Health Exchanges and Independent Agents

I am hearing and reading so much lately from the health insurance agent community about the future of agents under healthcare reform. Specifically as relates to the health insurance exchanges set for 2014. A minority believe that independent agents will have a place in the system while a majority, it seems, are suffering from "Chicken Little Syndrome". Truthfully, no one knows yet what place independent health agents will have in the new system. I do have some thoughts.

For those who know me and my business, I write a lot of HIPAA. HIPAA is guaranteed-issue health insurance, available kind of on an exchange (pick from available carriers and plans) and has no underwriting or medical screening component. Somewhat similar to the future exchanges (if you can get information which is generally only available on web sites like mine).

One would think that with the fairly small choice of guaranteed-issue plans (perhaps 25 at most in California) and fairly similar plan designs (HMO are similar and PPO/POS are similiar in deductible and general benefits) that choosing a HIPAA plan would be easy. Honestly, for every 10 people I help enroll under HIPAA, at least 9 of them need help in determining the most appropriate carrier and plan for their needs. And that is a good thing. Getting a coverage plan is important. Getting the best fit for coverage is more important.

There are a variety of factors that come into play during proper case development. Plan design and usage limitations are one area. Plan benefits and any exclusions or limitations is another. Then there is the network of participating providers and the prescription drug formulary to consider. All of these things before we really even look at the price of the plan. These services are easily and readily provided by independent agents who can compare multiple carriers and plans. The other option would be to call each carrier and then try to put it all together yourself. One of the problems with calling a carrier is...they only know their own plan. For example:

Blue Cross of California originated a plan in California called RightPlan PPO. It was the first no deductible non-maternity individuals-only PPO in California. It was subsequently copied by several other carriers and duplicated in their respective plan portfolios. Health Net has SimpleValue PPO (copy) and Blue Shield has ActiveStart PPO (copy).

Under the current market, you could call Anthem Blue Cross about the RightPlan PPO but they are not equipped to compare it against SimpleValue or ActiveStart. Each carrier only knows their own plans. You'd end up having to call three carriers, get whatever information you think is important, put it all together and try to decide which clone plan would work best. Or you could call an independent agent (for free by the way, there is no cost to have an agent) who can run that scenario for you.

Fast forward to the health insurance exchanges. Like HIPAA, the plans will all be similar but, like HIPAA, there will be differences between each insurance company's plans (network, formulary, benefits, tiers of drug coverage and so on).

Let's assume hypothetically that six companies in California offer plans to the exchange. The plans will be denoted as Gold, Silver, Bronze and Platinum. Benefit levels will be determined by mandates in the healthcare reform law. Seems simple enough, right?

Well, what if you take six medications and one of them is not in any drug formulary for the exchange plans? Which plans have tier 3 drug coverage and which don't. Are there restrictions on tier 3 benefits? How do I search their drug formulary? Are my doctors participating with this carrier's Gold plan? How about hospitals? Do the networks differ between Gold, Silver, Bronze and Platinum? Does this plan cover me locally only or can I use it in-network when I travel? Is this an HMO Gold, PPO Gold or POS Gold? What's the difference?

Needless to say, this list could go on forever.

Another factor that I believe may come into play are deviations from basic design. With Medicare Supplement plans, there are some carriers who offer the Medicare mandated benefits but also create enhanced plans with other options above the Medicare minimum standard. Could we see this in the exchange as well? I believe it is very possible. So instead of six carriers offer six Gold plans, you might see something like this:

Carrier A - Gold
Carrier B - Gold, Gold Preferred, Gold Plus, Gold Enhanced
Carrier C - Gold, Gold Preferred
Carrier D - Gold, Gold Select
Carrier E - Gold, Gold Select
Carrier F - Gold, Gold HMO

Gold = Standard Gold design based on reform rules for plan minimum standard
Gold Select = Gold plan benefits with a select network of providers (smaller)
Gold Preferred = Gold plan health benefits plus a long-term care rider
Gold Plus = Gold plan benefits with a dental HMO plan
Gold Enhanced = Gold Plus plan design (with dental) plus additional vision and chiropractic coverage
Gold HMO = HMO plan adhering to Gold plan design rules

Under this scenario, as many as 13 Gold plans could be available (or more, or less) from the six insurance companies. It could get really confusing really quickly. And what if they do the same with Silver and Bronze? Or Platinum?

The bottom line is that a person should not have to match their medical needs to a health plan. All of my case development for HIPAA plans is directed at matching the plan to meet the medical needs, not the other way around. While no plan is always absolutely perfect, good case development should find the one plan that, given overall medical needs, is the "best" fit for each client.

I would think, given these variables, that the role of the independent agent would be extremely important in matching people's medical needs with the appropriate health plan, whether through the exchange or privately outside of the exchange.

Certainly the states, or insurance companies, or federal government could set up "call centers" staffed by non-agents who would be available to review coverage options and answer questions. Would it be less expensive? Probably not. But more to the point, there comes a time in this business when experienced, veteran independent agents really get a feel for the way certain insurance companies operate with regard to networks, formulary and benefits. I have found that EOC (Evidence of Coverage) booklets are often sorely lacking in certain areas when it comes to benefit utilization or the way a claim is "really" processed. Just because something is written in a booklet or spreadsheet or benefit summary does not mean that is exactly how it works, or in all situations.

We learn from experience. I write mostly HIPAA. Claims for HIPAA tend to be much greater and much more varied than underwritten coverage. That is the nature of guaranteed-issue coverage. I have seen situations which absolutely contradict what was written in the benefit summary, spreadsheet or EOC. I have also learned over the years many of the little nuances of the plans and insurance carriers that can be very critical when a prospective client brings their medical needs to me.

I hope that our leadership understands the value that we independent health agents provide.

On a side note:

I was a bit saddened to read an article recently in an industry publication in which President Obama told a health agent who expressed concern about her career that she was "the one who has to tell her clients about the insurance company's rate increase". While that is part of our job, I'd like to think we do a bit more than just pass on rate increase information. I certainly hope this is not how our leadership sees us and perceives our value to our clients.

I don't always have time to tell people about rate increases since the carrier will tell them anyway. I am often quite busy running drug formularies, trying to find which network doctor X is actually in and trying to help my clients get the plan that will best cover their immediate needs like chemotherapy, heart surgery, infusion therapy, transplant surgery or self-injectible life saving medication.

Large Companies Contemplate Dropping Employee Health Coverage

The Dallas Morning News is reporting that several very large companies "have concluded that they might be financially better off canceling their health care coverage and moving their workers to government-subsidized exchanges that will be available in four years".

At least four companies have investigated to varying degrees the impact of dropping health care coverage and pushing their workers onto the new exchanges, where they will be able to buy their own insurance.

While doing this would subject companies to fines, the size of the fines would be substantially less than the cost of providing health insurance to their workers.

The four companies identified so far are:

*AT&T
*Verizon Communications, Inc.
*Caterpillar, Inc.
*Deere and Co.

If these four are looking at this option, it is a pretty safe bet that other large employers are doing the same.

Temporary Risk Pool (California)

Just a quick update on one of the provisions of healthcare reform that goes into effect in September--the temporary risk pools for the uninsurable who have 6 months or more uninsured (and are uninsurable).

Each state was given the option to use a federal risk pool (HHS) or, if that state has its own risk pool, to use the state program and receive federal $$ for it ($5 Billion earmarked for these temporary risk pools).

While I assume California will likely us the California MRMIP program for eligible California residents, a decision has still not been made by the MRMIB (Major Risk Medical Insurance Board) in Sacramento.

I called them this week for an update and was told that they are still meeting about it and working through the myriad of implications for using MRMIP.

I will provide updates as they become available and as we get closer to the initial changes under the new Healthcare Reform law.

For more information on California's MRMIP health insurance risk program (and other state programs), visit my CalHealth page.

This Is What Happens When You Don't Read The Bill!

I guess someone forgot to tell the administration and those who voted for health insurance reform to actually read the bill.

The current bill signed into law yesterday does not, in fact, provide guaranteed-issue health insurance coverage from children this year, sort of.

I assume this will be fixed but we will have to wait and see.

Gap in law for children's healthcare protection

Impact - MLRs (Medical Loss Ratios)

I am watching President Obama sign the new health insurance (care) reform bill on CNN. I wanted to share some things I have heard recently that may eventually impact the number of carriers in California selling individual and family plans either through exchanges or privately, or both.

While carriers (insurance companies) can boast an overall MLR (medical loss ratio) above 85%, this number is generally inclusive of all sectors of insurance (large group, small group, individual and senior). However, when small group and individual (especially individual) is segregated out, the MLR often falls well below 80% with an average running about 74% on individual and family health plans.

"MLR" is the ratio of premiums paid in to what is paid out for medical care and wellness. The current reform will require in 2011 that all carriers selling individual and family plans must meet 80% MLR in that market. That means every company selling health plans in California by 2011 must be spending at least 80 cents of every dollar received in premiums on healthcare and related expenses.

I will save the reduction in administrative costs necessary for another post. Needless to say it certainly is probable that reduction in those expenses, including agent commissions, will occur.

My concern is if and how some carriers will be able to meet the new MLR.

I suspect that some carriers may choose to exit the market in California instead of trying to achieve 80% MLR on individual & family health coverage.
I will be curious to see who is left standing between now and 2014.

Health Insurance Reform Has Passed

In a very close vote, HR 3590 was passed this evening 219-212.

Health Insurance Reform - What To Expect

Happy Sunday to you all. I am watching the House vote and waiting for the final determination on the Health Insurance (Health Care) Reform Bill.

Since I have received many questions concerning changes I thought I'd quickly summarize here what to expect initially if/when this Bill is passed and signed into law today.

During the first year you can expect:

Pre-Existing Conditions - The Bill includes $5 billion in immediate support to provide temporary coverage to uninsured Americans with pre-existing conditions. The money would help until the new health insurance exchanges are created in 2014.

Elimination of Benefit Caps - New policies sold will not have annual caps on benefits nor lifetime caps on benefits.

Children with Pre-Existing Conditions - Children with pre-existing health conditions will not be excluded from purchasing health insurance coverage.

Preventive Care - New insurance policies will be required to offer free preventive care benefits.

Small Business Tax Credit - A tax credit for small businesses up to 50% of premiums to help small businesses purchase health insurance.

Help for Seniors - $250 towards drug coverage in the "donut hole" to help pay for prescription drugs.

Appeals Process - An independent appeals process will be set up for those who feel that they were unfairly denied a claim by their insurance company.

Other changes take place in 2014 and beyond.

Medicare You Can Buy Into Act - Grayson (D-FL)

Congressman Alan Grayson of Florida has authored H.R. 4789. The Bill, titled "Medicare You Can Buy Into Act" or "Public Option Act", would open up Medicare enrollment to US residents of all ages 19 and above. The link below is for this bill, which is only four pages long.

Read The Bill Here