From Tom's Desk

Medigap, 2019 and You

Open enrollment mania for 2018 is upon us—-and enrollment is indeed expected to be huge. I'll go on record that sign-ups are going to far exceed even the highest expectations. But as we all breathe deeply before taking the plunge, it’s worth taking a moment to think about the changes to be faced at this time next year.


In 2019, Medicare supplements will be forbidden from offering first dollar coverage. Beneficiaries are going to be required to pay about $80 dollars of their medical expenses out-of-pocket every month before supplements kick in.


The results?


High accounts receivable for providers, a marketing edge for Medicare Advantage organizations, but probably not lower Medigap premiums for patients.


Your tactic?

Make sure this year that your  beneficiaries understand this is coming. They just might jump to a Medicare Advantage plan a year early—-and you just might get the jump on keeping your accounts receivable down for 2019.

You Should Know...

New Plan Creation Less Onerous

As we discussed last month, CMS is cracking down on Medicare Advantage Organizations (MAOs) regarding adequacy of provider networks. This in response to multiple beneficiary complaints and failed network audits. The CMS pressure is to take the form of routine electronic submissions of provider network composition by MAOs to CMS. These new regulations were looking to significantly increase compliance costs across the board.


Well, there might be some relief after all.

Documentation of provider adequacy is accomplished through the healthcare service delivery (HSD) table portion of the Medicare Advantage application that’s submitted by MAOs to CMS for both the renewal of and new Medicare Advantage plans. It's easily the most complex portion of the application.


The draft  Medicare Advantage new plan application for 2019 has been released and It contains one big surprise—-the removal of the HSD requirements for new plans. Tighter ongoing enforcement will proceed as planned, it’s just that network adequacy won’t be assesses for new plans. Additional, longer-term enforcement was discussed as were heavier sanctions for non-compliant plans.


The upshot—-you won’t have to prove your provider network meets CMS standards with your new plan, but you better make sure they do.  If your network is found wanting on subsequent audits, the sanctions are going to be much more severe than currently.


If the draft is approved as written, then it should be much easier and less expensive to get your plan approved. However, if you try to cut corners and your patients complain of their inability to access care, it just might cost you more in the long run.

High-Value Insight


This one is simple.

No matter what type of amputation it is, if it’s above the waist, there’s no associated increase in risk-based capitation.

If it’s below the waist, there is.

Q&A with Dr. Tom

I'm opting out of Medicare as a provider, but many of my Medicare Advantage patients want to stick with me even if they have to pay full price out-of-pocket for my services.

How can this be arranged?



Find a prime who is willing to carry them on her panel as their PCP while they still see you for their care.


It’s a great deal for everyone.


The patient gets what they want.


You get to hold on to a patient.


The PCP gets the capitation knowing you’re going to take excellent care of the patient.

She may need to see them once a year to make sure they are getting what they need and for code submission—-but still it’s a big win all round.

Tom Davis Consulting Get Your Copy Now! Contact Tom
Copyright © 2017 Tom Davis Consulting, All rights reserved.