Understanding Drug Formularies On New Individual Health Insurance Plans In Colorado

Colorado residents only: Compare how each health insurance company covers your medication with our exclusive Colorado prescription drug formulary transparency tool. Opponents of the ACA have raised the issue of drug formularies as a negative aspect of the new ACA-compliant plans, complaining that the new plans won’t cover all of the medications people need.  Just like many of their […]

Questioning The Medicare Status Quo

R.J. Weiss made his hosting debut today with the 189th Cavalcade of Risk – be sure to check it out.  This article from David Williams gets my vote as one of the most interesting in this edition of the Cavalcade.  David writes about a small but growing number of doctors who are choosing to not […]

Exchange Subsidy Eligibility Impeded By High-Priced Group Health Insurance Access

We were talking with a client last week about her health insurance situation, and it inspired me to do a little more digging around to see how eligibility for subsidies could be impacted by the availability of employer-sponsored health insurance.  In our client’s situation, she’s a homemaker and her husband makes about $20,000 per year, working for a small business.  They also have a child, who is currently covered by Medicaid.  Her husband can get health insurance from his employer for $75/month.  But if he adds his wife, the cost goes up to $500/month.  $6,000 per year for health insurance when you earn $20,000 isn’t really a viable option.  Fortunately, as of January 2014, Medicaid will be available in Colorado to families with household incomes up to 133% of FPL (in 2013, that’s almost $26,000 for a family of three).

But let’s consider a hypothetical family that makes a little more – say $28,000/year – and has the same option for employer-sponsored health Exchange Subsidy Impeded by Access to High Priced Group Health Insuranceinsurance.  They would be above the cutoff for family Medicaid, but well below the 400% of poverty level that determines eligibility for premium assistance tax credits (subsidies) in the exchange  (400% of FPL for a family of three is a little over $78,000 in 2013).  And I think we can probably all agree that spending $6000 a year on health insurance would be a significant burden for a family that earns $28,000 a year.

We’ve all heard lots of talk about how subsidies are available in the exchanges for people who don’t have access to “affordable” employer-sponsored health insurance.  I think most of us take that to mean that for families who earn less than 400% of FPL, subsidies are available both to those without an option to purchase employer-sponsored health insurance, and for families that have the option to do so but at a prohibitively high premium.  You’ve probably also heard that the cutoff for determining whether employer-sponsored health insurance is “affordable” is 9.5% of the employee’s wages.

Unfortunately, it’s not as simple as it might sound, and the official rules might leave some families without a lot of practical options.  I discussed this scenario last week with the Colorado Coalition for the Medially Underserved (CCMU).  Gretchen Hammer is the Executive Director of CCMU, and she’s also the Board Chair of Connect for Health Colorado (the state’s exchange), so there’s a good flow of information between the two organizations.  CCMU (and Connect for Health Colorado, via CCMU) responded to my questions quickly and thoroughly, and I highly recommend both sources if you’re in Colorado and curious to see how your specific situation will be impacted as the ACA is implemented further (here’s contact info for CCMU and Connect for Health Colorado).

My concern in the case of our hypothetical family was that the employee’s contribution for his own health insurance is $75/month, which works out to only 3.2% of his income – well under the threshold for “affordable,” based on the 9.5% rule.  And as […]

The New Individual Health Insurance Application Questions

For more than a decade now, we’ve been helping our clients complete individual health insurance applications.  Before online applications were common, we would drive to our clients’ homes and help them fill out paper applications.  These days, Jay spends many hours each week on the phone with clients who have questions at some point during […]

Medicare Part D Needs Price Negotiating Power

[…] very clearly how we could save $20 billion per year if the feds could negotiate drug prices with pharmaceutical manufacturers. That’s forbidden by the language of the original legislation that created Medicare Part D (I know, it’s ridiculous, but that’s how it is), so it would require some legislation at this point to change things. Nobody in power seems to want to address this issue, probably because pharmaceutical companies make such large campaign contributions. But as I’ve pointed out several times, they also earn huge profits (far more than any health insurance company, although health insurance companies are the ones that are repeatedly targeted by the media as having excessive profits). Maybe it’s time for a change.[…]

Possible Solutions For Long Term Care Funding Problems

[…] 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 Opposite Of Transparent

[…] David also points out that the amounts allowed by his Blue Cross Blue Shield carrier don’t seem to have anything to do with the amounts billed by his physical therapies – the lowest allowed amount on his EOB was for the service that was billed with the highest price tag. We’ve also seen little rhyme or reason (that we can detect, anyway) in terms of how billed amounts and allowed amount correlate. […]

Grand Rounds – Colorado Fall Colors Edition

Henry Stern of InsureBlog brings us an interview with the whistleblower who has brought a lawsuit against LabCorp for allegedly charging a lower price to United HealthCare than to Medicare. The post is particularly interesting because Hank adds his own thoughts after the interview, and he sees things a little differently than Andrew Baker (the whistleblower). Hank agrees that it does look like LabCorp lowered their fees for UHC […]

Increased Medicare Cost Sharing Might Not Be The Best Plan

[…] The healthcare providers make recommendations, order tests, perform surgeries… and in general, the patient does what the doctor recommends. And really, isn’t that the way it probably ought to be? Most of us have not been to medical school. When something seems amiss with our health, we need to feel that we can rely on our doctors to tell us the best course of action. Increased cost-sharing tends to increase the number of people who skip healthcare in general – including very necessary care like keeping diabetes and blood pressure under control.

Healthcare Topics In The Cavalcade Of Risk

[…] Some lawmakers have proposed making people pay higher deductibles or doing away with first-dollar coverage on Medigap policies, with the idea being that if people have more of their own money on the table, they would be less likely to over-utilize non-essential healthcare. The problem, of course, is that seniors who are already struggling to pay for healthcare would be more likely to skip necessary care if they had to come up with additional money to pay for it. […]

The Challenge Of Creating Unbiased Health Insurance Exchanges

[…] In order to attract high-quality health insurance carriers to the exchanges, we have to make sure that the exchanges represent a business environment that is appealing to carriers. We also have to make their appealing and fair to consumers, in order to attract enough people into the exchanges. To work well, the exchanges will need to have a delicate balance between the interests of consumers, providers, and health insurer carriers, with no one group more heavily favored than another.

Tips For Sorting Through Medigap Advertising

[…] I would add that the advertising tactics Trudy mentions also apply to regular health insurance plans too – not just those related to Medicare. Unfortunately, health insurance advertising can sometimes get a bit murky. If in doubt, always ask for more details or get a second opinion… and as with most things, if it sounds too good to be true, it probably is (there’s no such thing as comprehensive individual health insurance for $150/month for a family of four with no deductible and all pre-existing conditions covered).

Grand Rounds Vol. 7 No. 40

Welcome to Grand Rounds! It’s the third time we’ve hosted Grand Rounds at the Colorado Health Insurance Insider and we’re honored to be hosting again. It was a pleasure to read so many great articles for this edition. Since our blog tends to focus on health care policy and reform, I’m starting things off with the posts that pertain to that topic. Enjoy!

Aetna Purchasing Genworth’s Medigap Business

The first of the Baby Boomers turn 65 this year, and health insurance carriers are paying attention. Aetna has agreed to purchase Genworth’s Medicare supplement business for $290 million. Going forward, Aetna expects to post yearly gains from the Medicare supplement (also known as Medigap) business. This makes sense given that the Baby Boomers will be flooding into the Medicare (and Medicare supplement) system over the next two decades. […]

Retiree Health Insurance Benefits Based On Age Makes Sense

Last week, the Equal Employment Opportunity Commission agreed that employers have the right to reduce or eliminate medical benefits for retirees who reach age 65 and become eligible for federally funded Medicare. This ruling has been met with both support and criticism from several sides. It includes a specific provision that exempts employers from age […]