Episode Transcript
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Speaker 1 (00:01):
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial solutions.
With hosts licensed insurance agents Jennifer Lee, you are guided
through the ins and outs of Medicare, whether you are
(00:22):
nearing retirement, navigating your options, or just curious about what's available.
Everything you need to know is covered. Tune in for
knowledgeable insights, tips and answers to your Medicare questions so
you can take charge of your health and your future.
And Now Medicare three.
Speaker 2 (00:40):
Sixty Welcome back to another episode of Medicare three sixty Radio.
I'm your host, Jennifer Alfonso Lee, certified long Term care Specialist,
investment Advisor, representative and owner a premier three sixty insurance
and financial solution. Today's show is packed with some of
(01:02):
the biggest Medicare issues impacting seniors right now. Things affecting
your doctors, your prescriptions, your rights, and your wallet. We're
going to talk about what's happening behind the scenes with
Medicare advantage and medicap shifts, doctor and group medical terminations,
(01:26):
prior authorization, denials, drug affordability, and then new two thousand
and twenty, I mean, the new twenty one hundred dollars cap.
Medicare is twenty twenty six, changes, risk adjustment audits, real
life case studies, and how drug manufacturers are reacting to
price negotiations. This is one of the most important shows
(01:47):
I'll do all year, So let's get started. So part one,
Medicare advantage versus medicap. What's really changing. Let's start with
something most seniors are feeling the growing between medic advantage
and medigap. The debate isn't new, but in the past
two years, differences have sharpened. Medicare advantage has lower cost,
(02:11):
higher control. Advantage plans offer low to zero dollar premiums,
even money back, sometimes extra benefits, integrated drug costs, maximum.
Speaker 3 (02:23):
Out of pockets.
Speaker 2 (02:24):
But in exchange networks are tightening, authorizations are increasing, doctor
contracts are getting unstable, and denials are rising. So meta
gap is higher costs and lower control. So metagap offers
nationwide provider freedom, no referrals, predictable bill, free coverage, free
(02:46):
administrative barriers, but premiums continue to rise due to age inflation,
and cost of healthcare. Why this matters now, what's happening
behind the scenes, especially in twenty twenty five and going
into twenty twenty six, is pushing more seniors to reconsider
which direction is right to them. It's not about good
(03:08):
or bad, it's about fit and risk tolerance. So this
is also going to depend depending on where you live,
what part of the country you're from, what county are
you in. Some metropolitan areas do have large medical groups
with the many specialists and primary doctors to fit to
(03:29):
choose from, while other parts of the country really have
no not that many medical groups doctors are specialists, so it's.
Speaker 3 (03:39):
Very hard to say per se go.
Speaker 2 (03:42):
Into a Medicare advantage plan. And with that, there's so
many PPOs terminating. So just it really does depend on
fit and risk tolerance. So Part two, How doctor and
medical group termination disrupt senior care. One of the biggest
(04:03):
stories affecting seniors right now is a rise in doctor
and group terminations. Every January, first, seniors wake up to
surprise letters. Your doctor will no longer be a network,
your medical group will no longer contract with your plan,
And this is happening more often, not less, and so
(04:24):
why this matters If you stay on that current health
insurance plan, and I've seen people with twenty thirty years
on these plans. If you want to stay on that
particular plan, you lose your PCP, your primary care physician,
your referrals will no longer work, Your specialists may drop off.
(04:47):
Your chronic care treatment plans may get interrupted. You may
need new prior authorizations to restart services. You may lose
access to your preferred hospital years dan scramble to finding
you doctor, move to a different medical group, switch plans,
or switch to a metagap. So why this is happening
(05:09):
because carriers and medical groups are locked into tough for
reimbursement negotiations. If they can't agree, the contract ends and
the seniors pay the price. And that is definitely correct.
This is how has been going on throughout the whole country.
(05:30):
And if you're a senior that is not reading their
mail answering their phone calls, you may be quite unsurprised
if you go to the doctor or they no longer
accept that plan. So the beauty of it is there
are plans out there that may take your doctor, so
(05:51):
it's just as an easy switch to a different plan
of course, sometimes seniors are very used to the plan
they're on, so it just is harder to make that change.
But here at premiere three sixazin we make it easy,
convenient and help you transition.
Speaker 3 (06:09):
Through that process.
Speaker 2 (06:12):
So Part three the increasing trend of prior authorizations and denials.
So prior authorizations have become the number one frustration inside
medicare advantage. Here's what's rising, MRI and CAT stand denials,
in patient to outpatient reclassification, the lad cancer treatment approvals,
(06:34):
therapy session limits, home health approvals, and skilled nursing days
between being cut short. Why are denials increasing because plans
are under pressure to reduce costs, CEMS, audit requirements, improve
star rating, utilization metrics, control inappropriate care. But the consequence
(06:57):
is seniors often wait five days, ten days, sometimes thirty
days for tests or treatments that doctor really already recommended.
This is why knowing how to appeal and whether your
plan has high denial rates matter, and that's going to
look at your star rating. And you know, sometimes I
also see that the insurance company didn't even get the
(07:18):
request right like, and it's denied. Well, it's not really
denied if it was never sent through or just fallen
through the cracks, so definitely keep that mind as well. Okay,
So where are we at?
Speaker 3 (07:41):
Okay?
Speaker 2 (07:48):
So Part four part date drug affordability, the big changes coming.
Let's talk about the prescription drugs twenty one hundred out
of pocket cut. In twenty twenty six, every Medicare beneficiary
will have a hardcap of twenty one hundred per year
on prescription drugs that are covered.
Speaker 3 (08:09):
So for many of you.
Speaker 2 (08:11):
On insulin inhalers with dinners or cancer meents, this is
life changing. Insullin savings program still continues at thirty five
dollars per month max, no deductible, and the drug price
Negotiation program, so Medicare has begun negotiating prices for high
cost brand ning drugs. Manufacturers spot it and they're still
(08:33):
fighting it, but the process is moving ahead. So what
this means is lower drug prices for seniors, lower catastrophic
drug spending, more consistent formularies, fewer shock bills at the pharmacy.
How drug manufacturers are responding this is important. Manufacturers are
cutting back to direct to consumer marketing, shifting research investments,
(08:59):
offering fewer rebates, preparing for tighter profit margins negotiating harder
with Part D carriers. These changes will definitely shape what
Part D looks like in twenty twenty six. Also, there
are some drug plans that are terminating, so if you
are on a drug plan, make sure to review that
(09:20):
and make sure you still have a drug plan for
next year. There are very low cost drug plans out there.
It's just all about putting your drug information, making sure
that it's in the formulary meaning they're covered, then looking
at what tier it is if it's tier one, two, three, four, five, six,
(09:40):
and what people ask, well, how do you know? You
do have to look at the carrier's formulary, but tier
one is preferred generics. Tier one is generic, Tier three
are brand name drugs, Tier four are like specialty drugs,
and just five some more specialty drugs as well. So
(10:01):
with that, I have found seniors that their plans are
terminating and got to just kind of look at the
cost involved in what's covered to make a informative decision
on it. The thing you could do if your drunk
drug is not covered is you could follow appeal. So
(10:25):
the process is your doctor would prescribe the medication, the
insurance or PHARMI says it's not approved. You call the
insurance company and you ask them for an appeal.
Speaker 3 (10:38):
They will then.
Speaker 2 (10:39):
Contact the doctor's office to get that approval and they'll
be sentive insurance company to see if it's approved that way.
So Part five Risk adjustment audits and how they impact seniors.
Speaker 3 (10:55):
This is a most.
Speaker 2 (10:59):
This is a top with most seniors never hear about,
but it does affect everything. So Medicare advantage plans get
paid on your risk ore the number of documented conditions
you have. So CMS, which is center of Medicare Services,
is tightening audits and reducing payments for undocumented conditions. This
(11:20):
means doctors are pressured to document more plans tighten utilization
carrier we consider participating in certain counties. Benefits may shrink
in some areas. Some plans may exit the market completely.
When risk adjustment gets tighter, plans have less money to
(11:41):
spend on benefits. This is why many extras dental vision,
flex card.
Speaker 3 (11:47):
May get reduced. In twenty twenty six and.
Speaker 2 (11:49):
So I have seen so much decrease of the benefits.
Biggest one is those grocery card and they helda card.
It was laxed before in regards to chronic conditions, and
so chronic conditions were never verified on it, so now
(12:10):
they are so kind of like a crackdown on that.
On dental benefits, I've also seen decrease as well as transportation,
even gym membership. I've seen even eyeglasses, which is kind
of staple in these Medicare advantage plans. So definitely, there
(12:31):
are so many changes. It is definitely great to review.
If no changes are on your plan, then it's probably
a bit stable and solid. Okay, let's go over how
plan reimbursements affect seniors. Okay, So insurance companies are being
(12:53):
reimbursed less for twenty twenty five and twenty twenty six.
Meanwhile the cost of cares rise. And so consider this.
When we were in COVID, seniors weren't going to the
doctor's office, right, they weren't getting their exams or labs done.
Now everyone's in the swing of things going back to
(13:17):
the doctors. And so while reimbursement rates are going down,
healthcare is rising. So what are the carriers doing in
response to this? Narrow networks, stricter preauthorizations, lower provider reimbursements,
reduce care coordination budgets, lower out of network caps, more
(13:42):
aggressive utilization review. So the end result is that seniors
do feel the squeeze, right, Inflation, costs, everything just keeps rising.
Speaker 3 (13:52):
Doctors drop plans.
Speaker 2 (13:54):
So you're going to see that maybe a doctor won't
take a plan, or maybe they actually didn't qualify or contract. Again,
specialists refuse certain MA plans, so this also does happen.
And then the biggest one is the way times have increased.
But really also many doctors are retiring or going in
(14:18):
different fields that burns out as.
Speaker 3 (14:21):
Well, so that could be the case.
Speaker 2 (14:26):
So plan reimbursement does drive everything, including whether your favorite
doctor stays and network, so you've got to make sure your.
Speaker 3 (14:36):
Doctor is in network.
Speaker 2 (14:39):
Okay, so the future of Medicare marketing regulations, let's do
part seven. CMS is cracking down on Medicare marketing. New
rules restrict celebrity endorsements, generic commercials.
Speaker 3 (14:54):
I call this number to see if you.
Speaker 2 (14:56):
Qualify misleading mailers over the phone, enrollment third party marketing organizations,
and future change is likely to happen.
Speaker 3 (15:06):
Mandatory call recordings.
Speaker 2 (15:08):
Actually that is already in place, documented needs and assessments.
If your benefit exaggerations, stronger disciplinary action, more oversight on
lead vendors. So what does this matter for seniors? Because
marketing regular regulations protect you from being switched into the
(15:28):
wrong plan without your full understanding. The biggest thing too,
I've seen insurance companies that have really misleading mailers, so
I'm not sure why they're getting approved, but I'm not
happy with that. So let's go over some part some
real life cases part with seniors switching plants. So case one,
(15:56):
Linda was on a insurance company plan for more than
twenty five years. The medical group got terminated, so if
she stays with the plan, she'll lose her cardiologists and drunkronologists,
(16:16):
her pain management provider. Okay, So what she needs to
do is find a plan that takes her doctor and
her cardiologists and drink knuckle and drinknologists in pain management.
Speaker 3 (16:32):
So it's really a comparison with that. Okay.
Speaker 2 (16:37):
So here's another one I just recently came into, and
I'm just using fictitious names. So Evelyn was on a
Medicare plan G plan. She's paying two hundred dollars per
month and the drug plan.
Speaker 3 (16:58):
She's healthy, she.
Speaker 2 (17:00):
Didn't take any medication, and the reason why she wanted
this plan is she was a snowbird. A snowbird, she
travels to Florida a few times every year, a couple
months each time, so she thought she needed her plan G.
(17:20):
She subsided to try the Medicare Advantage HMO because there
was no cost, she was able to keep the doctor
that she wanted to be with, and she knew even
though she traveled to Florida, she would get emergency and
(17:41):
urgent care covered.
Speaker 3 (17:43):
So that was a big deal to her. So we
will see.
Speaker 2 (17:46):
But I have successfully helped those that wanted to pay
less whether medicare.
Speaker 3 (17:55):
Okay.
Speaker 2 (17:57):
So here's another one. I have Tom, who was diabetic,
had insulin and inhalers METS cost four hundred and twenty
seven dollars a month, but under the insulin cap and
(18:22):
actually some of the plans paying zero dollars on that,
we are able to drop his costs tremendously and so
he's not a camper, right, Okay. So preparing for Medicare
(18:42):
in twenty twenty six, the medicare world in twenty twenty
six will look different. Drug reforms fully implemented, tighter rules
on advantage, more transparent utilization, stronger marketing oversight, metagap pricing increases,
(19:06):
fewer extra benefits and advantage and then more stable network.
Twenty twenty six will be a year when seniors should
review plans earlier.
Speaker 3 (19:16):
And more carefully than ever.
Speaker 2 (19:19):
Just my last client asked, why are the prescription drugs terminating?
And it's just because they are insurance companies are not
really making any money if anything. If you think about
the max cap of twenty one hundred and before the
cap was at eight thousand, and there was a doughnut hole.
So now they are taking that responsibility off the senior's plate, right,
(19:44):
So that is why drug plans are terminating. And some
of them have definitely higher costs one hundred two hundred
dollars when there's some plans at zero cost. That's another
story though. The biggest thing I would say is trust, right,
(20:09):
Who does a senior trust with their information? And also
if you were called legally, meaning you gave someone permission
to call you, I mean if you called them right
and they're calling you back, or if you meet your
agent at a booth, so those are ways right, But
(20:33):
if you do get calls off the blue with no
knowledge or no reason why they called you, no connection
I would not take the call. They're just a call center,
could be a call center overseas as well, So you
definitely need to be careful. Right, your Medicare number is
(20:54):
like your social so there are times people are very
adamant to ask you for your Medicare. See if they're
your agent or you're the ones who called them, then
that is legit. But someone randomly calling you and they'll say, oh,
you clicked on the button on Facebook and things like that.
But just just be extra careful because it has happened
(21:16):
where seniors do get taken advantage of and then they
go to the doctor and their plans totally change. They
can't see their doctor, they have upcoming surgery, things of
that nature.
Speaker 3 (21:30):
That definitely happens.
Speaker 2 (21:34):
Okay, so as we wrap up today, remember Medicare is
changing quickly and seniors who stay in form will get
the best care and the most value. Right, not trying
to scare anyone. Plans are still you're still going to
get your coverage, but that is why it's really important
(21:57):
for you to review it because while some plans may
be stable, there are plans that are so bad, like
benefits have decreased substantially and so like for seniors, some
clients of minds really need the transportation, and the transportation
(22:20):
is basically they pick you up, take you to your
medical appointment, and then also drop you back home, and
that is important. So some plans have really decreased or
just took it off altogether on the plan.
Speaker 3 (22:36):
So if you do need.
Speaker 2 (22:37):
Help, reviewing your plan right, checking your doctors, making that
sure your medical group is the correct one with your
doctor alignment, understanding the drug changes, because there are some
plans that before they didn't have that deductible and now
that deductible could be six fifteen to fifty or whatever.
Speaker 3 (22:59):
It may be.
Speaker 2 (23:01):
Or just preparing for twenty twenty six or twenty twenty
seven or turning sixty five. My team at Premiere three
sixty is here for you. You can email us, call us
Texas whatever is easier, or we send you a link.
It's called ww dot my medicare no sorry ww dot
(23:25):
review my medicare dot org and we will definitely help
you navigate with clarity, confidence and peace in mind. It
has been raining in my neck of the whats so
hopefully it does stop. Have a wonderful Thanksgiving week and
(23:53):
I'm Jennifer Alfonso Li and This has been Medicare three
sixty Radio show. Have a wonderful weekend, everyone, Stay safe,
your heart's content for Thanksgiving. Okay, we will talk soon.
Thank you, boyebye.
Speaker 1 (24:13):
Thank you for joining the program Medicare three sixty. Hope
you found today's episode insightful and empowering. Remember understanding your
Medicare options is key to making the right choices for
your health and financial well being. If you have questions
or topics you would like covered in future episodes of
Medicare three sixty, don't hesitate to reach out and speak
(24:36):
with our licensed insurance agent. Until next time, stay informed
and take charge of your healthcare journey. This has been
Medicare three sixty, your trusted source for all things Medicare.
Take care,
Welcome to Medicare three sixty, where the world of Medicare
is simplified and you are empowered to make informed healthcare choices.
With over two decades of experience and insurance and financial solutions.
With hosts licensed insurance agents Jennifer Lee, you are guided
through the ins and outs of Medicare, whether you are
(00:22):
nearing retirement, navigating your options, or just curious about what's available.
Everything you need to know is covered. Tune in for
knowledgeable insights, tips and answers to your Medicare questions so
you can take charge of your health and your future.
And Now Medicare three.
Speaker 2 (00:40):
Sixty Welcome back to another episode of Medicare three sixty Radio.
I'm your host, Jennifer Alfonso Lee, certified long Term care Specialist,
investment Advisor, representative and owner a premier three sixty insurance
and financial solution. Today's show is packed with some of
(01:02):
the biggest Medicare issues impacting seniors right now. Things affecting
your doctors, your prescriptions, your rights, and your wallet. We're
going to talk about what's happening behind the scenes with
Medicare advantage and medicap shifts, doctor and group medical terminations,
(01:26):
prior authorization, denials, drug affordability, and then new two thousand
and twenty, I mean, the new twenty one hundred dollars cap.
Medicare is twenty twenty six, changes, risk adjustment audits, real
life case studies, and how drug manufacturers are reacting to
price negotiations. This is one of the most important shows
(01:47):
I'll do all year, So let's get started. So part one,
Medicare advantage versus medicap. What's really changing. Let's start with
something most seniors are feeling the growing between medic advantage
and medigap. The debate isn't new, but in the past
two years, differences have sharpened. Medicare advantage has lower cost,
(02:11):
higher control. Advantage plans offer low to zero dollar premiums,
even money back, sometimes extra benefits, integrated drug costs, maximum.
Speaker 3 (02:23):
Out of pockets.
Speaker 2 (02:24):
But in exchange networks are tightening, authorizations are increasing, doctor
contracts are getting unstable, and denials are rising. So meta
gap is higher costs and lower control. So metagap offers
nationwide provider freedom, no referrals, predictable bill, free coverage, free
(02:46):
administrative barriers, but premiums continue to rise due to age inflation,
and cost of healthcare. Why this matters now, what's happening
behind the scenes, especially in twenty twenty five and going
into twenty twenty six, is pushing more seniors to reconsider
which direction is right to them. It's not about good
(03:08):
or bad, it's about fit and risk tolerance. So this
is also going to depend depending on where you live,
what part of the country you're from, what county are
you in. Some metropolitan areas do have large medical groups
with the many specialists and primary doctors to fit to
(03:29):
choose from, while other parts of the country really have
no not that many medical groups doctors are specialists, so it's.
Speaker 3 (03:39):
Very hard to say per se go.
Speaker 2 (03:42):
Into a Medicare advantage plan. And with that, there's so
many PPOs terminating. So just it really does depend on
fit and risk tolerance. So Part two, How doctor and
medical group termination disrupt senior care. One of the biggest
(04:03):
stories affecting seniors right now is a rise in doctor
and group terminations. Every January, first, seniors wake up to
surprise letters. Your doctor will no longer be a network,
your medical group will no longer contract with your plan,
And this is happening more often, not less, and so
(04:24):
why this matters If you stay on that current health
insurance plan, and I've seen people with twenty thirty years
on these plans. If you want to stay on that
particular plan, you lose your PCP, your primary care physician,
your referrals will no longer work, Your specialists may drop off.
(04:47):
Your chronic care treatment plans may get interrupted. You may
need new prior authorizations to restart services. You may lose
access to your preferred hospital years dan scramble to finding
you doctor, move to a different medical group, switch plans,
or switch to a metagap. So why this is happening
(05:09):
because carriers and medical groups are locked into tough for
reimbursement negotiations. If they can't agree, the contract ends and
the seniors pay the price. And that is definitely correct.
This is how has been going on throughout the whole country.
(05:30):
And if you're a senior that is not reading their
mail answering their phone calls, you may be quite unsurprised
if you go to the doctor or they no longer
accept that plan. So the beauty of it is there
are plans out there that may take your doctor, so
(05:51):
it's just as an easy switch to a different plan
of course, sometimes seniors are very used to the plan
they're on, so it just is harder to make that change.
But here at premiere three sixazin we make it easy,
convenient and help you transition.
Speaker 3 (06:09):
Through that process.
Speaker 2 (06:12):
So Part three the increasing trend of prior authorizations and denials.
So prior authorizations have become the number one frustration inside
medicare advantage. Here's what's rising, MRI and CAT stand denials,
in patient to outpatient reclassification, the lad cancer treatment approvals,
(06:34):
therapy session limits, home health approvals, and skilled nursing days
between being cut short. Why are denials increasing because plans
are under pressure to reduce costs, CEMS, audit requirements, improve
star rating, utilization metrics, control inappropriate care. But the consequence
(06:57):
is seniors often wait five days, ten days, sometimes thirty
days for tests or treatments that doctor really already recommended.
This is why knowing how to appeal and whether your
plan has high denial rates matter, and that's going to
look at your star rating. And you know, sometimes I
also see that the insurance company didn't even get the
(07:18):
request right like, and it's denied. Well, it's not really
denied if it was never sent through or just fallen
through the cracks, so definitely keep that mind as well. Okay,
So where are we at?
Speaker 3 (07:41):
Okay?
Speaker 2 (07:48):
So Part four part date drug affordability, the big changes coming.
Let's talk about the prescription drugs twenty one hundred out
of pocket cut. In twenty twenty six, every Medicare beneficiary
will have a hardcap of twenty one hundred per year
on prescription drugs that are covered.
Speaker 3 (08:09):
So for many of you.
Speaker 2 (08:11):
On insulin inhalers with dinners or cancer meents, this is
life changing. Insullin savings program still continues at thirty five
dollars per month max, no deductible, and the drug price
Negotiation program, so Medicare has begun negotiating prices for high
cost brand ning drugs. Manufacturers spot it and they're still
(08:33):
fighting it, but the process is moving ahead. So what
this means is lower drug prices for seniors, lower catastrophic
drug spending, more consistent formularies, fewer shock bills at the pharmacy.
How drug manufacturers are responding this is important. Manufacturers are
cutting back to direct to consumer marketing, shifting research investments,
(08:59):
offering fewer rebates, preparing for tighter profit margins negotiating harder
with Part D carriers. These changes will definitely shape what
Part D looks like in twenty twenty six. Also, there
are some drug plans that are terminating, so if you
are on a drug plan, make sure to review that
(09:20):
and make sure you still have a drug plan for
next year. There are very low cost drug plans out there.
It's just all about putting your drug information, making sure
that it's in the formulary meaning they're covered, then looking
at what tier it is if it's tier one, two, three, four, five, six,
(09:40):
and what people ask, well, how do you know? You
do have to look at the carrier's formulary, but tier
one is preferred generics. Tier one is generic, Tier three
are brand name drugs, Tier four are like specialty drugs,
and just five some more specialty drugs as well. So
(10:01):
with that, I have found seniors that their plans are
terminating and got to just kind of look at the
cost involved in what's covered to make a informative decision
on it. The thing you could do if your drunk
drug is not covered is you could follow appeal. So
(10:25):
the process is your doctor would prescribe the medication, the
insurance or PHARMI says it's not approved. You call the
insurance company and you ask them for an appeal.
Speaker 3 (10:38):
They will then.
Speaker 2 (10:39):
Contact the doctor's office to get that approval and they'll
be sentive insurance company to see if it's approved that way.
So Part five Risk adjustment audits and how they impact seniors.
Speaker 3 (10:55):
This is a most.
Speaker 2 (10:59):
This is a top with most seniors never hear about,
but it does affect everything. So Medicare advantage plans get
paid on your risk ore the number of documented conditions
you have. So CMS, which is center of Medicare Services,
is tightening audits and reducing payments for undocumented conditions. This
(11:20):
means doctors are pressured to document more plans tighten utilization
carrier we consider participating in certain counties. Benefits may shrink
in some areas. Some plans may exit the market completely.
When risk adjustment gets tighter, plans have less money to
(11:41):
spend on benefits. This is why many extras dental vision,
flex card.
Speaker 3 (11:47):
May get reduced. In twenty twenty six and.
Speaker 2 (11:49):
So I have seen so much decrease of the benefits.
Biggest one is those grocery card and they helda card.
It was laxed before in regards to chronic conditions, and
so chronic conditions were never verified on it, so now
(12:10):
they are so kind of like a crackdown on that.
On dental benefits, I've also seen decrease as well as transportation,
even gym membership. I've seen even eyeglasses, which is kind
of staple in these Medicare advantage plans. So definitely, there
(12:31):
are so many changes. It is definitely great to review.
If no changes are on your plan, then it's probably
a bit stable and solid. Okay, let's go over how
plan reimbursements affect seniors. Okay, So insurance companies are being
(12:53):
reimbursed less for twenty twenty five and twenty twenty six.
Meanwhile the cost of cares rise. And so consider this.
When we were in COVID, seniors weren't going to the
doctor's office, right, they weren't getting their exams or labs done.
Now everyone's in the swing of things going back to
(13:17):
the doctors. And so while reimbursement rates are going down,
healthcare is rising. So what are the carriers doing in
response to this? Narrow networks, stricter preauthorizations, lower provider reimbursements,
reduce care coordination budgets, lower out of network caps, more
(13:42):
aggressive utilization review. So the end result is that seniors
do feel the squeeze, right, Inflation, costs, everything just keeps rising.
Speaker 3 (13:52):
Doctors drop plans.
Speaker 2 (13:54):
So you're going to see that maybe a doctor won't
take a plan, or maybe they actually didn't qualify or contract. Again,
specialists refuse certain MA plans, so this also does happen.
And then the biggest one is the way times have increased.
But really also many doctors are retiring or going in
(14:18):
different fields that burns out as.
Speaker 3 (14:21):
Well, so that could be the case.
Speaker 2 (14:26):
So plan reimbursement does drive everything, including whether your favorite
doctor stays and network, so you've got to make sure your.
Speaker 3 (14:36):
Doctor is in network.
Speaker 2 (14:39):
Okay, so the future of Medicare marketing regulations, let's do
part seven. CMS is cracking down on Medicare marketing. New
rules restrict celebrity endorsements, generic commercials.
Speaker 3 (14:54):
I call this number to see if you.
Speaker 2 (14:56):
Qualify misleading mailers over the phone, enrollment third party marketing organizations,
and future change is likely to happen.
Speaker 3 (15:06):
Mandatory call recordings.
Speaker 2 (15:08):
Actually that is already in place, documented needs and assessments.
If your benefit exaggerations, stronger disciplinary action, more oversight on
lead vendors. So what does this matter for seniors? Because
marketing regular regulations protect you from being switched into the
(15:28):
wrong plan without your full understanding. The biggest thing too,
I've seen insurance companies that have really misleading mailers, so
I'm not sure why they're getting approved, but I'm not
happy with that. So let's go over some part some
real life cases part with seniors switching plants. So case one,
(15:56):
Linda was on a insurance company plan for more than
twenty five years. The medical group got terminated, so if
she stays with the plan, she'll lose her cardiologists and drunkronologists,
(16:16):
her pain management provider. Okay, So what she needs to
do is find a plan that takes her doctor and
her cardiologists and drink knuckle and drinknologists in pain management.
Speaker 3 (16:32):
So it's really a comparison with that. Okay.
Speaker 2 (16:37):
So here's another one I just recently came into, and
I'm just using fictitious names. So Evelyn was on a
Medicare plan G plan. She's paying two hundred dollars per
month and the drug plan.
Speaker 3 (16:58):
She's healthy, she.
Speaker 2 (17:00):
Didn't take any medication, and the reason why she wanted
this plan is she was a snowbird. A snowbird, she
travels to Florida a few times every year, a couple
months each time, so she thought she needed her plan G.
(17:20):
She subsided to try the Medicare Advantage HMO because there
was no cost, she was able to keep the doctor
that she wanted to be with, and she knew even
though she traveled to Florida, she would get emergency and
(17:41):
urgent care covered.
Speaker 3 (17:43):
So that was a big deal to her. So we
will see.
Speaker 2 (17:46):
But I have successfully helped those that wanted to pay
less whether medicare.
Speaker 3 (17:55):
Okay.
Speaker 2 (17:57):
So here's another one. I have Tom, who was diabetic,
had insulin and inhalers METS cost four hundred and twenty
seven dollars a month, but under the insulin cap and
(18:22):
actually some of the plans paying zero dollars on that,
we are able to drop his costs tremendously and so
he's not a camper, right, Okay. So preparing for Medicare
(18:42):
in twenty twenty six, the medicare world in twenty twenty
six will look different. Drug reforms fully implemented, tighter rules
on advantage, more transparent utilization, stronger marketing oversight, metagap pricing increases,
(19:06):
fewer extra benefits and advantage and then more stable network.
Twenty twenty six will be a year when seniors should
review plans earlier.
Speaker 3 (19:16):
And more carefully than ever.
Speaker 2 (19:19):
Just my last client asked, why are the prescription drugs terminating?
And it's just because they are insurance companies are not
really making any money if anything. If you think about
the max cap of twenty one hundred and before the
cap was at eight thousand, and there was a doughnut hole.
So now they are taking that responsibility off the senior's plate, right,
(19:44):
So that is why drug plans are terminating. And some
of them have definitely higher costs one hundred two hundred
dollars when there's some plans at zero cost. That's another
story though. The biggest thing I would say is trust, right,
(20:09):
Who does a senior trust with their information? And also
if you were called legally, meaning you gave someone permission
to call you, I mean if you called them right
and they're calling you back, or if you meet your
agent at a booth, so those are ways right, But
(20:33):
if you do get calls off the blue with no
knowledge or no reason why they called you, no connection
I would not take the call. They're just a call center,
could be a call center overseas as well, So you
definitely need to be careful. Right, your Medicare number is
(20:54):
like your social so there are times people are very
adamant to ask you for your Medicare. See if they're
your agent or you're the ones who called them, then
that is legit. But someone randomly calling you and they'll say, oh,
you clicked on the button on Facebook and things like that.
But just just be extra careful because it has happened
(21:16):
where seniors do get taken advantage of and then they
go to the doctor and their plans totally change. They
can't see their doctor, they have upcoming surgery, things of
that nature.
Speaker 3 (21:30):
That definitely happens.
Speaker 2 (21:34):
Okay, so as we wrap up today, remember Medicare is
changing quickly and seniors who stay in form will get
the best care and the most value. Right, not trying
to scare anyone. Plans are still you're still going to
get your coverage, but that is why it's really important
(21:57):
for you to review it because while some plans may
be stable, there are plans that are so bad, like
benefits have decreased substantially and so like for seniors, some
clients of minds really need the transportation, and the transportation
(22:20):
is basically they pick you up, take you to your
medical appointment, and then also drop you back home, and
that is important. So some plans have really decreased or
just took it off altogether on the plan.
Speaker 3 (22:36):
So if you do need.
Speaker 2 (22:37):
Help, reviewing your plan right, checking your doctors, making that
sure your medical group is the correct one with your
doctor alignment, understanding the drug changes, because there are some
plans that before they didn't have that deductible and now
that deductible could be six fifteen to fifty or whatever.
Speaker 3 (22:59):
It may be.
Speaker 2 (23:01):
Or just preparing for twenty twenty six or twenty twenty
seven or turning sixty five. My team at Premiere three
sixty is here for you. You can email us, call us
Texas whatever is easier, or we send you a link.
It's called ww dot my medicare no sorry ww dot
(23:25):
review my medicare dot org and we will definitely help
you navigate with clarity, confidence and peace in mind. It
has been raining in my neck of the whats so
hopefully it does stop. Have a wonderful Thanksgiving week and
(23:53):
I'm Jennifer Alfonso Li and This has been Medicare three
sixty Radio show. Have a wonderful weekend, everyone, Stay safe,
your heart's content for Thanksgiving. Okay, we will talk soon.
Thank you, boyebye.
Speaker 1 (24:13):
Thank you for joining the program Medicare three sixty. Hope
you found today's episode insightful and empowering. Remember understanding your
Medicare options is key to making the right choices for
your health and financial well being. If you have questions
or topics you would like covered in future episodes of
Medicare three sixty, don't hesitate to reach out and speak
(24:36):
with our licensed insurance agent. Until next time, stay informed
and take charge of your healthcare journey. This has been
Medicare three sixty, your trusted source for all things Medicare.
Take care,
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