To compete in Medicare Advantage, health plans must have operating capabilities that can deliver superior processes and service, maintain margins and price competitiveness, and fund differentiating characteristics. For all players, this level of operational excellence depends on four critical elements: Robust Utilization and Care Management.
Full Answer
How are new Medicare Advantage payers entering the Medicare Advantage market?
Medicare Advantage payers are expanding into new geographic areas and offering new plans with more diverse benefits. New entrants to the market are eager to identify distinctive value propositions—for example, a wider network of doctors, or nonmedical benefits such as meals or transportation—to carve out a niche and establish their right to win.
What is it like to sell Medicare Advantage plans?
The unique thing about selling Medicare Advantage plans is that you don’t get to sell a product unless you’ve passed tests and meet knowledge requirements. LM: Correct. Further, you may have face-to-face training requirements before selling. You’ll be in a room of other new agents.
How do Medicare Advantage plans get funded?
The answer lies primarily in the way Advantage plans get funding. Private insurance companies offer Advantage plans, also known as Part C, to Medicare beneficiaries. Advantage plans enable participants to receive multiple benefits from one plan, but all Advantage plans must also include the same coverage as Original Medicare (Parts A and B).
Is the Medicare Advantage plan right for You?
The Medicare Advantage Plan may offer a $0 premium, but the out-of-pocket surprises may not be worth those initial savings if you get sick. “The best candidate for Medicare Advantage is someone who's healthy," says Mary Ashkar, senior attorney for the Center for Medicare Advocacy.
How do I succeed in Medicare Advantage?
The success of Medicare Advantage has been centered on building four foundational principles, regardless of the model chosen.Strategic contract arrangements that account for the risk profile of the population. ... Accurate coding and documentation. ... Optimal Medicare Advantage star ratings.More items...•
Are Medicare Advantage enrollees healthier?
Traditional Medicare and Medicare Advantage enrollees have historically had different characteristics, with Medicare Advantage enrollees somewhat healthier.
What are the advantages and disadvantages of Medicare Advantage plans?
Medicare Advantage offers many benefits to original Medicare, including convenient coverage, multiple plan options, and long-term savings. There are some disadvantages as well, including provider limitations, additional costs, and lack of coverage while traveling.
Does Medicare Advantage pay less than traditional Medicare?
In 2021, virtually all Medicare Advantage enrollees (99%) would pay less than the traditional Medicare Part A hospital deductible for an inpatient stay of 3 days, and these enrollees would pay $747 on average (Figure 3).
What are the negatives of a Medicare Advantage plan?
Medicare Advantage can become expensive if you're sick, due to uncovered copays. Additionally, a plan may offer only a limited network of doctors, which can interfere with a patient's choice. It's not easy to change to another plan. If you decide to switch to a Medigap policy, there often are lifetime penalties.
What percent of seniors choose Medicare Advantage?
A team of economists who analyzed Medicare Advantage plan selections found that only about 10 percent of seniors chose the optimal Medicare Advantage plan. People were overspending by more than $1,000 per year on average, and more than 10 percent of people were overspending by more than $2,000 per year!
What is a key advantage of Medicare Advantage plans?
If you join a Medicare Advantage Plan, you'll still have Medicare but you'll get most of your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare. Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
What is the highest rated Medicare Advantage plan?
List of Medicare Advantage plansCategoryCompanyRatingBest overallKaiser Permanente5.0Most popularAARP/UnitedHealthcare4.2Largest networkBlue Cross Blue Shield4.1Hassle-free prescriptionsHumana4.01 more row•Jun 22, 2022
Do Medicare Advantage plan premiums increase with age?
The way they set the price affects how much you pay now and in the future. Generally the same monthly premium is charged to everyone who has the Medigap policy, regardless of age. Your premium isn't based on your age. Premiums may go up because of inflation and other factors, but not because of your age.
Is Original Medicare more expensive than Medicare Advantage?
The costs of providing benefits to enrollees in private Medicare Advantage (MA) plans are slightly less, on average, than what traditional Medicare spends per beneficiary in the same county.
Is Medicare Advantage the future?
After a 9 percent increase from 2021 to 2022, enrollment in the Medicare Advantage (MA) program is expected to surpass 50 percent of the eligible Medicare population within the next year. At its current rate of growth, MA is on track to reach 69 percent of the Medicare population by the end of 2030.
Can you switch back from Medicare Advantage to regular Medicare?
Yes, you can elect to switch to traditional Medicare from your Medicare Advantage plan during the Medicare Open Enrollment period, which runs from October 15 to December 7 each year. Your coverage under traditional Medicare will begin January 1 of the following year.
What are the requirements to compete in Medicare Advantage?
To compete in Medicare Advantage, health plans must have operating capabilities that can deliver superior processes and service, maintain margins and price competitiveness, and fund differentiating characteristics. For all players, this level of operational excellencedepends on four critical elements:
How much will Medicare Advantage increase in 2023?
By 2023, available annual profit pools will range from $11 billion to $13 billion, making Medicare Advantage the single biggest driver of profit growth for health care payers.
How much will Medicare be in 2023?
It’s a vast market—projected to reach more than $360 billion a year by 2023—with attractive growth baked in. Below the surface, though, lie difficult dynamics and increasingly tough competition. Medicare Advantage—the insurance programs that private companies offer through Medicare—has established itself as a hot market segment that shows no signs of cooling, and lots of health care payers are eyeing it. But they should look carefully before they leap. Large incumbents such as United Health, Humana, CVS Aetna, and Anthem, along with powerful regional players such as WellCare, have built strong defenses. New entrants must develop a compelling value case if they are to gain a foothold, much less seize significant share. Here’s what companies need to know to get into the market or increase their current share.
How does risk stratification work?
Accurate Risk Stratification. Payers need to conduct risk assessments in concert with providers, incorporating data from external sources to achieve as full and accurate a view as possible (consistent with privacy laws and regulations) of the member’s risk and needs. Newer models incorporate self-learning technologies enabled by machine learning algorithmsthat increase predictive accuracy over time, and they connect the patient’s risk stratification with provider treatment plans. Having best-in-class risk stratification capabilities enables payers to address potential gaps in care for members and also to capture important patient risk factors, thereby ensuring accurate scoring of the risk adjustment factor and, where appropriate, additional payment revenue from CMS.
How can Medicare help Baby Boomers?
In particular, they expect to continue to live on their own terms. Payers can drive growth and improve overall care, consumer convenience, and experience by integrating innovations that appeal to this generation of Medicare consumers. These include incorporating high-touch, convenient, easy-to-schedule primary-care models and providing in-home care management support for consumers who prefer to age in place and maintain their daily routines. Some payers are investing in in-home care and wellness programs designed to help people return home more quickly after hospitalization or live more easily at home when managing long-term illnesses or chronic conditions.
Why do payers invest in in-home care?
Some payers are investing in in-home care and wellness programs designed to help people return home more quickly after hospitalization or live more easily at home when managing long-term illnesses or chronic conditions. Listening to Members. Payers in general receive low trust scores from consumers.
What is traditional care management?
The traditional care management approach focus es on intervention at a point in time. Payers need to step back and take a long-term view of patients’ health needs, including social determinants of health, and apply predictive analytics to anticipate care demands and, if possible, avoid adverse outcomes.
Why don't Medicare patients choose MA plans?
The majority of Medicare recipients do not choose MA plans, either because they aren’t aware of them or because their preferred doctors may not always be part of the plans , but the numbers are growing. Based on CMS data, more than 32 percent of Medicare members in 2016 — some 19 million out of the 58 million total — enrolled in MA plans.
How to succeed in the MA market?
But to truly succeed, payors will need to build a coherent strategy that holistically ties these four areas with a corresponding “way to play.” For example, a clinic-based care coordinator, such as Illinois-based Riverside Healthcare, can emphasize in-person care experiences and maintain a low-cost model by automating or outsourcing operations including compliance, all while leveraging MACRA principles for its narrow network design. A regional plan with large membership, such as Florida-based managed care company Wellcare, should seek to enhance the member experience by expanding its digital footprint while developing proactive risk management and operational excellence capabilities that ensure compliant and low-cost operations.
What is the 2015 Medicare Access and CHIP Reauthorization Act?
The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) is accelerating this shift by rewarding or penalizing Medicare providers (i.e., doctors and hospitals) through the addition of a bonus to, or subtraction of a fine from, their FFS payments based on the quality of care.
How much will MA revenue be in 2025?
Accordingly, we expect annual revenues for MA plans to rise from US$215 billion in fiscal year 2017 to more than $500 billion by 2025. The underlying growth of MA is good news for healthcare payors. But not all participants will benefit equally.
Is there any uncertainty surrounding the repeal of the ACA?
There is great uncertainty surrounding attempts to repeal, reform, or replace the Affordable Care Act (ACA). But as we’ve noted, market participants can’t afford to sit still. Regardless of what happens, there is one very significant sector of healthcare that is positioned to succeed in this environment of uncertainty: Medicare Advantage (MA). As baby boomers age into qualification for Medicare, members are more likely to opt for plans that have benefits beyond what Medicare has traditionally offered. As a result, MA will present a significant source of growth for insurers. But to access a substantial share of this profit, plans need to urgently invest in key differentiating capabilities.
Does Medicare cover all costs?
Although Medicare reimburses providers, it doesn’t cover all costs. This is where Medicare Advantage comes into play.
Do baby boomers qualify for Medicare?
As baby boomers age into qualification for Medicare, members are more likely to opt for plans that have benefits beyond what Medicare has traditionally offered. As a result, MA will present a significant source of growth for insurers.
What is an HMO plan?
Health Maintenance Organization (HMO) plan is a type of Medicare Advantage Plan that generally provides health care coverage from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). A network is a group of doctors, hospitals, and medical facilities that contract with a plan to provide services. Most HMOs also require you to get a referral from your primary care doctor for specialist care, so that your care is coordinated.
What happens if you get a health care provider out of network?
If you get health care outside the plan’s network, you may have to pay the full cost. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed. In most cases, you need to choose a primary care doctor. Certain services, like yearly screening mammograms, don’t require a referral. If your doctor or other health care provider leaves the plan’s network, your plan will notify you. You may choose another doctor in the plan’s network. HMO Point-of-Service (HMOPOS) plans are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance. It’s important that you follow the plan’s rules, like getting prior approval for a certain service when needed.
What is a special needs plan?
Special Needs Plan (SNP) provides benefits and services to people with specific diseases, certain health care needs, or limited incomes. SNPs tailor their benefits, provider choices, and list of covered drugs (formularies) to best meet the specific needs of the groups they serve.
Do providers have to follow the terms and conditions of a health insurance plan?
The provider must follow the plan’s terms and conditions for payment, and bill the plan for the services they provide for you. However, the provider can decide at every visit whether to accept the plan and agree to treat you.
Can a provider bill you for PFFS?
The provider shouldn’t provide services to you except in emergencies, and you’ll need to find another provider that will accept the PFFS plan .However, if the provider chooses to treat you, then they can only bill you for plan-allowed cost sharing. They must bill the plan for your covered services. You’re only required to pay the copayment or coinsurance the plan allows for the types of services you get at the time of the service. You may have to pay an additional amount (up to 15% more) if the plan allows providers to “balance bill” (when a provider bills you for the difference between the provider’s charge and the allowed amount).
How to see how a Medicare Advantage Plan cherry picks its patients?
To see how a Medicare Advantage Plan cherry-picks its patients, carefully review the copays in the summary of benefits for every plan you are considering. To give you an example of the types of copays you may find, here are some details of in-network services from a popular Humana Medicare Advantage Plan in Florida:
What should prospective Medicare Advantage customers research?
Prospective Medicare Advantage customers should research plans, copays, out-of-pocket costs, and eligible providers.
What is Medicare Supplement?
Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). To help pay for things that aren't covered by Medicare, you can opt to buy supplemental insurance known as Medigap (or Medicare Supplement Insurance). These policies are offered by private insurers and cover things that Medicare doesn't, such as copayments, deductibles, and healthcare when you travel abroad.
What is Medicare Advantage Plan?
A Medicare Advantage Plan is intended to be an all-in-one alternative to Original Medicare. These plans are offered by private insurance companies that contract with Medicare to provide Part A and Part B benefits, and sometimes Part D (prescriptions). Most plans cover benefits that Original Medicare doesn't offer, such as vision, hearing, ...
Does Medicare Advantage plan have a $0 premium?
As this non-exhaustive list of copays demonstrates, out-of-pocket costs will quickly build up over the year if you get sick. The Medicare Advantage Plan may offer a $0 premium, but the out-of-pocket surprises may not be worth those initial savings if you get sick. “The best candidate for Medicare Advantage is someone who's healthy," says Mary Ashkar, senior attorney for the Center for Medicare Advocacy. "We see trouble when someone gets sick." 3
Can you sell a Medigap plan to a new beneficiary?
But as of Jan. 2, 2020, the two plans that cover deductibles—plans C and F— cannot be sold to new Medigap beneficiaries.
Does Medicare Advantage cover doctor visits?
Not necessarily. Medicare Advantage only works a limited network of healthcare providers, so double check to make sure your doctor visit is covered.
How To Get Certified To Sell Medicare Advantage Plans?
DD: What’s the process for somebody who wants to learn how to become a Medicare Advantage insurance agent?
What Is Medicare Advantage?
I’m sure there are a lot of people who have heard about Medicare, maybe they’re brand new agents or somewhat experienced in the business of selling insurance.
What Are The Long-Term Benefits Of Selling Medicare Insurance?
DD: What would you describe as the long-term advantages selling Medicare Advantage plans as your primary line of business?
How Long Would It Take To Write 500 Sales?
DD: How long do you think it would take to write 500 pieces of business? Somebody who’s serious about this business, they’re full-time , they really give it their all.
How often do you need to take AHIP certification?
Now, certifications in AHIP have to be done every year. It’s a yearly requirement for all Medicare Advantage agents. DD: When you take these certifications, you’re learning all the intricacies of the product, which helps you sell more Medicare Advantage plans. So, these tests are important.
What is the age limit for Medicare?
LM: When somebody has Medicare they’re normally 65 and over. You do have a segment of the population under 65 that get Medicare who are usually disabled. Once someone is on Medicare they have two options – Medicare Advantage or Medicare Supplement. There’s not a good or a bad option, there is simply two options.
Is Medicare Advantage a good or bad plan?
There’s not a good or a bad option, there is simply two options. We’re going to focus today on selling Medicare Advantage plans. Medicare Advantage is a plan that helps fill the gaps that naturally occur with a Medicare plan. For example, common carriers include:
Why are Advantage plans advertised?
Advantage plans are heavily advertised because of how they are funded. These plans' premiums are low or nonexistent because Medicare pays the carrier whenever someone enrolls. It benefits insurance companies to encourage enrollment in Advantage plans because of the money they receive from Medicare.
What is an Advantage Plan?
Advantage plans enable participants to receive multiple benefits from one plan, but all Advantage plans must also include the same coverage as Original Medicare (Parts A and B). When you have an Advantage plan and receive care, the insurance company pays instead of Medicare. Advantage plans are often HMOs or PPOs, ...
What is the primary source of funding for Advantage Plans?
The Centers for Medicare & Medicaid Services (CMS) is the principal source of funding for Advantage plans, paying insurance companies for each beneficiary's expected healthcare costs. Thus, the more people who enroll in Advantage plans, the more funds Medicare gives insurance companies offering these plans. In exchange, the Advantage plans, rather than Medicare, pay for enrollees' care. Critics have raised concerns that CMS steers enrollees to Advantage plans because of this.
How much is Medicare premium for 2021?
Those who paid into Medicare taxes for fewer than 40 quarters must also pay a Part A premium. The monthly premium for 2021 is $259 for individuals who have contributed taxes between 30 and 40 quarters. It is $471 for those who have contributed for fewer than 30 quarters. People who have paid Medicare taxes for 40 or more quarters receive Part A premium-free.
How much is Part B premium?
Still, those on Advantage plans must continue to pay their Part B premium. The standard Part B premium is $148.50. Those with lower incomes can get help paying this premium, while higher-income earners are subject to premium adjustment.
Does Medicare accept estimates?
Plans make bids regarding estimated costs per enrollee, and Medicare accepts those meeting requirements. Each county (or region for regional PPOs) has a benchmark amount to which Medicare compares the bids.
Can you see a doctor with Medicare?
With or without secondary Medigap insurance, Original Medicare coverage enables you to see any doctor accepting Medicare assignment. As of 2020, only 1% of physicians treating adults had formally opted out of Medicare assignment, so this is similar to having an unlimited "network."