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Highmark Medicare Plans will lose in-network
Thousands of seniors with Highmark’s Medicare Advantage plans will lose in-network access to UPMC hospitals a year earlier under a Wednesday state Supreme Court decision than they would have under a lower court’s ruling.
Seniors with the plans will lose in-network access at the end of June 2019, when a state-brokered consent decree between the two health care giants expires. A Commonwealth Court judge had interpreted the consent decree to mean UPMC would have to continue to accept the insurance through June 2020.
“We are disappointed in today’s Pennsylvania Supreme Court ruling,” Highmark spokesman Aaron Billger said in an emailed statement. “While this is not how we interpreted the consent decrees intended to guide the Highmark and UPMC relationship, we will work in full compliance with the ruling and trust UPMC will do the same.”
Doctor visits and hospital services typically cost much less when the doctors and hospitals are in an insurer’s network than when they aren’t. Seniors with Highmark Medicare Advantage plans who see UPMC doctors will have to either switch doctors or pay much higher prices to see their UPMC doctors as of next July. Or they can switch insurers during the open enrollment period for the plans, which will run from Oct. 15 to Dec. 7, to pick a plan that includes their UPMC doctors and hospitals.
Some Highmark Medicare Advantage plans include access to UPMC hospitals and doctors and some don’t. About 50,000 seniors living in Allegheny and Erie counties have Security Blue and Freedom Blue plans, which include UPMC, Billger said. People with Community Blue plans, which don’t include UPMC, won’t see any changes, he said. About 17,000 seniors in Westmoreland County have Medicare Advantage plans that provide access to UPMC.
“UPMC is grateful the Supreme Court expeditiously reached this decision, allowing seniors ample time to make the best choices for their health care,” UPMC spokesman Paul Wood said in an emailed statement.
The change to networks coming in the middle of the plan year could create confusion for seniors who don’t know it’s coming, said Bill McKendree, coordinator for the Allegheny County APPRISE program, which helps seniors with enrollment.
McKendree said the federal Centers for Medicare and Medicaid Services could decide to create a special window in which seniors losing access to UPMC doctors could switch plans after June 30. Or CMS might not do that, he said.
“This is a big old question mark,” he said.
UPMC Health Plan, Aetna, Cigna and United Healthcare have all sold Medicare Advantage plans in the region in previous years. Highmark owns Allegheny Health Network and includes its hospitals in its plan networks.
Seniors may also elect to enroll in traditional Medicare, rather than the Medicare Advantage plans. The traditional program includes all hospitals and doctors in the country who accept Medicare. McKendree advises seniors considering traditional Medicare to think about getting a Medigap supplemental plan, which covers many of the co-pays, deductibles and other costs of traditional Medicare. McKendree said all hospitals and doctors who accept Medicare must accept Medigap.
The state brokered the consent decree between Highmark and UPMC in 2014 to govern relations between them until 2019. The two nonprofits had been unable to resolve contract disputes on their own that arose after Highmark Inc. announced it was buying the former West Penn Allegheny Health System to form the basis of Allegheny Health Network. UPMC said it wouldn’t contract with an organization owning competing hospitals.
Aetna releases New telephonic enrollment option for Medicare Advantage sales
To use RATE, you must have an iPad. You’ll also need to complete a short user training and quiz. Just contact us at 800-998-7715 to schedule a training session.
How it works
Step 1: First, you meet with your client and provide the required sales presentation and materials. (Please note that RATE does not replace your one-on-one client appointments.) If your client decides to enroll sometime after that meeting, you can schedule an appointment to complete the enrollment by phone.
Step 2: At the scheduled date and time, your client will call you on your unique RATE-specific 1-800 phone number. You’ll receive that call on your iPad.
Step 3: Next, you’ll walk them through an approved telephonic enrollment script that’s built into RATE to complete the enrollment. The calls are instantly and automatically recorded.
What are the benefits?
Social Security and the Senior Market
"Social Security Benefits Lose 34% of Buying Power Since 2000, According To Latest Study By The Senior Citizens League"
Social Security remains the most stable retirement pillar for about 85% of the population, yet S.S. benefits have lost 34% of buying power since 2000, says the 2018 Social Security Loss of Buying Power Study.
The findings represent a significant one-year loss of 4% in buying power, with the loss growing from 30% to 34% from Jan. 2017 to Jan. 2018. The loss occurred even though beneficiaries received a 2% annual COLA for 2018.
The two expenses that have increased fastest since 2000 are both health care-related:
The average retired worker’s Social Security benefit is $1,412.14 per month in 2018, or $16,945.68 per year, just $4,805 above the poverty line.
Understanding The Difference Between
Medicare Advantage and Medicare supplemental insurance (Medigap) are each intended to enhance the value of traditional Medicare coverage. Understanding how Medicare Advantage and Medicare Supplements operate can help agents determine how to structure, market and support these plans. What are the differences between Medicare Advantage and Medigap insurance, and what does each offer its beneficiaries?
How Medicare Advantage health plans operate
Medicare Advantage plans, or Part C plans, are comprehensive benefit packages offered by private payers and funded by the Medicare program. Medicare Advantage companies may also offer plans that include additional services or benefits to members for a higher premium.
Medicare Advantage uses a benchmark bidding system that awards a private payer a set amount of dollars per beneficiary to provide health plan benefits. Health plan bids for MA funds.
Payers in the MA program can sponsor various types of health plans including HMOs, PPOs, private fee-for-service plans (PFFS), and HMO point of service plans (HMOPOS). HMOPOS plans offer out-of-network services for slightly higher costs.
Medicare Advantage can also sponsor a special needs plans (SNP) that provides focused care for members that are dual-eligible for Medicare and Medicaid, members receiving care in acute settings, and members that have high-cost chronic conditions.
Beneficiaries need to be eligible for Medicare Part A and Part B to enroll in an MA plan. Individuals must also live in the MA plan’s regional area to enroll. Medicare Advantage members may also add Part D coverage to their benefits package, which covers prescription drugs.
How Medicare supplemental insurance plans operate
Medicare supplement insurance, or Medigap plans, are health plans sold by private payers to help cover copays, coinsurance, or deductibles not covered under Medicare insurance. Medicare explains that supplement insurance “fills in gaps for certain healthcare cost.”
Medicare Supplement plans standardized and the benefits do not vary from company to company. The plans are divided into categories with an alphabetic label ( Medigap plans A through N). The below chart shows basic information about the different benefits that Medigap plans cover.
CMS will no longer provide “Medigap C and F” plans by 2020, which are plans that cover extra Part B costs.
Beneficiaries with Medicare Part A and B can enroll in a Medicare Supplement plan, however beneficiaries cannot purchase a Medicare Advantage plan and a Medigap policy at the same time.
What type of consumer is likely to enroll in these plan types?
The most recent demographic data for Medicare beneficiaries shows that total 2018 enrollment reached 59 million beneficiaries as of April 2018.
Twenty-one million Medicare beneficiaries enrolled in either an MA plan or a Medicare supplemental insurance policy. A Kaiser Family Foundation analysis estimates that 19 million beneficiaries are enrolled in MA.
Medicare Advantage and supplemental insurance enrollment is the highest in the Midwestern region of the United States. Minnesota has the highest rate of MA and supplemental insurance enrollment, with 59 percent of the population electing for MA or Medigap coverage.
Enrollees in the Medicare program, and consequently MA and Medigap enrollees, are likely to have several chronic conditions at once.
Medicare’s Chronic Conditions Data Warehouse found that 58 percent of Medicare beneficiaries have hypertension, while 47 percent have hyperlipidemia. In addition, nearly a third of Medicare beneficiaries have been treated for either rheumatoid arthritis (32 percent), ischemic heart disease (28 percent), or diabetes (28 percent).
How to take advantage of growing demand for MA and Medigap
Healthcare companies offering MA plans posted significant profits in the first quarter of 2018. Currently, the Medicare Advantage market is a $187 billion segment of the industry. This is great news for agents currently selling MA plans.
A CMS final rule also allows payers to tailor Medicare Advantage benefits to address the needs of chronic beneficiaries. In addition, Medicare Advantage can help companies generate greater cost savings and improved patient outcomes.
Compared to Medicare fee-for-service, Medicare Advantage was more effective at improving beneficiary outcomes and reducing care costs. Lower costs may leave more profit left over after the bidding process.
Companies that want to maximize their market position within the Medicare Advantage should invest in value-added benefits for their members. Payers could extend preventive care benefits, design more affordable cost sharing for specific services, and help MA members make informed health plan decisions.
The Medigap market has also grown steadily.
About 35 percent of Medicare fee-for-service beneficiaries in 2016 had a Medigap policy. The number of Medigap beneficiaries increased from 12.3 million in 2015 to 13.1 million in 2016, said AHIP.
In 2015, 36 percent of Medicare beneficiaries with a single or combined income of $30,00 or less purchased a Medigap policy to help cover costs. Medigap N plan enrollment grew faster than any other Medigap plan type from 2015 to 2016 and has a promising market presence across the Medicare program.
Medigap payers can position themselves favorably in the Medigap market by investing in technologies that improve customer service with health plans and manage the plan’s medical loss ratio (MLR). Health plans in the Medigap market should also invest in strategies that help target desirable consumers and ensure the right beneficiaries are able to find a Medigap plan.
The growing number of seniors in the US, as well as climbing enrollment numbers, could create a highly successful market atmosphere for agents offering either Medicare Advantage or Medigap policies to their prospective clients.
Medicare Advantage Plans Can Pay for Many
The Centers for Medicare and Medicaid Services is getting ready to let Medicare Advantage plan issuers add major new long-term care benefits to their supplemental benefits menus.
The Better Medicare Alliance, a Washington-based coalition for companies and groups with an interest in the Medicare Advantage has posted a copy of a memo that shows CMS is reinterpreting the phrase “primarily health related” when deciding whether a Medicare Advantage plan can cover a specific benefit.
Kathryn Coleman, director of the CMS Medicare Drug & Health Plan Contract Administration Group, writes in the memo, which was sent to Medicare Advantage organizations April 27, that CMS will let a plan cover adult day care services for adults who need help with either the basic “activities of daily living,” such as walking or going to the bathroom, or with “instrumental activities of daily living,” such as the ability to cook, clean or shop.
A Medicare Advantage plan could not, apparently, cover skilled nursing home care, or assisted living facility fees. But, in addition to adult day care, a Medicare Advantage plan could pay for:
The Better Market Alliance says the memo is a form of subregulatory guidance. It’s possible that CMS could revise the guidance, and there’s no indication whether any Medicare Advantage issuers will be in a position to add major LTC benefits to their benefits packages for 2019.
CMS said it would be changing the 2019 Medicare Advantage program benefits uniformity requirements in the preamble to a collection of 2019 Medicare program regulations posted in April.
The Medicare Advantage programs lets insurers offer consumers comprehensive plans that serve as an alternative to traditional Medicare coverage. CMS tries to control current costs, avoid any incentives for patients to get more care, and help patients shop for plans on an apples-to-apples basis by putting tight limits on the benefits the plan issuers can offer.
The Better Medicare Alliance serves many health care providers and provider groups. It also includes many insurance- and benefits-related players, including the National Association of Health Underwriters, the American Benefits Council, and Aetna Inc., Humana Inc., Scan Health Plan and UnitedHealth Group Inc.
Issuers of private long-term care insurance once treated Medicaid and Medicare benefits that “crowded out” private insurance benefits as a serious problem.
In recent years, however, as low interest rates, strict rate increase rules, and actuarial projection problems have reduced private insurers’ participation in the private LTCI market, the private issuers themselves have talked about the need for public-private partnerships.
Medicare Advantage Will Soon Have Even
Air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals may be among the new benefits added to Medicare Advantage coverage when new federal rules take effect next year.
The Centers for Medicare & Medicaid Services expanded how it defines the "primarily health-related" benefits that insurers are allowed to include in their Medicare Advantage policies. And insurers would include these extras on top of providing the benefits traditional Medicare offers.
"Medicare Advantage beneficiaries will have more supplemental benefits, making it easier for them to lead healthier, more independent lives," said CMS Administrator Seema Verma.
Of the 61 million people enrolled in Medicare last year, 20 million have opted for Medicare Advantage, a privately run alternative to the traditional government program. Advantage plans limit members to a network of providers. Similar restrictions may apply to the new benefits.
Many Medicare Advantage plans already offer some health benefits not covered by traditional Medicare, such as eyeglasses, hearing aids, dental care and gym memberships. But the new rules, which the industry sought, will expand that significantly to items and services that may not be directly considered medical treatment.
CMS said the insurers will be permitted to provide care and devices that prevent or treat illness or injuries, compensate for physical impairments, address the psychological effects of illness or injuries, or reduce emergency medical care.
Although insurers are still in the early stages of designing their 2019 policies, some companies have ideas about what they might include. In addition to transportation to doctors' offices or better food options, some health insurance experts said additional benefits could include simple modifications in beneficiaries' homes, such as installing grab bars in the bathroom, or aides to help with daily activities, including dressing, eating and other personal care needs.
"This will allow us to build off the existing benefits that we already have in place that are focused more on prevention of avoidable injuries or exacerbation of existing health conditions," said Alicia Kelley, director of Medicare sales for Capital District Physicians' Health Plan, a nonprofit serving 43,000 members in 24 upstate New York counties.
Even though a physician's order or prescription is not necessary, the new benefits must be "medically appropriate" and recommended by a licensed health care provider, according to the new rules.
Many beneficiaries have been attracted to Medicare Advantage because of its extra benefits and the limit on out-of-pocket expenses. However, CMS also cautioned that new supplemental benefits should not be items provided as an inducement to enroll.
UnitedHealthcare, the largest health insurer in the US, also welcomes the opportunity to expand benefits, said Matt Burns, a company spokesman. "Medicare benefits should not be one-size-fits-all, and continued rate stability and greater benefit design flexibility enable health plans to provide a more personalized health care experience," he said.
But patient advocates including David Lipschutz. Senior policy attorney at the Center for Medicare Advocacy, are concerned about those who may be left behind.
"It's great for the people in Medicare Advantage plans, but what about the majority of the people who are in traditional Medicare?" he asked. "As we tip the scales more in favor of Medicare Advantage, it's to the detriment of people in traditional Medicare."
The details of the 2019 Medicare Advantage benefit packages must first be approved by CMS and will be released in the fall, when the annual open enrollment begins. It's very likely that all new benefits will not be available to all beneficiaries since there is "tremendous variation across the country" in what plans offer, said Gretchen Jacobson, associate director of the Kaiser Family Foundation's Program on Medicare Policy.
Medicare Advantage expected to grow to 50% of the market, says UnitedHealth Group
UnitedHealth Group reported first quarter earnings from operations growth of 18.8 percent year-over-year, driven by a strong performance in the Medicare Advantage and Medicaid markets as well as double-digit percent increases in its Optum segments.
UnitedHealth Group reported $4.1 billion in Q1 earnings from compared to $3.4 billion for the three months ended March 31, 2017. First quarter net earnings grew by 28.7 percent over the previous year.
Based on first quarter results and the business outlook for the balance of the year, UnitedHealth Group has increased its outlook for 2018 net earnings.
UnitedHealth Group looks very different from five years ago, said CEO David S. Wichmann during Tuesday's earnings call. Today clinical and technical professions are the first and third largest job categories across UnitedHealth Group. Five years from now the company will also be different.
"Within 10 years, we expect half of all Americans will be receiving their healthcare from physicians operating in highly evolved and coordinated value-based care designs," Wichmann said.
UnitedHealthcare, the company's insurance arm, reported earnings from operations for the quarter of $2.4 billion, compared to $2.1 billion the year before, a 12.5 percent increase.
The insurer serves 2.2 million more consumers quarter-over- quarter, but as forecasted, the employer and individual market served 195,000 fewer people in commercial group plans.
This was due to employers shifting their retirees from self-funded offerings to group Medicare Advantage plans and lower retention due to pricing to cover the full cost of the health insurance tax.
The Medicare Advantage and Medicaid markets are growing. UnitedHealthcare grew to serve 375,000 more seniors with medical benefits during the first 90 days of this year, including 330,000 more in Medicare Advantage, according to Steve Nelson, CEO of UnitedHealthcare.
Related - Medicare Advantage cleared to go beyond medical coverage - View
Medicare Advantage enrollment grew 10.6 percent year-over-year.
The Medicare Advantage market has always been competitive, said Brian Thompson, CEO for UnitedHealthcare Medicare & Retirement, to a question on other insurers jumping into the space.
But the Medicare Advantage market is also under-penetrated, he said. It has 33 percent of senior citizens in plans today, but the company sees a path to over 50 percent in the next 5-10 years, he said.
"In Medicaid we continue to expect strong revenue growth in 2018, and that includes ongoing national growth serving dual special needs members, providing them aligned benefits and comprehensive service to address their often times more complex care needs," Nelson said.
The insurer closed gaps in care through simple preventative measures such as flu vaccines, to serving more complex needs. The social determinants of health such as lack of affordable housing, food insecurity and isolation weigh heavily on gaps in care.
Social investments are the next frontier to serving the whole person, executives said.
CMS Gives Medicare Advantage Plans a Raise
The CMS finalized a rule Monday giving Medicare Advantage plans a 3.4% pay hike in 2019. That's well above the 1.84% bump the agency initially proposed and higher than the 2.95% increase for 2018.
The CMS is also moving forward with plans to increase the use of encounter data to determine risk scores for plans. As a result of the finalized rule, 75% of Medicare Advantage risk scores will be based on traditional fee-for-service data, and 25% based on encounter data. That differs from 2018, when the agency used a risk score blend of 85% fee-for-service data and 15% encounter data.
Stakeholders such as the American Hospital Association have pushed back at using encounter data after a January 2017 Government Accountability Office report found such information often isn't accurate.
"Since the quality of the encounter data has improved, CMS believes it is appropriate to move forward with the proposed increased percentage of encounter data in the blend," the agency said in a release Monday.
The CMS also finalized a policy to prevent Medicare beneficiaries who are deemed at risk for opioid misuse or abuse from obtaining prescription drugs from multiple doctors or pharmacies. Instead, they'll be locked into one pharmacy or prescriber for Medicare Part D benefits.
This lock-in will limit an at-risk beneficiary's access to coverage for frequently abused drugs to those that are prescribed by a specified pharmacy or provider.
Medicare Advantage enrollment is projected to grow by 9% to 20.4 million in 2018. The CMS estimated that more than one-third of all Medicare enrollees, or 34%, will be in a Medicare Advantage plan in 2018.