Why Agents Should be Selling Cancer, Heart Attack, and Stroke Insurance
As a Medicare agent it can be tricky to explain to a client who already has Medicare and Medicare Supplement insurance why they may need additional ancillary insurance coverage.
This gets even more complicated when you’re trying to discuss illnesses that they may find difficult to talk about, or as the statistics imply, have a high likelihood of being diagnosed with.
Cancer, Heart Attack, and Stroke are some of the leading causes of death among men and women. Medicare managed Care (MAPD) and Medicare Supplements will offer some solutions to these problems, but they won't alleviate ALL of the costs associated with being diagnosed with one of these major illnesses.
If your goal is to educate your clients and provide solutions for all of life’s unexpected occurrences, then every agent should have some ancillary options in their quiver to ensure you’re providing the best possible options and mitigating as much risk as possible for your clients.
Is there a need for Cancer, Heart Attack and Stroke Insurance?
Thirty years ago Cancer Heart and Stroke Insurance didn’t exist. Most people just weren’t expected to survive many of the diseases that are survivable today, so they may be completely unfamiliar with these options or how they work.
With more people surviving these types of illness, more and more survivors of a major illness are facing financial difficulties because of them. It’s not just the lifesaving treatment that needs to be considered, but a number of possible financial hardships that may come out of the situation.
When people get sick they may soon realize that the expenses incurred due to lost work, continuing treatments and ancillary needs that weren’t considered, quickly become a mountain of debt.
Without trying to push the fear angle, it may be enough to simply review the statistics and help them realize the sobering fact that many people will need this coverage at some point in their life.
Let’s take a look at the statistics that support that need.
Heart Attack: Number one cause of death for men and women. 3
Cancer: Second most common cause of death. 1
Stroke: Third leading cause of death in women and fifth in men. 5
Survival Rates: Good News. Survival rates for all 3 illnesses are increasing.
The potential costs related to cancer, heart attack and stroke.
Cancer, heart attack and stroke are among the top 5 causes of new and existing long term disability claims. 9
This is why it is imperative to have additional insurance so you don't burn through your savings and 401K just to stay afloat and tackle the problem.
Costs for surgeries and procedures are expensive enough, but when you begin adding in the cost of missing work, travel to and from specialized facilities, and lodging is where people can get themselves in a real bind that could possibly lead to excessive spending or bankruptcy, if not properly mitigated through insurance.
Out of pocket costs of cancer, heart attack or stroke.
How Can a Lump Sum Policy Help?
While Medicare, Medicare Supplement Plans or Medicaid may cover most of your direct hospital costs, the other costs can vary depending on your illness and your personal situation. That’s where a lump sum payment works so well.
A lump sum benefit is paid directly to you or someone you designate, regardless of other health insurance coverage. A lump sum payment is distributed when you are diagnosed and can be used to help pay for whatever you choose, whether it’s medical expenses, groceries, a mortgage, electric bill, etc.
It covers the gap left by other policies and quickly gives you 100% of the selected benefit. This provides the additional coverage needed to withstand the financial impact of diagnosis.
There is no one plan that can cover everything, but the right plans do exist to create the best coverage for an individual based on their needs. A Cancer, Heart Attack and Stroke policy can provide much needed coverage when illness expenses extend outside those directly related to the treatment.
People’s financial well-being doesn’t need to suffer because of the total cost involved with a major illness. Reviewing their needs, risks and options is the first step to helping them put together a complete insurance coverage plan.
The more wrap around policies/coverage you offer to your clients the more secure they can feel knowing they have a “Blanket” of protection to cover them, in case something unexpected occurs.
1 American Cancer Society, Cancer Facts & Figures 2017, cancer.org
2 Pediatric Cancer Research Foundation Annual Report 2015, pcrf-kids.org
3 American Heart Association, American Stroke Association, Heart Disease and Stroke Statistics 2018 At- A-Glance
4 Centers for Disease Control and Prevention, Heart Disease Facts 2017, cdc.gov
5 National Stroke Association, 2017 Facts, stroke.org
6 Cancer costs may rise 27% by 2020, John Commins, HealthLearers Media, January 2011
7 Stroke Fact Sheet, CDC and Prevention, cdc.gov
8 Top Ten Things to Know About Heart Disease and Stroke Statistics, American Heart Association heart.org,
9 https://www.uphelp.org/Emmet%20Pierce, download 8/29/18
Medicare Blog | Medicare News | Medicare Information
76,000,000. That hefty number – 76 million – is the number of Baby Boomers living today in the United States. As an agent, it’s important to consider how annuities can be an important part of a Boomer’s retirement. There are solid reasons to focus on selling to this particular group. Boomers are at the perfect age to benefit from the consistent income stream annuities provide. And, put simply, no other financial products have been developed at the moment that offer the unique value for investment that annuities do. What should you keep in mind as you talk to your clients about which financial vehicles to choose? In regard to annuities, there are numerous benefits: safety, flexible time frame, tax deferral and shorter surrender charge periods.
You have likely already considered the benefits that annuities can offer to boomers, so it may seem like a novel idea at first. But there are solid reasons to focus on selling to this particular group. Boomers are at the perfect age to benefit from the consistent income stream that annuities can provide, among other benefits I’ll mention below. And, put simply, no other financial products have been developed at the moment that offer the unique value for investment that annuities do. As a result, annuities shouldn’t be overlooked as part of your selling strategy.
It’s important to remember that clients are looking to you to provide an asset accumulation approach that is reliable and will succeed no matter what happens in the stock market. Thus, your approach should include safe options that offer clients what they want most: stability. Because of this, annuities are a strong option that will earn clients’ trust and grow your business at the same time.
Why Baby Boomers?
While annuities offer benefits to clients no matter what their age, boomers are at the stage in their life where they are demanding greater principal protection. This growing demand largely stems from the fact that they are coming closer to the end of their working years, thus they are becoming more financially conservative and can’t afford to lose what savings they’ve accumulated. With their preferences shifting, there is a growing convergence between what they want and what annuities offer.
Thus, more of their asset allocation should be to safer products such as annuities. As they approach and enter retirement, the question becomes what to do with the growing portion that they want to keep safe. Boomers are major investors in mutual funds, but the unpredictable nature of the markets are likely causing increasingly cautious baby boomers to think twice about their existing asset allocation, one that can lead to losses during periods of market volatility.
A major benefit of fixed and indexed annuities is that they are not directly tied to the stock market and are protected from downward swings. This makes annuities an increasingly attractive option for your boomer clients, since they are not susceptible to loss when the market is in turmoil. With interest rates higher now than they were a few years ago, annuities give clients a solid interest rate, along with the safety and protection they seek. Money market funds generally can’t keep up with the interest rate of an annuity, and while bond mutual funds sometimes offer adequate interest rates, they don’t provide the security or protection annuities do in case of market turmoil. Bond mutual fund balances fluctuate daily, whereas annuity values do not.
Approaching the Annuities Conversation
What should you keep in mind as you talk to your clients about which financial vehicles to choose? In regard to annuities, there are numerous benefits.
For clients who are becoming uncomfortable risking their money in the stock market, annuities provide a stable solution.
Annuities lock in growth without constant monitoring. Annuities offer a simple and safe option that doesn’t require constant upkeep. They guard against the psychological shock of market dips and having to watch a nest egg evaporate with every market move. The end result: annuities are simply one of the best ways for baby boomers to strengthen a portfolio that needs protection and stability.
The Bold Goal program has improved population health for Humana Medicare Advantage members since 2015.
By Jessica Kent – HealthPayerIntelligence – April 25, 2019
Medicare Advantage members living in Humana’s seven original Bold Goal communities have seen an improvement in population health, with these individuals experiencing a 2.7 percent reduction in their Unhealthy Days since 2015, according to Humana’s 2019 Bold Goal Progress Report.
Humana’s Bold Goal program aims to improve the health of the communities it serves 20 percent by 2020 and beyond. Since the program began, Humana has used the CDC’s health-related quality of life measurement, known as Healthy Days, to track and trend progress.
Healthy Days takes the whole person into account by measuring self-reported physically and mentally unhealthy days over a 30-day period. The healthy days measurement aligns with the Bold Goal’s aim to address individuals’ physical well-being, along with the social determinants of health, such as food insecurity, loneliness, and social isolation.
San Antonio, the first Bold Goal community, is halfway to its 20 percent healthier goal, with members in this area experiencing a 9.8 reduction in unhealthy days. Humana worked with community organizations, physician practices, and others to screen 500,000 members, employees, and patients for social determinants of health in 2018, leading to the gains in everyday wellness.
The report stated that on average, a Humana Medicare Advantage member who is food insecure may experience 26.6 unhealthy days, while Medicare Advantage members who experience loneliness may see an average of 24.4 unhealthy days.
Humana noted that of those experiencing food insecurity, 66 percent have to choose between food and medical care. Food insecure members are also 50 percent more likely to be diabetic and 60 percent more likely to have congestive heart failure.
Those experiencing loneliness and social isolation are four times more likely to be re-hospitalized within a year of discharge, and 64 percent more likely to develop dementia.
These non-clinical influences can also have detrimental effects on mental health. For those Bold Goal communities that did not see significant improvements in population health, Humana stated that one of the contributing factors was a higher number of mentally unhealthy days versus physically unhealthy days.
“Throughout the country, we are seeing a rise in mental health concerns as well as loneliness and social isolation, especially in our aging adult population. In fact, since the 1980s, the rates of loneliness in adults over the age of 45 have doubled,” said Caraline Coats, Vice President of Bold Goal and Population Health Strategy.
“With the knowledge that mentally unhealthy days and new membership are driving many of our results, several of our Bold Goal communities are looking at ways to address this growing need. We’ve already seen efforts emerge in Tampa Bay, New Orleans and Louisville.”
In Louisville, Kentucky, the Louisville Health Advisory Board’s Behavioral Health Committee trained more than 2200 volunteers in emergency response techniques designed to prevent suicide.
The Tampa Bay Bold Goal Health Collaborative has also been focused on addressing the behavioral health needs of members, partnering with mental health professionals, faith-based organizations, and other stakeholders.
In addition to the social determinants of health, the Bold Goal program aims to improve population health by managing chronic conditions. Nearly 77 percent of Americans aged 65 or older are living with two or more chronic conditions, the report said, making chronic disease management imperative for overall health.
“A large part of Humana’s focus is to help people living with multiple chronic conditions improve their health, which requires an integrated approach,” said Bruce D. Broussard, Humana’s President and CEO.
“The Bold Goal is not just our north star; it’s a quantitative way for us to address the holistic needs of multiple populations, and to measure our progress. This year’s report reflects our track record of success in managing chronic conditions over time. Given current demographic trends, we expect to see continued demand for a support structure that addresses social needs, along with clinical ones.”
In Knoxville, Tennessee, the Knoxville Health Advisory Board has focused on addressing diabetes, which has led to positive trends for low-income Humana Medicare members. These individuals experienced a 2.9 reduction in unhealthy days in 2018.
Going forward, Humana and its Bold Goal communities will continue to address the many factors that influence well-being, with an understanding of the important roles physical, mental, and social elements play in members’ overall health.
“The social barriers and health challenges that our Medicare Advantage members and others face are deeply personal,” said William Shrank, MD, Humana’s Chief Medical Officer.
“This requires us to become their trusted advocate that can partner with them to understand, navigate and address these barriers and challenges. With Healthy Days as our barometer, we are able to track and trend population health, measure outcomes and triage members in unique ways to the resources they need.”
Letter to State Medicaid Directors invites states to partner with CMS to improve outcomes for those dually eligible for Medicare and Medicaid
Today, the Centers for Medicare & Medicaid Services (CMS) sent a letter to State Medicaid Directors inviting states to partner with CMS to test innovative approaches to better serve those who are dually eligible for Medicare and Medicaid. Many of the 12 million dually eligible beneficiaries have complex healthcare issues, including multiple chronic conditions, and often have socioeconomic risk factors that can lead to poor outcomes. CMS and states spend over $300 billion per year on the care of dually eligible individuals, yet still do not achieve acceptable health outcomes. Today’s letter opens new ways to address those complex needs, align incentives, encourage marketplace innovation through the private sector, lower costs, and reduce administrative burdens for dually eligible individuals and the providers who serve them.
“Less than 10% of dually eligible individuals are enrolled in any form of care that integrates Medicare and Medicaid services, and instead have to navigate disconnected delivery and payment systems. This lack of coordination can lead to fragmented care for individuals, misaligned incentives for payers and providers, and administrative inefficiencies and programmatic burdens for all,” said Administrator Seema Verma. “We must do better, and CMS is taking action.”
As one of CMS’ Strategic Priorities for 2019, we are redoubling efforts to better serve older adults and people with disabilities dually eligible for Medicaid and Medicare. Our goal is to bring shared accountability for creating a more seamless experience for beneficiaries and providers across the two programs, while ensuring that the program’s incentives are aligned and pointed toward lower cost and better outcomes.
Approaches discussed in the State Medicaid Directors letter include:
Today’s letter complements a State Medicaid Director Letter CMS released in December 2018 that highlighted ten opportunities to improve care for dually eligible individuals, including using Medicare data to inform care coordination and program integrity initiatives, and reducing administrative burden for dually eligible individuals and the providers who serve them. The opportunities in today’s letter, together with the Primary Cares Initiative, present an array of options for transforming care delivery.
The State Medicaid Director letter is available through Medicaid.gov at: https://www.medicaid.gov/federal-policy-guidance/downloads/smd19002.pdf.
A letter from Administrator Verma to state Governors is available here: https://www.cms.gov/sites/drupal/files/2019-04/04-24-2019%20Governor%20Letter.pdf
A blog by Administrator Verma, titled "Better Care For People Dually Eligible For Medicare And Medicaid," is available in Health Affairs here: https://www.healthaffairs.org/do/10.1377/hblog20190423.701475/full/
By Allison Bell – ThinkAdvisor – April 24, 2019
Agents who focus on selling Medicare supplement insurance seem to be a lot more likely to cross-sell many other life, health and annuity products. Agent Link found that 29% of insurance agents surveyed are active in the Senior Market: about one-third of them sell Medigap, and about one-fifth sell Medicare Advantage. Both types of agents were equally likely to sell indexed universal life (IUL) policies: 27% of Medigap specialists and 27% of M/A sell IUL. About 65% of Medigap agents sell permanent life and term life and 8% sell variable annuities. Only 47% of M/A specialists said they sell term life, and just 40% offer permanent life.
WASHINGTON (AP) — The financial condition of the government’s bedrock retirement programs for middle- and working-class Americans remains shaky, with Medicare pointed toward insolvency by 2026, according to a report Monday by the government’s overseers of Medicare and Social Security.
It paints a sobering picture of the programs, though it’s relatively unchanged from last year’s update. Social Security would become insolvent in 2035, one year later than previously estimated.
Both programs will need to eventually be addressed to avert automatic cuts should their trust funds run dry. Neither President Donald Trump nor Capitol Hill’s warring factions has put political perilous cost curbs on their to-do list.
Total Medicare costs are expected to grow from 3.7% of gross domestic product in 2018 to 5.9% by 2038, according to a new report from the Social Security and Medicare boards of trustees released Monday.
The report also projected that Medicare's Federal Hospital Insurance Trust Fund that covers Part A will run out by 2026, which the trustees predicted last year.
Since 2008, national health expenditure growth has been below historical averages, the report said. Medicare costs will increase gradually after 2038 to about 6.5% of GDP as the rolls grow and baby boomers enter retirement age.
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Medicare General Enrollment Period (GEP)
As a Medicare agent one of the best ways to show your value is by staying on top of important events that may affect your clients.
If you have clients that weren’t automatically enrolled in Medicare, and missed their IEP, the good news is - they can still apply for Medicare Part A and/or Part B during the Medicare GEP. The bad news is, they may incur a penalty for a late enrollment.
There is no notice sent when someone turns 65 that says “It’s time to enroll in Medicare and if you don’t, you could have problems if you sign up later.” That’s where agents can step in and become known as a valuable resource for your senior clients.
When is the General Enrollment Period?
Medicare provides a General Enrollment Period (GEP) every year for people who missed signing up when they were first eligible. It’s like make-up time for Medicare enrollment.
The general enrollment period (not to be confused with the Open Enrollment Period) runs from January through March. But coverage doesn’t begin until July 1st of the same year.
If you didn’t sign up for Part B and recognize your error in March, you can be insured in July. If you figure it out in April, however, you can’t enroll until the following January and coverage wouldn't begin until July of the following year.
That could mean a coverage gap of well over a year, depending on when you discover the problem.
Here are some key points to remember:
Late Enrollment Penalties:
Last year, nearly 700,000 Medicare beneficiaries were paying Part B penalties, according to the Centers for Medicare and Medicaid Services.
If you can make your clients aware before they miss their IEP, you could help them avoid alot of frustration and money down the road.
Medicare Part A Premium Penalty
Part A is premium free if you or your spouse worked and paid taxes for at least 10 years. If you have to pay a premium, the penalty for late enrollment is 10%.
The Part A premium penalty is charged for twice the number of years you delay enrollment. If you wait 2 years, for example, you would pay the additional 10% for 4 years (2 x 2 years). The penalty applies no matter how long you delay Part A enrollment.
Medicare Part B Premium Penalty
The penalty for late enrollment in Part B is an additional 10% for each 12-month period that you delay it.
Let’s say your Initial Enrollment Period ended September 30, 2010, for example. Then you enroll in Part B during the General Enrollment Period in March 2013. Your late enrollment penalty would be 20% of the Part B premium, or 2 x 10%. This is because you waited 30 months to sign up, and that time period included 2 full 12-month periods.
In most cases, you have to pay the penalty every month for as long as you have Part B. If you’re under 65 and disabled, any Part B penalty ends once you turn 65 because you’ll have another Initial Enrollment Period based on your age.
Medicare Part D Premium Penalty
The penalty for late enrollment in a Part D plan is 1% of the average Part D premium for each month you delay enrollment. You pay the penalty for as long as you’re enrolled in a Medicare Part D plan.
You may delay enrolling in Medicare Part D without penalty if you qualify for Extra Help or have creditable drug coverage. If it’s been more than 63 days since you’ve had creditable coverage, then the penalty may apply.
Thanks for reading, and we hope you found this reminder helpful.
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The CMS’s recent announcement of increased flexibility for Medicare Advantage plans to offer supplemental benefits (benefits not covered under Parts A or B) are complicated. Beginning in 2020, M/A plans may offer chronically ill enrollees supplemental benefits not necessarily health-related but reasonably expected to improve or maintain health and function. CMS provided the following examples of supplemental benefits that would qualify as primarily health related:
These changes are incorporated into the 2020 Medicare Advantage and Part D Rate Announcement and Final Call Letter. Your supervisors will provide details and elaboration of new M/A plans’ benefits as the evolution of plans’ components continues.
A number of Democratic proposals call for eliminating private health insurance and replacing it with a universal Medicare plan, claiming it would help reduce administrative inefficiencies in the health-care system. Most recently, Sen. Bernie Sanders of Vermont unveiled a bill that would create a government-run system to provide health insurance for all Americans. Freshman Rep. Alexandria Ocasio-Cortez is pushing a similar plan.
Wichmann, who rarely discusses politics, told investors on a post-earnings conference call Tuesday such measures would "surely jeopardize the relationship people have with their doctors, destabilize the nation's health system and limit the ability of clinicians to practice medicine at their best."
"And the inherent cost burden would surely have a severe impact on the economy and jobs — all without fundamentally increasing access to care," he added.
The executive noted that health costs have grown less quickly than overall inflation for 16-straight months, saying "it has lessened considerably due to better management of price inflation and earlier and more effective management of care in lower cost settings."
Despite concerns from UnitedHealth, public support for a single-payer system has grown. According to a survey from the Kaiser Family Foundation last month, 56% of respondents supported a national health plan in which all Americans would get insurance from a single government plan, versus 39% who said they oppose it.
Health care has been the worst-performing sector in the stock market this year, rising by just 4.17% as of Monday's close, significantly lagging the broader market indexes. The Dow Jones Industrial Average is up 13.35% over the same period, and the S&P 500 is 16.12% higher.
The biggest decliners have been from insurers, which are under threat from "Medicare for All" proposals. Investors are also watching the Trump administration's legal challenge to former President Barack Obama's signature health insurance law, the Affordable Care Act.
A federal appeals court in New Orleans said last week that it will hear arguments in July on a lawsuit backed by President Donald Trump to overturn Obamacare. Dismantling the health-care law would lead to 32 million more uninsured people in the U.S. by 2026, according to an estimate from the Congressional Budget Office.
Earlier Tuesday, UnitedHealth reported first-quarter earnings and revenue that beat Wall Street's expectations. It was driven by strength in its pharmacy benefit management business and higher enrollment for its health plans.
The industry bellwether, which is the first health insurer to report quarterly results, also raised its full-year adjusted earnings forecast to between $14.50 and $14.75 per share from its prior projection of $14.40 to $14.70 a share.
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The 2020 payment updates will increase competition among Medicare Advantage and Part D health plans
By Jessica Kent – HealthPayerIntelligence – April 9, 21019
CMS finalized new Medicare Advantage and Part D payment policies for 2020 that will increase competition among health plans, leading to higher quality care at lower costs.
The changes will increase plan choices and benefits, enabling seniors to choose Medicare Advantage plans that are offering supplemental benefits tailored to their specific needs. The updated policies will also give chronically ill patients with Medicare Advantage the option of accessing a range of benefits that aren’t necessarily health-related, but can improve or maintain the overall health of beneficiaries.
These benefits may address the social determinants of health for beneficiaries with a chronic disease. For example, more Medicare Advantage enrollees may now receive meal delivery, transportation for non-medical needs like grocery shopping, and home environment services.
For beneficiaries with asthma, a Medicare Advantage plan could cover home air cleaners or carpet shampooing to reduce irritants that cause asthma attacks. Plans could also cover healthy food or produce for enrollees with heart disease, or education programs for those with diabetes.
“Today’s changes give plans the ability to be innovative and offering benefits and services that address social determinants of health for people with chronic disease,” said CMS Administrator Seema Verma. “With Medicare Advantage enrollment at an all-time high, plans need greater flexibility in offering benefits that they focus on preventing disease and keeping people healthy.”
The new policy updates will also include actions to help curb the opioid epidemic. Medicare Advantage plans can now offer targeted supplemental benefits to beneficiaries, as well as cost sharing reductions for patients with chronic pain. With the new policies, CMS is also encouraging Part D plans to offer at least one opioid-reversal agent on a lower cost-sharing tier.
CMS’s past efforts to reduce opioid use have had positive results. The agency reports that between 2010 and 2017, its overutilization policies have led to a 14 percent decrease in the share of Part D beneficiaries using opioids.
CMS first proposed these policy changes in January 2019, aiming to expand coverage opportunities for beneficiaries.
“CMS is committed to modernizing Medicare and our top priority is to ensure that seniors have more choices and affordable options in receiving their Medicare benefits,” Verma said at the time.
“Medicare Advantage enrollment is at an all-time high as more and more seniors are choosing to enroll in private Medicare health and drug plans, and we need to maximize competition by providing plans the flexibility to meet patients’ needs.”
The new updates will expand on last year’s Medicare Advantage and Part D policy changes. Released in April 2018, these policy changes expanded the health-related benefits Medicare Advantage plans could offer, with benefits mainly supporting the daily maintenance of health.
Because of these changes, Medicare Advantage plans can now offer supplemental benefits that aren’t covered under Parts A and B, if these benefits compensate for physical impairments, diminish the impact of injuries or health conditions, or reduce avoidable emergency room utilizations.
The 2020 policy changes will enable Medicare Advantage plans to tailor benefits to suit beneficiaries’ needs and combat the opioid crisis, which will become increasingly important as Medicare Advantage and Part D plan enrollment continues to grow.
“Medicare Advantage remains a popular choice among beneficiaries and has high satisfaction ratings. Average Medicare Advantage premiums are at their lowest in
six years, Part D premiums are at their lowest in three years, and plan choices have increased,” CMS concluded.
“Today’s announcement builds in additional flexibilities that will continue to increase choice and competition among Medicare health and drug plans.”
Access to telehealth services for seniors got another boost Friday when the Centers for Medicare & Medicaid Services said it would allow private Medicare Advantage plans to offer additional access to virtual doctors in their basic benefit packages.
The so-called final rule will bring new benefits to seniors in 2020 as part of their Medicare Advantage plans. Such coverage is growing rapidly and expected to account for half of Medicare beneficiaries in the coming years, some analysts say.
“Historically, Medicare Advantage plans have been able to offer more telehealth services, compared to Original Medicare, as part of their supplemental benefits,” the Centers for Medicare & Medicaid Services (CMS) said Friday. “But with the final rule, it will be more likely that plans will offer the additional telehealth benefits outside of supplemental benefits, expanding patients’ access to telehealth services from more providers and in more parts of the country than before, whether they live in rural or urban areas.”
It could be a huge boon to companies like American Well, MDLive and Teladoc and an array of startups getting into the business of offering access to physicians and patients via smart phone, tablet or computer. Employers and private insurers are already embracing the trend as a way to make healthcare more convenient and avoid costly and unnecessary trips to the emergency room or a more expensive physician’s office.
"This is a bold and important move by CMS, signaling to the rest of the healthcare system that telehealth based care is simply another form of care and should be treated as such,” MDLive’s chief medical officer and executive vice president of product strategy, Dr. Lyle Berkowitz said. “This is a rare win for providers, patients and payors.”
Increasingly popular Medicare Advantage plans contract with the federal government to provide extra benefits and services to seniors, such as disease management and nurse help hotlines, with some even providing vision and dental care and wellness programs. Medicare Advantage enrollment is projected to rise to 38 million, or 50% market penetration, by the end of 2025, L.E.K. Consulting projects.
“With these new telehealth benefits, Medicare Advantage enrollees will be able to access the latest technology and have greater access to telehealth,” CMS Administrator Seema Verma said Friday in a statement. “By providing greater flexibility to Medicare Advantage plans, beneficiaries can receive more benefits, at lower costs and better quality.”
Introduction and Summary
In 2017, Medicare Rights staff and volunteers addressed more than 15,000 questions and issues through the organization’s national helpline. In addition, over 2.8 million questions were answered for people with Medicare, their caregivers, and professionals serving them through Medicare Interactive, Medicare Rights’ free and independent online reference tool thoughtfully designed to help older adults and people with disabilities navigate the complex world of health insurance. This report will feature select helpline trends and highlight the most commonly searched for Medicare Interactive answers, providing a glimpse into the information and coverage needs of Medicare beneficiaries and their families.
As in previous years, helpline callers and users of Medicare Interactive were geographically and socioeconomically diverse, and needed help with a wide array of complex Medicare-related issues. Medicare Rights served clients in all 50 states. Approximately 30% of helpline callers were living on incomes of less than $19,000 per year. This number includes people dually eligible for Medicare and Medicaid, who represented 10% of all callers. Caregivers helping to resolve issues and asking questions for family members accounted for 20% of helpline callers. And around 25% of helpline callers were under 65 and eligible for Medicare due to disability. Medicare Rights has less robust demographic data on users of Medicare Interactive but knows that these users represent both beneficiaries and the professionals serving them, and the most popular sections in 2017 included one on Medicare-covered services and one that introduces Medicare eligibility and coverage topics.
Medicare Rights produces this report so that advocates, policymakers at the Centers for Medicare & Medicaid Services (CMS) and the Social Security Administration (SSA), and other stakeholders can better understand the needs of beneficiaries and work toward greater accessibility and affordability in Original Medicare and Medicare Advantage. For instance, in order to streamline and increase consumer awareness around Part B enrollment, the Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act, supported by Medicare Rights and further discussed in this report, was introduced in Congress in 2017. In 2018, additionally, Medicare Rights led advocacy efforts with CMS to extend the Medicare Part B time-limited equitable relief opportunity for Medicare beneficiaries who are enrolled in Marketplace health insurance instead of Medicare. Medicare Rights applauds CMS for extending and providing this relief opportunity through 2019 and beyond for those eligible in 2019 or prior years.
Around two-thirds of Americans receive their Medicare benefits through Original Medicare, and it is critical to protect Original Medicare as an important coverage option, even while Medicare Advantage may be the right choice for some beneficiaries. Medicare Rights expressed its concerns with CMS education and outreach materials prepared for the 2018 Medicare Annual Coordinated Election Period, which many perceived promoted Medicare Advantage over Original Medicare. CMS listened to Medicare Rights’ and other advocates’ concerns, and the final version of the 2019 “Medicare & You” handbook—the primary educational resource for those new to Medicare—was more balanced and accurate. Medicare Rights hopes that additional recommendations made in this report to increase Medicare’s responsiveness to beneficiary needs will be similarly heeded and acted on.
Through the program – which targeted at both Medicare Advantage beneficiaries and commercial members – Humana will support better care coordination and health outcomes through financial incentives.
The insurer said it will provide compensation for better care navigation based on quality and cost metrics across various parts of the patient journey ranging from inpatient admissions, ED visits, prescription drugs, diagnostics and radiology.
Humana lists 16 providers as inaugural participants in the program including multiple members of The US Oncology Network, along with health systems and practices like Cincinnati-based Tri Health and Kentucky’s Baptist Health Medical Group.
While the CMS Innovation Center has developed its own Oncology Care Model, the program is focused on episodes of care surrounding chemotherapy administration.
Humana is hoping to improve general cancer care for patients over the period of a year by emphasizing more face time between physicians and patients, access to proactive health screenings and the increased use of data analytics to better coordinate care around patients.
The new oncology program is the payer’s fourth specialty-care payment model, alongside bundled payment programs for Medicare Advantage spinal fusion patients and total joint replacement patients, as well as maternity care bundled payment programs for commercial group members with low-to-moderate risk pregnancies.
Humana has more than 2 million Medicare Advantage members and around 115,000 commercial plan members who are cared for by primary care physicians in value-based payment relationships.
In the company’s 2018 report on its value-based care practices, Humana found that MA members with physicians in value-based care relationships experienced 7 percent fewer emergency room visits and 5 percent fewer hospital admissions
Medical costs for patients who were affiliated with physicians in Humana MA value-based agreements were also 15.6 percent lower than traditional Medicare.
Humana’s recent activities are indicative of the larger payer industry making a full-scale business transition to value-based care.
Case in point, UnitedHealthcare is launching a Care Bundles program next year that will offer providers across 30 states the option of participating in bundled payment arrangements for eight medical procedures for MA patients.
By Michael Adelberg – STAT – April 4, 2019
Nearly a quarter century ago, then Speaker of the House Newt Gingrich said this about the original Medicare program: “We believe it’s going to wither on the vine because we think people are voluntarily going to leave it — voluntarily.”
Gingrich argued that original Medicare — based on a 1960s-style fee-for-service benefit package with a confusing set of deductibles, co-insurance, and copays — was stuck in the past. He saw a day when Medicare-contracted private health plans would prove so attractive that Medicare beneficiaries would have to choose them.
It’s taken a generation, but Gingrich is on the verge of being right about Medicare.
Medicare began experimenting with managed care as an alternative to the original program in the 1970s, and annually contracted health plans — called Medicare+Choice — were made a permanent part of the program in the 1990s. Because of funding reductions, it initially floundered.
That changed in 2003 with the passage of the Medicare Prescription Drug, Improvement, and Modernization Act, which renamed the program Medicare Advantage, raised payment rates, and added risk adjustment to the payment methodology. Leading managed care companies, such as UnitedHealth Group, Humana, Aetna, and Blue Cross Blue Shield companies, began marketing Medicare Advantage products every fall. So did dozens of smaller and health system-owned health plans.
Enrollment in these plans has increased every year since then. Today, more than 22 million beneficiaries choose Medicare Advantage, about 35 percent of all people
with Medicare, up from about 11 million people a decade ago. This has occurred despite a gradual phase down in funding put in place by the Affordable Care Act.
In 2019, Medicare Advantage plans stepped up their coverage to include the delivery of meals, rides to physician appointments and pharmacies, home safety improvements, and a host of other new benefits. As described in a new report on Medicare Advantage plans that one of us (M.A.) co-authored, 153 Medicare Advantage plans are now leveraging new Trump administration guidance and experimenting with 842 “flex benefits” this year. These benefits fall into two broad categories: reducing costs to encourage members to receive preventive care, such as free primary and podiatry care for people with diabetes; and non-medical benefits, such as home-delivered meals following a hospital discharge, home safety interventions, and non-skilled in-home caregiving.
Medicare beneficiaries select Medicare Advantage for a variety of reasons. These include catastrophic cost protection, care management programs, and a range of mainly health-related supplemental benefits such as dental checkups, eyeglasses, hearing aids, over-the-counter drugs, and gym memberships. The trade-off for these extras is limited choice of providers and managed care tools like prior authorization. These limitations put off some Medicare beneficiaries, but have not dampened the high overall satisfaction with Medicare Advantage or its continued growth.
Medicare Advantage’s competitive edge over original Medicare will take another step forward in 2020 when plans are expected to gain additional flexibilities in offering non-medical benefits for people with chronic diseases. The next wave of new benefits can include anything that the Centers for Medicare and Medicaid Services deems “has a reasonable expectation of improving or maintaining the health or overall function” of enrollees with chronic diseases. While CMS has not yet offered its final guidance, this will likely include meals, transportation, pest removal, and activities that combat social isolation and depression, which could include companionship services and pet therapy.
Some of the brightest minds in managed care are working to determine whether relatively inexpensive, newly permissible benefits like these will pay for themselves by reducing the number of expensive medical procedures. Actuaries at Wakely Consulting, for example, have modeled the value of a falls reduction benefit. Using Medicare claims data, they determined that injury-causing falls are associated with spikes in medical costs that average about $10,000 compared to pre-fall costs. So an intervention that reduces falls by even 10 percent would likely pay for itself if it costs less than $1,000 per fall-prone member receiving the service. Hiring a handyman for a couple hundred dollars to install grip bars in a shower or modify cabinetry would be a bargain.
How does original Medicare stack up in comparison to Medicare Advantage? The Affordable Care Act and the Medicare Access and CHIP Reauthorization Act (MACRA) introduced value-based reimbursement reforms into original Medicare. These may make the program a more efficient payer, but they do not necessarily improve benefits for Medicare beneficiaries. Medicare Supplement Insurance (Medigap) continues to be purchased by roughly 13 million Medicare beneficiaries. It plugs gaps and simplifies original Medicare’s idiosyncratic coverage, but it is too expensive for lower-income beneficiaries. In addition, state and federal laws prevent Medigap from keeping up with Medicare Advantage.
A 2017 report by the National Association of Insurance Commissioners demonstrates that only a handful of states permit Medigap carriers to offer any “innovative” benefits. And the modest flexibilities permitted — such as eye exams — pale in comparison to the richness and diversity of Medicare Advantage benefits.
In subtle and unsubtle ways, the Trump administration has seeded the ground for massive gains in Medicare Advantage enrollment. These include loosened restrictions on marketing Medicare Advantage plans, new consumer tools that accentuate the advantages of these plans, greater use of telehealth than permitted in original Medicare, the elimination of “meaningful difference” tests that limit the number of Medicare Advantage plans in a given market, and extra time for plan sponsors to secure a provider network. Meanwhile, the administration has finalized a regulation that may substantially lessen the number of accountable care organizations participating in original Medicare — the original Medicare reform with the greatest potential to align providers in reimbursement systems outside of Medicare Advantage.
Congress has also quietly added tools to Medicare Advantage that aren’t available in original Medicare. A little-noticed MACRA provision will remove two of the most popular Medigap plans from the market in 2020, further weakening its value proposition versus Medicare Advantage. This is not an accident: Many conservatives have long disliked original Medicare’s centralized pay schedules and the perverse incentives of fee-for-service medical care. And many liberals are willing to strengthen Medicare Advantage if that’s the only way to offer more generous health care coverage to seniors.
Intentionally or not, Congress and various administrations have created two Medicare programs: the original fee-for-service program with rules and coverage that the private market largely abandoned decades ago, and a managed care program that has just benefited from another set of favorable legislative and regulatory tweaks. Maybe it is unfair that policy makers are favoring Medicare Advantage. But if this is the only way to deliver modern and more generous health benefits to Medicare beneficiaries, then a thumb on the scale is better than denying beneficiaries access to 21st-century benefits.
It’s no wonder that Medicare beneficiaries are voluntarily leaving original Medicare — voluntarily.
The estimate is for an enrolled-in-Medicare couple’s retirement
By Rebecca Moore – PlanAdviser – April 3, 2019
In case you’re wondering how much of your retirement savings might go toward health care, Fidelity has a new number – and it’s going up. A 65-year old couple retiring in 2019 can expect to spend $285,000 in health care and medical expenses throughout retirement, compared with $280,000 in 2018, according to Fidelity’s annual Retiree Health Care Cost Estimate.
For single retirees, the health care cost estimate is $150,000 for women and $135,000 for men. The estimate assumes both members of the couple are eligible for Medicare. While Fidelity’s estimate is for a couple retiring in 2019, the firm says it’s a call-to-action to younger generations to prepare – such as buying the right insurance products – for a lengthy retirement.
Tags: Retirement Planning
While this product is positioned for individuals who are Medicare eligible the issue age is 19 – 99 for these policies. For more information and to see rates view the Dental Insurance Product and Rate Guide.
Medicare supplement and Dental Insurance – Better Together
First, good dental care is important to overall health. But do you know Medicare doesn’t cover dental services? That means dental bills have the potential to take a bite out of people’s savings.
Second, there is a need among individuals age 65 and older for dental insurance.
Third, it is an easy sale. If you are taking a Med supp e-App the dental plans are quoted up front and with a few simple questions at the end of the app you can complete a dental sale. Also, all Med supp paper apps have the dental application included in the application book. And with our mobile quote app you can provide your clients a quote on the spot.
How to Make an UpLine Change
In order for a business to be successful all parties involved have to benefit or the relationship will eventually break down.
As an insurance agent, it’s likely only a matter of time until you find yourself in a situation where you feel that your upline partnership isn’t working for you.
When that happens, it may be time to cut ties with your current upline and move on. This can be a simple or complicated process, depending on your upline FMO and the carrier involved.
It is important first to understand that, if the carrier in question will honor a signed release from your upline, it needs to be from the highest level in your hierarchy. Carriers will not accept a signed release from a mid-tier FMO.
For example, as an FMO we have a direct relationship with the carriers we broker for. For the most part, carriers will honor our release requests, no questions asked.
We have a general open release policy and would normally process a release without delay. Having said that, we also give our mid-level down lines flexibility to implement their own release guidelines and allow them to release down lines as they see fit, as long as carrier guidelines are respected.
For the most part there are 2 ways to transfer your contract to a new upline. A “Signed Release” or a “Self-Release”.
Let’s take a look at these options:
An agent may request to be released from their upline for immediate transfer to a new FMO. It is important to stress that this request must be signed by the top level upline and NOT by a mid-tier. If the top line FMO signs the release, the agent is then free to transfer to a different broker immediately.
If an upline doesn’t want to give an agent an immediate release, then an agent can exercise the Self-Release process. It may vary by carrier, but as a general rule there are a couple of ways to do it:
Below is a sampling of a few carriers and their release process:
Aetna Med Advantage/Part D - Notice and new contracting must be sent to Aetna to start the clock. You can continue to write business during their 3 month Self-Release period.
Mutual of Omaha - Non-Production for 6 months will allow an agent to transfer their contract.
Aetna Med Supp - Email notice must be sent to Aetna Supplemental to start the clock. You can continue to write business during their 6 month Self-Release period. However, different guidelines apply if you have producing downlines.
Humana - Notice and new contracting must be sent to Humana to start the clock. You can continue to write business during their 3 month Self-Release period.
United Healthcare – Email notice must be sent to UHC to start the clock. You can continue to write business during their 6 month Self-Release period.
Some Med Advantage carriers implement transfer freezes in the 4th Quarter of each year, which prevents an agent from transferring their contract no matter what the release scenario may be. UnitedHealthcare, Aetna, and Humana are a few of the major carriers who implement a transfer freeze period.
With that being said, it’s important to carefully consider the timing if you’re looking to initiate a self-release.
For example: If an agent were to start a self-release and that self-release time frame expired in the middle of a transfer freeze (9/1/19 to 12/31/19), they would be forced to stay under their current upline until the end of the freeze period. In other words, they are stuck until after AEP and usually until January 1st of the next year.
Obviously, if the agent could have timed the self-release so that the self-release time frame expired before the freeze period, that may have been the more favorable situation.
Again, not all carriers have the same process, so ensure you understand the carrier’s requirements before starting the process.
The important thing to remember is that, if your business relationship isn’t working, you have options. It is also a good idea to understand the release policy of your upline, before you work with them, so you are not surprised when the situation arises.
Your success is up to you, but a bad business relationship can definitely make that success more difficult.
If you have any questions, our experienced marketers are here to help.
|What are the Benefits of Using an FMO?
14 Ways to Generate Medicare Leads
An Agents Guide to Dual Eligible Special Needs Plans
Social Media Marketing for Insurance Agents
What is MACRA?
Download the Flyer here
The Implications Of Re-calibrating Medicare Advantage Risk Adjustment Using Encounter Data
MA plans play an increasingly important role in the Medicare program, with enrollment growing from about a quarter of all Medicare beneficiaries (or 11 million) in 2010 to 34 percent of beneficiaries (approximately 20 million) in 2018. And, according to the Congressional Budget Office, enrollment in MA is projected to exceed 40 percent (32 million) of the total Medicare population by 2028.
MA’s popularity indicates that it works well, and one of the reasons the system functions as well as it does is that plan payments are adjusted for the health risks of enrollees.
Until now, the Centers for Medicare and Medicaid Services (CMS) has estimated its MA risk-adjustment models using data from traditional Medicare, but the agency has signaled in the past its interest in using encounter data from MA to estimate (or recalibrate) the model. CMS reiterated this interest in its fiscal year 2020 performance budget.
Under such recalibration, CMS would recalculate the coefficients for the demographic characteristics and health conditions based on MA encounter data, instead of on traditional fee-for-service Medicare claims.
Read the full article: https://www.healthaffairs.org/do/10.1377/hblog20190412.299173/full/
|An Agents Guide to DSNP Plans
Medicare Marketing Guidelines - Changes for 2019
14 Ways to Generate Medicare Leads
Medicare Advantage and PDP Online Enrollment Solution
Tags: Medicare Advantage
We have some exciting news to share!
Mutual of Omaha is releasing a new Medicare Supplement in Georgia. Request details today and be ready when the product roles out for new sales.
Call us at 800-998-7715 and one of our marketing representatives would be happy to share this valuable information with you.
There are Medicare changes coming effective January 1, 2020 as a result of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Act eliminates Medigap plans that cover the Medicare Part B deductible (Plans C, F and High-Deductible F) for people who are Medicare eligible on or after January 1, 2020. That means those Medicare beneficiaries will not have a Medigap option with first-dollar coverage and will pay the Medicare Part B calendar-year deductible themselves.
How this impacts our new Mutual of Omaha Georgia Product:
For more information on how MACRA impacts your clients, click here.
Boomers Need Help Living in Retirement
More than 50% of Baby Boomers believe health care costs will consume 20% of their income, or less.
But an annual report by the Insured Retirement Institute shows a healthy 66-year-old couple who retired in 2018 would need 48% of their lifetime Social Security benefits to address total lifetime health care and long-term care expenses.
With nearly one-half of Social Security lost to health care, supplemental income or savings would need to be substantial for health care to be 20%, or less, of total income.
Expectation of Health Care and LTC Costs
The number one reason Boomers calculating savings goals do not include health care and LTC costs is that they expect Medicare to cover them – an erroneous assumption on both counts, especially for LTC, for which Medicare provides no coverage.
The second most common answer is simply that they are unsure of the costs involved and/or they don’t know how to calculate them – a powerful value-added service for insurance agents to provide.
Reasons For Not Owning Annuities
The chart above explores why annuity ownership is relatively low despite demonstrable income gaps. About as many boomers say they don’t have enough money to purchase an annuity as say they have no retirement savings, an unfortunate reality.
However, it is more common for boomers to say they simply don’t know anything about annuities than to be biased against them, and this is an opportunity for the insured retirement industry and for financial advisors.
Similarly, some of those who feel they don't think they'll live long enough for an annuity purchase to make sense may be overlooking the possibility that medical advances will result in them living longer than they expect, and that medically underwritten annuities may increase payments to the point where an annuity purchase becomes attractive.
Baby boomers, particularly those who are younger and still working, face an urgent need to save more and create financial plans for retirement.
Most will not have pensions, so it is imperative that they maximize Social Security, create guaranteed lifetime income from their savings, and employ insurance protection and financial management tools to mitigate the risk that health care and long-term care costs will erode their savings and income.
Medicare Marketing Guidelines
Rules Renamed to "Medicare Communications &
CMS has made some significant changes to the Medicare and Marketing Guidelines (MMG) for 2019. The MMG, which governs Medicare Advantage Organizations (MAO) and Plan D sponsors, was re-named to Medicare Communications and Marketing Guidelines (MCMG) for 2019.
In this article, we’ll take a look at some important changes to the regulations that you should be aware of moving forward.
Below, I have highlighted some of what we consider the most relevant changes to the guidelines. It is not an exhaustive list, but I think it’s a good place to start.
[ Note: Plans/Part D sponsors may impose additional restrictions on their subcontractors, downstream entities, and/or delegated entities, provided they do not conflict with the requirements outlined in the MCMG. ]
Let's look at some changes to the Medicare Communications and Marketing Guidelines:
20 – Communications and Marketing Definitions:
The most obvious change to this section is the distinction between Communications activities and Marketing activities. Communications activities do not need to be submitted for CMS review.
The MCMG defines Communications as:
Activities and use of materials to provide information to current and prospective enrollees. This is the more generic of the two categories and does not require CMS review. This can be seen as a loosening of the restrictions.
The MCMG defines Marketing as:
Marketing can be considered a subset of Communications and provides more detailed information. Marketing materials are those that could include information on a plan’s benefit structure, cost sharing and measuring or ranking standards. These types of materials are subject to CMS review.
Put another way, marketing materials are those with an intent to draw a beneficiary’s attention to a MA plan or plans to influence a beneficiary’s decision-making process when selecting and enrolling in a plan or deciding to stay in a plan and contain information about the plan’s benefit structure, cost sharing, and measuring or ranking standards.
30.6 – Electronic communication Policy:
Section 30.6 explains that a sponsor may initiate contact via email to prospective enrollees and to retain enrollment for current enrollees.
It also notes that text messaging and other electronic messaging (social media) is considered unsolicited and is not permitted.
40.2 – Marketing Through Unsolicited Contacts:
As in 30.6 above, Section 40.2 adds email to the list of allowable unsolicited contact methods, as long as there is an opt-out function in the email.
This section also clarifies that unsolicited text messages are not permitted.
50.3 – Personal/Individual Marketing Appointments:
There is no longer any language preventing an agent from asking for referrals during a one on one appointment. (No more excuses)
60.4 – Plan/Part D Sponsor Activities in the Healthcare Setting:
Section 60.4 clarifies that waiting rooms are considered part of the common areas and common areas are approved for sales activities.
It also states that Communication materials may be distributed and displayed in all areas of the healthcare setting.
90.1 – Material Identification:
Section 90.1 includes a new material identification process, as well as guidance on what types of materials will require submission to HPMS.
The section relating to the rules that apply to referral programs (30.9) has been removed. This will allow for some flexibility in gaining referrals.
If you offer a gift for referrals, just remember, you will still need to abide by the Nominal Gift standards (40.4).
Appendix 2, Disclaimers:
Disclaimers have been simplified and are now located in Appendix 2 of the MCMG. Some of the relevant proposed changes are listed below.
The following disclaimers may be removed from your materials:
The following disclaimer may be removed from your advertising materials:
The following disclaimer may be removed from your materials:
The following disclaimer may be removed from your materials:
You no longer have to put the following text in email subject lines. As long as the material is not considered Marketing.
Appendix 3, Pre-Enrollment Checklist:
The Pre-Enrollment Checklist was added to consolidate disclaimers on a given plan. The Checklist is designed to help enrollees understand important rules before making an enrollment decision.
This update marks a significant change to the MCMG. There are new additions, several sections have been moved around and others removed entirely.
We recommend reading through the entire guidelines to ensure you’re aware of any possible impact to your business.
As always, our experienced marketers are here to answer any questions you may have.
By Shelby Livingstone – ModernHealthCare – April 3, 2018
UnitedHealthcare and the American Medical Association said Tuesday they want to expand the set of ICD-10 diagnostic codes to include more specific diagnoses related to a person's social determinants of health.
The hope is that these codes would allow clinicians to document patients' social determinants in a standardized way, which would allow them to better tailor care plans or refer patients to community organizations that could meet those social needs.
"If someone has a transportation barrier and they are unable to get to their doctor's appointment or to pick up their prescription, today in the ICD-10 codes, there isn't a way to diagnose that," said Sheila Shapiro, senior vice president for national strategic partnerships in UnitedHealthcare's clinical services team. "There is no common way for the system to communicate around not only that barrier, but the solutions that can be brought to assist that individual."
Today, a clinician may use medical code that identifies a patient as low-income, but that's as granular as it gets. UnitedHealthcare's proposed set of codes would more specifically identify the person as unable to pay for transportation for medical appointments of prescriptions, for instance.
That would then tell the healthcare provider they should order prescriptions mailed to the home or possibly provide some form of transportation, explained Dr. Tom Giannulli, chief medical officer at the AMA's Integrated Health Model Initiative, which is supporting UnitedHealthcare's proposal.
Expanding diagnostic codes related to social determinants of health is another step in the healthcare industry's journey to address those factors outside of the doctor's office that often have a greater impact on outcomes than clinical care. In recent years, social determinants have become a buzzword in the healthcare industry as insurers and providers have looked for new ways to control health spending. Now insurers and health systems are moving beyond initial pilot projects to address those factors in a sustainable, scalable way.
The existing ICD-10 family of diagnostic and procedural codes includes 11 codes that identify social and environmental barriers to a patient's care, but they are broad categories. UnitedHealthcare's proposal would add 23 more codes to that list. Some of those codes would indicate a patient's inability to pay for prescriptions, inadequate social interaction, or fears about losing housing.
Trenor Williams, the founder of Socially Determined, a company that uses data to help organizations build programs to address their patients' social needs, said expanding the codes to include more specific diagnoses is a good start and an opportunity to better document social risk factors among a population.
It also could prompt more discussion among stakeholders about providing reimbursement that is risk-adjusted based on a patient's social determinants, Williams said. Some groups, including the National Academy of Medicine and the Medicare Payment Advisory Commission, have explored the feasibility of adjusting Medicare payments for socioeconomic status. Congress has also commissioned reports on the subject. But so far Medicare payments remain unadjusted for social factors.
UnitedHealthcare presented its recommendation to expand the codes at the ICD-10 Coordination and Maintenance Committee meeting in March. Following a 60-day comment period, the committee will determine whether to act on UnitedHealthcare's recommendation in the early summer. The new codes would be available to use as early as 2020, if the committee approves them, Shapiro said.
MA rates increase 2.53 percent. This includes the phasing-in of a risk adjustment model that takes into account the number of chronic conditions a person has, according to CMS Administrator Seema Verma.
CMS originally had released a rate increase of 1.59 percent.
The effective growth rate increased from 4.59 percent in the advance notice, to 5.62 percent today. Verma said the reason for the change is that CMS is continually updating information.
However, the biggest changes for Medicare Advantage insurers is in their ability to offer additional, non-health benefits to members who have a chronic condition, if there is a reasonable expectation of improving or maintaining the health or overall function of the enrollee. Plans can address the social benefits of health in these tailored benefits.
For example, beneficiaries could now receive transportation for non-medical needs like grocery shopping and home environment services to cover home air cleaners and carpet shampooing for asthma sufferers.
WHY THIS MATTERS
Today's supplemental benefit flexibility gives Medicare Advantage plans an edge in competition over traditional Medicare fee-for-service.
The flexibility in today's rule is due to legislation in the Bipartisan Budget Act, Verma said.
Asked why Congress would allow MA plans to have an edge in offering benefits over traditional Medicare fee-for-service, Verma said fee-for-service is an open-ended benefit program while MA is capped and is a value-based payment systems. CMS supports allowing the flexibility for plans to address the social determinants of health in a value-based arrangement, she said.
The varying benefits are also expected to spur competition between MA plan offerings.
Medicare Advantage is a growing program both for seniors and for insurers, with CMS not-so-subtly promoting the private health insurance option.
Average Medicare Advantage premiums are at their lowest in six years, Part D premiums are at their lowest in three years, and plan choices have increased, CMS said today.
WHAT ELSE YOU NEED TO KNOW
CMS calculates risk scores using diagnoses submitted by Medicare fee-for-service providers and by MA organizations.
CMS is including encounter data in calculating the risk scores despite objections by some stakeholders. For 2020, CMS will blend 50 percent of the risk score calculated using diagnoses from encounter data, the RAPS Risk Adjustment Processing System inpatient diagnoses and FFS diagnoses, with 50 percent of the risk score calculated with diagnoses from RAPS and FFS.
For 2020 CMS expects the underlying coding trend to increase risk scores, on average by 3.3 percent.
The payment and policy updates include actions to address the opioid crisis, encouraging Part D plans to provide at least one opioid-reversal agent on a lower cost-sharing tier.
CMS said its overutilization policies have resulted in a 14 percent decrease in the share of Part D beneficiaries using opioids between 2010 and 2017 (36.3 percent to 31.3 percent), with the largest decrease from 2016 to 2017 (5 percent).
Starting this year, Medicare Advantage plans could offer supplemental benefits that are not covered under Medicare Parts A or B, such as adult day health services, and/or in-home support services under an expanded definition of supplemental benefits.
The updates released today continue the Trump administration's efforts to increase competition among Medicare Advantage and Part D plans. CMS said.
ON THE RECORD
"Today's changes give plans the ability to be innovative and offering benefits and services that address social determinants of health for people with chronic disease," Verma said. "With Medicare Advantage enrollment at an all-time high, plans need greater flexibility in offering benefits that they focus on preventing disease and keeping people healthy."
Email or Call? The Best Way to Reach Out to a Prospect For the First Time
After all, first interactions with prospects are key -- you're aiming to establish trust, provide value, gather key information, and perhaps even secure a follow-up meeting. If you don't use the right medium, they'll be less receptive to your message (and that's assuming they engage at all).
Luckily for sales reps everywhere, more than 20 sales experts and practitioners on Quora decided to weigh in.
The Best Way to Reach Out to a Prospect For the First Time
When In Doubt, Email First
The majority of experts recommended starting with an email. "An initial email usually makes more sense because it doesn't require [the prospect to] answer at the moment they receive it," writes Robert Graham, author of Cold Calling Early Customers.
Plus, as others pointed out, you can use an email as a reason to call.
"I always start by referring to this first email to show we're one step further in our relationship," explains Stan Frering, head of Client Relationship Management for Easytrip France.
Emailing has a third advantage over calling, according to EchoSign co-founder Jason Lemkin. It lets you educate your prospect on the product's value proposition, and clearly connect it with the prospect's situation.
"The prospect needs to understand the value proposition first," he explains. "It needs to be very strong, and very clear. No one will take a random call about a product they've never heard of it's not 100% crystal clear they have a huge, pre-defined need for it."
When to Ignore the Email-First Rule
However, there is one exception to the "email first" rule.
Lemkin says once your brand has been established, it's time to start calling your prospects.
"If your prospect has already heard of [your company], they'll know if they want to speak to you about the product and learn more about buying," Lemkin writes.
For example, say you're a salesperson for Dropbox. You call a prospect and say, "Hi John, I'm with Dropbox, and I noticed your CEO tweeted that your company is almost out of free virtual storage. I'd love to discuss how we could get you some more so you can keep all your files in one place."
John already knows Dropbox and understands why it's a useful product -- so he's got a good reason to stay on the phone.
However, if you were selling a brand-new cloud storage solution, Lemkin argued that it would be better to send John an email first so he has more time to consider your value prop.
Not sure how much clout your company name carries? To quickly gauge brand awareness, go to Google Trends and compare how many people are searching for your company versus your top competitors. If your company gets the most searches, that means it probably has the highest name recognition in your space.
A Better Method Than Phone Or Email?
But to one expert, the question of "phone vs. email" is innately flawed.
SVP at LivePerson Sean Burke says that, in fact, your default shouldn't be calling or emailing. He recommends using your network to get an introduction -- great advice, considering that having a referral makes a buyer five times more likely to engage.
"You'd be surprised how often this crucial first step is ignored," Burke writes.
Once your mutual connection has agreed to introduce you, ask him or her which communication method the prospect prefers. Most people have an individual preference for calling or emailing.
However, if you don't have a shared connection, Burke suggests looking at the prospect's social media presence. If she is "social" -- meaning she's got 500-plus LinkedIn connections and an active Twitter or Instagram account -- use those channels to interact with her and start adding value. If she's "traditional" -- meaning she doesn't meet those criteria -- Burke gives you the go-ahead to call or email.
Whatever You Do, Don't Cold Call or Spam
While opinions differed on the relative merits of calls vs. email vs. social media, the experts were unanimous on one point: You should never reach out to a prospect via any channel without doing research first.
"Ultimately, you are in a much better position -- either calling or emailing -- if you have background information on the person you are contacting," notes Jeremy Boudinet, head of marketing for Ambition. "That way, you can tailor your message off the bat, since you have an idea of how you can add value to that person or company."
Sales Email or Sales Call? Experiment and Find Out
Although these guidelines should definitely guide your prospecting strategy, don't forget they're just that: guidelines. "Why not take a test-and-learn approach to this problem?" writes Nick Dellis, Weebly's VP of Business Development. "What works for you may not work for others."
Dellis suggests emailing first, then calling with 10 to 20 prospects, doing the reverse with another 10 to 20 prospects, and comparing the results.
"Taking this approach of testing ideas and optimizing is the only way to find out for yourself," he says. "And it'll help you be a better salesperson in the longer term."
First Contact Email
If you choose to start the conversation with an email, be sure you include a rapport-building element and communicate your value proposition.
Not sure what a first contact email should look like? Here's an email template you can use to start your outreach.
By Carlone Humer – Reuters – April 2, 2019
The government increased by 2.53% the average 2020 payments to health insurers that manage Medicare Advantage insurance plans. The rate represents an increase over the 1.59% increase proposed by the CMS in February. The 2020 rate reflects a decline in payments of 3.08% related to the ACA requirement that M/A and fee-for-service Medicare have the same payment structure.
Starting in 2020, M/A plans will also be able to offer supplemental non-health related benefits to chronically ill enrollees that address their social needs, such as adding ramps and widening doorways. Previously, plans were allowed to offer only health related benefits. A copy of the 2020 M/A and Part D program summary is available here.
For the CMS press release, view here
Tags: Medicare Advantage
The average payment rate from the federal government to companies that sell Medicare Advantage plans will go up 2.53% in 2020 — a sizable boost from what was
The big picture: Even though the 2020 pay increase isn't as generous as 2019's, health insurers will still benefit a lot from higher payments as well as other new, industry-friendly policies — like being able to cover meals and car rides to doctors' appointments, which could attract more seniors to these plans.
Yes, but: Against the industry's wishes, Medicare will change part of its process for calculating insurers' payments according to how sick their members are — known as a "risk score."
But, but, but: All MA risk scores originally were supposed to be based 100% on encounter data by 2020, so insurers are still coming out ahead.
Tags: Medicare Advantage
Medicare Advantage Managers Give 2020
Officials seem to be open to letting plans offer the new benefits alongside the 2019 mini LTC benefits.
By Allison Bell – ThinkAdvisor – April 2, 2019
Medicare Advantage plans can put permanent wheelchair ramps in enrollees’ homes in 2020, or even widen enrollees’ hallways to accommodate wheelchairs, if they choose to do so.
Officials at the Centers for Medicare and Medicaid Services (CMS) have included that change in the final rules for Special Supplemental Benefits for the Chronically Ill, or SSBCI.
CMS put the final SSBCI rules in the final bidder package for the Medicare Advantage and Medicare Part D prescription drug plans, which came out today.
The final package appears to suggest that Medicare Advantage plan issuers can offer samples of two types of long-term care (LTC) type benefits in 2020: the kinds of health-related health maintenance benefits that issuers could offer, and the new SSBCI benefits.
The final package also makes it clear that, from the perspective of CMS officials, “SSBCI” is a plural word.
A Little Bit of Post-Acute Care Coverage
Traditionally, Medicaid has paid for nursing home care for the poor.
Medicare has paid only for health care, not for non-medical support services.
In 2019, CMS officials wiggled that boundary by announcing, after most issuers had already started developing their 2019 bid proposals, that issuers could cover “primarily health-related” benefits meant to address the “social determinants of care.” In practice, a few issuers have used that flexibility to do things like giving caregivers access to a caregiver support line, or providing patients who had just come out of the hospital with a few days of coverage for adult medical day care services.
The Medicare Advantage social determinants of care benefits available this year are more like samples of the kinds of benefits available from convalescent care insurance policies, or short-term care insurance policies, than like full-blown long-term care insurance.
For 2020, the new SSBCI rules appear to be encouraging issuers to offer richer support benefits aimed patients with serious chronic conditions who require intensive care coordination and have a high risk of hospitalization or other bad health outcomes.
The list of conditions that could make a patient eligible for SSBCI benefits includes relatively common disorders, such as dementia, rheumatoid arthritis and diabetes, as well as conditions such as kidney failure, liver failure and metastatic cancer.
For those patients, SSBCI benefits could cover items and services such as “meals furnished to the enrollee beyond a limited basis, transportation for non-medical need, indoor air quality equipment and services, and benefits to address social needs,” according to the final call letter.
In the draft version of the call letter posted in January, officials said they would not let issuers cover installation of permanent wheelchair ramps or other improvements that could add to the resale value of a patient’s home.
“However, after reviewing comments, we do not believe such a limit is necessary to implement the statute and permit [Medicare Advantage] plans to offer SSBCI,” officials write in the final call letter.
Meals on Wheels
The new final call letter could be good for revenue for Meals on Wheels and other existing community-based organizations that serve the elderly.
A Medicare Advantage plan issuer must spend something on an SSBCI to count it as an SSBCI, and it can pay an existing community-based organization to provide the SSBCI, according to the final call letter.
CMS officials say an issuer should describe its SSBCI benefits in the plan benefit package narrative.
CMS officials will make the final decisions about SSBCI benefits during the annual benefit package review, officials say.
Medicare Plan Bidding Basics
The Medicare Part C Medicare Advantage program gives insurers the ability to sell plans that serve as an alternative to traditional Medicare A hospitalization coverage and Medicare Part B physician and outpatient services coverage.
Another related program, the Medicare Part D prescription drug program, gives insurers the ability to sell prescription drug coverage to Medicare enrollees.
About 22 million people have Medicare Advantage plan coverage, and about 21 million have stand-alone Medicare Part D prescription drug plan coverage, according to the CMS data.
The new “final call letter,” and a draft version that came out in January, are part of an elaborate bidding process.
Although CMS calls the new document a “final call letter,” the true final terms will depend partly on insurers’ reaction to the bidding process.
2020 Medicare Advantage Bidding Parameters
In the new rate announcement and final call letter, CMS officials say they expect Medicare program payments to 2020 Medicare Advantage plan issuers to increase an average of 2.53% over 2019 levels.
A year ago, CMS predicted that the 2019 revenue increase would be 3.4%.
Officials are predicting the “effective growth rate,” or increase in the underlying cost of care, will rise to 5.62% in 2020.
A year ago, CMS predicted that the 2019 effective growth rate would be 5.28%.
A copy of the 2020 Medicare Advantage and Medicare Part D plan program summary is available here.
A copy of the 2019 program summary is available here.
Links to a copy of the final 2020 rate announcement and the final 2020 bidder call letter are available here.
Tags: Medicare Advantage
CMS finalizes Medicare Advantage pay raise, ups encounter data use
By Shelby Livingston – ModernHealthCare – April 2, 2019
Medicare Advantage plans are getting a pay raise and more flexibility to tailor benefits for chronically ill patients next year, the CMS said Monday. But Advantage plans' payments will also be based on a higher percentage of patient "encounter data," a change that health insurers have fought hard to avoid.
The CMS on Monday finalized a rule giving Medicare Advantage plans a 2.53% pay raise in 2020. The agency had initially floated giving plans a 1.59% pay bump for next year. The final rate is less than the 3.4% raise Advantage plans received for 2019, which was one of the biggest pay raises plans have received in years.
"These changes to the model better reflect costs and improve the financing for the care of beneficiaries with multiple conditions," CMS Administrator Seema Verma said in a press call with reporters late Monday.
The final rule also allows Medicare Advantage plans more flexibility to offer supplemental benefits to patients with chronic illnesses that aren't necessarily going to cure their conditions but that will address the social and environmental factors that can harm health. Plans will also be able to tailor benefits or reduce cost-sharing to meet a certain members' needs.
For instance, Verma said a Medicare Advantage plan could pay for home air filters or carpet shampooing for a patient with asthma, or pay for heart-healthy meals for a beneficiary with heart disease. She noted that in the original Medicare program, 27 million people have chronic conditions. The agency also said it is encouraging plans to take advantage of the flexibilities to offer targeted benefits to patients with chronic pain or those undergoing addiction treatment.
With this new flexibility, "Coverage is determined by what a person needs, not just what's on a list of allowable items or services," Verma explained.
The change, which was called for by the Bipartisan Budget Act of 2018 is a significant departure to previous policy, which allowed coverage only for services that prevented, improved or cured a patient's conditions. Previously, plans were also barred from offering different benefits to different sets of patients. The CMS began introducing flexibility starting in 2019 by allowing plans to pay for in-home supports, such as grab bars and wheelchair ramps, for their plan members.
In comments to the CMS due in March, health insurers largely supported the increased leeway in what supplemental benefits they could offer patients. But most of them railed against the agency's proposal to increase the amount of encounter data it uses in calculating patient risk scores to 50% from 25%, saying encounter data is often inaccurate and will lead to lower funding for the plans.
The CMS didn't back down. Verma said the agency has been monitoring encounter data and feels comfortable moving ahead with plans to increase its use in the risk-adjustment model "because of the work we've done with the plans around improving the accuracy."
Federal payments to Medicare Advantage plans are adjusted based in part on patient risk scores. Generally, the sicker the person, the higher the risk score and, consequently, the higher the payment an Advantage plan receives. Plans have been accused of manipulating risk scores to nab higher payments, however.
The CMS has been using encounter data to calculate risk scores since 2016, but insurers have never embraced it. In a letter to the CMS in March, Cigna Corp. even said it was concerned the agency "may be using the EDS transition to reduce MA payments without providing full information about the impact to stakeholders and others."
Beyond encounter data, the CMS also said it is moving ahead with plans to adjust payments to reflect patients' total number of medical conditions, in addition to viewing each condition individually. This change is required by the 21st Century Cures Act. The CMS said it will implement what it called the "alternative payment condition count model," which accounts for some additional diagnoses, including dementia and ulcers. Insurers had supported the alternative model in their comments to the CMS.
Tags: Medicare Advantage
5 Medicare Advantage Sample-Size
The new benefits may not be much like short-term care insurance, let alone LTCI.
By Allison Bell – ThinkAdvisor – April 1, 2019
Medicare Advantage program managers abruptly encouraged insurers to jam a few non-medical “supplemental benefits” into their benefits packages for 2019.
Some insurers added the kinds of benefits that might be covered by a short-term care insurance or long-term care insurance (LTCI) policy, such as adult day care services, homemaker services, and support for caregivers.
Officials at the Centers for Medicare and Medicare Services (CMS) recently put more fleshed-out rules for “chronic care” benefits in a draft version of a bidding document for the 2020 Medicare Advantage program.
Insurance company executives now have time to decide, in an orderly way, if they want to build chronic care benefits into their 2020 Medicare Advantage plan benefits menus.
In theory, the chronic care benefits provision could be the start of Medicare creeping into the long-term care benefits business, or a dead end, or the beginning of an era in which Medicare simply provides want amounts to small promotional samples of LTCI-type samples. Medicare sample-size LTC benefits could help sell consumers on the idea of buying full-size short-care insurance or LTCI policies.
The recent Intercompany Long Term Care Insurance Conference presented a session on the topic. The speakers included Howard Gleckman of the Urban Institute, Jay Greenberg of NCO Services, and Anne Tumlinson, a consultant who previously served as a senior vice president at Avalere Health.
Here’s a look at five speaker insights about the new Medicare Advantage chronic care benefits, drawn from the speakers’ slidedeck.
The benefits offered in new short-term care insurance and LTCI policies tend to hold fairly steady from year to year.
Consumers who buy LTCI policies can lock in benefits for many years.
The new Medicare Advantage chronic care benefits “can vary from year to year,” according to the Medicare Advantage LTC session speakers.
In part because the opportunity appeared with such little advance notice, only a limited number of issuers submitted bids in 2019, according to the Medicare Advantage LTC speakers.
Issuers saw the 2019 supplemental benefits opportunity as a kind of pilot program.
“More will participate in 2020,” according to the session speakers..
Issuers see value in the idea of investing a little money in non-medical support services, such as a little help with transportation, laundry or caregiver respite care, to hold down preventable use of expensive acute medical services, according to the session speakers.
Many issuers would like to see a better risk-adjustment system in place before they add the new chronic care benefits, according to the session speakers.
One challenge is that issuers still need to hold rates down, and another is that issuers will feel pressure to sweeten important benefits with broader appeal, such as dental benefits, according to the session speakers.
The budget constraints could put tight limits on chronic care benefits value. This year, for example, the companies that have added adult day care benefits cover just a few days of adult day care. The coverage is much skimpier than the coverage available in typical convalescent care policies, or other short-term care insurance policies.
Issuers are supposed to target the new benefits at enrollees at high risk of needing expensive, preventable medical care.
That means that only certain enrollees will end up qualifying to use the benefits, which means that highlighting the benefits in marketing materials could mislead the many consumers who might have a need for the types of services covered but will not actually qualify to use their Medicare Advantage coverage to pay for the services, according to the session speakers.
More information about the Medicare Advantage chronic care benefits session, including a link to the presentation slidedeck, is available here.
No Donut Hole, But Drug Costs Still Bite
By the Kaiser Family Foundation – March 29, 2019
The 2006 introduction of the Medicare prescription drug benefit was a boon for seniors, but the coverage had weak spots. One was the so-called donut hole – the gap beneficiaries fell into after they accumulated a few thousand dollars in drug expenses and were on the hook for the full cost of their medications. Another was the lack of an annual cap on drug spending. Legislative changes have gradually closed the donut hole so that, this year, beneficiaries no longer face a coverage gap. But there’s no limit for prescription medications in Part D. With the cost of specialty drugs increasing, some Medicare beneficiaries could owe thousands of dollars in out-of-pocket drug costs every year for a single drug. Recent proposals by the administration would address the long-standing problem by imposing a spending cap. But it’s unclear whether any of these proposals will gain a foothold.
Tags: Medicare Part D
Mutual of Omaha: Med Supp Second Quarter Broker Bonus Program
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Continued Year-Over-Year Medicare Advantage and PDP Membership Increases
The Annual Election Period (AEP) for Medicare Advantage (MA) and prescription drug plans (PDPs) runs each year from October 15th through December 7th. Health companies compete by offering new pricing and product options to beneficiaries during the AEP. Plans then begin to analyze final enrollment results in February and March to evaluate their standing and assess which competitors gained and lost members during the last AEP.
Many companies conduct their post-AEP competitive assessments by using tools such as Mark Farrah Associates’ (MFA) Medicare Business Online™ and Health Coverage Portal™. As of March 1, 2019, total Medicare Advantage, including Medicare Advantage with Prescription Drug Plan (MA-PD) membership stood at 22,654,276 with a net gain of 1,554,366 members, year-over-year. Medicare stand-alone prescription drug plans (PDPs) covered 25,559,801 members as of March 1, 2019, a gain of 38,835 from the previous year. This brief assesses Medicare Advantage and PDP performance, market share and market penetration by state as of March 1, 2019.
MA Enrollment Growth by State
Click here to read more.