More insurance brokers would choose traditional Medicare over Medicare Advantage: Report

[somarco]

Not sure of the time frame but it's still on going. They're still not showing up when I run a quote. Neither is UHC.

A bigger problem down here is with doctors. Both Phoebe and non Phoebe. Seems they are turning away new patients that have anything other than OM.

Sorry, that is anecdotal.

MAPD agent will disagree and say their thousands of clients NEVER have a problem.

Somehow I find their comments tough to swallow . . . too much REAL evidence to the contrary.

 

[sman]

But what about the other parts of Georgia?

I'm in Albany. Two hundred miles south of Atlanta. Population around 80,000. Only one hospital.

But everything Somarco posted is happening here. No Anthem and no UHC. Two of the biggest in the state and nobody will take them.

Wasn't there an issue with Phoebe and Humana within the last couple of years? I think I remember Humana sending something out saying that even though Phoebe is out of network, they would treat it as in network. But you still had Phoebe people telling patients they didn't accept Humana.

 

[somarco]

I think I remember Humana sending something out saying that even though Phoebe is out of network, they would treat it as in network. But you still had Phoebe people telling patients they didn't accept Humana.

I don't have much business in that area of GA . . . I leave it for you and Robert to take of business there.

It really doesn't matter what the carrier says they will do with regard to claims . . . if the provider says '"no admission" they are acting as the gatekeeper and it is up to the patient (or their agent) to fight the battle.

Most patients are passive and won't challenge a denial . . . this includes claims denied. I run into this more than I should . . . doc office says we don't take that plan (yet they take Medicare).

This (below) deals with prior authorization which is essentially a claim that has not yet been filed.


Over 2 million prior authorization requests were fully or partially denied by Medicare Advantage insurers.
Just 11 percent of prior authorization denials were appealed.
The vast majority (82%) of appeals resulted in fully or partially overturning the initial prior authorization denial.

In 2021, data from 515 Medicare Advantage contracts, representing 23 million Medicare Advantage enrollees (87% of Medicare Advantage enrollment), included 35.2 million prior authorization determinations. Determinations reflect a Medicare Advantage insurers decision on a prior authorization request made on behalf of a plan enrollee. On average, that translates into 1.5 requests per enrollee.


https://www.kff.org/medicare/issue-...submitted-to-medicare-advantage-plans-in-2021

Prior authorization is usually handled by the provider, so the patient may not be as acutely aware of the problem as providers are. Still, it is a hassle for someone in the chain and one that does not happen with OM.

All of my clients are 65+ and I don't know any of them who want to spend their retirement years fighting with carriers for P A or claims.

 

[straightnochaser]

A number of large, specialty hospitals do not accept MAPD plans, or only accept a limited number of plans. Mayo, Sloan-Kettering, MD Anderson, Cleveland Clinic and Johns Hopkins come to mind but there are others as well.

Same is true for large medical practices, especially those owned by hospitals.

In some cases the issue is low reimbursement, but more often the conflict involves prior authorization required by most, if not all, MAPD plans. Original Medicare.only requires pre-authorization for certain DME supplies.

In the last few years some of the larger hospitals in Atlanta have had contract disputes with Anthem (BX) and UHC. Until the disagreement is ironed out, and a new contract is agreed upon, they will not admit new patients. This also applies to medical practices owned by the hospital.

Scheduled admissions and appointments are cancelled until after a new contract is executed.

This is unique to MAPD but does not apply to patients that have original Medicare.

Cleveland Clinic does accept MAPD, they even have branded MAPD plans with Humana

 

[sman]

I don't have much business in that area of GA . . . I leave it for you and Robert to take of business there.

It really doesn't matter what the carrier says they will do with regard to claims . . . if the provider says '"no admission" they are acting as the gatekeeper and it is up to the patient (or their agent) to fight the battle.

Most patients are passive and won't challenge a denial . . . this includes claims denied. I run into this more than I should . . . doc office says we don't take that plan (yet they take Medicare).

This (below) deals with prior authorization which is essentially a claim that has not yet been filed.


Over 2 million prior authorization requests were fully or partially denied by Medicare Advantage insurers.
Just 11 percent of prior authorization denials were appealed.
The vast majority (82%) of appeals resulted in fully or partially overturning the initial prior authorization denial.

In 2021, data from 515 Medicare Advantage contracts, representing 23 million Medicare Advantage enrollees (87% of Medicare Advantage enrollment), included 35.2 million prior authorization determinations. Determinations reflect a Medicare Advantage insurers decision on a prior authorization request made on behalf of a plan enrollee. On average, that translates into 1.5 requests per enrollee.


https://www.kff.org/medicare/issue-...submitted-to-medicare-advantage-plans-in-2021

Prior authorization is usually handled by the provider, so the patient may not be as acutely aware of the problem as providers are. Still, it is a hassle for someone in the chain and one that does not happen with OM.

All of my clients are 65+ and I don't know any of them who want to spend their retirement years fighting with carriers for P A or claims.

I've seen an uptick in this specifically related to SNF. I had 3 MAPD clients last year who either had their request for SNF denied or greatly limited (two denied, one limited to 6 days). And on all of these plus a few more who used SNF after a hospital stay, the SNF facility encouraged these patients to go back to original Medicare and get a Med Supp. I understand why the facility encourages it, but this also shows their ignorance since the patient obviously can't get a Med Supp.

One of the more frustrating things we deal with as agents is when a client gets bad info/advice from an admin person at a doctors office or facility. The patient believes the people at the doctors office know what they are talking about because they deal with insurance claims. Many times they don't have a clue. Even worse, the admin person is adamant they know what they are talking about when they are clearly misinformed.

 

[goillini52]

I may be wrong, but I believe Phoebe Putney did not accept BCBSGA a few years ago. This dispute was protracted for several months.

When SHBP changed to UHC there were hospitals & docs in parts of GA that were not in network.

UHC and Northside Hospital (Atlanta) also allowed a contract to expire a few years ago. I had a client at the time that was undergoing chemo there and was concerned about losing access to the Northside facilities.

More recently, Piedmont Hospital (Atlanta) and Anthem could not agree on a contract in 2021 or 2022 and would not admit patients who had Anthem coverage. This extended to physician practices that were owned or affiliated with Piedmont.

I had several calls from clients who had Anthem Medigap plans and they were told a physicians cardiology group would not accept their plan and they needed to make a switch to an MAPD plan suggested by the practice. This was outside of open enrollment (MAPD) and they would not pass underwriting for a Medigap plan.

I told them as long as the practice accepted Medicare their Anthem Medigap was also.

Still, the office manager was insistent that I was wrong. I had to get a honcho from Anthem to call the office manager and send a letter explaining that Anthem Medigap plans were still accepted by Piedmont & affiliates.

Sometimes these managed care disputes spill over into the Medigap side and that makes life interesting.

Contract disputes between providers and managed care plans can happen anywhere but seem to be more prevalent in larger cities.

I've seen some confusion with the carriers like Aetna and BCBS, that offer both Med Supp and MAPD.

 

[LostDollar]

I can only speak for my area, but Medicare Advantage has gotten so good and so strong here, I'd have to be a moron to piss money away on a supplement every single month. MAPD PPO.....99% of hospitals are all in-network. I very rarely ever find a doctor or specialist that isn't in-network, low MOOP, a $75 Part B buyback, and another (estimated) $250/month savings in not having to get a supplement, Part D plan, and dental/vision plan. If you want an honest take from an agent that offers both supplements and medicare advantage plans in Illinois, folks....there it is. I have over 500 clients and they're all as happy as can be on their MAPD.

(Caveat, not an agent)

What do you see as a long term possibility of the government reducing funding to MAPD carriers -- the funding that I assume enables them to offer some of the supplementary benefits like Dental, Vision and Part B buyback.

 

[Todd King]

I just spoke with an agent yesterday who is looking for UHC. He's looking to pick them up because in his area of KY, they are no longer taking MA plans for Humana or Wellcare.

 

[Todd King]

Im unsure why its ok to have managed care from age 0-64... then suddenly when you hit 65 its imperative that you have zero networks and complete freedom of providers.

What are the mortality rates on MAPD vs. Med Sups?

Are there any stats on longevity after diagnosis of a major illness between the two?

Does the industry have actual stats to back up the fear generated about managed care?

I dont work the Medicare market, so I am genuinely asking these questions...

I do get that as one gets older, more medical care is usually required. But are people actually having terrible experiences with not accessing needed care with MAPD?

Well, who said it was ok to managed care from age 0-64? Is there another choice? I'm betting if it was available, they would opt into a Medicare-like plan most of the time.

 

[LostDollar]

Seems like that most agents who are honest with themselves, would choose Original Medicare over MAPD when they turn 65. I of course would choose OM, what would you choose?

https://www.beckerspayer.com/payer/...medicare-over-medicare-advantage-report.html?

[EXTERNAL LINK] - The Challenges of Choosing Medicare Coverage: Views from Insurance Brokers and Agents

Most brokers and agents personally would choose traditional Medicare and Medigap over a Medicare Advantage plan. When asked, most said that they believe traditional Medicare, with the addition of Medigap supplemental plans, offers better health care coverage and choices, particularly as people age. One broker explained their choice, “If I ever have a medical issue, I’d want to be able to go to any physician I want.” A few participants, however, thought Medicare Advantage plans would be fine for their needs.

(Yes, only 29 brokers participated for a 105 min session)

I am not an insurance broker so I am not answering the survey, but my current choice is Medigap HDF.

It may be that l will need to switch to MAPD in the future because of income considerations, but at the moment I prefer the HDF option.

(This is even with having had $150K -$160K medical bills (before Medicare adjustment) in the past year + dental ins premiums + items not covered by Medicare.)

I could have used a food card, otc medication benefits, some dental coverage and a Part B buyback, but I am unwilling to give up access to original Medicare forever if I don't have to.