Dave's Health and Life Insurance Industry Tips

State health exchange will slash, not boost, choice

2010-09-24T06:03:00Z

OpEd Contributors

By: John R. Graham
September 9, 2010

Anticipating repeal, states are using a variety of tactics to oppose Obamacare, but in California the Legislature is trying to rush it into existence. That should concern every Californian, especially Gov. Arnold Schwarzenegger.

Unless repealed, Obamacare will require every American not dependent on government health plans like Medicaid or Medicare, or enjoying employer-based benefits, to purchase health insurance in a state-based “exchange” as of January 2014. On Aug. 24 and 25, the Legislature sent two bills to Schwarzenegger. These bills would create California’s exchange and supporting bureaucracy, which would be led by a board of five political appointees.

The governor’s signature on these bills would harm Californians’ access to health insurance. The best-case scenario for the California exchange is similar to the outcome in Massachusetts, where an April 2006 law created an exchange called the Commonwealth Connector, which also deploys a politically appointed board to limit people’s choice of coverage. Not surprisingly, limited choice means higher costs.

Economists John Cogan and Daniel Kessler of Stanford University, and R. Glenn Hubbard of Columbia University, found that premiums in Massachusetts increased by 6 percent more than in the rest of the country, and 14 percent more for small businesses, between 2006 and 2008. California’s exchange is likely to have significantly worse outcomes because of our Legislature’s commitment to government-monopoly (so-called “single-payer”) health care.

Fortunately, Schwarzenegger has vetoed this twice, in 2006 and 2008. President Barack Obama and Kathleen Sebelius, the U.S. secretary of Health and Human Services — along with many congressional Democrats — share our Legislature’s passion for government-monopoly medical care. Although they did not have the votes to pass a single-payer bill, they view Obamacare as an important step toward this goal and have left the door open for states to apply for “waivers” to keep moving toward single-payer.

Schwarzenegger should understand that the California exchange would soon embark on this mission. Its most important power would be to “selectively contract” with insurers to offer policies in the exchange. This is fundamentally different from traditional insurance regulation, which concerns solvency, fraud and good-faith claims processing by insurers. Instead, the exchange’s bureaucrats would choose the policies available to Californians that Obamacare will force into the exchange.

That will be most of us. John Goodman of the National Center for Policy Analysis concluded that any household earning less than $80,000 annually will lose its employer-based benefits and be driven into an exchange.

Schwarzenegger shouldn’t be fooled by the notion that the federal government will grant California oodles of cash to start up and operate the exchange. Right now, Sebelius has no more than $1 million to grant to each state. With polls indicating a Republican majority (committed to repeal) in at least one congressional chamber after the midterm elections, California should not expect any further grants.

Polls show that between 50 and 60 percent of Americans oppose Obamacare. Most Americans know that Obamacare will increase costs to governments, employers and individuals. These higher costs will not lead to better health care or innovation. Instead, every doctor’s decisions will be second-guessed by layers of new government bureaucracy.

Worse, the California exchange would persist even after Obamacare is repealed, implementing a government takeover that the nation will have rejected. Even if Obamacare survives, there’s more than enough time for the next governor to bring the state into compliance with its onerous rules. Schwarzenegger has twice vetoed a government-monopoly health system. He would leave Californians a bitter legacy if he allowed the Legislature to sneak it past him in the last few months of his administration.

John R. Graham is director of health care studies at the Pacific Research Institute.

Ramifications of Poorly Written Reform Law

2010-09-22T18:59:00Z

latimes.com/health/la-fi-kids-health-insurance-20100921,0,799167.story

latimes.com

Big health insurers to stop selling new child-only policies

Anthem Blue Cross, Aetna Inc. and others say they will make the move as soon as Thursday when parts of the new healthcare law take effect. They cite potentially huge and unexpected costs for insuring children.

By Duke Helfand, Los Angeles Times

7:02 PM PDT, September 21, 2010

Major health insurance companies in California and other states have decided to stop selling policies for children rather than comply with a new federal healthcare law that bars them from rejecting youngsters with preexisting medical conditions.

Anthem Blue Cross, Aetna Inc. and others will halt new child-only policies in California, Illinois, Florida, Connecticut and elsewhere as early as Thursday when provisions of the nation's new healthcare law take effect, including a requirement that insurers cover children under age 19 regardless of their health histories.

The action will apply only to new coverage sought for children and not to existing child-only plans, family policies or insurance provided to youngsters through their parents' employers. An estimated 80,000 California children currently without insurance — and as many as 500,000 nationwide — would be affected, according to experts.

Insurers said they were acting because the new federal requirement could create huge and unexpected costs for covering children. They said the rule might prompt parents to buy policies only after their kids became sick, producing a glut of ill youngsters to insure. As a result, they said, many companies would flee the marketplace, leaving behind a handful to shoulder a huge financial burden.

The insurers said they now sell relatively few child-only policies, and thus the changes will have a small effect on families.

"Unfortunately, this has created an un-level competitive environment," Anthem Blue Cross, California's largest for-profit insurer, said in a statement declaring its intention to "suspend the sale of child-only policies" on Thursday, six months after the healthcare overhaul was signed.

The change has angered lawmakers, regulators and healthcare advocates, who say it will force more families to enroll in already strained public insurance programs such as Medi-Cal for the poor in California.

The White House weighed in Tuesday, condemning Anthem corporate parent WellPoint Inc. and others that plan to stop selling child-only policies.

"It's obviously very unfortunate that insurance companies continue to make decisions on the backs of children and families that need their help," White House Press Secretary Robert Gibbs said at a news briefing.

The Obama administration had told insurers they could solve the problem by issuing policies only during designated enrollment periods. Some White House officials, however, noted that families who can't find policies might be able to sign up for high-risk pools being set up around the country as part of the new healthcare law.

In California, the stakes may be particularly high for insurers who abandon child-only policies. A bill awaiting Gov. Arnold Schwarzenegger's signature would bar such companies from selling insurance in the lucrative individual market for five years. A Schwarzenegger spokeswoman said the governor had not yet taken a position on the measure.

Assemblyman Mike Feuer (D- Los Angeles), the bill's author, voiced frustration over the insurers' plans and singled out Anthem Blue Cross, whose corporate parent notified brokers nationwide Friday of its decision to exit the child-only business in 10 states, including Colorado, Connecticut, Missouri, Nevada and Georgia as well as California.

"At a time when we are launching a national approach to ensure that all children have access to healthcare, Anthem's actions represent a step backwards," Feuer said. "By threatening to drop child-only policies in California, the company jeopardizes the health of families and children. I call on Anthem to reconsider its plan."

Other regional and national insurers also plan to stop selling insurance policies exclusively for children. Among the companies is UnitedHealth Group Inc., the nation's largest insurer by revenue. It did not say which states would be affected.

"We continue to believe that regulations can be structured that will enable child-only plans to be offered, and we are working toward that goal," spokesman Tyler Mason said.

Aetna said that effective Oct. 1 it would no longer offer policies in the 32 states where it conducts business, including California, Florida, Illinois, Virginia and Pennsylvania.

Cigna Corp. will halt the policies in 10 states, including California, Arizona, Colorado, Tennessee and Texas.

"We made a decision to stop offering child-only policies to ensure that we can remain competitive in the 10 markets where we sell individual and family plans," Cigna spokeswoman Gwyn Dilday said. "We'll continue to evaluate this policy and could reconsider changing this position as market dynamics change."

The explanations left healthcare advocates fuming. They accused insurers of trying to skirt the law's new requirement to cover children with health problems.

"Insurers need to decide if they are in the business of providing care or denying coverage," said Anthony Wright, executive director of Health Access California, a consumer group. "In California, we hope our insurers come to an equitable compromise that allows access for all children and affordability for those with preexisting conditions."

In Colorado, regulators and insurance carriers are trying to work out such a compromise. The state's insurance commissioner met Friday with several insurers, including Anthem, Cigna and Aetna. The two sides did not reach an agreement, but officials remain hopeful they can broker a deal before Thursday.

"Obviously this deadline looms large," said Jo Donlin, director of external affairs for the Colorado Division of Insurance. "The commissioner wants families to have access to the insurance they need. Both sides of this want to find a solution."

duke.helfand@latimes.com

Noam N. Levey in the Washington bureau contributed to this report.

Peace of Mind-Solutions for Families with Pre-Existing Conditions in today’s Marketplace

2010-06-21T23:28:00Z

One of the challenges I face most often these days, in our pre-2014, marketplace is helping give the small business owner some peace of mind when facing finding insurance when they have a family member with a pre-existing medical condition. For the purposes of this commentary, let’s define a pre-existing condition as something causing a decline in the Individual/Family market.

I often get referred to hopeless people faced with “nobody will insure me”. Well, as a skilled broker, committed to helping insure and provide peace of mind to as many clients as possible, most cases are not hopeless. Many times, the husband and wife business can get Small Group Health on a Guaranteed Issue basis. What does that mean? They cannot decline you for medical issues, or namely pre-existing conditions. All we have to do is prove we are a viable business here in California per the guidelines of AB 1672, which is the statute that defines small businesses in California.

So, when faced with a client who has been declined for health Insurance in the IFP market, I first ask if he or she is married. As long as they are married, we can get them GI Group Insurance in California. Period. If they have a Corporation, we need a current Statement of Information listing both husband and wife as Officers (not Directors) of the company. If they are not Incorporated, we can place them with two carriers who have liberal interpretations of AB1672. All they need to do is get a Business License that lists both the husband and wife as owners of the business entity of choice, and we can get them coverage.

One client was recently referred to me with a daughter, a little less than two years old, experiencing some medical issues that she would grow out of, but declinable conditions in the Individual/Family Plan Market at this time. They came to me with three weeks of Cobra to go…almost in a panic. They followed my instructions to the “t”, and promptly got the coverage they wanted for less than they were paying on Cobra and most importantly eliminated that panic from our first call.

Another client had he and his son on an IFP plan and his wife on a state HIPPA plan. We were able to consolidate all of them onto one plan, significantly improve the benefits to all, and save him some money each month.

In another case, I was working with a woman and her husband in the IFP market, and one of them was declined. She was feeling hopeless…I was able to get the carrier to re-visit their situation, provide a letter of explanation, and they were ultimately offered coverage by that carrier, saving them significant dollars in their monthly budget, while significantly improving benefits. Working with an experienced broker, with a reputation with the carrier can often pay dividends even though it costs you nothing!

Bottom line, I keep saying that here at the David Lindsey Agency, we are Insurance Specialists charged with creating peace of mind for our clients in this challenging and changing Health benefits climate we have now. We work hard to help our clients sleep at night so we can too!

Improving outpatient care could cut down on multiple readmissions, study authors suggest

2010-06-18T16:24:00Z

1 in 4 Patients Undergoes Revolving-Door Hospitalizations

THURSDAY, June 3 (HealthDay News) -- About one-quarter of all U.S. hospital patients are readmitted over a two-year period for the same conditions that led to their original hospitalization, a new study finds.

These revolving-door figures came from the federal Agency for Healthcare Research and Quality, which analyzed 2006-07 data on 15 million patients in 12 states. Among its findings:

More than one-third of patients with hardening of the arteries (atherosclerosis) were readmitted at least once to the hospital, along with 30 percent of patients with uncomplicated diabetes, 28 percent with high blood pressure, and 21 percent with asthma.
Among Medicare patients, 42 percent had multiple hospital admissions and 38 percent had multiple emergency department visits.
Among Medicaid patients, 23 percent experienced multiple hospital admissions and 50 percent had multiple emergency department visits.

Rates of hospital readmissions and multiple emergency department visits were 22 percent and 38 percent, respectively, for uninsured patients and 19 percent and 29 percent, respectively, for privately insured patients.

Although some patients do need to be readmitted, better outpatient care could prevent unnecessary repeat hospital admissions, which in turn can push up health care costs, according to the AHRQ.

The data in the study came from Arizona, California, Florida, Hawaii, Massachusetts, Missouri, Nebraska, New Hampshire, New York, South Carolina, Tennessee, and Utah.

More information

The AHRQ has more about health care quality.

-- Robert Preidt

SOURCE: U.S. Agency for Healthcare Research and Quality, May 27, 2010, news release.

The Massachusetts health care mess is coming soon to the rest of America

2010-06-15T18:19:00Z

Sally C. Pipes: The Massachusetts health care mess is coming soon to the rest of America
By: Sally C. Pipes
OpEd Contributor
June 11, 2010

Devotees of big government, like Archimedes, believe that if they have a long lever and a place to stand, they can move the world.

In 2006, a bipartisan band of such politicians in Massachusetts immersed themselves in wishful thinking, ignored both hard facts and proven theory, and used their political muscle to build bureaucracy, increase taxes, and aggregated power to remake health care in the Bay State.

President Obama, House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid took the act nationwide with the passage in March 2010 of the Patient Protection and Affordable Care Act. Like the canary in a mineshaft, Massachusetts provides a strong indication of our fate.

By now, Bay Staters should be celebrating reform. It promised to benefit all. The bureaucrats would design and broker affordable health plans, doctors and hospitals would get a bump in Medicaid rates, and the uninsured would no longer be a burden.

The system was cracked from the beginning, its promises undelivered even as it picked the pockets of business owners and taxpayers. The crack turned into a chasm this spring, when the state’s private carriers filed for double-digit rate increases for individual and small group plans.

This incensed Democratic Gov. Duval Patrick and the bureaucrats who simply said no. A court upheld their authority, and carriers were forced to continue at 2009 prices, booking loses daily.

They are still fighting in court, and another ruling is expected on the applications for rate increases on plans this summer.

In early June, two large carriers came back with more double-digit increases for plans renewing in July. They expect them to be declined. They are simply positioning themselves for a two-front war: One with the regulators and one with the providers they pay.

The system is inherently unstable and primed for a series of nasty fights. Like dry season at an Everglades watering hole, all the players confined in a tight space, hungry, and all eyeing the same receding resources. Like this tight ecosystem, the players will start to feed on each other, as survival of the politically-fittest takes hold.

This is the case in Massachusetts now. The state’s four largest carriers are hemorrhaging $150 million a month. Roughly a third of contracts are up for negotiation and they are pushing for givebacks.

Providers are crying poor. Reform actually hurt their numbers, as most of the newly-insured enrolled in government-run and subsidized plans under Commonwealth Care that pay less than the actual cost for care.

When you lose money on every unit, you can’t make it up on volume. Traditionally, the cost has been shifted to those with private insurance, but those days are over.

Hospitals and clinic operators maintain that two-thirds of the monies they collect are simply passed on to doctors, nurses, and other essential staff. Cuts here are akin to cuts in wages. Wage cuts will be resisted. The unionized will strike. Those who aren’t will slow down on the job. Doctors will reduce their level of service and some will take early retirement.

The political and bureaucratic response is naturally to clamp down with more control. Massachusetts’ political leaders and activists are making a strong push for a structure of mandatory global payments, which is merely a state-dominated HMO or single payer system. This, they claim, is the next logical step of health care reform.

Meanwhile, a bill in the state senate would force doctors to accept cut-rate reimbursements for Medicaid patients as a condition to practice medicine in the state. When voluntary exchange doesn’t work for politicians, they move to conscription.

In Massachusetts, it took four years to get to this point, and it’s certainly a downhill slide from here. Nationally, Obama’s bureaucrats are just getting started. The administration has yet to comply with the law’s requirement that it detail the myriad of powers it’s been granted, yet it has put the bureaucrats in place to get the job started.

While Obama did not get his Health Insurance Rate Authority into the final bill, the newly-created Office of Consumer Information and Insurance Oversight within HHS will perform the same function.

The new authority has been staffed at the top by four individuals known to be tough on private insurers and more comfortable with the views of Ralph Nader than Adam Smith.

Former Missouri Insurance Commissioner Jay Angoff is the head watchdog. We can expect this team to pick up where Obama and Democrats in Congress left off beating up the insurance carriers including writing regulations to define when premium increases are reasonable.

At the end of the day, the carriers are merely pass-through entities that are necessary to administer the system. They will probably survive but, like regulated public utilities, will be guaranteed after their Medical Loss Ratios (the percentage that an insurer must pay out in claims) and administrative costs are controlled by government, a modest surplus for their efforts. The ultimate payers will be consumers and taxpayers, who will either pay more for less or more for nothing at all. What happens in Mass won’t be staying in Mass.

Sally C. Pipes is president and CEO of the Pacific Research Institute, and author of The Top Ten Myths of American Health Care.

Study Finds Federal Government To Bear Virtually Entire Cost Of Medicaid Expansion.

2010-05-27T16:37:00Z

The Washington Post (5/27, MacGillis) reports, "The federal government will bear virtually the entire cost of expanding Medicaid under the new health-care law, according to a comprehensive new study by the Kaiser Family Foundation that directly rebuts the loud protests of governors warning about its impact on their strapped state budgets." Notably, "a disproportionate share of the 16 million people expected to enroll in the expanded Medicaid live in states in the South and West that until now have had very stringent eligibility rules for low-income adults. Governors of many of those states have predicted fiscal calamity for their budgets, and some have cited the Medicaid expansion in the suits they have filed against the new law, saying it violates their states' rights."
        Modern Healthcare (5/27, Evans, subscription required) reports that "the largest gains in coverage and federal spending" will occur "in states with low coverage levels and higher numbers of uninsured, the Kaiser Commission on Medicaid and the Uninsured said in newly released state-by-state estimates." The study also indicated that "Medicaid enrollment would increase by 22.8 million and the number of uninsured would drop by 17.5 million."
        Reuters (5/27, Lambert) explains that, according to the study, the federal government will spend an additional $443.5 billion on Medicaid through 2019. In contrast, the states' spending on Medicaid will increase by $21.1 billion, and other types of federal funding will reduce this amount even further. Thus, states such as Maine, Colorado, Massachusetts, and Vermont will reduce Medicaid spending by between 0.5 to 2.1 percent.
        NPR (5/27, Rovner) also points out in its Shots blog, "When 20 states filed suit over the new health law just after President Obama signed it in March, the expansion of Medicaid was a major part of their beef." Yet, "a new study suggests that the Medicaid expansion might cost states less than they think, and some states might actually make money on the deal." In fact, "on average, the federal government will pick up 95.4 percent of each state's expanded costs over that period."
        The San Jose Mercury News (5/27, Zapler) reports, "During the health care debate, Gov. Arnold Schwarzenegger estimated the new law would impose additional costs of $2 billion to $3 billion annually on California once it is fully implemented late this decade." This study estimates, however, "that from 2014 to 2019, as the reform law is ramping up, California could bear additional costs from $3 billion to $6.5 billion over that six-year period." CQ HealthBeat (5/27, subscription required), the Tennessean (5/27, Theobald), the Lafayette (IN) Journal and Courier (5/27, Groppe), Lexington Herald-Leader (5/27, Trumn), and the Mobile Press-Register (5/26, Reilly) also covered the story.

RESCISSIONS: MUCH ADO ABOUT NOTHING

2010-05-23T16:13:00Z

Kaiser Health News -

May. 17: How many times have you heard President Obama say, “Health insurers won’t be able to drop your coverage just because you get sick?” Or Kathleen Sebelius? Or the Democratic leadership in Congress? Or the mainstream news media?
You would think that the private health insurance industry was being revolutionized.

In fact, it has been illegal since 1997, under the Health Insurance Portability and Accountability Act, for insurers to drop coverage because someone gets sick. And even before then, the practice almost never happened.

Think of it this way: Do you think there would be a vibrant, active, ongoing life insurance industry if insurers could renege on their part of the contract after someone dies? How many of us would buy fire insurance if the insurers could change their minds and refuse to pay after our house burns down? Would you buy auto insurance from Allstate if the “good hands” could disappear after a collision occurs?

These things do not happen because:

1. Insurers are contractually obligated to keep their side of the bargain and courts enforce these obligations just like any other contract;

2. Regulatory agencies enforce good behavior, quite apart from any lawsuit, and;

3. An insurer that routinely refused to pay claims would lose customers and go out of business.

So what’s the fuss all about?

It’s about rescissions. This occurs when an insurer cancels a policy and returns the premiums to the policyholder, thus voiding the original contract. It almost always happens because the insurance application form is discovered to have fraudulent, misleading or simply wrong information on it.

Rescissions are very rare. They apply only to the individual market (less than 10% of private health insurance) and even then they occur less than 4/10ths of 1% of the time. Even when it does happen, there is almost always an appeals process where the decision is reviewed by an internal committee and often submitted to outside reviewers. Further, when insurers are wrong as they may sometimes be it is the job of state regulators to correct this injustice.

This has not stopped the Obama administration from demagoguing the issue, however. Based on a Reuters story, Secretary Sebelius accused WellPoint of targeting thousands of female policyholders for rescission after they were diagnosed with breast cancer, and President Obama repeated the charge in his weekend radio address. WellPoint’s response: The insurer paid for 200,000 cases of breast cancer last year and rescinded exactly four policies for fraudulent or misleading statements.

Even though such instances are rare, they can provoke differences of opinion on the proper response. Some cases are fairly straightforward. Suppose on my insurance application I say I am in good health when in fact I have chronic renal failure. Should the insurance company have to pay for my kidney dialysis? Obviously not.

Other cases get murky. Most life insurers will not sell to someone who is obese (girth measurement is often the test). Suppose I lie about this information, then get hit by a truck and killed. Should the insurance have to pay off?

On the one hand, you could argue that the lie I told about my obesity was irrelevant. Yes, I lied. But the lie had no material impact on the cause of my death. On the other hand, my lie was not innocuous. It allowed my family to reap a cash benefit it otherwise would not have been entitled to. It caused the insurer, and therefore the policyholders, to incur a cost they otherwise could have avoided.

Regardless of how you come down on this case, if you find the discussion to be one worth having it is probably because you believe there is economic value in a market for risk in which competition tends to price risk accurately.

Yet this White House does not believe in a market for health care risks. It certainly does not believe in pricing risk accurately. Indeed, they tend to think that the only legitimate function of health insurance companies is to pay medical bills. The reason they think ideal health insurance is a single-payer public plan is because they think government can write checks with less administrative hassle than private companies.

And if the truth were known, I suspect that these views are not confined to health care. I suspect they don’t really believe in a market for any kind of risk.

Reprinted with permission from kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, and sign up for email delivery at kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

Health overhaul law potentially costs $115B more

2010-05-14T04:24:00Z

By RICARDO ALONSO-ZALDIVAR, Associated Press Writer Ricardo Alonso-zaldivar, Associated Press Writer – Tue May 11, 7:04 pm ET
WASHINGTON – President Barack Obama's new health care law could potentially add at least $115 billion more to government health care spending over the next 10 years, congressional budget referees said Tuesday.

If Congress approves all the additional spending called for in the legislation, it would push the ten-year cost of the overhaul above $1 trillion — an unofficial limit the Obama administration set early on.

The Congressional Budget Office said the added spending includes $10 billion to $20 billion in administrative costs to federal agencies carrying out the law, as well as $34 billion for community health centers and $39 billion for Indian health care.

The costs were not reflected in earlier estimates by the budget office, although Republican lawmakers strenuously argued that they should have been. Part of the reason is technical: the additional spending is not mandatory, leaving Congress with discretion to provide the funds in follow-on legislation — or not.

"Congress does not always act on authorizations that are put into legislation by drafters," explained Kenneth Baer, a spokesman for the White House budget agency. "Authorizations for discretionary spending are not expenditures."

Congressional estimators also said they simply had not had enough time to run the numbers. Costs could go higher, because the legislation authorizes several programs without setting specific funding levels.

The health care law provides coverage to some more than 30 million now uninsured, offering tax credits to help purchase health insurance through new competitive markets that open for business in 2014. When Congress passed the bill in March, the CBO estimated the coverage expansion would cost $938 billion over 10 years, while reducing the federal deficit by $143 billion.

"If Congress were to approve all of this new discretionary funding authorized in the health care bill, almost all of the administration's highly touted savings would be made null and void," said Jennifer Hing, spokeswoman for Republicans on the House Appropriations Committee.

But Baer said Obama would demand that added spending be offset with cuts in other domestic programs. "The president made clear he will enforce that with his veto pen," said Baer.

Maximize Your Benefits to Save Time and Money

2010-05-07T16:13:00Z

I often hear from prospective clients, many who just bought online without the advice of a broker, that they did not know how their plan was going to pay until they used it. Often, they have used their plan in a fashion detrimental to their own best interests. So, I want to write this to inform you of some tips for best utilization and pre-emptive planning to reduce costs, aggravation and time when accessing care.

Please share this with your Employees and their loved ones.

Prescription Drug Cost- These are one of the top drivers of cost on a Health plan. Prescriptions are ungodly expensive. Doctors are coddled by the Drug companies to push their new brand drugs often before thorough studies are done to prove favorable outcomes. TIP: Be involved in your care. Ask for generic equivalents. Most plans have a Brand name deductible, so your co-pay will not kick in for the first month’s supply, and probably much longer depending on the plan. So, you end up paying for that medicine to get well. If you get generic, you have two choices. First, you can take your card to the pharmacy and as long as it has Generic coverage, you will simply make the co-pay. Second, go to Walgreens, Walmart, or Costco. Sorry to support the big boxes here, but they have lists of over 500 medications they sell for $4 per month/ $10 for 3 month supply. Hint: Do not show them your insurance card. They will have to charge you the copay of $10-$20.

Urgent Care over Emergency Room-Many people do not plan ahead, thus an accidental injury, or minor illness becomes an emergency. Emergency Rooms are NOT the best place to go for some broken bones and cuts requiring stitches. It is just that since we do not plan ahead, we don’t know where else to go, thus it becomes and Emergency to us. Emergency Rooms prioritize there services based upon need. Emergency Rooms serve those who come in by Ambulance. So, if you drove there, you automatically have lower priority. TIP: Plan ahead…right now, pull out your card and see who you are covered by and go to their website. Look up an Urgent Care Facility near your work and home. Become familiar with both and think of going there first. Emergency Rooms on Individual plans fall under the deductible, so you will be responsible for the whole cost up to your deductible. Group plans cover this better, but there is still the wait time. An Urgent Care facility can treat you faster and with lower costs. Become familiar with them, so when/if something happens, you can consider this faster and less expensive alternative.

I hope these tips will help you.

Cost of Health Care Services Remains an Under-Reported Issue

2010-05-06T14:45:00Z

While the underlying cost of health care services remains an under-reported issue, there are signs that this may be changing (see California and Wisconsin summaries below). The California legislature, for example, is beginning to turn its attention to rising hospital and provider costs, and not just the rising cost of premiums. Just in time, the U.S. Justice Department announced last week that California's largest health care purchasers can proceed with an extensive study of the costs of care at more than 300 hospitals statewide. The California Hospital Association tried to block the project claiming antitrust concerns, but the Justice Department rejected the claim. Only by addressing costs throughout the health care system will the nation begin to slow the overall cost of health care and truly deliver on the promise of health care reform. Transparency remains a very important part of the equation.

CALIFORNIA: Democrats on the Senate Health Committee passed legislation addressing greater premium rate transparency. The bill contains numerous problematic provisions that would require detailed actuarial justification for premium increases. However, the bill would also require health insurers to provide hospital and physician price increase information and anticipated trends in reimbursement ratesfor hospitals and other health care providers. With federal reform implementation underway, some legislators are beginning to think about costs in the system and are seeking answers from other stakeholders, rather than just health insurers. The last provision has caught the attention of the state medical society and hospital association.

WISCONSIN: The Governor has signed a transparency bill that requires a health care provider to specify charge information for diagnosing and treating 25 presenting conditions: the provider's median billed charges; the reimbursement amount under Medical Assistance; the reimbursement amount under Medicare; and the average allowable payment from private, third-party payers. This applies to health care facilities including hospitals, ambulatory surgical centers or nursing homes, and to associations of providers that include four or more practitioners. The law also requires a self-insured health plan of the state, county, city, village, town, or school district, and insurers providing coverage under a health insurance policy to provide, upon request, to an insured a good faith estimate of the enrollee’s total out-of-pocket cost for a specified health care service in the geographic region in which the service will be provided. The estimate is not legally binding.

Federal High-Risk Pool Will Exclude Those Who Already Have Insurance.

2010-04-29T17:13:00Z

USA Today (4/29, Young) reports, "About 200,000 Americans whose illnesses have kept them from getting regular health insurance will not be allowed to enroll this summer in a new lower cost federal program for people like them because they already buy pricey state-run plans." USA Today adds, "The nation's new health law creates a far cheaper insurance program opening July 1 for people with pre-existing medical conditions. To qualify, a person can't have had health coverage for six months." As a result, "it excludes people already enrolled in 35 state high-risk pools offering insurance of last resort. The state pools charge high premiums...to help cover costs." HHS spokeswoman Jenny Backus "said the federal pools are a temporary fix to help uninsured people with pre-existing conditions get coverage until 2014."

I trust this is an unintended result of their efforts. Those who sought safety in state high risk pools already cannot get on the new mandated Federal program....hmmm

New Strategies to Curb Rising Healthcare Costs

2010-04-26T15:52:00Z

By Duke Helfand, Los Angeles Times

April 24, 2010

Tom Taylor learned a lesson about healthcare finances when he had both his knees replaced a couple of months apart at separate hospitals in Northern California.

The tab at the first hospital was $95,000, but the second cost $55,000. The same doctor performed identical surgeries on both knees, and Taylor says he can't detect any differences between the two.

More... http://tinyurl.com/2aqq8uq

Health Reform May Lower Medicare Premiums, Boost Overall Health Tab.

2010-04-23T16:20:00Z

The Los Angeles Times (4/23, Levey) reports, "The new healthcare overhaul championed by President Obama may result in lower Medicare premiums for seniors and a more sustainable Medicare program, according to an analysis of the legislation issued Thursday night by independent actuaries at" HHS. In addition, this analysis "suggests that the Medicare program will remain viable until 2029 -- longer than some earlier projections. Before passage of the healthcare overhaul, Medicare had been projected to slip into the red in 2017." Nevertheless, "the healthcare law also will push up the nation's total healthcare tab, as the federal government spends more than $800 billion over the next decade to expand health coverage to more than 33 million Americans, the analysts concluded."
A brief AP (4/23) story on the analysis says, "The first comprehensive look at the health care law by neutral experts amounts to a mixed report card for Obama's top priority during his first year in office," because the "report says that the law falls short of the president's twin goal of controlling runaway costs. And it warns that Medicare cuts may be unrealistic and unsustainable."
The Hill (4/23, Cusack) also reports that the analysis "finds that the bill President Barack Obama signed into law would cost $828 billion over the next decade, while saving $577 billion." But, these "projections do not take into account changes to the tax code that have been enacted. The Congressional Budget Office (CBO) reported that over the next 10 years, the healthcare package would decrease the deficit." The Hill goes on to say that, although the analysis "concludes that the healthcare overhaul will reduce the number of the nation's uninsured from 57 million to 23 million," it "raises several warnings about the impact of healthcare reform." For instance, higher "demand for health services could be difficult to meet initially with existing health resources and could lead to price increases [and] cost shifting." In addition, some employers may "stop offering their employees healthcare coverage benefits."

Mandate for Healthcare penalties

2010-04-23T16:16:00Z

About four million people "could be fined for failing to buy health insurance when the health overhaul law is fully in force in 2016, the Congressional Budget Office forecast on Thursday," Reuters reports, adding: "Most individuals must buy health insurance under the landmark legislation passed by Congress last month, or face fines that will be phased in."

The penalty would raise about $4 billion a year from 2017-2019, the CBO said. Starting in 2016, people without coverage could be fined $695 or up to 2.5 percent of their income for not having health insurance, but many of the 21 million likely to remain uninsured in that year will avoid the penalties. "Democrats called the numbers unsurprising and said that those paying penalties amounted to 1.5 percent of the population" (Dixon, 4/22).

MRMIB Communicating With HHS About Federal High-Risk Insurance Pool

2010-04-01T23:33:00Z

Thursday, April 01, 2010

MRMIB Communicating With HHS About Federal High-Risk Insurance Pool
California's Managed Risk Medical Insurance Board has begun corresponding with HHS to inquire about a high-risk health insurance pool mandated in the national health reform law, Payers & Providers reports.

The pool would provide coverage to people with pre-existing conditions until the national health insurance exchanges begin operating in 2014.

Since the mid-1990s, MRMIB has operated a high-risk pool in California called the Major Risk Medical Insurance Program. However, funding pressures have kept the program capped at 7,100 members.

Jeanie Esajian, MRMIB's deputy director for legislative and external affairs, estimated that as many as 300,000 California residents could qualify for a federal high-risk pool.

Esajian said MRMIB is capable of running a new high-risk pool, but she warned that the board could face operational challenges. MRMIB currently employes fewer than 100 people.

HHS has yet to set regulations on how a federal high-risk pool would operate. The agency also has not commented on whether MRMIB would have the necessary expertise to run a pool in California (Payers & Providers, 4/1).

Reform has passed...what now?

2010-03-24T23:24:00Z

Ok, so Healthcare Reform is passed…what does that mean? Washington is still at each other’s throats. Schwarzenegger says it will add at least $4 billion to our already dire budget. Republicans are prepared to fight at every possible opportunity, states AGs are putting up State roadblocks. I could go on, but bottom line…it is a mess. So, what do we do?

As your benefits advisor, I would like to take this opportunity to provide you a summary of the key components of the health care reform legislation and how it may impact you and your business. I expect that given the number of years that it will take to fully rollout these reforms, there will continue to be changes to many elements of the legislation. However, for the first time in over a year, we have a much clearer view of the changes that will potentially take place. This bill will:

Mandate that everyone must have insurance.

Result in more than 30 million additional people becoming insured.

Provide for subsidized coverage for people that can’t afford it and increase the number of people that will qualify for Medicaid.

Make cuts to Medicare Advantage Plans and change their payment formula.

Increase taxes and fees to many individual Americans and Corporations.

Make many changes to the way Insurance Companies do business from not allowing them to use pre-existing conditions to limiting their rates based on medical loss ratios.

Many of these elements do not phase in for many years. Those that are most immediate and are expected to occur in 2010 are:

Tax credits for certain small businesses.

Elimination of pre-existing conditions and an increase in dependant coverage to age 26.

Creation of a temporary reinsurance program to provide coverage for retirees over 55 who are not eligible for Medicare.

The further creation of a temporary national high risk insurance pool.

The prohibition of lifetime limits on benefit payments.

Closing the so called “doughnut hole” by providing immediate tax credits for Medicare patients who face a gap in prescription drug coverage.

The real impact in the health insurance system won’t occur until the year 2014. During the interim, there will be the phase-in of additional new taxes that will provide added government revenue to pay for these changes. The four most significant changes occurring in 2014 are:

Insurers will be required to take all applicants.
Insurance will be mandated for all Americans.

· Tax credits to help pay premiums will start flowing to middle-class working families. The most aid – including help with copayments and deductibles – will be made available for those individuals and families on the lower end of the income scale.

· Insurance exchanges will be created to help administer subsidies for those individuals that require them.

When fully implemented, I believe that the majority of working-age Americans and their families will continue to have employer-sponsored coverage as they do today. In addition, through mandates and other subsidies, the number of people insured can grow by more than 30 million.

Please be assured that I will work to help you navigate through the various changes of this legislation to ensure that you and your employees are always offered the most choice and greatest value of benefits available in the marketplace. This will be a long road and I pledge to be with you every step of the way.

Meanwhile, if I can be of assistance to you in any way, please do not hesitate to call.

My Accident Plan giving me that calm peace of mind, so empathy and compassion can flow

2010-03-24T23:07:00Z

My Accident Plan giving me that calm peace of mind, so empathy and compassion can flow…so here is my weekend: Friday morning, Chandler our oldest is calling from the nurses office within 20 minutes of me dropping him off at school. He has just hurt himself “falling” down some stairs. The nurse says it is really bad. Melanie drops everything and spends ¾ of the day going to doctors, x-rays at the Imaging Center then back for analysis. The Health Insurance has a high deductible to be affordable like most of us are having to do these days. I am calm, no concern for the cost because I know that with the Accident plan, the most we will pay is $100 per incident. It turns out Chandler tore two ligaments and really did fall down the stairs. Good news is he will be back in action in 2-3 weeks and I did not allow the fear of cost to derail me from being the loving and supportive parent I need to be.

Fast forward to Saturday at about 1:20. Ethan the middle boy is catching and there is a bang, bang play at home. The opposing player is called out but Ethan comes up crying holding his left thumb. Again, I am in empathetic Dad, calm and peaceful because I know we got it covered. We ice it and it continues to grow…we are thinking another trip to the Urgent Care chasing x-rays…now fortunately for Ethan he just jammed it and he is fine, but I am so happy I was able to be the peaceful parent, full of empathy for my children, not the “oh my God, how much is this going to cost me” parent I would have been without the Accident Plan.

For this kind of peace of mind, call or email me. I want to share this with you!

Samuelson at Newsweek hits the Target on Healthcare Issue

2010-03-16T15:52:00Z

By Robert J. Samuelson | Newsweek Web Exclusive
Mar 15, 2010 | Updated: 1:18 p.m. ET Mar 15, 2010
"What we need from the next president is somebody who will not just tell you what they think you want to hear but will tell you what you need to hear."
—Barack Obama, Feb. 27, 2008
One job of presidents is to educate Americans about crucial national problems. On health care, Barack Obama has failed. Almost everything you think you know about health care is probably wrong or, at least, half wrong. Great simplicities and distortions have been peddled in the name of achieving "universal health coverage." The miseducation has worsened as the debate approaches its climax.
There's a parallel here: housing. Most Americans favor homeownership, but uncritical pro-homeownership policies (lax lending standards, puny down payments, hefty housing subsidies) helped cause the financial crisis. The same thing is happening with health care. The appeal of universal insurance—who, by the way, wants to be uninsured?—justifies half-truths and dubious policies. That the process is repeating itself suggests that our political leaders don't learn even from proximate calamities.
How often, for example, have you heard the emergency-room argument? The uninsured, it's said, use emergency rooms for primary care. That's expensive and ineffective. Once they're insured, they'll have regular doctors. Care will improve; costs will decline. Everyone wins. Great argument. Unfortunately, it's untrue.
A study by the Robert Wood Johnson Foundation found that the insured accounted for 83 percent of emergency-room visits, reflecting their share of the population. After Massachusetts adopted universal insurance, emergency-room use remained higher than the national average, an Urban Institute study found. More than two-fifths of visits represented non-emergencies. Of those, a majority of adult respondents to a survey said it was "more convenient" to go to the emergency room or they couldn't "get [a doctor's] appointment as soon as needed." If universal coverage makes appointments harder to get, emergency-room use may increase.
You probably think that insuring the uninsured will dramatically improve the nation's health. The uninsured don't get care or don't get it soon enough. With insurance, they won't be shortchanged; they'll be healthier. Simple.
Think again. I've written before that expanding health insurance would result, at best, in modest health gains. Studies of insurance's effects on health are hard to perform. Some find benefits; others don't. Medicare's introduction in 1966 produced no reduction in mortality; some studies of extensions of Medicaid for children didn't find gains. In the Atlantic recently, economics writer Megan McArdle examined the literature and emerged skeptical. Claims that the uninsured suffer tens of thousands of premature deaths are "open to question." Conceivably, the "lack of health insurance has no more impact on your health than lack of flood insurance," she writes.
How could this be? No one knows, but possible explanations include: (a) many uninsured are fairly healthy—about two-fifths are age 18 to 34; (b) some are too sick to be helped or have problems rooted in personal behaviors—smoking, diet, drinking or drug abuse; and (c) the uninsured already receive 50 to 70 percent of the care of the insured from hospitals, clinics and doctors, estimates the Congressional Budget Office.
Though it seems compelling, covering the uninsured is not the health-care system's major problem. The big problem is uncontrolled spending, which prices people out of the market and burdens government budgets. Obama claims his proposal checks spending. Just the opposite. When people get insurance, they use more health services. Spending rises. By the government's latest forecast, health spending goes from 17 percent of the economy in 2009 to 19 percent in 2019. Health "reform" would probably increase that.
Unless we change the fee-for-service system, costs will remain hard to control because providers are paid more for doing more. Obama might have attempted that by proposing health-care vouchers (limited amounts to be spent on insurance), which would force a restructuring of delivery systems to compete on quality and cost. Doctors, hospitals and drug companies would have to reorganize care. Obama refrained from that fight and instead cast insurance companies as the villains.
He's telling people what they want to hear, not what they need to know. Whatever their sins, insurers are mainly intermediaries; they pass along the costs of the delivery system. In 2009, the largest 14 insurers had profits of roughly $9 billion; that approached 0.4 percent of total health spending of $2.472 trillion. This hardly explains high health costs. What people need to know is that Obama's plan evades health care's major problems and would worsen the budget outlook. It's a big new spending program when government hasn't paid for the spending programs it already has.
"If not now, when? If not us, who?" Obama asks. The answer is: It's not now, and it's not "us." Pass or not, Obama's proposal is the illusion of "reform," not the real thing.

Single Payer fans suffer set-back

2010-03-03T23:28:00Z

Single-payer setback: It didn't help the cause of single-payers who are in love with the Canadian health care system when the premier of Newfoundland secretly traveled to the United States for heart surgery.

Danny Williams, 60, made the situation worse in an interview after the surgery at Mount Sinai Medical Center in Miami, Florida. "This was my heart, my choice, and my health," he said from his condominium in Sarasota. "I did not sign away my right to get the best possible health care for myself when I entered politics."

Yikes! Tell that to the hundreds of thousands of Canadian citizens who can't afford to buy their way out of the Canadian health care system and must wait months and months for care -- care that Premier Williams clearly didn't think made the grade as "the best possible care."

Medicare Made Simple

2008-09-12T22:43:00Z

Medicare Key Dates – 2008

October, 2008: Prepare and Compare
Look at the cost, coverage and convenience your current plan will offer in 2009. Compare with other plans in your area to see if there may be a better choice for you. Visit www.medicare.gov to find plans in your area. If you are satisfied with your current plan’s cost, coverage, convenience and the customer service you get, you don’t need to do anything. You will remain enrolled through next year without taking any action. You can also attend seminars provided by insurance companies to learn more about the other plans available in your area, without any obligation to take action.

November 15, 2008:
First day you can apply to change your Medicare health or prescription drug coverage for 2009.

December 31, 2008:
Last day you can apply to change your Medicare prescription drug coverage for 2008. If you have a Medicare Supplement or Medicare Advantage plan, you may change it during this period (November 15 – December 31), and the new plan will be effective January 1, 2009. You may also change your Medicare Supplement or Medicare Advantage plan one time between January 1 and March 31, 2009.

January 1, 2009:
New coverage begins if you made a change.

The Different Parts of Medicare
You can get the most from your Medicare benefits by learning what Medicare covers and by taking advantage of all that Medicare has to offer. Medicare has the following parts:

Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals. Part A also helps cover skilled nursing facility, hospice and home health care if you meet certain conditions.
Medicare Part B (Medical Insurance) helps cover medically necessary services like doctors’ services and outpatient care. Part B also helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse.
Medicare Part C (Medicare Advantage Plans) is another way to get your Medicare benefits. It combines Part A, Part B and sometimes Part D (Prescription Drug) coverage. Medicare Advantage Plans are managed by private insurance companies approved by Medicare. These plans must cover medically necessary services. However, plans can charge different copayments, coinsurance or deductibles for these services.
Medicare Part D (Prescription Drug Coverage) helps cover prescription drugs. This coverage may help lower your prescription drug costs and help protect against higher costs in the future.

Your Medicare Plan Choices
• The Original Medicare Plan managed by the Federal government, provides your Medicare Part A and part B coverage. You are usually charged a fee for each health care service or supply you get.
If you are in the Original Medicare Plan, you can add drug coverage (Part D) by joining a Medicare Prescription Drug Plan. These plans are run by insurance companies approved by Medicare.
You can also choose to buy a Medigap (Medicare Supplement Insurance) policy to help fill the gaps in Part A and Part B coverage.
• Medicare Advantage Plans (like an HMO or PPO) are another way to get Medicare benefits. Medicare Advantage Plans are health plan options approved by Medicare and run by private companies. Some Medicare Advantage Plans offer coverages not provided by Original Medicare. If you join a Medicare Advantage Plan that doesn’t offer drug coverage, like a Medicare Medical Savings Account (MSA) Plan or some Medicare Private Fee-For-Service (PFFS) Plans, you may be able to join a Medicare Prescription Drug Plan.
• Other Medicare Plans are plans that aren’t Medicare Advantage Plans, but are still part of the Medicare program, such as Medicare Cost Plans, Demonstrations / Pilot Programs and Programs of all-inclusive care for the elderly (PACE). These plans provide part A and Part B coverage, and some also provide Part D (Medicare Prescription Drug coverage).

Medicare Frequently Asked Questions

Q. When can I Sign up for Part A?
A. If you get benefits from Social Security or the Railroad Retirement Board, you will automatically get Part A starting the first day of the month you turn age 65. If you are not receiving benefits, you will need to sign up for Part A. You should contact Social Security 3 months before the month in which you turn age 65 to sign up for Part A.
Q. How do I enroll in Medicare?
A. The Social Security Administration handles Medicare eligibility and enrollment. You can contact the Social Security Administration at 1-800-772-1213 to enroll in Medicare or to ask questions about whether you are eligible. You can also visit their website at www.socialsecurity.gov
Q. Will I get Medicare at age 65 if I am not yet eligible for Social Security?
A. While the retirement age for Social Security is increasing until it reaches age 67, 65 remains as the starting age for Medicare eligibility. You will be eligible to apply for Medicare at age 65 if you have paid into Social Security for at least 10 years, or you are eligible to receive Social Security benefits on your spouse’s (or your former spouse’s) earnings.
Q. What about Part B?
A. Anyone who is age 65 and a citizen, or a lawfully admitted alien with 5 years of residency in the United States, can sign up for Medicare Part B medical insurance and pay a monthly premium. You should do this 3 months before you reach 65.
Q. I don’t go to doctors very often. Why should I pay for Part B until I need it?
A. You can delay adding Part B to your coverage, but if you do not elect it in your Initial Enrollment Period, which runs for 7 months, starting from 3 months before the month you turn 65, you will have to wait for the next General Enrollment Period to enroll. Your premium may go up 10% for each 12 month period that you could have had Part B but did not take it.
Q. How can I find help making these decisions?
A.1. The Social Security Administration provides assistance with enrollment and eligibility questions. You can also visit the Medicare website at www.medicare.gov , where you can run comparisons of the plans available to you in your area.
A.2. Friends and family members who are already enrolled in Medicare may be able to provide insight to you.
A.3. Licensed insurance agents can also help you to understand the differences between policies and types of coverage. Many agents represent multiple companies and can provide impartial advice about the differences in plans based on your anticipated needs for medical coverage. Purchasing a Medigap, Medicare Advantage or Medicare Prescription Drug Plan through an agent costs the same as doing it on your own.

For more information, contact our trusted agents:

Dave Lindsey
dave@davidlindseyinsurance.com
www.davidlindseyinsurance.com
858/ 245-4796

or

Pete Taylor
pete@petertaylorinsurance.com
www.petertaylorinsurance.com
760/ 448-5705

Dave's Health and Life Insurance Industry Tips

State health exchange will slash, not boost, choice

State health exchange will slash, not boost, choice

By: John R. Graham September 9, 2010

Ramifications of Poorly Written Reform Law

latimes.com

Big health insurers to stop selling new child-only policies

Anthem Blue Cross, Aetna Inc. and others say they will make the move as soon as Thursday when parts of the new healthcare law take effect. They cite potentially huge and unexpected costs for insuring children.

Peace of Mind-Solutions for Families with Pre-Existing Conditions in today’s Marketplace

Improving outpatient care could cut down on multiple readmissions, study authors suggest

The Massachusetts health care mess is coming soon to the rest of America

Study Finds Federal Government To Bear Virtually Entire Cost Of Medicaid Expansion.

RESCISSIONS: MUCH ADO ABOUT NOTHING

Health overhaul law potentially costs $115B more

Maximize Your Benefits to Save Time and Money

Cost of Health Care Services Remains an Under-Reported Issue

Federal High-Risk Pool Will Exclude Those Who Already Have Insurance.

New Strategies to Curb Rising Healthcare Costs

Health Reform May Lower Medicare Premiums, Boost Overall Health Tab.

Mandate for Healthcare penalties

MRMIB Communicating With HHS About Federal High-Risk Insurance Pool

Reform has passed...what now?

My Accident Plan giving me that calm peace of mind, so empathy and compassion can flow

Samuelson at Newsweek hits the Target on Healthcare Issue

Single Payer fans suffer set-back

Medicare Made Simple

By: John R. Graham
September 9, 2010