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HHS Allowing States To Define Essential Benefits In The Exchanges

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[…] Colorado already has a comprehensive small group benefits mandate. Until this year, one of the most glaring differences between small group and individual plans was that individual policies in Colorado were not required to cover maternity. But that changed in January when all new and renewing individual policies had to begin covering maternity. I would say that the primary difference now between most of the individual plans and small group plans in Colorado is that the small group policies are guaranteed issue, whereas the individual plans are medically underwritten. But in 2014, when the exchanges get underway, the individual policies will be guaranteed issue too. Individual policies are still quite a bit less expensive than group policies in Colorado, but I wonder if that will change too once the exchanges get underway? It would seem so, since the benefits and underwriting will be virtually identical.

The small group market in Colorado is already quite structured by state mandates. The individual market also has quite a few mandates, including the new maternity benefit mandate. But it appears that the individual policies that are sold in the exchanges beginning in 2014 will have benefits at least as comprehensive as the benefits offered by the largest small group plans in Colorado. That means that “bottom of the heap” individual plans (ie, the ones with tons of fine print and huge holes in their coverage) probably won’t be making an appearance in the exchange, or at least not without a serious overhaul. […]

Colorado Child-Only Open Enrollment Details For January 2012

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The next open enrollment for child-only policies is almost here, so I thought it might be helpful to provide some specific details in terms of what policies are available and what parents should expect when submitting child-only applications next month.

The first open enrollment window in 2012 will be the month of January. Applications for child-only policies have to be submitted between January 1 and January 31. Application not submitted by the end of January will have to wait and re-submit in July, which is the second open-enrollment period of the year. For most carriers, each child in a family will have to have a separate application.

All eligible child-only applications submitted during the open enrollment period are guaranteed issue, so the child cannot be refused coverage. However, the applications are still medically underwritten and the rate can be increased by up to 200% based on the child’s medical history (so if the standard price is $100, the policy could actually be assigned a rate of $300, which is equal to a 200% rate increase).

Colorado Senate Bill 128 requires all Colorado health insurance carriers that offer coverage for adults to also offer child-only plans during the two annual open enrollment windows. But the bill does not require carriers to provide guaranteed issue coverage for children who are eligible for health insurance from another source (other than a high risk pool like CoverColorado or GettingUSCovered – see the bottom of page 4).

Most Colorado carriers have selected one or two plan designs that will be available for child-only applications next month. To give you an idea of what is available in Colorado for child-only coverage, we’re providing information here regarding child-only options from six of the top individual health insurance carriers in the state. […]

Access To A Mini-Med Group Plan Does Not Prevent CoverColorado Enrollment

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[…] The person I spoke with at CoverColorado checked with a supervisor and then told me that mini-meds are an exception to CoverColorado’s rule banning eligibility for people who have access to group health insurance. In order to qualify, the applicant has to provide the usual proof of eligibility along with proof that their employer’s group health plan is a mini-med. This can be the declarations page from the policy or marketing materials for the plan (which now have to include language indicating that the plan has been granted a waiver by HHS and does not meet the minimum benefit requirements defined by the PPACA).

Hopefully this will clarify things for others in a similar situation. Normally, access to a group health insurance policy (even if it’s one you don’t like or your doctor isn’t on the network, etc.) makes a person ineligible for CoverColorado. But if that group plan happens to be a mini-med and you also meet the other eligibility criteria for CoverColorado, you can submit an application to CoverColorado.

Kaiser Permanente Announces Plans to Add Coverage in Fort Collins, Loveland and Greeley

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Yesterday, Kaiser Permanente filed for approval with the Colorado Division of Insurance to offer health care coverage in Northern Colorado beginning in late 2012. This expansion will include new Kaiser Permanente medical offices in Fort Collins, Loveland and Greeley, a contracted network of community providers and an exclusive hospital agreement with Banner Health hospitals and physicians. Technically, people in Loveland zip codes can already get coverage with Kaiser, but the closest facilities are in Longmont.

We don’t know yet if this expansion will include coverage for employer group as well as individual/family plans. For example, Kaiser has coverage in Colorado Springs, but only for employer groups. Individual/family coverage for Kaiser is limited to the south Denver metro area up through […]

Health Wonk Review And A Thoughtful Look At Life Expectancy

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[…] Lastly, Roy’s article points out that there isn’t just one “US healthcare system”. Rather, we have Medicare, Medicaid, private health insurance, and millions of people with no health insurance at all. Lumping everyone into one group when it comes to life expectancy doesn’t really tell us how our health insurance funded-healthcare systems are functioning, since there are so many people with sub-par health insurance or no insurance at all. It stands to reason that if we can get everyone covered by health insurance and secure realistic access to healthcare for the whole population, our life expectancy should increase. But that might be simply because of an increased life expectancy for the portion of the population that is currently under-insured or uninsured. It could be that the population that is currently covered by high quality health insurance would continue to have the same life expectancy, which is likely quite a bit higher than the population that is under-insured or uninsured.

Grand Rounds And A Defense Of Tiered Health Insurance Plans

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[…] Tiered health insurance plans seem sort of like HSA qualified high deductible plans, but with the added flexibility of being able to have a lower deductible if you’re willing to choose from a more limited network of providers. With a high deductible policy, you’re going to be paying a significant amount out of pocket if you have a major claim, regardless of where you go for treatment. You’ll usually pay even more if you go to an out-of-network provider, but even if you stay in-network, the deductibles on HSA-qualified plans are pretty steep. A tiered health insurance policy can be viewed as a high deductible policy if you opt for the high cost tier providers, or a low deductible/copay plan if you’re able to be flexible in terms of where you go for care. Yes, this might mean switching to a new PCP or opting for a clinic or hospital that isn’t quite as convenient. But as David points out, these plans usually have significantly lower premiums, and for some people, that will be a very worthwhile trade off.

Colorado Rises To 9th Place In America’s Health Rankings

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[…] With regards to health insurance coverage, the America’s Health Rankings survey gave Colorado props for decreasing the percentage of the population without health insurance over the past year, from 15.6% to 13.8%. However, the Colorado Health Access survey results that were released in November indicated the exact opposite results: that study determined that the uninsured rate in Colorado had increased over the past two year from 14% of the population to 16% now. We know that Colorado has been taking steps to expand access to public health insurance programs like Medicaid and CHP+, and we also know that plenty of Colorado residents have lost their health insurance as a result of the economic problems that have plagued the whole country over the past few years. But it’s unclear from the results of these two surveys whether the state is improving or losing ground in terms of health insurance coverage.

CoverColorado Assessment For 2012

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[…] As the cost of healthcare continues to rise, CoverColorado – just like every other insurer – needs more and more money to cover the cost of claims. Their website shows the fees that have been assessed over the past few years, and the increased fee that will go into effect next month for 2012.

Because the CoverColorado assessment is collected by health insurance carriers and passed on to CoverColorado, the fee is added to each policy’s premium every month. The end result is that we all pay a few dollars more per month than the actual cost of our policy. This can be confusing, especially if people are new to individual health insurance and haven’t had experience with paying their own health insurance premiums in the past. The amount that is going to be drafted from your bank account or billed to you will be a few dollars higher than your stated premiums because it includes the CoverColorado assessment. […]

Will Large Groups Encourage Sick Employees To Seek Coverage In The Exchanges?

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[…] Amy Monahan suggested that there could be a law making employees ineligible for coverage in the exchanges if they are eligible for employer group coverage. Or there’s the possibility of a law similar to the one that Colorado designed to protect the state’s high risk pool from a similar scenario – employers here can’t reimburse employees for individual health insurance premiums if they have had a group plan in place within the past twelve months (in the case of the exchanges, they could make employees ineligible for coverage in the exchanges for at least a year after leaving a group plan, assuming they are still eligible for coverage under the group plan and have just opted out). Either option would help to protect the exchanges, but they don’t do much to prevent employers from structuring their health insurance policies to make healthcare significantly more expensive for the sickest employees. […]
A lot of this remains to be seen. The health care reform law still has to be reviewed by the Supreme Court, and we have a major election cycle next year and another full legislative year after that. But if everything about the PPACA remains as it is now, lawmakers will eventually have to address the possibility of self-insured employers designing health insurance plans that encourage their sickest employees to opt for coverage in the exchanges instead.

Consumer-Driven Healthcare Debate

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[…]prior to reading Ungar’s article I wasn’t aware of the agreement between the Independent Physicians Association and Rocky Mountain Health Plans with regard to Medicare and Medicaid reimbursement. The doctors in the IPA were so determined to treat every patient equally that they worked out an arrangement with RMHP to have the insurance carrier accept payment directly from Medicare and Medicaid and then pool that money together with premiums collected from RMHP insureds.
[…] Hixon argues that patients with more financial responsibility for their own care do indeed make better decisions regarding efficient use of healthcare dollars. Furthermore, he cites a study that found that patients with high deductible health insurance policies (eg, HSA qualified plans) had more preventive care, lower rates of hospitalization, and were more compliant in terms of following their doctors’ recommendations. They were also more likely to question their medical bills and had overall lower medical costs than people with traditional low-deductible policies.

[…] In addition to probably being above average in terms of financial savvy, I would assume that the demographic that opts for high deductible health insurance is also probably healthier than average. It makes sense that the more health problems a person has, the more likely he’ll be to choose a lower-deductible policy, since he knows he’s likely to be using the policy at least somewhat regularly. On the other hand, a person with no health conditions at all is probably making a good gamble to select a high deductible policy, since there’s a decent chance he’ll be able to go for several years without having a major claim. So the fact that people with HDHPs have lower medical costs isn’t really surprising. It’s largely a self-selected group (employers who offer an HDHP usually offer another plan as well, and everyone shopping for individual health insurance who picks an HDHP has other options from which to choose). I’m not sure that medical costs would still be lower for people with HDHPs if they policy designs were assigned randomly across the entire population.

Access To Healthcare In Colorado Worsening

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The Colorado Health Access Survey results were released earlier this month, and the results aren’t particularly surprising given the state of the economy for the past few years. The total number of uninsured Colorado residents is now 829,000 – up from 678,000 in 2009. The survey also counts the number of “underinsured” residents (those who aren’t able to afford their out-of-pocket expenses that total more than 10% of their income, or 5% for those below the poverty line). The two categories – uninsured and underinsured – amount to 1.5 million people, which is about a third of the Colorado population.

The 22% increase in the number of uninsured residents came despite strong efforts in Colorado to expand access to Medicaid and CHP+ over the past few years. Without the expansion of those programs, the numbers would undoubtedly be even more bleak. […]

Employer Funding Of Individual Health Insurance Varies By State

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Over the past several months, I’ve written a few articles about the legality of employer reimbursement of individual health insurance premiums in Colorado. Our friend and fellow blogger Hank Stern (writing at InsureBlog) found the changes interesting, and noted that the laws surrounding employer reimbursement of premiums vary quite a bit from one state to another (he’s in OH).

Hank and I wrote a joint post about the topic, which he published last week on InsureBlog. Here’s Hank’s description of how the law works in OH (regular readers will note that it’s similar to how things used to be here in Colorado, before HRAs became a major issue, and of course before SB19 passed earlier this year). […]

Photo Session for the Colorado Health Foundation

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IMG_3109 A few weeks ago, the Colorado Health Foundation interviewed Jay for an article in an upcoming edition of their magazine due to come out in January. Yesterday, photojournalist Barry Staver came up to Wellington from Denver to take pictures of us to accompany the article. We were honored to be photographed by him, and impressed with his unassuming, friendly personality. And we were thrilled when he offered to take pictures of our family with our little pocket camera so that we could have our own copies. (with a baby and a three-year-old, we have to make the most of moments when everybody is clean at the same time!) So here we are, in front of our backyard office, in a family photo taken by Barry Staver […]

Combining Patient Satisfaction With Clinical Outcomes And Cost Efficiency

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[…] Particularly in the current era of spiraling healthcare costs, it’s a bit troubling to hear that hospitals are doing things like putting in extra elevators so that people don’t have to wait as long for an elevator… all for the sake of boosting their patient satisfaction rankings. Yes, it might increase patient satisfaction by a small margin, but somebody has to pay for it. Renovation projects like that add to the hospital’s overhead expenses, and that leads to increased charges for care at the hospital. Ultimately, health insurance carriers end up paying more for their insureds’ claims, and that translates directly to increased health insurance premiums […]

Cholesterol Testing For Kids, With An Extra Serving Of Fries

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[…] Congress released a spending bill this week that would do away with the steps the government has made recently to improve the nutritional content of school lunches. The winners? The potato industry and the makers of frozen pizzas. The losers? Children all across the country and the future of our already over-burdened healthcare system.

I find it a bit ironic that the spending bill was released almost simultaneously with the recommendation that we begin screening all children for elevated cholesterol levels starting between the ages of 9 and 11.

Instead of asking the frozen food makers, who supply our schools’ cafeterias, to come up with a pizza that has whole wheat crust and a few more veggies on top, Congress would rather define the tiny amount of tomato paste on the current slices as a serving of vegetables. And instead of limiting starchy vegetables (including the french fries that are served almost daily in many schools), the new bill would allow fried spuds to continue to be served without limitations.

Cleaner Hospitals Spread Fewer Infections

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[…] What is shocking is the fact that hospitals aren’t already at the top of the cleanliness scale. Although we’ve known for more than a century that germs cause disease, there is still a surprising lack of compliance with basic hygiene in the medical profession – even something as simple as hand washing between patients. Jessica’s post describes a study at the Mayo Clinic that involved cleaning high-touch surfaces with bleach wipes twice a day for six months. Their incidence of Clostridium difficile (C. diff) went from one case every few days to one case every three months. Pretty impressive results, and a very easy solution. Sterilizing high-touch surfaces in hospitals should be a matter of routine, but obviously that isn’t yet the case. Maybe the Mayo Clinic study will help to get other hospitals on board in order to reduce the incidence of hospital-acquired infections across the country.

You Don’t Want To Come Out Ahead With Health Insurance

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Browsing around Reddit this morning, we came across this thread (there is profanity). The initial sentiment in the title is no doubt one that has been expressed by a lot of people over the last few years, and the thousands of comments are testament to the fact that healthcare debate tends to get people fired up […] Another way to think about it: Health insurance is designed to spread risk. We all pay in (ideally, anyway) and then the carriers pay out when someone has a claim. The premiums from those of us who have been fortunate enough to not have health problems are used to cover the healthcare costs of people who have serious illnesses or injuries. And we never know when we might find ourselves in that second category. If you’re complaining because you’ve paid $13,000 in premiums over six years and have have very little paid out in claims, would you take a similar position if you suddenly had a $500,000 claim? Would you want the carrier to say that you have to pay in what you get out? Reversing the scenario like that highlights the lack of logic on the part of people who get annoyed because they haven’t gotten as much out of their health insurance as they’ve paid in. And yet that sentiment is one that is constantly tossed around when people talk about their health insurance.

To summarize: It will be a very bad day if and when you actually come out ahead financially with your health insurance. Please don’t wish for that day. Remind yourself that your health insurance is in place to protect you in the event of a medical catastrophe. Don’t buy a mini-med or a discount plan or any other type of coverage that won’t actually be there for you if you have a major health crisis. Get a policy that you’re confident will protect you if you have a major claim, and then be grateful if you’re one of the people who remains healthy enough to get less back in benefits than you pay in premiums.

Being A Savvy Healthcare Consumer Is Tougher Than It Sounds

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[…] I’ve long been a fan of high deductible, HSA qualified health insurance policies (our family had one until very recently when we switched to a high deductible plan that isn’t HSA qualified but has much lower premiums). But I’ve also always been aware that we’re fortunate to be able to utilize a high deductible health insurance policy – both in terms of being healthy and not needing much in the way of healthcare, and also in our ability to make contributions to our HSA to cover the cost of care we might need in the future. People who have serious health conditions and/or those with very limited funds […] When it comes to actually being a savvy consumer of healthcare, the vast majority of us wouldn’t even know where to begin. Google? Asking friends? Maybe, but chances are, we’re going to go to a doctor and follow (at least roughly) the recommendations the doctor makes. Most of the time, providers are the ones who control how much care a patient receives ie, it’s the supply that’s driving things, rather than the demand. We might know that something’s not right and take the initial step of going to the doctor. But what happens next (surgery? PT? wait and see? Medication? etc.) is generally up to the doctor. As Michelle pointed out, the patient’s number one priority is going to be getting better, especially if the problem being treated is a serious one. Shopping around for the best price and poring over comparative effectiveness research data probably isn’t going to be high on most patients’ lists.

Comparing Wall Street And Healthcare

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[…] Should hospital, insurance, and pharmaceutical executives be earning millions of dollars while millions of Americans have no health insurance and no realistic access to healthcare? Should those executives earn their millions regardless of how their company has performed? Or regardless of the overall state of healthcare in this country? Should decision-making at healthcare companies (hospitals, pharmaceutical companies, insurance carriers, device makers, etc.) be based more on the best interests of shareholders and executives, or on what is best for the health of Americans? Do healthcare companies need to be held to a different standard than other corporations, simply because of the importance of the product they provide? […]

More Flexibility With An Individual Health Insurance Plan

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[…] For the average person who has had an individual policy for a decade and is late 50s-ish, keeping that individual policy (even though a group plan may become available) might be the ticket to being able to have some flexibility in terms of when to retire. The group plan is guaranteed issue – health conditions won’t be a barrier to getting coverage. But the group plan is also tied to the current employer, and the policy will only be available for a maximum of 18 months after you leave that job (via COBRA). […] Linda’s article is an excellent reminder about the importance of looking at the specifics of your own situation – including long term issues that might outweigh short-term benefits – rather than following conventional wisdom or doing what everyone else is doing.

Colorado’s Average 2012 Premium Increase Is The Smallest Since 2000

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[…] I’m sure there will still be people who falsely claim that Colorado’s maternity mandate and federal reform are the reason for any increase. But when we place the 2012 increase in context with the increases we’ve seen over the past decade, it becomes harder to blame recent reform laws for the 2012 premium increases. I’m glad to see that after a year of having guaranteed issue coverage for children, no lifetime maximums, more comprehensive preventive care, and maternity benefits on all new and renewed individual policies, we are seeing the lowest average rate increase in over a decade.

Employer Reimbursement Of Premiums Causing Applicants To Be Declined

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[…] I know that the law was written with good intentions, but we’re noticing that it’s the employees – the applicants who are trying to get individual health insurance policies – who get the short end of the stick. It’s the employees who end up getting their health insurance application declined. It’s the employees who end up having to pay for their own premiums in order to obtain coverage, even if they thought that they were going to be able to rely on some level of reimbursement from their employer.

Millions Of Uninsured Children Are Eligible For Public Health Insurance

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[…] The first sentence of Jason’s article is the most striking: The fact that there are 4.3 million uninsured children in the US who are eligible for Medicaid or CHIP (Children’s Health Insurance Program). Obviously, not all states are pushing hard to enroll all (or even most) Medicaid/CHIP eligible children in those programs. And although Colorado received a $13.7 million grant last year thanks to the increased enrollment in the state’s Medicaid program, the expansion of public health insurance programs in Colorado has not been without criticism. Especially in the current economic climate, it’s hard to see how government health insurance programs could afford to insure an additional 4.3 million children. […]

Kaiser Permanente Colorado Gets Top NCOA Ranking

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Kaiser Permanente Colorado is the highest-rated private health insurance plan in Colorado and one of the top-ranked private health plans (#6) in the nation for clinical performance and effectiveness, as well as member satisfaction, according to new rankings by the independent, non-profit National Committee for Quality Assurance (NCQA).
Kaiser is one of the top 10 plans in the nation in 36 of the 40 health outcome measures, recognizing high quality clinical care

Walgreens Leaving Express Scripts Network

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If you’re insured through Anthem Blue Cross Blue Shield or another carrier using the Express Scripts network, Walgreens will be leaving the network on January 1, 2012. Express Scripts just posted on their website:
“At Express Scripts, we’re committed to keeping your prescription drugs affordable and accessible. That’s why we negotiate cost-competitive agreements […]”
Express Scripts is sorry that Walgreens did what they did and has expressed sincere regret about the situation:
“We regret any inconvenience that Walgreens’ actions have caused you. If you have any questions, please call us at 1.877.885.3409.”