Who to trust on RX comparisons

[somarco]

They aren't subsidizing the MAPD plans. MAPD plans have to spend X dollars or they get suspended in that area for the upcoming year.

And with the dental amounts increasing, I am not seeing the MAPD vs Part D spread I saw last year

I doubt CMS asks for a line of coverage breakout on profit margin. They are pretty much free to allot funds as needed.

 

[kgmom219]

I doubt CMS asks for a line of coverage breakout on profit margin. They are pretty much free to allot funds as needed.

Agreed, but the actual amount spent is what matters. So if they are taking a loss on meds, its makes up for all the money they are saving on SNF approvals

 

[Cenla Agent]

I already told Juliana and Tricia at KFF that I hope they are right but think they are wrong.

We are already seeing it at Aetna. There's a base plan with a great premium and formulary for T1's. And in most areas that means they will get the low income people. (And note that they stopped paying commission on it, too)

The premiums won't increase due to the IRA, but what they can (and will) do is tighten up the formularies. Most of the carriers offer at least 2 or 3 Part D plans. They will have a base plan with an incredibly low premium combined with a very tight, closed formulary. Then the 2nd or 3rd option will be a $100 premium with low or $0 deductible and a decent formulary. All those people we are seeing on Eliquis or Xarelto? They'll be paying $100 a month premium in 2025.

The low income people, i.e. those with extra help or duals, should enroll in the Choice plan, which is the middle Aetna/SilverScript plan that is priced in the $30-$35 range. That's the one that goes to $0 for people with extra help. The non-commissionable SmartSaver plan is designed for people who have low or no Rx costs and the premium doesn't drop for those with extra help. The SmartSaver has a narrower pharmacy network too. Walgreens isn't even in it at all, whereas at least it is a "standard" pharmacy with the other two plans. I don't know how common that is these days, but I think narrower networks may also become more common.

 

[Cenla Agent]

Margin on the medical claim side is subsidizing the D in MAPD.

I think so. If the MLR is off on a PDP, it will be suspended by CMS.

 

[somarco]

I think so. If the MLR is off on a PDP, it will be suspended by CMS.

CMS tracks loss ratios on PDP?

Same for the D in MAPD?

 

[Cenla Agent]

CMS tracks loss ratios on PDP?

Same for the D in MAPD?

I’m not sure if it is exactly the same, but at least one plan has been suspended over it. https://www.arkansasonline.com/news/2017/oct/12/blue-cross-sues-over-drug-plans-2017101/

 

[LostDollar]

I’m not sure if it is exactly the same, but at least one plan has been suspended over it. https://www.arkansasonline.com/news/2017/oct/12/blue-cross-sues-over-drug-plans-2017101/

Caveat, NOT an agent.

To me, it seems reasonable to say: If "The Rules" for Parts C and D say agents have to take special tests to sell Part C and D plans, the expense and profit rules spelled out in "The Rules" for Parts C and D should also apply to both categories of plans.

 

[somarco]

I’m not sure if it is exactly the same, but at least one plan has been suspended over it. https://www.arkansasonline.com/news/2017/oct/12/blue-cross-sues-over-drug-plans-2017101/

Odd . . .