Interesting Medicare Stuff

If you are a Medicare Advantage client have you ever asked yourself, how can I get great health care and have no monthly premium? To keep this as simple as possible, suffice it to say that the government pays insurance companies based on a per person fee and uses the star rating system to further pay these insurance companies bonuses based on the quality of care. The star rating system is based on many factors related to the overall health of their clients. The better the health, the higher the star rating and the higher the payment to the insurance company by CMS.

Recently there have been some developments that CMS have changed the way they calculate the star ratings thus lowering the ratings and paying less money to the insurance companies. Personally, I believe these ratings should be consistent year by year unless there is a more equitable way to calculate those ratings. I also believe that CMS owes these insurance companies an explanation of why they changed the methodology to these insurance companies so they can change the metrics to accommodate the new methodology.

Going into the methods is not something that is easily explained so we will skip that portion. Suffice it to say the insurance companies are losing millions of dollars on these changes. Whether the changes are justified or not is also up for discussion but believe it is too complicated to explain.

I personally believe that CMS and the insurance companies should sit down and review the potential changes and why they are happening before they are implemented. That way everyone is on the same page. The current method places CMS against all insurance companies and that is not the way to do business. Both parties need each other, and it makes sense to be on the same page.

The star ratings determine how much money CMS pays the insurance companies to take care of their seniors. I believe the ratings should be fair and equitable to both parties and not adversarial. Several insurance companies have sued CMS, and one has already won and CMS must pay them at the higher star rating. Now, several other insurance companies have also filed suit against CMS. It looks like the insurance companies will probably win their suit as well.

Government is there to provide goods and services to the American people, and they need to understand the situation and make sensible changes that all can live with. Perhaps the star rating system has reached the end of their run or CMS, and the insurance companies should simply sit down and agree on the rating procedure, so it is fair and equitable for all parties.

In closing what makes the government think they know more than the insurance companies about claims and policy procedures? In Medicare these insurance companies are subject to so many rules and regulations, but it seems to be profitable because so many companies are in the Medicare Advantage business. I hope they work out their differences and move forward to taking care of our seniors.

I hope this information is useful,and if anyone has questions, please contact me via phone or email and I will respond quickly.

Also, you may want to take a look at 2026 Medicare Information.

Len Barend, Broker

Cell: 702-250-2200

Email: len@insurance4unevada.com