PDP Trial Right

[sman]

My perspective was/is, if she had the surgeries 3 months apart over 2 calendar years the surgeries + PT, etc would likely exceed the Medigap premiums + OOP during that time frame . . . plus the inconvenience of long distance travel to access par providers.

The outpatient surgeries are generally manageable copays on most MAPD's ($300-$400 range per surgery). But those copays for PT can add up. Typically, if there is a MAPD plan in a rural area, one of the local hospitals will be in network. Plans don't make a habit of offering plans in an area where the local hospital isn't in network. But in that situation, I'd take a Med Supp all day every day.

 

[Brande]

FYI, I don't know where you are, or how long this offering has been in place, but providers have a discouraging success rate with these ventures. They seem to play out better in rural area where there are fewer provider choices and the sponsoring hospital has acute care facilities and a "captive" audience.

Providers are not in the risk managemen/abatement business and quite often find profits marginalized due to non-paying patients . . . those who are insured but can't/won't pay the OOP balance.

Lower premium and no underwriting waves a red flag at me.

MAPD plans essentially do the same thing but also have a managed care iron fist to hold down claims.

Rural area, few provider choices, and hospitals with a captive audience is exactly what is happening out here.

I live in South Dakota, and we have two main healthcare systems out here(meaning my half of the state), Avera and Sanford. It's a lot like Democrat Vs Republicans: They're the only two options, and they don't get along. In the bigger cities, half of the healthcare options are Avera, the other half are Sanford. In the smaller towns, like mine, that have 10-20 thousand people, it will either be an Avera town or a Sanford town. So my town, Yankton, is an Avera town. The hospital is Avera and they do not accept Sanford. Thirty miles away we have Vermillion, which is a Sanford town. Both systems offered their own supplements. The Sanford one never really took off, but the Avera one is a beast (again, keep in mind our numbers are puny compared to a place that has a lower cow to people ratio). Anywhoo, Avera markets their med supp like crazy and is only second in enrollment behind BCBS. MOO, UHC and all the others are pretty far behind. Usually, Avera only opens up their "no underwriting" period during AEP, but this year they decided to keep the G group open for the rest of the year.
This thing is pretty hard to market against. A T65 non smoking single male in my zip code comes in at:
BCBS: $164.20
UHC: $127.77
Avera Select: $92.50

So, when I come across those already on MAPD who are looking for stronger coverage I show them the Medica Cost plan that we have, offer to put them through underwriting for a regular supp, and I also show them the Avera plan- complete with pricing and an explanation of what no underwriting means. At the end of the day, if I have to hide a product from someone to make a sale, that means I didn't deserve the sale. The person deserves to know what all of their options are. A lot of the T65 folks do decide to go with a regular supplement, though, because they appreciate the freedom that a regular supp has compared to the select plan.

But, you are right on the other hand, because Sanford did just try to shut their supplement down. I guess the Division of Insurance wouldn't let them pull it from the market, so now they are just going to price everybody out of it with massive increases.

 

[XpressInsurance]

What level of Medicaid does the client have? Did she just get the Medicaid? Some states will enroll them directly into a MAPD. TennCare asks on the Medicaid application which provider you want. Medicaid is a question of eligibility on Medigap applications.

 

[somarco]

copays for PT can add up

You are right about the PT, and knee replacement PT often has a longer recovery than other joint surgery.

When Rachel broke her hip a few years back she had 3x weekly PT for a month or so followed by another 2x weekly for 4 months. The PT gross billed charges were almost as much as the 4 day hospital stay + surgeon charges.

A client with rotator cuff repair had 6 months of PT.

What level of Medicaid does the client have? Did she just get the Medicaid? Some states will enroll them directly into a MAPD. TennCare asks on the Medicaid application which provider you want. Medicaid is a question of eligibility on Medigap applications.

No idea. She is not a client, not even a prospect, just trying to help out a lady across the country that found me. This is one of those situations where there is no money for me, just the satisfaction of knowing I helped.

BTW, just found out the mom is 103!