It's Novermber and Everybody's Busy (Too Busy to Talk)

The days before Thanksgiving are a time of unrelenting activity. Some people are finalizing the big meal for Thursday. Others are preparing for the December holidays. In fact, I’ve been told that there are even elves working overtime somewhere near the North Pole. Thanks to climate change they are wearing Hawaiian shirts, but they are still working hard.

Speaking of working hard, the folks at the Department of Health and Human Services (HHS) have been very busy this week. On Tuesday, November 20, 2012, our busy elves at HHS released a new set of rules and regulations designed to flesh out the Patient Protection and Affordable Care Act (PPACA).

Tuesday’s new rules and regs cover a host of areas from defining the benefits to creating the framework for future premiums and options. You can find the public relations version of all of this at healthcare.gov. Don’t worry about going to the government’s website. This will all be coming to you – on TV, on billboards, and door-to-door solicitation, if necessary – thanks to a special campaign.
The new rules reaffirm the definition of the Essential Health Benefits (EHB). The PPACA demands that all policies offered for individuals and small groups provide coverage for a “core package of items and services known as Essential Health Benefits. EHB must include items and services within at least the following 10 categories”:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription Drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

Most of this looks pretty reasonable. Though you may wonder how much that maternity benefit will add to the cost of a woman’s policy. And if that woman can’t have children, how much is she wasting?

Employer sponsored group health policies have included maternity “covered as any other illness” for years. We know how to evaluate the risk and how much each policyholder needs to pay. That is, after all, the concept of insurance – evaluate risk and share the cost. What happens when the risk is open-ended? How do we share an unknown cost?
#7, above, is coverage for rehabilitative and habilitative services and devices. We are all familiar with rehabilitative care such as physical therapy which is designed to restore the patient to his/her former state of health and previous level of skills. The current fight over rehabilitative care is about the number of treatments. Today’s policies cover 15, 20, or maybe 25 visits to the physical therapist. We don’t know if future policies will be allowed to have such limitations. But rehabilitative coverage is much easier to assess than habilitative.

Habilitative therapies create skills. Teaching an autistic child to interact with his/her peer group is a wonderful thing. In fact, improving social skills and communication is life-changing for the children and adults touched by autism and certain forms of mental illnesses. Those suffering from other illnesses or conditions, such as cerebral palsy, have had their lives improved through habilitative care. Much of this has been open-ended, where patients weren’t actually cured, just made better. So as long as someone was willing to pay for services, another appointment was warranted.

Both the government, through Medicare and Medicaid, and the insurance industry have fought habilitative care for decades. The insurance industry lives by black and white. Habilitative therapies exist in a grey area. The industry has avoided paying for much of these services by labeling them experimental or educational. That may end soon.

Do you care? Is this good? As always, the answer is Yes and No.

Please don’t get distracted by the pictures of your neighbor’s autistic child. This has very little to do with her. It is important to remember that the healthcare debate has very little to do with health. With the possible exception of someone personally touched by a particular condition, this is, and always has been, a discussion of how we compensate doctors and hospitals. Who gets paid from the deep pockets and who doesn’t.

The insurance industry is still trying to retain the right to offer a stripped down contract that will exclude some of the open-ended coverages. It is far easier to price a policy that has fewer gray areas. A policy that doesn’t cover habilitative services; a policy that doesn’t pay for infertility treatments; a policy that included some limitations for rehab, would be significantly less than the federally mandated coverage. My guess is that we won’t have that option for long, if ever.

Seeing how much these other benefits add to the cost of coverage would force us to finally have a national discussion about our priorities. What are we willing to pay for? It still appears that no one in Washington, Democrat or Republican, wants to have that discussion.

And who can blame them? It’s November and everybody’s busy. Way too busy to talk.

Sorry, You're Screwed

The letter came from The State of Ohio, The Ohio Department of Insurance, and Medical Mutual. Good news never comes with that many names on the top of the letter.

We are sorry to inform you that your Ohio High Risk Pool coverage will be canceled at the end of the day on November 30, 2012.

The letter was dated November 12, 2012.

Some of the unhealthiest residents of the State of Ohio were being tossed off their insurance policy, the Ohio High Risk Pool. In less than three weeks they would no longer be insured. And nobody is standing in line to cover them. How could this happen?

The Ohio High Risk Pool is part of the Patient Protection and Affordable Care Act (PPACA). A stop gap measure, the states were charged with the duty of offering coverage for the chronically uninsured suffering from significant preexisting conditions. The federal government also provided five billion dollars of which Ohio received $152,000,000 for the four year program.

To qualify for the Ohio High Risk Pool you must prove:

1. Citizenship
2. That you have not been credible insurance coverage for at least six months
3. That you have been declined by two insurers within the last six months
4. You may skip #3 if your medical records show that you have a major illness that would have gotten you declined

You can not have had credible insurance coverage in the six months leading up to your application for coverage under the Ohio High Risk Pool. This is a federal requirement. Neither the State of Ohio nor Medical Mutual of Ohio, the insurer running our plan, has anything to do with this rule. Some people who are not easily insured have purchased supplements, a better than nothing option. If something happened while they were attempting to find real insurance or qualify for an affordable program, these responsible people were trying to do what they could.

My friend Dave is a conscientious insurance agent. He took a letter from American Medical and Life Insurance Company (AMLI) to the Ohio High Risk Pool. The letter, dated February 11, 2011 was sent to clients to advise them that their policy was no longer HIPAA credible coverage. Dave verified that since the AMLI CoreValue policy was no longer credible coverage, his clients, including family members, could retain this minimum semblance of coverage until they had six months of no real insurance and could enter the Ohio High Risk Pool. NO PROBLEM.

It is those people, those responsible people who attempted to have some coverage, no matter what, who are being kicked to the curb. The letter from the State specifically notes:

Our records indicate you were enrolled in an AMLI policy in the six months prior to enrolling in the Ohio High Risk Pool Program. Therefore, CMS directed us to cancel your coverage because you are not eligible for this program.

The PPACA is a poorly written law. We know that. Worse, the rules and regulations are being written on the fly. What complies one day is non-compliant the next. We went through this with the grandfathering rules. The costs, both human and financial, can’t possibly be calculated.

The Ohioans being kicked out of the High Risk Pool did nothing wrong. They followed the rules of that moment. We are talking about individuals who are gravely ill. What do they do now? 

DAVE
www.bcandb.com