A recent thought-provoking article in the Fort Collins Coloradoan delves into the future of independent medical practices and the pros and cons of hospital mergers and “closed” healthcare systems like Kaiser Permanente (Kaiser opened for business in northern Colorado last fall) moving into the area. The article notes that the split between employed physicians and… Read more about Doctors Moving Away From Independent Practice – What That Means For Patients
May 15th was the deadline for health insurance carriers in Colorado to submit rates for new plans that will be sold in the individual and small group markets in Colorado, both in and outside of the exchange/marketplace (Connect for Health Colorado). Much has been said about today – May 22nd – being the date when those rates are available to the public, and there has been a lot of anticipation about getting to find out what health insurance premiums are going to look like next year in Colorado. We know that in the Pacific Northwest, rates have come in lower than expected, attributed partially to the “heavy competition” in the WA and OR marketplaces (9 and 12 insurers, respectively). Colorado has even more competition than that, with 19 different carriers submitting rates for plans to be sold through Connect for Health Colorado and on the open market (I’ve seen other reports that say 17 carriers, but either way, it will be a robustly competitive market – just as we’ve always had in Colorado).
There has been much speculation about what the new rates will look like. 9News did a piece last week that highlighted the concerns that rates – particularly in the individual market – could be much higher next year. Over the last year or so, in talking with knowledgeable representatives from the various health insurance carriers (who are themselves talking with knowledgeable actuaries), we’ve heard predictions that range from rate decreases for older policy-holders to rates more than doubling for younger insureds… and just about everything in between. So we are very curious to see how things look once the DOI releases rates.
Today’s the day that those rates are scheduled to be made public, but I doubt that things will be particularly clear anytime soon […]
Joe Paduda of Managed Care Matters did an excellent job with the most recent Health Wonk Review – be sure to stop by his blog and check it out. I thought this article from Dr. Roy Poses was especially interesting. Writing at Health Care Renewal, Dr. Poses shines the spotlight on UnitedHealth Group’s CEO Stephen Hemsley’s oversized compensation. Roy notes that while the increase in CEO compensation does mirror the company’s overall financial success of late, it must also be considered in light of the fact that the company has made some missteps in terms of fulfilling its stated mission to provide health care “at an affordable price” and “expand access to quality health care.” Roy’s article cites several examples of allegedly unethical behavior, and concludes by noting that “Real health care reform needs to make health care leaders accountable, and especially accountable for the bad behavior that helped make them rich.”
I definitely do not disagree with Dr. Poses, and we’ve noted in the past that UnitedHealth Group has had issues with large executive compensation and backdating stock options (that was with a previous CEO, however). But I do want to use this as an opportunity to remind our readers and clients that most health insurance companies have CEO compensation packages that are far lower. Forbes compiled a list of the 498 highest-paid CEOs in 2012, and I scrolled through the first 150 on the list. UnitedHealth Group is there on the first page, ranked number 8 (they’re also ranked number 31 in Fortune 500 total profits, so as Roy said, the CEO salary is at least in the same ballpark with the company’s financial performance).
But you have to click through several pages of the CEO compensation list to get to the next health insurance carrier. Humana was the next one I found, ranked at […]
We recently heard from one of our clients who is dealing with a balance billing issue resulting from a NICU stay. For her baby’s birth, she chose a large hospital in Denver that was on her Humana health insurance network. Her OB/GYN was also on the Humana plan, and she figured she had all of her ducks in a row. But complications necessitated an emergency transfer to the NICU, where her new baby was cared for by doctors who are contracted with the hospital, but are not part of the Humana network.
When patients are treated by out-of network providers, there’s no contractual obligation between the doctors and the health insurance carrier. The patient will usually be responsible for a higher deductible when using a non-network provider (although this is not typically enforced for emergency care), but even after the deductible is met, the provider is not obligated to accept the “reasonable and customary” payment from the health insurance carrier. The provider can choose to bill the patient the shortfall between what was originally billed and what was paid by insurance.
Our client has been balance billed over $5,000 by the NICU doctors. Humana paid the doctors their in-network amounts for the NICU stay and counted it as an in-network expense (ie, no additional out-of-network deductible was charged) because it was an emergency situation. But the doctors refused to accept the insurance reimbursement as payment in full, and billed the family for an additional $5,000+. I suppose it could be worse – this family ended up with a $50,000 balance bill from their baby’s NICU stay.
But it could also be better. People who are recovering from an illness or injury don’t need to also be finding out that an in-network facility where they were treated also has providers who are not […]
Last month, Colorado became the third state to prohibit health insurance carriers from denying claims based on sexual orientation and/or gender identity. At first, we were puzzled when we saw the headlines in the news, since they mostly mentioned discrimination based on sexual orientation or discrimination directed at LGBT insureds. We were thinking mainly in terms of gay, lesbian and bisexual clients, and we couldn’t remember ever dealing with a claims denial issue based on sexual orientation. We also had never seen any questions on a health insurance application regarding sexual orientation.
The only issue we had ever come up against in terms of LGBT discrimination had to do with same-sex partners who wanted to apply together for family health insurance policies in the individual market. Although individual health insurance for two people was the same total price regardless of whether they were on one policy or two, it was often inconvenient for families to have to have two separate policies, and in the case of HSA-qualified plans, it was also financially detrimental to have to split up the family for health insurance purposes.
But we never had any issues with applications being rejected or claims being denied based on sexual orientation. I posted last month on Google+ that although I’m always in favor of expanding equality, I was a bit perplexed by this new regulation, given that we weren’t aware of any carriers using sexual orientation as an initial underwriting and/or claims issue.
Then I started discussing this issue with Dede de Percin, Executive Director of the Colorado Consumer Health Initiative, and Ashley Wheeland from One Colorado, and I’ve learned a lot more about it in the last few days. As far as I’ve been able to tell, the DOI bulletin, titled “Insurance Unfair Practices Act Prohibitions on Discrimination Based Upon Sexual Orientation” is primarily a response to broad exclusionary language in health insurance policies that allowed for claims to be denied if the insured was transgender. The claims exclusions could range from specific treatment related to gender transitioning, to onerous exclusions for just about any medical care at all: De Percin notes that one transgender person was denied coverage for a broken arm because the health insurance carrier determined that the hormones the person was taking weakened the bone and thus led to the break. This is absurd, and it does sadden me to learn that such broad exclusions were being […]
One of our all-time favorite bloggers, Julie Ferguson of Workers’ Comp Insider, hosted the most recent Health Wonk Review – the “why hasn’t spring sprung?” edition. Maybe Julie just needs to move to Colorado… here on the Front Range, we’re definitely starting to see signs of spring – today was a beautiful sunny day,… Read more about Most Americans Might Not See Big Premium Hikes, But The Individual Market Is Different
Right in the middle of the sequestration mess seems like a good time to discuss the subsidies that are going to be a major part of the ACA starting next year. As of 2014, nearly everyone in the US will be required to have health insurance, and all individual health insurance will become guaranteed issue. There are concerns that premiums in the individual market might increase significantly, but for many families the subsidies enacted by the ACA will help to make coverage more affordable. The subsidies will be available to families earning up to 400% of the federal poverty level; the premium assistance will be awarded on a sliding scale, with the families on the upper edge of that income threshold receiving the smallest subsidies.
But how much will those subsidies cost the taxpayers? How will a government that is so cash-strapped that it’s curbing spending on programs like Head Start and special education be able to fund the subsidies called for in the ACA?
Last summer, the CBO estimated that the exchange subsidies will cost $1,017 billion over the next ten years. Undoubtedly a large sum, but probably necessary in order to make guaranteed issue health insurance affordable for low- and middle-income families.
That sum is partially offset by the CBO’s projections of $515 billion (over the next ten years) in revenue from individual mandate penalties (fines imposed on non-exempt people who opt to go without health insurance starting in 2014), excise tax on “Cadillac” group health insurance policies, and “other budgetary effects” enacted by the healthcare reform law.
That leaves us with $502 billion. Not an insignificant sum of money even when […]
One of our clients recently told us about a health insurance plan that was being marketed to him, and we were curious enough to want to look into the situation further. In a nutshell, it’s not a discount plan, not a mini-med, and not a traditional limited-benefit indemnity plan. All of those plans should be avoided in general, and the ACA has sort of skirted around them a bit: numerous mini-meds have been granted temporary waivers in order to continue to operate, discount plans aren’t addressed by the ACA at all (and aren’t regulated by most state Division of Insurance departments either, since they aren’t actually insurance), and limited benefit indemnity plans are exempted from ACA rules (although people who have them will likely have to pay a penalty for not meeting minimum benefit requirements).
Anyway, the plan that was marketed to our client resembled traditional health insurance, but was very convoluted and sold with numerous riders to cover all sorts of different scenarios. The brochure was 27 pages long and included numerous detailed examples showing how awesome the marketed coverage was when compared with “traditional major medical.” It noted that the plan isn’t subject to ACA mandates, and the policy is still being marketed with a $5 million lifetime maximum. When I spoke with an agent for the plan (a captive agent, of course – plans like that are never marketed by brokers who have access to other policies), he told me that the policy will not be guaranteed issue next year, and that they aren’t concerned about the potential penalties that their clients will have to pay starting in 2014 for not having ACA-compliant coverage. His reasoning (and the marketing pitch that they’re making to their clients) is that their premiums will be so much lower than ACA-compliant plans that their clients will save enough money to more than make up for the penalty (currently their premiums were roughly the same as those of reputable health insurance policies).
In short, everything about this policy sounded sketchy.
A rather lengthy Google search didn’t bring up much in the way of regulations pertaining to this sort of issue. I remembered my efforts in the fall of 2011 to get specific details about regulations regarding mini-meds… and I wasn’t encouraged. At the time, the Colorado Division of Insurance wasn’t aware of a solution to the problem our client was facing (although to give them credit, I was able to speak with someone as soon as I called them). They referred me to HHS, where I had to leave a voice mail. The outgoing message said that someone would get back to me within five business days, but that was a year and a half ago and I’m not holding my breath for a reply. I also left a message for the National Association of Insurance Commissioners (NAIC) about the issue and never heard back from anyone there. We ended up getting the client onto an Anthem Blue Cross Blue Shield plan, but we never heard back from any of the government agencies we contacted regarding his mini-med situation.
So back to our current questions about the sketchy-sounding health insurance being marketed to our client. I contacted HealthCare.gov via Twitter but got no response. I called the Colorado Division of Insurance and was told that I should send in an email with the specifics. I did that on Wednesday and haven’t heard anything back from them yet. I called them this morning to follow up, and they told me that they had received my email but didn’t know to whom it had been assigned yet – this is two days after I sent it, so I would assume that perhaps the employees there are overworked and understaffed. I didn’t contact the national HHS office again, because I didn’t feel like wasting my time any further. However, I did send an email on Friday morning to the regional HHS office in Denver, so hopefully I’ll hear back from them sometime soon.
I’m also hopeful that I’ll hear back from the Colorado DOI sometime next week. They usually end up being a helpful – and local – resource, even if we have to wait a few days. Once we get some more information, I’ll write a follow-up post about how an individual carrier is apparently able to operate entirely outside the regulations of the ACA.
But for now, I’m struck by how difficult it can be to obtain information from a government agency, or even speak with a real person as opposed to just leaving a message or sending an email that may or may not ever get read. I know that private companies aren’t always shining examples of customer service, but I can’t imagine calling the claims or customer service number on the back of our Anthem Blue Cross Blue Shield card and being told […]
Ever since the PPACA was first being discussed, the individual mandate has been touted as a buffer to protect health insurance carriers – and in turn, policyholders – from adverse selection that would otherwise certainly occur in a guaranteed issue individual market. It seemed that as long as people were required to maintain health insurance coverage, adverse selection would be minimized and people would be unlikely to purchase health insurance only during periods of sickness. But there was still enough concern about adverse selection that HHS issued a proposal for open enrollment periods in the individual market starting next year. This proposal was released at the end of November, and the specific details regarding the open enrollment period are on page 70595 of this Federal Register.
To sum it up, they’re proposing an initial open enrollment period for individual/family health insurance that starts in October 2013 and runs through the end of March, 2014 (a six month window in order to accommodate the large influx of initial applications), and then open enrollment periods that mirror Medicare’s: October 15th until December 7th each year. Beyond that window, only “qualifying event” applications would be allowed for […]
I understand the trade off we got when we switched to a really inexpensive high deductible plan when even our high deductible HSA qualified plan was too rich and expensive. So I wish my health insurance had a monthly credit card billing option. Our current health insurance company, Anthem Blue Cross of Colorado used to have it, like most health insurance companies did. But then, like most other companies also did, they stopped offering that as an option about a year ago.
What would you change about your health insurance company or plan? It could be the coverage, billing, customer service, anything…
Did you receive a health insurance premium rebate this year? If so, how much was it? We created a simple visualization of how the PPACA (Obamacare) health insurance premium rebates break down between the individual/family, small group and large group markets and how Colorado’s rebates compared to the national average.
CoverColorado announced that there will be no assessment in 2013 on Colorado health insurance carriers. The 2012 assessment was roughly $3.79/month/contract for individual/family insureds.
Anthem Blue Cross of Colorado has also announced that their membership this year was higher than expected this year. They were making up for a shortfall by charging $4.36/month/contract in 2012. Due to the higher enrollment, Anthem BCBS has enough funding to satisfy December without billing subscribers a CoverColorado assessment.
Last week we added a post about contraceptive coverage under the PPACA and what changes people could expect to see starting in August. We just received an information sheet regarding this subject from Anthem Blue Cross Blue Shield, and wanted to share it with our readers. It will be useful for our Anthem clients, and is also helpful to give people a rough idea of how the contraceptive coverage will be implemented by most carriers. There may be some small variations from one carrier to another, but in most cases things will be similar across the board, since federal legislation is guiding the changes.
The Anthem preventive care info sheet is relevant in Colorado and nine other states where Anthem operates Blue Cross Blue Shield plans, and applies to individual health insurance as well as small and large group plans.
The Anthem info sheet specifically notes that sterilization procedures for men are not included in the new contraceptive coverage – which is the conclusion I came to last week after quite a bit of reading on the subject – since all of the guidelines apply to adding contraceptive coverage to preventive care for women rather than preventive care in general. […]
[…] This is a scenario that I could see being implemented even without a monopoly by one health insurance carrier. Grand Junction aside, if we look at the whole state of Colorado, the top 70% of the health insurance market is comprised of ten carriers. I wonder if it would be possible for medical offices to set up agreements whereby they pool money received from those ten carriers and from Medicare, Medicaid, and CHP+. Then instead of paying physicians directly from the health insurer depending on the insurance coverage of each specific patient, the doctors could simply be paid either a salary or an average reimbursement for each patient, regardless of which insurance that patient had. This would require some restructuring in terms of how medical billing is done, but it would allow medical offices to continue to negotiate competitive contracts with private health insurers (and the higher the contracted rate, the more total dollars the medical practice would have to put into their payment pool).
One of the major factors that contributes to the success of the system in Grand Junction is that doctors there are ok with receiving lower total incomes than they would in other areas that don’t function the way Grand Junction does. When you pool Medicare and Medicaid payments together with private health insurance payments, the public health insurance reimbursements drag down the average payment. In order to make sure that people with public health insurance are receiving equal access to healthcare (which they currently do not, especially those with Medicaid), the per-patient average reimbursement for physicians would have to decrease, since it would mean that more lower-paying patients would be treated. The caveat that doctors would have to be willing to work for a little less money is especially true of specialists, which is where the highest incomes are. […]
[…] None of that is true however. As long as the treatment provided is a covered service on the patient’s health insurance plan, and as long as any required pre-authorization was taken care of, the health insurance carrier does not withhold payment simply because the patient acted against medical orders and checked out of the hospital. This is also true of other forms of non-compliance: for example, patients who don’t fill their prescriptions or those who resume activity too soon after surgery will generally find that their health insurance still covers their bills according to the language of the contract.
If “never events” on the patient end of the scale were cause for claims denials, I have a feeling that there would be a lot more denied claims. Health insurance carriers can and do charge higher premiums for various choices people make (like smoking, for example). But once a policy is in force, and premiums are paid on time – and assuming the application was completed honestly – the coverage is usually not dependent on the patient following doctors orders
[…] The collaboration between Cigna and CSHP will focus on improving patient outcomes, making healthcare more accessible and affordable, and improving patient satisfaction. One of the key components of the Cigna program is registered nurses working at the medical offices who will serve as care coordinators. These care coordinators will follow up with recently hospitalized patients to try to avoid preventable re-hospitalizations (costly and definitely not likely to result in a satisfied patient). They will also work with patients who have chronic illnesses to make sure the patients are filling their prescriptions, receiving needed office visits and screenings, and getting referrals to disease management programs that could help to prevent the conditions from worsening. The hands-on approach that the medical offices will be taking is likely to result in fewer re-hospitalizations and better overall compliance with medical advice.
Hopefully the program will also provide guidance for patients who aren’t filling prescriptions because they cannot afford to do so (for example, a referral to pharmaceutical company programs that provide free medications to people who can’t afford them), and help to address issues like lack of transportation or inability to fit medical office visits into inflexible work schedules. Some people truly just need a reminder to go get a screening test or refill a prescription. Others have more significant obstacles preventing them from doing so. […]
A few months ago, I wrote about the new website that the Colorado Division of Insurance has created to improve transparency in the health insurance market. I particularly liked the features of the site that allow consumers to see how the rate filing process works and track a health insurance carrier’s rate increase history. Colorado used money from a $1 million grant from HHS last year (a provision of the PPACA) to create the website, and it’s obvious that the Division of Insurance is taking the goal of transparency seriously.
I’m a bit late to this party, but I just read a news release from the Division of Insurance from back in September noting that the HHS Regional Director, Marguerite Salazar, commended the Colorado Division of Insurance for the website, calling it a “shining example of consumer-friendly and transparent information…” […]
The next open enrollment for child-only policies is almost here, so I thought it might be helpful to provide some specific details in terms of what policies are available and what parents should expect when submitting child-only applications next month.
The first open enrollment window in 2012 will be the month of January. Applications for child-only policies have to be submitted between January 1 and January 31. Application not submitted by the end of January will have to wait and re-submit in July, which is the second open-enrollment period of the year. For most carriers, each child in a family will have to have a separate application.
All eligible child-only applications submitted during the open enrollment period are guaranteed issue, so the child cannot be refused coverage. However, the applications are still medically underwritten and the rate can be increased by up to 200% based on the child’s medical history (so if the standard price is $100, the policy could actually be assigned a rate of $300, which is equal to a 200% rate increase).
Colorado Senate Bill 128 requires all Colorado health insurance carriers that offer coverage for adults to also offer child-only plans during the two annual open enrollment windows. But the bill does not require carriers to provide guaranteed issue coverage for children who are eligible for health insurance from another source (other than a high risk pool like CoverColorado or GettingUSCovered – see the bottom of page 4).
Most Colorado carriers have selected one or two plan designs that will be available for child-only applications next month. To give you an idea of what is available in Colorado for child-only coverage, we’re providing information here regarding child-only options from six of the top individual health insurance carriers in the state. […]
[…] As the cost of healthcare continues to rise, CoverColorado – just like every other insurer – needs more and more money to cover the cost of claims. Their website shows the fees that have been assessed over the past few years, and the increased fee that will go into effect next month for 2012.
Because the CoverColorado assessment is collected by health insurance carriers and passed on to CoverColorado, the fee is added to each policy’s premium every month. The end result is that we all pay a few dollars more per month than the actual cost of our policy. This can be confusing, especially if people are new to individual health insurance and haven’t had experience with paying their own health insurance premiums in the past. The amount that is going to be drafted from your bank account or billed to you will be a few dollars higher than your stated premiums because it includes the CoverColorado assessment. […]
[…]prior to reading Ungar’s article I wasn’t aware of the agreement between the Independent Physicians Association and Rocky Mountain Health Plans with regard to Medicare and Medicaid reimbursement. The doctors in the IPA were so determined to treat every patient equally that they worked out an arrangement with RMHP to have the insurance carrier accept payment directly from Medicare and Medicaid and then pool that money together with premiums collected from RMHP insureds.
[…] Hixon argues that patients with more financial responsibility for their own care do indeed make better decisions regarding efficient use of healthcare dollars. Furthermore, he cites a study that found that patients with high deductible health insurance policies (eg, HSA qualified plans) had more preventive care, lower rates of hospitalization, and were more compliant in terms of following their doctors’ recommendations. They were also more likely to question their medical bills and had overall lower medical costs than people with traditional low-deductible policies.
[…] In addition to probably being above average in terms of financial savvy, I would assume that the demographic that opts for high deductible health insurance is also probably healthier than average. It makes sense that the more health problems a person has, the more likely he’ll be to choose a lower-deductible policy, since he knows he’s likely to be using the policy at least somewhat regularly. On the other hand, a person with no health conditions at all is probably making a good gamble to select a high deductible policy, since there’s a decent chance he’ll be able to go for several years without having a major claim. So the fact that people with HDHPs have lower medical costs isn’t really surprising. It’s largely a self-selected group (employers who offer an HDHP usually offer another plan as well, and everyone shopping for individual health insurance who picks an HDHP has other options from which to choose). I’m not sure that medical costs would still be lower for people with HDHPs if they policy designs were assigned randomly across the entire population.
[…] This fee is similar to the one that is assessed to pay for CoverColorado (except that it’s a much smaller amount). Basically, carriers will collect the fee from members and then pass the money on to the Patient-Centered Outcomes Research Institute, much the way carriers pass on the CoverColorado fee. The fee will not be counted as premiums for the purpose of calculating medical loss ratio numbers, and should not be confused as being part of the premium that we pay for our health insurance.
[…] As long as we’re looking at a fragmented public/private hodge podge of long term care funding that includes Medicaid, private long term care insurance, private assets, and help from family and friends, I think it’s important that we look for ways to make things as fair as possible and also keep Medicaid financially afloat. The CLASS Act got nixed from the ACA, but the problem of funding long term care isn’t going away, and is only going to grow as the baby boomer generation ages. John’s article is a good one to read if you’re interested in possible solutions.
[…] The rep I spoke with at World Insurance said that it wasn’t clear yet which states will be in the November round of notifications, so we aren’t sure when World/American Republic policyholders in Colorado will be officially notified that their carrier is leaving the market. But I confirmed with both World Insurance and Celtic that the change is happening and that the initial stage of it will begin next month. Colorado residents who are currently covered by either World Insurance or American Republic would be wise to begin looking for other health insurance options. […]
[…] One of the comments on the post was from Dede de Percin, the Executive Director of the Colorado Consumer Health Initiative (CCHI). […] Dede’s comment on my article referenced the point I made about consumers not having to pay additional fees to have a broker. Basically, health insurance is priced the same whether you go directly through a health insurance carrier (calling Anthem Blue Cross Blue Shield directly, for example) or through a broker (who will compare options from multiple carriers for you). Dede made this point:
“While a consumer or business doesn’t not pay a health insurance broker directly, broker fees and commissions are paid by the insurance companies – and rolled into […]”
[…] These numbers are much more in line with the rise in health insurance premiums that we’ve seen over the past few years. I have no explanation for why the data from the two sources is so dramatically different in terms of medical trend in 2010, but if the trend was really closer to 7.5% rather than 1.7%, the health insurance premium increases would be a lot easier to understand. […] In addition to the MLR rules, some states (including Colorado) have implemented strict review processes for rate hikes. The ACA now calls for insurers who propose a rate hike of 10% or more […]