Republicans want to repeal the 2010 Affordable Care Act which impacts a broad range of medical and health  insurance issues.  Many of the reforms are actually quite popular with the public.  Here are some changes that will affect Medicare beneficiaries in 2011.

Medicare will increase payments for primary care services by 10 percent. This increase applies to all fees for services provided by primary care physicians as well as nurses, nurse practitioners, and physician assistants.

Preventive health services, such as vaccinations and cancer screenings, will be covered for people on Original Medicare at no cost to the patient. Also, Medicare beneficiaries can now get a free annual “wellness exam” from their doctors.  Note:  People enrolled in Medicare Advantage plans have had these preventive and wellness benefits for many years. Medicare seems to have learned from the Medicare Advantage model which encourage seniors to get preventive screenings.

The Part D doughnut hole is being changed in 2011. Anyone who falls into the doughnut hole in 2011 will receive a 50% discount on their brand drugs while they are in the gap.  Generics will be discounted by 8%.  So a person whose brand drug costs are $500 per month would pay $250 instead.  This should provide serious relief to people who take expensive brand drugs.

Medicare Advantage plan payments from Medicare will be frozen at 2010 levels, so 2011 Advantage plans have not seen major changes to benefits. Actual reductions in what Medicare pays Advantage plans will begin in 2012, so we’ll have to wait and see what the plans will look like next year.

In the meantime, the Advantage plans will be working hard to upgrade their customer service so they qualify for bonus payments Medicare will offer to plans that get three or more stars on the Medicare.gov rating system.  People enrolled in Medicare Advantage plans can expect more attention from their plan this year, which might be a good thing.

Good news for Medicare Advantage plans in Arizona!   In what Kaiser Health News called a “surprising move”, the Obama administration “will extend special bonus payments meant to reward top-performing Medicare Advantage plans to those that score only average ratings”.

With most Advantage plans in Arizona rated as average (3 stars), our plans will get additional money even as Medicare reduces payments to the insurance companies that run the plans.

Part of the health care reform law requires Medicare to reduce payments to all Medicare Advantage plans by about 15% over three years starting in 2012. At the same time, the law provides for bonus payments to Advantage plans that are highly rated, or earning 4 or 5 stars based on a range of quality measures.

In Arizona, only Cigna in Maricopa County gets 4 stars or more.  In Tucson, the major Advantage plans (Secure Horizons, Health Net and Humana) get 3 stars.

I have written previously that the three-star ratings of Advantage plans in southern Arizona would not bode well for the 45% of Medicare beneficiaries in Pima County who are enrolled in these plans. With payment cuts to Medicare Advantage looming, would all plans have to start charging premiums in 2012?  Would co-pays for doctor visits and hospital stays be increased? Would free gym memberships be dropped?

The Kaiser Health News article says the move to reward 3 star-rated Advantage plans is a way to prevent areas like southern Arizona from having a market shock in 2012 where Advantage plans drop out of the market and large numbers of seniors are forced to change plans or return to Medicare.  This happened in the late-90′s when payments to private Medicare plans were cut drastically from one year to the next and companies like Blue Cross Blue Shield dropped out of the the Medicare HMO business.

So, while Medicare is going to cut payments to Medicare Advantage plans, the plans are being encouraged to improve their ratings so they will get bonus payments.  One of my clients, who is enrolled with Humana, said she was surprised to get a phone call from Humana asking her why she hadn’t gotten her annual physical.  The Humana representative encouraged her to use the preventive screening benefits provided in her Medicare Advantage plan. This is a sign that Humana is trying to improve its rating.

The summary rating gives an overall score on the health plan’s quality and performance on 33 different topics in 5 categories:

• Staying healthy: screenings, tests, and vaccines. Includes how often members got various screening tests, vaccines, and other check-ups that help them stay healthy.
• Managing chronic (long-term) conditions. Includes how often members with different conditions got certain tests and treatments that help them manage their condition.
• Ratings of health plan responsiveness and care. Includes ratings of member satisfaction with the plan.
• Health plan member complaints, appeals, and choosing to leave the health plan. Includes how often members have made complaints against the plan and how often members choose to leave the plan.
• Health plan telephone customer service. Includes how well the plan handles calls from members.

On Friday I participated in a conference call with the Head of CMS (Centers for Medicare and Medicaid) and I got to ask a question as well as offer some advice about the Medicare.gov Plan Finder.

First, I pointed out to the top administrator of Medicare, Dr. Don Berwick, and his assistants on the call that Medicare.gov Plan Finder is not working properly.  I told them the largest Medicare Advantage plans in Pima and Maricopa counties are not showing up on the Plan Finder list.  One of the assistants said they’d look into that problem – and I will be watching to see if they indeed put some techie on this project as quickly as possible.

Second, I informed Dr. Berwick and his assistants that they were using the wrong terminology for the period of November 15 to December 31.  They kept calling this period the “Open Enrollment Period”.  This label was even used in their press release announcing the conference call.  I informed them that the proper term for November 15 – December 31 is the “Annual Election Period” and that the “Open Enrollment Period” (OEP) referred to January through March. I pointed out that the  OEP has been terminated and does not exist for 2012.

I asked Dr. Berwick and his assistants about the cancellation of OEP and what will happen when a person decides on February 1st that he doesn’t like his Medicare Advantage plan.  His only choice will be to dis-enroll from the Advantage plan and go back to Medicare. He can enroll in a stand-alone Part D.  But I asked the question, “Can that person get a Medicare Supplement with guaranteed issue?”  Well, I have a feeling these bureaucrats had no idea what I was talking about.  One of the assistants said, “Of course a person can get a Medicare Supplement”.  So I clarified, “But what if that 75-year old has health issues that might cause him to be refused/declined by the Medicare Supplement company?” The assistant mumbled a bit and said he’d get back to me on that.

Part of the assistant’s answer about the cancellation of OEP (January – March) was that “consumer advocates”  pushed for this change because of what they saw as “unnecessary marketing” by Advantage plans to seniors. The “consumer advocates” think seniors need only 45 days (with two holidays in this period) to choose their Medicare coverage for the entire next year.

I was fortunate to talk to the top administrator of Medicare and his assistants as they only took about ten questions at the end of the conference call. The Denver Post and Wall Street Journal were on the call and their questions were more about politics than process.  I will be  watching and waiting to see if the Plan Finder gets fixed and if I hear back on my question about seniors getting Medicare Supplements during OEP-D (disenroll).

Follow-up:

I did hear back about my Medicare Supplement guaranteed issue question. As I thought would be the case, a person who drops their Medicare Advantage plan in February is not guaranteed a Medicare Supplement.  If a person answers “yes” to any questions on a Medicare Supplement application he will be turned down.  So before anybody thinks about dis-enrolling from their Medicare Advantage, plan they need to be sure they can get  Medicare Supplement.

As of today, Tuesday, the Plan Finder was still broken.