Medicare is a federal program that provides health coverage if you are 65+ or under 65 and have a disability, no matter your income and resources, you must qualify based on certain criteria and maybe subject to premiums and deductibles.
On the other hand, Medicaid is a state and federal program that provides health coverage if you have a very low income and resources.
If an individual qualifies for both coverages (AkA dual coverage) then both Medicare and Medicaid would be used together to pay for the health services needed and provide a full and comprehensive insurance package.
Are there differences between Medicare and Medicaid in term of coverage?
Is Medicare better than medicaid?
Each coverage has its merits, however, Medicaid covers some services that Medicare typically doesn't i.e Dental, vision and hearing aids.
Medicaid, can also cover the cost of nursing homes, assisted living facilities, and other long-term care alternatives as long as they're deemed medically necessary.
Medicaid has a state component, since it is administered by each state, while Medicare is entirely federal and managed through Social Security administration.
Dual individuals who are eligible for both coveraged have the best of both worlds and when they add a Medicare Advantage, AKA part C(to be discussed later on), they pretty much get full and comprehensive coverage at typically a very low cost or no cost depending on their type and level of Medicaid (FPL Federal Poverty Level).
Managed Care in general Developed in the United States as a response to spiralling healthcare costs and dysfunctional fragmented services, Medicaid and Medicare Managed care was adopted to prevent various types of Fraud, Waste and Abuse by both Consumers and providers.
Managed care had been constantly in a progressive mode and constantly is constantly changing and adapting.
It seeks to cut the costs of health care while maintaining its quality, but many skeptics still question its merits as the evidence of it working as intended has yet to be proven.
The Jury is still out.
Due to its constantly changing nature, managed care is very complex and intricate but all forms of it have one thing in common, simply stated:
An attempt to influence and modify the behavior and practice of patients and doctors as well as other health professionals towards cost effective care.
Bosses only care about results whereas Leaders are responsible for the results and the people who achieve them.
1. Leaders listen and speak and never order around.
A boss will always give orders, they just want followers to obey.
Leaders, listen and ask for opinions.
Leaders take feedback of staff members and employees which ultimately creates a positive environment where they feel confident about the tasks at hand and to follow their leader.
2. Leaders lead but never rule.
Leaders gain and command respect, top leaders are always on the front of the action.
Leaders help their teams move forward.
3. Leaders motivate.
Leaders motivate staff and never intimidate them.
Leaders coach, mentor and teach, they are always available to land a hand and support physically and morally.
4. Leaders take initiative and never take a passive stand.
A leader always takes action, never awaits for things to happen on their own, a leader will take action in any situation, leaders consider themselves part of the team and act on it.
5. Leaders teach but are always open to learn.
Leaders are always eager to learn and never consider themselves above new knowledge.
Leaders are not afraid of teaching others to become leaders and/or to take over leadership, they inf act empower their proteges and give them an opportunity to learn, lead and flourish.
6. Leaders reprimand never yell or talk down to their followers.
Leaders give feedback and positive criticism and take advantage of the situation to make a learning one. True leaders never yell at others.
Discussions are never public and never condescending.
7. Leaders do not promote favoritism.
In the eyes of leaders all staff members and/or employees have equal value, there is no favoritism practice.
What is an EGWP or Egg Whip?
Click on the RDS vs EGWP infographic for full size image.Because of recent healthcare reform initiatives, an EGWP is the most cost-effective way for organizations to provide retiree prescription drug coverage.
An EGWP, commonly referred to in retiree benefit plan parlance as an “egg whip”, is a group Medicare Part D prescription drug plan option that is offered to retirees who have been promised prescription drug coverage as part of their Other Post-Employment Benefits (OPEB).
Benefit solutions partners contract with the Centers for Medicaid and Medicare Services (CMS) to serve as a Medicare Part D Plan Sponsor and manage compliance with CMS regulations with regards to Part D prescription drug plans for retirees.
Medicare Part D subsidies and discounts are used to reduce the fully insured premium. With an EGWP there is no subsidy filing required for the group sponsor.
Key EGWP Information
Normally EGWPs are administered through a pharmacy benefit manager (PBM) or insurer (Health Plan/Carrier)that contracts directly with the Centers for Medicare & Medicaid Services (CMS). Plan options are available that close the gap in retiree Medicare coverage, known as the doughnut hole. Under the EGWP there are three substantial subsidies and discounts that lower the cost of prescription drugs for plan sponsors and their members.
1. CMS Direct Subsidy – Per member subsidy of approximately $500 annually, based on risk scores calculated by Medicare. This subsidy alone is often equal to or more than the amount plan sponsors receive from the RDS Subsidy.
2. The Coverage Gap Discount Program – Provides a 50% Discount on brand-name drugs when the member is in the Part D coverage gap.
3. Catastrophic Insurance – Medicare provides 80% reinsurance for the highest utilizers.
The Medicare Part D law was passed in 2003 and took effect in 2006. The federal government created two methods that gave employers impressive subsidies and tax incentives to keep retired employees on their prescription drug plans. Under the Retiree Drug Subsidy (RDS), the government was paying up to 28% of the covered Medicare-eligible retirees maintenance drug program (MDP) expenses directly to the participating enterprises. The RDS subsidy was tax free to the employer.
Changes in RDS That Make EGWPs very attractive?
The original Retiree Drug Subsidy (RDS) has been adversely affected by the 2013 Patient Protection and Affordable Care Act (PPACA) for self-funded employers. Effective January of 2013, the PPACA wipes out the full value of the tax deduction of those retiree drug expenses. This is now causing self-funded retiree drug benefit plan providing companies to see a significant cost increase. This is where the EGWP solution becomes a much more desirable option as it decreases administrative costs while at the same time increases the per participant contribution substantially.
Accounting Benefits of EGWP Programs for Governmental Entities?
Governmental entities receive an additional accounting benefit under an EGWP program. The savings from the EGWP can be reflected in the current year liability calculation. Under the RDS subsidy program, future projected RDS reimbursements cannot be included. The savings involved can positively impact accounting for GASB 43/45.
How an EGWP +wrap Maximizes Retiree Prescription Drug Benefit Savings?
By combining an EGWP with a non-Part D commercial wrap plan, EGWP benefit solutions partners can help plan sponsors take full advantage of the Coverage Gap Discount Program. The wrap plan is transparent to plan participants as they receive a single prescription drug card for all their Rx purchases.
Salespeople use both their mouth and their brain to generate income .
It is vital the two mechanisms are in sync.
Many salespeople lose a deal saying the wrong thing because of a lack of thinking or the opposite overthinking .
Probing and assessing a client’s need is a must.
That being said, this doesn’t mean we have to be overly cautious and shy away from asking certain questions even if they are frowned upon by many and also we have to ensure that we cover the key questions to determine the course of the sale.
The following are sample questions salespeople should ask
1. “How can I help you? ( with their need)
2. “Can you tell me about your top priorities?”
3. “What’s the driver today and motivation that prompting you to discuss this with me today?”
4. “Is there anyone else who needs to be involved or will have part in the decision making process?”
5. “Is it ok to share a little about myself and company?
6. “What’s your timeline for getting this done?”
7. “Have you had any good or bad experience before?
8. “Would you have any problem saying no to me?”
9. Is there anything else that I need to know before I proceed that may prevent me from earning your business today?
These are all great questions that you can rephrase in your style to get the most feedback and build the most report as well as understand your prospect and gauge whether there is a deal or not.
Selling is part of life, it is a process that occurs around us both in our personal and professional environments.
The selling process is simple in nature but can appear to be complex.
There is a salesperson in each and everyone of us, while we might not reflect on it, we have been pitching and selling for a long time and it dates back to our childhood.
The truth, kids are the best at it, they always close.
Selling is both a science and an art.
Science: There is a specific process that is thorough and methodical, there are multiple steps that take place and when carefully executed the results just happen.
Art: Not everyone can sell and pitch a product and service, there is a certain personality, finesse and touch that is required to make it happen.
Some people can simply evolve to this level others just don't at least that is true in professional sales, in personal lives we continue to excel.
Selling is a profession, not a talent or a gift.
Selling requires certain innate attributes, such as the ability to emphasize and drive to success.
Professional sales techniques must be used effectively in the earlier phases of the sale, in order to set up the close.
What one is selling has a real value for the customer.
Even though someone understands the sales process, they can always gain a lot by studying and working with other successful sales professionals to deepen and advance their understanding.
There is a constant structure to selling and a professional salesperson must dedicate himself or herself to mastering it.
Their self confidence can be an asset or drawback as it can either attract customers in and makes them want to buy or create doubt and prevent deals.
Now, let's take a close look at the sales process and define the various steps regardless of product of services.
Today, we will address step 1:
Finding the customers or clients: AKA, marketing, prospecting and canvasing
This step is vital: no customers, no sales period.
Marketing is complex in its own, but in simple words, it is the understanding of the market, defining the geographical target areas, demographic trends, behaviors and how to make in pact through branding and various media tactics and strategies.
Prospecting and canvasing:
The process of which a marketer, salesperson or producer develops the customer base through grass root efforts.
A sales professional must set attainable goals,written, specific, thoroughly planned and most importantly time bound.
They must be prepared as my best friend says" Prior Planning Prevents Poor Performance" territory and time management are the core of it all.
Scheduling outreach properly and maximizing time is a priority, a knowledgeable seasoned sales professional will take the time to strategically pre-schedule various visits around a particular zip code or region in a cluster in order to minimize time travel time and maximize pitch opportunities.
Always going to the source, a key technique is to find a way to pitch to decision makers and not intermediary 3 rd parties.
I sometimes find it interesting e.g. someone trying to pitch a claims program yet they reach out to the head of sales.
They might thing that by doing so, the latter will relay the message to the proper party but in fact, the latter may not see a priority to the pitch and may delay or even prevent the connection from happening.
A better way would be to immediately seek audience with the head of operations.
An insurance producer must always ask for all decision makers to attend the pitch, caregivers, family members etc...
Time is of the essence in sales, all organizations set daily, weekly and monthly goals and planning properly both time and territory will ensure that those targets and goals are met.
What are the main types and main reasons that drive health plan organizations’membership dis-enrollment levels?
Understanding trends can help plan executives assess and remedy the issue and put a solid plan together to address and turn the numbers around to acceptable levels.
There are many reasons that affect membership pre and post enrollment:
A. Pre-enrollment Causes:
1. The front line staff.
2. Possible lack of adequate education on plan benefits and services
3. Misrepresentation by plan representatives
Drive by presentation, quick and superficial presentations
4. Not using marketing tools properly
1. Focus on home presentations, Self gens, provider referrals and company generated leads
2. Staff development program, better and thorough training Educational orientation seminars
3. Tighter program policies including a serious and swift disciplinary process.
Use of CMS approved presentation portfolios to assist and guide the presentation at the time of enrollment including questions to help remove objections.
B. Post Enrollment causes.
I. Delivery and access to services:
a. Operational issues, cards not sent on time, too many points of contacts etc...
b. Unable to receive expected services when in need of service.
c. Unable to resolve provider access because of complicated I.V.R systems prompts
Dissatisfaction with Customer service experience (attitude, long wait on hold, run around etc...
1.Ensure that members receive their info on time.
2. Ensure accuracy of demographics from the start and throughout the membership.
3. Simplify I.V.R prompts and make proper adjustments to language needs.
4. Better customer service training, using calibration calls, Ad-hoc training etc…
5. Member outreach and re-education after initial enrollment both on the phone and in person throughout seminars and events including member ambassadors and testimonials.
II. Providers: main reasons:
1. Provider contract rates leading providers to steer membership because of better reimbursement from a competitive plan.
2. Network deficiencies: lack of key providers in service area.
3. Docs having claim payment issues.
4. Provider access to authorization approvals which could be due to how easy is the access to the plan's authorization system or simply to the lack of the response time or the plan'staff's attitude.
More education outreach to providers on plans and why their patients are better off with the plan's products.
Ensure that claims are paid on time.
Offer more lucrative contracts (possible risk)
Contract more key providers in different geographic areas
Simplify the authorization and referral process
Adopt a customer friendly approach with docs
Death: Simply involuntary and part of life especially for MA and MLTC plans.
a. Fierce competitors, poaching members, guerilla marketing tactics.
b. Better retention efforts using outside companies to maintain membership.
c. Massive advertising and branding campaign, including Billboards, print, TV and radio.
d. Larger field teams and Mobile fleets.
e. Larger community relation and events teams.
f. Larger pockets with dedicated budgets.
1. Use similar approach providing it is done compliantly.
2. Foster exclusive deals in exclusive geographic markets.
3. Better or competitive staff compensation and retention to attract and retain talent.
What is Managed Care?
A healthcare delivery system which purpose for managed care plans is to reduce the cost of healthcare services by stimulating competition and streamlining administration and where patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company.
Managed care plans are a type of health insurance.
They have contracts with health care providers and medical facilities to provide care for members at reduced costs.
These providers make up the plan's network. ... Point of Service (POS) plans let you choose between an HMO or a PPO each time you need care.
Simply stated, managed care is a system that integrates the financing and delivery of appropriate health care using a comprehensive set of services.
Managed care is any method of organizing health care providers to achieve the dual goals of controlling health care costs and managing quality of care
Benefits of Managed Care:
The most common forms of managed care providers are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Point-of-Service Plans (POS).
They all come with their various pros and cons. Obviously, the first and main advantage of managed health care is the lower costs associated with them.
What is Medicare?
Medicare is the federal government program that provides health care coverage (health insurance) if you are 65+, under 65 and receiving Social Security Disability Insurance (SSDI) for a certain amount of time, or under 65 and with End-Stage Renal Disease (ESRD). The Centers for Medicare & Medicaid Services (CMS) is the federal agency that runs Medicare. The program is funded in part by Social Security and Medicare taxes you pay on your income, in part through premiums that people with Medicare pay, and in part by the federal budget.
Once you have become Medicare-eligible and enroll, you can choose to get your Medicare benefits from Original Medicare, the traditional fee-for-service program offered directly through the federal government, or from a Medicare Advantage Plan, a type of private insurance offered by companies that contract with Medicare (the federal government). Original Medicare includes:
Part A (Inpatient/hospital coverage)
Part B (Outpatient/medical coverage)
If you want Medicare prescription drug coverage (Part D) with Original Medicare, in most cases you will need to actively choose and join a stand-alone Medicare private drug plan (PDP).
You still have Medicare if you enroll in a Medicare Advantage Plan. This means that you will still owe a monthly Part B premium (and your Part A premium, if you have one). Each Medicare Advantage Plan must provide all Part A and Part B services covered by Original Medicare, but can do so with different rules, costs, and restrictions that can affect how and when you receive care. Medicare Advantage Plans can also provide Part D coverage. Note that if you have health coverage from a union or current or former employer when you become eligible for Medicare, you may automatically be enrolled in a Medicare Advantage Plan that they sponsor. You have the choice to stay with this plan, switch to Original Medicare, or enroll in a different Medicare Advantage Plan, but you should speak with your employer/union before making any change.
It is important to understand your Medicare coverage choices and to pick your coverage carefully. How you choose to get your benefits and who you get them from can affect your out-of-pocket costs and where you can get your care. For instance, in Original Medicare, you are covered to go to nearly all doctors and hospitals in the country. Medicare Advantage Plans, on the other hand, usually have network restrictions, meaning that you will be more limited in your access to doctors and hospitals. However, Medicare Advantage Plans can also provide additional benefits that Original Medicare does not cover, such as routine vision or dental care.
Medicare is different from Medicaid, which is another government program that provides health insurance. Medicaid is funded and run by the federal government in partnership with states to cover people with limited incomes. Depending on the state, Medicaid can be available to people below a certain income level who meet other criteria (e.g., age, disability status, pregnancy) or be available to all people below a certain income level. Remember, unlike Medicaid, Medicare eligibility does not depend on income. Also, eligible individuals can have both Medicare and Medicaid and are known as dual-eligibles.
Everyone who has Medicare receives a red, white, and blue Original Medicare card. If you choose to receive your coverage through Original Medicare, you will show this card when you get services. If you choose to receive your Medicare benefits through a Medicare Advantage Plan, you will still get an Original Medicare card but you will show your Medicare Advantage Plan card when you get services. No matter how you get your Medicare health benefits, only give your Medicare number to your doctors and health care providers.
A seasoned healthcare sales executive and a leader with 26 years of Health Insurance and Managed Care experience, a strategist, innovator and motivator with a vast and deep understanding of Managed Care Organizations and the health insurance industry and its critical nuances and complex design..