Hot Topics I Martin Swanson NE DOI Ron

Hot Topics I Martin Swanson, NE DOI Ron Kotowski, Moderator Mary Mealer, MO DIFP 1

MACRA: Medicare Access and CHIP Reauthorization Act 2015 Genetic Swabbing for Cancer of Seniors Short Term Long-Term Care Model 171: Accident and Health 2

MACRA 2015 -What is it? -Avoiding misleading information: Know the facts. 3

MACRA: What is it? • Effective as of 1/1/2020: • • • Removes Medicare Supplement Part B deductible coverage for those newly eligible Medicare Beneficiaries: Plans C, F and High Deductible F. Re-designates Guaranteed Issued Plans and Creates High Deductible G. Medicare Eligible Beneficiaries of prior to 1/1/202 are “grandfathered”. Applies to Newly Eligible Medicare Beneficiaries as defined by law. Applies to Waiver States Defines Newly Eligible Medicare Beneficiary 4

• MACRA’s Pools: Medicare Eligible PRIOR to 1/1/2020: Can purchase all plans including C, F, High Deductible F and newly created High Deductible G Medicare Eligible ON or AFTER 1/1/2020: Can Buy all plans EXCEPT C, F or High Deductible F. New Guaranteed Issued Plans: D, G and High Deductible G 5

MACRA: Why is it important? States must adopt the Medigap Model changes Prior to 1/1/2020 otherwise authority to regulate reverts to the federal government. First time for two different “populations” impacted by different laws: A lot of misinformation and confusion. Penalties apply for inappropriate sales 6

MACRA: Know the Facts The NAIC has issued several guidance documents to help with the transition for states, carriers and the public: FAQ: https: //naic. org/search_results. htm? q=MACRA FAQ Consumer Alert: https: //www. naic. org/documents/cmte_b_senior_issues_related_macra _consumer_bulletin. pdf Agent Bulletin: The NAIC is in the final stages of releasing this bulletin. 7

• MISINFORMATION: • “But, as many financial advisors have stated, you may find that your monthly premiums increase due to two factors: (1) the aging risk pool of Medicare beneficiaries who will remain in a Medigap Plan F after 2020, and (2) the shrinking number of members in the Medigap Plan F policies. In short, current Medigap members can keep their Plan C or Plan F policies, but can expect increasing monthly premiums as plan healthcare costs rise without the addition of new, healthier plan members. ” 8

“Another massive change that’s coming as a result of MACRA is in relation to Medicare Supplements. Specifically, two of the more comprehensive Medigap plans are being discontinued in 2020. These plans are Medigap Plans C and F, both of which are notable because they cover the Medicare Part B deductible…. . ” Source: living. medicareful. com Moneytips. com: …. ” Therefore, this leaves many current Medicare enrollees with some decisions to make: enroll in Plan F now so you can keep it or switch out of Plan F before it is discontinued. “ 9

• “Medicare Bob” at seniorhealthcaredirect. com 2018 article: “If I have Plan F should I keep it? ? ? Plan F is the “Guarantee Issue plan: Some situations allow people to join Plan F without medically qualifying. Over the past few years, The Part B deductible has increased from $147 to $183 ($36. 00). If a carrier has 1 million people on Plan F, it is now costing the insurer $36 million dollars more per year to cover the same 1 million people. No one that turns 65 after 01/01/2020 will be able to purchase Plan F. 10

• Maturehealthcenter. com: “But if you enroll in Plan F or Plan C before 2020, you will be able to renew your existing plan moving forward. ” • Healthscapte. com: “Section 401 of MACRA eliminates the ability for plans to cover the Part B deductible, effectively eliminating Plans C and F. ” and “These individuals are grandfathered into Plan C or F in that if they are enrolled in either plan prior to 2020, they can continue with their coverage. ” 11

• Genetic Testing: A rash of genetic testing entities have popped up around the nation. • Entities have been going into senior centers, assisted living facilities and nursing home to “test” seniors for cancer • Typically, a testing entity will get “consent” from the senior, run a telemedicine check, allegedly for medical necessity, obtain the swab and submit to a contracted lab. • The entity will obtain the Medicare card and other information from the senior for billing. 12

• • The lab will bill Medicare or the Medicare Advantage plan The bill submitted to a carrier or to Medicare can range from $1, 000 to $10, 000 per swab It is possible, depending upon the documents signed by the senior, the senior could be balanced billed for the swabbing. CMS allows for the payment of genetic testing for cancer for the purpose of the treating physician to create a treatment plan for that type of cancer, however…. . 13

• CMS has very specific rules as to its’ allowance and payment o The person being swabbed must have recurrent, relapsed, refractory, metastatic, or advance stages of III of IV cancer o The test must be ordered by a treating physician o The results must be provided to the treating physician • • In numerous instances, none of aforementioned have been followed It is unclear what happens to the genetic material after the test 14

• The entities have changed tactics and now have decided to clone phone numbers and contact consumers directly to get them a kit o One such call came to the administrator for SHIIP in Nebraska. The cloned phone number was from the Office of Rural Health that is located in the Nebraska Department of Health and Human Services. • We’ve issued a consumer alert as has the HHS Office of Inspector General. o The NAIC has also discussed further action and may issue a letter as well. o Carriers have been contacted and are looking into this issue through their SIU units as well. 15

Short Term, Long Term Care Model: • Why the need? • Review of various state laws finds variations on the definition of shortterm, long term care. • Differentiate any confusion regarding short term duration medical policies • Ensure delineation from Long Term Care polices and Partnership policies. 16

• Short Term LTC Model: • Applies to policies or riders providing coverage for less than 12 consecutive months • • • Life and annuity policies or riders that provide direct or supplement LTC insurance Policy or rider providing payment based on cognitive impairment or loss of functional capacity Coverage for one or more medically necessary services or personal care provided in other than acute care in a hospital Does NOT apply to Medicare Supplement or limited benefit or major medical expense policies Intent: designed to allow maximum flexibility Extraterritorial only if another state with substantially similar laws approved 17

• Model 171: Accident and Sickness changes • Changes Accident and Sickness to ANCILLARY HEALTH • Applicable to: individual and group; hospital indemnity or other fixed indemnity; accident only, specified accident, specified disease, limited benefit health, disability income protection, limited scope dental and vision. And Short Term limited duration health plans (included because Feds did no consider as “individual health insurance” so not subject to HIPAA or ACA) • Does not restrict combining the above coverages, if permitted by regulation • Please Note: some states laws, like MO’s, are antiquated and refer to “accident and sickness” Some states, like NE, hasn’t adopted the earlier model. 18

• Model 171: Ancillary Health • The definition of “hospital indemnity or other fixed indemnity insurance” in model states “coverage that provides benefits on an independent, noncoordinated basis…” • Required disclosures are found in Sections J and K • Adds “extension of coverage” with terms or renewability or… • Drafting note stresses being cognitive of post claims underwriting when reviewing policy rescissions due to fraud or intentional misrepresentation. • Insurer shall not be required to deliver outline of coverage for group plans if cert contains description of benefits, exclusions, eliminations, restrictions, limits, etc; and termination 19

• Questions? ? ? • Contact: • • • Ron. Kotowski@gmail. com Martin. Swanson@Nebraska. gov Mary. Mealer@insurance. mo. gov 20