KEY AREAS OF FOCUS:
All the benefits of the Medicare-Advantage-For-All.com plans should be the highest quality and provide the comprehensive coverage necessary to ensure the financial security of the American people. There should enough program choices to make this coverage affordable at every level of income. This means NEW thinking. The kind of thinking and benefit design that must be left to the experts. The Milliman accounting firm has studied and proven that:
ACA “Essential Health Benefits” has increased premiums by an average of 3 percent to 17 percent depending upon the state. Also, the ACA requires “Minimum Actuarial Value” of 60% for all plans resulted in an additional 8.5% to the cost of plan premiums.
As explained in our Finance Page, the Minimum Essential Benefits package is a political intrusion into the science of designing cost-effective benefit plans that are affordable under our current health care delivery system. Essential Benefits are a great idea but requiring them for everybody, covering them exhaustively and including them in every contract is wasteful, unnecessary and expensive. In the United States, employers cover more Americans than all the government health insurance programs combined. Employers are vitally interested in paying less for their health insurance plans. They have the dual interest of both providing for the financial security their employees need to be secure and productive and in saving money. Their benefits packages are a key resource for attracting and retaining the talent that they need to be successful. Employers (and their health insurance carriers) have a natural interest in designing health plans that work for the American people.
In the re-engineering of the Medicare-Advantage-For-All.Com (MAA) plans, HHS should require the MAA health plans to design the health insurance programs for which they assume financial risk. The U.S. Government should be in the business of reducing the health risk of its citizens and sharing the cost of the health risk with the businesses that support that risk. We cannot endlessly continue to add liability to the Treasury and cost to the American taxpayers. At some point, the system will break down and it will not be the for the better! If Congress and HHS have the guts to require the health plans to take the risk, as they have with Medicare Advantage plans and with ACO's, they must also give them the ability to design the programs that they are required to support. The health plans are the professionals in this business and that know best how to get the job done.
WHAT BENEFITS DO WE REALLY NEED?
In the real world, even with the current practice of medicine, there are lots we can do to reduce the cost of health insurance without reducing the health and well-being of the American people. Most ACA and conventional group comprehensive health benefit plan designs focus on the use of high deductibles to reduce cost and act as a deterrent to utilization, rather than promoting benefits that support our general welfare. This is why most Americans feel cheated. They don't feel they are getting their money worth because the spend thousands of dollars a year for health insurance and they still have to pay more every time they go to the doctors. This is because they are often paying for the worst-case scenario. In the future, we need to cover services that keep us healthy, but under our current medical delivery system which focuses on reducing symptoms, in order to reduce the cost, we have to reduce the coverage, especially for those things that most of us don't need or use. We need to favor coverage for the treatment of our most common ailments. Rather than blanket coverage for inpatient care, maternity, mental health, and rehabilitation, we should be paying for at least four (4) primary care visits a year for the necessary treatment of an illness or injury.
For instance, ACA requires coverage of inpatient hospitalizations, which are generally provided for 365 days or, a full year and is automatically renewable and revolving. So, essentially, most plans cover inpatient hospital care for the rest of your life, so long as you remain covered and can stay inpatient. However, the average length of an inpatient admission the United States is less than seven (7) days. Question: "If only 2% of the population has inpatient admissions that last for more than are seven days, does it really make sense for ACA carriers to charge everybody for the risk of a revolving 365 days of inpatient hospital care?" The cost savings of covering fewer days is not that great, because obviously, almost no one uses the coverage. But, there is a cost to covering everyone for this benefit. Is that cost necessary when 10's of Millions of Americans are not able to afford health insurance? We don't think so. Doesn't it make sense to create health insurance plans that do not OVER INSURE the basic needs of the people? Anyway, there are more economical ways to handle extended hospital stay coverage, including the reinsurance programs suggested by the Robert Wood Johnson Foundation and the Commonwealth Fund.
The current trends in medicine continue to favor outpatient and ambulatory care. The American Hospital Association's (AHA) 2019 Hospital Statistics report shows net out-patient care revenues were $472 Billion Dollars in 2017 compared with only $498 Billion Dollars for all inpatient care. These statistics clearly show a continued shift of procedures from the inpatient to the outpatient settings. The ratio of inpatient to outpatient care in 2013 was 83% and in 2017 this ratio was 95%. Experts believe outpatient revenues will eventually eclipse inpatient revenues. Even so, hospital outpatient visits only increased by 1.2% in 2017 because patients are also choosing non-hospital providers and Medicare is supporting this trend. Emergency Medical Clinics are everywhere and these are often the preferred Workers Compensation for on the job-related injuries. CVS and Walmart have established MinuteClinic's and Health Centers for their customers and employees. CVS MinuteClinic's have seen 40 Million patients since their inception and half of their patients did not have a primary care physician.
On average, an normal American visits the doctor only four (4) times a year. If these visits are not for a routine physical, they usually fall under their health insurance plans deductible. Common sense tells you that we should pay for primary care physicians visits, because they may avoid more serious treatments. In addition to a routine physical, at least four physician visits for the treatment of an illness or injury should be covered without a deductible.
Prior to the American Disabilities, Act (ADA) maternity was generally covered by health insurance contract riders. Because this benefit was not uniformly added, this was seen as sexual discrimination. After the ADA in 1990, the law required that maternity be covered the same way as any other medical condition (disability) by health insurance contracts. A thriving industrialized society needs population growth. In our lifetimes we have seen Russian, European and our own country suffers from lower birth rates. In Russian and elsewhere the benefits for childbirth have been advertised on public billboards. No one in an industrialized society wants to discriminate against maternity. Alternatively, as a less developed country, China adopted a one-child policy that was so successful there is now a scarcity of females to future foster the future growth they now desire.
When a woman became pregnant in the United States, she used to sign up for maternity coverage, including pre and postnatal and pediatric coverage. The father and mother would bear the added cost of the coverage. The rules were generally flexible enough to provide for the enrollment and problems mostly involved women, who were unaware, forgot or ignored the requirement. The benefit of this practice was the cost falling on the women having children and not on everybody else. Having babies is good but perhaps not everyone should have to pay for it.
OUTPATIENT MENTAL HEALTH
Prior to the ACA, treatments for Mental Health and Alcoholism were also generally handled by health insurance riders to group contracts. Individual contracts either included benefits or excluded them. When they were included, coverage for mental health conditions and alcoholism were generally limited. If you wanted the benefit, you generally had to select it and you had to pay for it. This was a sore subject with the psychiatric establishment, which has been pushing for benefit parity since Sigmund Freud popularized psychology. Psychiatric counseling is a great skill and a bi-product of a rich society, especially where the influence of more traditional moral influences of family and church have been greatly diminished. While it may be true that everybody would benefit from it, only a few people suffer mental illness as a disease. The backdrop to mental health benefit disparity is an explosion of mass and school shootings, workplace violence, opioid deaths and addiction, alcoholism, the Me-Too movement, identity politics and every sort of violent and anti-social behavior imaginable make the need for improved mental health undeniable.
Unfortunately, just as health insurance coverage will not necessarily make you healthy, mental health coverage will not necessarily make you sane. The practice of outpatient mental health therapy in some cases has been reduced to the skillful prescription of antipsychotic medications. Some psychiatrists employ psychologists simply to engage in the more mundane interlocutory while reserving their professional talents to the monitoring of medication.
There is little question that we all need help dealing with the issues of our modern-day society. However, one of the reasons insurance companies may have dragged their feet on mental health and alcoholism benefits because there are limited verifiable measurable outcomes. For this reason, the application of the old paradigm model of medical care which treats symptoms in pursuit of a cure is perhaps inappropriate. It may be more reasonable to limit outpatient mental health coverage to those people that need it and require them to pay for it. It also may be more reasonable to limit the benefits to that which are necessary to provide people with a positive healthful direction.
For instance, there is almost a unanimous medical consensus that one successful program for Alcoholism is Alcoholics Anonymous (AA). This is a completely voluntary program and there is no cost to the taxpayers. Inpatient detoxication has an abysmal rate of re-admission and providing health insurance coverage for that treatment without a proper referral to AA, is tantamount to promoting of the illness. Likewise, with most anti-social behaviors, the patient is often responsive to spiritual healing. Most religious denominations provide some form of spiritual healing and counseling and the positive treatments rely on the 1,000 points of light and not the taxpayer largess.
WELLNESS AND WELL-BEING
The Medicare-Advantage-For-All.Com Family believes our entire health care system needs to be reoriented toward promoting healthy lifestyles (PPPM Approach) and not leaving anyone behind. Unlimited inpatient and outpatient benefits for maternity, mental health and alcoholism benefits should be sufficient to get the typical patient oriented to the correct behavior and to programs that will help them with their conditions, but not necessarily offer unlimited coverage for services that can not and should not be supported by everybody insured and paid for with taxpayer dollars.
This is what the KKF Polls (and almost anybody on the street) are telling us. The American people want health insurance that covers the things they are most likely to need! And, they may be willing to sacrifice some long-term financial security to get it. Insurance policy pricing issues aside, this focus dovetails with the cost savings we are beginning to see with coverage for value-based primary care and the well-documented need for a more comprehensive primary care physician practice of following patients, who are at risk for chronic disease. If we have more of an orientation to making everybody more healthy, we can have a positive effect on many of these mental and psychological issues and drastically lower the cost of health care in the process.
Before Obamacare; the Commercial Individual Insurance Market (CIIM) plans were comprehensive Non-QHP health insurance contracts that generally provided for more than adequate financial risk protection against the unexpected cost of personal illness and injury and were far less expensive. Such contracts were standard before the ACA. However, as a result of Obamacare, many health insurance companies discontinued their individual health insurance plans. The ACA law prohibits insurance companies from selling any such new plans and the ones still remaining in force are Grand-Mothered till October 2019. Licensed insurance advisors tell anyone, who is lucky enough to have these grandfathered or grand mothered programs that if they do not qualify for federal premium subsidies, they should keep these plans as long as possible. President Trump has extended the legally required termination of these plans through October 2019. Holding onto their old plans is like people hoarding the incandescent light bulbs because they don’t want to pay more to shed light on their daily lives.
Is this the informed insurance advice to which the Affordable Care Act has been reduced? “If you can’t get the government to pay for it, you are better off NOT signing up.” The ACA required the legal termination of all the old plans so that the American people would be forced to join the ACA because their old plans were declared illegal. The general public, academics, politicians and many D.C. policy wonks believe that this is OK. The myth is that the ACA will be OK if they can just spread the risk among the greatest number of people? That is why everyone is so upset with the authorization of Association Health Plans and the renewed Short-Term health plans.
Unfortunately, the Truth is, people didn’t sign up because ACA Plans are NOT that attractive. They are generally too expensive. The risk health pool may never be large enough to cover the underlying problems and health risks. Twenty-eight (29) Million Americans will not enroll in an ACA plan unless the government pays for it, even though they do not have any other alternative. Despite what ACA proponents claim, a major problem is the benefit design.
MEDICARE-ADVANTAGE-FOR-ALL.COM BENEFIT PLANS
At Medicare-Advantage-For-All.Com, we propose that Medicare Advantage For All benefit plans be designed by the health plans to the standards supervised by the Centers for Medicaid and Medicare (CMS). This federal office under HHS currently manages the health insurance programs that cover 74 Million Medicaid recipients, 57 Million Fee for Service Medicare and 22.4 Million Medicare Advantage subscribers as well as the 8.5 Million ACA participants. All Congress needs to do is authorize them to the re-engineering of the MA programs and to fund them. Because CMS is in charge of both the Medicare Advantage (MA) Programs and the Medicaid programs, MA re-engineering can be a relatively uniform set of programs approved by the federal government (HHS) and managed from Washington D.C., plans like Medicaid supervised by CMS, administered and managed at the state level, effectively taking the money and some of the power out of Washington as desired by President Trump and his administration.
In a Kaiser Family Foundation (KFF) Health tracking poll in April 2017, Eighty-Nine percent (89%) of those surveyed said that lowering the amount individuals pay for health care was important. Sixty-three percent (63%) said that lowering the patient out-of-pocket costs was a top priority. For continuity we think the value designations of Bronze, Silver, and Gold make sense, however, maybe we also need a copper and a platinum option. Whatever the final selection and whatever the venue, the health plans must have the flexibility to respond to changing markets, developments in the delivery of medicine and changing physician practice patterns that focus on wellness and wellbeing. Value-Based models are emerging as breakthroughs in the treatment of certain illnesses and represent the latest efforts to deliver quality outcomes with global financing, as you can read the article below on Humana investment in primary care delivery. None of this can be done under the ACA programs. We are talking about freeing the American insurance industry so that it may demonstrate the skill and innovation that they have shown in their administration of the Medicare Advantage plans under the direction and watchful eyes of CMS, which has the ultimate authority.
There is a revolution in the development of practice patterns that effectively cope with the incidence of chronic illness in the United States. There is a renewed focus on value, global capitation, and primary care remuneration. In our Wellness and Well Being you can learn about the need to change primary care physician practice patterns in order to support a reduction of chronic illnesses risks and incidence. This is critical to the reduction in the cost of health care in the United States.
MEDICARE ADVANTAGE PLAN BACKGROUND
Medicare Advantage (MA) is a program that originated with the HMO Act of 1973. The HMO Act was an inspired Law proposed by Senator Edward M. Kennedy after several Health Maintenance Organizations in his home state of Massachusetts demonstrated the ability to organize and deliver health care to the employers at a lower cost. The HMO Act, signed into law by Richard M. Nixon, allowed the federal government to contract with HMO’s for the same purpose. Since then, the group practice model has successfully saved huge amounts of money for private enterprises across the country. In the early '70s, before the passage of the HMO Act, the average annual U.S. health care inflation rate was in double digits year after year and there was a lot of interest in health care reform. After the HMO Act, the inflation rates of medical inflation declined to more reasonable single digits (like they are now) and the urgency of the effort to reform our entire health care system faded from the American public’s list of priorities.
It still took almost ten (10) years for the federal government to take advantage of the potential savings that group practices offered to the Medicare program. Sluggish federal bureaucracy overburdened with administrative responsibilities usually work like that. Everything takes longer than it should and ends up costing more than expected. In 1982, the Tax Equity and Fiscal Responsibility Act (TEFRA) was signed into Law by President Ronald Reagan. At that point, a determined group of Health Plans had successfully contracted with HHS to deliver services to Medicare beneficiaries in pilot programs called Medicare HMO’s or Medicare + Choice plans. TEFRA gave this fledgling group a real shot in the arm. They all got the new name - Medicare Advantage Plans and formally organized under Title XVIII Medicare Part C.
Hillary Clinton’s goal was to have the Clinton Health Plan designated as Medicare Part C. Medicare Advantage later came into full flower as a viable federal health insurance program with the 1997 Balance Budget Act later signed into law by Bill Clinton. This was the first major piece of federal health care legislation since the failure of Hillary Clinton’s health plan. Ever since the Medicare Advantage program has been growing like a weed.
The important thing to know about Medicare Advantage is that the program was created to SAVE the American people money. It was created to allow Medicare to be a LOWER tax burden on the American people. This was certainly a good idea at the time. More importantly, however, is the fact that MA is still saving us money by delivering quality health care to Medicare beneficiaries at the lowest possible cost. That is what we ALL want in a health insurance plan.
This is what Congress has tried and failed to do with the Affordable Care Act. And this is what the federal government has been doing every day for over twenty (20) years for our seniors with Medicare Advantage. To achieve our goal of getting the best health insurance coverage for the lowest possible cost for everybody, all we need to do is authorize HHS to work out the details of extending this very successful Medicare-Advantage-For-All program to All Americans. IT IS THAT SIMPLE!
HOW DOES MEDICARE ADVANTAGE (MEDICARE PART C) WORK NOW?
- Includes all benefits and services covered under Part A and Part B.
- Usually includes Medicare prescription drug coverage (Part D) as part of the plan.
- Run by Medicare-approved private insurance companies that follow rules set by Medicare.
- Plans have a yearly limit on your out-of-pocket costs for medical services.
- May include extra benefits and services that aren’t covered by Original Medicare, sometimes for an extra cost.
- CMS just approved the addition of in-home services, personal aides and palliative care.
- Telemedicine is now also covered under certain specified conditions.
- And, consideration is being given to covering ambulance and transportation to doctors appointments.
For more details on Medicare Advantage Plans benefits, download the "Medicare And You 2019" booklet below or go directly to www.medciare.gov.
WHAT ARE MEDICARE ADVANTAGE PLANS
A Medicare Advantage Plan (like an HMO or PPO) is another way to get your Medicare coverage. Medicare Advantage Plans, sometimes called “Medicare Part C” or “MA Plans,” are offered by Medicare-approved private companies that must follow rules set by Medicare. If you join a Medicare Advantage Plan, you’ll still have Medicare, but you’ll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan, not Original Fee for Service Medicare. You’ll generally get your services from a health plan’s exclusive network of providers. Remember, in most cases, you must use the card from your Medicare Advantage Plan to get your Medicare-covered services. An MA beneficiary will have the right to switch back to Original Medicare on at least an annual basis at Open Enrollment. Medicare Advantage Plans cover all Medicare Part A and Part B services In all types of Medicare Advantage Plans, you’re always covered for emergency and urgent care. Medicare Advantage Plans must cover all the services that Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies. Most Medicare Advantage Plans offer extra coverage, like vision, hearing, dental, in-home services, telemedicine and other health and wellness programs. Most include Medicare prescription drug coverage (Medicare Part D).
For the current Medicare Advantage plans, in addition to your Part B premium, if you are over the age of 65, you might have to pay a monthly premium for the Medicare Advantage Plan, but this is rare. If Medicare-Advantage-For-All.com is successful in re-engineering and extending the program to everybody, we anticipate sliding scale premium contributions, tax credits and government subsidies consistent with those currently available under the ACA to make the program affordable to the low wage workers and the poor.
Medicare Advantage Plans must follow Medicare’s rules Medicare pays a fixed amount (commonly known as a capitation fee) for your coverage each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare (HHS). However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how you get services (like whether you need a referral to see a specialist or if you must go to doctors, facilities, or suppliers that belong to the plan’s network for non-emergency or non-urgent care). These rules can change each year. The plan must notify you about any changes before the start of the next enrollment year.
Participating Medicare beneficiaries will have the option each year to keep their current plan, choose a different plan, or switch to Original Medicare. Every MA participant receives the “Evidence of Coverage” (EOC) and “Annual Notice of Change” (ANOC) each year. The EOC gives them details about what their plan covers, how much they may have to pay, and more. The ANOC includes any changes in coverage, costs, provider networks, service area, and any changes that will be effective in January. These important documents will allow the participants to make an informed decision on the insurance plan they wish to maintain before the start of the annual Open Enrollment.
WHAT ARE THE DIFFERENT TYPES OF MEDICARE ADVANTAGE PLANS
- Health Maintenance Organization (HMO) plans
- Preferred Provider Organization (PPO) plans
- Private Fee-for-Service (PFFS) plans
- Special Needs Plans (SNPs)
- HMO Point-of-Service (HMOPOS) plans
- Medical Savings Account (MSA) plans—These plans combine a high-deductible health plan with a bank account. Medicare deposits money into the account (usually less than the deductible). You can use the money to pay for your health care services during the year. MSA plans don’t offer Medicare drug coverage. If you want drug coverage, you have to join a Medicare Prescription Drug Plan.
WHAT SHOULD PARTICIPANTS KNOW ABOUT MEDICARE ADVANTAGE PLANS
- You have Medicare rights and protections, including the right to appeal.
- You can check with the plan before you get a service to find out if it’s covered and what your costs may be.
- You must follow the plan rules. It’s important to check with the plan for information about your rights and responsibilities.
- If you go to a doctor, other health care provider, facility, or supplier that doesn’t belong to the plan’s network for non-emergency or non-urgent care services, your services may not be covered, or your costs could be higher. In most cases, this applies to Medicare Advantage HMOs and PPOs.
- Providers can join or leave a plan’s provider network anytime during the year. Your plan can also change the providers in the network anytime during the year. If this happens, you may need to choose a new provider. You generally can’t change plans during the year if this happens.
- Plans may include fitness and wellness benefits.
- Medicare Advantage Plans can’t charge more than Original Medicare for certain services, like chemotherapy, dialysis, and skilled nursing facility care.
- Medicare Advantage Plans have a yearly limit on your out-of-pocket costs for medical services. Once you reach this limit, you’ll pay nothing for covered services. Each plan can have a different limit, and the limit can change each year. You should consider this when choosing a plan.
You can join a Medicare Advantage Plan even if you have a pre-existing condition, except for End-Stage Renal Disease (ESRD), for which there are special rules. If the plan decides to stop participating in Medicare, you will have to join another Medicare Advantage Plan or return to Original Medicare.
- Medicare Advantage Plans must follow certain very strict rules when giving you information about how to join their plan.
- Medicare Advantage Plans are strictly regulated to insure consumer protection. But, the regulation does not prevent the health plans from delivering the best possible benefits programs for the lowest possible cost in a competitive and vibrant market. ACA regulations forced the industry into a monopoly, reduced the services and raised the cost to participants and taxpayers. Alternatively, MAA federal regulations are designed to enhance the product, not destroy it.
WHO IS ELIGIBLE FOR A MEDICARE ADVANTAGE PLAN
- You have Part A and Part B, usually American citizens who have reached the age of 65 or are disabled
- You must live in the MA plan’s service area.
- You don’t have End-Stage Renal Disease (ESRD)
- You’re a U.S. citizen or lawfully present in the United States.
WHO SHOULD BE ELIGIBLE FOR MAA WHEN WE ARE TRIUMPHANT WITH MEDICARE ADVANTAGE FOR ALL
- You must be working, seeking employment or doing community service work.
- You must live in the MAA plan’s service area.
- You don’t have End-Stage Renal Disease (ESRD)
- You’re a U.S. citizen or lawfully present in the United States.
- You must NOT be eligible for any other federal, state or employer sponsored health insurance program.
MEDICARE AND YOU 2019
Going to the CMS Web site for your Handbook and other information is very helpful. Your handbook, which is mailed every year to Medicare-eligible citizens has a wealth of useful information on Medicare and Medicare Advantage. If you are new to Medicare eligibility, this is yours just like the benefits handbook you may have received at work. All of the benefits information on this website can be found in your Handbook and at www.medicare.gov. What may surprise you is that you can learn as much about Medicare Advantage programs as you can about the Traditional (fee-for-service) Medicare Program. Download one today!
INVESTING IN PRIMARY CARE DELIVERS VALUE-BASED CARE RESULTS
Some value-based care models are floundering, but Humana is lowering costs and improving the quality of health care through value-based agreements by paying primary care physicians more for their critical role in patient care. They believe transitioning to the value-based model will generate continued improvement in quality which will improve the health and well-being of the American people.