Enrollment Still Growing In Medicare Advantage Plans, GAO Says

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Cassandra Q. Butts by Center for American ProgressWhile the health law’s changes had little impact on MA enrollment this year, more changes may be in store. The GAO report notes that the Congressional Budget Office has predicted that those $136 billion in cuts to MA plans would decrease enrollment by about 35 percent through 2019. The Office of the Actuary at the Centers for Medicare and Medicaid Services has found that the reduction in MA payments would eventually lead to those plans offering less-generous benefit packages.
Source: kaiserhealthnews.org

Video: Understanding Medicare Advantage Plans

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The original Medicare program has two parts: Part A (Hospital Insurance), and Part B (Medical Insurance). Only a few special cases exist where prescription drugs are covered by original Medicare, but as of January 2006, Medicare Part D provides more comprehensive drug coverage. Medicare Advantage plans, also known as Medicare Part C, are another way for beneficiaries to receive their Part A, B and D benefits. All Medicare benefits are subject to medical necessity. Part A: Hospital Insurance Part A covers inpatient hospital stays (at least overnight), including semiprivate room, food, tests, and doctor’s fees. Part A covers brief stays for convalescence in a skilled nursing facility if certain criteria are met: 1. A preceding hospital stay must be at least three days, three midnights, not counting the discharge date. 2. The nursing home stay must be for something diagnosed during the hospital stay or for the main cause of hospital stay. 3. If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision then the nursing home stay would be covered. 4. The care being rendered by the nursing home must be skilled. Medicare part A does not pay for custodial, non-skilled, or long-term care activities, including activities of daily living (ADL) such as personal hygiene, cooking, cleaning, etc. The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2009, $133.50 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset and the person qualifies for a new 100-day benefit period. Part B: Medical Insurance Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or their spouse is still actively working. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working. Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as Lupron, and other outpatient medical treatments administered in a doctor’s office. Medication administration is covered under Part B only if it is administered by the physician during an office visit. Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered. Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) only apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Coverage information is also located in the CMS Internet-Only Manuals (IOM), the Code of Federal Regulations (CFR), the Social Security Act, and the Federal Register. Part C: Medicare Advantage plans With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the original Medicare plan (Parts A and B). These programs were known as “Medicare+Choice” or “Part C” plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, “Medicare+Choice” plans were made more attractive to Medicare beneficiaries by the addition of prescription drug coverage and became known as “Medicare Advantage” (MA) plans. Traditional or “fee-for-service” Medicare has a standard benefit package that covers medically necessary care members can receive from nearly any hospital or doctor in the country. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a capitated rate, or a set amount, every month for each member. Members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B), such as prescription drugs, dental care, vision care and gym or health club memberships. In exchange for these extra benefits, enrollees may be limited in the providers they can receive services from without paying extra. Typically, the plans have a “network” of providers that patients can use. Going outside that network may require permission or extra fees. Medicare Advantage plans are required to offer coverage that meets or exceeds the standards set by the original Medicare program, but they do not have to cover every benefit in the same way. If a plan chooses to pay less than Medicare for some benefits, like skilled nursing facility care, the savings may be passed along to consumers by offering lower copayments for doctor visits. Medicare Advantage plans use a portion of the payments they receive from the government for each enrollee to offer supplemental benefits. Some plans limit their members’ annual out-of-pocket spending on medical care, providing insurance against catastrophic costs over $5,000, for example. Many plans offer dental coverage, vision coverage and other services not covered by Medicare Parts A or B, which makes them a good value for the health care dollar, if you want to use the provider included in the plan’s network or “panel” of providers. Because the 2003 payment formulas overpay plans by 12 percent or more compared to traditional Medicare,[11] in 2006 enrollees in Medicare Advantage Private Fee-for-Service plans were offered a net extra benefit value (the value of the additional benefits minus any additional premium) of $55.92 a month more than the traditional Medicare benefit package; enrollees in other Medicare Advantage plans were offered a net extra benefit value of $71.22 a month more.[12] However, Medicare Advantage members receive additional coverage and medical benefits not enjoyed by traditional Medicare members, and savings generated by Medicare Advantage plans may be passed on to beneficiaries to lower their overall health care costs.[10] Other important distinctions between Medicare Advantage and traditional Medicare are that Medicare Advantage health plans encourage preventive care and wellness and closely coordinate patient care.[13] Medicare Advantage Plans that also include Part D prescription drug benefits are known as a Medicare Advantage Prescription Drug plan or a MA-PD. Enrollment in Medicare Advantage plans grew from 5.4 million in 2005 to 8.2 million in 2007. Enrollment grew by an additional 800,000 during the first four months of 2008. This represents 19% of Medicare beneficiaries. A third of beneficiaries with Part D coverage are enrolled in a Medicare Advantage plan. Medicare Advantage enrollment is higher in urban areas; the enrollment rate in urban counties is twice that in rural counties (22% vs. 10%). Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more. Because of the 2003 law’s overpayments, the number of organizations offering Fee-for-Service plans has increased dramatically, from 11 in 2006 to almost 50 in 2008. Eight out of ten beneficiaries (82%) now have access to six or more Private Fee-for-Service plans.[14] Each year many individuals disenroll from MA plans. A recent study noted that about 20 percent of enrollees report that “their most important reason for leaving was due to problems getting care.”[15] There is some evidence that disabled beneficiaries “are more likely to experience multiple problems in managed care.”[16] Some studies have reported that the older, poorer, and sicker persons have been less satisfied with the care they have received in MA plans.[17] On the other hand, an analysis of the Agency for Healthcare Research and Quality data published by America’s Health Insurance Plans found that Medicare Advantage enrollees spent fewer days in the hospital than Fee-for-Service enrollees, were less likely to have “potentially avoidable” admissions, and had fewer re-admissions. These comparisons adjusted for age, sex and health status using the risk score used in the Medicare Advantage risk adjustment mechanism.[18][19] In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data were not available. Almost six out of ten (59%) of MA plans did receive ratings, and these plans represented 85% of the enrollment for 2009. The average rating was 3.29 stars. Twenty-three percent of enrollees were in a plan with four or more stars; 20% were in a plan with fewer than three stars.[20] Twenty percent of African-American and 32 percent of Hispanic Medicare Beneficiaries were enrolled in Medicare Advantage plans in 2006. Almost half (48%) of Medicare Advantage enrollees had incomes below $20,000, including 71% of minority enrollees.[21] Others have reported that minority enrollment is not particularly above average.[22] Another study has raised questions about the quality of care received by minorities in MA plans.[23] The Government Accountability Office reported that in 2006, the plans earned profits of 6.6 percent, had overhead (sales, etc.) of 10.1 percent, and provided 83.3 percent of the revenue dollar in medical benefits. These administrative costs are far higher than traditional fee-for-service Medicare.[24] [edit] Part D: Prescription Drug plans Main articles: Medicare Part D and Medicare Part D coverage gap Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the Medicare Prescription Drug, Improvement, and Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies. Unlike Original Medicare (Part A and B), Part D coverage is not standardized. Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. The exception to this is drugs that Medicare specifically excludes from coverage, including but not limited to benzodiazepines, cough suppressant and barbiturates. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases. It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by part D of Medicare, such as benzodiazepines, and other restricted controlled substances.
Source: medicare-health.com

Medicare Advantage Plan Star Ratings and Bonus Payments in 2012

This report looks at the star ratings that have been used for many years to help consumers compare plans, and examines how Medicare Advantage quality scores will interact with plan payments, beginning in 2012.   To encourage Medicare Advantage plans to provide quality care, the 2010 health reform law authorized Medicare to pay plans bonuses beginning in 2012 if they receive four or five stars on the program’s five-star quality rating system, or are unrated.  Building on that provision, the Centers for Medicare and Medicaid Services subsequently launched a demonstration that allowed more plans to receive bonuses and increased the size of the bonuses to encourage plans to maintain or improve their rating.   Authored by Foundation researchers, the report is the fourth in a series looking at various aspects of the Medicare Advantage star ratings. Report (.pdf)
Source: kff.org

Gorman Health Group’s Jeff Fox to Provide Insight on the 2012 Medicare Advantage and Part D Annual Election Period : e Yugoslavia

During the Dec 15 webinar — just one week after the end of the AEP — Jeff Fox, president of Gorman Health Group and one of the industry’s top MA and Part D marketing experts, will lead a post-mortem on what happened this fall and why. Long before CMS data for 2012 enrollment will be released, webinar participants will get insider insights on what worked, what didn’t and what it all means as plans work to finalize their applications to CMS for 2013 MA and Part D product offerings. During the 60-minute presentation and 30 minutes of Q&A, webinar attendees will get reliable strategic information on such key topics as:
Source: eyugoslavia.com

Big Government Brings Big Profits To Texas Health Plans

A recent New York Times editorial suggested that the federal government overpays for Medicare Advantage (also known as Medicare Part C), noting that these privately run plans cover roughly a quarter of all enrollees but “cost an average of 10 percent more than what the same coverage would cost in traditional Medicare.” In a letter to the Times in response, Karen Ignagni, president of the trade group America’s Health Insurance Plans, rejoined that the plans provide more comprehensive benefits than fee-for-service Medicare.
Source: texasreport.net

Medicare Advantage Plans and Your Family

People who are overweight, tend to have many more health problems than people who are physically fit. Losing weight can save you money by cutting down on the number of doctors visits you have to go to. Health insurance companies like when you are healthy because it saves them money and they also like it when you buy medicare advantage plans that have got more coverage then what you need. Many companies offer free or discounted memberships at various gyms, as an incentive to be more physically active, and healthy.
Source: spicandproud.com

Medicare on Main Street: Obamacare hammers Granite State

“Remember when President Obama said that if his health care ‘reform’ law passed, you’d still get to keep your doctor?  Medicare Advantage participants in the Granite State are finding out what a lie that was. “Medicare Advantage is a subset of Medicare in which the federal government pays private insurers a set monthly rate to provide coverage that is approved and regulated by Medicare. The private insurers can charge different rates and offer a wider variety of services than are offered in traditional Medicare.  Though Medicare Advantage costs more in its startup phase, the idea is to save money in the long run by providing incentives for insurers to reduce costs.  But because the plan is market-based, the Obama administration wants to kill it. Obamacare eventually defunds it. “New Hampshire has a high percentage of Medicare Advantage enrollees. Last month, 7,600 of them received notices that their coverage was being cancelled. Obamacare and another federal law passed in 2008, the Medicare Improvement for Patients and Providers Act, are killing Medicare Advantage to steer senior citizens back into regular Medicare, which offers fewer choices and is more heavily controlled from Washington. “As a result, thousands of Granite State seniors are being forced to switch doctors because they have to switch coverage. “This is just a taste of what is to come if Obamacare takes effect in full force.  Its regulations will so skew the private insurance market that millions will lose the coverage they have and be forced into plans preferred by bureaucrats in Washington.  They will lose access to their doctors, too. It would make a lot more sense to reform the health insurance market by working to give people more control over their own care, not less.”
Source: gop.gov

Medicare Advantage Plans Still Popular as Premiums Fall

Medicare Advantage is becoming more popular among senior citizens in the United States as premiums fall, a direct contradiction of what Republicans said about Obama’s health care law halting the expansion of the program.
Source: agentnavigator.com

Big Drug Hikes in Some 2012 Medicare Plans

Washington walked through the Plan Finder with U.S. News, using a hypothetical Medicare participant in Chevy Chase, Md., who takes two prescription drugs: Cimzia for rheumatoid arthritis and Cozaar for high blood pressure. Cimzia is an expensive drug that is placed in the top pricing tier of many drug plans, she said. Cozaar has a generic equivalent, but the branded version was retained for this price comparison. Based on these two drugs alone, there was more than a $1,000 difference in projected 2012 out-of-pocket costs for the 10 cheapest plans out of more than 30 available in Chevy Chase. Plans with the lowest premiums did not always have the lowest out-of-pocket costs.
Source: mytopnews.net

Insurance Agents Look to Dataman Group for New Prospects in their Areas

Dataman Group helps Insurance Agents find the right prospects for the Medicare Supplement Plans they offer. Most Agents simply select prospects in the zip-codes/counties closest to their location and select those individuals that recently turned 65 or are Turning 65 in the next few months.  These individuals must sign up for a program no later than December 31st and smart marketers will contact prospects in their area as soon as possible.
Source: eduspeaks.com

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