Congratulations! You’ve worked hard, and now you’re turning age 65! Navigating through the myriad of solicitations you are receiving and the choices you have to cover the expenses not paid by Medicare can be overwhelming.
The first thing is what not to do!
DO NOT CALL AN 800 NUMBER and talk to some anonymous employee of an insurance company. Not only are they restricted to limiting you exclusively to their company’s options—but your personal information will be instantly sold and shared. Your phone is going to begin ringing off the hook!
I’ve been specializing in Medicare-related insurance for over thirty years, right here in The Woodlands, Texas, USA! I represent every Medicare-related product, including Supplement, Advantage, and Part D Drug plans, from virtually every “A” rated company doing Medicare-related business in Texas. And I CHARGE NO FEE for my services! Deal with a local agent/broker who values your business enough not to share it with anyone!
D. Kenton Henry Editor, Agent, Broker Office: 281.367.6565 Text my cell 24/7 @713.907.7984 Email: Allplanhealthinsurance.com@gmail.com
By D. Kenton Henry Editor, HealthandMedicareRelatedInsurance.com Agent, Broker 28 January 2025
Hello again, and welcome to 2025! Early last October, just prior to the Medicare Annual Election Period (AE), I informed you of the many changes coming to Medicare Part D Prescription Drug Plans in the coming calendar year in which we now find ourselves. I explained the pros and cons that many of you are now experiencing in real time. On the positive side, I am certain many are celebrating that their annual drug costs (for Part D covered drugs) can never go beyond the new annual maximum out-of-pocket (OOP) of $2,000! And, hopefully, you are not experiencing the negatives—such as learning your Rx drug (which was previously covered) is no longer or its price has increased dramatically! Once again, we realize the government can giveth or taketh away.
But there is one thing in which you have a certain amount of control, and this is the ideal time of year to exercise that control. During the AEP, insurance companies, agents, and brokers work overtime seven days a week to see that their clients, and prospective clients, are guided to the Medicare Advantage and Part D Drug plans that best meet their needs. To do this correctly, an agent must understand the client’s needs and objectives and then do, what is often, extensive research to ensure a person’s drugsare covered and they have access to their preferred providers. In some cases, this can take minutes and, in others, hours over repeated phone calls. In most cases, you won’t get the latter from a company employee on the end of an 800 number, but you will get it from me.
Now that the AEP ended December 7th, agents have much more time to assist you in improving the cost of your Medicare Supplement coverage. As you may know, Medicare Supplement is not subject to annual enrollment periods in Texas or most states. What this means, is you can re-shop your Supplement coverage to find identical (or improved) coverage 365 days per year. The incentive for doing so is that you may save 30% or more in premiums. Because Medicare Supplement premiums go up each year as we age, it doesn’t take too many years before most of us begin to wonder if our premium is still reasonable or competitive. The reality is, if your policy is three years or older, you will indeed safe significantly by switching to a policy with the same letter designation, e.g., Plan G. I have many clients whose policy premiums had increased to well over $300 per month that I was able to lower (with new coverage) to less than $200 per month!
Additional reasons to re-shop now are that a few “A” rated companies are particularly interested in expanding their block of business. This does not imply a compromise in the quality of their customer service or rate stability. It simply means that through prudent management and staff expansion, they can be more competitive, significantly lowering your premium. Additionally, you may now have a spouse, or in some cases, simply another adult living with you—making your new policy available for a “Household Discount”. Typically, these discounts can lower your premium 7-12%, and—if the other person is covered by the same company—that discount will apply to their existing policy also!
So what is the catch? The catch is that now that you have been in Medicare Part B 6 months or more, you must go through underwriting and be approved for the new coverage based on your current health and relatively recent health history. The bottom line is, if your current conditions are well controlled with medication, you do not suffer from any chronic condition that poses a long-term liability to the insurance company, and you have no pending surgeries or hospitalizations—you are a good candidate for replacement coverage. The worst scenario is you are declined. In this case, all you are out of is the small amount of time you took to complete the application.
THE FOLLOWING IS A SYNOPSIS OF THE PROS AND CONS OF RE-SHOPPING YOUR COVERAGE:
Re-shopping a Medicare Supplement (Medigap) policy can provide several advantages for recipients, especially if their needs or circumstances have changed since they first enrolled. Here are the key benefits:
1. Cost Savings
Premium Reduction: Medigap premiums can vary significantly between providers for the same coverage. Shopping around may uncover lower premiums for the same plan (e.g., Plan G or Plan N).
Health Status Discounts: If your health has improved since your initial enrollment, you might qualify for a lower premium rate with another insurer.
Household Discounts: Some insurers offer discounts if multiple members of the household enroll in their Medigap plans.
2. Better Coverage Options
Change in Needs: If your healthcare needs have increased or decreased, you might find a plan that better aligns with your current situation, such as switching from a high-deductible plan to one with lower out-of-pocket costs.
Additional Benefits: New Medigap plans might include perks like fitness programs, telehealth, or wellness benefits that weren’t available when you initially enrolled.
3. Access to New Insurers
Competitive Market: New insurers entering the market may offer attractive rates or better customer service than your current provider.
Provider Reputation: Switching to a more reputable insurer can improve your overall satisfaction and ensure reliable claims processing.
4. Avoiding Rate Increases
Age-Based Increases: Some policies increase rates as you age. Shopping around may allow you to switch to a community-rated policy where premiums are based on a group average rather than individual age.
Annual Adjustments: If your current insurer has raised premiums significantly, exploring alternatives can help you lock in a more stable rate.
5. Improved Customer Service
If your current insurer has poor customer service or limited support, switching to a provider with higher satisfaction ratings can enhance your overall experience.
6. Medicare Advantage Comparison
While re-shopping Medigap policies, some recipients may realize that a Medicare Advantage (Part C) plan is more cost-effective or suitable for their needs. These plans often include additional benefits like dental, vision, and hearing coverage.
7. Regulatory Benefits
Guaranteed Issue Rights: In some situations (e.g., losing coverage or moving), recipients have guaranteed issue rights, allowing them to switch Medigap plans without medical underwriting.
Trial Rights: If you tried a Medicare Advantage plan for less than 12 months and decide to switch back to Original Medicare, you may have a guaranteed right to re-enroll in a Medigap plan.
8. Customizing for Future Needs
Planning ahead for potential healthcare changes can ensure that you are prepared for costs that might arise later, such as skilled nursing care or extensive outpatient services.
Considerations When Re-Shopping
Medical Underwriting: Outside of guaranteed issue periods, you may need to answer health questions, which could affect your eligibility or rates.
Plan Standardization: All Medigap plans with the same letter (e.g., Plan G) offer identical core benefits, regardless of the insurer, making it easier to compare prices.
Timing: The best time to switch is typically during your open enrollment period or when you have guaranteed issue rights.
By re-shopping their Medigap policy, Medicare recipients can ensure they are getting the best value and coverage for their evolving needs.
I am an independent agent with more than three decades in the medical insurance industry. As I have aged, so have my clients, and Medicare-related insurance (Supplement, Advantage, Part D) has become my specialty. I represent virtually every “A” rated insurance company in Texas as well as three others. I provide objective advice based on empirical numbers inclusive of costs and satisfaction surveys.
Significantly, I do not charge a fee for my service. You are charged no more for acquiring a product through me than if you went in the front door of the insurance company whose product you elected and acquired it directly from them!
Please allow me to assist you in lowering the cost of your Medicare-related insurance. I look forward to working with you!
In addition to owning the first insurance agency in The Woodlands, Texas, and most of the United States, to create a website (Allplaninsurance.com) in 1995, I was among the first to offer Medicare Advantage and Medicare Part D Prescription Drug Plans (MAPD plans) to Medicare recipients following their creation by the Medicare Modernization Act of 2003. Congress created them to provide a lower premium insurance product as an alternative to Medicare Supplement policies, which has been the standard insurance product to serve as secondary insurance covering medical expenses not paid by Original Medicare. And—with premiums as low as $0—they have certainly done that. Contrary to what may be the common perception of the public, every good agent has a little bit of social worker in them and wants to think they have really helped a person and improved their situation. As an agent (before the advent of Medicare Advantage plans), I would sit across coffee tables from prospective clients living in single-wide trailers and subsisting on social security income alone. I would watch tears come in their eyes as they told me they simply did not have another dime to spend on insurance, leaving me to drive off and them no better off for my visit. So, from that standpoint, they have been a source of great relief for me as well as my clients.
In addition to lower premiums, MAPD plans offer other advantages. Specifically, they are:
The convenience of combining medical coverage with prescription drug coverage under the cover of one policy. Effectively eliminating the necessity of paying a second premium for the latter.
The provision of “extra” benefits such as dental, vision, and hearing benefits
“Guaranteed Approval” during the Annual Election Period October 15th and December 7th and the option of changing your plan each January 1 as the plans and your needs change.
Premiums are not age-based and do not increase due to age as one gets older.
Seniors are inundated with seemingly endless television and radio commercials promoting Medicare Advantage plans ad infinitum. But while they drive home the advantages mentioned above, they virtually never mention the disadvantages or compromises that come with electing them over a Medicare Supplement policy. There are many reasons for this, but this is the one most relevant to you:
Medicare, like Social Security, is hemorrhaging dollars. Please don’t take it from me. Google it. Financial prognosticators project it will enter a default position by 2031. Medicare trustees say the Part A (Hospital and Skilled Nursing coverage) program will begin running deficits again in 2025, drawing down the trust fund until it depletes in 2031. After that date, the program will not bring in enough money to fully pay out Part A benefits. *(See Feature Article 2 below.)
Now, we all know our government will just tax us more, and our treasury will print enough more money to keep things going. But the bottom line is that Medicare is seeking any way of saving money and limiting its losses. The easiest way to do this is to lower its share of claims. The easiest way to lower its share of claims is to increase enrollment in Medicare Advantage plans relative to Medicare Supplement. And why is that?
Opposed to Supplement, Advantage plans . . .
1)Force the insured member to share in more expenses as the medical claims come in.
2) They influence the member to utilize a limited network of providers or pay a higher cost for not.
3) They subject the member to preauthorization of medical tests and procedures, often resulting in significant delays in treatment. *(See Feature Article 1, 2 and 3 below.)
4)Advantage plans that combine prescription drug coverage with medical coverage (MAPD plans) lock the member into a drug plan that may not provide the lowest total cost for drugs or cover them in the first place.
5)Once a member foregoes Medicare Supplement in favor of an Advantage plan beyond 12 months, they may find themselves locked into an Advantage plan—and out of a Medicare Supplement plan—due to preexisting medical conditions for the remainder of their lives.
One reason for these differences in how things are covered is that when a person elects Medicare Advantage, their benefits and administration are assigned to the insurance plan and company issuing it and away from Medicare. Medicare no longer plays a role in your coverage. As Advantage plans are allocated a limited amount of dollars per plan member, the companies will seek to limit expenditures. Recent adjustments in budgets for the plans will result in more of this. *(See Feature Articles below.)
And now, we learn that in addition to the increasing number of denials for tests and procedures by Advantage plans, Medicare is allocating less money to cover benefits, resulting in an actual reduction in benefits in 2025. Depending on the Medicare Supplement plan option (A-N) one elects, these compromises seldom, if ever, apply to their coverage.
All this being said, we get back to affordability and the reality that Medicare Supplement premiums will increase due to the member’s age as the member ages. This could bring me back to that coffee table where clients simply can no longer afford their premiums. While their costs for treatment may increase, some will need a lower premium to afford some type of coverage. Those people should know I offer Medicare Advantage plans from virtually every major carrier in one’s county or region. These include (among others) Aetna, Anthem, AARP Unitedhealthcare, BlueCross BlueShield, Cigna, Kelseycare Advantage, and Wellcare.
Regardless of your situation, I offer whatever product is appropriate and best suited to meet your Medicare-related insurance needs. When you work with me, I will be an advocate on your behalf. I represent you over the insurance company. Yes, I still have a little bit of social work in me.
Please get in touch with me. I am waiting to answer your questions and assist you with your coverage.
Hospitals’ Medicare Advantage problem hits an inflection point
Jakob Emerson – 5 April 2024
The tensions between hospitals and Medicare Advantage plans continue to grow. With the program hitting nearly 34 million enrollees in March, paired with recent policy moves by the federal government, the scene has been set for those relations to worsen.
“The relationship between hospitals and managed care is strained at best right now,” Chip Kahn, president and CEO of the Federation of American Hospitals, told Becker’s. “[Insurers] are finding every way to not pay for the care that Medicare beneficiaries should receive. I don’t know how the issue gets worse — we’re at a critical stage, and I think CMS is sending those signals.”
On April 1, CMS finalized a slight decrease in MA benchmark payments for 2025. The agency has also issued more strict prior authorization rules this year and cracked down on when MA plans must cover inpatient care.
The health insurance industry has said the new rates will “put even more pressure on the benefits and premiums” of MA beneficiaries, a warning that individual insurers have also issued in recent months.
“Payers know that they’re going to have to cut supplemental benefits, and premiums may even have to go up, but I wouldn’t want to be the first one to do it,” Scott Ellsworth, founder and president at Ellsworth Consulting, told Becker’s. Mr. Ellsworth is a former insurance executive, overseeing entire divisions at Centene, Optum and a BCBS plan throughout his career.
“Seniors have seen their benefits get better every year, but now we’re at an inflection point and the free lunch is over,” he said. “There is going to be a sharing of the pain. Providers have disproportionately shared the pain and now you’re seeing many of them say ‘enough is enough, we’re out.'”
In 2023, Becker’sreported on at least 15 hospitals and health systems nationwide that dropped some or all of their Medicare Advantage contracts. Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. Some systems have noted that most MA carriers have faced allegations of billing fraud from the federal government and are being probed by lawmakers over their high denial rates.
“It’s become a game of delay, deny and not pay,” Chris Van Gorder, president and CEO of San Diego-based Scripps Health, told Becker’s in September. “Providers are going to have to get out of full-risk capitation because it just doesn’t work — we’re the bottom of the food chain, and the food chain is not being fed.”
Scripps terminated MA contracts in January for its integrated medical groups, citing an annual loss of $75 million on its contracts with insurers.
In March, Bristol (Conn.) Health announced it was eliminating 60 positions, 21 of which are occupied and will result in layoffs. Its CEO, Kurt Barwis, laid blame on Medicare Advantage saying, “All the nice-to-haves are being taken out by the lack of insurance payment and the lack of reimbursement.”
In January, the Healthcare Financial Management Association released a survey of 135 health system CFOs, which found that 16% of systems are planning to stop accepting one or more MA plans in the next two years. Another 45% said they are considering the same but have not made a final decision. The report also found that 62% of CFOs believe collecting from MA is “significantly more difficult” than it was two years ago.
“Medicare Advantage net reimbursement right now is terrible for hospitals — our clients average about 85 cents on the dollar, and it’s only getting worse,” Mr. Ellsworth said. “MA is a race to the bottom, and I would argue that we’ve hit that bottom. Payers are going to struggle with this too, but no one wants to be the first to blink.”
Medicare Advantage denials increased almost 56% for the average hospital from January 2022 to July 2023, according to data from a joint American Hospital Association and Syntellis report. The denials and inconsistent reimbursement led to a 28% drop in hospital cash reserves.
Both Mr. Ellsworth and Mr. Kahn noted that it isn’t feasible for most health systems to completely walk away from Medicare Advantage, given that it now makes up more than half of the Medicare population. Instead, many hospitals are paring down contracts and looking for payer partners that align best with their financial objectives. Some systems are even exploring launching their own MA plan built in tandem with one insurer. Others have partnered with grocers or other health systems.
“We will ultimately pick a couple of partners going forward, and I think a lot of health systems are going to do this,” Will Bryant, CFO of Chapel Hill, N.C.-based UNC Health, told Becker’s in November. “They’re going to be the partners who act like partners and not who deny care in order to bolster their billions of dollars of quarterly earnings.”
Sachin Jain, MD, CEO of SCAN Group — one of the nation’s largest nonprofit Medicare Advantage companies — cautioned hospitals that dropping MA plans is a short-term trend that is “going to backfire in a big way for these large health systems.”
“You’re a nonprofit system saying you’re no longer going to accept the insurance that low-income people actually have,” he said. “We’ll see how that works out for you.”
Dr. Jain said any public policy program is going to create unintended consequences, adding, “What I would say to anybody who’s critical about the program is that you’re right, but let’s fix that.”
Former CMS Administrator Don Berwick, MD, toldBecker’s in February that the battle between hospitals and Medicare Advantage is a “manifestation of an underlying broken system in which everyone that gives care wants to give more, and everyone that pays for care wants to pay less.”
“To me, the untold story yet is about the physicians and nurses who don’t feel directly tied to ongoing Medicare Advantage trends, but they are certainly immersed in a changing financial landscape,” Dr. Berwick said. “As venture capital, private equity and ownership of healthcare by private interests increases, it changes their worlds, what it’s like to practice, their feelings about themselves, and the degrees of freedom they have to care for their patients. That chicken is going to come home to roost.”
Despite the tensions with hospitals, the MA program has bipartisan support in Congress and a 95% quality satisfaction rating among enrolled members in 2023. There are about 4,000 MA plans being offered this year nationwide, and MA members spend an average of $2,434 less on out-of-pocket costs and premiums per year compared to traditional Medicare enrollees.
“Medicare Advantage is very important, especially for low-income seniors,” Mr. Ellsworth said. “Hospitals need to acknowledge the reimbursement problem and proactively address their relationships [with payers] head-on.”
The fund covering Medicare‘s hospital-insurance benefits is now projected to run out of money in 2031, according to a new report by Medicare trustees.
This new insolvency date gives policymakers three more years than previously estimated to address impending financial setbacks that are facing the social safety net program, which provides health care benefits to tens of millions of Americans.
The ultimate insolvency date will likely change, the trustees say, due to difficulties in accurately projecting program expenditures. That leaves the exact timeline unclear for lawmakers to hash out a plan to mend Medicare’s finances, which could require an increase in taxes, a cut in benefits or a combination of both to keep benefits paying out in full.
What the report says
In a report released Friday, Medicare’s Board of Trustees provided the latest snapshot of the program’s finances. On the whole, Medicare is on sounder financial footing than indicated in last year’s trustee report, though financial shortfalls still loom.
Medicare hospital insurance benefits, aka Medicare Part A, are expected to fully pay out until 2031, a three-year improvement from the last trustee report.
Medicare Part B and Part D do not face insolvency, the report said, because they are funded separately — partially by premiums and general revenue from the U.S. Department of the Treasury. These benefits help cover typical health-insurance and prescription-drug expenses, respectively.
By contrast, Medicare Part A, which generally covers inpatient hospital care, skilled-nursing facility care, home-health care and hospice care, uses a separate reserve that’s funded by a 2.9% Medicare payroll tax. This is the trust fund at risk of insolvency.
In 2022, Medicare’s balance sheet looked better than previous years, the report shows. The hospital-insurance trust fund had a surplus of $54 billion, and Medicare overall brought in about $84 billion more than it paid out.
Nearly every year since 2008, the Part A trust fund has run a deficit, the report notes, with the exception of 2021 and 2022. The fund ran a steep shortfall in 2020 of more than $60 billion, largely because Medicare began making loans to health care providers to increase their cash flow as they grappled with the COVID-19 crisis. Then in 2021, providers began to repay Medicare, leading to the current surpluses.
The surpluses aren’t expected to last, however. Medicare trustees say the Part A program will begin running deficits again in 2025, drawing down the trust fund until it depletes in 2031. After that date, the program would not be bringing in enough money to fully pay out Part A benefits.
Key context
Medicare covered 65 million Americans last year. The vast majority of those people, about 88%, were 65 or older, though the program also provides health coverage to millions of disabled Americans.
Medicare — particularly Part A — has long faced financial issues. The nation’s changing demographic makeup is a big reason why. Because Medicare Part A relies on payroll taxes, it is more susceptible to insolvency when a growing share of the population is older, ultimately changing the worker-to-beneficiary ratio. In other words: less money coming in and more money going out. These demographic changes are also leading to insolvency issues for Social Security.
Compared to Social Security, projections for Medicare’s insolvency are less certain because it’s difficult for the trustees to accurately predict future health care expenditures. This can lead to some larger swings in the predicted insolvency date. By contrast to the trustee’s estimate, the Congressional Budget Office estimates the fund will remain solvent until 2033.
According to the nonprofit Center on Budget and Policy Priorities (CBPP), if Medicare Part A went insolvent, it would still be able to pay out almost all benefits. This leads some experts to call for tempered reactions to the newly projected insolvency date.
“Medicare does not face a financing ‘crisis’ and is not ‘bankrupt,’ as some critics charge,” tweeted Paul Van de Water, a senior fellow at the CBPP who specializes in Medicare. “Even if policymakers took no further action … tax revenues would still cover 89 percent of scheduled benefits” after the insolvency date.
Avoiding Medicare insolvency
Policymakers have several options to avoid impending insolvency headed for Medicare Part A. The trustees note two options that could immediately solve the issue:
The standard 2.9% payroll tax could be immediately raised to 3.52%, which would be enough to plug any financial shortfalls over the next 75 years.
In lieu of a tax increase, expenditures (read: benefits) would need to be reduced immediately by 13%, the trustees say.
Realistically, a combination of the two could work and the benefits cuts and/or tax increases could be implemented over a longer period of time.
Additionally, President Joe Biden released a plan last month to push the insolvency date back by 25 years.
The central change under the president’s plan would be a Medicare payroll tax increase on Americans earning more than $400,000.
Currently, earnings over $200,000 for individuals are taxed at 3.8% (while income under that amount is taxed at the standard 2.9% rate). These rates are split 50-50 between employees and employers.
The president’s plan introduces a new tier for income over $400,000, a tax rate of 5%.
The president’s Medicare proposal — part of a larger 2024 budget plan — is not expected to make it through the Republican-controlled House of Representatives.
Dozens of health systems ask CMS to crack down on Medicare Advantage Denials
Becker’s Hospital CFO Report
Rylee Wilson – Friday, March 22nd, 2024
Over 100 hospitals, health systems and providers signed on to a call for CMS to do more on Medicare Advantage denials.
Members of Premier, a healthcare services company, penned a letter to CMS administrator Chiquita Brooks-LaSure on March 21, requesting CMS collect more data on claims denied by Medicare Advantage plans and take enforcement action against plans not following the coverage rules set out by Medicare.
A survey of Premier’s member hospitals and health systems found 15% of claims to private payers are denied. A slightly higher portion of Medicare Advantage claims, 15.7%, are denied, according to the survey.
On average, hospitals spend $47.77 in administrative costs to appeal a denied Medicare Advantage claim, according to the Premier survey.
In the letter, the health systems asked CMS to monitor how much MA plans spent on direct patient care to address “potentially dire impacts on Medicare beneficiaries and providers.”
“It is imperative that CMS leverage its full authority to ensure that MA plans’ medical loss ratio (MLR) requirements for revenue used for patient care are satisfied in alignment with the benefits to which Medicare beneficiaries are entitled,” the providers wrote.
Dozens of health systems signed the letter, including CommonSpirit Health, Ascension, Advocate Health, AdventHealth and Providence.
The providers also asked CMS to bar MA plans from delaying or denying claims approved through electronic prior authorization and weight patient experience more heavily in its ratings of MA plans.
A growing number of hospital executives have criticized Medicare Advantage, often citing excessive prior authorization hurdles and delayed payments. A handful of systems have moved to drop the program entirely.
FEATURE ARTICLE 3
Nearly 15% of claims submitted to private payers are initially denied
Nearly 15% of medical claims submitted to private payers for reimbursement are initially denied, according to new survey data released Thursday.
Denied claims are more prevalent for high-cost treatments, with the average rejected charges at $14,000 and up, Premier Inc. reported. Medicare Advantage and other private payers eventually overturned more than half (54%) of denials, with the claims paid, but only after “multiple, costly rounds of provider appeals.”
The findings are from a national survey of hospitals, health systems and post-acute providers, conducted by the Charlotte-based healthcare improvement company.
“To address these potentially dire impacts on Medicare beneficiaries and providers, we urge CMS to stringently monitor MA plans’ reporting of expenditures on direct patient care,” Premier and 118 member organizations wrote in a March 21 letter to the head of the Centers for Medicare & Medicaid Services. “It is imperative that CMS leverage its full authority to ensure that MA plans’ medical loss ratio requirements for revenue used for patient care are satisfied in alignment with the benefits to which Medicare beneficiaries are entitled.”
Premier partnered with member hospitals to conduct the survey from October to December 2023. A total of 516 hospitals across 36 states, representing 52,123 acute care beds responded. Answers were based on claims submitted to private payers in 2022.
On average, hospitals and other providers incurred a cost of $43.84 per claim to fight denials. With insurers processing about 3 billion claims per year, this equates to $19.7 billion per year in expenses for these reviews. An average of about 3% of all claims denied included those that were already preapproved via prior authorization, Premier noted.
The continued burden from these delays and denials has impacted hospital finances. During the past year, average days of cash on hand at hospitals declined by 44 days or 17%. Meanwhile, days of cash on hand increased among insurers such as UnitedHealth Group (up 25.5% on average since 2019) and Cigna (24.4% on average).
The letter writers—who included numerous large health systems and other provider organizations—want CMS to take enforcement action against MA plans that “fail to abide by the coverage rules of Medicare.”
“Additionally, we note that CMS has moved away from holding MA plans accountable for [Consumer Assessment of Healthcare Providers and Systems] and other patient experience measures in recent rulemaking by reducing the weighting of patient experience and access measures in the Star Ratings program. We recommend that CMS return to its past policy of weighting patient experience and access measures more heavily in the MA Star Ratings methodology, empowering beneficiaries to hold their health plans financially accountable,” the letter stated.
The analysis does not specifically mention radiology services, but it mirrors ongoing problems imaging providers have had with prior authorization and the No Surprises Act (links to previous coverage below).
Everyone with Medicare Supplement knows the value and convenience it provides in allowing the policyholder to seek medical attention from any medical provider that sees Medicare patients. All hospitals see Medicare patients, so, heaven forbid, should we get cancer and want to go to MD Anderson Hospital in Houston—we may go directly there. And, depending on which Medicare Supplement plan we elect, we can be out of virtually nothing for our medical care.
The only real disadvantage to a Medicare Supplement plan is the premium. And it's not the first-year premium upon entering Medicare at age 65, but rather the premium in the ensuing years. This occurs because, as we age, each year, on our policy anniversary, the premium is usually increased to account for the additional risk an insurance company assumes to cover us as we age. The older we are, the more likely we are to generate medical insurance claims, and larger ones at that. Hence, the older we get, the more burdensome our premiums will become.
The only solution to that (while remaining insured)—other than to switch to a Medicare Advantage plan—is to re-shop our supplement plan. Typically, it does not behoove us to do this every year. Assuming our insurance company is ethical and competitive, the savings involved in moving to a more competitive plan won't be large enough to warrant the effort. But by the time we have experienced a second or third annual increase—it will be. In only a few states, is a Medicare Supplement policyholder allowed the right to move to a lower-cost plan and be guaranteed approval. This transition will be accomplished during that state's Open Enrollment Period. Texas has no Open Enrollment Period for Medicare Supplements. In Texas, Open Enrollment only applies to Medicare Advantage and Part D Drug Plans. In Texas, a Medicare recipient can apply for a new Medicare Supplement policy 365 days per year. Still, they must qualify based on their current health and health history. If their health is good, or their medical conditions are well controlled, they may be approved for the new and lower-cost plan. And this can be accomplished while maintaining equal benefits or even upgrading to superior benefits, if available.
If you are wondering if lower-cost Medicare coverage is available and considering applying for such—now is the time to do so. Brokers and agents, like myself, are currently in our slow period. This is because the government (Medicare) dictates when Medicare recipients may apply for a Medicare Advantage or Part D Drug Plan. That is each year between October 15 and December 7—the Open Enrollment Period for those products. Plans applied for during that period are guaranteed approval with a January 1 effective date. Brokers and agents who specialize in Medicare-related insurance products, like myself, begin studying and testing for national tests, which must be passed each fall in order to represent these plans in the coming calendar year, along with certifying (testing) with each insurance company whose product we want to represent. So from September, when most of us study and test, to the end of December, we are inundated with identifying our client's best plan options for the coming year and enrolling them in that product. Even with the best of staff, our market feels as though we are surrounded by "sharks in a feeding frenzy." Especially if we also assist Under Age 65 clients in obtaining Individual and Family health insurance with an overlapping Open Enrollment Period!
So—if you are at all considering obtaining a lower-cost Medicare Supplement plan—now—and the next three months—is the time to do so. I can scan the market to identify equal or superior benefits at meaningful premium savings. Sometimes a very meaningful 30% or more! Once I have done that, I will make the application process go as quickly and smoothly as possible. I charge no fee for my service, and you will be charged no more for the insurance plan than if you acquire it directly from the insurance company itself. You will not cancel your current coverage until we know you have been approved for all pre-existing conditions.
Please email or give me a call. I have been in the industry for 37 years and am not going anywhere. I enjoy what I do, and that is helping others find their best medical coverage at the lowest possible cost.
*(Please see feature article 1 below on prescription drug shortages and feature article 2 on Medicare Advantage Claim Denials.)
D. Kenton Henry
Office: 281-367-6565 Text my cell 24/7: 713-907-7984 Email: Allplanhealthinsurance.com@gmail.com
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FEATURE ARTICLE 1
Drug price caps in Inflation Reduction Act exacerbating shortages, Gottlieb says . . .THE HILL
BY JULIA SHAPERO - 05/21/23 4:58 PM ET
Former Food and Drug Administration (FDA) Commissioner Scott Gottlieb
Former Food and Drug Administration (FDA) Commissioner Scott Gottlieb said on Sunday that drug price caps in the Inflation Reduction Act are exacerbating drug shortages.
"The features under the Inflation Reduction Act will exacerbate this problem, because it'll prevent these generic manufacturers from being able to take price increases," Gottlieb, who now serves on the board of Pfizer, told CBS' "Face the Nation."
"For example, if they enter a market for the first time, or they spend a lot of money upgrading a facility to be compliant with state-of-the-art regulations, they're not gonna be able to take a price increase to recoup some of those costs," he added. "So, it's going to come out of their own pocket."
Gottlieb said that sterile injectable drugs are particularly susceptible to shortages, suggesting that they should be carved out of the Inflation Reduction Act.
"The reimbursement for these drugs under government programs has been driven down very low, something above the marginal cost of manufacturing the drugs, and that's fine when it comes to a pill form drug where there's not a lot that can go wrong."
"But when it comes to an injectable drug, you need to leave a margin in so people can reinvest in manufacturing facilities, make sure they're high quality," he added. "They haven't done that, and things go wrong, and it results in shortages."
A March report from the Senate Committee on Homeland Security and Governmental Affairs found that there were more than 295 active drug shortages at the end of 2022, marking a five-year high.
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FEATURE ARTICLE 2
SENATORS PRESS MEDICARE ADVANTAGE INSURERS OVER CLAIMS DENIALS
FIERCE HEALTHCARE MAY 19, 2023
By Paige Minemyer
There were no insurers represented on the hearing panel, and the senators instead heard from multiple policy experts, the Office of Inspector General and the widow of a patient who was harmed by care denials and delays. (Getty Images/designer491)
Pharmacy benefit managers weren't the only ones on the hot seat in Congress this week.
The Senate's Permanent Subcommittee on Investigations put Medicare Advantage (MA) plans on notice Wednesday, demanding answers for claims denials. Chairman Richard Blumenthal, D-Connecticut, said in an opening statement during the hearing that the committee sent letters to the three largest MA plans—UnitedHealthcare, Humana and Aetna—seeking documentation on how they make decisions around claims denials.
Blumenthal said these coverage denials have become commonplace for many MA enrollees.
"These denials have become so routine that some patients can predict the day on which they will come," he said.
He added that "there is growing evidence" pointing to MA plans using artificial intelligence and data algorithms in making denials, rather than relying on feedback from physicians or other clinical experts. A recent investigation from Stat found that these tools are taking on an increasing role in coverage decisions, though there is limited oversight and transparency
Blumenthal said the Department of Health and Human Services Office of Inspector General (OIG) has also identified a "large number of cases" where MA insurers refused to authorize services that met coverage requirements under Medicare. For example, a cancer patient seeking a routine scan to determine whether the disease had spread was held up by their insurer for a month, and another payer refused to cover a walker for a patient as they had already received a cane.
"In each of these cases, the insurer's decision overlooked the treating physician's assessment of what their patient needed," Blumenthal said.
There were no insurers represented on the hearing panel, and the senators instead heard from multiple policy experts, OIG and the widow of a patient who was harmed by care denials and delays. Megan Tinker, chief of staff at OIG, said in her submitted statement that in 2018, MA plans denied 1.5 million prior authorization requests, about 5% of the total. In addition, they rejected 56.2 million payment requests, or 9.5%.
Tinker said that between 2014 and 2016, MA plans overturned their own coverage denials 75% of the time when a member or provider appealed the decision. OIG also found that 13% of coverage denials were for services that met Medicare's coverage rules.
Tinker noted in her opening remarks that the program has grown rapidly over the past several years, and enrollment in MA now accounts for more than 50% of total Medicare enrollment.
"Fast growth has increased vulnerabilities and the need for robust program integrity measures," she said. "OIG work has demonstrated that the risk of waste, fraud and abuse in managed care are significant."
Jean Fuglesten Biniek, Ph.D., associate director of the Program on Medicare Policy at KFF, noted in her submitted remarks that the way payments work in MA may create financial incentives for insurers to deny care. It costs MA plans 83% of what it costs traditional Medicare to cover key services, while they are paid 106% of what the Centers for Medicare & Medicaid Services pays in fee-for-service Medicare, according to data from the Medicare Payment and Advisory Commission.
This means plans retain $2,300 above the cost of paying for a member's care, she said.
She added that there are also significant gaps in the data around prior authorization in MA; for example, there is no information about what services are denied or whether there are certain beneficiaries who are denied care more often. There is also a dearth of detail on how long it takes MA plans to respond to these requests.
"As a result, policymakers don't have the information they need to conduct oversight," she said.
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