Obama Coming After Medicare Advantage

[azmedsupagent]

HA no kidding...

Anyone else have anything to say about this? Its kind of a big deal.

 

[G.Gordon]

I could not agree more. The same thing happened with medicare+c, they started out over funded to entice new enrollees into the program and they started to back funding out untill plans started getting out of the program because there was no room for profits. Any healthy business seeks a profit margin between 10-15% and that conveniently happens to be about the amount these companies are overpaid. Not to mention the fact that these plans tend to have some adverse selection for healthier enrollees which means even less of the captation is going toward healthcare. Some would argue that this adverse selection should mean that MA companies should recieve less than 100% of medicares cost to insure its beneficiaries.

Your point on the adverse selection is spot on.

Look at what happened...

Our brilliant Gov. thought: "Let private companies handle beneficiary healthcare therefore saving us money." So... they passed laws making plans available to just about everyone.

Joe Citizen, good health, healthy retirement income, looks at theses plans as an alternative to paying $100-150/mo for a supplement. Thinking... "I can handle some out of pocket cost, I'm healthy, see the doc once per year. I'll do it."

WHAM!! A beneficiary that used to cost medicare a few dollars one/two times per year now cost them $750-850/mo in fees to the private carrier.

Bill Citizen, horrible health with several cronic conditions, lives on a budget, looks at these plans as too much risk since he see's his doctor on a weekly/monthly basis. Thinking... "The copays will kill me, God forbid I end up hospitalized, I'm safer on a supplement with no deductible, but a premium... I know exactly what my out of pocket will be each year."

WHAM!! A beneficiary that cost medicare thousands per month... continues to do so.


The only thing I can say good about MA's in rural America is they gave me 25+ new supplement clients during this AEP. I was there to get them back to security.

 

[Russ]

Your point on the adverse selection is spot on.

Look at what happened...

Our brilliant Gov. thought: "Let private companies handle beneficiary healthcare therefore saving us money." So... they passed laws making plans available to just about everyone.

Joe Citizen, good health, healthy retirement income, looks at theses plans as an alternative to paying $100-150/mo for a supplement. Thinking... "I can handle some out of pocket cost, I'm healthy, see the doc once per year. I'll do it."

WHAM!! A beneficiary that used to cost medicare a few dollars one/two times per year now cost them $750-850/mo in fees to the private carrier.

Bill Citizen, horrible health with several cronic conditions, lives on a budget, looks at these plans as too much risk since he see's his doctor on a weekly/monthly basis. Thinking... "The copays will kill me, God forbid I end up hospitalized, I'm safer on a supplement with no deductible, but a premium... I know exactly what my out of pocket will be each year."

WHAM!! A beneficiary that cost medicare thousands per month... continues to do so.


The only thing I can say good about MA's in rural America is they gave me 25+ new supplement clients during this AEP. I was there to get them back to security.

I live and work in a rural area and I'll vouch for your statements about MA plans vs. med-supps with 99% of those on Medicare around here.

 

[MedSuppPro]

The only thing I can say good about MA's in rural America is they gave me 25+ new supplement clients during this AEP. I was there to get them back to security.

G.Gordon Rocks --25 New MedSupp's during AEP!

Your after my heart. Selling security... letting them know that they don't have to worry about their benefits changing every year!

And if your able to show them a Mutual Company, let them know about how a Mutual Company operates differently then a stock company.

Ding Dong... Hello sir, my name is G. Gordon, and I'm here to get back your security!
...Sir, why are you pulling me inside of your house!


​

 

[Mac1958]

Private Fee for Service plans are a much bigger target than are the managed-care PPO and HMO plans, which can control costs much more efficiently.

PFFS is toast, the others probably are not. The insurers can most likely survive cuts down to standard Medicare rates by utilizing managed care.

 

[azmedsupagent]

Private Fee for Service plans are a much bigger target than are the managed-care PPO and HMO plans, which can control costs much more efficiently.

PFFS is toast, the others probably are not. The insurers can most likely survive cuts down to standard Medicare rates by utilizing managed care.

This is exactly my point, the HMO and PPO plans will have to control costs. How will they do this? Reducing benefits, denying claims, and making it even more difficult for enrollees to recieve the healthcare they need. This will likely cause many enrollees to leave the program. Correct me if Im wrong here but this sounds like a logical progression to me.

 

[retread]

This is exactly my point, the HMO and PPO plans will have to control costs. How will they do this? Reducing benefits, denying claims, and making it even more difficult for enrollees to recieve the healthcare they need. This will likely cause many enrollees to leave the program. Correct me if Im wrong here but this sounds like a logical progression to me.

Managed care plans manage costs... that's what they do best... (courtesy of "Tigger" from Winnie the Poo).

I helped a client today that went to the pharmacy to get a refill for drugs that she had been paying $0 for on a SNP plan I sold her last year. This time the pharmacist wanted $50. Right away I recognized the Tier 3 co-pay amount, so thought the change-over to Medco was to blame... long story short, NO, the carrier changed the formulary for 2009 and moved the drug from Tier 5 to Tier 3. When I got my hands on the formulary and noted the "ST" in the limits column. I called the client back and asked to call her doctor and see if he would put her on another drug in the same therapeutic class, and tell him that if he did and it didn't work out, we would have ammunition to demand an exception, since we followed the Step Therapy regimen. She called back later and the doctor agreed. Now she is back on a $0 drug, and it is generic.

This is what is going on.... MCOs are watching costs... another carrier is raising their high end plan to an exhorbitant rates that no one wants, in order to get customers off that plan in preparation for dropping it altogether.

If you are observant, you will see the subtle shifts.

I helped my client preserve her benefits, and the carrier was able to lower their exposure. The doctor co-operated, and the system worked.

Yet Rep. Stark considers me overpaid.

I am good at what I do... reminds me of the time when I was flying at 35,000 feet and......

 

[Josh]

Haven't you heard? This stuff is all the fault of the agents.

There really is no reasoning with you, is there?

 

[azmedsupagent]

Managed care plans manage costs... that's what they do best... (courtesy of "Tigger" from Winnie the Poo).

I helped a client today that went to the pharmacy to get a refill for drugs that she had been paying $0 for on a SNP plan I sold her last year. This time the pharmacist wanted $50. Right away I recognized the Tier 3 co-pay amount, so thought the change-over to Medco was to blame... long story short, NO, the carrier changed the formulary for 2009 and moved the drug from Tier 5 to Tier 3. When I got my hands on the formulary and noted the "ST" in the limits column. I called the client back and asked to call her doctor and see if he would put her on another drug in the same therapeutic class, and tell him that if he did and it didn't work out, we would have ammunition to demand an exception, since we followed the Step Therapy regimen. She called back later and the doctor agreed. Now she is back on a $0 drug, and it is generic.

This is what is going on.... MCOs are watching costs... another carrier is raising their high end plan to an exhorbitant rates that no one wants, in order to get customers off that plan in preparation for dropping it altogether.

If you are observant, you will see the subtle shifts.

I helped my client preserve her benefits, and the carrier was able to lower their exposure. The doctor co-operated, and the system worked.

Yet Rep. Stark considers me overpaid.

I am good at what I do... reminds me of the time when I was flying at 35,000 feet and......

Sounds like you did an excellent job navigating the red tape for your client and they are lucky to have you as an agent Im sure...

But, what about the rest of it? Copays, deductibles,referrals, pre authorization, HMO capitation rates for doctors etc... what effect do you see funding cuts having on these aspects of medicare advantage?

 

[fostever]

One issue you don't hear much about is Medicare fraud. In my years as an agent one thing that burns my ears is when I hear clients say they don't get billed for the 20% because the were told by the doctor to ignore any extra services billed to Medicare that they did not receive because they will not be responsible for them. This is more widespread than you might think. MA plans will not double bill themselves. Once the government pays that capitation fee they shift the accountability to the private company. Yes there are issues with overpayment and that should be looked at, but fraud may be an even bigger issue.