Tuesday, January 16, 2018

Throw Momma From the Plan

Have you ever bought something that sounded sooooo good at the time but later regretted it? Perhaps that salesperson made it seem absolutely wonderful but neglected to tell you a few things. You know, stuff that, had you known at the time, might have led you to a different decision. But the salesperson kept talking and talking and talking.

Some people without brains do an awful lot of talking, don't they? - Wizard of Oz

One of InsureBlogs favorite curmudgeon's, Wendell Potter, penned an article for Medicare Resources that caught my eye. Recent discussions with fellow agents regarding how Medicare treats SNF care led me to an article titled "Why Mom Went Back to Traditional Medicare".

This is allegedly a true story and the names have not been changed to protect the innocent.

As it seems Wendell's real mom had a real Medicare Advantage plan. At age 91 Mrs. Potter is in relatively good health for someone her age. But according to her son she might not have been so lucky had she stayed on a Medicare Advantage plan. Like a good son, Wendell switched his mom from the Advantage plan to original Medicare when she was "critically ill".

Many Medicare Advantage enrollees do exactly what Mom did after a serious illness or injury, and the MA plans they “disenroll” from couldn’t be happier to see them go. When they go back to traditional Medicare, the MA plans are off the hook for covering expensive care.

(The Medicare Advantage disenrollment deadline is Valentines Day every year, so mark your calendar for 2/14/2018).

According to Wendell, his reason for throwing Momma from the plan was this.
the head nurse took me aside and told me that another nurse – not at the facility but at Mom’s Medicare Advantage plan – had come to the conclusion that the skilled nursing was no longer “medically necessary.” This other nurse – a so-called “utilization management” nurse – had never laid eyes on my mother, much less treated her. But she was able to insert herself between my mother and her treating physician and, for all practical purposes, determine whether or not she would get the care her doctor said she needed.
Beyond being a dutiful son, Mr. Potter had RESEARCH to back up his decision.
Kaiser Health News quoted J. Michael McWilliams, the Harvard professor who led the research team, as surmising that “beneficiaries who developed serious ailments might leave the (MA) plans to get unfettered access to physicians and treatments through traditional Medicare.
Unfettered access as opposed to managed care that is baked in to Advantage plans.

Claims submitted to original Medicare are still required to meet medical necessity standards, but there are no utilization monitors overseeing the ongoing claim. Claims are adjudicated AFTER THE FACT rather than ongoing when you have an Advantage plan.

That's not as bad as it sounds.

If the attending physician cannot prove medical necessity for the treatment under original Medicare the beneficiary is not responsible for the claim. An exception occurs if the patient signed an Advance Beneficiary Notification form PRIOR TO the procedure or treatment.

ABN applies to claims with original Medicare, but not Advantage plans.

So Wendell was able to use the system to get Momma off the managed care plan and into an un-managed plan with original Medicare.

But he neglected to mention one thing.

Disenrolling from the Advantage plan the way she apparently did negated any guaranteed right to purchase a Medicare supplement plan. The way his article is worded it appears this was a VOLUNTARY disenrollment, not one triggered by moving out of the service area or because her current plan was discontinued.

Perhaps his mother was healthy enough to qualify for a Medigap plan, or perhaps not. He does not elaborate on this point.

Disenrolling from an Advantage plan does allow you to go to original Medicare without answering health questions. But without the protection of a supplement plan the beneficiaries exposure on Part B is unlimited.

Or as I like to explain it, your 20% share of Part B expenses continues until you get well, run out of money or die.

Only one of those results is optimum.

While the saga of Mrs. Potter and the nursing home makes for an interesting read it can be a bit misleading to those who think disenrolling means you can automatically enroll in a Medigap plan.

But now you know.

#MedicareAdvantageDisenrollment  #ManagedCare  #NursingHomeCoverage





Monday, January 15, 2018

Dr. Facebook

With so many wonderful and useful site where one can get medical information and "advice", we find it odd that people would troll social media for health information. Yet, according to Dr. Audrey Nath (Kevin MD) if you want REALLY GOOD advice you go to Facebook.

Here is a sample query as paraphrased by Dr. Nath.
“Help! My baby has a fever, what do I do? I have a pediatrician, but I
clearly trust you guys more than that guy,”
or, even better, “My child is ill and also having mental status changes that are rather concerning. Also, of equal importance, I need you to tell me exactly when the Mongolian spot on her back will disappear. Thanks in advance!”
Whatever happened to mom's advice about "never trust a stranger"?

One response to a question related to stomach distress.
“Grape juice is a remedy for any gastroenteritis, given that it changes the pH of stomach acid, and therefore, has some sort of antiviral effect.”
If grape juice is all that is needed take them to communion. Sure, some churches use real wine but even Apostle Paul said a little wine is good for digestion.

With sterling advice like this it makes you wonder why doc's charge so much for a consultation. And remember that Facebook does not charge a dime for membership.

Gives a whole new meaning to socialized medicine.

#Facebook #MedicalAdvice


Sunday, January 14, 2018

This Sceptered Isle - Part MMXVIII

Britain’s NHS is seeking to charge co-pays for certain patients.  Up to now, NHS has always claimed to be “free” for everyone . . . Free at the point of service, anyway. (I suggest you read the entire linked article.  Its headline is a bit misleading.)

While charging of co-pays would be a departure, it should come as no great surprise.  In the first place, NHS financial problems have been public for quite a while.  And, after all, NHS is just another insurance company - albeit a giant, national monopoly. Aside from the political control of its management and budgets, NHS behaves very much like private insurance companies around the world. Specifically, NHS has a large bureaucracy that determines what medical services are reimbursed, and under what terms.  Also, NHS is financed by premiums that must must cover its costs - although NHS “premiums” are disguised as taxes.

And now - co-pays?

What next?  Refusal to cover services of non-approved physicians and hospitals?

Will NHS end up a British HMO?

Friday, January 12, 2018

And The HIT Just Keeps on Coming

Obamacare imposes a "fee on insurance companies" for fully insured plans that is referred to as the HIT (Health Insurance Tax). Last year this tax was in a one year moratorium thanks to Congressional relief. But this year it is back in full effect.

The tax on health insurers is non-deductible, meaning for every $1.00 in taxes the insurer will need to take in $1.54 (assumes 35% corporate tax rate). For 2018, the amount this tax must generate is $14.3 billion - meaning insurers must generate $22 billion of additional premiums to pay for it. Insurers have to pay their portion based off of market share so the larger presence they have the greater the amount they have to charge. This also makes it a moving target from year to year.

The tax applies to all fully insured coverage including:
  • Individual On Exchange
  • Individual Off Exchange
  • Small Group Fully Insured - Both ACA and Pre ACA
  • Large Group Fully Insured - Both ACA and Pre ACA
  • Medicare Advantage
  • Medicare Part D
  • Medicaid Managed Care

To offer transparency, many insurers are breaking out these taxes on renewals for consumers to see. But, for most employer plans - where a large amount of this revenue is generated - this tax isn't transparent to employees.

Employers offer a total compensation package to employees. Wages and benefits are the biggest drivers of what makes up an employee's compensation. The HIT hurts employee wages and benefits while providing zero value to the business.

How bad does the HIT hurt employers? For my clients it's extremely painful. Reviewing my January 2018 renewals I found the average cost per employee is $356.50. That doesn't seem like much right?Until we do the math and show that this tax averages a cost of $0.17 per hour.

This puts an employer in a tough position. Do they give a $0.25 an hour raise but increase premium contributions by $0.17 an hour? Do they cut benefits by $0.17 an hour? Or, do they decline to expand, cut overtime, or reduce staff to pay the tax? These are tough decisions employers have to make that are all done behind the scenes.

Employees see these decisions to increase the amount deducted from their paychecks, higher deductibles, higher copays, more restrictive provider networks, and higher prescription costs as if the employer or the insurer is screwing them.

The reality is Obamacare's HIT is causing the problem. It's been screwing employees since 2014 and every year it will get worse.

The next time someone says Obamacare doesn't impact employer sponsored insurance remember the HIT. It's the sucker punch that keeps on coming.

Half Empty or Half Full?

You are probably familiar with the phrase "Is the glass half empty or half full?". A popular meme says, the problem is obvious. You need a smaller glass. Better idea, more wine.

This may be the solution when you are talking about wine. But how about health care?

No, not health insurance. Health CARE.

A recent Kaiser Foundation report addressed the issue of "robust physician networks" in popular Medicare Advantage plans. (Full report here).

Many people are confused about Medicare Advantage plans, especially those that do not charge a premium. (Free insurance. How can they do that?).

Excellent and logical question and one that comes up quite a bit. Most folks on Medicare are smart enough to know if someone offers you a product or service at no charge there must be strings attached.

But the $0 premium plans are a marketing gimmick by the carriers, not something baked into Medicare rules.

That is a discussion for another day.

Regarding doctor networks and Medicare Advantage plan consumers are once again faced with the question. If I like my doctor can I keep my doctor?

The answer is "yes".

Advantage plans do not forbid you from seeing certain doctors. You are free to use any doctor you wish . . . as long as you are willing to pay for that privilege.

From the KFF report (linked above):

 As of 2017, 19 million of the 58 million people on Medicare (33%) are enrolled in a Medicare Advantage plan, yet little is known about their provider networks.

"Little is known about provider networks". I wonder how many of those 19M people really understand networks and what that means. In particular, what happens if you are in treatment at the end of the calendar year and your doctor(s), hospital(s) and clinic(s) are not in network the following year?

According to Kaiser, 78% of Advantage plans did not include all doctors who practiced in the service area. On average, less than half (46% per the survey) of physicians did not participate in Advantage plans. Some plans included 60% of physicians who practiced in a particular county while other plans had less than 10% of doctors participating.

The report included the following eye openers:

  • 20% of plans had fewer than 5 thoracic surgeons
  • 18% of plans had less than 5 neurosurgeons
  • 16% of plans had fewer than 5 radiation oncologists
Remember, you are free to use any doctor you wish, including your own, but using someone that is not on the approved list can be harmful to your wallet.


And some doctors, including your regular one, may refuse to see you if you have an Advantage plan.

The size and composition of Medicare Advantage provider networks is likely to be particularly important to enrollees when they have an unforeseen medical event or serious illness. However, accessing the information may not be easy for users, and comparing networks could be especially challenging. Beneficiaries could unwittingly face significant costs if they accidentally go out-of-network. Differences across plans, including provider networks, pose challenges for Medicare beneficiaries in choosing among plans and in seeking care

If you opt for a Medicare Advantage plan, make sure you understand the rules and are willing to play by them. Otherwise you may be in for a rather costly surprise.

You can pick a plan with a broad network and fewer restrictions for using non-par providers, but you can expect to pay more.

Higher premiums. Higher copay's. Higher deductibles. Higher out of pocket limits.

And how DO they offer plans that don't charge a premium?

Maybe I will address that next time . . .

#MedicareAdvantage #NarrowNetworks #HalfEmptyHalfFull



Thursday, January 11, 2018

Doctors, Doctors, Everywhere

and all the networks did shrink. Doctors, doctors, everywhere but man does it really stink.

Access to health CARE was never a problem until Obamacare.

Most people, including those without health insurance, could AFFORD to see a doctor for routine care. But now many have little left over to pay a doctor after paying HUGE health insurance premiums.

But wait, there's more!

Even if you can afford the premiums AND have money left over to pay for your care, there is a new problem.
People who bought policies from Centene, a large for-profit health insurance company, filed a federal lawsuit on Thursday claiming the company does not provide adequate access to doctors in 15 states.
 “Members have difficulty finding — and in many cases cannot find — medical providers,” who will accept patients covered under policies sold by Centene, according to the lawsuit filed in federal court in Washington State. - NY Times
You have government dictated and designed health insurance but no place to use it.

Isn't that a fine kettle of fish?

#Obamacare

Sharing, Caring and Talking

So Politico's Paul Demko reached out to me yesterday to ask about Health Care Sharing Ministries (HCSM), and specifically about whether or not I'd decided whether or not to market them. He was also interested in connecting with any (former?) clients who'd made the leap from Major Med to HCSM.

I was intrigued, and we agreed to speak this morning. In the meantime, I contacted several folks I knew who'd gone that route, especially hopeful that one in particular will respond.

Why her?

Well, because she was actually referred to me by a mutual friend at our synagogue. We had looked into ACA major med plans for her, but she ultimately chose a Ministry. Since these tend to be church-based I was intrigued, and Paul thought that would be really interesting to hear more about, as well.

Ultimately, we had a very nice conversation, and I told him that I'd let him know if I was able to connect with any of these folks so that I could send them his way (if they agreed that would be a good idea).

I don't know when (or even if) this article will be published, but will post a link to it here once it is.

Wednesday, January 10, 2018

Interesting Carrier News

Good news:

"Aflac is doubling its 401(k) match and adding additional employer-sponsored benefits as part of what the company says will be a $250 million investment initiative over the next three to five years."

The company says that these are a direct result of the recent tax bill.

Nice.

Interesting news:

"Gladys is apprehensive about getting her blood drawn ... With Legacy Optimizer Indexed Universal Life insurance. Gladys can apply without needing to provide blood work or visiting a doctor"

This from the folks at North American, for folks who need the protection (and the potential for cash value growth) but have trypanophobia.

Financial news:

"Low 2016 Individual Health Margins Trimmed Insurers' Rebate Bills"

As expected, MLR itself put the squeeze on carrier profitability (and notice that as MLR has increased, agent comp has declined, even though there should be no direct correlation).

And there's this:

"[F]ewer insurers earned enough to owe rebates to the enrollees."

Thus offering even more proof (as if it was needed) that the ObamaCare's end-goal has always been Single Payer.

Always.

Tuesday, January 09, 2018

Companion Life takes a hit


Related: About 20 or so years ago I had a similar situation with a client. Small group health plan with $15,000 life and AD&D ("Accidental Death and Dismemberment);" the idea was that the death benefit doubled if one died from an accident (as opposed to illness). One of the employees, a young man (of course), decided to play chicken with a Ford Explorer (he was riding a motorcycle).

To my surprise, they actually care-flighted him to the hospital (to no avail, of course).

We submitted the death claim, which was approved for the underlying amount, but the AD&D portion were denied because the wording (more explicit than was the case here) said no "double indemnity" if alcohol was involved.

I had a few questions about that wording, too, but never had the opportunity to raise them.

Top 30, Baby!

The folks at Feedspot have graciously named us as one of the Top 30 Health Insurance blogs.

Blogs are ranked based on:

Google reputation and Google search ranking


Influence and popularity on Facebook, twitter and other social media sites
 

Quality and consistency of posts.
 

Feedspot’s editorial team and expert review

We're in pretty august company, too, including 404Care.gov's blog, Blue Cross and Aetna blogs, and our friend David Fluker's, too.