This week I have been asked about this so many times that I wanted to address some confusion concerning federal COBRA.
Federal COBRA runs a standard 18 months, not 15 months. There are cases where it can be 29 months (disability extension) or 36 months (divorce, separation, death of the employee, state extension or dependent age-off of parent's plan). Generally it runs 18 months for most people.
The subsidy for COBRA (for those who qualify) runs 15 months. It was originally set up to run 9 months but was extended.
You do not exhaust or lose COBRA at 15 months. You only lose the subsidy at 15 months. You still have 3 more months of COBRA (or more if extended) after the subsidy goes away.
You are not eligible for HIPAA at 15 months. You have to complete the 18 months.
Sunday, May 23, 2010
Bintang Leo dlm Ramalan tahun 2010
Ramalan Bintang Leo
Kesibukan membuat kalian jarang bertemu. Karena kedewasaan Anda berdua, hal itu tidak mempengaruhi hubungan. Anda berdua saling merindu. Karier Anda akan melejit dengan cepat. Anda mempunyai sifat yang aktif dan selalu berusaha untuk maju. Bagi Anda waktu merupakan sesuatu yang berharga. Kesehatan Anda berpengaruh pada perjalanan panjang yang akan dilakukan. Sebaiknya Anda mempersiapkan obat-obatan untuk mengantisipasi hal yang tidak diinginkan.
Asmara : Cinta sejati bisa bertahan
Keuangan: Kegigihan bisa mendapatkan lebih
Kesehatan: Cepat ngantuk, jangan dianggap remeh
Jodoh dan Keuangan untuk Bintang Virgo
Thursday, May 20, 2010
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.
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.
Wednesday, May 19, 2010
MRMIP Clears Backlog (No Enrollment Waiting Period)
The California MRMIP (Major Risk Medical Insurance Program) has apparently received some additional funding and has cleared the backlog of applications.
As of today (5/19/10) there is no waiting list for MRMIP enrollments.
I am working on obtaining specific information regarding the federal temporary risk pool which is scheduled to open July 1. In the meantime eligible uninsurables may enroll in the MRMIP without an enrollment waiting period.
More MRMIP information here
As of today (5/19/10) there is no waiting list for MRMIP enrollments.
I am working on obtaining specific information regarding the federal temporary risk pool which is scheduled to open July 1. In the meantime eligible uninsurables may enroll in the MRMIP without an enrollment waiting period.
More MRMIP information here
Monday, May 10, 2010
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.
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.
Sunday, May 9, 2010
HIPAA Enrollment Change (Yet Again) - Anthem
Anthem Blue Cross (CA) has made another enrollment change to the HIPAA plans.
Under the prior change, all enrollments in HIPAA were subject to approval followed by a premium notice. The notice would allow payments in two 15-day periods (1-15th, 16-31st paid or postmarked) to start on the first of the following month. Example:
*Premium paid or postmarked 1-15 June would start July 1 (30-day gap)
*Premium paid or postmarked 16-30 June would start August 1 (60-day gap)
Under the latest change, the premium payment period has changed as follows:
*Premium paid or postmarked 1-15 June would start June 1 (slightly retroactive)
*Premium paid or postmarked 16-30 June would start July 1
Also, Anthem Blue Cross CA has indicated that it will accept certain "substitute" documents in lieu of the Certificate of Creditable Coverage which is not issued until after the expiration of continuation coverage.
Under the prior change, all enrollments in HIPAA were subject to approval followed by a premium notice. The notice would allow payments in two 15-day periods (1-15th, 16-31st paid or postmarked) to start on the first of the following month. Example:
*Premium paid or postmarked 1-15 June would start July 1 (30-day gap)
*Premium paid or postmarked 16-30 June would start August 1 (60-day gap)
Under the latest change, the premium payment period has changed as follows:
*Premium paid or postmarked 1-15 June would start June 1 (slightly retroactive)
*Premium paid or postmarked 16-30 June would start July 1
Also, Anthem Blue Cross CA has indicated that it will accept certain "substitute" documents in lieu of the Certificate of Creditable Coverage which is not issued until after the expiration of continuation coverage.
Wednesday, May 5, 2010
A Good Story (sadly not health insurance but life insurance)
Every day it seems the health insurance companies are making mistakes, denying claims, rescinding coverage and all of the rest. They pay claims grudgingly (if at all) and, according to many media sources, try to get out of paying as many as they can.
I asked my doctor during a recent checkup if it was true what 'Dr. Dean' says about doctor spending 1/2 their time working on patient files. He told me "not anymore", most of his time is spent fighting with health insurance companies. Sigh!
So, I wanted to share the following true story. It is not a health insurance story, but a life insurance story. I dream of the day even one California health insurance company could tell a story like this. I doubt any of them could..........
In 1999 I attended the annual agents meeting of Northwestern Mutual Life in Milwaukee, WI. This is an annual "must" for NML agents and it is both educational and a lot of fun.
Then-CEO Jim Ericson opened the first morning session with the following story (and yes it has stuck with me 11 years now).
In early 1999 an agent's client applied for a life insurance policy for his young teenage daughter. Something for the future I guess. Well, for some reason the case got hung up in underwriting and they didn't get what they wanted with medical records and never completed the underwriting.
The client called his agent in late spring to inquire as to whether or not the life insurance policy on his daughter was ever issued. The agent checked and told his client that it had not completed underwriting and was never issued.
The client told his agent, "well, I guess it doesn't matter anyway, my daughter has passed away".
The agent took the case to NML where it ended up on the desk of Mr. Ericson. He directed his underwriting department to complete the underwriting on the young girl's application and report to him whether or not the policy would have been issued at that time (given the missing information).
Underwriting reviewed the application, received the missing information and reported to Mr. Ericson that, indeed, a policy would have been issued at that time had they received all of the information they required.
Mr. Ericson directed Northwestern Mutual Life to issue the life insurance policy posthumously on the young girl, waive premium payments, and immediately pay the benefit to the beneficiary.
Northwestern Mutual did not have to do this. They could have simply said that the policy was never issued due to missing medical information. But they didn't.
This story never made the press, was never published in any newspaper. Quietly, as their nickname "The Quiet Company" suggests, they made a decision to do the right thing, or more to the point, to do the honorable thing.
It's about honor and being honorable. That's what it really means to be an insurance company!
I asked my doctor during a recent checkup if it was true what 'Dr. Dean' says about doctor spending 1/2 their time working on patient files. He told me "not anymore", most of his time is spent fighting with health insurance companies. Sigh!
So, I wanted to share the following true story. It is not a health insurance story, but a life insurance story. I dream of the day even one California health insurance company could tell a story like this. I doubt any of them could..........
In 1999 I attended the annual agents meeting of Northwestern Mutual Life in Milwaukee, WI. This is an annual "must" for NML agents and it is both educational and a lot of fun.
Then-CEO Jim Ericson opened the first morning session with the following story (and yes it has stuck with me 11 years now).
In early 1999 an agent's client applied for a life insurance policy for his young teenage daughter. Something for the future I guess. Well, for some reason the case got hung up in underwriting and they didn't get what they wanted with medical records and never completed the underwriting.
The client called his agent in late spring to inquire as to whether or not the life insurance policy on his daughter was ever issued. The agent checked and told his client that it had not completed underwriting and was never issued.
The client told his agent, "well, I guess it doesn't matter anyway, my daughter has passed away".
The agent took the case to NML where it ended up on the desk of Mr. Ericson. He directed his underwriting department to complete the underwriting on the young girl's application and report to him whether or not the policy would have been issued at that time (given the missing information).
Underwriting reviewed the application, received the missing information and reported to Mr. Ericson that, indeed, a policy would have been issued at that time had they received all of the information they required.
Mr. Ericson directed Northwestern Mutual Life to issue the life insurance policy posthumously on the young girl, waive premium payments, and immediately pay the benefit to the beneficiary.
Northwestern Mutual did not have to do this. They could have simply said that the policy was never issued due to missing medical information. But they didn't.
This story never made the press, was never published in any newspaper. Quietly, as their nickname "The Quiet Company" suggests, they made a decision to do the right thing, or more to the point, to do the honorable thing.
It's about honor and being honorable. That's what it really means to be an insurance company!
Monday, May 3, 2010
Blue Shield CA Adds 5th HIPAA Policy
Effective May 1, 2010, Blue Shield of California has added a 5th policy to the HIPAA guaranteed-issue individual & family portfolio.
The new addition, Access+ Value HMO, is a lower-priced HMO option than the Access+ HMO that was made available 3/2/10.
This is the first time I have seen a carrier offer three plans under one plan registration for HIPAA.
The new addition, Access+ Value HMO, is a lower-priced HMO option than the Access+ HMO that was made available 3/2/10.
This is the first time I have seen a carrier offer three plans under one plan registration for HIPAA.
Thursday, April 29, 2010
MRMIP Will Not Be Used For Risk Pool
Today the CA Governor announced that California will not use the MRMIP program as the temporary high risk pool for uninsurable California residents.
Instead, MRMIP will continue to operate alongside the federal risk program to be established by HHS in the next few months.
Stay tuned for more details on the temporary risk pool and how to enroll. Remember, the federal risk pool is a temporary program to 2014 to help cover those who cannot obtain private health insurance and have been without insurance coverage for six months or longer.
MRMIP is a California state risk program for CA residents who are unable to obtain private health insurance. The current waiting list for MRMIP enrollment is 3-4 months from application submission.
Instead, MRMIP will continue to operate alongside the federal risk program to be established by HHS in the next few months.
Stay tuned for more details on the temporary risk pool and how to enroll. Remember, the federal risk pool is a temporary program to 2014 to help cover those who cannot obtain private health insurance and have been without insurance coverage for six months or longer.
MRMIP is a California state risk program for CA residents who are unable to obtain private health insurance. The current waiting list for MRMIP enrollment is 3-4 months from application submission.
Anthem CA Rate Increase Withdrawn
According to KGO Radio, Anthem Blue Cross CA has withdrawn the proposed 39% rate hike for California. Apparently they will be re-working the numbers for a more moderate change at some point in the future. Members will be given 30 days notice before any rate changes would go into effect.
KGO Article
KGO Article
Friday, April 23, 2010
Anthem Fights Back (Finally!)
On Thursday, a "reporter" at Reuters wrote a story about Anthem/Wellpoint deliberately rescinding health insurance policies on women who developed breast cancer. The article, which was then rebroadcast by other media, is full of factual errors (one of the women was not even insured by Anthem/Wellpoint and another's name was mispelled throughout the article). The media "report" even caused HHS Secretary Sebelius to fire off a nasty letter to Angela Braly (CEO Wellpoint/Anthem).
After getting beaten up over the last few months and being portrayed as an evil cross between Attila The Hun and Adolf Hitler, Anthem finally is fighting back against this kind of lazy and inaccurate "journalism".
Anthem Response to Reuters Article
Anthem Response to HHS Sebelius' Letter
It gets better, folks. The url for the original story is no longer active and the "corrected" story (minus the woman who was not even a Wellpoint/Anthem insured) is available here. Here's the top quote on the "revised" article:
After getting beaten up over the last few months and being portrayed as an evil cross between Attila The Hun and Adolf Hitler, Anthem finally is fighting back against this kind of lazy and inaccurate "journalism".
Anthem Response to Reuters Article
Anthem Response to HHS Sebelius' Letter
It gets better, folks. The url for the original story is no longer active and the "corrected" story (minus the woman who was not even a Wellpoint/Anthem insured) is available here. Here's the top quote on the "revised" article:
Corrected: WellPoint routinely targets breast cancer patients(Removes all references to Robin Beaton in first paragraph and throughout to reflect that the insurance company that canceled her policy was not a WellPoint subsidiary)
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 $$ for it ($5 Billion earmarked for these temporary risk pools).
While I assume California will likely us the California MRMIP program for eligible California residents, a decision has still not been made by the MRMIB (Major Risk Medical Insurance Board) in Sacramento.
I called them this week for an update and was told that they are still meeting about it and working through the myriad of implications for using MRMIP.
I will provide updates as they become available and as we get closer to the initial changes under the new Healthcare Reform law.
For more information on California's MRMIP health insurance risk program (and other state programs), visit my CalHealth page.
Each state was given the option to use a federal risk pool (HHS) or, if that state has its own risk pool, to use the state program and receive federal $$ 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.
The HIPAA Tango Continues (Anthem Blue Cross)
For those who may be looking at my HIPAA page and wondering what is going on with Anthem Blue Cross enrollments, I thought this might help (I hope!).
Effective 5/1/10, Anthem has a new enrollment process for HIPAA plans. The process works like this: application and supporting documents to get approval to enroll, premium notice sent out upon Anthem's "OK" to enroll (approval), then you pay future premium to get future start date. Gaps can run 30, 60, 90 days or more. Sounds crazy, huh?
I have spent the better part of this week tee-ing off Anthem trying to get clarification and work-arounds for enrollments for Californians in need of HIPAA coverage and don't want to gap coverage.
So, to answer the question of whether or not there would be a necessary gap in coverage from group to HIPAA, a firm "maybe". It is going to depend on how early on we can start the process.
It is possible to enroll under the new system at Anthem and have a seamless start date. But it is tricky. Here's what needs to happen to make it work.
60 days prior to the expiration of continuation (or loss of group is terminating active coverage), we will need to provide some or all of the following to help get you enrolled:
1. Completed HIPAA enrollment application.
2. Copy of Termination Notice (either COBRA, Cal-COBRA or from group. This is a letter you receive about 60 days prior to exhaustion indicating that your continuation coverage will expire on a certain date.
3. Records to reflect payments of premiums for the full period including the final month (bank online statements, letter from administrator, etc.). Something to show you've made 18 or 36 months of premium payments (if continuation coverage).
4. Copy of current health insurance ID card and name of employer (usually on the card)for those not eligible for the Cal-COBRA extension to 36 months.
5. If covered 1st 18 months federal COBRA and now on Cal-COBRA extension, a copy of your group health certificate issued after federal COBRA expiration (from the COBRA Administrator or Health Plan)
The purpose of such documentation is twofold. One, we need to help you get Anthem Blue Cross to generate a premium payment "approval letter" as soon as possible within the 60 days prior to eligibility date so that you can submit your HIPAA premium and receive your desired 1st of month start date. Two, your Group Health Certificate (Certificate of Creditable Coverage/Certificate of Prior Health Coverage, it goes by several names) will normally not be provided until 10 days AFTER the expiration of the group health plan. Anthem has stated that they will accept "substitute" proof of exhaustion in lieu of the CoCC to expedite the enrollment process.
Effective 5/1/10, Anthem has a new enrollment process for HIPAA plans. The process works like this: application and supporting documents to get approval to enroll, premium notice sent out upon Anthem's "OK" to enroll (approval), then you pay future premium to get future start date. Gaps can run 30, 60, 90 days or more. Sounds crazy, huh?
I have spent the better part of this week tee-ing off Anthem trying to get clarification and work-arounds for enrollments for Californians in need of HIPAA coverage and don't want to gap coverage.
So, to answer the question of whether or not there would be a necessary gap in coverage from group to HIPAA, a firm "maybe". It is going to depend on how early on we can start the process.
It is possible to enroll under the new system at Anthem and have a seamless start date. But it is tricky. Here's what needs to happen to make it work.
60 days prior to the expiration of continuation (or loss of group is terminating active coverage), we will need to provide some or all of the following to help get you enrolled:
1. Completed HIPAA enrollment application.
2. Copy of Termination Notice (either COBRA, Cal-COBRA or from group. This is a letter you receive about 60 days prior to exhaustion indicating that your continuation coverage will expire on a certain date.
3. Records to reflect payments of premiums for the full period including the final month (bank online statements, letter from administrator, etc.). Something to show you've made 18 or 36 months of premium payments (if continuation coverage).
4. Copy of current health insurance ID card and name of employer (usually on the card)for those not eligible for the Cal-COBRA extension to 36 months.
5. If covered 1st 18 months federal COBRA and now on Cal-COBRA extension, a copy of your group health certificate issued after federal COBRA expiration (from the COBRA Administrator or Health Plan)
The purpose of such documentation is twofold. One, we need to help you get Anthem Blue Cross to generate a premium payment "approval letter" as soon as possible within the 60 days prior to eligibility date so that you can submit your HIPAA premium and receive your desired 1st of month start date. Two, your Group Health Certificate (Certificate of Creditable Coverage/Certificate of Prior Health Coverage, it goes by several names) will normally not be provided until 10 days AFTER the expiration of the group health plan. Anthem has stated that they will accept "substitute" proof of exhaustion in lieu of the CoCC to expedite the enrollment process.
Wednesday, March 24, 2010
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
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
HMO health insurance plans
Health Maintenance Organizations (also widely referred to as HMOs) is a variation of health benefits distribution, which provides coverage on a fee-for-service basis. Insurance companies that provide HMO coverage plans each have an agreement with certain medical facilities and professionals in order to offer reduced fees to those, who purchase such plans.
What HMO plans are all about?
HMO plans are based around primary care physicians (PCPs) that a person buying such a plan has to choose from the network of medical providers the company works with. The PCP is the person who will manage and coordinate all the actions and services provided to the customer, as well as offer consulting and basic care measures such as check ups and exams. Preventive medical services are usually free of copayments within HMO plans.
In case the health problem of a person exceeds the professional field of knowledge of the PCP, the doctor refers this patient to another physician specialized in that very domain. The said specialist will further investigate the problem and use his expertise to resolve it, but only after he or she receives the referral from the PCP. Otherwise, you won't be able to receive any medical attention with the exception of situations of critical emergency when the risk of complications is very high.
The coverage you receive through an HMO plan is provided only within the limits of the medical network specified by your provider. In case the member of an HMO plan chooses to receive any medical services in a facility that doesn't make part of the network, there won't be any coverage and the person will cover all the expenses in full out of own pocket. Besides, HMO plans will allow you to receive medical care from an additional specialist only when you have the corresponding referral provided by your PCP. Otherwise, this is regarded as using out of network services and your expenses won't be covered at all even if it's the same medical facility where your PCP is located.
Why would you want to choose an HMO health insurance plan?
HMOs represent the most affordable and cheap health insurance amongst managed care options. If comparing the rates of POS or PPO, HMOs offer lower premiums and fewer copayments. This is why many employees choose HMOs as the type of group insurance plans for their workers. This is especially useful for those, who rarely visit a doctor and don't need an extensive medical care with their plan or don't have pre-existing conditions that they want to cover. Employers find these plans useful because they can cut their costs and provide additional benefits to their workers rather than paying only for health insurance.
If you are worried by the constant trend of medical costs and insurance rates rising every year, it's highly recommended to see if an HMO plan meets your insurance requirements. Get health insurance quotes from multiple providers and you will definitely find a good plan for a reasonable and competitive price. However, if you have more specific insurance needs and can spend additional money on extensive coverage, it's better that you investigate other plan options outside HMOs.
Preferred Provider Organization health insurance possibilities
In case you are looking for a comprehensive type of health coverage with much room for flexibility that still has a reasonable price-tag, a PPO insurance plan may be just the thing you need to cover your health needs.
Preferred Provider Organizations represent a network of medical workers, facilities and other professionals that are contracted by the insurance company in order to get more competitive fees for their customers. So those who are getting their medical services within the specified network will be charged with lower rates than if looking for them outside. However, you can still receive medical coverage outside the network too, only that your rates will be higher compared to what you get within the network.
PPOs can be regarded as a mix of traditional indemnity health plans and later-developed managed care options. In what concerns the network organization of medical services, PPOs are quite similar to HMO insurance plans. However, when you get a PPO plan, you aren't required to choose a primary care provider (PCP). It's the main difference between these two quite similar health insurance plan types. And since there aren't any PCPs in PPO plans, you aren't required to provide a referral when addressing any given specialist within the network. And when you receive your medical care in a facility or with a specialist outside the specified network your copayments will be considerably higher, but you still will receive partial coverage.
The advantages of PPO plans:
- PPO plans help keeping out of pocket costs within certain annual limits.
- PPO plans let you consult with any medical service provider even if he or she doesn't make part of your network.
- PPO plans offer substantial money saving potential when receiving healthcare services within the specified network of doctors and facilities.
The disadvantages of PPO plans:
- PPO plans require you to pay the deductible before receiving any coverage.
- PPO plans make services you get outside the specified network a lot more expensive.
- PPO plans have higher copayment rates if compared to other managed plan types.
Flexibility has its price
As my may guess, when a plan provides more flexibility and options it will usually cost more than a cheap health insurance plan with greater restrictions. That's why PPOs are generally more expensive than HMOs.
Even in case you choose a lower amount of coverage with your PPO plan, there are additional fees and payments that will make your plan more expensive. So don't base your estimations on the amount of coverage alone.
For instance, besides the usual premiums you have to pay every month, there are also additional coinsurance fees, except for the cases when you use a preventive healthcare service. There is also a deductible to be paid before you can receive any benefits from your PPO plan.
How to get a good plan?
Sometimes it may be quite hard to get a good PPO plan that would provide increased flexibility for a reasonable price. If you feel that a PPO plan is just the thing you need to cover your medical costs, you first would want to get health insurance quotes from numerous providers or talk to your insurance agent about the options you have. Shopping around doesn't take much time but as a result you can expect substantial savings if you manage to select the right provider.
What does form the auto insurance rates?
Most of insurance buyers often forget that they are insuring a certain thing and it directly influences the final price of the policy. When speaking about auto insurance, the car you drive is the primary factor that affects your insurance costs and at certain moments the insurance company point of view of the car can be quite surprising to usual drivers. Insurance companies have internal charts and ratings, assessing how much it will cost you to insure any given car make or model. And the primary elements that set the car in this rating are the risk factor and the theft factor of this particular make and model. The risk factor relates to how the car will perform in an accident and how likely it is to end up in one, while the theft factor, eventually, deals with the likelihood of the vehicle to be stolen.
When a new car comes out, it is placed at a certain place within the rating as compared to other similar models and the insurance rates are set accordingly. And as experience with this particular model accumulates in the company's records, the model can be moved in either direction within the rating, making it cheaper or more expensive to insure. Of course, other things like your driving record and credit score also influence the cost of insuring your vehicle, but the car is actually the most important and crucial factor you will have to deal with.
In general, it will be more costly for you to insure sports cars, luxury cars and SUVs. Some companies rate SUVs differently because of their increased safety for the people inside, while others take in regard the fact that these vehicles are likely to cause more collision damage than others. Sports cars are much more likely to end up in a serious or even tragic accident due to their power and speed that is so tempting to be pushed to the limits. And luxury cars are usually the target of auto theft due to their price, and are more expensive to repair because of exclusive parts and costly service.
Car insurance experts state that the most attractive and non-expensive class of vehicles to insure are mid-class and middle sized cars. It is important that the car has good crash-test ratings and additional safety features installed, being safe in case of an accident. Small light-weight cars are cheaper to repair but they get damaged more easily and this may lead to serious injuries to those who are inside of it. The higher is the mass of your vehicle the less damage it will take in case of collision. That's why big SUVs are considered to be quite safe from this point of view.
It is good to see what car insurance rates you can get for different cars before you actually buy the auto. If the question of insurance price really concerns you then choose a vehicle that is cheaper to insure. And if the rates don't bother you much, just buy a car that you really like.
POS (Point of Service) health insurance benefits explained
When it comes to health coverage these days, we sure have a lot of various options to choose from. One of such options, which has become quite popular lately are Point Of Service (POS) plans that can be viewed as a mix of traditional indemnity and modern managed coverage options. And what such a combination provides you with are money saving potential and flexibility, all in a single package.
Health coverage on two levels at once
People familiar with HMO plans can easily see the similarity between HMOs and PPOs when it comes to organizing the services. Here you are also required to choose a PCP (Primary Care Physician), who will coordinate your services and provide referrals to other specialists within the network when required. But you are also free to choose any facility or physician that doesn't make a part of the specified network. And a POS plan will pay for such services out of the network, however to a narrower extent than with in-network services. So it will still cost you less to get your services within the POS network.
This is what is meant by two levels of insurance coverage, which are called "in plan" and "out of plan" health insurance. In plan coverage is usually more advantageous but it also has tighter restrictions imposed on the user. Like in case of HMO plans, in order to get full coverage at the "in plan" level you will have to provide a referral from your PCP and get your services within the network. You will also sometimes be required to get additional approval from your insurance administrator beforehand.
This all means that even sticking to the specialists and facilities of your POS network won't give you full coverage unless you provide a referral from your PCP. This is the so called "red tape", which is one of the biggest complaints about managed insurance plans and the formalities within them. However, when compared to indemnity plans, managed health care provides substantial money saving possibilities that can't be beaten.
The indemnity part of POS
POS plans provide the best of both worlds, that's why they are so popular. And when it comes to the indemnity part of POS plans, people find a lot of flexibility and freedom that just can't be obtained through typical managed care options. Just like in the case of PPO plans, you are still able to get insurance coverage even when addressing to a specialist outside of the POS provider network.
In other words, you can use "self-referrals" in order to get care from a specialist you choose. When treatment is required, you are free to choose any physician or facility without needing a special referral from your PCP, Still, you won't get much coverage when choosing this option, so flexibility still has its price.
However, this is a great way to avoid the restrictions typical for managed care plans. That will be very useful for those who have a long-term trusted physician outside the network. Still, in such a case you will have high co-insurance payments (up to 40%) that will make your visits a bit more costly if compared to a doctor from the POS network.
Finding the right plan
In order to get cheap health insurance with your POS plan you have to shop around first. Try getting as much health insurance quotes from different providers as you can, compare them and choose the right policy.
EPO (Exclusive Provider Organization) health insurance in-depth overview
Having an Exclusive Provider Organization (EPO) means that the medical service providers you will receive care from should have signed up an agreement with the insurance company to allow offering you these services. This way EPO plans are somewhat similar to PPO (Preferred Provider Organization) plans, meaning that the person having such a plan can obtain inexpensive medical services at a facility that makes part of the EPO network. Still, if you choose to receive your medical care at a facility outside the network, a PPO plan will still cover your costs, only to a smaller extent. With most EPO plans, you won't receive any insurance coverage when visiting a specialist outside the network.
When you choose an EPO plan, you will instantly notice that the fees you are charged with by the medical service providers that have accepted to join your insurance company's network are significantly lower than those normally charged. So when you receive your health benefits within the EPO network, you can rest assured that the rates you will be charged for the services will be very advantageous and your insurance provider will pay for all the services you receive.
However, if you have a condition that none of the specialists making part of the EPO network can help you with and you are forced to seek medical attention outside of the network, make sure you have enough money because you will pay for the service to the full extent. This is because EPO plans do not include any services provided outside the selection of facilities and specialists that have an agreement with the insurance carrier. Moreover, in contrast with PPO and HMO plans that have fairly large networks of health service providers, EPO plans usually have a much smaller number of specialists and facilities being part of their network. This means that you have fewer professionals to choose from when you need medical attention.
In what concerns health service providers, their advantage in joining an EPO network is in the increased number of patients they work with. So instead of charging higher rates to a smaller number of patients, they charge lower rates for a much higher number of people and get more revenue as a result. This is especially useful to those providers who target themselves at a certain geographical area and want to get more people through group health insurance coverage plans. The insurance companies, which choose to provide EPO plans charge their customers with monthly premiums and act as mediators between the customers and the medical service providers.
As a conclusion, EPO plans would definitely be appealing to those looking for cheap health insurance and having no special medical needs such as pre-existing conditions. The group of people who will probably benefit the most from such plans are young healthy workers with no serious health risks. And those who will find EPO plans quite uncomfortable are older people with complicated conditions that need regular and special care from certain specialist, who may be outside the network. Think well before you purchase such a plan and make sure to shop around to get the best rates. Use health insurance quotes online or contact your agent to see what local providers can offer and start from there.
Tuesday, March 23, 2010
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.
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.
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