Name: The Hidden Profit Centers of Medicare Advantage: A Community Pharmacy Primer
Uploaded: 2025-10-14T18:16:03.059Z
Duration: 59 min 12 s
Description: The Hidden Profit Centers of Medicare Advantage: A Community Pharmacy Primer

Transcript for "The Hidden Profit Centers of Medicare Advantage: A Community Pharmacy Primer": Welcome to today's webinar hosted by EnlivenHealth. Our topic today is the hidden profit centers of Medicare Advantage, a community pharmacy primer. Thank you for joining us today. Before we get started, I'd like to highlight a few housekeeping items. Please type your questions in the q and a tab to ask questions throughout the presentation. We'll be sure to answer your questions during the dedicated q and a session towards the end of our time together. We are recording this webinar and will email the recording to all attendees. And now I'm delighted to introduce our speakers today. Marvin Guardado has worked with community pharmacies for over ten years. He started at AmpliCare in 2015 where he held several notable roles. Marvin currently has Enliven Health solution sales and strategy team for Match. He ensures customers are set up for success and contributes to the product roadmap by aligning market expectations with product capabilities. Traci Bayer is a pharmacist with seventeen years of experience. Fourteen of those years were spent as an independent pharmacy owner deeply involved in her community. For the past twelve years, Tracy has specialized in helping patients navigate Medicare plan d plan comparisons excuse me, Medicare part d plan comparisons, ensuring that they find coverage that truly meets their needs. Recently, she became a licensed insurance agent, allowing her to be compensated for the same trusted guidance she's been offering for years. And without further delay, I'll hand it over to Marvin. Hey, everyone. Thanks, Nikki, and thanks, everyone. Glad you could join us here today. And we're gonna have a practical conversation about what's changing in the Medicare space, how pharmacies can uncover opportunities and revenue by looking closely at Medicare Advantage Plans, and we'll start by looking at the market. What's driving plan changes this year? We're gonna hear from Traci, of course, about how our pharmacy approaches plan comparisons and the impact she's made. And then we're also gonna connect the dots between Medicare Advantage plans and clinical services. So things like vaccinations, testing, consultations, how those can become meaningful profit centers for your pharmacy. And we're gonna wrap with how to identify the right patients for plan comparisons and build stronger relationships heading into open enrollments. So let's start with our mission real quick, which in short, it's to help pharmacies to to help and enable pharmacies to stay at the center of care, deliver more value, and get recognized for it. So you'll see that reflected in our new approach, which is about unifying patient engagement, pharmacy outcomes, and operational efficiency into one connected model. And one pharmacy that's been ahead of the curve in doing just that is Hillcrest Pharmacy in Vernon, Texas. Hillcrest Pharmacy has been family owned and operated for more than thirty years, serving the community in Vernon, Texas. They offer vaccinations, point of care testing, compliance packaging, home delivery, really a full service community pharmacy that knows patients by name. So, Traci, tell us a bit more about your pharmacy and your role there. Yes. My husband and I are both the pharmacist and owners there, and we have, one other full time and a part time pharmacist, onboard now. We, serve a community of about 10,000 rural in rural Texas that, is predominantly low income. And so we're able to really just, yeah, with as far as the Part b plan comparisons go this time of year, able to help them select plans that are the the best for them in our pharmacy. But, yes, our pharmacy in general, we have a large also med sync program where we compliance package, so we're able to, take the additional benefit of the long term care billing for medical at home. So those are some big things we do. And, of course, vaccines, like all of you guys, I just left a vaccine clinic in town. So, yes, lots of lots of all the extras to keep us going. Yeah. So Traci sprinted here from a flu flu clinic here, so she's out of breath. Great. First party chairs. That goes to going from one part of town to help your community to come and help the community of pharmacy owners across the country. Yes. So appreciate that, and I appreciate your your sprints to make it here, on time for the webinar. And you've been doing as you said, you've been doing plan comparisons for quite a while now. And even before you got licensed, can can you tell us about, you know, what got you started and how that's evolved over the years? Yeah. We originally started doing it back when it was iMedicare. Is that what we started as, iMedicare? It was back in the day. Yeah. Yes. It was a tool just a useful tool because we're just being clueless on where how to navigate it all. It just really helped us help the patients and then also, our pharmacy in the end, helping patients get their medications where they wanted. And all that to say, we've been doing it as a free service for our community for, yeah, over ten years, during open enrollment. And I think over the years, when you get into that space and help people, they kinda start going to you for their Medicare questions. And so last year, I told my husband one day after getting getting a lot of questions about insurance. And one day, I said, I think people think I'm an insurance agent too, because I didn't have the expertise, per se outside of part d. And in the last year, I have, really six months to a year, have, taken a deeper dive and gotten my license and explored other Medicare Advantage Plans and supplements, things outside of the Part d space that people were asking me about. Because then rural communities, a lot of times, there's just not, not a lot of resources for for good trusted information. They trust us as independent pharmacists, and they're, you know, trusted medical professional in town. So, yeah, we just found our spot ourselves in a place to really be able to help people navigate that, even new to 65 outside of Part d. Yeah. And and you said alright. You know these patients better than than anyone. They're coming to you at least on a monthly basis, so you understand their needs beyond their plans and really connecting the dots to what they're missing with their coverage to, you know, what you're offering at your pharmacy to what's gonna help them with taking better control of their their health care. So that's, you know, it's great context and, you know, it's perfect example of how pharmacies can use these conversations to build, deeper trust with with patients. For sure. Yeah. Now let's, move on and set the stage for what's happening in 2026. So now we've talked about it, the previous sessions, and now that we're a day before AEP, the EU of open enrollment is, there's gonna be a lot of planned shopping this fall. So carriers pretty much across the board are pulling back because their cost and medical cost ratios are up. And the one exception is Humana. They already scaled back in 2025 and are now looking to grow again in 2026. But for most carriers, you know, if you wanna borrow a sports analogy, it's a rebuild year. So the inflation reduction hack, you know, it's shifting more the financial burden to carriers. If you look at that $2,000 cap that's now going up to 2,100 in 2026, that's forcing these carriers to scramble and really forcing a multiyear recalibration on the way they approach this this market. And if you look at UnitedHealth, you know, they're coming back on plans that impact 600,000 patients, that are on their MA plans. Aetna, another 150,000. On the PDP side, we see WellCare and Cigna. They're consolidating from three PDPs down to two. So we're seeing fewer options. We're seeing higher premiums and tighter margins, especially on the PDP side. And what's drive and that's what's really driving more patients to MA plans, even the ones who have not looked at them before. So, again, we're seeing fewer plans, more volatility. And when we look at PDP premiums, you can see how much that's driving patient engagement or patient, behavior. So a few years ago, if you look at the PDP market, Medicare beneficiaries had about 20 stand alone Part d options. So next year, that number is gonna be closer to half. So here's a look at PDP enrollment, the largest PDPs in the country by enrollment. And you'll notice the third column, it's gonna say, it's gonna indicate which ones are national, which ones are more regional. So not every plan you see here is available to everyone. So if you compare 2025 to 2026, if you look at the average premium and you see the trend is pretty clear. Right? It's gonna be that most carriers are raising premiums on their richer plans and dropping the price on their lower end option. And if you look at Centene down here, it operates two WellCare plans, the ones here at the bottom. They've captured about 43% of the PDP market, and that's mainly because of their value script plan that had a $0 premium in most states last year or this year in 2025. And if you look at those WellCare plans, they will love to express scripts Medicare network that's reimbursing pharmacies, something around AWP minus 24% on brands. So if you're reviewing strictly PDPs, patients are gonna keep gravitating towards plans that look cheap, but they're gonna hurt you financially. So patients have fewer options. They're potentially paying more for PDP coverage overall, and that's pushing more of them to advantage plans where premiums are often a lot lower or even $0 on prescriptions. So with that in mind, we're gonna shift gears and look at MA plans, what pharmacies should know, and what's driving more patients to, choose these types of plans. Alright. So there's about twenty four million people that are enrolled in a, Medicare Advantage Plan in the individual market. And by individual market, I mean plans that aren't tied to a group or employer. And about three quarters of of these patients were enrolled in a plan that offers a $0 premium on prescriptions. So we saw on the previous slide where premiums are are going up, and that's pushing more more patients into these types of plans. And then for patients that are worried about medical cost, this is where Medicare Advantage Plans really stand out. They include an annual out of pocket maximum. So once a patient hits that limit, they don't pay for anything more for covered services for the rest of the year. So it's similar to the February cap on drugs, but this applies to health costs on the, advantage side. So if you look at original Medicare, on the other hand, requires patients to pay 20% of covered cost indefinitely. So there's no cap. So these costs can add up quickly, especially if, a patient has a hospital stay or a major procedure coming up. And these out of pocket maximums, they vary, but they average about 5,500 per plan. So, Traci, let's get you back in here. When you look at your patients in Vernon, what percentage would you say are on MA plans today, and what transit trends are you seeing locally? Yeah. It's very close to the national average, the 50 to 60%. We do have a large employer that has a retirement UnitedHealthcare Advantage plan, so it's tied to their retirement. But, yeah, we have a larger percent. We like I said, we have a large low income population, and a lot of the dual eligible Medicare, Medicaid go with the advantage plans because of the extra shiny things is what I like to call them. You know, the the OTC cards, the the rides, the dental, the things that, you know, that they're that are just extra and they really can benefit from them. The big thing is just making sure that your doctors network. Because in a rural area, that can be the biggest the biggest barrier is making sure that you can get the the medical care you need. But we have a we have a large number of them, and it does seem to be trending upwards each year, regardless of what the health care you know, we have a also have a lot of, I feel like awareness being raised in our community and surrounding rural areas about the limitations to advantage plans, and there are some, but it's they're still on the rise. Yeah. No. Absolutely. You made a good point there about the doctor network. Right? That's the main caveat when it comes to these plans is that on original Medicare, if the doctor accepts Medicare, which is about, you know, every doctor across the country, patient can go go in there and have their services covered. But then that's where it adds up, right, with the 20%, and MA is able to cover for the health cost that that go beyond that. But making sure the doctor is in network, and we'll get into a couple of ways that you go about doing that, how some of our customers using match can can go about doing that. But it it certainly also, opens a conversation with the provider. Right? If you're getting them in the process to make sure that they're they're they're in network with some of the plans that you're reviewing, for for for patients. And and, you know, that's a good setup for where we headed next, and it's and it's really about, how these plans, these Medicare Advantage Plans affect your ability to deliver and bill for medical serve for clinical services. Yes. And, so yeah. So let's, you know, let's connect these these dots here. Right? So with clinical care, which, you know, we heard a lot, from what you're offering, Traci, at your pharmacy, but more pharmacies across the country are offering vaccine, testing, consultations more than ever. A huge rise since the pandemic, and plan comparisons are gonna make a big difference here. Some of our customers are billing MedSync consults to Medicare Advantage Plans using CPT code 99212. We got some carriers, and it depends on the state, obviously, like United and Humana that are paying, for these services in certain states. Pharmacies are seeing about $30 per consult each month across dozens of patients. And if you look at that, it's it's kinda like a subscription subscription like revenue stream, right, that can turn a patient who could have previously been unprofitable into a profitable one. And then if you couple that with Humana MA, for instance. Right? They used to have that DIR fee depending on your performance as a pharmacy. Now DIR fees have have gone away and plans have adjusted their reimbursements accordingly, but Humana still has a performance bonus that they provide to pharmacies that are top performing, that consist of patients that are only on their MA plans. Right? So if your contract, Prudential Humana, you're billing Medsync consoles to them and you're theoretically having higher adherence because you have so many of these patients on Medsync, then you're optimizing or maximizing your ability to get that rebate check or, in this case, not a rebate check, but a performance bonus check, at the end of the year. So you'll want, you know, more patients on plans from carriers that you're already contracted with on the on the medical side. So, you know, if you're contracting your credentials to bill to the medical benefits, this is a clear opportunity for you to capture, the new revenue. And and and that's where plan comparisons, you know, becomes less of a seasonal task and something that provides more of a gateway into aligning patients with plans that expand your your clinical revenue. And and, Traci, you know, you touched on OTC cards that many of these advantage plans offer, especially, special needs plans. They offer these OTC cards that patients can use like a debit card at your pharmacy. So if you have a nutrient depletion program and at your pharmacy that recommends supplements to patients based on their medications, they can use these OTC cards to pay for supplements. And we also have pharmacies billing for OTC consults, having a fifteen minute conversation and billing CPT nine 9401 for for for $30. So, Traci, you know, you built out clinical services, as you said before, at Hillcrest Pharmacy, and you're billing for vaccines and consults. Why do your patients come to you? You'd say for vaccines and testing and other services instead of their physician. Access I think accessibility is the primary, and we they can they can come in. They know we'll take care of them. They trust us. They're already coming there, and we make it pretty seamless. We build our insurance. They fill out a quick form, and we we get them in and out the door. We it's kinda like like I said, for insurance or Medicare, we've just become over the years, probably in the same amount of time, the place to go for vaccines and and just to get, you know, quick consults for things that you don't necessarily need appointments for. And so, yes, they come to us for all that. We do clinical services. We are set up to do to bill medically for the medical bills side of the consults for your time, the vaccines. Right now, we're doing a lot of vaccine consults. So like you said, it's added you know, the time you spend to review their vaccine administration record, the form that you have whenever you're going to see, oh, they're do also due for an RSV vaccine. Let me talk to them about that. It's the time that you're spending with them, not necessarily giving them the shot, but, reviewing clinically their vaccine screening is what we call it, is the time that you can bill for. And Medicare doesn't, I haven't seen more traditional Medicare pays, but the Advantage Plans do in our area. And so we're able to bill for that time, and we're also sending them the vaccine to the medical side, which does pay a little more in our experience than the PDM. Absolutely. So it sounds like your credentials, your contract, you've gone through all of that so that you're able to build to the to the to the medical benefit, it sounds like. Right? Correct. Mhmm. Yeah. So for, you know, for those, that are attending the the webinar, you know, if that's something you're considering or you're just getting into, right, that's a a big barrier. Right? Really, the biggest barrier in terms of being able to bill to the to the medical benefits. So I think about the time and effort and really the financial investment you're making on that and connect some of the other things you're doing at the pharmacies, you really drive that initiative forward. And that's why we're we're considering our customers that plan comparisons and especially when you're looking at MA plans. It's really a gateway to providing more of these clinical services and getting paid for it. Right? Because if you can be providing services for someone right now that you can be getting paid for, but they're not on the right plan or they're not on the plan that you're contracted and credentialed with on the medical side. And that's why on the advantage, when you're having these conversations, it's more of a consultative approach. It's less about pushing any plan, but more about listening, understanding where patients are struggling with and connecting those concerns with plan options that make sense to them that align with some of the offerings you're you're you're having, available at your pharmacy. And that's that's really where pharmacies can shine. Right? Because you already know these patients, Traci. You know them so well. They come to you all the time. You're the main provider for them in the area. You know the patients. You know the challenges. And it's really about connecting the dots. Yes. Yes. So let's talk about building a plan for for open enrollment. Right? Who are the patients you wanna focus on? Why do you wanna focus on them? And we recommend you start with your high volume Medicare patients, you know, those that are filling at least four prescriptions a month. Then look at patients with chronic conditions, those who influence decisions at their within their pharmacy or within the community, and, check with patients, again, who aren't who are on plans that you aren't contracted with on the medical side. You know, you're providing services for them that you could be billing for if they were on a different plan. And finally, you know, think about, new care models like long term care at home. Both Optum and ESI recognize LTC at home, and they can open up additional, reimbursement as for your pharmacy. So I'll throw that back to you, Traci. You know, what do what do you look for when you're deciding which patients to run comparisons for? Yeah. So, you know, you guys in in the Medicare match, there's, you know, there's opportunities. The opportunities tab that can bring up bring to light some opportunities. I also run reports within our pharmacy dispensing system just that that show, you know, where we're getting paid below cost. So the lowest margin for us and the highest cost for the patient are the two biggest factors. So if you notice too, we have an kind of an ongoing spreadsheet, a Google Sheet too, where people are adding, oh, they've really had I know they've had trouble with their co pays this year. They've, added a new medicine. So just an ongoing, open enrollment spreadsheet, that that identifies people that have really struggled and have expressed that and then also the ones that have been hard for us to keep, and stay profitable. So there's two factors for sure that go into that. Most people just want it across the board every year, want me to check, just to make sure. So I always go off of last year, the year before as well. But, yeah, those are the two main factors. Yeah. And you, you know, you said about, you know, plans and where they are on the reimbursement scale. I know a lot of pharmacy has been reaching out to us the last few days because the rates are starting to come out for 2026. So they wanted to do just that. Right? Start filling their list, their reports on who to reach out to and, you know, certainly looking at patients that are on some of these plans that are reimbursing you below cost. You know, we bring we we mentioned WellCare before because that's been, a big thorn a lot of on the side of a lot of our pharmacies where, you know, that plan, if you're filling a brand medication on that, there's no way you're buying at the cost that will allow you to be profitable for for a brand. So being able to help those patients find something that they're looking for a $0 premium, then if you look at MA plans, there's gonna be so many more offerings with a $0 premium that have a better reimbursement where if you're again, just looking at PDPs, we're so limited on those lower cost options. And those options, like WellCare, some of the Cigna plans, again, they roll up to that ESI network, and that's not gonna be, one that's favorable to your to to your pharmacy. And a long term care at home, Traci, is that something you've been doing for for some time now? How long have you been doing that, and how do you incorporate plan comparisons into, that that strategy at your pharmacy? Yeah. So we've probably been doing long term care at home about five years or so. We do you know, there's certain requirements you need to go ahead you have to have to have special packaging. So we do compliance packs and the strip packaging strip packages. But there are, like you mentioned on the slider too before, two PBMs that recognize medical at home as being long term care. So we can bill that, at an enhanced reimbursement plus a dispensing fee for both for both of those PBMs. So you do have to consider that whenever you're doing their plan comparison, that you will get enhanced reimbursement. And so, honestly, that is a big thing for us, looking, okay. Does this patient fit the medical at home requirements? Do they get their meds package? Do they do they need help with their meds? Do they take multiple meds? And then if they do, looking at those, the the two, you know, Express Scripts and Optum, so it's gonna be WellCare and those AARP Part d plans, and then also the UnitedHealthcare Advantage Plans are, you know, processed through Optum. And so they recognize, medical at home so we can build long term care. We anybody that we can, you know, that qualifies, we try to get on a a plan, a WellCare or an AARP plan for that purpose. Yep. And and that's an important nuance there is that, yeah, if you're doing long term care at home, right, and you're providing these services and the patient qualifies, then you you do want them on a WellCare plan, right, in that case? Because they are being recognized by the PBM Express Scripts Right. For these services. Yes. So so that's a poor distinction. If you have that capability at your pharmacy, you're gonna want them on WellCare. If it's strictly, you know, retail and you don't have that set up, then that plan is is probably gonna, you know, leave you unprofitable across, a lot of patients. We know there's organizations out there, you know, LTC at home, GerryMed that help pharmacies with, getting set up in in that way. But certainly, again, you know, that's something where you have a strategy at your pharmacy and really bringing it all together is is making sure in which plan is the patient on, how does that align with some of the other things that I'm offering at my pharmacy, some of the other things I can get paid for, at my pharmacy. So certainly, you know, that comes my colleague the other day in a town nearby that, you know, it I don't think a lot of the agents, you know, especially these like, a Humana plan's gonna come up best. They don't know what that means for an independent pharmacy. I mean, it it's really it's really hard. So it's it's important to get these get get them be the person, you know, as of as their pharmacy. Yeah. Absolutely. And that's where you being a broker and a pharmacist, you know, obviously, just really combines the best of of both worlds. You have a deeper understanding, as you said, especially in the last six months or so, the nuances of MA plans, how to, obviously, get paid and compensated for this, but just being able to deep answer questions at a deeper level for patients and then understanding the clinical side. Aligning all that with how profitable you are on the pharmacy side because it's great. You wanna get commission on these plans, but you don't wanna undermine what you're building at the pharmacy in order to chase that. So there's certainly a way we could combine all those initiatives into one. Mhmm. For sure. Alright. So let's, yeah. So let's, move on here and talk about community outreach and patient engagement. Traci, you've been a you've done a great job with this. As you said, you just ran over from a flu clinic few minutes before this. And, you know, we're showing one of your Facebook ads here or your Facebook post. You know, what's worked well for your community, and what advice would you give other pharmacies to build awareness? Well, yeah. Just typically every year during open enrollment, we send out a a message to our 65 and upper Medicare population, letting them know that that's a free service that we offer. And, again, in the last year, I've definitely taken it a step up, because of my insurance license and and the lack of, just resources in our community. Been doing, like, some Medicare one zero one classes just to kinda go over the basics, and a lot of people just aren't sure their options when they start, when they're new to 65 or new to Medicare. So just just really raising awareness, being available. I've been I have an opportunity to step a little bit out of the pharmacy. I know it's really hard if if you're working the bench every day and checking every prescription to dive into it, but I have had that opportunity. And so, just really been put myself out there as the Medicare, kind of person that that's available and ready to help anyone. Yeah. No. That's that's that's awesome. And and really, you know, think about what that does for the community, the word-of-mouth. You're saving patients money year over year. You're helping them afford their medication, and you're driving yeah. And and you're driving that awareness in many ways. Right? Whether it's text messages, phone campaigns, whatever you use to communicate with your community now, use that to leverage the fact that you're offering this this this service. And, you know, over the years, we hear so much about, patients are coming in with letters that they're getting from their PBM or their plan, making the patient feel like they have to go elsewhere. And oftentimes, you know, those are worded in a pretty misleading way where where patients you know, either they know you're offering this service and they come to you and say, Traci, what does this letter mean? Or they don't know you're doing this, and they just go to another pharmacy. Right? Mhmm. Yes. Yeah. So, you know, definitely important driving that that awareness, so that those letters that you get, patients aren't taking them, you know, again, at at at face value. Right. Yeah. And and, so that speaks, you know, a lot, you know, Traci, to what's been working for for you. And, you know, obviously, the results speak for for themselves. You know, you've done this so much or had so much success that you decided to invest the time and money in getting licensed and, being able to provide a deeper service for your for your patients. But let's talk about the the ROI because the plan comparisons, as we mentioned, they can drive value in different ways. You can move patients to plans with stronger reimbursement, get them onto MA plans that pay for med sync consults or other services that you're offering at your pharmacy, shift them to plans that cover LTC at home. But the biggest and most consistent return comes from retention. Right? So patients who receive a plan comparison were twenty eight percent more likely to keep filling out their pharmacy, in 2025. So if you recently you know, if you dropped any contracts or you're debating whether to, you know, this is a strategic approach that that pays off. You know, identify those patients that are impacted early and help them switch to in network plans before, the year end. And, you know, we know that, you know, we have PSEOs that are dropping, contracts or not coming to agreements with ESI, and that's leaving it up to the pharmacy if they want it directly contract. So if that is now up to you and you've decided to opt out, we certainly wanna identify these patients, make sure they're getting the awareness to know that, hey. You're no longer gonna be in network on that plan, and that they're gonna have to switch to something else to keep them, at your pharmacy. And you can scan the QR code here. Use our calculator to see what the retention r ROI could look like for your pharmacy. It's gonna default to industry averages, but you can plug in your own number, your average prescription charge, or even your profit per Medicare patient or per per Medicare prescription, and how many comparisons you plan to do, due each year. And, it's a simple tool, so hopefully, that can help you with setting realistic goals, measure your return, or even you know, if you haven't done plan comparisons, give you an idea on what that can do for you retention wise going into 2026. What have you seen in terms of retention? At at at your pharmacy, Traci, have you seen that this is and, obviously, like you said, you're getting people that have been getting comparisons year over year, but has this been a big driver for retention that then you're also able to facilitate some of these other clinical conversations also? Yeah. I think it's definitely one of the things. You know, we are we're a hometown community pharmacy, so we offer a lot. And but I think this is definitely one of the things, for sure, that keeps them keeps them there. They really appreciate it. They they know that it's beneficial to them and it needs to be done, but they don't know which direction to go. So it's something that we just help them. It's an extra service that we provide for them. Yeah, it helps keep it sticky for sure and helps them keep it keep them coming back. They know that we care, and they know they wanna get their meds where they at our pharmacy. Our our patients do. So whatever they can do in order to do that and also continue to keep their costs low, they know that we have their best interest in mind. Absolutely. And and and that's the why. Right? So if you wanna see the how, you know, on Friday, we're having a, live walk through session of Medicare match. So, you know, we've learned a lot today from Traci's experience, how that's evolved over the past decade or so. So think about this as a classroom session. And on Friday, we'll move into the lab, you know, for those of you that miss school, and we can do a live walk through of, EnlivenHealth match. So you can use the scrolling link below to register and see how match works in real time and decide whether it's a good fit for your pharmacy. Right? If you're looking to be very deliberate, strategic, trying to tie the, loose ends and connect the dots on your clinical offerings, you know, certainly, again, this is a gateway into you really connecting all that into a unified, unified workflow. And then next month, join us for another session in this series. It's the season finale, so to speak. We'll be focusing on post open enrollment strategy. So, you know, AEP ends December 7, but think about that as just a holiday pause. Right? From January 1 to this to March 31 is gonna be the Medicare Advantage open enrollment period. And we saw, right, more than half of patients, more than half of the patients at Traci's Pharmacy are Medicare Advantage, so they have another open enrollment period in which they can switch to another Advantage plan in the first quarter of the year. And then you're also seeing dual eligible patients, patients turning 65 throughout the year. So it's important to think about this as a a year round service, not a not a seasonal one. And, you know, Traci, how's that work with you? Obviously, you get less traffic on the comparison side outside of AEP, but how you incorporated some of these outside open enrollment strategies to make sure you're connecting with patients year round? I'm doing more now because of the new I'm helping people with their Medicare supplement. So when they're new to 65, they need to transition it from their, you know, private insurance to Medicare. And so they need guidance then, and they wanna make sure their drugs are covered. And so there's an opportunities tab in, on the match, Medicare match platform, where I'm able to see, oh, these people are coming up due, coming up they're turning 65 in the next three months. So that's what I use it predominantly for now. I also if there's ever any dual eligibles, they can switch your low income subsidy patients. They can switch throughout outside of open enrollment and in special enrollment periods throughout the year. So I'll use it for that. Really new to 65 and those those patients that get extra help would then have opportunities to change outside of the open enrollment. Yeah. Absolutely. And then new to 65 is key. Right? Because we've seen that, also leads to the most churn with patients because that's a major life event. Right? They're going from private insurance mostly to Medicare, and they can sign up for a plan that you know, if you're not involved in that conversation, what if you're not in network with that plan? What if, you know, they're going to a plan that, again, is gonna reimburse you or put you in a financially tough spot? You know, making sure you're engaging with these patients. Three months before their 60 birthday is when they can sign up for a plan. But engaging them even three or six months prior to that is gonna be important because, yeah, brokers, you know, outside brokers and and other, individuals and entities that are reaching out to them well in advance to try to get them, to to use their services. And that's not necessarily a bad thing. Right? Brokers, obviously, they provide a great service, but we certainly believe that you should be involved in that process, either partnering with a broker. You know, Traci become our own broker or, you know, we partner with, some brokers at HP One that are pharmacies that are not as comfortable, perhaps, just talking about MA as Traci and others are. They can leverage them as an extension of the staff and answer some questions for your patients about medical benefits, doctor networks, and any other nuances that are a bit more complicated than than just, the PDP side. And then, if you go to NCPA this weekend, right down in New Orleans, stop by our booth. We're gonna be there. Booth 1606. We'd love to connect with you on person. You can book an appointment with with us to talk about us about Match, about Treat, our clinical service platform, and, talk more about, you know, clinical workflows and plan comparisons. So I'll be there with a few colleagues and, you know, Traci gonna be there too. So definitely stop by and say hello. That applies to you, Traci. And we're looking forward to it. Thank you. Yes. So that brings us to the q and a. So first, I wanna give a big thank you to Traci, again, for sharing her perspective today. I know a lot of you can relate to the stuff she's doing at her pharmacy and what she shared today. And, I know Nikki gave some, instructions on the q and a. So let me see if we've gotten any questions here. So first question is from Elizabeth is, how long does each plan comparison take on average? Is this prepped by a tech first, Traci? For us, I do it I do it outside of work flow completely. Some people there is an integration with with, you know, your pharmacy operating system. It doesn't take me long at all, especially for the people that fill at our pharmacy. I would say ten minutes or less, maybe five, especially if the data's in there correct or their their prescriptions. Well and also too, I think later on in the open enrollment, it gets a lot easier to spot the plans that are gonna be beneficial in our area for the patient in our pharmacy. It really usually, in my experience, it comes down to two or three plans that are, that are gonna be best in our area. And so we look at all of them, but it typically will, take less time a few weeks into open enrollment for me. Yeah. And and it looks like are you setting appointments with with everyone and having them schedule with you ahead of time? Yeah. I I do have that option this year. In the past, I've done, a lot of the staff will take a take their name, see if they want the comparison, and most of them are mutual to our pharmacy patients. And this year is a little different because of broadened, the reachings to outside of prescription drug plans, the Part b. So but I do, I'll typically do quite a few of them and then then call the patient, on an appointment on the phone. But I will also have in person in person fifteen, twenty minute appointments as well. It's a touch point, that a lot of people like. Yep. That's convenient time and certainly does a lot for your pharmacy, obviously, for the patient. And, you know, we have some customers that bunch of you probably using some sort of scheduler right now for vaccines, right, for clinical services. And some of our customers, they'll set up some slots for during AEP, even outside of AEP, for Medicare plan reviews and send out a text message to patients, put something on the website where it can be more of a self serve for folks that are comfortable Yeah. And booking appointments that way. Yes. We do that as well. Alright. So another question for you, Traci, from Ivy. Traci, do you help them and I think you kind of addressed this before. Do you help them with a and b, or do you just help them once they already have a and b already? Well, I, they need they really need to go ahead and apply for a and b themselves, on the Social Security Administration website. It's actually pretty simple. I have helped multiple people just to kind of understand it a little better. There's no real benefit. They there's a lot of personal information on there that they really need to answer. And so the best strategy is to have them come to you after they have their Medicare a and b card with an effective date. So, yeah, you can't get them a supplement or a Part b plan without without their effective date and their number. So I have helped some, but it's best for them to do that, either in person at the Social Security office or online. Gotcha. That makes sense. Thanks for that, Traci. And Ivy had another question too. I think I could take this one is, does your state have to recognize you as a pharmacist, as a provider in order to bill for these clinical services? So that is a, yeah, a very good question. Right? Because that's gonna vary from state by state. You know, I'm in New York, and there's not as much as pharmacists can bill for here as there is in Tennessee, Kentucky, other parts of the country. And, we actually have a scope of practice tool. So if you're a Syncora customer, you know, you should have access to that through the ABC solutions portal, where you can go in there and, look to see what you're able to bill for as a pharmacist in your state. So it breaks it down per state. And then, of course, you know, to bill on the medical side, you need to take the extra step of being credentialed and contracted, in order to to be within that, carrier's network as a as a provider. So it certainly does depend, Ivy. So, you know, if you're able to have access to the scope of practice tool, I'd get in there through the, through that portal that I mentioned if you're, Syncora. If not, if you wanna shoot us a shoot me, an email or I see your question here, we could follow-up and get your exact state, and we can do some research for you. Jim asked a question about OTC cards. Why do the OTC cards not work in my pharmacy, but they work at chains? So good question here is that the, so let me go back here a couple of slides. I think we had listed the different, processors that do this for OTC cards. Is this the slide here? The number here. Let's see. It won't take care. Let's see. But really so, Jim, what you have to do is you have to, reach out to some of these, vendors that process these cards, and they often have another separate device that they sent to your pharmacy. So it's gonna be OTC network, which is, administered by INCOM out of Atlanta. You have s three that, is owned by United, so they're gonna process the United plans for OTC network. I believe those are mostly Humana and Aetna plans, and they have smaller ones like Nations Benefits and ProHealth. So, you know, where you'd want a monopoly in this in this in this area, right, we don't have one. So there's different providers that you'd have to reach out to. So what I'd say is look at your patient your breakdown of your patients, which plans are they mostly in on the MA side, and use that as a as a guide to which one of these companies you'd like to reach out to. Because, again, they're gonna provide an extra device that you need to scan, and that's probably, Jim, why they're not working at your pharmacy. So, yeah, follow-up with us if you have any other questions on that, but it would require, again, working with some of these other companies that it seems like the chains in your area are already doing that. But, yeah, you mentioned, Traci, you have OTC cards too. So have you, worked with some of these providers, some of these, I think are we ProHealth, I believe? We do the United we have predominantly UnitedHealthcare in our area, but we do have their it's a separate reader and does take a little extra effort. So you can use them. It's just a whole separate It's not processed really through your credit card processor. It's a separate portal. Yep. So, yep, it's a separate portal. So There was there. There was someone there that helped get us hooked up. So I can't remember. I think it's ProHealth. But, yes, we did we did get set up about a year ago, and it's worked. Yeah. And, yeah. I'm curious to Traci, if you can, yeah, after this share if you have a contact, whoever you're working with. Because, yeah, I'd like to see if there's a way we can partner with some of these because, what we've heard from some pharmacies is that, you know, again, having all these different scanners if the pharmacy wants to carry more than one, and sometimes the workflow could be a little clunky. So, you know, we certainly if we have anyone in the audience right now from one of those companies, reach out to us because, you know, I think there's definitely some things we can do to help pharmacies, with better taking advantage of this this opportunity. Right. Let me see other questions here. So how do you separate so, Javier asked, how do you separate the pharmacy hat and the broker hat when selling insurance as a broker to avoid any conflicts from Javier? Yes. Yeah. That that is important for sure. I I don't work the bench as much as I used to. So like I said, I've been given an opportunity to kinda step out. It's more of our staff will, either identify or if I identify, I'll set up an appointment. You have to have a there's a lot of rules for agents agents, and so you have to have a scope of an appointment and make sure that you're, following all those rules. So you do have to to separate it and wear two different hats. And so I'll typically set up an appointment for the following day or, just just take a minute later on that day. It just depends, but you do have to separate it. And it it can be challenging, but, you can't it's it's I bet it would be a lot harder if you're the only pharmacist, which in the past, I've had that role, and it I think it will be really hard. Yeah. No. Absolutely. And and, you know, I think that's good, opportunity to talk about. You know, you become a broker, but you've been using Match years before your broker. You're still using it now. So we have more and more pharmacies that are looking into this. So how are you, you know, still seeing value with Match as a broker? Because I know, you know, as a broker, you also have some other software to submit your enrollments. But how are you still getting value out of Match as a broker now to make sure that you're still, you know, looking at this tool in a beneficial way? Yeah. You can go I mean, I think most brokers use their, like, platform that that they sell their advantage plans through or their part d plans through. Also, medicare.gov. The big thing for me with, with the match platform is it it shows us the pharmacy side of it. It shows us the reimbursement, the maximum the cost. Also, really live touch breaks down, like, especially the last year and this coming year when the patient's gonna they love to see when they're gonna reach their out of pocket. So it predicts, oh, in June, you can you can expect for all your co pays to go to zero. I was hesitant last year, but it really happened. It was real. So, it it was very, very accurate as far as predicting what their year would look like. And then also, I just like the report. I like the report that prints, and I'm able to really go over that with them. Again, I usually prepare that before I call them or meet with them. And so it's, something I can just I'm I'm used to it and I really like it. Yeah. That that's that's great. And on the, you know, AP starts tomorrow. Right? And on the reimbursement side, we're gonna be updating it to the to the average conflated rates that we're seeing out there for 2026, towards the end of next week. Right? So you'll be able to see, hey. This is what the estimated reimbursement is gonna be for the pharmacy. If the patient that's on these five, six drugs still signs up for this plan or that plan, again, that's gonna drive your prescription revenue for 2026, but then as we said, potentially open up the opportunities for LTC at home, clinical services. So, you know, certainly look at that reimbursement information, and we even have some tags in there that'll say, hey. This plan is reimbursing you below AWP minus 22%. So we're tagging this as a profit loss because we wanna make sure that you're at least taking a quick view at, like, hey. These patients on these plans are not gonna be viable for me, financially. So that is, I like to wait. I'm not setting any appointments until, I think, October 23. Just give it a little time, for the numbers to all the desk to settle, because, yeah, I think things change a little bit early on. Yeah. After NCPA, right, we'll get started. Right. The twenty third. Okay. I'm not even pretending like open enrollment's tomorrow. I know. Right? It just snuck up on us. I can't believe it. Gonna have nightmares tonight. I have, so Javier, thanks. I see I have a contact for ProHealth, he says, and would be happy to make a connection. That's great. I think ProHealth is out here in New York somewhere, so that'd be great, to make that connection, Javier. Carl, not sure if this is a Humana now has a special network for OTC card. Is your question seems like a question. But, so so yeah. They work with, Incom, that, and they offer the OTC network and the OTC network cards, which Humana that's what Humana works with to process these these cards. So, I think that answered your question. So I don't know if it's a special network, but it's the OTC network that Humana works with. Oh, wait. Then Carl said, I think it's called nation's benefits. Can I forward an email to you? Yes. You can. You can email me. Oh, look. I'll use my easy email instead of spelling out my last name. You can email me marvin@amplecare.com. Oh, wow. You all have contacts. Nation Benefits. Someone can give me a number for it. That's great. Awesome. Thank you, everyone. And then I think we had another question here about does 99401 get used to bill for vaccine consults? I don't know off the top of my head. I don't know if you do, Traci. If not all the code. I think it's, like, a 10 to I don't know the I don't know the definition of it, but it's their CPT codes for 99 I believe the two the two we use the most are the 99212 and the 99401 or 402. They're all very specific or they're not specific. They're actually very broad. When you look at them, it's not specific for a vaccine consult or a antibiotic consult. It's for your time, and it's an evaluation and management code. I CPSN helped us a lot with their medical billing services program just to help get our feet wet and figure all that out. So I learned a lot there too. I'm just learning a lot these days. You're doing a lot. So is the, so there's another one, for you to kind of along those same lines. Is the vaccine consult only billed medically? Yes. Okay, Joseph. The answer is yes. And Yes. I do not k. Yeah. Another question we had here, is about doctor network. So how do you go about making sure that the doctor is in network? Right? So that's something you mentioned before, Traci. So, I'll allow you to touch on, and then I'll have my my, comment on it as well. Yeah. I like to go even the people I work with for insurance, they're like, it's best to go. There are resources kinda within probably different platforms, but it's if you wanna be sure, sure, sure, that the carrier's website does have, resources for provider networks. You can put in, like, your ZIP code and, the patient's or the the provider's last name to make sure, but it can change at any time too. They can go out of network, tomorrow. So there's no guarantees, but I go to the I go to, like, UnitedHealthcare's website or Humana's, whichever one. We don't have a lot of different options here, so those are the two main ones for me. Yeah. And, and that's true. Right? These networks and I know CMS is trying to hold the carrier's, feet to the fire a bit more on this to put up some rules around making sure that this is updated on a regular basis, that it's accurate. So, you know, we'll see, I guess, how sharp the teeth are in in, that that rule and how it's implemented in the coming years. But for others that aren't as familiar as Traci, you know, this is what we recommend as best practice, you know, if you're using match or you're planning on using match is that, you know, pull up the patient, review their drug coverage and their total drug cost, narrow it down to three plans, and keep that keep the patient in network at your pharmacy, offers good coverage to their medication that's gonna reimburse you, you know, as fair as what we can find in 2025 or 2026. And from there, print or email or share those plan details with the patient, and that's their starting point for confirming that their doctors are in network. Right? So then there, depending on, on your setup, you can take a couple different approaches. Right? You can call the you you or your staff can call the doctor's office, directly confirm the network status. It's a nice way to, build that provider relationship, or you can, you know, also use you know, as Traci said, going into the, the carrier, portals themselves. Or, if you'd rather, you know, the patient take the printout and they can connect with, you know, our HP one partner agents who are licensed brokers. They'll confirm network participation, handle the enrollment side, and and ensuring the patient stays into your pharmacy. But, again, if you work with a local broker, or someone is licensed at your pharmacy, then that hand off naturally goes, to them instead. So the goal is to make this a collaborative process between the pharmacy, the patient, and the provider and make sure the plan fits, you know, medically, covers their drugs, and, financially for the patients. Mhmm. And, let me see. I think we had another question here. Vaccine consults medically, we already answered that. How do we know advantage plans in our area that covers vaccine consults? So I think that goes similar, Joseph, to some of the questions we have about the scope of practice, right, depending on your state, how, they're able to provide coverage for you or reimbursement options they have for you as a provider. So if you wanna leave a chat with your state, we can do some research into that as well. Yeah. Again, you just it's for us, it was about a six months to a year of, like, doing it and just trying it. Trying, you know, to do providing the service, billing the code, and it and you it takes, you know, like like you had mentioned before, the credentialing, and then also you need to set up with a partner to send your codes and make your office your notes and stuff. And so, yeah, it's a we we partnered with CPSN originally to help us, connect the dots to get started. Yep. I know CPSN, you know, offers that can help pharmacies with credentialing. We have other organizations out there that some of our customers are using. Provider CSAO can help with that as well. Right? So there's some options for you to go to, but, certainly, yeah, it's gonna take some investment upfront time wise financially. But once you're set up with that and you're able to set up that workflow and, again, tie all these other end things into that process, then, you know, it certainly is gonna allow you to diversify yourself away from relying so much on prescription revenue and PBM revenue. Right. Alright. So, so so I think that that's it. We got a lot of questions. I think we got through most of them. For everyone that sent some of those contact details, thank you. You can also email me, marvin@amplicare.com. But thanks again, everyone, for spending the time with us today. Special thanks to you, Traci, for sharing your thoughts, your experience, your insights. Again, looking forward to seeing you in New Orleans this weekend. And we, you know, this gave a few new ideas to take back to your pharmacy ahead of open enrollment as it gets underway tomorrow. And if you'd like to see, again, EnlivenHealth match can help your pharmacy in putting this into action, just click the get demo button or reach out to us, after this session. So, again, thank you, Traci. Take care, everyone. Have a great rest of your week, and we'll see you next time. Bye.