From WXXI news.

This is Connections.

I'm Evan Dawson.

Our connection this hour is made with the start of open enrollment.

Open enrollment are two words that, if you consistently feel a little confused or frustrated.

It can be a tough time of year, but we always try to answer questions that you have, particularly if you've got questions about individual plans that are out there.

Now, I know some some listeners sent us links to some of the stories that they're reading about open enrollment, but we're going to try to distinguish between if we're talking about we have emails about the essential plan, which we can talk about this hour, but we're talking really about what's going on with Medicare.

So, you know, the Gothamist covered it this morning, and had a long piece about what people are seeing and why some plans are different or why some subsidies are different, or what they can expect in the marketplace.

The reality right now is that more than 1 in 4 adults in the United States reported that they, or a family member had a medical debt in December 2025, including 26% of adults with health insurance.

That's according to a recent Robert Wood Johnson Foundation report.

So if any of you got questions this hour, we're going to try to get them answered for you.

And I'm glad to have Andy Napierala back with us.

He's vice president of Medicare and in individual market sales for Blue Cross Blue Shield.

Welcome back has become a good annual conversation.

Thanks for being here.

Thanks for having me very much.

Next to Andy is Dave Kamholz's.

He is a licensed Medicare agent for triple of Western and Central New York.

Thank you for being here.

Thanks for having me.

And welcome to Cindy McDaid in studio, who's a Medicare Advantage enrollee talking about her story.

Cindy, thank you for being here as well.

So, Andy, what's keeping you busiest these days here?

You're an open enrollment now.

Here.

Very busy.

Yeah.

Looking at the dates here, it started October 15th, goes through Medicare Advantage, goes through December 7th, December 7th.

That's right.

Okay.

So what's going on?

So we're busy helping a lot of people, now that we have the opportunity to start talking about 2027 plans October 1st, then we can take applications starting October 15th.

So we've got a lot of people that now are coming in to talk to us or giving us a call working with a broker partner like Dave, that are making coverage selections for 2027.

So this year compared to last year, I know when when we were here, we had a lot of planned discontinuance is in Rochester.

Luckily, we're not discontinuing any plans like we were last year.

We're still going to have for Medicare Advantage plans.

And hopefully we'll be able to help people stay on the right one for them.

And if you've got questions, listeners, this is the hour to do that.

It's 844295 talk.

If you want to call the program 8442958255263 WXXI.

If you call from Rochester.

2639994, you can email the program.

As always, the email address is Connections@wxxi.org.

And if you're watching on YouTube, you can join the chat right there.

And we'll get your questions in this hour.

Dave, what are you hearing most often from people these days?

It's really about the plan changes that are going on right now.

You know, they're going through they're looking at it and they're wondering what these changes are.

Why is it going on?

And is this plan still going to be in my best interest?

And, you know, what are my other options?

So we're going to get into some of those specific, specifics, I should say, with Dave coming up here, we're going to talk about industry level change, the efforts in the industry to keep costs down and why plans do change.

But I think we should start with Cindy story here, and that's why you're here.

How are things going for you?

Not too bad this year.

The past two years, I've had, a, program that I used.

I lost a lot from the programs, so I'm going to.

I'm looking around to try and find what's what's available.

I'm switching providers looking to.

Okay, I haven't actually decided yet.

Okay.

This hour.

Are we going?

Is it.

Is it Cindy's hour?

Are you ready to do that?

I know I, I laugh because, I mean, like you, probably many people feel like the plans can be either overwhelming or very, very hard to decipher.

And what the best numbers are going to be for you.

What do you specifically looking at and what's the challenge?

I'm looking to find what I lost.

Interesting.

So for example, I lost, over the counter.

Okay.

Which is very helpful.

I also lost comprehensive dental, which is something that I'm looking to get back again.

I'm doing it on my own.

In the past years, I've, I've gone to someone to help me navigate through it.

But this year, I'm kind of trying to do it on my own and see if I can figure it out.

How is that going so far?

You I'm laughing because you gave me a little bit of a look there.

Well, it's it's okay.

It's pretty easy.

If you go on, like, the Medicare website and they give you comparative, you know, comparisons, you can click the, the, box and they'll compare everything side to side for you.

So that makes it kind of easy.

But this is something that Dave said before the program.

Sometimes you hear people will say, well, you know, I looked at I started looking at plans this one looked good.

And I'm taking it like you and I just kind of seeing the first thing that looks like they would want that coverage, grab that and go, what?

What is your message about, about that particular set of choices?

Well, you know, we just want to make sure a lot of times people tell me, hey, I looked at this plan X, and it looks really good.

It's going to give me this, give me this, give me that.

But you look at it, you look a little closer.

And doctors or hospitals are out of network for you.

Or you're, you're losing things like prescription drug coverage.

You know, you got to be careful that those things are out there as well.

Plan looks really good.

And then all of a sudden, you're stuck in a situation where you're playing where you're losing these.

And, depending on what time of year you figure that out, you might be stuck through the rest of the year with that option.

I'm listening to Cindy story Dave, and she's listing a couple things that she lost and things that are pretty clearly very important to her.

Do you have that conversation where you say, like, look, tell me what what is at the top of of your needs list?

Is that a good place to start?

It is.

And it's not an uncommon thing that we're hearing these days.

These these are the benefits that we're seeing rolled back a lot.

You go back, you know, 4 or 5 years ago, these benefits were growing and growing and growing.

You all, you know, in these last few years, you're starting to get contracted.

You're seeing a pullback of these.

So it's not an uncommon thing that we're seeing out there.

So either navigate that and find a place where you're going to get the most out of your plan and get you the most coverages that you're looking for.

Is really our goal.

And can you speak more generally when you hear Cindy story?

I mean, we're not we're actually not here to counsel one person, but I don't I can't do that.

But yeah, absolutely.

It might be good to just provide some additional context.

Yeah.

So, a couple years ago, if we were to have this conversation, it would be the opposite of what I'm talking about.

All the new benefits that we're introducing and all the new plan options.

And for a variety of reasons, the pendulum, if you want to think about it that way, it's kind of swung back in the other direction based off of the financial changes, some of the regulatory changes and the changes in utilization that we saw as plans starting probably three years ago.

Things we talked about last year, like the wage index increase and other part D prescription drug changes and everything like GLP ones and other emergent treatments have just kind of added up.

So as an industry and this is true around around the country, we're a member of the Blue Cross Blue Shield Association.

So we hear it from around the country that it's just a tough time financially, and plans are trying to figure out what can we do to stay viable and do the best we can for our members.

What are the things that we do have to make changes that would be least impactful, so we can keep our, you know, our core Medicare about our medical benefits, in place.

And then you do see changes and a lot of those more supplemental, quote unquote benefits, like an OTC or dental or vision or things like that.

You might see more changes there as a result.

Can I just ask you about GLP ones briefly.

This is part of the Gothamist reporting this morning.

Quote, insurance analysts project health care spending will rise sharply for employer based health plans in 2027, which also typically have open enrollment around this time.

One factor is the rising popularity of costly GLP one weight loss drugs, and some of these costs could ultimately be passed on to consumers.

End quote accurate.

All I can say is I know the GOP wants is something that that everyone kind of has an eye on, just because they're popular and people are seeing great outcomes.

So I would I don't want to speak specifically to commercial.

But I know on the Medicare side, it's something that that's very important.

So we're always evaluating our guidelines.

Who's going to get approved for those and when and how.

And the federal government is actually, through CMS has come out with a cost savings program that people can look into, which they're going to be rolling out.

So it's something that is top of mind, I think, for everybody, as people are seeing, there's a demand for them.

People are seeing good outcomes.

And as an industry, hopefully we can partner to make them as affordable as possible for as many people as possible.

But when you talk about a couple of years ago, it was a different story.

It was a it was a very different conversation.

Yeah, very much so.

What's the what's the leading reason that so much has changed in a couple of years?

I think just with, with the amount of additional cost that we've had to take on, as carriers, whether it's from, from a wage index increase where we had to we were basically passed along a big increase of what we had to pay hospitals, which, you know, our hospital partners are valued partners and they deserve their revenue.

We want to keep those those relationships healthy.

But that came as an unfunded mandate.

Lots of part D changes on the on the prescription drug side, which we had to figure out how we were going to take those on, which were heavily on the, on the carrier.

And then these new emergent treatments.

So you figure all of that at the same time, and we didn't get corresponding revenue increases to kind of balance that out.

So as a nonprofit health plan here in upstate New York, we got our revenue really from two sources.

Either has to come from the government or it has to come from consumers who premiums and cost shares.

So when the money isn't there from the government, and we're always lobbying to say here, you know, here's where we need more funding or we need changes to risk revenue, whatever the case might be, then we're forced to either bring those costs on to our members, which we don't want to do, or cut our benefits, which we also don't want to do.

What do you think most people get wrong when they make assumptions about what is driving costs?

That that's a tough one.

I'm not I'm not really sure because it is.

It is balanced out.

I think that it's hard to appreciate this.

Even people that work in our industry probably have a hard time figuring out what all of this put together, the impact, that it has.

The other thing which is important, which I'll just share, is our provider partnerships are very important to this as well.

People have probably heard the term value based care and value based, arrangements.

So that's really what we're trying to do with all of our providers and make sure that we have aligned incentives.

So typically how providers get paid is they they have to code lots of services and tasks.

And that's how they maximize their revenue.

But what if it were the opposite?

What if it were you're actually going to receive more money if you can do it.

But but less tests, and your share is going to be higher with the same outcomes of course, because of how if outcomes if outcomes go back, then that doesn't help anyone, does it?

Up the numbers doesn't help us.

Well, let's make sure I think we put a fine point on that.

So my here's how I'm hearing that.

And you tell me if I'm hearing this correctly.

So when you talk about providers running tests or doing procedures and getting paid on that basis, and you're asking like, what if we flip this, what if we can keep the outcomes really good?

But run fewer tests or procedures?

It is easy to assume that the incentives, as they currently are, are pushing people into unnecessary tests of procedures.

Do you think that that's true in some cases, yeah.

Generally speaking, I wouldn't I would give specifics.

No, no, no, not specifically.

But in general, are we running too many tests and doing too many procedures.

And is it tied to financial incentive?

I think there are cases where that where that often does happen.

Yeah.

And it's only natural if that's how they're incented to get maximize their compensation is by is by having as many procedures and coding as much as they can.

That's, that's that's how their incentive and how that how the industry has been trained.

What's the kind of test or procedure you're talking about?

I mean, there's a million.

But like what's an example, a million?

You know, I can just give a personal example that, I have a history of something in my family.

And I was initially denied the test, which is what should happen because I'm too young to normally get a test for something.

And I spoke to the doctor and made an argument and said, I have a family history and here's everything documented.

And they said, yeah, okay, we're going to approve it for you because it, it makes sense.

So things like that are okay.

But it's also okay for us to say, well, why would we have that test when there's no reason that someone at your age in your health should have it?

So I think that there are scenarios like that where if we can if we can very if we can work with our provider partners to address some situations like that, then that means less overall cost in the system.

It means less benefit cuts for people like Cindy.

I think the reason I was asking you what you think the public sometimes gets wrong is sometimes the public gets cynical about the system and would have a hard time believing that one of the actors within the system is actually, first and foremost invested in better health care outcomes as opposed to bottom line outcomes.

But you're saying, that those things don't have to be mutually exclusive, perhaps, or that that you can be focused on better health care outcomes first?

Absolutely.

Yeah.

And and I think for us, you're speaking from Excel us, BlueCross BlueShield and our viewpoint being a community owned health plan in upstate New York, that truly is our mission.

We talk about that and and we try to live it every day.

I can say honestly, it's been it's been a wonderful experience for me with the company.

We do try to live that every day.

Over 92% and $0.92 out of every dollar that we bring in goes right back out to pay a claim, which we would put that up against anyone in the industry.

Very, very proud of that.

So and hopefully that only continues to grow.

So we really do want to take care of our people, take care of this community, because this is what we're a part of.

You did mention emergent treatments as one of the drivers of costs going up.

Did that include we were talking about GLP ones, for example.

Is that up on that list?

Yeah, emergent could be.

Although we don't we have world wide urgent emergent care.

So if it if it's necessary, we do want people to to go to go seek that care.

But also you've seen things like telehealth in the last couple years.

Sometimes people just need an answer right away.

So you can get an answer right away from telehealth and not wait for a couple hours in an emergency room.

And chances are, in most cases, it's going to be okay.

Okay, so I actually took the word emergent wrong.

I always thought of me, like, emerging like and growing new kinds of treatments.

You're talking about emergency care?

Could be both.

Yeah.

Emergent care is an emergent procedures, let's say, as in, like, you know, immunotherapy.

Okay.

Certain cancer drugs, more experimental treatments, which are very promising, but at the same time very costly.

So we have to figure out as an industry, how are we going to be able to bring that to market and make it affordable for as many people as possible?

So after we take our very short first break of this hour, we're going to come back.

We will have some of your questions.

We already have some on email.

We'll get to some of those.

And we're going to see what Cindy, how she's going to navigate this.

I think it's interesting to have Cindy McDaid here, who, has been a Medicare Advantage enrollee, and we're talking about how she's trying to work through open enrollment, on her own, but also today, with the help of people like Dave Kamholz and others.

So let's take this break.

We'll come right back and get more questions.

And next.

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This afternoon at four.

This is Connections.

I'm Evan Dawson, so Cindy McDaid was telling us about her experience.

And I'm curious to know, at this stage, as you kind of try to choose the right plan for you, what do you wish you would have known prior to whether it's this year or previous years?

First, let me say that in my search for a plan, there are caveats and all of them.

Okay.

So you know, yeah.

So what I get out of one, I'm missing something out of the other.

So I just have to kind of, compare to to.

Anyway, so, what I the first year I contacted somebody to help me get to navigate through the different plans, and I did that right up until last year.

And that, to me was helpful because the broker actually said to me, you know, you only have the option of two plans and this is the best one for you.

So I just kind of took it by her word and it worked out fine.

But like I said, there were parts that I am that I missed.

So, as far as what I wish I knew, I pretty much had the answers for me through through the people that were helping me navigate through it.

Okay.

And when you look at what you need now, what is at the top of your list when you look at it?

Well, obviously, aging people want to make sure that they have good hospitalization.

And, you know, the low co-pays, things that come out of a lot of out of pocket, because the, you know, being, being and Social Security, the out of pocket is a huge thing.

But, as far as, you know, as far as, you know, as it goes down the list, you know, with the, with the hospitalization and the doctors and the, specialists, co-pays and whatnot.

What the out of pocket is, say, for long term, hospitalization.

What how much for an ambulance?

How much for, specialists?

So, I mean, I look at all of that when I go through it, sometimes you have to say, all right, well, this one's a little bit more for emergency room, but this one, I get this this benefit that I don't get with this one.

It is it can get pretty confusing, but you just have to pay attention.

Okay.

And so do you feel like you are at least kind of sorting through the murk and finding what you need?

Yes, I am, and I do it just about every day.

I've been on the phone with a couple different, a couple different groups.

The, the one frustration is that they say, oh, yes, we have comprehensive dental.

And this is, you know, do your provider search and there's the providers.

And so you call them up and you say you accept this.

And they said, no.

Okay.

Well you're on there.

And I've run into this several times.

Well I know we've tried to contact them and they won't take us off the list.

So it but we don't take that insurance.

So that brings me down to one dentist in my area that would take the specific insurance.

This is troubling.

Let's ask Dave Kamholz about this.

A licensed Medicare agent for Triple-A of Western in Central New York.

Can you weigh in on what she's experiencing there?

Yeah.

Absolutely.

I mean, I mean, we look into those those are those scale back and benefits.

And, I think dental is one of those ones that, that, that a lot of people on Medicare really hold dear.

And it's and it's a great one, especially the comprehensive side.

Talk about having that extra work besides just cleanings.

But finding a network that works within a plan, some carriers obviously have more robust networks, but you might find a reduction in what they're covering there.

A lot of times I, I know, I know what kind of which direction you're going in here.

You're who you're working through and who you're talking to.

They got scaled back, availability out there.

And finding that network that's going to work for you, we do that needs analysis.

When you sit down, you know what's most important to you.

You know, obviously, doctors and the network for those doctors is going to be at the top of the list for those next things that dental, you know, can we find something that's going to work with you?

Who's your preferred dentist?

You know, are you open the new dentist?

That's a big thing.

And nobody wants a new dentist.

After a while, I feel like if you're, like, surprised.

Well, my dentist stopped taking my insurance.

Okay, so.

And that was that, Yeah.

That's common.

Yeah.

That's common.

That's common.

As did the eye doctor.

The common as in in the last year or two.

You know, just in general, dentists just wanting to work outside that insurance.

So file the reimbursements for you.

A lot of the companies will let you go out of network with the dental, but it also doesn't stretch nearly as far as you want it to at that point either.

Okay.

So how do you help people avoid some of what Cindy is dealing with?

I mean, at least Cindy seems pretty wise, pretty open eyed about a lot of this stuff.

But how do you avoid, you know, being in a situation where you thought there would be, you know, someone who could work with you, and it turns out they're actually not going to be on the list.

How do you how do you get that?

It's it's the same process we go through.

And she's doing all the right steps.

She's following up and checking those networks so that she doesn't get caught with a surprise.

When that plan stops, it starts because we get calls for that all the time.

At the beginning of the year in January and February, hey, I joined this plan and now all of a sudden, this doctor's not accepting it.

This is not working.

It's not what I thought it was.

So you doing the right steps in there?

And that's just what it is.

It's the diligence.

And now we are working that every day doing that.

So we've called made these calls, we've gotten out to these doctors.

You might come in and be like, hey, I'm reaching out.

I'm looking at this plan.

I'm thinking this, well, we can tell you this is where that hold up is, you know, if you're looking for this, they say you got this, but you might have to you're going to be very restricted in where you're able to go with it as well.

She's also talking about you know, every plan has its her word was caveat.

That's a I think a wise observation to hear.

So know what you're looking for.

So for for Cindy she's talking about hospital hospitalization and and wanting to make sure that she's going to be taking care of, in certain scenarios.

So how do you how would you guide her in the right direction of a particular choice?

So, I mean, she's right.

I mean, every plan you look at, it's going to have a little bit.

There's no one size fits all is what we always like to say with the with Medicare here.

You're going to find a plan depending what you're looking for, those hospitalizations, you know, it's going to be something that comes into their, you know, are you someone who's looking at possible hospitalization next year?

Are we going to weigh that further?

And the plans do trade off benefits when you when you put them side by side.

And Cindy, you've done this.

You're looking at them.

You know, you might get a little bit more here on something, but you're going to give it back somewhere else.

You know, you're going to lower those hospitalizations.

You're going to give it back on a little other program.

So it's really about, you know, what is it looking like for you for the year?

You know, no crystal ball in hand.

So we can't tell you exactly what's going to happen.

But we're going to do our best to guide you towards what we believe is in your best interest and stay out of the hospital.

That's insurance is insurance.

You don't use it.

We all are.

But since you at the outset you talked about getting back what you lost.

So remind people what did you lose in terms of coverage?

I lost over the counter, which it was very helpful.

Yeah.

Sometimes you don't use it all, and but when it's when you need it, it's there.

Oftentimes as you age, doctors recommend you take vitamins and you take, you know, vitamin D or whatever, and you take a supplement.

So that's what over-the-counter covers.

Also it covers blood pressure monitors.

It covers scales, it covers, you know, whatever, whatever is needed health wise.

You can purchase through of the counter.

And if you've priced blood pressure monitors there, not there are some that aren't expensive, but there are also some that are.

And those are usually the better ones.

So, the other is comprehensive dental.

That is important to me, trying to keep my teeth in good shape and, so just because that's, that's part of staying healthy and my dentist stopped taking my insurance, so once, once the dental was used up, I can't go back, you know, I can't go back to get anything else done without either a credit card or, you know, they have their own insurance plan that you can buy into for some ridiculous amount of money.

So those are the two things that I can think of off the top of my head now.

My medication, I get very lucky with my medication and I pay very little for, medication to change plans.

I might be paying a little more.

Not a lot, but a little more.

But I want to try and, weigh the differences between the two.

You know, they they take by losing my comprehensive dental isn't worth taking off the the amount of money for the medication.

It's very consuming.

And do you want to add to that?

Yeah.

Thank you.

I know you want to keep this moving long.

No.

It's okay.

This is a really good, important point.

So, Cindy, first of all, thank you for being a member of ours.

I really mean that.

And thank you for also being as transparent as you are.

I got my notes over here.

And and they matter, that our member feedback is really important to us.

It allowed us to do a bunch of changes, that we put into effect for this year.

So we hear about dental.

Quite a bit, especially on the comprehensive side.

I was in a meeting last week where we were talking about how are we going to evolve our overall dental strategy.

Network access costs, all those things, because this is this is what we're hearing.

So unfortunately may not be fixed for this AP, but we're taking the feedback and, and honestly trying to improve our programs.

So it's going to be a better fit for, for you and for everybody else down the road.

Dental is really important.

Over the counter, flexible benefits.

People have talked about that as well.

Unfortunately for most carriers, those were some of the things where you saw cuts over the past couple of years.

And I hope we can get to a day sooner rather than later, where we're looking back at adding back into those benefits, and improving the experience as opposed to what's happened over the last couple of years.

So, you know, certain things, like we've heard feedback on, hey, I didn't get my ID card until almost January.

Well, we're getting our ID cards out faster.

If people wanted to add dental afterwards, a standalone dental plan, they had to fill out a whole application.

So now you know, we heard them and came up with the shorter form.

So the feedback really is important.

I honestly try to incorporate as much as we can.

We want to keep members.

We want to keep everybody as happy as they can be and working with us.

So may not be able to get to everything this year.

In time for AP.

But but I really appreciate the feedback and the transparency and there's a lot.

And now you got Cindy is sort of the picture of what she lost and what she would love to, to kind of roll all together.

I don't know if there is one thing, Dave want one particular plan that says, hey, you got you got a great plan for hospitalization if you need it.

You're also you're going to get over the counter back.

You're getting all the things that you want.

Other options like that.

I mean, we can find those options, but there's it's going to come at a cost.

You either going to pay some extra premium to get into something like that.

You know, I mean, I think a lot of people are used to is with these advantage plans having zero premium plans where they're not paying an extra monthly amount for them.

Unfortunately, these days, to get all those things included in there, you're probably going to have to pay a little bit extra for something like that.

So we kind of lay out those options.

But I do say, like, if you're going to go into a plan, the comprehensive dental paying extra through the plan is usually better than purchasing a standalone.

You eliminate waiting periods and different things like that.

So if that extra dental is something you're really looking at, you're probably better off getting it embedded into a plan than a standalone plan.

On the side.

Okay, so how do you feel about working within a budget here?

Because we're talking about paying a little more for all the things you want.

I'm going to be honest with you.

There aren't that many.

Even if you pay a premium and I'm willing to pay a premium monthly premium, I just am still not finding.

What works best for me?

I have found one.

I'm not convinced yet, so I got to do a little more research on it.

But, you know, as I, you know, I am willing to pay a premium.

There are premiums that are like $300 a month.

I'm already paying $200 for part B. I don't want to pay another 300.

That's too much money.

So I'm trying to be, I'm.

I'm just trying to weigh all the options, and and I don't mind paying a premium.

I just don't want a large one.

Okay?

It's got to be realistic for you.

Yeah, and they're not.

And there's there really isn't that much that's going to fill the needs that I, that I lost.

I've gone through them all and you know and I'm willing to I'm willing to be realistic as well.

About things.

But I still, you know, there are things I want and and I don't think that means you're spoiled.

It's just me.

Anything you want to add here?

No, I mean, I, I hear it, I hear from people all the time.

You know, they're in the same situation, you know, especially the market over here in Rochester.

It's become a much more difficult market to navigate when it comes to looking for those things.

It's can I ask you a question?

Go for it.

If you sign up for a plan and they say, oh, you know, this dentist, this doctor, I'll use a doctor.

This doctor accepts this plan.

And then January 1st comes and you doctor says, no, I don't accept that plan.

That qualifying event they're working on that I haven't heard an update on that.

They currently, as far as they know, unless it's been changed, they're trying to get it passed.

So like if you're primary care or doctor, that's important to your care of your cardiac condition, your cardiologist, someone like that leaves your network.

You do have a qualifying event to make a plan change.

I don't know, Andy, if if you know, I don't know if that's been passed.

That's my understanding as well.

Yeah.

Outside of that, you'd have, the beginning of the year and there was Medicare Advantage plans.

You always have January 1st to March 31st.

You're allowed to make a one time plan change at the beginning of the year.

I tell people it's kind of your test drive, it's your safety net.

Something like that happens to you at the beginning of the year.

You're able to make a one time plan change, that there's other great programs out there like epic from New York State.

Most people qualify for it.

If you're rolling it.

It's designed to help manage the cost of prescription drugs for individuals 65 and older on Medicare.

If you're enrolled in that, it allows you to change your plan once throughout the course of the year as well.

So it's another thing to help mitigate, risks, like you just spoke you spoke to there.

So those are great things I always tell everyone you encounter situation like that.

Give us a call.

Can't guarantee we could do something, but we'll do everything we can to help you find something.

Great.

Thanks.

Those are two things that I think are really important.

Is everybody knowing that there is the oep period, the open enrollment period for Medicare, which is January, February and March, where they we call it a I of a get out of jail free card, basically, that if they made a plan switch and into a plan that they're like, oh, it turns out I can't get the drug that I need or the physician that I work with is not going to accept this.

They're going to be able to switch into something else.

And I'm glad that CMS gave them that flexibility back.

They had that period and went away and now they reintroduced it.

I think that's better for everybody.

The fact that people have the opportunity to make sure they're in a plan that's going to fit.

You also mentioned epic.

There's things like extra help in the low income subsidy that we talked about that we really want to make sure the people are aware that there are programs to help bring down people's out-of-pocket costs.

Then maybe not everybody knows about you know, we're in this rising cost environment, and we want to make sure that everyone is aware of everything that they have available to them to help bring down those costs.

Yeah, absolutely.

All right.

Keith and Victor, we're going to take your call in a moment.

Jack and Grace, we lost your calls back.

If you want to.

I've got emails to share as well.

And here's what we're going to do after our last break of the hour.

We're going to come back and we're going to get as much of your feedback in as we can and have the experts answer your questions.

And this is when we're going to let Cindy McDaid go, because she's done enough for us this hour.

You want to stay?

You want to oh, she's doing great.

She looked at me.

She said, I'm going to stay.

I'm so glad that you're here.

Thank you very much for being here.

And I hope this is helping.

It actually is, because I know it can be challenging.

But I do appreciate all of our guests here.

Cindy is, telling about talking about her own story and trying to find the right fit for a plan.

And you're hearing Dave Kamholz's, who's a licensed Medicare agent for all of Western and Central New York, and Andy Napierala.

Barela is here, vice president of Medicare and individual markets sales for is Blue Cross Blue Shield.

Let's take the last break.

Now.

We'll come right back to all of your feedback.

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This is Connections.

I'm Evan Dawson.

All right, Keith and Victor, you're up first.

Go ahead sir, I have an interesting show.

And I just hope you hear me out on this.

Is there any oversight, that, Yeah.

You're a not for profit, and everybody thinks, That's good, but it doesn't mean everybody works for low wages.

For example, in 2012, the CFO retired.

He got an $11 million bonus.

The following year, the president, or the CEO retired, he got a $13 million bonus.

So my question, even though you're not for profit and everybody thinks that you have to use pencils down to the nub, is there any oversight, real oversight to possibly maybe higher than average or higher than needed, expenses, payroll expenses.

I mean, they have the Blue Cross Arena.

What did that cost?

The ratepayers for that naming rights?

All right.

Thank you very much.

Andy, you want to hit that?

Go ahead.

Sure.

Yeah.

I'm not desperate to speak to compensation levels, or anything like that.

I would I would defer to our compensation team or to our corporate communications team.

But again, what what I can say is that we are very proud of spending 90 or $0.92 of every dollar that we bring in on care, that goes right back out the door to pay a claim, which we would really put up against, against anyone.

So that that's been our focus, and continues to be providing affordable access to, you know, to, to high quality health care.

Do you think there's any evidence linking executive pay to any rising costs?

I'm not aware of it, but I'm not the expert there now.

Okay.

Keith, I mean, I appreciate the phone call.

Hope that answers that.

This is going to be Jack and grease next.

Thanks for calling back, Jack.

Go ahead.

Sir.

Oh.

Hi, Evan.

Thanks again for doing this.

Sure.

By the way, I would just make a pitch for Blue Cross and Blue Shield.

The press.

Okay.

The, we had an experience.

I don't know if I should mention other companies, but I guess I. Well, when we, I had an insurance coverage through Aetna, and, it turns out that they had a great sales pitch in the beginning, but they outsourced all their customer service to the Philippines.

So the customer support, you know, when you have things like surgeries, you didn't expect to come up with them.

You have to try and deal with that and deal with somebody like a, you know, another nation having local support for cross the Blue Shield turned out to be very important because my wife and I, the other was, that, my wife has to take a drug.

I think it's 2 or 4, but it's one of those.

It's an injector, for her psoriatic arthritis.

And, the concern we have every year is it's still on the formulary.

And to try and sort through that, because my wife's drug, we hit the maximum, after one shot, which is like two weeks out of a year.

So that maxes out at 2600 bucks right away.

So good drug coverage is critical for some folks like my wife.

The other is unfortunately, we're losing vision coverage with Blue Cross Blue Shield.

So that's catastrophic.

But it's like, you know, it was kind of it turns out every year we pretty much need to get new life passes.

I'll just share that.

Okay?

Yeah.

Jack, thank you very much.

Andy, what do you think?

Appreciate appreciate the feedback.

And most most importantly, I'm glad that she's able to get access to the to the care that that she needs is what it sounds like.

Unfortunately, no eyeglasses and some of the supplemental benefits, those were some of the things the last couple of years that that I think you saw a lot of carriers make some changes there.

So, hopefully those are things that will be able to put a little more investment into in the future.

Okay.

Why drop them in the last couple of years?

Just tight margins.

I mean, what's the answer.

Yeah, I would say, you know, extremely tight margins.

And what ended up happening is we took a look at our overall spend.

And so the way or what what's most fundamental and obviously we took a look at the medical being the most fundamental right along with, you know, with, with the drug coverage.

And that's some of the other things more supplemental benefits.

Those were we thought a little bit there's less utilization.

And if we had to make any changes, it was more on some things like that.

Although we we didn't take anything lightly and you know, and really didn't want to do any of those things.

But as I mentioned, you know, last time we were here, we're at significant negative margins on our Medicare business.

Things have improved a little bit, but it's still very, very challenged.

And the hope is that with some additional changes that hopefully, you know, by the end of 2027 will be a little bit different story.

And I think you're hearing a little bit more of more of like the light at the end of the tunnel type story from around the industry.

So my hope is that in the future we might be having a little bit different conversations.

Let me address two other kind of related points about who is on this program today and what we try to do to put it together.

And also I, you know, I got a text from somebody saying, hey, you dodged Keith's question.

So let me address both those together here.

First of all, we reached out to MVP, Aetna, Fidelis and Cigna as well to join this conversation.

And they either did not respond or are not here.

They didn't respond like they didn't respond at all.

Excels is here Andy is here the second year in a row and he's been here.

And I'm really appreciative that Andy is here.

Keith, I don't think or whoever texted me that we're dodging Keith's question.

If you are like Jack and you love your health plan or you, it's been really good for you and it's been helpful.

That's awesome.

If you like Keith and you are uncomfortable with executive pay, that's also fair.

But that is not Andy's job.

I'm not running interference for anybody.

That's my job.

My job is to ask questions that helps the audience get answers.

That is a conversation for a separate day if you want to have it.

And we can try to do that.

Keith's question was about oversight, about who approves.

And, you know, why is it this way?

I can tell you it's done anything that brella and that's not me running interference for Andy.

So I'm not trying, Keith, to dodge the question.

I think the question is fair, but it is a question that we will address on a different day, and that is that that work for you.

Is that fair?

That that works.

And thank you.

And as far as oversight, we do have an independent governing board.

We do answer all of our products.

Our Medicare bid has to be approved by CMS.

There's a lengthy process.

All of our rates, like for individual and small group, are set by the state.

So there is a there's no lack of oversight into our business.

I could tell you that for sure.

All right.

So, Keith.

Jack.

Thank you.

Charlie.

Rise to say, Evan, can I offer a cautionary tale?

Last year, I let my Medicare Advantage plan from Excel, which should not cost me anything.

Read up.

Wasn't I surprised I to find I would owe $180 a month?

When I was billed in December?

My lesson read the materials sent to you every year I know I will.

That is from Charlie.

Is that that line up to experience that you're aware of?

Randy?

I'm not sure.

But if, if if we have Charlie's name and contact information, we can have someone reach out to him.

I can share it after the show.

If Charlie's good, but then he.

I'm sure he's listening now.

He'll send me an email.

If he is, I'll.

I'll share him.

Yeah, that'd be good.

Okay.

Charlie, thank you very much.

Laura says, as a reasonably well educated individual, I find the Medicare insurance process a nightmare.

Not only are the benefits becoming more limited, the out of pocket maximums and deductibles are increasing, pharmacy benefits are changing, and coverage for more and more drugs is being curtailed.

In addition, and quite outrageously, in my opinion, there is now a facility fee added to primary care appointments or urgent care appointments that take place in a hospital affiliated facility.

So contrary to the $10 primary care copay or the $40 urgent care co-pay that was advertised in the prospective for the plans, there's an additional $55 charge, and Laura concludes, we need single payer health care for all.

Laura is in.

Victor.

That $55 charge, is that accurate?

Facility fee?

Dave not something I'm aware of.

I've seen too many people getting billed on something like that.

Usually, you know, you're going to see your primary, you go into your specialist, you pay that copay that you're that's a contracted in your ear insurance.

Now, if they perform something else while you're on site, like a sonogram or EKG or something like that, you might be liable for that.

But the facility fee I'm not familiar with sounds like a one off.

And that's where I would just encourage someone call the customer care number on the back of your card.

Maybe it was billed an error and we can take a look at that.

Does it sound to you like an error?

It could be.

Yeah.

I don't know the specifics, so.

Okay.

Yeah.

Okay.

Thank you.

Laura, this is Ann in Pittsford on the phone next.

And go ahead.

Yes.

Good afternoon.

I'm obviously about Medicare, and I'm in Medicare and so very complicated, and I, I guess my comment would be for people to consider original Medicare.

I have been under the advantage plans and I just because I do have Excel is and, I buy my meds from Canada until Trump stops that because they're so expensive to access.

But I will use the health care.

And they needed an MRI because unfortunately, I have something discovered in my brain.

I have a couple of growths in there that may be benign, but they're trying to manage them.

So when my neurosurgeon wanted to have me monitored, on Saturday and I called basically saying your MRI was denied, which cost me as a copay, $300, an Excel space, 96 I'm a medical provider myself, and this was very serious to get something in your ventricle, stopping a super profound slow.

So I, I just want to encourage people to look at the word to Medicare because I will never, ever use it against Karen again.

And I've never had health problems.

And now I have one thing and I'm being denied for 96 hours.

And thank you for the phone call.

Anything we can add on the panel here?

I would say again, if we can get the callers name and information, we can we can take a look at that and maybe escalate it.

Okay.

So, and hang on the line there.

Oh, one of our team will jump on with you and we can share that after the show there.

Yeah, absolutely.

That's that sounds like a situation that it needs to be escalated up.

That's something, you know, we can always help you with.

Do that through the through your insurance carrier.

But Andy's right I mean that's something.

Sounds like it should be getting covered.

I wouldn't know why.

We do hear more people looking at original Medicare, but, Yeah.

Okay.

And thank you very much.

Let me get Tim and Jim.

Tim wants to know, is the Trump Drug website still up and does it help?

I don't know about this one.

I don't have any expertise on this one.

Dave.

No, I it's not something I really deal with because any coverage on that is outside of Medicare.

Is that a real thing?

Yeah.

Is that a real thing?

I don't know what it's I, I know very little.

I'm very limited on my knowledge.

I won't get that any.

I think it is a is a real thing, but it's not what we do.

So I can't really speak to it.

Okay.

And that's, Cindy, that's not something you've looked at.

No.

Okay.

No.

Maybe someone on the team can help me find out if that that Trump drug website's still operational.

I don't, I actually, and I'm not making light of it.

I have no information on it.

So.

Tim, sorry, but we'll try to get more information on that.

Separate from you.

Jim sends an email, says I want to raise an issue that affects many people who live alone and no longer have access to transportation.

When you have to rely on outside services to get to medical appointments or even to obtain basic necessities, the cost of everyday living can become prohibitive.

This morning, I tried to arrange transportation to a dental appointment and was quoted $100 each way by an outside transportation vendor.

Even using Uber around trip to the dentist that once cost me around $50 has become increasingly expensive.

This is more than an inconvenience for people living on fixed incomes.

These costs can make essential medical care unaffordable.

What happens when you need to see a dentist or a doctor but simply cannot afford to get there?

We talk a great deal about access to health care, but access means very little if people cannot afford the transportation necessary to reach it.

Those who live alone no longer drive and have no family or friends available to help are particularly vulnerable.

And I don't pretend to know exactly how this problem should be solved, but it is a problem that deserves serious attention.

Perhaps communities or health care providers, or local governments or other organizations could develop affordable transportation services, specifically for seniors and for people who have no other means of getting around, because no one should have to choose between paying an exorbitant transportation bill and getting the medical care they need.

That's from Jim.

That's an interesting piece of feedback.

I wonder if you've had any similar Andy from, from folks in your sphere at all.

We have.

So it really it depends on on line of business where, transportation benefits are much more common with Medicaid as opposed to Medicare.

We did have some plans that had some limited transportation benefits and honestly, our experience was that the utilization was lower than what we expected.

Now, with that said, I think that the issue that the caller brings up is legitimate.

One is just making sure people have access.

So that's not to say that in the future, we should be looking at ways to help people get that access, whether it's through partnerships or what, whatever that might look like.

The other thing that we're doing very actively is where we have the opportunity is getting people to come into the home to provide care.

Maybe that's not as plausible with the dentist as an example, but whether it's to do checkups or physical therapy, that people can can get the care that they need in the comfort of their own home.

It helps their outcomes pretty significantly.

It's one of the things, one of the many things that's help improved some of our our financial improvement.

It's contributed to that.

So these are very important.

And that's an issue I think as an industry we need to continue to solve a lot better.

Cindy does that one.

I mean transportation is a different challenge for different folks.

But in general, I'm curious to know if you feel like that's an example that those in the industry need to be hearing more from, that people need to see the full picture.

Yes.

As I was mentioning, my sister is, she's her mobility is limited.

And I take her to her doctor's appointments, I take her to her dentist appointments, whatever she has to go to.

But it would be nice if she could get transportation through another, avenue.

Not that I mind taking her, but you never know what might come off.

Of course.

So, she, And I don't know what her insurance is.

What her, advantage plan is, but I she's I mentioned that to her, and she doesn't think that she has any kind of transportation.

I have noticed.

Also, I used to work in a nursing home, and it's very expensive when you have to call transportation to come pick somebody up and take them somewhere.

It's very expensive.

So yeah, that's definitely something that would be helpful.

Okay.

And let me, a couple of people to ask about essential planning changes, which is not what we're talking about today.

Is there anything you want to say about that, Dave?

Essential planning.

Yeah.

Do you get questions on the essential plan?

Get a little bit.

I specialize more on the Medicare side.

We do help people a little bit when, you know, couples, when they get one that's going to be enrolling in the marketplace prior.

But, I mean, Andy might have a little more information on on the on the, essentials.

Yeah, just just high level.

There were some pretty significant changes to the essential plan.

A lot of it came down through the HR one, working class, tax families, act, I guess now the one big, beautiful bill, it has like three different names.

So whichever one you want to use.

But there were some significant funding cuts that that came out of that which impacted essential plan eligibility then.

So we had a pretty significant percentage of our population.

That was essential plan eligible, that was no longer eligible, and had a team of people that worked through them to say, okay, what product are you eligible for?

Are you in a standalone qualified health plan?

You qualify for Medicaid now, and we actually end up retaining more of those folks than than what we thought, thankfully.

So they're still insured, which is which is important.

CBS news reports that the essential plan restricted eligibility in July as a result of the federal cuts, with the income limit for an individual falling to $32,000 from $40,000.

And about 60,000 New Yorkers affected by the cuts turned to different plans, during a special enrollment this past summer.

As a result, that lines up with what you're saying there.

That sounds right.

We had a similar conversation, actually with the state, which I'm glad to say, they're very involved.

They asked for our input, as one of the larger insurers in upstate New York and saying, you know, what was your experience here?

What did you see?

They're aware of the issue.

And I specifically said, you know, unfortunately for more and more people, it seems like their their decision here is not about coverage, but about their cash flow, which is really, really unfortunate.

All right.

This hour has flown by take about 20 or 30s.

Why do you want to leave with the audience as they consider open enrollment?

Like I said, just just make sure you're going through you're checking those benefits.

I know it's a crazy year out there for you in the rollbacks and everything like that, but just be careful what you're looking at that you're not, getting yourself in a situation where you're giving up something you really need to chase after, something that, you just want.

And about 30s, we want to leave with the audience.

Yeah.

Real quick.

Cindy, great to meet you.

For all the other Cindy's out there who are evaluating their options.

Please do your homework.

As Dave said, we try to make ourselves as available as possible.

Just know that even with all the online tools and the research you can do on your own, about 90% of people still work with an agent because it is so complicated and there's so much to, you know, to to keep in mind.

And by the way, I want to say this, this is so weird, but what by an agent, you mean a human being, a human being, not not an artificial intelligence agent, a real person.

It actually bears explaining a real human being, real person, a real person.

And good luck to you.

Thank you.

What are you going to do next?

I I'm not sure.

I guess I'll just keep keep evaluating, evaluating and, you know, I, like I said, I have something in mind.

I just have to make sure that it's going to work.

Well, if you need people like Dave Kamholz's from Triple-A of Western Central New York, how do they find you?

You can give us a call, at eight, seven, seven, 47771 two zero.

And somewhere you can schedule an appointment with us.

We're also online at a.com/medicare.

Thank you for being here, Andy Napierala.

Thank you for making the time for the program again.

Cindy, great to meet you.

Thank you very much.

And audience, great questions.

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