Hewitt Report Shows Potential Impact of Health Care Reform on Retiree Medical Programs

Excerpt: LINCOLNSHIRE, Ill., April 20, 2011 — Most large employers are now beginning to rethink their retiree health care strategy as a result of federal health care reform, according to a recent report by Aon Hewitt, the global human resource consulting and outsourcing business of Aon Corporation (NYSE: AON).
In late 2010, Aon Hewitt surveyed 344 companies, representing 2.2 million retirees nationwide, and found that 61 percent were either already evaluating or were expected to evaluate their long-term retiree medical strategy by the end of 2011, due to health care reform. Meanwhile, 23 percent of respondents indicated they were still considering whether to assess their current strategy and only 16 percent had no immediate plans to review their current approach.

CMS Announces Indexed Medicare Part D Amounts for 2012

Excerpt: On April 4, 2011, the Centers for Medicare & Medicaid Services (CMS) announced the indexed Medicare Part D standard benefit and Retiree Drug Subsidy (RDS) amounts for 2012.1 This Capital Checkup features charts comparing the 2012 numbers to the 2011 numbers.
The Medicare Modernization Act (MMA) requires CMS to announce indexed Medicare Part D standard defined benefit amounts each year that reflect the increase in drug costs. In 2012, the Medicare Part D standard defined benefit amounts will increase by 3.34 percent, a rate that is based on drug cost trend of 4.67 percent in 2011 (almost the same trend as one year earlier: 4.63 percent), adjusted by CMS for prior year revisions.

Factbox: States’ Underfunding Of Retiree Health Benefits

Excerpt: (Reuters) – Many states cannot afford to cover promises made to their future retirees, with the Pew Center on the States reporting on Tuesday that there is a $1.26 trillion gap between what they have pledged to pay and the amount they have set aside. Nearly half of that amount, $604 billion, is for healthcare and other benefits not included in pensions, such as life insurance.


Seniors Not Getting Important Preventive Health Services Too few getting recommended vaccines and screening for cancer, diabetes and osteoporosis, report warns

Excerpt: TUESDAY, March 15 (HealthDay News) — Many Americans aged 65 and older are not receiving potentially lifesaving preventive health services, says a new report by several U.S. Department of Health and Human Services agencies. Too few seniors are getting recommended vaccinations for influenza and pneumococcal disease, including bloodstream infections, meningitis and pneumonia; help with quitting smoking; or screenings for breast cancer, colorectal cancer, diabetes, high cholesterol and osteoporosis, according to the report released March 14.


‘Common sense’ bill would change Medicare requirement

Excerpt: A bill to cover seniors’ need for skilled nursing care following an observational stay at a hospital is making its way through Congress. The bipartisan legislation, entitled the Improving Access to Medicare Coverage Act of 2011, is being praised by provider groups, such as the American Health Care Association.


Medicare Reform’s OPEB Side Effects Public employers need preemptive cost-control strategies.

Excerpt: Last week the U.S. House majority leaders announced a sweeping $6 trillion strategy to reduce the federal budget deficits structurally. State and local officials are largely focused on the immediate impact on intergovernmental assistance programs and the Medicaid program. They should also pay attention to the hidden impact that Medicare reforms would have on their retiree medical benefits plans (or “OPEB” for other post-employment benefits).

Medicare’s Drug Coverage Gap to Shrink Away Under Health Care Reform
Experts say changes kick in this year, with the ‘donut hole’ disappearing by 2020

Excerpt: Starting this year, Medicare Part D’s widely despised “donut hole” — the gap in drug cost coverage enrollees encounter when they reach a certain spending threshold — will start to disappear, one result of the health care reform package enacted last year, experts say.