In Time magazine’s March issue Bitter Pill: Why Medical Bills Are Killing Us Steven Brill gets to work on answering the ever elusive Why are Medical Costs So High? The 21,000 word article is longest article in Time Magazine history that can boiled down to simply there is no free marketplace in health care. We think everything in this country is a free market but is there a free market when one needs to got to an emergency room or a free market when one must take a cancer pill? According to Howard Dean the singular reason is to get away form the current fee for service system where providers get paid per procedure and not per patient.
Here’s an eye opener: “Insurance Companies are not really the problem they run pretty terribly. They process claims, a lot of us think they process claims and fairly consistently but they are increasingly at the mercy of hospitals which are consolidating buying a doctors practices. We should tax profits on so-called nonprofit hospitals and put that money back into the system. We should control all the prices for prescription drugs because if I have a monopoly a cancer wonder drug I can charge anything I want for them that’s obviously not a free market and it’s completely two different uses you see this article once you follow the money.”
Transcript of the video:
“This is not a free-market. You don’t get health care because you want it. You don’t wake up in the morning and gee I love to go down to the emergency room today. You enter that market and will you know nothing about the products of you being asked by no choice of those products. Hi I am Steve Brill I’ve got the cover story this week in TIME Magazine looking at the health care debate from a very different perspective. Everybody focuses on who should pay for the exorbitant cost of health care and that I decided to do was ask for more fundamental question which is why does health care cost so much.
I look behind the bills and trace the bills all the way back to who’s getting what money is making what profits and the results are really surprised one of the things I found that everybody in the healthcare industry knows about that that nobody else knows his something called the charge-master. The charge master is a internal listing each hospital of the thousands of different items that they charge and nobody could explain it to me. Indeed would be hard to explain for example why would you charge $77 for a box of gauze pads? You can buy for a dollar at the drugstore. why would you charge thousands of dollars for CAT scan it really isn’t cost you anything?
It’s emblematic if you will, of the irrationality of the higher healthcare system because no one can explain the cost no one tries to and the only people who are guaranteed surefire to pay to be asked to pay the charge-master prices are the poorest people who don’t have health insurance.
Real profit makers are way hospitals markup very expensive drugs that you get. If you have cancer to have pneumonia but they’re making thousands of dollars on these drugs and drug companies in turn making still more thousands of dollars.
Obamacare does very little to solve any of these problems and just probably why you got to Congress I’m it doesn’t do anything to control the prices of prescription drugs or medical devices CAT scan. In fact if anything it will increase the profitable the players in the market by making equal insurance and therefore more people are in the marketplace with the funds from insurance companies to buy all these products.
Insurance Companies are not really the problem they run pretty terribly. They process claims, a lot of us think they process claims and fairly consistently but they are increasingly at the mercy of hospitals which are consolidating buying a doctors practices. See Provider Consolidation Info-graph– “The proliferation of hospital mergers and hospitals’ appetite for buying doctors’ practices—in part to assure a steady stream of patients to fill hospital beds—could create local monopolies that raise prices without increasing efficiency. ‘Historically,’ says Deloitte’s Mr. Keckley, ‘hospital consolidation hasn’t reduced costs.’”
We should tax profits on so-called nonprofit hospitals and put that money back into the system. We should control all the prices for prescription drugs because if I have a monopoly a cancer wonder drug I can charge anything I want for them that’s obviously not a free market and it’s completely two different uses you see this article once you follow the money.”
The ACO (Accountable Care Organization) referenced in our post NYU Beth Israel Merger and ACOs are models encouraged in Obamacare in fact as examples of Provider capitated reimbursement that Howard Dean is in favor of. An ACOI cordiantes patient care and provide the full range of health care services for patients. The health reform law provides incentives for providers who join together to form such organizations and who agree to be accountable for the quality, cost, and overall care of Medicarebeneficiaries who are enrolled in the traditional fee-for-service program who are assigned to the ACO.
The fee-for-service system has evidentially driven costs by incentivizing volumes of added procedures. The ACO model is built on par excellence hospitals such as Mayo Clinic where there is team of providers are financially incentivized for patient care coordination outcomes and high quality of care. The ACO’s payment would be tied to achieving goals that improve health care and save money. Members of the ACO would divvy up that payment. Today’s payment system, investments in providing better care are doubly penalized. If a hospital hires a nurse to follow up with patients after they are discharged in order to reduce readmissions — for example, to help patients with diabetes improve blood sugar control — it must pay for the nurse, which is typically not reimbursed by insurance companies or Medicare, and it loses revenue by preventing the readmission.
Congress included ACOs in the health care law as a way to rein in Medicare spending. That federal program pays for health care for people 65 and older and the disabled. The federal government estimates ACOs could save the Medicare program up to $940 million over four years. Medicare recently began testing this system with 32 pilot ACOs in 18 states, including one in the New York City area – Bronx Accountable Healthcare Network.
Some have pointed to ACO Model just as a pro-merger supporting argument with the FTC. These significant mergers create market dominance and therefore limit competition and drive up health care dollars. And yet Hospitals operate on thin profit margins and cannot afford to lose market share therein lies is the conundrum.
Note: At time of this article MVP and Hudson Valley Health Plans announced a merger –Hudson Health Plans joins MVP. Hudson Health Plan, the Medicaid managed care organization based in Tarrytown, will join the MVP Health Care group of companies, the two nonprofit health plans jointly announced today.
“Size and diversity of offerings are important for health plans in the new world of the health insurance marketplaces. A 55-year-old person would like to join a health plan that can continue to cover him when he turns 65. Likewise, if someone is no longer eligible for Medicaid, she might prefer to buy a commercial product from that same insurer. Together, MVP and Hudson now can cover people through all of life’s stages and changing needs.
In the coming months, Millennium Medical Solutions Inc will host seminars and will share information you’ll need to know as the countdown continues to October 1st. Please contact us for immediate information on how to implement these initiatives for your group-specific needs at info@medicalsolutionscorp.com or Call (855) 667-4621.
Health Insurance Mandates 2012. The Councel for Affordable Health Insurance in VA released their annual “Health Insurance Mandates in the States” for 2012 last week. While NYS did not crack the top 5 they did come close at number 7 this year.
NYS Mandates were discussed in our posting Empire Leaving Small Groups Nov 2011. ” Today, we have so many State mandates that many of the mandates(overage dependents coverage, preventive care, pre-existing for kids) in PPACA didnt even affect NY since they were already in place. Mandates account for approx 17% of the costs of which Small Businesses pay more than fair share. Large corporations and Unions can self insure and avoid some mandates as they are governed by ERISA and not State. To the relief of of our struggling clients on subsidized Healthy NYthe State doesn’t play by their own rules and instead opts out of its very own mandates.”
According to the study CAHI Identifies 2,271 State Health Insurance Mandates “The sheer number of state mandates will make it difficult for states to deliver on one of the key promises repeatedly made by supporters of Obamacare: it would provide all Americans with affordable health coverage. The essential health benefit plan design was supposed to give states the flexibility to craft benefit packages which would be suitable and affordable for their unique populations. But HHS shackled the states to the full load of mandated benefits on their books, and the prices of next year’s offerings in the health insurance exchanges are going to bear witness to the free-wheeling mandate craze of the last twenty years. Recent studies have predicted double digit increases in health insurance premiums next year — the mandates are coming home to roost,” said Roy Ramthun, CAHI’s Director of Federal Affairs.”
The United Hospital Fun estimates that approximately 2.2 million New Yorkers lacked insurance coverage in 2009, (Health Insurance Coverage in New York 2009.)
The collective cost of paying for New York’s health insurance mandates equates to 12.2% of overall premium cost. Based on 2008 premiums, this translates into $1,538 expense per year for an average family policy and $566 per year for a single person policy. (Employer Alliance, NYS Mandated Health Insurance Benefits, 2003)
Higher health care costs increase the number of uninsured. In New York, it is estimated that for every 1% increase in premiums, 30,000 New Yorkers lose health insurance. (Barents Group, 1999)
Mandates have a cumulative impact on premium costs. It is estimated that the cost of the 12 most common mandates can increase the cost of health insurance by as much as 30%. (Milliman and Robertson 1996)
Rising health care costs have the biggest impact on the small business sector. For every 1% increase in premium costs, small business sponsorship of health insurance drops by 2.6%. (Morrisey et al., 1994)
The percentage of US small business workers receiving insurance through their employer declined 5% between 1996 and 1998 – from 52% in 1996 to 47% in 1998. (KPMG Peat Marwick, 1999)
Nearly one of every four uninsured Americans has no health care coverage as the direct result of state mandates. (Jensen, Morrisey, 1999)
Health insurance premiums for New York’s working families skyrocketed between 2000 & 2007
increasing by 80.7 percent. (Families versus Paychecks, Families USA 2008)
Since 1999, family premiums for employer-sponsored health coverage have increased by 131 percent, placing increasing cost burdens on employers and workers. (Kaiser Family Foundation and Health Research and Educational Trust. Employer Health Benefits 2009 Annual Survey. September 2009).
the HIT is actually a hidden tax on small business. PPACA assesses a tax on all health insurance companies based on their “net premiums” written. The tax will raise $8 billion starting in 2014, $14.3 billion in 2018 and more in later years. This is [aid for by fully insured health plans which are comprised mostly by small businesses.
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The AHIP infograph provides visually a great infograph describing how provider consolidation increases costs. According to Wall Street Journal Article this week –Four Key Questions for Health-Care Law “The proliferation of hospital mergers and hospitals’ appetite for buying doctors’ practices—in part to assure a steady stream of patients to fill hospital beds—could create local monopolies that raise prices without increasing efficiency. ‘Historically,’ says Deloitte’s Mr. Keckley, ‘hospital consolidation hasn’t reduced costs.’”
If we as a society ask our hospitals to behave as industries then size matters in achieving economies of scale. However, the important question we must then answer are we operating in a true free market economy when someone gets sick?
So what are are Medical Loss Ratios and why should we care?
Medical Loss Ratio (MLR) – The minimum percentage of premium dollars a commercial insurance company must spend on the reimbursement of certain medical costs. The health reform law requires insurers in the large group market to have an MLR of 85% and insurers in the small group and individual markets to have an MLR of 80% (with some waivers granted to states to reduce the threshold for certain markets).
The MLR calculation is determined on a state-by-state basis by each insurer or HMO. Rebates are calculated separately for the individual, small group and large group markets in each state.
The final regulations issued onDecember 2, 2011:
• The rebate distribution processwassimplified to allowmostrebatesto be distributed to group policyholders rather than to each participantin a group plan.
• Employers can distribute rebatesin a variety ofwaysincluding future premiumreductions and benefit enhancementsthatwill allowrebatesto be tax-free to recipients.
This is arguably the most significant change in Health Care Reform. In short, this is a price control on health insurers regulating profits ceilings. Unlike many industries, however, insurers must maintain a high minimum in reserves. After-all if Health Underwriters incorrectly predict unknown future costs by pricing too low there is no recovery of losses. Conversely if they priced policies too high they must return premiums to subscribers. While this is altruistically great, in today’s Oligopoly Business with an avg of 3-4 insurers in a NYC Metro Area the realities are little motivation to compete. Furthermore, health insurers in NYS have higher MLR rates and must place rate filings a year in advance. This complicates the ability of actuarial to predict future costs thus asking for higher rate increase just in case. The State then reacts by cutting increase in half which forces more insurers out of State and actually emboldens remaining health insurers to push for more aggressive cuts in benefits, challenging underwriting participation’s and limit an insurers will to go above and beyond minimum essential benefits requirements.
In full disclosure, the Benefit advisor (broker/consultant) commissions have been cut close to 50% as this cuts into insurers profits. See our interview in Crain’s regarding this https://medicalsolutionscorp.com/p/crains-article-on-broker-commissions-cuts. Small Businesses and Sole Prop feel this the most as the resources needed to intelligently shop for benefits, reinsurance, navigate state/federal laws, employee annual open enrollments meetings have been defrayed by using a Broker. In many cases, good Brokers have become the de-facto HR.
The Federal Gov has already spent $2.2 Billion on State Exchanges. And this figures does not include remaining States as there are only 19 States working on an Exchange for 2014. The Exchanges will be built up for 2 years and then must be fully independent by 2016. If 88% of small groups coverage purchased by Brokers acc. to Boston’s Wakely Report in research study- Role of Producers and Other Third Party Assisters in New York’s Individual and SHOP Exchanges the distribution infrastructure is already there. Access to care is not the difficulty in finding a plan its the very cost of the plan! Why then does NYS decide to spend on building up new infrastructures? Agents/Brokers can easily outreach and council to uninsured as well. In fact many small businesses such as construction, consulting services and dining have many uninsured that an Agent/Broker already has a relationship with.
So where is this going? A weakened health insurer market place with the new domination of powerful large Medical groups numbering in the thousands + mega Hospital chains dictating rates. To be sure some the Hospital market is becoming close to an Oligopoly as well see: http://www.nytimes.com/2012/03/08/health/hospital-groups-will-get-bigger-moodys-report-says.html?_r=0.Still disagree? Hospital stocks have averaged 20-30% increases while insurance stocks have remained net net stagnant and down after initial spike. Ask yourself why NYS had 10 – 15 private health insurers 20 years ago while there are no rumors of new insurers or returning insurers?
If additional changes aren’t made, there could be unintended consequences including less competition, a reduction in consumer choice and higher health insurance costs. Oh I almost forgot, most clients especially NY SMB were not entitled to a rebate check with a small minority receiving avg $120.
*Based on 3-6-50 Plan: 3 years nursing home or 6 years homecare or a combination of both where 2 homecare days is equal to 1 nursing home day.
Basic policies are those that are written to meet the minimum standards for the Partnership including:
Minimum daily benefit amount of $253 for Nursing Home or $127 for home care including assisted living.
Respite care 14 days per year
Care Management 2 times per year
Alternative level of care provided in a hospital
Elimination period no great than 100 days
5% inflation protection
Guaranteed renewal
Extended Grace Period
Denied Benefits Authorization Request are monitors by the Partnership
Please note: This is the average annual premium. Please shop wisely. Some companies’ premiums are lower and some are higher.
Some insurance companies offer reduced premiums for certain individuals, for example, discounts for spouses who each purchase a policy. Make sure you shop wisely before selecting your policy . Get Quote Here
All LTC premiums, generally speaking, remain constant starting with the premium at purchase and continuing year after year. In other words, your premium will not increase based on a decline in your health, advancing age, or other personal reasons . However, a future premium increase is possible if your insurance company requests this of t your State based on greater than expected claims experience.
What is an Exchange? One of the centerpieces of the recently passed Patient Protection and Affordable Care Act
(PPACA) is the establishment of state based health insurance exchanges by the year 2014.
An “Exchange” is a mechanism for organizing the health insurance marketplace to help
consumers and small businesses shop for coverage in a way that permits easy comparison of
available plan options based on price, benefits, service and quality. By pooling individuals
and small groups together, transaction costs can be reduced and transparency can be increased.
Exchanges can create more efficient and competitive markets for individuals and small
employers.
Historically, the individual and small group health insurance markets have suffered from adverse
selection and high administrative costs, resulting in low value for consumers. “Exchanges” will
allow individuals and small businesses to benefit from the pooling of risk, market leverage, and
economies of scale that large businesses currently enjoy.
Beginning with an open enrollment period in 2013, Insurance agents and Benefits professionals
will help individuals and small employers shop, select, and enroll in high-quality, affordable
private health plans in these “Exchanges” to fit their specific needs at competitive prices.
Individuals in these “Exchanges” may also be eligible to receive premium subsidies through the
Federal or State government. By providing one-stop shopping, we will make purchasing health
insurance easier and more understandable through these “Exchanges” and provide the same level
of service that you have become accustomed to.
Middle-class people will be able to pick from a range of private insurance plans, and most people will be eligible for help from the government to pay their premiums.
Low-income people will be steered to safety-net programs for which they might qualify. This could be a problem in states that choose not to expand their Medicaid programs under a separate part of the health care law. In that case, many low-income residents in those states would remain uninsured.
Q: How will I know if I can get help with my health insurance premiums?
A: You’ll disclose your income to the exchange at the time you apply for coverage and they’ll let you know. Only legal residents of the United States can get financial assistance.
The health care law offers sliding-scale subsidies based on income for individuals and families making up to four times the federal poverty level, about $44,700 for singles, $92,200 for a family of four.
But do yourself a favor and read the fine print because the government’s help gets skimpier as household income increases.
For example, a family of four headed by a 40-year-old making $35,000 will get a $10,742 tax credit toward an annual premium of $12,130. They’d have to pay $1,388, about 4 percent of their income, or about $115 a month.
A similar hypothetical family making $90,000 will get a much smaller tax credit, $3,580, meaning they’d have to pay $8,550 of the same $12,130 policy. That works out to more than 9 percent of their income, or about $710 a month.
The estimates were made using the nonpartisan Kaiser Family Foundation’s online calculator. Some people will also be eligible for help with their copayments.
Final note: Though it’s called a “tax credit” the government assistance goes directly to the insurer. You won’t see a check.
Q: What will the benefits look like?
A: The coverage will be more comprehensive than what’s now typically available in the individual health insurance market, dominated by bare-bones plans. It will be more like what an established, successful small business offers its employees. Premiums are likely to be higher for some people, but government assistance should mostly compensate for that.
All plans in the exchange will have to cover a standard set of “essential health benefits,” including hospitalization, doctor visits, prescriptions, emergency room treatment, maternal and newborn care, and prevention. Insurers cannot turn away the sick or charge them more. Middle-aged and older adults can’t be charged more than three times what young people pay. Insurers can impose penalties on smokers.
Because the benefits will be similar, the biggest difference among plans will be something called “actuarial value.” A new term for consumers, it’s the share of expected health care costs that the plan will cover.
There will be four levels of coverage, from “bronze,” which will cover 60 percent of expected costs, to “platinum,” which will cover 90 percent. “Silver” and “gold” are in between. Bronze plans will charge the lowest premiums, but they’ll have the highest annual deductibles. Platinum plans will have the highest premiums and the lowest out-of-pocket cost sharing.
This part is insurance nerdy but an important point – The government’s subsidy will be tied to the premium for the second-lowest-cost plan at the silver coverage level that’s available in your area. You could take it and buy a lower cost bronze plan, saving money on premiums. But you’d have to be prepared for the higher annual deductible and copayments.
If you have additional questions regarding how SHOP Exchanges and Individual Exchanges can benefit you please contact our team at Millennium Medical Solutions Corp. Stay tuned for updates as more information gets released. We’re inside of 75 days until exchanges open, and information will be coming quickly in the next few months. Sign up for latest news updates.
Anti Mandatory Mail Order Victory. A little noticed NYS Healthcare Law has gone under the radar amidst fast changes in Affordable Care Act tumult. AMMO – Anti-Mandatory Mail Order passed late Dec 2011 effective for groups renewing after Jan 11, 2012. A significant signal by Governor Cuomo to stand up to the billion dollar industry no doubt.
According to trade group Pharmacists United for Truth the PBM (pharmaceutical benefits managemnt) claim that mandatory mail order lowers costs proves otherwisee. Plan sponsors are routinely charged far more than retail price in mandatory mail order plans, and their lack of transparency keeps plan sponsors to detecting the unreasonable prices.
After spending a good part of a day in early March helping a NYS client faced with mandatory mail order I learned of this change. For certain medications the insurer limits retail pharmacy coverage. While the incentivisation of 90 day supply at 2 copays was attractive this has now declined to 2.5 copay. With few exceptions such as specialty pharmaceuticals retail pharmacists are given the same advantages and evening the playing field.
The National Community Pharmacists Association’s blog post below offers a helpful FAQ. Additionally with the steady decline of the local independent pharmacist a quality of personalized care has been eroded. The price paid in patient compliance and safety has received little attention. Independent Pharmacists have been the canary in the mine for fellow small businesses competing with large copra big box chain stores. At least now NYS is finally listening.
Community pharmacists in New York scored a significant win for their patients, communities and pharmacy choice in late 2011 with the enactment of the Anti-Mandatory Mail Order or AMMO with overwhelming, bipartisan backing. What lessons might the campaign in support of the AMMO law hold for community pharmacists across the country?
To find out, NCPA recently asked one of the legislation’s staunchest supporters and advocates to share his observations on the effort to enact the AMMO law. Craig Burridge, M.S., is Executive Director of the Pharmacists Society of the State of New York (PSSNY). Mr. Burridge credits PSSNY members as most instrumental to enacting AMMO over the fierce opposition of mandatory mail order proponents, principally large pharmacy benefit managers (PBMs). He notes people including Ray Macioci, Charles Catalano, Vinny Chiffy and literally hundreds of pharmacy owners helped win a hard fought battle by gathering tens of thousands of signatures on petitions from their patients and coordinating tens of thousands of phone calls, emails and letters.
What follows is a Q&A with Mr. Burridge, in hopes that his advice would benefit patients and independent community pharmacists in other states advocating for patient choice.
NCPA: When it comes to the forced or mandated use of mail order pharmacies, many of the concerns expressed by patients and the community pharmacists who care for them are not new and have, in fact, been voiced for a number of years. What made 2011 different in New York?
Mr. Burridge: In New York, consumers by the tens of thousands signed petitions at their local pharmacy against mandatory mail order. Patients wrote dozens of letters to the editor of many regional newspapers telling about their horror stories with mail order. Finally, pharmacy owners had had enough of losing their patients to self-dealing PBMs. Tens of thousands of phone calls to the Governor’s Office and to Legislators were made by pharmacy owners, their staffs and their patients in support of passage of the no mandatory mail order bill.
NCPA: One obstacle to ensuring patient choice of pharmacy is the myth of mail order savings. This persists in some minds despite what appears to be rampant mail order waste and studies demonstrating how health plan sponsors that incent or require the use of mail order can end up paying more for drugs. Did you encounter such misperceptions and, if so, what did you do to alter or overcome them?
Mr. Burridge: We did in New York. The PBMs came at us with ads stating that costs would go up and that it was a ‘prescription drug tax’ or that it would ‘prohibit mail order.’ We responded with evidence that exposed the ‘spreads’ being used at mail for generics and the fact that the legislation requires participating pharmacies to agree to the same reimbursement and the same co-pays.
NCPA: The health care benefits of a patient’s face-to-face consultation with a community pharmacist and the preference of most patients for going to a local pharmacy are both well-established. But how did you chronicle and reinforce the economic and tax benefits of buying local when it comes to pharmacies?
Mr. Burridge: According to national data (IMS Health) for 2009, the last year we had data before introducing legislation, 22.8 percent of the national drug spend was for mail order prescriptions. Using New York’s percentage of total drug spend (11 percent), we removed hospital expenditures and Medicaid (which had less than one percent mail order) and came up with a mail order drug spend in NY in access of $5.8 billion annually. New York State has no major mail order facilities so this represents thousands of lost pharmacy jobs.
NCPA: Like PSSNY, NCPA continually stresses to its members the importance of grassroots activism, whether it is at the federal or state levels or with local employers and leaders. Did you find that your memberships became more engaged than usual in 2011 and, if so, what did you do to encourage their further involvement?
Mr. Burridge: It helped to have the PBM industry fly in colleagues from around the country and host their own Lobby Day. They told legislators that New York’s pharmacies could survive on acute medications only. This only caused yet another round of thousands of phone calls from our pharmacists, their staffs and patients. Our grass roots turned into a raging grass fire. Livelihoods were at stake and our opponents showed their hand. They wanted ALL maintenance medications going to their wholly-owned out-of-state mail order facilities. Our legislators saw that too.
NCPA: What surprised you the most about your 2011 campaign against mandatory mail order?
Mr. Burridge: I’ve been doing this too long to be surprised. We expected the worst from our opponents and they did not disappoint us.
NCPA: What were some of your opponents’ most challenging arguments and how did you address them?
Mr. Burridge: That depends if you consider outright lies as a challenge. Their ads said that it was a “Prescription Tax” or, when that flopped, they said our bill “would prohibit mail order.” These were easily swept aside and only upset legislators who felt the PBM industry was accusing them of passing a tax on prescription drugs.
NCPA: Do you have any other words of wisdom that you would like to share with concerned patients or your colleagues in community pharmacy?
Mr. Burridge: Choosing one’s pharmacy should be a basic right. If the playing field is level, it only makes sense to buy local. Watch out for PBMs calling all maintenance medications so-called ‘specialty drugs’ as a way of getting around no mandatory mail order laws. We’ll have a lot more to say on that in the near future.
In years past, most health insurance policies had limits or “caps” on the benefits they would pay. These limits were on any health plan participant (individual or family) – either over a lifetime or in a plan year. If someone exceeded that limit, benefits ended. While this rarely occurred, it resulted in major financial troubles for the few people it hit. The new law does not allow lifetime limits on”essential health benefits”. The law also restricts annual limits from now until 2014, when their use will become more limited. However, the law doesn’t prevent a plan from excluding all benefits for a condition.
Lifetime limits
Employers must eliminate lifetime limits on essential health benefits.
Effective
This applies to all health plans, including grandfathered plans.
Grandfathered plans will lose their grandfathered status if they impose an overall annual or lifetime limit on the dollar value of essential benefits if their plan did not include that limit prior to March 23, 2010. Plans can keep their grandfathered status if they convert lifetime limits into an annual limit at a dollar value that is lower than the lifetime limit on March 23, 2010.
Annual limits
Employers must eliminate annual limits by 2014. Until then, plans may place only “restrictive” annual limits on essential health benefits. The limits have been set for plan years that begin:
9/23/2010 to 9/22/2011 – $750,000 annual limit
9/23/2011 to 9/22/2012 – $1.25 million annual limit
9/23/2012 to 12/31/2013 – $2 million annual limit
Annual limits must apply on an individual-by-individual (not family) basis.
Essential Health Benefits defined
According to the law, the list of essential health benefits must include:
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
The government has not released the final regulation on essential benefits. Until it does, the government will take into account an employer’s “good faith effort” to comply with reasonable consistent interpretation.
With increase in demand and already shortages of Doctors the Obamacare – Affordable Care Act will put significant severe strains on patient access.
According to todays WSJ article – John C. Goodman: Why the Doctor Can’t See You “Here is the problem: The health-care system can’t possibly deliver on the huge increase in demand for primary-care services. The original ObamaCare bill actually had a line item for increased doctor training. But this provision was zeroed out before passage, probably to keep down the cost of health reform. The result will be gridlock.”
The Department of Health and Human Services, estimated the minimum number of primary care physicians to ensure “adequate supply” at 60 to 80 per 100,000 population. By 2020 an estimated 45,000 new PCP would ne needed 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.
The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.
“Take preventive care. ObamaCare says that health insurance must cover the tests and procedures recommended by the U.S. Preventive Services Task Force. What would that involve? In the American Journal of Public Health (2003), scholars at Duke University calculated that arranging for and counseling patients about all those screenings would require 1,773 hours of the average primary-care physician’s time each year, or 7.4 hours per working day.”
In 2014 an expected 30 Million people will be added The expected wait time would increase form 3 weeks to about 2 months. The 2 month estimate is a approximately how long it takes to schedule a check up in Boston which had enacted universal healthcare 5 years ago. Furthermore, the positive measures to encourage preventive care such as healthy screenings and well-care will only add to the gridlock.
“When people cannot find a primary-care physician who will see them in a reasonable length of time, all too often they go to hospital emergency rooms. Yet a 2007 study of California in the Annals of Emergency Medicine showed that up to 20% of the patients who entered an emergency room left without ever seeing a doctor, because they got tired of waiting.” Be prepared for that situation to get worse even with Urgent Care Centers.
“A New York Times survey of dermatologists in 2008 for example, found an extensive two-tiered system. For patients in need of services covered by Medicare, the typical wait to see a doctor was two or three weeks, and the appointments were made by answering machine.However, for Botox and other treatments not covered by Medicare (and for which patients pay the market price out of pocket), appointments to see those same doctors were often available on the same day, and they were made by live receptionists.”
As with any economic model the shorter supply of provider will drive up costs. Aside form provider fees increasing, those who can afford concierge service and pay $2,000-$4,000 may be able to get same day services and easy access but for most Americans with insurance will be waiting longer to see their Doctors. The irony is that people with coverage will have limited access to care.
Bluecard PPO – Outside members home region, the PPO medical plan is known as BlueCard PPO. The BlueCard plan offers a network of quality doctors and hospitals known as the BlueCard Provider Network.
freedom to seek care in-network or out-of-network;
no need to select a primary care physician to coordinate your care;
visit specialists directly — no referrals are required;
no claim forms to submit when using an in-network provider;
no balance bills when using an in-nework provider;
wellness programs, including fitness reimbursement and discounts on alternative health care services, at no additional cost;
enhanced programs to control and manage chronic conditions;
preventive care for children and adults;
enjoy in-network coverage anywhere in the United States when you use providers that participate in the Personal Choice or BlueCard PPO networks;
worldwide coverage and recognition of the Blue Cross® symbol.
How Does it Work?
Blank Suitcase Logo
A blank suitcase logo on a member’s ID card means that the patient has Blue Cross Blue Shield traditional, POS, or HMO benefits delivered through the BlueCard Program.
“PPO in a Suitcase” Logo
You’ll immediately recognize BlueCard PPO members by the special “PPO in a suitcase” logo on their membership card. BlueCard PPO members are Blue Cross and Blue Shield members whose PPO benefits are delivered through the BlueCard Program. It is important to remember that not all PPO members are BlueCard PPO members, only those whose membership cards carry this logo. BlueCard PPO members traveling or living outside of their Blue Plan’s area receive the PPO level of benefits when they obtain services from designated BlueCard PPO providers.
How to Verify Membership and Coverage
Once you’ve identified the alpha prefix, call BlueCard Eligibility to verify the patient’s eligibility and coverage.
1. Have the member’s ID card ready when calling.
2. Dial 1.800.676.BLUE.
Operators are available to assist you weekdays during regular business hours (7am – 10pm EST). They will ask for the alpha prefix shown on the patient’s ID card and will connect you directly to the appropriate membership and coverage unit at the member’s Blue Cross Blue Shield Plan. If you call after hours, you will get a recorded message stating the business hours.
Keep in mind BCBS Plans are located throughout the country and may operate on a different time schedule than Anthem Blue Cross and Blue Shield. It is possible you will be transferred to a voice response system linked to customer enrollment and benefits or you may need to call back at a later time.
International Claims
The claim submission process for international Blue Cross and Blue Shield Plan members is the same as for domestic Blue Cross and Blue Shield Plan members. You should submit the claim directly to Anthem Blue Cross and Blue Shield.
Doctor Shortages-covered but less access?
