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Tuesday, February 18, 2014

Health Care Reform Articles - February 18, 2014

Tips For New Obamacare Coverage: Stay In Network, Avoid Out-Of-Pocket Costs

TOPICS: HEALTH COSTS, INSURANCE, MARKETPLACE
By JAY HANCOCK
KHN Staff Writer
FEB 17, 2014

Congratulations. You bought insurance through one of the online Affordable Care Act exchanges, possibly after days or weeks of trying to get the site to work.
Don't relax. Joining the plan is only the first challenge. Now you have to understand it.
Policies sold through the online portals -- to more than 3 million people so far -- cover essential benefits and put a cap on your out-of-pocket medical costs.
But you need to follow the rules. And the boilerplate explanation you got from the insurance company may be hard to understand.
What do members need to know about these plans that they probably don’t?
Carry your membership card everywhere.
Make copies. It'll save huge amounts of hassle if you have an unexpected doctor or hospital visit.
Understand your plan's doctor and hospital network.
Insurance companies negotiate participation and payment rates with a network of providers to control costs.
"A lot of these exchange plans, in order to stay affordable, have much smaller networks than people are used to," says Nancy Metcalf, a senior editor for Consumer Reports. For many new members, "just because their friend has a plan and can go to a particular hospital doesn't mean that they necessarily can."
You can check a plan's directory -- either online or often part of the documents you receive when you enroll -- to find out if specific physicians are part of your network. You can call doctors' offices to confirm, too.
Stay in the network!
The health law says that, once you join a qualified plan, you won't pay more out of pocket per year than $6,350 for an individual and $12,700 for a family.
But this applies only to in-network care. Whether you’re in an HMO that pays almost no out-of-network benefits or a PPO that covers some, the pocketbook protections don't apply if you use a non-network doc or hospital.
Non-network providers also frequently bill you far more than what they charge patients in theirnetworks for the same procedure.
Try to stay in-network even if it's for emergency care.
Insurance plans do have to pay for non-network emergency visits under the health law. If you're in a car crash far from home you can’t be picky about which hospital saves your life.
But non-network hospitals often "balance-bill" the difference between what your plan pays and what they charge, which is often much more.
Avoid all emergency rooms unless it's really an emergency.
Traditionally, health plans came with a modest copayment for an emergency visit -- maybe $150.
But many policies sold under the health law, even those in the more expensive "gold" category, not only have ER copays of several hundred dollars but also subject ER charges to the overall deductible. (Copays are flat fees for specific services. Deductibles are what you pay out of pocket before the insurance kicks in.)
That means you could be billed for the full cost of an emergency visit -- up to the out-of-pocket limit.
"This is a huge difference and will really hurt the unsuspecting person," says John Jaggi, an Illinois insurance broker. "We're putting a lot more people into that exposure here."
Broken leg? Head to the hospital. Sprained ankle? Maybe wait until the urgent care center or doctor's office opens.
Pay monthly premiums on time and accurately.
"Do not mess around. Pay your premium," admonishes Karen Pollitz, a consumer specialist at the Kaiser Family Foundation. (KHN is an editorially independent project of the foundation.) "Otherwise that will be the end of you and you won’t get to sign up again until the next open season."
(Open enrollment for 2014 coverage ends March 31. Open enrollment for 2015 begins Nov. 15.)
Even underpaying the premium by a few cents could give the insurance company grounds to kick you off, she said. Insurers allow a brief grace period if you get behind -- somewhat longer if you're receiving premium subsidies -- but they will terminate coverage for nonpayment.
Register online with your new insurance company.
Insurance sites are good for tracking claims. Increasingly they also let you shop around for the best deals on non-emergency treatment.
"Your health plan might pay one imaging center half what it pays another imaging center," Metcalf said. "That's really important if you've got a big deductible."
Save paperwork. Make sure you really owe what doctors and hospitals bill you for.
"Now is a good time to become a pack rat," says Pollitz. "If you’ve got any concern, it really is worth it to make a call and get them to explain what they did."
If you don't get satisfaction from providers or insurers, try regulators.
Check the insurer's explanation of benefits detailing your claims. It may show a phone number for a consumer assistance program in your state to help deal with medical coverage.
Here is a list of consumer assistance programs. This list has contact information for state insurance departments and other regulators. 
Do read the plan's summary of benefits and coverage.
"Get it and print it out, because that has the details of your plan," says Metcalf. "How it works. What do you have to pay in order to go to a primary care doctor? Is it before or after the deductible?
"How big is your deductible? How much does it cost to go to the emergency room?"
It's not like reading John Grisham. But the subjects -- your health and your money -- are really important.

The 10 Least Expensive Health Insurance Markets In The U.S.

TOPICS: HEALTH COSTS
By JORDAN RAU
KHN Staff Writer
FEB 13, 2014
People in much of Minnesota, northwestern Pennsylvania and Tucson, Ariz., are getting the best bargains from the health care law’s new insurance marketplaces: premiums half the price or less than what insurers in the country’s most expensive places are charging.
The 10 regions with the lowest premiums in the nation also include Salt Lake City, all of Hawaii and eastern Tennessee. This ranking is based on the lowest cost of a “silver” plan, the mid-range plan most consumers are choosing.
The cheapest cost regions tend to have robust competition between hospitals and doctors, allowing insurers to wangle lower rates. Many doctors work on salary in these regions rather than being paid by procedure, weakening the financial incentive to perform more procedures. 
Health systems focus on organizing patient care rather than let specialists work detached from each other.
The lowest monthly silver premium in the country is offered in the Minneapolis-St. Paul region, where a 40-year-old will pay $154 a month for a PreferredOne plan. Just across the Wisconsin border, that same level plan -- but with a different insurer and other doctors and hospitals -- costs nearly three times as much.
Insurers were able to negotiate low rates with hospitals and doctors in the Twin Cities because they could choose among four major health care systems. Both Fairview Health Services, which runs the University of Minnesota Medical Center and is included in the lowest plan’s network, and Allina Health, the largest system in the Twin Cities and operator of Abbott Northwestern Hospital, have been in the vanguard of experimenting with more efficient ways to care for patients, such as accountable care organizations and putting doctors on salary, said Stephen Parente, a health economist at the University of Minnesota.
“Minnesota has had years if not decades of experience with managed care,” he said. 
Most counties in central and northern Minnesota also have premiums that are among the lowest in the nation. Michael Rothman, commissioner of Minnesota’s Department of Commerce, which regulates insurers, said the state moved early to enact cost-control measures such as restricting how much insurers can spend on things other than medical care and requiring annual insurance rates to go through state review.
Several of the other lowest cost areas, including the Salt Lake City region and Hawaii, also have major hospitals and health systems that have been at the forefront of integrated care, in which rules, payment methods and the bureaucracy are designed to foster collaboration among primary care doctors, specialists and nurses. But people who buy the cheapest Salt Lake City plan will not have access to Intermountain Healthcare, the most prestigious system in the area.

On Health Act, Democrats Run to Mend What G.O.P. Aims to End

By 

WASHINGTON — The ad supporting Representative Ann Kirkpatrick, Democrat of Arizona, opens with a montage of Americana Main Streets, followed by the green fields and dirt roads of the West — the “small towns and wide-open spaces,” the narrator explains, where Ms. Kirkpatrick “listens and learns.”
His voice remains tranquil even as he turns to a more cutting message about President Obama’s signaturehealth care law: “It’s why she blew the whistle on the disastrous health care website, calling it ‘stunning ineptitude’ and worked to fix it,” he says, before adding, “Ann Kirkpatrick: Seeing what’s wrong, doing what’s right.”
As Democrats approach the 2014 midterm elections, they are grappling with an awkward reality: Their president’s health care law — passed almost entirely by Democrats — remains a political liability in many states, threatening their ability to hold on to seats in the Senate and the House.
http://www.nytimes.com/2014/02/17/us/politics/on-health-act-democrats-run-to-mend-what-gop-aims-to-end.html?ribbon-ad-idx=3&rref=homepage&module=Ribbon&version=context&region=Header&action=click&contentCollection=Home%20Page&pgtype=Blogs

In the Debate Over Health Care, ‘Real People’ Become Human Volleyballs

By WASHINGTON — In the Republican response to the State of the Union address, Representative Cathy McMorris Rodgers of Washington lamented the travails of “Bette in Spokane,” whose insurance policy had been canceled because of the health care law and who faced huge premium increases to replace it.
The reality for Bette Grenier of Chattaroy, Wash., was more complicated.
She did dash off an angry letter to Ms. McMorris Rodgers, her congresswoman, in September, but on further exploration Ms. Grenier’s options were wider than she had thought. She qualified for a subsidized insurance plan through the health care law, an option she opposed philosophically. Instead, she bought insurance through a Christian ministry that is cheaper and better than her canceled policy. Since her star turn, she has been harassed and mocked by “some pretty mean people,” she said.
The “real people” political prop is a durable ingredient in politics, first popularized at the State of the Union address when Ronald Reagan invited Lenny Skutnik, who had dived into the icy Potomac River to rescue victims of a plane crash, to serve as an example of Everyman heroism. It is a trope that every president since has used. But with the continuing fight over the Affordable Care Act, it has become a blood sport for both parties. Every real face is fact-checked, every perceived distortion attacked. And real people have been caught in the crossfire.
http://www.nytimes.com/2014/02/16/us/politics/human-volleyballs-in-the-health-care-clash.html?hpw&rref=health

Transition to ICD-10 May Cost 3X More Than Predicted For Physician Practices

Submitted by  on February 12, 2014 – 3:40 pm
The mandated implementation of the ICD-10 code set will be dramatically more expensive for most physician practices than previously estimated, according to an updated cost study released by the American Medical Association (AMA).

The 2014 study found that in some cases, the estimated ICD-10 implementation costs are nearly three times what had been predicted by a landmark 2008 study.
The federal government requires the health care industry to transition to the ICD-10 code set for reporting diagnoses on all health care claims and other transactions as of Oct. 1, 2014. Implementing ICD-10 will result in a five-fold increase in diagnosis codes from the current 14,000 codes to a staggering 68,000 codes. It is a massive administrative and financial undertaking for physicians who are already overwhelmed by overlapping regulatory requirements and uncertainty in a rapidly changing health care landscape.
In the AMA’s continuing effort to urge the U.S. Department of Health and Human Services to make good on its commitment to improve the regulatory climate for physicians, the AMA today sent a letter to Secretary Kathleen Sebelius asking her to again reconsider the ICD-10 mandate.
“The markedly higher implementation costs for ICD-10 place a crushing burden on physicians, straining vital resources needed to invest in new health care delivery models and well-developed technology that promotes care coordination with real value to patients,” said AMA President Ardis Dee Hoven, M.D. “Continuing to compel physicians to adopt this new coding structure threatens to disrupt innovations by diverting resources away from areas that are expected to help lower costs and improve the quality of care.”
In 2008 the predicted cost to implement ICD-10 ranged from $83,290 for a small practice, $285,195 for a medium practice and $2,728,780 for a large practice. Based on new information, the 2014 study found the following cost ranges for each practice size based on variable factors such as specialty, vendor and software.
Small practice:        $56,639 – $226,105
Medium practice:    $213,364 – $824,735
Large practice:        $2,017,151 – $8,018,364

State House Notebook: Maine DHHS argument against Medicaid expansion pivots from Alexander study

Also: Republicans charge House Speaker with conflict of interest.

By Steve Mistler smistler@pressherald.com
Staff Writer
As the debate over Medicaid expansion rages in the Legislature, the LePage administration is rolling out a coordinated effort among state agencies to focus on the program’s “cannibalizing” of their respective budgets.
The administration also appears to be pivoting from the taxpayer-funded study that it originally hoped would bolster its anti-expansion position.
Hints of the two-pronged strategy were included in a series of emails inadvertently forwarded to a reporter at the Portland Press Herald. The messages between high-level staff at the Department of Health and Human Services, including Commissioner Mary Mayhew, show how the agency is trying to ramp up its argument against expansion of MaineCare, as Medicaid is called in Maine.
The administration’s anti-expansion case was expected to lean heavily on what’s known as the Alexander Group report, which has already cost the state $185,040 for a Medicaid expansion feasibility study. The report, included in a $925,000 no-bid contract for Gary Alexander, the former welfare chief for Pennsylvania, has been under siege since its release Jan. 10. A national health care analyst said the report contained a $575 million calculation error, omitted savings measures and overstated poverty projections that could balloon the costs of expansion.
While Democrats plan to submit a bill that would nullify the contract, the emails show how officials at DHHS are weighing whether to defend Alexander’s Medicaid study or divert attention from it. On Feb. 11, DHHS spokesman John Martins emailed Mayhew, Sam Adolphsen, the deputy finance director, and Nick Adolphsen, a legislative liaison. He discussed a memo from Erik Randolph, a member of the Alexander Group, that presumably defended the Medicaid study. Sam Adolphsen wrote Friday that he liked the memo, but questioned whether the agency should wait for the “next attack” to make it public.

Maine DHHS seeks to steer conversation away from $1 million welfare report

By Scott Thistle, Sun Journal
Posted Feb. 17, 2014, at 4:11 p.m.
AUGUSTA, Maine — Officials within the Maine Department of Health and Human Services appear to be working behind the scenes to change the public and political discussion about an expansion of Medicaid.
Email messages published by the Portland Press Herald after they inadvertently were sent to the newspaper suggest DHHS officials may be trying to downplay the controversial Alexander Group study of the state’s welfare programs.
The messages, sent between Feb. 11 and Feb. 14, also suggest a strategy to highlight how much other state departments are being cut in order to sustain the state’s existing Medicaid program, MaineCare.
It’s a theme that Gov. Paul LePage also emphasized last week when he suggested state agencies were being “cannibalized” by the state’s Medicaid costs.
“Because Maine already expanded welfare a decade ago, Medicaid is now cannibalizing funding from all other state agencies,” LePage said in a prepared statement Feb. 13. “That means the state cannot fully pay its 55 percent share of local education costs. It cannot hire more Maine State Troopers or repair National Guard facilities. The state cannot adequately promote fishing and hunting programs or conduct research on our fisheries. It cannot expand job-training opportunities or properly fund programs for environmental emergencies. Everything the state of Maine does is adversely impacted by Medicaid spending. Now liberals want to expand welfare again.”
Democratic lawmakers shot back Monday and said it was income tax cuts passed under a Republican majority in 2011 and signed into law by LePage that were the source of the state’s budget woes.
“This new rhetoric is a clear public relations ploy,” Jodi Quintero, communications director for House Democrats, wrote in a memo sent to media on Monday. “What’s really cannibalized the state budget is Gov. LePage’s tax cuts for the wealthy.”
The emails released Monday also show “Communications Directors” around the state have been instructed to send in guest editorials to Maine newspapers highlighting what is being cut as a result of Medicaid costs.
“We are succeeding on all fronts on getting the expansion message out, and the focus on the AG report has died down,” DHHS communications director John Martins wrote in one message to Commissioner Mary Mayhew, DHHS Deputy Finance Director Sam Adolphsen and department legislative liaison Nick Adolphsen.
Martins noted a memo from one of the Alexander Group’s analysts, Erik Randolph, that apparently defends the group’s work. DHHS officials appear to be weighing when they would make it public.
Martins also referenced a draft press release about the memo noting, “I’ve drafted the attached release, which is pretty ‘weedy’ and has some strong quotes in it that may need to be tempered.”
In another message Martins asked for “quotable and reliable” sources on the topic of how many people in Maine would be eligible for a federal subsidy for health insurance were they to buy it on the federal exchange.
Republicans have argued Maine does not need to add 70,000 people to the Medicaid roles because many of them (those earning above 100 percent of the federal poverty level) would be eligible for a subsidy on the exchange.
It’s unclear still how many people that may be, but it’s a talking point, along with the projected cost of the expansion the administration appears intent to tout.
“If we want to message around the subsidies and the $800 million, we can do a release, if we have the data that shows the numbers of those eligible for subsidies and keep the focus squarely on expansion,” Martins wrote.
The exchange of emails includes a brief response from Mayhew, who noted one of the attachments “looks good.”

Maine Obamacare signups slow but steady, with 20,000 selecting plans

By Jackie Farwell, BDN Staff
Posted Feb. 12, 2014, at 4:23 p.m.
More than 20,000 Mainers have signed up for health coverage under the Affordable Care Act, according to a new round of federal data released Wednesday.
Since the launch of healthcare.gov on Oct. 1, 2013, through Feb. 1, 20,511 Maine residents selected a private health plan through the federal government’s gateway for the marketplaces in Maine and 35 other states, according to a report from the U.S. Department of Health and Human Services. That’s up from 13,704 Mainers at the end of December, though a drop off from December’s more rapid pace.
The White House anticipated a rush of enrollments in December by Americans seeking to get coverage by the new year.
In Maine, about 65,000-104,000 people are estimated to be eligible to shop on the marketplaces.
Also called “exchanges,” the marketplaces are geared toward small businesses and individuals who buy their own health insurance rather than receive coverage through work or government programs such as Medicaid and Medicare.
Enrollment through healthcare.gov and state-run health insurance exchanges also jumped nationally, rising 53 percent from the prior three months to 3.3 million people. January accounted for nearly 1.1 million health coverage signups, marking the first month enrollment has beat government projections. Young adults outpaced older enrollees, accounting for about a quarter of the signups, according to HHS.
The enrollment numbers reflect consumers who have chosen a plan but may not have paid their first premium, which is how insurers typically define enrollment.
The new batch of data showed little change in the age mix of Maine enrollees, with most middle-age or older. Health policy experts are closely watching that breakdown, as the Affordable Care Act’s overhaul of the insurance market for those who buy their own coverage relies on healthy Americans, who tend to be younger, signing up to help share the risk with older, sicker consumers and keep costs from skyrocketing.
In Maine, the oldest state in the country, 61 percent of enrollees so far are between the ages of 45 and 64, according to the HHS report. Nineteen percent are ages 18-34, ticking up from 18 percent in December but still among the lowest showings in the country for young adult signups.
Many experts predict that younger, healthier adults will put off buying coverage closer to when open enrollment winds down on March 31. Older, sicker consumers are more likely to already have coverage that they want to continue, or to jump at the chance to buy it, while younger adults tend to lack coverage and may wait to purchase a health plan.
Nearly 90 percent of Mainers who have chosen a plan qualified for federal financial help to afford their coverage. Three out of four Mainers chose a “silver level” plan, which is linked to a discount that lowers the amount policyholders pay out of pocket. Policies range from platinum to gold, silver and bronze, with the higher metal tiers carrying heftier monthly premiums but lower co-pays and deductibles.
Tax credits also are available to lower consumers’ monthly premiums.


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