Monthly Archive: April 2014

California bill would bar higher out-of-network cost sharing when timely in-network care unavailable

Pending California legislation would bar health plans and insurers from imposing higher out of pocket costs for out of network services in instances where a plan or insurer is unable to ensure timely access to a medically necessary, covered service by a contracted provider.

Under existing law, California managed health care service plans are required to provide members timely access to providers. AB 2533 would require the California Department of Insurance to develop similar rules for insurance plans it regulates including waiting time for doctor appointments.

The proposed legislation comes amid reports of individuals in plans purchased through the state’s health benefit exchange marketplace, Covered California, being turned away by providers they believed were included in their plans. (Additional background here)

The measure passed its first policy committee this week in the state Assembly. Click here for the text of AB 2533 as amended April 22, 2014.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Looking at Costs and Risks, Many Skip Health Insurance – NYTimes.com

Looking at Costs and Risks, Many Skip Health Insurance – NYTimes.com.

The Patient Protection and Affordable Care Act’s reforms of the individual health insurance market — a mix of carrots and sticks aimed at restoring the market to functionality — may fall short for many who will remain medically uninsured for various reasons.

For self-employeds, The New York Times piece shows the calculation on whether to participate is sharply focused on the present state of their health and finances. It also identifies what might be termed “older invincibles” — middle aged people in good health who don’t believe they will have a major illness or injury that will make buying coverage worth the cost, which rises with age. For some, that even includes factoring in advance premium tax credit subsidies.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Achieving single, integrated marketplace for individual, Medicaid health plans faces initial difficulties

Section 1413(c)(1) of the Patient Protection and Affordable Care Act requires each state to “develop for all applicable State health subsidy programs a secure, electronic interface allowing an exchange of data …that allows a determination of eligibility for all such programs based on a single application.” That means state health benefit exchanges must operate as integrated marketplaces offering both commercial insurance plans (referred to as Qualified Health Plans or QHPs) as well as Medicaid coverage for those whose household incomes meet their state’s Medicaid eligibility guidelines. The policy rationale – known as “no wrong door” and “one touch and you’re done” – is to reduce the ranks of the medically uninsured by simplifying the process of getting health coverage and removing roadblocks to enrollment.

Implementing that Affordable Care Act mandate, however, has been challenging from IT integration standpoint given the variety of legacy state computer systems that manage their Medicaid programs and state rules governing them, including those of the three dozen states using the federal marketplace, healthcare.gov.

That’s also been the case in California, where enrollment elegance has proven elusive. “I think we’ve oversold simplicity,” said Frank J. Mecca, executive director of the County Welfare Directors Association of California. Mecca made that observation today at a California Healthcare Foundation (CHCF) briefing in Sacramento on early consumer experiences with enrollment in the Golden State’s exchange, Covered California.

Mecca described the IT interface between the California Healthcare Eligibility, Enrollment and Retention System (CALHEERS) and the IT system that manages Medicaid eligibility and enrollment, the Statewide Automated Welfare System (SAWS) as a “clogged highway.” Consequently, Mecca noted, a large backlog of potential Medicaid enrollees remain stuck in the system. Mecca credited Covered California and the California Department of Health Care Services (DHCS), the state’s Medicaid administrator, for their efforts to remedy the backlog and improve the interface between the two IT systems. “It’s not an easy thing to fix,” Mecca added. “Things have improved tremendously, but we still have a long way to go.”

Both Mecca and another panelist at the briefing, Sonya Vasquez, policy director of the community-based health advocacy and policy organization, Community Health, said greater emphasis should be placed on marketing both Covered California QHPs as well as Medi-Cal, the state’s Medicaid program, particularly given Medi-Cal does not have set enrollment periods. They also said more effort should be made to make consumers aware in-person assistance is available for those seeking to enroll in coverage, including welfare department staff who can sign up applicants for either Covered California QHPs or Medi-Cal. (California is among those states have expanded Medicaid eligibility to 138 percent of federal poverty guidelines).

Consumers participating in focus groups conducted in early 2014 by PerryUndem Research/Communication were mostly uninsured and had substantial knowledge gaps for both Medi-Cal and QHP coverage and advance tax credit subsidies for the latter for households with incomes between 138 and 400 percent of federal poverty. (Click here for the full report on the findings presented at today’s CHCF briefing.)

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Double digit individual plan premium hikes seen for 2015

A senior executive of WellPoint predicts plan year 2015 premiums in the individual market could go up by double digits in some areas of the United States.

Larry Levitt, senior vice president at the Kaiser Family Foundation, predicts 2015 premiums could rise by 10 percent, based on a  5 to 6 percent medical services cost trend plus the effect of a reduction in payments to plan issuers under the Patient Protection and Affordable Care Act’s Premium Stabilization Programs to $6 billion in 2015.

via Will Premium Spikes Cause Another Round of Obamacare Bashing? – NationalJournal.com.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Healthcare Town Hall » Insurers adjust to paradigm shift

Milliman’s Tom Snook

via Healthcare Town Hall » Insurers adjust to paradigm shift.

Milliman’s analysis suggests the key to keeping the individual market actuarially viable isn’t only about getting enough so-called young invincibles into individual market state risk pools. It’s also about bringing in older people in good health — and keeping them healthy.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Short, long term changes could bode well for small group market

The small employer group market will be changing over the short and long term. Both changes could bolster the market segment as well as the Small Employer Health Options Program (SHOP) within the state health benefit exchange marketplace, which is seen by some as facing competition from the individual plan exchange marketplace.

Over the immediate short term, small group plans will be able to be sold with higher deductible limits under legislation signed last week by President Barack Obama. Section 213 of H.R. 4302 repeals a provision of the Patient Protection and Affordable Care Act at Section 1302(c)(2) limiting small group plan deductibles to $2,000 for individuals and $4,000 for families. The repeal is effective April 1, 2014 and is available to all plan year 2014 small group plans. The deductible limits presented a challenge to health plan issuers wishing to offer small group plans with bronze metal tier actuarial value that on average pay 60 percent of covered medical services.

The Employers Council on Flexible Compensation (ECFC), which said it joined forces with several other organizations to successfully lobby for the repeal of the provision, said the repeal of the limit will allow small employers to continue to provide affordable medical insurance to their employees, including flexible compensation options such as FSAs, HRAs, and HSAs while enabling employees to set aside tax advantaged dollars to help pay for their health care out-of-pocket and deductible expenses. Click here for the ECFC’s news release.

Over the longer term, the small group market will in all states be uniformly defined as plans sold to employers with up to 100 employees beginning with plan year 2016. For plan years 2014 and 2015, Section 1304(b)(3) of the Affordable Care Act gives states the option to define their small group market as plans sold to employers of 50 or fewer employees.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Primary care medicine on retainer may offer better value than richer insurance plans

Check out this article on the trend of having a primary care physician on retainer published in the current issue of Sacramento-based Comstock’s Magazine. For people who need to consult a doctor frequently when they need to (such as parents of young children, those with complex, chronic conditions, and individuals making a major health-related lifestyle change), combining this arrangement with a high deductible insurance plan could be a better value than an all-inclusive plan that factors frequent doctor visits into premium rates. Such as, for example, individual health plans rated “gold” or “platinum” that have lower cost sharing for frequent users of medical services but come with the tradeoff of higher premiums.

There is a concerning aspect to the trend as author Jeff Wilser points out in his piece. Primary care physicians who work on a retainer basis manage to get more time to devote to patients (great for those types of aforementioned patients who need more time and attention) by substantially reducing the size of their patient panels. That’s counter to the projected growth in demand for primary care doctors due to insurance market reforms of the Patient Protection and Affordable Care Act — at the same time there are fewer primary care docs providing services due to economic incentives to specialize and growing retirements.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

Analysis: First year enrollment churn could be nearly half of QHP enrollees, quarter of Medicaid beneficiaries

In health insurance, “churn” refers to people moving between various forms of coverage as their life and economic circumstances change. Those in employer-sponsored plans who are dismissed or leave their jobs move into the individual market, COBRA, Medicaid or go uninsured. Those on Medicaid can earn off eligibility if their household income rises above their state’s cut off point. People move back to employer-sponsored coverage when they or their partners are employed by an entity that offers health coverage either on its own or as required starting next year in the case of large employers.

As well as these forms of coverage, the Patient Protection and Affordable Care Act adds a new category this year: those eligible for advance tax credit-subsidized coverage in the state health benefit exchange marketplace. Like Medicaid, eligibility for this form of coverage is means tested and can change as household income rises above 400 percent or falls below 138 percent of federal poverty.

An analysis of the nation’s largest state health benefit exchange marketplace, Covered California, finds churn over a 12 month period could amount to nearly half of those enrolled in subsidized qualified health plans (QHPs) and a quarter of those enrolled in Med-Cal, California’s Medicaid program. Click here for the report by the UC Berkeley Center for Labor Research and Education.

The churn among QHPs has implications for the exchange marketplace insofar as exchanges are financially reliant on health plan issuer participation fees assessed on QHP premiums starting in 2015 when federal establishment grant funding will no longer be available. In that vein, the report concludes Covered California (and by implication other state-based exchanges) must devote ongoing attention to enrollment throughout the year outside of open enrollment periods including outreach, web portal, in-person and call-center assistance.

 


Need a speaker or webinar presenter on the Affordable Care Act and the outlook for health care reform? Contact Pilot Healthcare Strategies Principal Fred Pilot by email fpilot@pilothealthstrategies.com or call 530-295-1473. 

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