Category Archives: Exchanges

Lost in the Marketplace: Thoughts on the ACA Exchange

Like many of you, I have been unable to apply for an insurance policy on the Marketplace that opened October 1.  That was also the start of “open enrollment” at my work, and I was hoping to see if there was a cheaper option for my family available with similar coverage, even though I would not qualify for a subsidy.  I also wanted to be able to give you more detail about the process and possible pitfalls by trying it myself, since I didn’t have time to train as a navigator.  My window of choice closed for a year, and I gave up trying to log in to stay out of the way of those still trying. 


Twice, I got a user name and password and was sent an email to complete the registration process.  Although I clicked the email link as quickly as my fingers would go, within 10 seconds of receiving it and 30 seconds of completing the password entry, the site said I was too slow—sorry, go back to the beginning and try again.  Perhaps I would have had to grow up with video games to get the required hand-eye coordination speed? Maybe it was a subtle way to get younger, healthy and well-coordinated sign-ups first?


It is possible to look at the available plans for a given county without registering—in my county, for an individual/ family policy, I would have a choice of BCBS or Humana.  There is no link within the site to provide nitty-gritty details though.  To get those on your own, you have to apply.


I’m going to recommend you work with a navigator unless you are very well versed in health insurance policies.  Be very careful of fraud and check the credentials of whoever you are working with.  Here are some factors to consider.  Remember that the 60% cost coverage on bronze policies and 70% for silver does NOT mean it will work out that way for you personally.  All that means is that for a “typical” subscriber, the insurance will pay 60 or 70% of the total covered services after the premium.  From what I am hearing, the costs to subscribers will be front loaded in the form of significant deductibles that must be paid before the insurance kicks in.  I would advise not selecting a deductible of an amount you don’t have already in savings.


If you don’t have insurance now, you may be getting some services from a free clinic, discounted/sliding scale service from a physician or clinic, and/or free medications from a Patient Assistance Program.  I know none of these safety net services is ideal and that people with insurance generally have more options than you have right now.  However, you need to know that once you have insurance, these options will no longer be a plan B for you.  You can’t go to the free clinic on a day when you don’t have your co-pay or co-insurance money unless you are going to lie, because the ones I know of only accept uninsured patients. Your doctor or clinic may not be able waive a part of your co-pay or deductible—that is considered criminal fraud in some cases, against their contracts with the insurer.  Every policy I’ve ever had says, in fine print within the manual, that my policy can be cancelled for breaking the contract if I don’t pay my share through co-pays and deductibles.  So you want to check and see if that is in a policy you are considering.


Medication co-pays can add up quickly.  If you are getting 4-5 medications through free Patient Assistance Programs, even if they aren’t the most effective ones for your condition—will you have the funds to buy them? Depending on the co-pay tier, you could be shelling out $150 or more a month. If it is possible to view the formularies for the plans you are considering, and find out the co-pays for your medications, I would recommend it.  You need to know that insurers can change their formularies without your permission and without warning.  If you aren’t in an open enrollment period when that happens, you’ll be stuck with it for awhile.


If possible, it would be good to look at the provider networks for each plan, for both primary care and specialists you need, and see if they are taking new patients.  Be careful to note if there are restrictions on laboratories and radiology facilities you can use—I have learned there are a couple of new plans that will restrict lab services to only one company, Quest.  You don’t want to go to a non-contract lab for blood work and find out later the bill is fully on you.  If you see mental health providers, check to see if there is a carve-out policy that delegates management to a sub-insurer.  I’ve been told by a navigator this is not an issue with the plans in our county.  These can be a significant barrier to care, in my experience.  Even without a carve-out, check the mental health provider network and ask if your primary care provider can be included—a critical feature to allow initiation of treatment while you are waiting for a mental health referral.


If you are uninsured and have significant chronic conditions already being managed through charity services, you may find out that you can’t afford to switch to insurance even with the subsidy and even considering the tax penalty.  Being uninsured is frightening, because the gaps in charity coverage are tremendous and you never know if you will acquire a new condition and be left without help.  At the same time, you do not want to be left unable to purchase ongoing treatment you already know you need.  You don’t want an insurance card you can’t afford to use.  I have seen this happen many times, in person, to families who had insurance and too much income for their children to get Medicaid or AllKids but not enough to pay for services or prescriptions.  It is a difficult decision—don’t make it lightly.


If you have no chronic conditions, you may decide it is worth the risk to sign up for insurance.  That’s the function of insurance, as you know—it is a risk pool, where we enter not knowing who will need to use the funds we add to the pot.  We don’t expect to each get back the amount of services we have paid for with our premiums—we don’t even want to, because that would require illness or injury.  The more healthy people who sign up and contribute, the lower the cost for everyone in the pool, and the more total profit for the insurers.  You could be helping other people in your state more than yourself, or they could wind up helping you. 


One thing is for sure—we are all, through the forced wealth transfer in the ACA, helping to line the pockets of private insurers and strengthen their position at the lobbying table.  We are taking a large step away from single payer, a public option and even community level grassroots safety nets by doing so.  Ought we to use much time and energy to prop up a plan with such fatal flaws at the core? 


Filed under Exchanges, Healthcare reform

Cruelty or Care? The Choice is Yours

Well.  From the beginning, I have been telling you all that the so called “Patient Protection and Affordable Care Act” is neither protective nor affordable to patients.  We can keep the same PPACA abbreviation and call it what it is:  The Profiteering Protection and Affordable Cruelty Act.  Although I read the whole darn thing, I lack a background in law or politics.  As the specific corporate protections emerge from this convoluted mess, I have to say I didn’t foresee some of them.  I knew it would be bad, just not all the details of said badness.


The latest in our story of woe?  Insurers and some employers have discovered an irresistible loophole that allows skimpy policies covering only a few outpatient services.  The key phrase is “minimal essential coverage”, previously defined in federal law under the IRS Act of 1986.  I noticed some folks had conflated that term with “essential health benefits”, but EHB are mandated items on state Exchange policies starting in 2014.  No plan will be allowed to put lifetime or annual dollar limits on coverage, but outside of the Exchanges, other details of minimal essential coverage are minimally described.


I think I was fooled by the ACA’s opening paragraphs allowing insurers to temporarily restrict annual limits on essential health benefits until 2014.  I missed the absence of any requirement to offer those benefits at all, at any date, except on the Exchanges.  Insurer can’t restrict annual dollar amounts of those benefits if they are offered.  In a stunning twist on catastrophic coverage, it is possible for insurers to cover only the required preventive services and omit the catastrophes.  You can get your colonoscopy “free” if you have a non-grandfathered plan, but any follow-up surgery is entirely on you.     


The most minor effect is that employers who offer bare-bones policies and employees who get them are exempt from the ACA penalties.  I see some reference to this loophole only applying to large employers, but I don’t know how that was determined.  I don’t see it in the IRS code that I found, which includes as minimal essential coverage “B) any other plan or coverage offered in the small or large group market within a State.”—it may be elsewhere.  It seems to me it would apply to any size group policy offered outside of the Exchanges. If one of you can find me the relevant law making this only applicable to large employers, I’d be grateful.


The worst effect is that employees who have minimal essential coverage are not eligible for premium subsidies on the Exchanges, as far as I can tell.  This also seems to be the IRS’s interpretation: “A month is not a coverage month for an individual, and thus no premium tax credit is allowable for the individual’s coverage, if the individual is eligible for minimum essential coverage other than coverage offered in the individual market for that month.” If you can show me in the law itself or in administrative policy how it can be read otherwise, please post a link.  Maybe the IRS can do some creative adjusting.  Generally their creativity seems to apply only to corporations.


How many employers will use these plans to avoid penalties and thus apply this affordable cruelty to their employees in the process?  You know it will start with those who already pay poor wages.  As healthcare costs rise, don’t be surprised if you get this offer you can’t refuse in your own benefits package.   


Do I have grounds to put the word “cruelty” in place of “care” in the ACA?  The law is no longer new.  It is now part of our healthcare system.  I don’t know what else to call a system that not only allows but entrenches the abuses I see in my office.  Children who desperately need skilled child psychiatrists but whose insurance does not have a single child psychiatrist, skilled or unskilled, on the panel.  Children who don’t get the care they need because their parents delay over co-pays and deductibles.  Parents who work long, hard hours at low pay, producing goods and services we use without gratitude or notice, whose “non-emergency” pain goes untreated because of money.   Who try to smile at me in front of their kids, as if it doesn’t hurt, but cry when I take them in another room.  I refuse to make excuses for this awfulness or play around with euphemisms.  Cruelty, brutality, callousness—many words apply, and none of them is “care.”


I can hear the defensive talk already, from people who won’t be able to believe their beloved party would intentionally expose us to this treatment.  It was an oversight, right?  The law is complicated.  We missed this problem, and they did too.  We have a bumbling, well-meaning but hapless government, like a dog that’s so ugly it’s almost cute.  Don’t buy it.  Somebody had better ask what the President and insurers knew and when they knew it.  Remember the industry was mighty cozy with our Executive Branch during construction of the law.  Is it just now that this minimalist option has been discovered?  Or is this a convenient time for discovery, well into the second term?  Will we allow the President to wash his hands of the disaster and pretend he never imagined anyone would behave so?


What will it be, folks?  Do you want to keep trying to pass legislation to close loopholes, even though the insurers are always one step ahead?  How long will you continue to support and vote for people who cater to them?  When will you finally say “don’t let the door hit your butt on the way out”—and insist on real insurance and real representation?


Improved, expanded Medicare for All is a simple, achievable, affordable, practical next step.  It doesn’t require revolution, utopia or socialism.  Even conservatives can embrace it.  We have the structure in place.  We are only waiting for you.  Will you speak up?


Filed under citizen responsibility, Exchanges, Healthcare reform

A Surprise Move on Alabama’s Health Insurance Exchange

I learned yesterday that Governor Bentley has decided to throw the job of choosing an Essential Health Benefits package back at the feds.  Very interesting choice and I’m still scratching my head—all I can do is speculate on his motives, but I’ll tell you a couple of possible scenarios.  If you have other ideas, please share.


In his letter, Dr. Bentley does make some good points—there was a link in the Montgomery Advertiser to the actual letter yesterday, which has now been taken down.  I can’t find it elsewhere, but if one of you does, please post the link.  He wrote about the lack of guidance from HHS and their failure to fulfill their responsibilities, and then complains about Health Savings Accounts not being included as an option.  I believe he is wrong to praise Health Savings Accounts, since cost-sharing at the point of service is  an ineffective means of improving healthcare utilization (people do reduce spending but in equal measure on necessary and unnecessary care).  I completely agree with him about HHS abdicating responsibility.


The ACA states that HHS is to make a determination on the items included as Essential Health Benefits (EHB).  EHB are services insurers were supposed to cover without lifetime limits way back in 2010 on non-grandfathered plans, even though they have still not been officially selected by HHS yet.  They will be mandatory on the Exchanges in 2014—Exchanges will offer insurance policies on the state market outside of the typical employer and individual plans, also still in the mix.  Some of the Exchange policies will have government subsidies and out of pocket caps for lower income families above the Medicaid Expansion cutoff (but no subsidies if a family is actually poor, one reason we need the Expansion to happen).  As I’ve discussed previously, the subsidies and out of pocket caps will likely be insufficient to provide adequate coverage, and families may have cards they can’t afford to use—but we at least need to establish the best coverage possible at the beginning.


Even though the ACA did say EHB must reflect “typical” employer-based coverage currently offered, it didn’t specify how HHS was to determine “typical”.  There was some uproar in 2011 when the Institute of Medicine advised the selection of a small group plan instead of a typical large employer plan, since the small group plans tend to be skimpier.  HHS finally settled on punting the decision to states (recall our recent Constitutional Amendment for definition of punting).  States were supposed to select from one of four typical plans to determine the EHB included in our Exchanges.  If you live in a state where one or more of those plans has poor coverage, you could get stuck with poor choices on your Exchange.


Here is the “guidance” from HHS provided to states in 2011, and some interesting commentary.  It’s worth a close read.  The sticking point seems to be that although 10 broad categories of services are supposed to be included, there is a wide variety of ways to apply coverage.  This is particularly true for something called “habilitative” services, which apparently has no consistent definition and was not defined in the ACA itself—these are therapies designed to preserve function or gain function that a person never had initially, rather than recover lost function.  If you have a leg injury that can be overcome with physical therapy, for instance, a plan covering rehabilitative services would help you.  On the other hand, some insurers refuse to cover therapy for maintenance or development of function—for example, with cerebral palsy.   


HHS could have gone a much better route, by selecting coverage from typical large group plans in the country and telling states this is it—this is your EHB, deal with it.  No Congress to fight over the decision, so this can’t be blamed on partisanship.  President Obama, in fact, could have picked up the phone and said do it right.  Instead, a condition like cerebral palsy (which doesn’t actually change upon crossing state lines, go figure) will be potentially eligible for very different levels of service across the nation.  If the purpose of the Exchanges is to make sure people have access to real insurance, not just a card for show, the coverage needs to be meaningful.


You may recall that we had a comment period for our state’s selection process this summer, with very short notice and no press coverage I saw except on Left in Alabama.  Although the general public wasn’t actively encouraged to join in discussion, I know at least one advocacy group was invited to give a recommendation.  We recommended the most comprehensive coverage in the options, the FEHBP plan.  If you look at the comparison chart here, you will see that we had no options where all items were well-covered.  Maybe you think that’s no big deal, but if you or your family happens to come down with a disorder where the treatment or testing involves a non-covered service, you might feel differently.


If a state doesn’t choose, HHS has said that state’s EHB benchmark will be the largest small group policy sold in the state.  That’s the first column in our chart—not the skimpiest, but not the most comprehensive either. 


HHS can change their policy within the loose ACA language, without partisan agreement.  They are already late in choosing EHB, so it isn’t too late to speak your mind to HHS and our President.  Go back, folks, and do your job—set a meaningful, comprehensive EHB package.


Now, why did Governor Bentley take a stand?  I don’t know for sure, but I have a couple of guesses.  First, I don’t know what other advocacy and special interest groups recommended to the Insurance Commissioner for our benchmark plan.   If there was too much conflict between certain influential groups, it might have put Bentley in a political quandary.


Another possibility, maybe more likely—most groups could have selected the more comprehensive choice but interested insurers are pushing the less comprehensive options.  They want to be free to offer poor choices on the Exchange and rake in those federal subsidies without providing good insurance.  Even though plans are not supposed to exclude groups of patients by limiting coverage options, a minimalist EHB permits some sneaky cherry-picking.  Allowing the default to kick in (by appearing to hand the ball back to HHS) is probably the most politically savvy way for our Governor to satisfy the insurance lobby without appearing to do so.  A third possibility—and there could be a mixture of motives—is that the refusal of HHS to provide more specific guidance on items like habilitative services is making it impossible for states to be certain the EHB they choose will pass muster.  I’m not buying the rhetoric about Health Savings Accounts as his primary objection.


Here’s a chance for citizens to speak up.  Push HHS and Obama harder—don’t abandon Alabama to the greedy insurers and state policymakers who can’t or won’t stand up to them.  Our healthcare should not be controlled by political maneuvering.  The best choice—Medicare for All.  In the meantime, being stuck for now with the ACA, the least we can ask is decent coverage for money we will be forced to pay, specified at the federal level.  There is no reason coverage in one state, subsidized by federal money, should be inferior to that in another.  This is not a battle between Republicans and Democrats—it is a battle between citizens and big money, and big money is going to win unless we work harder. 

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Filed under Exchanges, Healthcare reform

Speak Up Now—Comment on Essential Health Benefits due Friday July 6

I just found out about this yesterday—I’m not sure when it got posted.  The Alabama Department of Insurance is in the process of deciding which package of Essential Health Benefits will be required for the insurers that participate in Alabama’s Exchange.  On their website, they are requesting public comments, but the deadline is in 3 days.  I only found out because one of the organizations I belong to was asked to provide feedback—and I’ve searched the Internet including without finding any press mention of this opportunity.  Could it be they don’t really want to hear from you? 

So if you want to weigh in, do it quickly!  Quick review on Essential Health Benefits (EHB)—these will be the covered items insurers are required to include in order to be allowed into the Exchange.  States are supposed to choose a benchmark package from 4 types of plans already in place in that state.  It isn’t the insurance product itself that will be on the exchange, just what will have to be covered.  Here’s a chart with the plans that meet requirements in Alabama, along with comparisons of benefits.  Whatever is noted as required in the federal rules will have to be added to the EHB package, whether it is in the benchmark plan chosen or not.  States can add extra to the benchmark EHB they pick, but they can’t subtract. 

Just by scanning quickly, you can see that some plans cover more than others.  Pay attention to the “prior authorization required”, because these are tricky to use sometimes.  I don’t know why some of them don’t cover local anesthetic (like getting lidocaine before having stitches, or trigger point injections).  Guess they don’t like people who get trigger point pain.  Which services look best for you and your family and which do you expect to need in the next few years?  Will you have trigger points?  Will you need genetic testing?  Yep, just like with Medicare Part D, you need ESP.  That’s part of your personal responsibility, after all.  I have a few patients with the plan that has the most checkmarks, the FEHBP column, and it seems pretty decent.  That’s my guess as the best pick. 

Most likely Alabama will be pressured by insurers to pick the skimpiest version possible.  The number of items included in the EHB does not appear to affect the premium (unless I’ve misread that section of ACA, entirely possible), so they can cover a smaller range of services. 

If you think this doesn’t apply to you because you already have employer group insurance, think again—some analysts expect there will be a significant percentage of companies who will drop group insurance, because the penalty is cheaper than the premium.  This could have a domino effect.  So it is probably worth your time to think about what you want covered.

 Why are the services covered important, if out of pocket costs are now limited and the insurer can’t turn you away based on medical history?  Because if your condition is best treated by a service they don’t cover, it DOES NOT APPLY to your out of pocket maximum.  That amount is all on you, and it is in addition to whatever you have to pay for premiums and cost-sharing (deductibles and co-pays).

The out of pocket costs, even with the maximum, are pretty substantial in some cases.  The Kaiser calculator is interesting—play around with it some.  There are complaints it may far underestimate the predicted premium costs because of medical inflation, so take it as a low-end estimate.  If you qualify for the subsidy, you don’t get the money beforehand—you have to either file for it the next year on your taxes or ask for it to be paid in advance straight to the insurer, based on what you predict your income will be.  If you are wrong and get too much subsidy, you will have to pay some or all of it back as a lump sum, depending on your income.  There are concerns that the planned methods to estimate subsidies are not going to be very accurate.  One dollar too much in income can boot you from being subsidized to suddenly owing thousands of dollars.

Even if you do it correctly, try the calculator as a 40 year old heading a family of 4, making 40K a year, in a medium cost area.  You will only have to pay about $1900 of the premium yourself, if you use advance assignment of your subsidy to the insurer—you can only do this if you buy the “silver” plan of 70% actuarial value, meaning the plan would pay on average 70% of a standard population’s total cost (so does not mean it will cover 70% of your personal cost).  You can get a lower premium for the “bronze” plan (60% actuarial) but then no subsidy.  Want gold (80%) or platinum (90%)?  Tough luck for you, unless you can buy out of pocket, in which case you are a 1% member and I need to ask you for a donation to my favorite charity.

After that $1900, you’ll be on the hook for a max of $4100 out of pocket more, for a total of about 6K.  If you are making 40K and caring for a family of 4, do you have 6K a year for medical costs?  That’s over 10% of your salary, meeting the usual definition for underinsurance.  With what you have left, you are almost poor enough for Medicaid, meaning SOL in Alabama.

That’s why the EHB package really matters, because if you have to buy another $2000 or so of non-covered services, you aren’t going to be able to pay for the rent or groceries or something essential to life.

If you are a 50 year old, in a family of 4 with total family income of 100K in a medium cost area, your premium would be around 16.8K in 2014, no subsidy available, with additional out of pocket cost of 12.5 K maximum.  That’s about 29K you might be out for covered medical costs, almost a third of your pretax income—so you don’t want much to be uncovered.  There goes the college fund. 

If your insurance would cost more than 8% of your income—true for most of us including me— you don’t have to pay a tax or penalty or whatever the Court would like to call it, for not getting insurance.   You can wait until you get sick and buy the policy, but you’ll still have to shell out then.

 Numbers making your head spin?  Have a champagne hangover from last week?  We could eliminate all this number crunching and guesswork quickly.  Put the heat on for HR 676, Medicare for All.  Prepay through taxes at far less than your current premium—it’s Constitutional.  Then go to the doctor without your credit cards, to get the care you need.  Forget about the Medicaid Expansion and the state’s General Fund shortfall, who will do AllKids, the subsidy estimates, and insurers tricking you out of your money.   Medicare for All:  everybody in, nobody out.


Filed under Exchanges, Healthcare reform