Friday, January 23, 2015

January 2015 Update

Punta Cana 2015

We are now two-thirds through this year’s open enrollment period. This blog and client update will be published the week of January 19th once I return from vacation. I am actually writing it on the 15th, the February 1st cut-off, from the beach of Punta Cana. This promised to be the best week to get away. The January 1st deadline, December 15th, is the new April 15th of health insurance. February 15th, the last day to apply for open enrollment coverage in 2015, will also be very busy. Today? Not too bad.

Shared Responsibility Fee (The Tax you pay if you don’t have insurance) – It’s here. It’s now. And it will be enforced. If you don’t have an official Patient Protection and Affordable Care Act (PPACA) qualified plan, a grandfathered policy, or in some instances a grandmothered contract, you are subject to this tax. For 2015 it will be $325 or 2 percent, whichever is higher.

Tax? So What! – According to a recent Gallup Poll, 35% of all uninsureds have decided that paying the Shared Responsibility Fee is better than buying the insurance. Another 30% didn’t realize that they may be forced to pay this tax.

Short Term Major Medical – Against all odds, the insurers are doing record business selling non-compliant short term major medical policies. These policies do not cover preexisting conditions and Preventive Care. But, they are significantly cheaper and may have a deductible and out-of-pocket maximum that is thousands less than the standard PPACA compliant policy. These policies also don’t suffer from the new, restrictive networks found with many of the major carriers. It is hard to argue with a healthy 40 year old woman who wants to pay less when she purchases the policy and much less if she has to use it.

Pediatric Dental – All policies purchased off the Exchange must include Pediatric Dental whether or not any children are to be covered. Companies like Medical Mutual of Ohio include this at no charge for adults. HealthSpan and InHealth require a separate application for a no-charge Delta Dental contract. Others have charged adults extra much the same way that men now have coverage for maternity. The new Pediatric Dental includes medically necessary orthodontia. The definition of medically necessary changes daily. I’m waiting to see a claim paid before I tell you that this a real benefit and not just fluff.

Changes – A year into this and the biggest flaw of this system remains the ability to make any changes to an existing Exchange policy. Your insurer cannot add on your new baby, cancel your policy, or even change your address. Everything must go through the Exchange. Whether you go online or call the phone center, you must still reopen the application and ALL BETS ARE OFF. There is no guarantee that your subsidy, or even your eligibility won’t be jeopardized by the call.

I have called the national frustration number for clients. We have verified, with the clients sitting in my office, that I am their agent, only to have the transaction muffed and my name disappear from the system. This makes resolution that much more difficult a week or two later when we discover that the problem has not been fixed.

Winners – Unhealthy individuals, especially singles in their fifties earning approximately $30,000 a year, are some of my biggest winners. Families with two or more children earning well in excess of the subsidy limits are also doing well under the new law.

Losers – The people most adversely affected by the PPACA are middle income workers where someone in the household has employer sponsored health insurance. The rest of the family faces higher premiums and no assistance. In truth, healthy Ohioans, even with a subsidy, are being priced out of the market.

I have been monitoring the progress of the PPACA through my clients, news reports, and Social Media. I have found that most of the news follows a specific agenda – for or against the PPACA = for or against President Obama. Social Media, especially Facebook, usually includes posts from the extremes, the incredibly unhealthy guy who now has amazing coverage for next to nothing or the young family forced to choose between unaffordable coverage or a Medicaid plan that may, or may not, send them to unfamiliar doctors and cross-town hospitals.

My clients, and those of my peers, have experienced the full range of benefits and problems of a new system created by a poorly written law and regulated by well-meaning if not always competent bureaucrats. And as much as any failure frustrates us, we must admit that we can’t turn back the clock to 2009. We must make it work for every American.

Insurance agents from around the country are scheduled to meet with members of Congress next month in Washington. I have found similar meetings in Columbus with our state legislature both rewarding and frustrating. This trip to the nation’s capital is worth my time and money if we can solve just one PPACA issue.

Feel free to comment on this post or to send me a private message if there is anything you would like me to convey to our elected officials during these meetings.

We will get through this together.


Sunday, January 4, 2015

When Trust Is No Longer An Option

No Money

The client was more than a little agitated. She also wasn’t reticent about sharing her displeasure with me. She and her husband had purchased excellent coverage for themselves and their employees. Since this was about twenty years ago in the middle of the 1990’s, excellent really meant EXCELLENT. Yet the tests performed in her doctor’s office had not been covered completely. I looked at the Explanation Of Benefits and asked her when she had been in the hospital.

I wasn’t in the hospital!

The bill says that you were. That’s why it wasn’t paid completely. That test doesn’t require hospitalization.

I was in my doctor’s office at the Mount Sinai building.

The one in Beachwood by the mall?

Yes. That’s where his office is.

That’s not a hospital. My kids’ orthodontist is there.

What followed was a long and unpleasant phone call with Mount Sinai. By labeling their medical office building a hospital, Mt. Sinai could substantially increase their fees. Now all they had to do was get the insurance companies and the federal government to play along.

I may have been 6’4” and have played basketball weekly in the 90’s, but I couldn’t claim that I was NBA ready. But if your doctor’s office and his stethoscope are owned by a hospital 10 miles away, it is time to send some flowers ‘cause you’re in the hospital.

Last Friday’s Plain Dealer had a Letter to the Editor from a father facing an unexpected bill for $162.54. He had taken his two children to a MetroHealth satellite office for their flu shots. The charge wasn’t for the shots. The bill was for the facility fee, his family’s charge for sitting in the waiting room, walking past the water fountain, and breathing the air. The total negotiated charge for the two flu shots was $258. The facility fee was over half the bill.

MetroHealth is probably no better or worse than any of the region’s other major providers. No better or worse because there is no way to determine what these charges will be until you get your bill. Here is the result of my search of MetroHealth’s hospital charge information list.

The Cleveland Clinic began adding facility fees for outpatient services in March 2009. The initial charge for an office visit was an astounding $55. Why $55? Because! The Cleveland Clinic doles out information on a need to know basis. And just because the money is coming out of your wallet doesn’t mean The Clinic thinks that you need to know.

This game of cat and mouse continues. The government or the insurers block one path, the hospital administrators develop another avenue to increase cash flow. This is not about doctors and it is not about care.

The government is now trying to limit facility fees charged by hospitals for Medicare patients treated in the Emergency Room. The solution, one national fee regardless of the severity of the case, is hardly logical. But the current system, “Let us charge whatever we want. Trust us”, is neither logical nor sustainable.

Trust is no longer an option. Giving the hospitals unfettered access to our wallets is no longer an option. Unfortunately, we may have run out of options without finding a solution.