Former CMS Administrator Weighs in on Advantage Plans

[URDRWHO]

Not necessarily . . .

The hospital clinics you mention are either out of network to all but a few local MA plans or don't accept any of them. Mayo has been for MA then against them and then for them. I can't keep up with them any more.

For the rest of that gang, if you search their website for MA insurance they accept you see things like this . . .


If you are enrolled in a managed care plan (HMO, PPO or POS), your treatment at MD Anderson may be covered by insurance. Before scheduling an initial appointment, please call your health plan/insurance company and ask if you have access to health care services at MD Anderson. We encourage you to refer to Questions to Ask Your Insurance Company when speaking to your insurance provider.

If MD Anderson is not a participating provider, you may still be able to receive treatment here. Contact your insurance company and ask about obtaining authorization. It is important to note that some benefit plans utilize what are referred to as "narrow" or "limited" networks; that is, they further narrow or limit the choices of doctors and hospitals that their customers can use. Often, these networks exclude MD Anderson. Additionally, some plans, such as HMO's, have primary care physician referral and/or other authorization guidelines.

Your MD Anderson patient access specialist will help you obtain the full benefit from your insurance plan by:

Answering your questions about insurance verification and/or prepayment requirement
Responding to insurer requests for additional medical information.
DISCLAIMER: MD Anderson's participation with any product or insurance plan is subject to change without notice. Additionally, insurance companies offer a variety of plans and may change the names and benefits at any point. A patient's level of coverage depends on the specific benefits outlined in their plan.

To ensure that MD Anderson and its physicians are in-network, it is the patient's responsibility to verify that MD Anderson is a participating provider and their benefit plan allows them access as of the day of a visit and/or admission. Please contact your insurance plan to obtain this information.

Revised 2/23/2023

Insurance Plans

If you are enrolled in a managed care plan (HMO, PPO or POS), your treatment at MD Anderson may be covered by insurance. See the list of accepted insurance plans here.

www.mdanderson.org

We MAY admit you but you will need to jump through a bunch of hoops plus sign an agreement that you are responsible for paying claims that are denied or where there is a spread between what your carrier pays and what we bill.

My guess is very few people are willing to take that kind of beating and are willing to sign on for an OOP without caps . . . which is essentially what this kind of arrangement turns out to be.

There are any number of reasons why specialty clinics refuse to participate in MA plans, or only contract with a very small number of plans.

Here is another phrase that comes to mind, but it did not originate in the south. Put some lipstick on that pig . . .

There is not enough lipstick to make these hospitals want to accept MA plans into the fold.

And yes, I can see you are singing a different tune but you are tilting at windmills.

Yes this would be true. I was not thinking and shooting from the hip. It was late in the day (for me ) and earlier in the day I was reading about another JHH doctor for pain and his site said they don't take MA plan. I know my brother-in-law went to the Cleveland Clinic for transfusions for melanoma. I remember my sister talking about not being able to afford them. I need to call her anyhow, I'll ask.

The article in the link mentions our city / county hospital, the big main hospital dropped some MA plans. The hospital is one of two hospital's but they are the hospital with ancillary locations all over the country, they are and have been the big dog.

Before MA plans came along with their Sirens song, I did have some good traditional gap insurance companies in my file cabinet to offer. I think the people need to hear the "this could be you story" and traditional gap policies have to back the bigger stage.

"Hospitals are dropping Medicare Advantage plans left and right
Jakob Emerson - Updated Thursday, December 14th, 2023

"Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. "

Hospitals are dropping Medicare Advantage plans left and right

Hospitals nationwide are dropping Medicare Advantage plans due to excessive prior authorization denial rates and slow payments from insurers. Scripps and St. Ch

www.beckershospitalreview.com

 

[somarco]

I think the people need to hear the "this could be you story" and traditional gap policies have to back the bigger stage

They (prospects and clients) hear that story from me almost daily. In addition to personal stories there are plenty of third party stories from the providers and consumers about how MA plans work, or don't work, when you have a major claim.

Here are a few examples.

Is Medicare Advantage a Disadvantage For Patients With Cancer?

Medicare Advantage plans have been associated with increased screening rates. But managed care tactics and narrow networks may be a disadvantage for people needing care.

www.managedhealthcareexecutive.com

https://www.cityofhope.org/city-hope-study-finds-medicare-advantage-may-put-complex-cancer-surgery-patients-disadvantage

City of Hope formerly known as Cancer Treatment Centers of America.

I read over a dozen health care and Medicare related newsletters every day. It is eye opening to read studies and stories by real people who are not marketers.

The only time I Google topics is when I need more information and need to document where I read something earlier.

Of course there are some agents that claim the studies, reports, etc are fiction because they never hear, or choose to ignore, the truth about how MA functions (or dysfunctions) when the tough times hit.

I don't write MA (but refer it out when someone wants those plans) but folks quite often will say they don't want an MA plan . . . they have heard too many horror stories from friends and relatives.

I also get calls from folks who have an MA plan and now they want off because they "can't afford to pay their bills". Of course this normally disqualifies them from a Medigap because they are outside of the time frame to avoid underwriting and their health is an automatic decline.

Health care is expensive when you have something major and quite a few folks don't have the reserves, or available credit, to cover their bills.

 

[URDRWHO]

The stories are real and they are often tales of horror. Yeah if you never get a dreaded disease, a MA plan will usually work. I had my gallbladder removed last fall and it worked out fine. But who can know the future? Read the headlines and these days cancer cases are increases. Rates of cure have gotten better but now there are more cases. Without any insurance I could have paid for my gallbladder removal but could never have paid for a leukemia event with bone marrow transplant.

The agents that don't believe the stories have probably never sat and looked closely at their spouse's chest to make sure it is still going up and down, the breath of life. They've never had to move furniture in the living room to make room for the hospital bed. They live in denial.

We went through most of the hard part while Covid was happening and that made me #1 caregiver, the only caregiver. The entire affair changed me. I am always watching, listening for another fall on the second floor, ready to bound up the stairs. She says stop treating me like a patient, I'm fine. It is true but her walking will never, ever be 100%.

The experience changed my giving $$$$. For decades I donated to St Judes but now I've increased the amount. I've added in the Leukemia Foundation, donations to Johns Hopkins and other foundations. Into my 70's and the plan was not this one but we are living, breathing and moving forward. I'll also say that the nurses are angels walking among us. Yeah it was never great having those many visits in the middle of the night but they were always watching and helping. Many nights I lay there on that hospital cot, by wife silent and asleep, talking to .... well you can give it a guess and it wasn't anyone walking the floors.

I did my CE this January and renewed my license but don't know if I have the energy to go back into the insurance business.

My number one is sitting at night with a blanket covering us and my wife and I watch tv. Not enough money in the world to buy such a thing as our evenings.

Think I'll finish up on this because I'm probably getting boring to read, I will soon attract unwanted / unneeded attention from MA fans and it leads me down some negative pathways that should stay lying dormant.

 

[Millwood]

Interesting read about demographics of MA and OM enrollees.

 

[somarco]

When you take on the mantle of primary caregiver for a family member your world changes forever.

My wife had a medical issue about 4 years ago. Not life threatening, but life altering. Following the hospital discharge I became her primary caregiver for 4 months. Our OOP expense was nominal compared to yours but it was enough to make me appreciate the coverage she had.

Your story may be boring to some, but it is inspirational to me, and confirms what I have known for years about dealing with health care, providers and insurance.

Most folks are not willing to share their experiences . . . probably because they feel it involves matters of privacy and can expose deep emotions.

Our industry is built on emotion, not just dollars and cents. An agent that relies on pitching low cost and "rich" benefits but fails to mention "this is how your coverage will work" is doing a disservice to his/her clients. In fact, they are not really clients but merely policyholders generating an income stream.

Once more I want to thank you for sharing this very personal story. I suspect the naysayers are sitting on the sidelines and not attacking you because deep down they know you are speaking the truth. Because of that they have no defense in taking an adversarial position . . . they have a gun but no bullets.

If you have more to say, then say it. This kind of honesty from an agent who knows and understands our business from the client side is something we need more of in this forum.

This is akin to stories I have read about "when the doctor becomes the patient" and their eyes are opened to how the health care and health insurance industry performs.

Quoting Shakespeare from Macbeth . . . "Lay on Macduff"

 

[URDRWHO]

Interesting read about demographics of MA and OM enrollees.

That is interesting and I skimmed through but will read in greater detail. It looks like what I've read and have seen of the general population.

To gather things like this they must have done some data mining -
"FFS enrollees are more likely to have certain conditions, including cancer, joint issues (rheumatoid arthritis, osteoarthritis, and osteoporosis), and heart issues (ischemic heart disease and prior experience with heart failure). On the other hand, MA enrollees are more likely to have diabetes"

 

[gregj]

It did not, in my opinion, fulfill its original promise of saving money.

some may have humped the idea MA plans would "save" money; many would be satisfied if they merely did not cost as much or more money than original Medicare.

On the whole, treatment costs for Medicare beneficiaries have undershot projections for quite a few recent years. The reasons are many & tangled; causation's elusive.

My personal bias is that any health care 'dial tone' increases the likelihood that rescue-care-averting attention is given to people who would otherwise wind up getting more of the costly 'hail Mary' care that in the end burdens all of us while not exactly upping quality of life for those who get it.

MA plans, by their benefit designs, increase low-acuity health treatment 'touches' (the 'dial tone'), by no means efficiently, but probably, in a statistical sense. The single most predictive 'datum' for high-cost rescue-care events in a population in a given year? No health care system contact in the previous year(s). Not very strong, to be sure, but if you're looking for the strongest predictor, look there.

There's nothing perfect about MA plans, & the profitability of that portion of health insurers' business deserves all the scrutiny it gets & more.

 

[Ashmeade]

...

This is akin to stories I have read about "when the doctor becomes the patient" and their eyes are opened to how the health care and health insurance industry performs.

Quoting Shakespeare from Macbeth . . . "Lay on Macduff"

I haven't been in Medicare for a while, but I always think about the one guy who laid it out better than I had ever done until that point.

"It's great until you need it around here."

Rural areas get hosed a bit on Medicare. Our clients choose a cheap plan and regret it later, or an expensive plan and regret it until they have to use it. If they're astute enough, they understand a cost/benefit analysis isn't always clear enough. If you get slapped with the big C or keel over from TIA, get ready to get ***ed on MAPD around here. All the money goes to the big cities. Unless you're gonna go hungry affording it, you're doing yourself a great disservice not buying the supplement in most cases. I am close to the WV border (God bless you, Highmark) but in OH, it's tricky.

Something to chew on, and this may be confirmation bias, but supplements are hands-off to me. I could go on a bit about that, but EVERY client that has switched complains they are forced into being engaged with the provider and insurance. I am a true believer in not stressing a sick person over finances. I don't know. This is my own opinion. Once you get into our major cities, it could be a completely different story. In Columbus, there are three major hospitals very, very close to each other. I imagine the MAPD benefits are cheaper and easier to manage there.

A family member of my own had cancer, in a metropolitan area, and their spouse switched them to MAPD to save money. They spent more money than they were spending in monthly premium. It is what it is. We do the best we can for our clients and try to direct them to the decision that makes the most sense. If you aren't doing that, you're just a sales-person.

Edited: That last sentence wasn't calling you out or anything, Somarco.

 

[somarco]

"It's great until you need it around here."

Rural areas get hosed a bit on Medicare. Our clients choose a cheap plan and regret it later, or an expensive plan and regret it until they have to use it.

I use that line all the time . . . and it works on prospects and clients.

Wait until you need your Medigap plan for something major. If you are not happy I will refer you to an agent who can help you change to MA next open enrollment.

So far, no one has asked.

A family member of my own had cancer, in a metropolitan area, and their spouse switched them to MAPD to save money. They spent more money than they were spending in monthly premium

Had that happen a few times, but most of the time they keep their mouth shut.

No apology needed @Ashmeade , no offense taken.

I don't apologize to anyone for my position in the MA vs OM/Medigap discussion.

When talking with a prospect, I lay out the differences and sprinkle in stories about how each work. If they still want an MA plan I refer them to a friend. I don't chase after them, I don't try and get them to change their mind.

They made their choice, now they will have to live with it.

The agent that get's my MA referrals also writes Medigap but he has never tried to snake someone away from me if they decide Medigap is better.

 

[Ashmeade]

I use that line all the time . . . and it works on prospects and clients.

Wait until you need your Medigap plan for something major. If you are not happy I will refer you to an agent who can help you change to MA next open enrollment.

This is it, really. I have converted a bit on the GI - MA Trial. It's almost pro-bono work. Had a person break down in tears because they got 'ripped-off' by the television. I try to be empathetic in situations as I could only imagine how embarrassing it would be. My personality wants to lay blame on them, though. They should have known, right? Not, really. Look at the convoluted mess Medicare is and the equally convoluted mess the marketing aspect is with it. You have agents getting paid more to shill products that may NOT be in their clients best interest. You have tax-payer dollars working non-stop to limit their influence. It's maddening.

I wanted to edit for that last part. I went off the deep-end on a Facebook page for insurance agents about this topic. The fact is, no-one REALLY knows what's going to happen to someone health-wise. That's the spirit of indemnity. I want to put you as close financially to where you were prior to your loss. Fight me if you don't agree. All the extra stuff is fluff that takes away from that CENTRAL point. Philosophically and actuarially.

I have very distinct conversations on income and how much an individual planned on spending on healthcare during retirement. (Spoiler alert: Not many do.) I force them to understand the implications of their decision. And I never, ever, ever act like any of their concerns are beneath me or trash a product. I have sold MAPD and I actually think the plans are decent but it takes a lot more calculation and discussion than more agents probably ever have with their clients.

I love two things in my field:
1. Being proven wrong.
2. Not knowing.

That's a bold statement, I guess. But, I want to know as much as I can about what I am presenting. It could literally mean someone's livelihood. If someone asks, it probably has happened, and may need addressed in the future. One of the worst feelings I have ever had in this industry is asking myself, 'How bad did I just screw this up?'.