Lasso MSA

[sshafran]

somarco , respectfully , I don't understand your point.
I do understand the MSA , my POINT IS that if you call
CMS they will tell you that providers can refuse to accept
the product even if they accept medicare and new patients.

I read the thread , all that I knew. I am sharing an experience\
currently happening to me in AZ.

Sorry for doing that ,, I will stop commenting

Raise of hands for those shocked that a CMS rep would give inaccurate information.

 

[AZSHIS]

I think it is varying by state. I haven't been following things closely, but I think our current state orders expire May 3 and our governor is going to allow some reopening. I'll do some more reading towards the end of the week.

Because of a post by kstein, I did a little reading about St Louis and I had the sense that the Missouri governor might be going to allow some limited reopenings in MO as well.

It seems like I saw something over last weekend that indicated a group of governors in your area were going to act in concert for reopening, but I did not have the patience to read further for a lot of detail.

I haven't been following the covid threads but I am surprised some reopening commentary hasn't started there.

Why do you continue to add nonsense and responses to posts that ask for specific information? Get some help dude. You were writing idiotic crap before the Covid shutdown. Go away. By the way, I know why they call you Lost Dollar ( your picture is below). A silver dollar was lost in the fat fold of your skin in 2002. In 2018 when you attempted to pass through TSA to board a flight, the moldy yeast covered piece of currency was discovered by a soon to be PTSD sufferring TSA Agent.

 

[goillini52]

I think it is varying by state. I haven't been following things closely, but I think our current state orders expire May 3 and our governor is going to allow some reopening. I'll do some more reading towards the end of the week.

Because of a post by kstein, I did a little reading about St Louis and I had the sense that the Missouri governor might be going to allow some limited reopenings in MO as well.

It seems like I saw something over last weekend that indicated a group of governors in your area were going to act in concert for reopening, but I did not have the patience to read further for a lot of detail.

I haven't been following the covid threads but I am surprised some reopening commentary hasn't started there.

Illinois is picking up steam on the # of cases, we're in 4th place now. That's mostly Chicago. I wish they'd get their own state.

 

[goillini52]

Why do you continue to add nonsense and responses to posts that ask for specific information? Get some help dude. You were writing idiotic crap before the Covid shutdown. Go away. By the way, I know why they call you Lost Dollar ( your picture is below). A silver dollar was lost in the fat fold of your skin in 2002. In 2018 when you attempted to pass through TSA to board a flight, the moldy yeast covered piece of currency was discovered by a soon to be PTSD sufferring TSA Agent. View attachment 6241View attachment 6241 View attachment 6241 View attachment 6241

LD can be annoying at times, but he's a good poster and digs up some really hard to find sh*t. LD chose the handle LostDollar...not the Forum members.

 

[Jeff Fowler]

A provider does not have to take an MSA nor or they required to. I had a provider that told my clients that he would under no circumstances take Lasso even though he takes MA PPO's. "It is just one more MA to deal with", he said. I ran it by compliance and was told the provider was within their rights to do so. Ritter is skating on thin ice by saying a provider who takes Medicare assignment must accept the MSA plan. There is no CMS guidance backing this statement. I wish him and his plan all the best, but his plan is not the solution that it portends to be in all situations. Notice I did say all so please don't respond that the MSA worked well for you and I just didn't pitch it correctly to the doctor..

I am very concerned about Lasso's and Ritter's market claim that is cited in Lasso's product literature. I did speak with Jim Handlan, Lasso's president. He did state he was confident in the claim because CMS approved all Lasso's product literature. Not really good enough for me - people at CMS "occasionally" make mistakes...

So far, my clients have more providers state that they would not be taking Lasso than those saying they would accept it. Frankly, the plan is starting to develop some derogatory history with care providers. The word is out that providers can just say "no, we don't know about it", "no, we are not in-network", or "no, we don't take it". I have asked Lasso to get involved on some of these and they were not able to get most providers to accept Lasso even though they would be getting full Medicare reimbursement.

I was given some insight with a provider group I work closely with. They felt accepting Lasso would interfere with their contractual agreements with other Medicare Advantage plans. So unless they were getting some confirmation directly from Medicare compelling them to change their decision, they were not going to accept it. If other provider decide the same, this going to create another provider access for Lasso. After all, we have to tell the client it is a Medicare Advantage plan.

It's a huge foundational problem for Lasso and MSA plans in general. Frankly, unless their provider access marketing claim holds up for clients, Lasso does not have, in my opinion, a viable business model. Nor do they seem to have now nor seem to be currently willing to invest resources to get our Phoenix-Maricopa county provider groups "on-board" or friendly to their plan. It does seem like it is being left to agents with their clients initiating the effort with providers. I don't have the ability to fight this fight with potentially each provider my client would want to use. Frankly, there are not enough resources to make it a fair fight for an agent.

In the end, all I am saying is Lasso's provider access marketing claim just does not hold water. Not overly comfortable saying it must be true because CMS approved Lasso literature. I won't do it knowing what I know now because it's not fair to the client.

I have been to the top of the mountain to the bottom of the rabbit hole trying to make this work.

Someone, please, show me how to make it work. Anyone? Hello?

 

[LostDollar]

I begin to see your problem.

Here is a CMS booklet:
https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf

There is a chart on page 24.

Providers line, question column:

Can I use any doctor or hospital that accepts Medicare for covered services?

MSA column:

You have flexibility in choosing your health care services and providers.

The chart, and information in the text section above it (in the booklet), talk about flexibility of choice for the beneficiary but I don't see a requirement to treat for the provider.

Edit:
I was rereading your post and noticed this:

......."no, we are not in-network" . ........

I don't think that is an allowable reason for a provider not to take the plan.

End edit.

 

[Jeff Fowler]

I begin to see your problem.

Here is a CMS booklet:
https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf

There is a chart on page 24.

Providers line, question column:


MSA column:


The chart, and information in the text section above it (in the booklet), talk about flexibility of choice for the beneficiary but I don't see a requirement to treat for the provider.

Edit:
I was rereading your post and noticed this:



I don't think that is an allowable reason for a provider not to take the plan.

End edit.

Read it and it does not satisfy the issue for the client or agent. I would hope Lasso did not rely on these very vague guidelines. This is why I am concerned about Lasso's marketing claim not holding up and a real exposure for agents and Lasso.

However, I do thank you for sharing.

"no, we aren't in-network" ends up being an effective block to accessing care when the client is speaking to the provider's office and they are offering to let the client pay their "full" rate.

Unless their is something that makes it clear cut from the provider that Medicare has deemed provider access and they are obligated to follow Medicare's rules, then the only remaining thing the client could do is file a grievence with Medicare on either the provider or Lasso. A lengthy process to say the least and might not yield any clear-cut results.

Football fans probably know how Bill Belichick is. He once said, "a rule not enforced is not a rule". He would coach to make that work in his team's favor. He was right to do so until the league changed its mind about the rule or its enforcement.

Unfortunately, the current situation does not favor the client, agent, and/or Lasso. So, first, Lasso could wait for CMS to change its mind about the rule or its enforcement. I would not bet my business model on that any time soon. Another option or co-tactic, what every other carrier has had to do with their plans, put boots on the ground to gain provider support for Lasso. An up hill climb for sure, but this would either get support or help or better identify the problem for Lasso or expose the huge flaw in their business model. I will say it is not fair to expect agent or member to do the heavy lifting on this over a long-period of time on a provider by provider basis. A true "fail" for taking care of the member on a very basic level. Yes, I am full of spit and vinegar today.

In the end. There are no short cuts in developing any carrier's business model. Without this key fundamental addressed, I just an not seeing a challenge I can meet with my clients in terms of provider access. Completely erodes the value out of presenting it as an client option. Too bad because I'm totally in love with the value proposition from almost every other aspect. I have sold this plan the past two AEPs. Nearly 20 years of Medicare selling experience, but learn something new everyday. I may not be the very smartest, but I don't feel like I'm prone to missing too much either.

Does anyone see a way around this and take care of the client?

P.S. I would welcome the comments from Lasso or any organization that actively promotes Lasso.

Please tell me how to win for my clients...

 

[LostDollar]

(Caveat, I am not an insurance agent.)

Hunting for answers, I found this document:

https://www.cms.gov/Medicare/Medica...pps/downloads/2007_MSA_Useful_Information.pdf

According to this, in 2007, providers were not required to accept MSA plans (with two exceptions). See pp 5-6

Provider Issues

Q: Can a provider decide whether or not to treat an MSA plan member?

A: Yes, with the exception of rules regarding emergency rooms, and any contractual obligation that may be in place under a contract with the MAO

.

From page 4 ( I quoted this for beneficiary access question-first one and the appeals question-third one ):

Access and Coverage Standards

Q: Are there access standards for MA MSA plans?

A: MSAs do not have to demonstrate heath care access since members are able to access any Medicare certified provider.

Q: Do MSAs have to follow the local coverage policy of a local carrier for areas out of the plan's service area.

A: Yes. Similar to all other MA plans.

Q: Do MSA plans have all the same obligations as an FI in regard to claim edits and payments? What about appeals and other administrative processes?

A: Subpart M of Part 422 of the 42 CFR (and related CMS guidance) provides information on the appeals process MA organizations must follow for all MA plan enrollees. The rules on coverage of services can be found in 42 CFR 422.101. Generally, an MSA organization for all MA plan enrollees must provide coverage consistent with Medicare statute, regulation, original Medicare manuals and instructions – unless they are superseded by regulations. Additionally, MA organizations must also abide by original Medicare local coverage policy.

Page 7, a network and contracting question and comments (bolding is mine):

Q: Can an MA MSA plan offer a network of preferred providers with whom it has negotiated lower total payment amounts for MSA plan enrollees?

A: Yes, the MSA plan can offer enrollees access to preferred providers who have contracted to offer services to MSA plan enrollees at total prices that are lower than what the providers would charge under fee-for-service Medicare. However, MSA enrollees may not be restricted to those providers. By including MSA plans under 1852(k)(1) of the Act, Congress made it clear that MSA enrollees are subject only to permitted “balance billing” in the same way that all other Medicare beneficiaries are. The inducement for an MSA plan enrollee to use network providers prior to meeting the annual deductible would be solely to obtain covered health care at a “discounted” rate. After the deductible is met, the inducement would be either to avoid permitted “balance billing” or to maintain a trusted provider relationship – in other words, continuity of care considerations. Note that the MAO sponsoring the MSA plan would be responsible for “full” reimbursement (see 42 CFR 422.103(c)) to all providers (including non-network providers) after the deductible is met.

Folks seriously interested in the MSA plans may find the entire document of some use. Do keep in mind it is an old document and I do not know if any significant rule changes have happened since it was compiled.

 

[LostDollar]

"no, we aren't in-network" ends up being an effective block to accessing care when the client is speaking to the provider's office and they are offering to let the client pay their "full" rate.
.

I think I am going to express some disagreement with that. If it is illegal for an insurance carrier to restrict MSA access to a limited network of providers, I think it would also be illegal for a provider to say they don't take the plan because they are not in network. With that statement, it seems to me they are implying they would take the plan if they and the insurance carrier were in an illegal contractual relationship.

I think providers could find less legally risky "reasons" not to provide service under the MSA.

 

[Jeff Fowler]

I think I am going to express some disagreement with that. If it is illegal for an insurance carrier to restrict MSA access to a limited network of providers, I think it would also be illegal for a provider to say they don't take the plan because they are not in network. With that statement, it seems to me they are implying they would take the plan if they and the insurance carrier were in an illegal contractual relationship.

I think providers could find less legally risky "reasons" not to provide service under the MSA.

It's fine to disagree...

The stated reason is not the main issue. The fact that the providers are not taking is. This needs to be fixed. I can't do it.

Think of it as a client trying to access care. Perhaps with other coverage options via rapid disenrollment. Certainly with the ability to file a grievence on the provider, Lasso, or the agent. A situation I really prefer to avoid.