How Can They Do It?

[Bob_The_Insurance_Guy]

I called Universal Health Care today and asked them what I should say to someone who is told that PFFS Plans are going by the wayside in 2010 or 2011.

All I got as a response is that they will do whatever is necessary to keep their PFFS line of products.

I ain't buyin' it.

Now, from what I've heard on the street is that some companies are exiting the market entirely, and that some rural areas are conceding to PPO's and HMO's.

Here, in Atlanta, more than one player is staying in the PFFS market. Some are exiting.

Disclaimer: I sell more than just PFFS. I also sell MAPD, MA, PDP and Med Supp, so don't think that I have an angle. Just want some feedback.

 

[jdeasy]

I called Universal Health Care today and asked them what I should say to someone who is told that PFFS Plans are going by the wayside in 2010 or 2011.

All I got as a response is that they will do whatever is necessary to keep their PFFS line of products.

I ain't buyin' it.

Now, from what I've heard on the street is that some companies are exiting the market entirely, and that some rural areas are conceding to PPO's and HMO's.

Here, in Atlanta, more than one player is staying in the PFFS market. Some are exiting.

Disclaimer: I sell more than just PFFS. I also sell MAPD, MA, PDP and Med Supp, so don't think that I have an angle. Just want some feedback.

BY 2011 all the PFFS plans have to have a network if there is more than one PFFS plan available in the county. What implementation of that means is anyone's guess at this time. Some say that a PFFS plan with a network is the same as a PPO. Others say that, while they will have a network, the person is still free to see any Dr. that will accept the PFFS terms.

We won't know until we get there and we, agents, will be the last to know.

Some companies, Wellcare and Coventry, have pulled completely out of the PFFS field effective Dec. 31, 2009. Others, Humana, UHS, Aetna and others, have pulled out of PFFS in certain areas.

If someone asks you about it, this is all you can you tell them for now because it's all the news we have.

 

[Bob_The_Insurance_Guy]

JDeasy,

Thank you very much. That is what I thought, but I wanted an informed individual to confirm, not some company lackey.

Appreciate it.

 

[Josh]

BY 2011 all the PFFS plans have to have a network if there is more than one PFFS plan available in the county. What implementation of that means is anyone's guess at this time. Some say that a PFFS plan with a network is the same as a PPO. Others say that, while they will have a network, the person is still free to see any Dr. that will accept the PFFS terms.

We won't know until we get there and we, agents, will be the last to know.

If someone asks you about it, this is all you can you tell them for now because it's all the news we have.

Yes/No.

The biggest change that is going to happen is that if there are at least two network plans (ppo/hmo) then the PFFS is going to have to file a network the same as any other plan. Until this change many companies have not had to undergo the expense of building and maintaining a network under the FFS model. CMS will now require them to meet certain network requirements before receiving approval from CMS. Just like with the commissions, it could all change after the eleventh hour, but as it sits right now any company that has, or will have, at least two network based plans in an area will have to have a network if they want to keep the plan. This is putting an end to a lot of plan service areas because part of the reason they went that route was because it was a less expensive way of building a health plan. Now they're going to have more expenses from the network perspective, lower reimbursement levels, and more marketing restrictions, so it's little surprise that some of the players are scaling back their service area or closing this line of business completely.

What does this mean to you?
You can tell your clients with a straight and honest face that their PFFS plan is going to do everything in their power to continue to offer their product. If you want to get into a more involved conversation with them then you should tell them that before the companies never had to have a written agreement with providers in order to market their product, and while this has usually not been an issue (especially with you Gertrude, Dr. Jones has been taking this for years), because of some problems some folks have had Medicare is now requiring them to get at least a certain percentage of doctors to sign a contract agreeing to accept their plan. You can also point out that while some plans wont being doing this because they haven't had many members (whatever plan she has) has over 10k (or however) members they look forward to continuing to serve so they've started doing the contracting over a year ago (or more if you know the numbers).

I may have glossed over some points, but does that give you a better idea of what you're looking at?

 

[jdeasy]

Yes/No.

The biggest change that is going to happen is that if there are at least two network plans (ppo/hmo) then the PFFS is going to have to file a network the same as any other plan. Until this change many companies have not had to undergo the expense of building and maintaining a network under the FFS model. CMS will now require them to meet certain network requirements before receiving approval from CMS. Just like with the commissions, it could all change after the eleventh hour, but as it sits right now any company that has, or will have, at least two network based plans in an area will have to have a network if they want to keep the plan. This is putting an end to a lot of plan service areas because part of the reason they went that route was because it was a less expensive way of building a health plan. Now they're going to have more expenses from the network perspective, lower reimbursement levels, and more marketing restrictions, so it's little surprise that some of the players are scaling back their service area or closing this line of business completely.

What does this mean to you?
You can tell your clients with a straight and honest face that their PFFS plan is going to do everything in their power to continue to offer their product. If you want to get into a more involved conversation with them then you should tell them that before the companies never had to have a written agreement with providers in order to market their product, and while this has usually not been an issue (especially with you Gertrude, Dr. Jones has been taking this for years), because of some problems some folks have had Medicare is now requiring them to get at least a certain percentage of doctors to sign a contract agreeing to accept their plan. You can also point out that while some plans wont being doing this because they haven't had many members (whatever plan she has) has over 10k (or however) members they look forward to continuing to serve so they've started doing the contracting over a year ago (or more if you know the numbers).

I may have glossed over some points, but does that give you a better idea of what you're looking at?

We said the same thing. I just used less words.

 

[Josh]

We said the same thing. I just used less words.

No you didn't. You said less and gave inaccurate information. I was trying to politely correct your statement and add some more info so that this guy could have more info to have a conversation with his clients/prospects if he'd like. You said if there more than one PFFS plan then they would need to have a network. It's if there are two or more network based plans in the same service area. That's a huge difference to the folks in the rural counties that only have PFFS plans.

BTW- A PFFS with a network is just that, a PFFS with a network. PPO's have entirely different rules, especially for the cost share the member has. If someone is enrolled in a PPO they can see any physician that is par with Medicare and only pay the applicable cost sharing, the doc can't refuse service, that's a HUGE difference. As an example of that many PFFS plans have already started building their networks, but doctors still have the right to refuse service. The biggest change that will come as a result of this legislation from the consumer perspective is that the plans will have to invest more in building their networks or pull out of markets which will almost certainly reduce the plan benefits.
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JDeasy,

Thank you very much. That is what I thought, but I wanted an informed individual to confirm, not some company lackey.

Appreciate it.

Although I respect the amount of MA business JDeasy has written, I think going as far as calling him an informed individual is a bit of a stretch. If you really want accurate information about what MA plans are doing you need to talk to someone who has experience working with and looking at things from a plan perspective, not an agent who's never spent time becoming involved in how plans are run. Again, I have all the respect in the world for other agents, but the notion that someone has an understanding how the dollars and cents, legislation, and mechanics of how a healthcare plan is run, based on the fact that they've sold a lot of business, strikes me as a bit absurd.

 

[jdeasy]

No you didn't. You said less and gave inaccurate information. I was trying to politely correct your statement and add some more info so that this guy could have more info to have a conversation with his clients/prospects if he'd like. You said if there more than one PFFS plan then they would need to have a network. It's if there are two or more network based plans in the same service area. That's a huge difference to the folks in the rural counties that only have PFFS plans.

BTW- A PFFS with a network is just that, a PFFS with a network. PPO's have entirely different rules, especially for the cost share the member has. If someone is enrolled in a PPO they can see any physician that is par with Medicare and only pay the applicable cost sharing, the doc can't refuse service, that's a HUGE difference. As an example of that many PFFS plans have already started building their networks, but doctors still have the right to refuse service. The biggest change that will come as a result of this legislation from the consumer perspective is that the plans will have to invest more in building their networks or pull out of markets which will almost certainly reduce the plan benefits.
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Although I respect the amount of MA business JDeasy has written, I think going as far as calling him an informed individual is a bit of a stretch. If you really want accurate information about what MA plans are doing you need to talk to someone who has experience working with and looking at things from a plan perspective, not an agent who's never spent time becoming involved in how plans are run. Again, I have all the respect in the world for other agents, but the notion that someone has an understanding how the dollars and cents, legislation, and mechanics of how a healthcare plan is run, based on the fact that they've sold a lot of business, strikes me as a bit absurd.

I do know how they work and I do know how to talk to clients in the field. Something your arrogant ass has never learned.

The reason you don't do business in the field is because you don't know how to do business in the field. You sit behind a desk and posture very well, however.

It is preposturous for you even try and say how the PFFS stuff is going to look and work in 2011 because no one knows how it's going to look at this time. Of course, you will still be touting the greatness of lock-in at that time. That is the only one sure thing. Well, you'll still be an arrogant ass, so, that's two things.

 

[Bob_The_Insurance_Guy]

Listen, guys.

Can we keep this civil. My intent was not to start an argument. You are both on the same track.

 

[Josh]

It is preposturous for you even try and say how the PFFS stuff is going to look and work in 2011 because no one knows how it's going to look at this time. Of course, you will still be touting the greatness of lock-in at that time. That is the only one sure thing. Well, you'll still be an arrogant ass, so, that's two things.

The fact that you think "it's preposterous for me to even try to say how the PFFS stuff is going to look and work in 2011" demonstrates to me and anyone else reading this that you don't know what it looks like now. PFFS plans have already started making the changes they need to make in order to be ready for 2011 and that's been going on for well over a year now. That's common knowledge to anyone working from a plan perspective; the plans have already been told, for the most part, what changes they'll need to make regarding their networks and filing requirements. Congress may in their infinite wisdom decide to change things, but as far as any agent looking to speak with a client and let them know the truth about things as they sit right now, that's exactly the way things sit and how they've been sitting for over a year.

As far as the lock-in thing goes, you're just being stubborn and only looking at it from a narrow perspective. As I've repeatedly stated, I'm not a huge fan of the way things are running now, but lock-in does have some merit and the elimination of it would not put an end to even the majority of problems with the MA program as you have claimed in the past.

JD, something you might not realize is that I could outwrite you any day of the week. I'm not saying that you aren't good at what you do, but you've lost your mind if you think that I can't and haven't gone out and sold MA. You've never considered what it looks like from the administration side of things. Marketing, sure. At best you probably have an idea of what the reimbursement levels are to the carrier, but you're understanding of how a plan works is limited as evidenced by the remarks you've made on here. At the end of the day your a hot headed sales rep who doesn't have the humility to accept that he doesn't know everything. You've never worked with a health insurance carrier outside of sales and anyone who has would know that after listening to you for less than two minutes. There's no shame in admitting that you are just a sales guy and you don't know how the mechanics of things works.
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Listen, guys.

Can we keep this civil. My intent was not to start an argument. You are both on the same track.

I'd love to. You didn't start this argument, JD and I go back from time to time, it just happened to be on one of your posts. Did you have your question(s) answered and feel comfortable with the amount of info you've received?

 

[policy doctor]

I heard at one mtg that there is difficulty in building a network in many rural areas, so they;re thinking PFFS may get a year extension. They don't think 2010 sell season will be ready.

Alert.....this is hearsay...not a fact!