Build on the steady progress in risk adjustment. Risk adjustment is a tool used to address selection bias in Medicare Advantage and other private insurance programs. The goal is to mitigate an insurer’s ability to tailor plans to attract a disproportionate share of the most profitable enrollees—healthier enrollees that consume less medical services. Every major Medicare reform proposal, based on premium support, would provide risk adjustment or significantly improve the risk-adjustment formulas or mechanisms that currently exist in the MA or Medicare Part D program. Risk adjustment could either be prospective or retrospective. Prospective risk adjustment already characterizes Medicare Advantage and Medicare Part D, where government per capita payments are adjusted by demographic factors, such as age, sex, institutional or Medicaid status, and medical conditions. Retrospective risk adjustment—back-end adjustments—would be based on new pooling arrangements, such as a risk-transfer pool. In that arrangement, health plans that attracted higher-risk or more costly patients would be cross-subsidized by plans that attracted fewer high-risk or less costly patients. The value of these types of arrangements is that they would be based on hard data and not on educated guesswork or projections. The Wyden–Ryan plan, for example, includes such an approach. The Heritage proposal would include both prospective and retrospective risk adjustment. Applying the lessons from MA’s risk-adjustment experience could mitigate the risks that only the unhealthy would be stuck in Medicare fee-for-service plans, leaving the plans’ costs to escalate and grow further away from the premium support benchmark, and thus more expensive for enrollees. Over the past decade, as Alice Rivlin and others have noted, the risk-adjustment mechanism used in Medicare Advantage has significantly improved and succeeded in reducing favorable selection in the program. In the future, with the adoption of defined-contribution financing for the entire Medicare program, one can expect further refinements and innovative approaches to adjusting government per capita payments. One particularly interesting approach has been developed by Zhou Yang, professor of economics at Emory University. Professor Yang’s proposal, to be implemented within an environment of competitive health plans, would tie Medicare payments to positive behavioral changes: Enrollees would be rewarded for enrollment in wellness or preventive-care programs that promote a healthier (and thus less costly) lifestyle.
The Evolving Reimbursement Rights of Medicare Advantage Plans
Arkansas will not recognize an insurer’s right to subrogation unless the insured has been “made whole” for his or her injuries. Franklin v. Healthsource of Ark., 942 S.W.2d 837 (Ark. 1997). In determining whether or not an insured has been “made whole,” Arkansas employs the “Franklin Test” under which the recovery (including recovery from the third party tortfeasor and insurance proceeds) is subtracted by the loss sustained and expense incurred. Id. Arkansas will uphold this rule even where there is an express subrogation agreement but the insured has not been fully compensated for his/her loss. Am. Underwriters Ins. v. Turner, 944 S.W.2d 129, 130 (Ark. App. 1997). The Supreme Court of Arkansas has also recently held that unless an agreement has been reached between an insured and its carrier, the “subrogation lien cannot arise, or attach, until the insured has received settlement proceeds or damage award and until there is a judicial determination that the insured has been made whole.” Riley v. State Farm Mutual Auto. Ins. Co., 2011 Ark. 256.
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UPMC’s Medicare Advantage Provider Contracts with Highmark Will Not Be Extended for 2016
Nearly a year ago, however, Highmark stopped paying UPMC the rates specified in those contracts for that world-class care—including treatment for cancer at the renowned Hillman Cancer Center—and claimed that it has the right to reduce rates whenever and however it wishes. Although UPMC gave Highmark more than sufficient opportunity to take the required corrective actions, it has refused. As a result of Highmark’s breach of its UPMC contracts, and in keeping with UPMC’s right to end the contracts at the end of each calendar year with or without cause, UPMC has provided Highmark with notices of non-renewal of the current Medicare Advantage contracts effective January 1, 2016. No responsible organization could enter into—let alone extend—such illusory and one-sided contracts.
Easy Choice Health Plan (HMO)
If you are looking for a Medicare Advantage Prescription Drug Plan that not only allows for “one stop service” for all your physician, hospital and prescription drug needs, but also provides additional, non Medicare covered benefits, at virtually no cost to you, you’ve come to the right place! Easy Choice Health Plan (HMO) is a federally approved Medicare Advantage Prescription Drug (MAPD) and Special Needs Plan (SNP) designed to provide medical and prescription drug coverage for qualifying individuals in Los Angeles, Alameda, Fresno, San Diego, Santa Clara, Stanislaus, Riverside, Orange, San Joaquin, and San Bernardino counties, California.