Medicare Compliance & Reimbursement

Plans hopeful Congress will deliver on Medicare reform, funding increases. 

Things may be looking up for the Medicare+ Choice program.

The American Association of Health Plans announced Sept. 8 survey results showing that fewer plans will be exiting the program next year than in any of the previous six years in which AAHP has conducted the survey. M+CO exits should affect roughly 40,000 enrollees, a stark drop from last year, when the survey predicted that exits would affect nearly 190,000 enrollees.

"This is a strong statement that plans are doing whatever they can to offer choices to seniors," said AAHP President and CEO Karen Ignagni in a conference call with reporters.

More significantly, AAHP's survey also asked plans if they would expand their Medicare+Choice offerings if Congress came through with increased funding - and an overwhelming number said "Yes." Increased funding could not only preserve the fragile program, but give it a jolt of adrenaline so it can reverse its long trend of enrollment cuts.

"There is an opportunity for Congress to get value from an investment this year," Ignagni said. Her focus on "value" seems to be an implicit acknowledgement of Congress' severe budget constraints. In the current economic climate, it may be difficult for plans to get any money from Congress, so AAHP is hoping to sweeten its request by arguing that any money given to the Medicare program will more than pay for itself through plans' increased efficiencies and cost-saving methodologies.

"Plans have proven tools that can be deployed" to save money for Medicare, Ignagni said.

She also argued that the survey results put pressure on Congress to act now. Representatives just spent the summer recess hearing their constituents' calls for Medicare reform, Ignagni said. That, combined with the survey's findings and the fact that the House and Senate have both passed Medicare reform bills, makes this the best opportunity M+COs have had in years to finally win increased funding.

And because it's possible Congress could increase funding in the coming weeks - after the deadline for plans to file for M+C in 2004 - AAHP has been speaking with congressional representatives about the possibility of plans refiling and expanding their M+C offerings after the deadline. That way plans that decide to opt out now but learn six weeks later that the economic landscape has changed could be allowed to reverse course and stay in the program.

The number of withdrawals has decreased because plans are doing whatever they can to tweak their offerings and stay in the program, Ignagni says. Also, the M+C program is simply smaller than it used to be as a result of past withdrawals, which were occurring at an unsustainable level.

The remaining M+C plans are "die-hards" who are committed to the program and want to make it work, says consultant John Gorman of Gorman Health Group in Washington. "They're finding a way to make this work, and everybody's holding on to see what Congress does."

"I think after five years of living with the Balanced Budget Act and its effects, folks have found that the way that you survive in this program is by doing really intense market analysis and by operating where you know you can make the product work," Gorman says.

The House- and Senate-passed reform bills gives plans a sense of optimism that they haven't had for some time, Gorman adds. Of course, that conference has its work cut out for it, but Gorman says that "no matter which way reform goes, it's almost certainly going to include at least some modest payment increases and possibly some expanded opportunities" for M+C plans.

Indeed, if the bill collapses and the conference has to strip out the many contentious provisions and pass a lesser bill consisting of only those terms that the conferees can agree on, even that should include givebacks to M+C plans and a discount drug card. And even though most of the current bills' provisions would not kick in until 2006, plans would receive payment adjustments in the interim.

Despite M+COs' optimism, AAHP insists that "the crisis has not passed." If the conference fails and if Congress opts not to increase funding, then the troubled program will face a bleak future. AAHP is clearly hoping it can use its survey results to give Congress the final push it may need to pass the reform bills before partisan bickering kills the bill and election-year gridlock strikes.

Although the survey did not ask respondents if they would be making any changes to their products and benefits, Ignagni says she expects that to be the case. An AAHP press release was somewhat bleaker, predicting that "years of Congressional underfunding will continue to have a significant effect on the benefits and cost-sharing structure that M+C beneficiaries will see in 2004."