Medicare Recipients Get Short End of the “Affordable Care Act” Stick

Op-Ed

Admin. – Kenton Henry

 

It seems to me, Medicare recipients are forfeiting the most benefit and assuming the greatest liability as a direct result of the Patient Protection and Affordable Care Act (ACA) of any group of Americans. This opinion is based, in part, on two traps recipients can fall into which can significantly compromise their financial and physical well-being. To appreciate them, you must first understand:

 

What is this new Center for Medicare Services Re-admission program and what is the purpose of it?

 

The Affordable Care Act of 2010 requires HHS to establish a readmission reduction program. This program, effective October 1, 2012, was designed to provide incentives for hospitals to implement strategies to reduce the number of costly and unnecessary hospital readmissions. CMS defines a readmission in this context as “an admission to a subsection(d) hospital within 30 days of a discharge from the same or another subsection(d) hospital.” Subsection(d) hospitals, per the Social Security Act, include short term inpatient acute care hospitals excluding critical access, psychiatric, rehabilitation, long term care, children’s, and cancer hospitals. http://www.acep.org/Legislation-and-Advocacy/Practice-Management-Issues/Physician-Payment-Reform/Medicare-s-Hospital-Readmission-Reduction-Program-FAQ/

 

What this gets down to is–if a hospital readmits a patient within 30 days of a prior hospitalization–they pay a penalty. What is the Center’s motivation? We already know that last year the administration authorized the transfer of approximately $716 billion from Medicare to fund Obamacare. Medicare is projected to be on the path to insolvency around 2023. A Medicare recipient (or his private insurance plan) is charged a $1,184 deductible per hospital stay for each medical condition or for the same medical condition separated by 60 days or more. Therefore, if a patient is readmitted within 30 days for the same medical condition – no deductible is due. Medicare pays the full cost for the stay. On track to be broke (and having shifted dollars to those under the age of 65 in need of health care) Medicare has created a disincentive to readmit patients by fining the hospital when this takes place. The objective is to encourage alternative methods and venues for treatment.

 
If you are, or will someday be, a Medicare recipient – how do you feel about this? If you think you really would like to be more closely monitored because of your fragile heart – do you really want your provider saying, “There is a pill for that!” and sending you home with your spouse? Certainly readmissions have been unnecessary in the past. Certainly, some were ill advised. But don’t you think the decision whether to readmit you should be left to your doctor free of considerations of poor job performance. Free of concern about the hospital blaming him or her for any penalties they must pay?
The second trap lies in failure to know whether your hospital admission is classified as for “medical observation” or “in-patient”?
The difference in terminology is not a mere technicality. The distinction can make all the difference in terms of your financial liability and leave you with a huge hospital bill. The trap is set when the hospital does not inform you or your guardian of your status upon admission. If you are not an in-patient–guess what? You are an out-patient. Without supplemental coverage, you will be responsible for the 20% (plus excess charges) of your out-patient medical expenses Medicare does not pay. People kept in the hospital beyond the usual 24-48 hours for observation can find themselves responsible for tens of thousands of dollars depending on the length of their stay.
Now . . . follow the bouncing ball on this. If a hospital does not code a stay an admission – it does not get penalized if, within 30 days, it then does admit the patient. Hence, a hospital has in essence double dipped. It’s billed you and Medicare both as an out-patient and an in-patient while avoiding penalties. Is it simply smart business or do the Medicare regulations and their accompanying financial incentives / disincentives affect the decision making process of your doctor? A more detailed analysis of these issues is outlined in the feature articles below. Mine is just an opinion piece but . . . methinks something may be rotten in Denmark.
Your counter points are welcomed.
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FEATURE ARTICLES:
NEW BEDFORD (MA) STANDARD TIMES
By BEVERLY FORD
NEW ENGLAND CENTER FOR INVESTIGATIVE REPORTING
August 25, 2013 12:00 AM
Massachusetts hospitals will lose millions of dollars in funding this year — and perhaps tens of millions more in the future — because of penalties imposed by the federal Medicare program on hospitals that excessively readmit some of the state’s sickest patients, the New England Center for Investigative Reporting has found.
“In Massachusetts, we’re facing approximately $5 billion in cuts to Medicare over 10 years,” said Tim Gens, executive vice president with the Massachusetts Hospital Association. Add to that an anticipated $1.5 billion in sequestration cutbacks due to be imposed in January along with other potential funding cuts, and “it’s a very scary time for hospitals,” Gens notes.
A provision of the Affordable Care Act of 2012, the Hospital Readmission Reduction Program was designed to force hospitals to change the way they treat elderly patients by keeping them out of the hospital and in their own homes. To realize that goal, Medicare imposed penalties that increase annually from less than one percent in fiscal 2012 to a top rate of three percent by 2014, based on a hospital’s total Medicare payments
“In the long run, it will reduce per patient cost because if a patient isn’t going back into the hospital to have the same treatment done, we’re not going to be paying for those same treatments twice,” Ray Hurd, regional administrator of the Centers for Medicare and Medicaid Services, said of the penalties.
It’s not that Medicare is against readmissions, Hurd said. Patients who need hospital care will still be able to get it. The policy only aims to cut unnecessary readmissions.
With Medicare’s penalty program in its early stages, however, it’s still too soon to tell whether reducing readmissions will actually result in better patient care, said Katherine Baicker, a professor of Health Economics at Harvard.
“The goal is to reduce patients from coming back to hospitals because it’s not good for patients and it’s not good for Medicare,” said Baicker.
Nationally, one in five Medicare patients is readmitted to a hospital annually at an estimated cost of $17.5 billion. Under its new program, Medicare expects to save about $280 million in the first year alone.
In Massachusetts, of the 61 hospitals that accept Medicare payments, 54, or 88 percent, were penalized during fiscal 2012 under the readmission reduction program, according to Medicare statistics. That program targets seniors who are most likely to be re-hospitalized within 30 days for pneumonia, heart failure and heart attacks, the three ailments Washington claims are responsible for 30 percent of all elderly readmissions.
Of those 54 penalized hospitals, 12 received the severest penalties which require them to pay back between 0.90 and 1 percent of all Medicare funds received during fiscal 2012. Many of those penalties, health officials said, were imposed against “safety net hospitals” that treat poor and minority communities and teaching hospitals, where mortality rates are often low.
“We all agree readmissions are an important thing we need to work on, but the concern about the penalty is that it really penalizes hospitals for things that are out of their control,” said Karen Joynt a cardiologist and instructor in health policy at Harvard School of Public Health who has studied readmission rates.
The data, she says, shows outside factors such as access to outpatient care, patients with mental health or substance abuse issues, seniors with chronic health conditions and a transient patient population dramatically affect the number of patients hospitals readmit.
Yet, while many larger hospitals are feeling the pinch, others aren’t getting penalized at all, Joynt said.
“The bad part is that the penalties seem so unfair,” she said.
The Massachusetts Hospital Association agrees.
“The penalties are flawed,” said Gens, whose organization has been working with Bay State hospitals to reduce readmission rates since 2009. “The time has come for policymakers to realize this (policy) was not a good decision.”
A congressional advisory committee concurred.
In June the Medicare Payment Advisory Committee suggested that Congress change the penalty formula by setting annual target readmission rates and exempt from penalties those hospitals that reach those targets.
Dr. Robert Klugman, chief quality officer for UMass Memorial Health Care system, the largest healthcare system in Central and Western Massachusetts, said the real worry, however, is that the pressure put on hospitals will cause some medical facilities to turn away patients that really do need to be readmitted.
“We clearly have to change the trajectory of healthcare costs,” Klugman said. “The problem is when you look at Medicare, they place rules to penalize the bad people but sometimes it hurts the innocent people too.”
Whether the penalties are unfair or not, hospitals still find them to be burdensome, taking away money that would generally be used for equipment, programs and treatments that could benefit Medicare patients and others as well.
At Beth Israel Deaconess Medical Center in Boston, Dr. Kenneth Sands, senior vice president of Health Care Quality, said the hospital expects to lose $2 million in Medicare funding in the fiscal year that began Oct. 1, 2012.
“It’s a relatively big portion of our budget,” Sands said of the Harvard-affiliated teaching hospital, one of several teaching facilities affected by the Medicare penalties. Because Beth Israel Deaconess operates on “very low margins” of about 2 percent annually, the impact is noticeable, Sands said.
It also means there will be less money for capital outlay, infrastructure improvements and new programs — “all the things that keep us one of the better medical centers nationally,” he said, adding that the cutbacks should have no affect on patient care or result in additional patient charges.
Klugman said he too worries that the $1.5 million in penalties imposed on the UMass Memorial Health Care system this fiscal year may impact the six hospitals served under the UMass system.
“If we have less income, we can’t invest in necessary equipment. We’ll be forced to reduce programs and services,” Klugmen said.
Toby Edelman, a senior policy attorney for the non-profit Center for Medical Advocacy in Washington, DC, says Medicare’s mandate may also be too daunting for some hospitals, forcing them to look to alternative measures to meet the government’s new standards.
To skirt Medicare’s readmission rules, she said, more hospitals may begin classifying returning patients as “outpatients” even though the patients may spend the same amount of time in the hospital and get the same tests, medications and other care given to admitted patients.
The problem with outpatient status, however, is that patients who need additional care outside of a hospital — in a nursing home for example — may end up paying for that care out of their own pocket since Medicare reimburses for outside costs only when admitted patients transition into a nursing home or rehabilitation center setting, Edelman explained. Patients classified as “outpatients” just don’t qualify.
Take, for example, the 86-year-old woman who was listed as an outpatient during her hospital stay and ended up with a nursing home bill of more than $17,000. Another family cashed in an elderly relative’s life insurance policy to pay for nursing home care after their loved one was hospitalized as an outpatient instead of being listed as admitted.
“It’s very frightening,” said Edelman. “People assume when they’re in a hospital bed they’re an admitted patient. (But) a lot of people are listed as observation status for much of their stay.”
Yet, hospitals say they are making progress.
At Beth Israel Deaconess and at other medical facilities, new programs are being implemented that help Medicare patients deal with their own healthcare after they are discharged. By hiring nurses to check on patients, forging partnerships with doctors, nursing homes and other facilities and installing software that can predict which patients will need more help after leaving the hospital, Beth Israel Deaconess has cut readmission rates by between 15 and 20 percent, Sands said.
Helping to fund that program is a $5 million federal grant that will allow the hospital to add seven transition councilors to help patients make the move from hospital to home. The grant will also place four pharmacists in the community and employ nurse practitioners to work with family members and primary care physicians to ensure that post-discharge plans are followed.
At UMass Memorial and its sister hospitals, staff members work closely with high-risk patients to ensure that once discharged, they have ample outside resources to help in their recovery.
“We do everything we can to make sure they have a soft landing,” said Klugman.
That includes contacting patients within 24-hours after they are discharged to see if they need further assistance from a nurse. The hospital also is implementing software to identify patients who may require frequent hospitalizations. The measures have already helped the hospital system cut readmission rates by about 20 percent. Whether that’s enough to reduce next year’s Medicare penalty, remains to be seen, says Klugman..
Yet, Baicker remains optimistic.
“The hope is that this improves the quality of care,” she said.
Now that’s something just about everyone — even Medicare — can agree on.
The New England Center for Investigative Reporting (www.necir-bu.org) is a nonprofit newsroom based at Boston University. NECIR intern Anais Vaillant contributed to this report.
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Medicare Billing Practices Detailed.
On its front page, the Boston Globe (8/25, Kowalczyk) details how Medicare patients can face higher hospitalization costs depending on whether their stay is classified as “medical observation” or “inpatient.” Medicare patients who are under “observation” receive “a huge bill” even though they “usually share rooms with regular inpatients and receive care from the same doctors and nurses, making their status invisible to them.” Although “hospitals say it’s not their fault,” facilities “are increasingly keeping patients in observation status longer” than the usual 24 to 48 hours. Some claim that the growing trend is “a response to aggressive reviews of hospital billing practices in recent years.”
The Cleveland Plain Dealer (8/24, Harris) reported on the case of an 83-year-old woman who is being sued by a nursing home for a $6,000 bill that went unpaid because she was admitted after nine days of “observation” at a hospital instead of the three days of inpatient care required by Medicare. The Plain Dealer says that the Center for Medicare Advocacy is suing HHS on behalf of Theresa McGarry and other Medicare patients who face bills that are $10,000 on average for being transferred to another facility without the in-patient classification. The Plain Dealer says it “may take an act of Congress” to help McGarry.
In a similar article, the Pittsburgh Tribune-Review (8/25, Nixon) reported on the case of an 85-year-old woman who “was surprised by a $15,000 nursing home bill after spending three days in a hospital for a broken ankle in 2009,” only to find out that she was “under observation” at the hospital, which “doesn’t count toward the three-day minimum needed for Medicare coverage.” The Tribune-Review says that Betty Rickett eventually filed for bankruptcy and is among the “estimated 600,000 Medicare beneficiaries” similarly affected by being admitted for observation. It says that “like Rickett, most people who are hospitalized never know they are under observation and not admitted.”

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BOSTON GLOBE

Status of Medicare patients can result in huge bills
Elderly patients hospitalized but not ‘admitted’ can face higher costs
By Liz Kowalczyk
| Globe Staff
August 25, 2013
Harold Engler recently spent 10 days in a Boston teaching hospital, trying to snap back from complications after urgent hernia surgery. Nurses provided around-the-clock treatment, changing the 91-year-old’s catheter, for example, and pumping him with intravenous drugs for suspected pneumonia.
It all seemed like textbook hospital care to his wife, Sylvia. So she was shocked to learn that Beth Israel Deaconess Medical Center had never “admitted” her husband at all.
“Mrs. Engler, we have bad news for you. This was marked ‘medical observation,’ ” said a nurse at the nursing home where her husband was sent for rehabilitation. The hospital had decided Harold Engler was not sick enough to qualify as an official “inpatient.”
The difference in terminology was not a mere technicality: the observation classification left the Englers with a huge bill. It triggered a mystifying Medicare rule that required the Framingham couple to pay the entire $7,859 cost of his rehabilitation care and the medications he needed while at the nursing facility. If Harold Engler, a retired sales executive, had been admitted to the hospital, they would have likely paid nothing.
It is a striking example of just how impenetrable the US health care system can be for those who use it. Thousands of Medicare enrollees in Massachusetts and across the country are finding themselves caught in the same perplexing bind: Despite long hospital stays, they have been deemed observation patients or outpatients whose follow-up care is not covered. They also can face higher costs for the hospital stay itself when they are not officially admitted.

These observation patients usually share rooms with regular inpatients and receive care from the same doctors and nurses, making their status invisible to them. “I just assumed he was an inpatient. He was on a medical floor,’’ Sylvia Engler said.
Hospitals say it’s not their fault. Executives at Beth Israel Deaconess and other institutions say they are just trying to follow Medicare billing rules that even they don’t always fully understand.
Medicare originally intended observation care as a way to give doctors time to evaluate whether a patient should be admitted to the hospital or is stable enough to go home, usually within 24 to 48 hours. But hospitals are increasingly keeping patients in observation status longer: 8 percent of Medicare recipients had observation stays longer than 48 hours in 2011, up from 3 percent in 2006.
That increase may partly be a response to aggressive reviews of hospital billing practices in recent years. Medicare contractors have demanded refunds from hospitals that admit patients the government believes should have been treated as observation patients or outpatients. Medicare pays hospitals less for those patients.
Medicare officials said they could not comment, in part because the American Hospital Association last year filed a lawsuit against the federal government over the issue.
Beth Israel Deaconess reached a $5.3 million settlement with the government last month over allegations that it improperly admitted patients between 2004 and 2008. And while the hospital denied any wrongdoing, investigators implied the hospital was motivated by profit.
Sylvia Engler believes the hospital has now gone too far in the other direction. She cashed in a money market account to pay the nursing home bill, and took her case to Diane Paulson, a senior attorney at the Medicare Advocacy Project of Greater Boston Legal Services. Paulson plans to appeal to Medicare.
Toby Edelman, senior policy attorney at the Center for Medicare Advocacy in Washington, D.C., said she believes hospitals also could be trying to avoid readmission penalties, which are assessed if too many patients are readmitted within 30 days. Harold Engler, for example, went home after five days, grew sicker, and then returned for another five-day observation stay. If he had been an inpatient, he would have counted as a readmission within 30 days.
Dr. James Hart, who heads a Beth Israel Deaconess committee that makes sure the hospital follows Medicare rules, said he could not comment on Engler’s case. But he said the hospital uses a sophisticated computer program that tries to match patients with the correct Medicare designation based on their illness and the intensity of hospital services required. “We are very focused on getting the level of care accurate,’’ he said.
JONATHAN WIGGS/GLOBE STAFF
Ann Gillis paid a $7,100 rehabilitation bill after a stay at Milton Hospital, where she wasn’t considered an inpatient.
Case managers generally inform patients of their status, especially if they require skilled nursing care, he said. But that doesn’t mean patients digest the information, at a time when they have so much to focus on. “Part of the challenge from a patient perspective is there really is an information overload,’’ Hart said.
Ann Gillis also was surprised to learn she wasn’t a hospital inpatient. At age 83, she fell in her Milton home in February. An ambulance sped her to Milton Hospital, where doctors discovered she had broken her pelvis in two places. “The doctor said, ‘We are going to send you upstairs,’ ’’ she recalled.
Gillis was in terrible pain but doctors decided she didn’t need surgery. Instead, they provided pain medication and advised her to lay absolutely still. On the fourth day, a hospital social worker said she would require rehabilitation at a nursing home. To her surprise, the social worker said she’d have to pay herself.
“I was not admitted and I didn’t know that,’’ Gillis said. “I was in a regular bed and a regular room.’’ Gillis used part of her IRA to pay $7,100 for two weeks of rehabilitation. Medicare publishes a pamphlet titled “Are You a Hospital Inpatient or Outpatient? If You Have Medicare — Ask!” but she never saw it.
Since becoming aware of Gillis’s case, Milton Hospital executives said they have scheduled talks on navigating the health care system. Gillis’s first appeal to Medicare was rejected but she plans to file another.
In a letter to Medicare, Paulson described another case she is fighting. A 90-year-old Lynn woman with numerous medical problems fell and broke her shoulder and was rushed by ambulance to North Shore Medical Center. Two doctors and a caseworker recommended that she be admitted as an inpatient, but the caseworker’s supervisor overruled them. The patient had to pay $40,000 for rehabilitation in a nursing home.
“Our clinical staff and case managers do what is in the best interest of the patient, working within existing Medicare guidelines,’’ said Rich Copp, spokesman for Partners HealthCare, the hospital’s parent company. “However, it is no secret that current Medicare policy is not perfect.’’
If hospitals determined that these patients were not sick enough for inpatient care, who would be?
Hart said that Medicare lists operations that are always inpatient, including heart bypass and valve surgery and many neurosurgical procedures.
Beyond that, hospital doctors and managers decide case by case. A heart failure patient with fluid in the lungs and trouble breathing might feel better with a single dose of a diuretic. That patient likely would be listed as outpatient or observation. But if the patient required a longer round of medications to become stable, the patient probably would be admitted, he said.
“Medicare isn’t making this easy for patients,’’ he said.
Medicare officials have said they are concerned about patients being observed for days in the hospital without being admitted, and issued regulations this summer they believe will help provide clarity to hospitals. But advocates for the elderly are not so sure.
“They’re contradictory and unclear,’’ Edelman said.
The rules, which take effect Oct. 1, allow hospitals to change a patient’s care level up to a year after discharge. One worry is that patients will be switched from inpatient to observation status months after they leave the hospital — and get socked retroactively with a rehabilitation bill.
Instead, patient advocates back federal legislation that would require Medicare to pay for nursing home care after three days in the hospital — no matter what those three days are called. Medicare now requires a three-day inpatient stay before it will pay for nursing home care.
At the very least, Paulson said, patients should receive immediate written notice of observation status and the chance to appeal while they are still in the hospital. For now, she and Edelman recommend that patients and families always ask — and push back if needed.
Edelman said one patient’s son and her lawyer met with a hospital chief executive and convinced him to change the patient from observation to inpatient.
“Do anything you can to get the hospital to change your status,’’ she said.
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http://thewoodlandstxhealthinsurance.com

Navigator Vs. Insurance Broker: Who To Go To For Your New Affordable Care Act Health Insurance?

By Kenton Henry, Administrator

 
Let me preface this article with an admission. I am a health insurance broker and have been for 27 years. So consider that as you weigh the comparison suggested in the title of this piece.

 
Very shortly (October 1 to be exact) you are going to be able to enroll in a new Affordable Care Act (ACA) compliant health insurance plan to be effective January 1. Having health insurance at that time is no longer an option – it is a mandate. You probably know this by now and there is no need to review the details and I will not be addressing the penalties for not having coverage next year and beyond. Rather, I will be addressing your options for enrolling and factors you might want to weigh before electing the path you take to enrollment. I will strive to be as objective as possible in light of my preface.

 
First, let’s consider going through an insurance agent or broker like myself. Before I could consider selling my first health insurance policy back in 1986, I had to study for and pass my state’s insurance exam in order to obtain my license. I did this initially in Indiana and again in 1991 when I moved to Texas. While not the Bar Exam or Medical Board Exams – on both occasions they were comprehensive tests and I recall spending weeks of self-study in the quiet of the local library for the first and–after 5 years of experience–another week and a 40 hour prep course to boot for the second. They covered my knowledge of things not the benefit of common sense–and they were certainly not IQ tests–but measured my grasp of esoteric insurance laws, regulations, the principles and components of insurance and ethics among other topics. Next, I had to be appointed with an insurance company before I could represent their products. In addition to an application, an appointment entailed a thorough background and credit check. Approximately twenty years ago, every company with whom I applied to for an appointment made it mandatory I purchase errors and omissions coverage just as required of your attorney or doctor. Every person is fallible and the insurance makes certain an agent’s clients can be compensated for any negligence or unintentional mistake on the agent’s part resulting in the client’s harm. Fortunately, I have never had to file a claim with my E & O company nor have I had a complaint filed against me with a state insurance commission. I must also undergo and complete a minimum of 30 hours of continuing education every 24 months in order to keep my license. A record of this is made the State Insurance Commissioner. My license binds me to the same rules and regulations regarding my client’s privacy, confidentiality and personal information as the aforementioned professionals with whom you share the same type of information. Any compromise in it could result in revocation of my license not to mention civil liability on my part.

 
Who pays for these tests, licenses, continuing education and insurance? I do. It comes out of my personal income. Not to mention the cost of all my supplies, office overhead and gas utilized in seeing my clients at their convenience. Oh yeah . . . and I pay for my own health insurance. And I have never minded these expenses. These are merely the costs of doing business and I was happy to pay them when compared to the alternative which would have required being someone’s employee. So these are pretty much the facts as to my professional background, what is required of me and the protection afforded you by such.

 
Before contrasting this with the alternative – consider:
“The 2010 (ACA) law is intended to prod millions of Americans to buy health insurance, many for the first time. Those seeking coverage must provide details on citizenship, family size and income to determine whether they’re eligible for subsidies, and complete a form that can stretch to seven pages.” – Bloomberg 08.23.13

 
And the alternative to licensed agent or broker? As of October 1st, you will also have the option of going through a “Navigator” hired by your state and whose compensation will be subsidized with federal funds. (Clue: federal funds is code for your tax dollars). The Navigator’s job is to be educate you as to your options and help you elect one before being turned over to an enroller, otherwise known as a customer service representative. The latter will make this happen mechanically and it will most likely be accomplished by you going to a link and completing an electronic enrollment form estimated to be up to 21 pages or greater in length. (We don’t know yet. They and the premiums for coverage are yet to be released.)

 
While the requirements will vary from state to state, the federal requirements for Navigators are 20 hours of training. The federal health insurance exchange will apply in Texas, Indiana and Ohio. These are three of four states where I am licensed. There will be no background checks involved in the hiring process for Navigators as we are told there is no time for such. The administration says “we need to get as many people as possible to sign up as quickly as possible.” The Navigators will not be licensed. They will not pay for errors and omissions insurance. You will pay for their supplies, their insurance and their benefits.

 
I certainly don’t have to be your agent but these are factors you might want to consider before seeking assistance in enrolling in your new health insurance plan. If you feel I have unfairly or otherwise misrepresented things, please feel free to comment as much. In the feature articles below, some opposing or off-setting opinions are expressed–mostly by administration officials.

 

 

Admin. – Kenton Henry

 
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Coming Articles: Biggest Traps of the Affordable Care Act for Medicare Recipients
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Feature Articles:

 
BLOOMBERG August 23, 2013

 
State Laws Hinder Obamacare Effort to Enroll Uninsured
By Alex Nussbaum & Alex Wayne – Aug 23, 2013 2:32 PM CT

 
New laws passed by a dozen Republican-led states, the latest in Missouri last month, may make that harder, imposing licensing exams, fines that can run as high as $1,000 and training that almost doubles the hours required by the federal government. Republicans say the measures will protect consumers. Obamacare supporters say they’ll undermine the effort to get as many people as possible enrolled.
The rules are “like voter intimidation,” said Sara Rosenbaum, a health law professor at George Washington University in Washington, D.C., who supports Obama’s act. “In many, many cases these laws may be a direct interference with outreach assistance and that’s going to be quite serious.”
The Obama administration awarded 105 grants last week, steering money to hospitals, social-service agencies, local clinics and other groups. The navigators are meant to offer “unbiased information” to help people through the complexities of the new system, with its deductibles, copays, provider networks and tax credits, according to an Aug. 15 statement from the U.S. Department of Health and Human Services.
October Deadline
The grants were issued barely a month before the online exchanges are scheduled to open for enrollment on Oct. 1. The administration has said about 7 million people may enroll next year and it needs to motivate millions of young, healthy customers to sign up to keep the markets financially stable.
The state laws may complicate that task. The restrictions go farthest in a handful of states like Georgia and Missouri, where Republican legislators have already refused to set up the new insurance websites or spend money to promote the law.
In Florida this week, Governor Rick Scott told a Miami audience that federal privacy protections for consumers working with navigators were “behind schedule and inadequate.” He urged people to use brokers and agents instead.
Georgia Governor Nathan Deal, a Republican, believes navigators need state regulation because they’ll give advice on “a highly complicated and highly important topic,” his spokesman, Brian Robinson, said in an e-mail. They will also handle personal information that is open to abuse.
Consumer Protection
“This is a consumer protection issue more than anything,” said Kenneth Statz, an insurance broker on the legislative council of the National Association of Health Underwriters, a Washington-based group representing agents and brokers. “We just want to make sure that somebody who is sitting down with a consumer, trying to help them make this major decision, is going to be properly prepared.”
The state laws have passed with the backing of insurance agents and brokers, who view the online exchanges as competition and navigators as potential rivals with an unfair advantage absent new rules.
States require agents to be licensed and undergo periodic training, said Statz, who’s based in Brecksville, Ohio. He also has to carry insurance to protect clients who may be hurt by bad advice or malpractice, he said.
The 2010 law is intended to prod millions of Americans to buy health insurance, many for the first time. Those seeking coverage must provide details on citizenship, family size and income to determine whether they’re eligible for subsidies, and complete a form that can stretch to seven pages.
Federal Requirements:
While states controlled by Democrats such as Maryland, New York, Minnesota and Illinois have also passed rules, these generally follow federal requirements, said Mark Dorley, a health-policy researcher at George Washington University.
Other states have been more restrictive.
Georgia’s navigators need a license from the insurance commissioner. Each person assisting the uninsured has to pay a $50 application fee, complete 35 hours of training — 15 more than the federal requirement — pass an exam, and complete a criminal background check. Licenses must be renewed every year, requiring another $50 and 15 more hours of training.
Missouri defines navigators more broadly than the federal government, said Andrea Routh, executive director of the Missouri Health Advocacy Alliance in Jefferson City. Violating certification requirements risks a $1,000 fine.
Seeking License
Routh’s group, which seeks to educate people on the health law, didn’t apply for a grant. It may seek a license just to be safe, she said.
“Anyone who does outreach and education, or anybody who assists anyone with enrollment had better be checking that law to see if they need to be licensed,” she said.
Missouri voters approved a ballot initiative last year barring Governor Jay Nixon, a Democrat, from setting up the exchange without the assent of the Republican-controlled legislature, which has declined to act so far.
The rules may scare off churches, clinics or others who want to help, said Cindy Zeldin, executive director of Georgians for a Healthy Future. The Atlanta-based nonprofit was part of a group that won a $2.1 million grant.
Georgia’s law implies “navigators are somehow problematic,” she said in a telephone interview, “rather than that they’re groups that likely have a history of working in communities and are trusted.”
‘In Conversations’
The Obama administration has been “in conversations with states” to ensure their laws don’t hinder the effort, said Chiquita Brooks-Lasure, a deputy director at the federal health department, in an Aug. 15 conference call with reporters.
The federal law doesn’t require background checks, though navigators must provide quarterly reports and can lose their grants in cases of fraud or abuse. The administration is requiring them to undergo an initial 20 hours of training.
Some people opposed to Obama’s overhaul “want to see it fail,” said Missouri Health’s Routh. “If you put a lot of barriers in place that make it tough for nonprofits to go out and educate people and assist them in understanding the exchange, that may be one way to have it fail.”
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The Washington Post
Health and Science
States scramble to get health-care law’s insurance marketplaces up and running
By Sarah Kliff and Sandhya Somashekhar, Published: August 24
With a key deadline approaching, state officials across the country are scrambling to get the Affordable Care Act’s complex computer systems up and running, reviewing contingency plans and, in some places, preparing for delays.
Oct. 1 is the scheduled launch date for the health-care law’s insurance marketplaces — online sites where uninsured people will be able to shop for coverage, sometimes using a government subsidy to purchase a plan. An estimated 7 million people are expected to use these portals to purchase health coverage in 2014.
The task is unprecedented in its complexity, requiring state and federal data systems to transmit reams of information between one another. Some officials in charge of setting up the systems say that the tight deadlines have forced them to take shortcuts when it comes to testing and that some of the bells and whistles will not be ready.
“There’s a certain level of panic about how much needs to be accomplished but a general sense that the bare minimum to get the system functional will be done,” said Matt Salo, executive director of the National Association of Medicaid Directors. “It will by no means be as smooth and as seamless as people expected.”
Oregon announced this month that it will delay consumers’ direct access to its marketplace, opening the Web site only to brokers and consumer-assistance agents in order to shield consumers from opening-day glitches.
“Even though we’re testing now, once you actually have the system up, you don’t know what the bugs will be,” said Amy Fauver, spokeswoman for Cover Oregon, the state agency implementing the law there.
In California, which has the nation’s largest uninsured population, health officials have begun hinting that they may have a similar problem.
“It’s a complex system, and there’s a lot of navigation that needs to happen,” said Oscar Hidalgo, a spokesman for Covered California. He said the agency will know by early September whether the system will be ready in time.
If not, he said, customers will still be able to log on to the Web site and peruse insurance plans and view prices. When they get to the final step, however, they will not be able to sign up. They will have to contact a customer service representative to complete the final enrollment step.
Officials with the District of Columbia’s Health Link decided to put off building a Spanish version of its Web site until later this year, giving its staff bandwidth to complete other tasks they see more critical to the launch.
Until then, the District will have bilingual call-center workers and in-person helpers who will be able to help Spanish speakers navigate the site.
The hiccups are troubling to advocates, who worry that there will be mistakes that result in people being erroneously rejected by Medicaid or denied subsidies to which they are entitled. They are concerned that impediments will discourage the uninsured from signing up for coverage.
“There will be something up and running, but there will be serious, serious difficulties with it” that could result in delays and errors initially, said Robert H. Bonthius Jr., a lawyer at the Legal Aid Society of Cleveland. “It’s an extremely ambitious program, well-intentioned, that is going to be very difficult to accomplish, and it’s going to be months and maybe years before it really gets sorted out.”
With a key deadline approaching, state officials across the country are scrambling to get the Affordable Care Act’s complex computer systems up and running, reviewing contingency plans and, in some places, preparing for delays.
Oct. 1 is the scheduled launch date for the health-care law’s insurance marketplaces — online sites where uninsured people will be able to shop for coverage, sometimes using a government subsidy to purchase a plan. An estimated 7 million people are expected to use these portals to purchase health coverage in 2014.
See how the states have sided on some of the key provisions of the Affordable Care Act:
The task is unprecedented in its complexity, requiring state and federal data systems to transmit reams of information between one another. Some officials in charge of setting up the systems say that the tight deadlines have forced them to take shortcuts when it comes to testing and that some of the bells and whistles will not be ready.
“There’s a certain level of panic about how much needs to be accomplished but a general sense that the bare minimum to get the system functional will be done,” said Matt Salo, executive director of the National Association of Medicaid Directors. “It will by no means be as smooth and as seamless as people expected.”
Oregon announced this month that it will delay consumers’ direct access to its marketplace, opening the Web site only to brokers and consumer-assistance agents in order to shield consumers from opening-day glitches.
“Even though we’re testing now, once you actually have the system up, you don’t know what the bugs will be,” said Amy Fauver, spokeswoman for Cover Oregon, the state agency implementing the law there.
In California, which has the nation’s largest uninsured population, health officials have begun hinting that they may have a similar problem.
“It’s a complex system, and there’s a lot of navigation that needs to happen,” said Oscar Hidalgo, a spokesman for Covered California. He said the agency will know by early September whether the system will be ready in time.
If not, he said, customers will still be able to log on to the Web site and peruse insurance plans and view prices. When they get to the final step, however, they will not be able to sign up. They will have to contact a customer service representative to complete the final enrollment step.
Officials with the District of Columbia’s Health Link decided to put off building a Spanish version of its Web site until later this year, giving its staff bandwidth to complete other tasks they see more critical to the launch.
Until then, the District will have bilingual call-center workers and in-person helpers who will be able to help Spanish speakers navigate the site.
The hiccups are troubling to advocates, who worry that there will be mistakes that result in people being erroneously rejected by Medicaid or denied subsidies to which they are entitled. They are concerned that impediments will discourage the uninsured from signing up for coverage.
“There will be something up and running, but there will be serious, serious difficulties with it” that could result in delays and errors initially, said Robert H. Bonthius Jr., a lawyer at the Legal Aid Society of Cleveland. “It’s an extremely ambitious program, well-intentioned, that is going to be very difficult to accomplish, and it’s going to be months and maybe years before it really gets sorted out.”
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http://allplanhealthinsurance.com

Your More Affordable 2014 Health Insurance Exchange Plan is Likely to Work Like an HMO or Medicaid

By Kenton Henry

If you have ever been covered on an employer’s group health insurance plan, you may have had to select your medical providers from a Health Maintenance Organization (HMO). If you were enrolled in a plan of this type – it was probably because it was your only option or because you were young and thought yourself bullet proof. And the reason is – most older people would not elect an HMO if given a choice. Because if your plan utilizes one – you either see a provider within the network or you have no coverage at all. Most older people know that when your health problem is anything more than a common runny nose (which is all young people believe they’re ever going to suffer from) – a person wants to be able to select their own doctor or hospital.

 
Has your income ever been at the poverty level or below? If so then you probably qualified for Medicaid. That’s the government’s health plan administered by the states for the poor. And if you were covered by Medicaid, you know how difficult it was to find doctor’s to take Medicaid, get into an appointment or see a specialist.

 
Now comes Obamacare. And when the premiums for the new health care compliant plans become available for individuals and families to choose from October 1 for a January 1 effect date – be prepared for sticker shock. Without going into projections of an unknown quantity, suffice it to say, the word on the insurance street is the cost of these plans is going to make people in most states “have a cow”!

 
So naturally, you’re going to review the lowest cost plans – the bronze or “catastrophic” options and hope they meet your needs. And when you do – you best hope you ARE young and bullet proof because you are probably going to find your selection of providers is going to be what you had available in a larger group plan HMO divided by 10 . . . or more. Be prepared to wait a long time for appointments and heaven forbid you need to see a specialist or a special procedure because–if you do–you are probably going to have to get the President to issue another of his executive orders to make it happen.

 
And what if you’re not young and bullet proof? Get used to rationing. Because Obamacare doesn’t like specialists and who do you want to see when you have a serious problem? Who do you think is going to authorize a more sophisticated (expensive) procedure? I love my family doctor but when he thinks I need a more expensive procedure – he refers me to a neurologist or an orthopedic surgeon, etc. But be prepared for your new health plan pre-certification department to tell you – “There must be a pill for that.”

 
In conclusion, you’d better hope you qualify for the subsidy so you can add all or a portion of your premium to the national debt. If not . . . be prepared to pay Cadillac prices for what at best will be an Oldsmobile.

 
(For more a perhaps more objective take on this – go to:
THE WALL STREET JOURNAL; BUSINESS AUGUST 14, 2013:
Many Health Insurers to Limit Choices of Doctors, Hospitals
By Anna Wilde Mathews @ http://online.wsj.com/article/SB10001424127887323446404579010800462478682.html

 

http://allplaninsurance.com

The Chameleon Which Is The Affordable Care Act

08.14.2013

The Affordable Care Act, like a chameleon, is capable of changing its color or otherwise morphing to fit the pragmatic motives of its creator.

As I have said before, the Patient Protection Affordable Care Act (PPACA) (or ACA for short) is law. Therefore, of late, I have attempted to focus on the reality of it and its ramifications for all of us whether we are currently uninsured, covered by our employer’s plan or have our own individual or family health insurance plan. The primary purpose of this blog is to educate and inform– not to editorialize. If the latter were my objective, I would establish a separate blog where I would rant and rave ad infinitum about all I see wrong with the Act and big government in general. But it is not, so writing for The MedPlus Messenger, I try to remain objective and minimize expression of my feelings. But it is difficult. Increasingly so. Each day I try to put more lipstick on this pig but each day I awaken to more news the White House has selectively chosen another segment of the ACA not to implement in 2014 pursuant to the law.
Yesterday’s headlines broke news that the caps on insured’s out-of-pocket (OOP) maximums–set to go in effect in 2014–have been delayed until 2015. This potentially doubles (or worse) the liability of an insured and benefits the insurance company by allowing it to avoid covering expenses above the current OOP’s. Do you believe that is the objective of the White House? To benefit the insurance companies? And I thought the whole reason for the ACA was to better protect the patient, consumer, insured member. After all, it is the Patient Protection … … … Act is it not?
So what was the motive behind the White House’s reprieve for insurance companies? “General Math” provides the answer. I.e.:
Lower patient out-of-pockets = higher insurance premiums
Higher insurance premiums = less participation in coverage and greater backlash against the ACA

 

Greater backlash = trouble for the Democrats in the 2014 mid-term elections
Conclusion = this reprieve was politically motivated

 

Reader and followers – if you can argue this to a different conclusion – please feel free to do so here for my erudition and that of the rest of us.

 
Admin – Kenton Henry
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Feature Articles:
Washington Times
By Tom Howell Jr.
Tuesday, August 13, 2013
President Obama has granted yet another part of his health care law a delay, quietly announcing a one-year grace period before imposing a strict limit on consumers’ out-of-pocket medical expenses.
The delay means some health care plans in the group market will have until 2015 to begin paying for all expenses exceeding $6,350 for an individual’s out-of-pocket spending, or $12,700 for a family.
________________________________________
SPECIAL COVERAGE: Health Care Reform
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Language on the delay has been posted on the Labor Department’s website since February, but it did not surface in the political arena until The New York Times reported on it Tuesday.
Mr. Obama used the limits as a key selling point when he pushed the Affordable Care Act through Congress in 2010. Now, Republicans are using the delay as part of last-ditch bids to dismantle the law before key implementation dates this fall.
“Burying this announcement online in a ‘maze of legal and bureaucratic language’ shows little concern for the promises with which this law was sold,” said House Speaker John A. Boehner, Ohio Republican, borrowing language from the Times article. “What else in the law isn’t working that we don’t yet know about?”
The Obama administration also announced in a pre-July Fourth blog posting that it was delaying the mandate that requires employers with at least 50 full-time employees to provide them with health care coverage.
For the Obama administration, the setbacks are ill-timed and leave officials trying to convince consumers that the delays don’t signal an inability to carry out other parts of the law.
Erin Shields Britt, spokeswoman for the Department of Health and Human Services, said the health care law is still implementing historic consumer protections from “the worst insurance company abuses, by banning discrimination based on pre-existing health conditions, ending lifetime and annual limits on what an insurance company will cover, and capping out-of pocket spending to protect Americans and their families.”
“The February guidance builds on these landmark consumer protections by requiring that health plans limit out-of-pocket spending for major medical coverage for the first time, in 2014, on time,” she said. “This single limit will apply to additional benefits in 2015.”
The newly reported delay arose because some employers and insurers use separate companies to administer major-medical coverage and drug benefits, resulting in separate out-of-pocket limits.
Because of this fractured landscape, parties needed time to streamline their data systems . The rule says that, for the first plan year after Jan. 1, 2014, the annual limit on out-of-pocket expenses will be satisfied if a group health plan that uses more than one service provider complies with the cap on major medical coverage and maintains a similar cap on the non-major medical coverage.
Even as it delays some parts, the administration has said the individual mandate requiring most Americans to have coverage remains in effect. Officials also are working feverishly to implement by Oct. 1 state-by-state health care exchanges where those without employer-based coverage can buy insurance with the help of tax credits.
A recent inspector general report suggested that Health and Human Services is months behind in setting up the federal data hub that will allow federal and state agencies to synchronize information about consumers on the exchanges.
Senate Minority Leader Mitch McConnell, Kentucky Republican, wrote to the Obama administration Monday to suggest that it delay the rollout of the exchanges.
Conservative lawmakers are waging a rhetorical war against Obamacare ahead of a spending showdown on Capitol Hill in September.

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Forbes

Pharma & Healthcare |

8/13/2013

Yet Another White House Obamacare Delay: Out-Of-Pocket Caps Waived Until 2015

WASHINGTON, DC – MARCH 18: U.S. President Barack Obama (L) speaks as Assistant Attorney General of Justice Department’s civil rights division Thomas Perez (R) listens during a personnel announcement March 18, 2013 at the East Room of the White House in Washington, DC. Perez has succeeded Hilda Solis as the U.S. Secretary of Labor. (Image credit: Getty Images via @daylife)

First, there was the delay of Obamacare’s Medicare cuts until after the election. Then there was the delay of the law’s employer mandate. Then there was the announcement, buried in the Federal Register, that the administration would delay enforcement of a number of key eligibility requirements for the law’s health insurance subsidies, relying on the “honor system” instead. Now comes word that another costly provision of the health law—its caps on out-of-pocket insurance costs—will be delayed for one more year.

According to the Congressional Research Service, as of November 2011, the Obama administration had missed as many as one-third of the deadlines, specified by law, under the Affordable Care Act. Here are the details on the latest one.

Obamacare contains a blizzard of mandates and regulations that will make health insurance more costly. One of the most significant is its caps on out-of-pocket insurance costs, such as co-pays and deductibles. Section 2707(b) of the Public Health Service Act, as added by Obamacare, requires that “a group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish lifetime limits on the dollar value of benefits for the any participant or beneficiary.” Annual limits on cost-sharing are specified by Section 1302(c) of the Affordable Care Act; in addition, starting in 2014, deductibles are limited to $2,000 per year for individual plans, and $4,000 per year for family plans.

Move up http://i.forbesimg.com t Move down

Obamacare Increases Costs of College Health Plans by as Much as 1,112% Avik Roy Contributor

There’s no such thing as a free lunch. If you ban lifetime limits, and mandate lower deductibles, and cap out-of-pocket costs, premiums have to go up to reflect these changes. And unlike a lot of the “rate shock” problems we’ve been discussing, these limits apply not only to individually-purchased health insurance, but also to employer-sponsored coverage. (Self-insured employers are exempted.)

These mandates have already had drastic effects on a number of colleges and universities, which offer inexpensive, defined-cap plans to their healthy, youthful students. Premiums at Lenoir-Rhyne University in Hickory, N.C., for example, rose from $245 per student in 2011-2012 to between $2,507 in 2012-2013. The University of Puget Sound paid $165 per student in 2011-2012; their rates rose to between $1,500 and $2,000 for 2012-2013. Other schools have been forced to drop coverage because they could no longer afford it.

According to the law, the limits on out-of-pocket costs for 2014 were $6,350 for individual policies and $12,700 for family ones. But in February, the Department of Labor published a little-noticed rule delaying the cap until 2015. The delay was described yesterday by Robert Pear in the New York Times.

Delay needed to align ‘separate computer systems’

Notes Pear, “Under the [one-year delay], many group health plans will be able to maintain separate out-of-pocket limits for benefits in 2014. As a result, a consumer may be required to pay $6,350 for doctors’ services and hospital care, and an additional $6,350 for prescription drugs under a plan administered by a pharmacy benefit manager.”

The reason for the delay? “Federal officials said that many insurers and employers needed more time to comply because they used separate companies to help administer major medical coverage and drug benefits, with separate limits on out-of-pocket costs. In many cases, the companies have separate computer systems that cannot communicate with one another.”

The best part in Pear’s story is when a “senior administration official” said that “we had to balance the interests of consumers with the concerns of health plan sponsors and carriers…They asked for more time to comply.” Exactly how is it in consumers’ interests to pay far more for health insurance than they do already?

It’s not. Unless you have a serious, chronic condition, in which case you may benefit from the fact that law forces healthy people to subsidize your care. To progressives, this is the holy grail. But for economically rational individuals, it’s yet another reason to drop out of the insurance market altogether. For economically rational businesses, it’s a reason to self-insure, in order to get out from under these costly mandates.                         Patient groups upset

While insurers and premium-payers will be happy with the delay—whose legal justification is dubious once again—there are groups that grumbled. Specifically, groups representing those with chronic diseases, and the pharmaceutical companies whose costly drugs they will use. “The American Cancer Society American Cancer Society shares the concern” about the delay, says Pear, “and noted that some new cancer drugs cost $100,000 a year or more.” But a big part of the reason those drugs cost so much is because manufacturers know that government-run insurers will pay up.

“The promise of out-of-pocket limits was one of the main reasons we supported health reform,” says Theodore M. Thompson of the National Multiple Sclerosis Society National Multiple Sclerosis Society. “We have wonderful new drugs, the biologics, to treat rheumatoid arthritis,” said Patience H. White of the Arthritis Foundation. “But they are extremely expensive.”

The progressive solution to expensive problems? More subsidies. But subsidies don’t reduce the underlying cost of care. They only excuse the high prices that manufacturers and service providers already charge.

It’s one of the many aspects of Obamacare that should be repealed, if we are to combat the rate shock that the health law imposes on tens of millions of Americans. But that will require Republicans to come up with a smarter strategy than shutting down the government.

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http://allplaninsurance.com

What is Coming with Your Health Insurance Between Now and January 1!

Just Practical Information On What is Coming with Your Health Insurance Between Now and January 1!

08.12.2013
This is not an editorial. Today’s post is simply non-political, practical information regarding coming changes in health insurance between now and 2016 and beyond. The Patient Protection and Affordable Care Act (PPACA) is law and is on schedule to be fully implemented (for all but groups of 50+) January 1, 2014. For this reason it is my responsibility to inform my clients – and followers of this blog – of what they can expect in the coming months. Specifically, their insurance options and the mechanics involved in transitioning to health plans that provide minimum “essential benefits” that are in compliance with the PPACA. In this post, I will be addressing individuals and families which includes the self-employed and those who have a personal policy because their employer does not provide coverage. All others, including those covered by group plans for less than 50 employees will be addressed in subsequent posts.
First – those of you who currently have a personal or family policy will be allowed to keep your policy until your policy anniversary in 2014. You should check your anniversary date or–if you are my client–call me. Many companies have changed your anniversary date to December 1. This allows you to keep your current plan until December 1, 2014. After that, you must convert to a health care “compliant” plan which will be described below. I can simplify and assist you in this process when the time comes.
If you do not currently have health insurance you must purchase a health policy to be effective January 1 or pay a penalty on your tax return for 2014 and beyond. Another reason you may want to purchase a plan is if you have previously been unable to acquire a policy which covers your pre-existing health condition(s). Your new compliant plan must cover them and health issues will not factor into your cost.
When October 1 arrives (the earliest date you may apply for compliant coverage) I will provide you a link where you will enter your estimated income for 2014. It will instantly tell you whether you qualify for a subsidy. If you do – you are going to want to choose from and apply for plan options in your state health insurance exchange. If your state has not established a state exchange (as is the case in Texas) – you will select from plans in the Federal Health Insurance Exchange. If you do not qualify for a subsidy (which is the case if your income is 400% or greater than the Federal Poverty Level*) – you are probably going to choose a policy offered outside an exchange and direct from an insurance company. The reason being, it is anticipated these plans will offer the same benefits at a lower cost. I can assist you with this option as well.
Below, I will offer further and detailed information on exchanges, plan options and more. Please do not hesitate to call me for clarification or to discuss this information.

Admin. – Kenton Henry

*
FEDERAL POVERTY LEVEL GUIDELINES 2013

http://allplanhealthinsurance.com

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STEP 1:
Note these key dates and deadlines in your calendar:
If your employer offers health insurance, get key dates from your HR department. These are key dates if you’re planning to buy health care through your state’s Marketplace, which is available through a web site, a call, or an in-person visit.
• Oct. 1, 2013: First day you can enroll in a health plan on your state’s Marketplace
• Dec. 31, 2013: Last day you can enroll in a health plan and have your coverage start Jan. 1, 2014
• Jan. 1, 2014: First day you have insurance coverage if you buy a plan in the Marketplace — if, of course, you buy before this date
• March 31, 2014: The last date you can enroll in a plan on your state’s Marketplace to be covered for part of 2014
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Requirements:
* Be a citizen or legal resident.
• Buy your coverage through your state’s or Federal new health insurance Marketplace, also called an “Exchange”.
• Make about $11,490 to $45,960 a year if you are single – or $23,550 to $94,200 a year if you are in a family of four.
If you make less than the lowest amount, you may be eligible for Medicaid. Medicaid will cost you less than you’d save with a tax credit.
Unfortunately, if your state is not expanding Medicaid based on the guidelines in the Affordable Care Act, you may not be able to enroll in Medicaid or be able to get a tax credit. It’s possible that if you make less than $11,490 in 2013, which is the poverty level, you may not qualify for Medicaid if you live in a state that isn’t expanding Medicaid.
In general, you’re not eligible for the tax credits if you could get coverage through a workplace. However, the coverage offered by your employer must be considered affordable. If your company offers a plan that costs more than 9.5% of your income, or that does not cover at least 60% of the cost of covered benefits, you can look for a more affordable plan through your state’s Marketplace and may receive tax credits to lower your costs.
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Insurance Exchanges
State Didn’t Set Up a Marketplace? Relax
You may have heard that not all states will have their own health insurance Marketplace, also called an Exchange. If your state doesn’t set up a Marketplace, what does that mean for you?
Rest assured that no matter which state you live in, you can buy insurance through a Marketplace starting October 2013.
The way you use the Marketplace will be similar in every state. You’ll access a web site, or call, or see someone in person. And you’ll have tools to compare health plans.
But Marketplaces won’t all be the same in every state. There are three ways your state’s Marketplace can be managed — and this affects your choice of health plans and coverage.
1) State-run Marketplaces
Seventeen states are creating their own Marketplaces. These states will have a lot of local control.
Each state will decide which insurance companies can sell policies on its Marketplace.
States also choose the core benefits each plan has to offer. They can set extra requirements for health plans, like benefits that are more generous or more affordable limits on your out-of-pocket costs.
The state is also in charge of getting people to use the Marketplace.
*Indiana and Ohio will have their own State Exchange. Residents of these states should call Kenton Henry @ 800.856.6556
2) Partnerships Between a State and the Government
A few states are teaming up with the federal government to develop Marketplaces.
The federal government:
• Sets up the Marketplace web site and in-person sites
• Decides which health plans will be sold in the partner state
• Sets the benefit levels
• Runs the Marketplace
The states:
• Monitor health plans
• Help people find the best insurance for their needs *(Call Kenton Henry @ 800.856.6556)
• Handle complaints
Federal-run Marketplaces
Some states decided not to set up their own Marketplaces. In those states, the federal government will step in to run the marketplaces directly. It will make all the decisions: how the Marketplace will work, what plans are sold, and how to promote the Marketplace. Each state is considered separately and has its own Marketplace web site. (Texas residents call Kenton Henry @ 800.856.6556)
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Your Insurance Choices in a Marketplace: FAQ

A health insuranceMarketplace, also known as an Exchange, is a one-stop shop for affordable insurance in your state. Your state’s Marketplace has tools to make it easy for you to compare your choices and pick the best for your needs.
On a state Marketplace site, health plans are grouped by levels of coverage — how much the plan will pay for your health care and what services are covered.
Each level is named after a type of metal:
• Bronze
• Silver
• Gold
• Platinum
Bronze plans offer the least coverage and platinum plans offer the most.
How do the bronze, silver, gold, and platinum levels differ?
The metal plans vary by the percentage of costs you have to pay on average toward the health care you receive.
Here are the percentages of health care costs you pay for each type of plan:
• Bronze plan: 40%
• Silver plan: 30%
• Gold plan: 20%
• Platinum plan: 10% of your health care costs.
The way you pay your portion of these costs is in deductibles and copayments or co-insurance.
In general, the more you are willing and able to pay each time for health care service or a prescription, the lower your premium. A premium is your monthly payment to have insurance.
As an example, when you compare the bronze and platinum plans:
With a bronze plan: You pay the most each time you see your doctor or get a medicine. This is also called having higher “out-of-pocket” costs. But in a bronze plan you pay the least premium each month.
With a platinum plan: You pay the least each time you see your doctor or get a medicine. But in a platinum plan you pay the highest premium each month.
How does coverage from a metal plan compare to my current insurance?
The bronze through platinum coverage levels are new. So you probably don’t know how the benefits of the plan you use today compare to them. The coverage level you have now depends on whether you bought your plan:
• From an employer: Your coverage level is likely between a gold and platinum level.
• On your own: Your coverage level is likely between a bronze and silver level.
Having a sense of how the insurance you’re used to compares with the new plans will help you decide on a plan. You should compare the out-of pocket costs you are currently paying, the services provided (including prescription drugs), and anticipated changes in your health.
If you shop for insurance on your state’s Marketplace, you’ll see the health plans organized in this way:
• 1st by metal level: Bronze, silver, gold, or platinum
• 2nd by brand, such as Blue Cross, Cigna, Humana, Kaiser, United, and others
• 3rd by type of health plan, such as HMO, PPO, POS, or high-deductible plans with a health savings account.
The type of health plan affects how much choice you have in providers, the amount of paperwork you have, and your out-of-pocket costs.
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Tax Penalty At-a-Glance: Who Will Pay The Penalty & How Much Is It?
By law, you need to have health insurance by 2014. If you already get insurance through your employer or your partner’s employer, you’re all set. But what happens if you don’t follow this requirement from the Affordable Care Act?
If you can afford health insurance and don’t buy it, you’ll pay a fine when you file your 2013 income taxes in April 2014.
For the first year of the new law, 2014, the fine for not having insurance is the lowest it will be. After that, it goes up steeply in 2015 and again in 2016.
In 2014: There are two ways the government calculates what you owe. You have to pay whichever amount is higher.
• One way is to charge you $95 for each adult and $47.50 for each child, but not more than $285 total per family.
• The other way is to fine you 1% of your family income. If your family makes $50,000 a year, the fine will be $500.
In 2015: There will still be two ways to calculate what you owe. You have to pay whichever amount is higher.
• One way is to charge you $325 for each adult and $162.50 for each child, but no more than $975 total per family.
• The other way is 2% of your family income. If your family makes $50,000 a year, the fine will be $1,000.
In 2016 and beyond: There will still be two ways to calculate what you owe. You have to pay whichever amount is higher.
• One way is to charge you $695 for each adult and $347.50 for each child, but no more than $2,085 per family.
• The other calculation is 2.5% of your family income. If your family makes $50,000 a year, the fine will be $1,250.

http://allplanhealthinsurance.com

Democrats Can See Their Hometowns From the Steps of the Capitol!

08.09.2013

Sarah Palin was made the butt of jokes – which were later extended to include Republican Paul Ryan – when she proclaimed Medicare recipients would be subjected to “death panels” if the Affordable Care Act’s Independent Payment Advisory Board (IPAB) or Medicare’s cost cutting board remained part and parcel to the statute.

Now it seems even Howard Dean and other notable Democrats are concurring. Like the President, these Democrats are attempting to excise key components of a statute (already law) by repealing the board’s power. In light of next year’s mid-term’s their effort appears politically motivated. Perhaps the Senators and Representatives cited in today’s Feature Article can see their hometowns from the steps of the Capitol Building! It seems they are more concerned with their political lives than the welfare of their constituents. Otherwise, why did they pass the bill with this liability to their constituents in it in the first place? Oh–I forgot–they had to pass it before they could read it!

Admin. – Kenton Henry

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Feature Article:

The Hill

ObamaCare ‘death panel’ faces growing opposition from Democrats

By Elise Viebeck – 08/08/13 05:00 AM ET

ObamaCare’s cost-cutting board — memorably called a “death panel” by Sarah Palin — is facing growing opposition from Democrats who say it will harm people on Medicare.

Former Democratic National Committee Chairman Howard Dean drew attention to the board designed to limit Medicare cost growth when he called for its repeal in an op-ed late last month.

Dean was quickly criticized by supporters of the Independent Payment Advisory Board        (IPAB) who noted his ties to the healthcare industry as an adviser to a major D.C. lobbying firm.

But the former Vermont governor is not the only Democrat looking to kill the panel.

A wave of vulnerable Democrats over the past three months has signed on to bills repealing the board’s powers, including Sen. Mark Pryor (Ark.) and Reps. Ron Barber (Ariz.), Ann Kirkpatrick (Ariz.), Kyrsten Sinema (Ariz.) and Elizabeth Esty (Conn.).

All five are considered vulnerable in next year’s election, highlighting the stakes and the political angst surrounding the healthcare measure.

The four House Democrats faced criticism from their party in July after voting with Republicans to delay ObamaCare’s individual and employer mandates — moves widely interpreted as political positioning ahead of 2014.

Two of the lawmakers explained their opposition by suggesting the board would limit care for Medicare patients.

But the National Republican Congressional Committee (NRCC) blasted the four Democrats for “desperately trying to jump off the ObamaCare train.”

The cost-cutting board has been dogged with controversy over the last three years.

Major healthcare interests like the American Medical Association, the American Hospital Association and the pharmaceutical lobby have supported IPAB repeal, saying the panel would cut providers’ pay arbitrarily.

Public awareness of the board shot up last year when Palin called it a “death panel,” connecting the IPAB to her previous attacks on a proposal to encourage end-of-life planning in the Affordable Care Act.

“Though I was called a liar for calling it like it is, many of these accusers finally saw that ObamaCare did in fact create a panel of faceless bureaucrats who have the power to make life and death decisions about healthcare funding,” Palin wrote on Facebook.

This claim experienced a revival on the right after Dean published his op-ed, which argued that the board would ultimately ration care for Medicare patients.

“The IPAB will be able to stop certain treatments its members do not favor by simply setting rates to levels where no doctor or hospital will perform them,” Dean wrote in The Wall Street Journal.

“Getting rid of the IPAB is something Democrats and Republicans ought to agree on.”

The piece quickly went viral, prompting conservative bloggers and Fox News hosts to cheer: “Dean confirms that Sarah Palin was right!”

The IPAB is designed to kick in when Medicare cost growth grows above a specified rate. It is charged with making recommendations on how to reduce Medicare spending, and its proposals are required to be fast-tracked through Congress.

The Affordable Care Act prevents the IPAB from making recommendations that would directly ration care. But critics say reducing provider reimbursements would have the same result by making it difficult for healthcare professionals to make money in Medicare.

While it’s unlikely the board will be convened soon, Medicare cost growth is not high enough to trigger its work, and any nominees would face long confirmation fights in the Senate, Dean’s op-ed renewed focus on bills to repeal the IPAB.

The Senate and House measures currently have 32 and 192 co-sponsors, respectively, including 22 Democrats in the House. Co-sponsors include lawmakers like Rep. John Barrow (D-Ga.), a longtime GOP target.

But calls for repeal are not taking up the whole debate.

Dean’s piece also drew strong arguments in favor of the panel from supporters like Peter Orszag.

The former White House budget director said the IPAB is necessary in light of Medicare’s transition to new payment models that are meant to lower costs while improving care.

It’s preferable to the “old way,” which saw Congress “simply slash Medicare payments” to providers, Orszag wrote in a column for Bloomberg.

“The point of having such a board — and here I can perhaps speak with some authority, as I was present at the creation — is to create a process for tweaking our evolving payment system in response to incoming data and experience, a process that is more facile and dynamic than turning to Congress for legislation,” he wrote.

In the meantime, the Democratic National Campaign Committee (DCCC) is warding off criticism of the anti-IPAB Dems with a push to turn the ObamaCare tables on the GOP.

The committee pointed to evidence Wednesday that resisting the healthcare law could hurt Republicans in the next election.

A new poll commissioned by the Service Employees International Union found that undecided voters prefer an anti-repeal Democrat over a pro-repeal Republican in a generic match-up.

“Instead of fighting old political battles on healthcare, polling shows that Americans want Republicans to work with Democrats to implement Obamacare and move on to focus on creating good jobs,” said Emily Bittner, a spokeswoman with the DCCC.

“The public strongly disapproves of Republicans’ plan to give insurance companies free rein over our health care.”

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http://allplaninsurance.com/medicare/medicare-supplement.htm

The Foxes Long Ago Took Over the Hen House

08.06.2013
Last Friday, the President met behind closed doors with Congress to grant they and their staff (who have incomes of $100,000 or more) a waiver from paying for participation in health insurance exchanges. Supposedly, 75% of their premium will be paid by us – regardless of their income.You already knew he had reserved the right to grant waivers to unions and donor corporations, correct? And he has done that over 1,200 times to date. Well now he has done it for our employees who ultimately determine their own salaries and benefits. News of this was not released until they had left town under cover of darkness for their month long recess.
It is anticipated this special dispensation will be formally acknowledged next week by President Obama’s Office of Personnel Management (OPM)–one in the same as the federal government’s H.R. department–which is charged with administering federal benefits within the government.

For a succinct and cogent summation of what the unintended consequences of full Affordable Care Act implementation mean to the quality of our nation’s health care, please view this video of Michigan’ Congressman Rodgers as he makes his opening statement to the Chair on health care reform:

http://safeshare.tv/w/zwhKdMtFHf

Admin. – Kenton Henry
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Feature Article

Grassfire

08.05.2013

Moments before shuttering Capitol Hill for a month-long recess, Congress exempted 11,000 members and staff from ObamaCare. News of Friday’s last-minute deal making is especially frustrating since part of ObamaCare’s original sell to the American people was that lawmakers and aides had to use the plan.
According to The Wall Street Journal, both parties went ballistic when they learned staff would incur dramatically higher healthcare costs. “Democrats in particular, begged for help,” and President Obama leapt into action telling them in a closed-door meeting that “he would personally moonlight as H.R. manager and resolve the issue.”

He did … for Congress.

“A behind-closed-doors deal announced after Congress is safely away from the crime scene. This is exactly why America rightly hates Washington,” charged Sen. David Vitter (R-LA) in a press release posted on his official website. “Obamacare’s a train wreck, even for Congress. So it gets fixed … FOR CONGRESS ONLY” (emphasis in original).
Vitter is right. All Americans should be extended the same “resolution” that Congress is getting.

But with Congress safely tucked away in their districts, the countdown continues for the “less fortunate” Americans who, on October 1, start enrolling in ObamaCare.

* Congress returns on Monday, August 9

Obama About To Do Another Side-Step?

08.01.2013
Obama About To Do Another Side-Step?
Op-Ed

Do you remember when the snidely Governor of Texas, played by actor Charles Durning, in the movie, The Best Little Whorehouse in Texas, croon’s …
” Ooh … I love to dance the little sidestep / Now they see me, now they don’t / I’ve come and gone / And ooh, I love to sweep around a wide step / Cut a little swath / And lead the people on!”?
This is exactly the image I have of the President so often but–most recently this morning–on hearing his plans to meet again with the federal Office of Personnel Management. The purpose will be to address their concerns about being forced to abandon their Cadillac federal health plans to enter the Federal Health Insurance Exchange like so many of the rest of us. While this mandate became law when the Senate surprisingly went along with the House vote to do so – now that the time for them to enroll in the exchange is rapidly approaching – they are beginning to balk. (I guess they didn’t read the bill till it was passed!) Now it seems they would like, at the very least, for their premiums to be subsidized by the taxpayers to the tune of (a minimum) 75% as is currently the case. This in-spite of the fact that low paid interns and aides can apply for a regular subsidy (just like you and I) while Rank and File Senators and Representatives receive $174,00 in annual salary; Senate Majority and Minority Leaders $193,400; and The Speaker of the House $223,500. Doesn’t your heart just bleed for them?
Rumor has it the President has promised to see what he can do about it and meet with them again soon. Hence, I hear the words …
” Ooh I love to dance a little sidestep, now they see me now they don’t-I’ve come and gone and, ooh I love to sweep around the wide step, cut a little swathe and lead the people on.
I’m a poor boy, come to greatness. So, it follows that I cannot tell a lie.”
Admin. – Kenton Henry
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FEATURED ARTICLE:

POLITICOPro
Lawmakers, aides may get Obamacare exemption
By JOHN BRESNAHAN and JAKE SHERMAN | 4/24/13 9:49 PM EDT
Congressional leaders in both parties are engaged in high-level, confidential talks about exempting lawmakers and Capitol Hill aides from the insurance exchanges they are mandated to join as part of President Barack Obama’s health care overhaul, sources in both parties said.
The talks — which involve Senate Majority Leader Harry Reid (D-Nev.), House Speaker John Boehner (R-Ohio), the Obama administration and other top lawmakers — are extraordinarily sensitive, with both sides acutely aware of the potential for political fallout from giving carve-outs from the hugely controversial law to 535 lawmakers and thousands of their aides. Discussions have stretched out for months, sources said.
A source close to the talks says: “Everyone has to hold hands on this and jump, or nothing is going to get done.”
Yet if Capitol Hill leaders move forward with the plan, they risk being dubbed hypocrites by their political rivals and the American public. By removing themselves from a key Obamacare component, lawmakers and aides would be held to a different standard than the people who put them and aides would be held to a different standard than the people who put them in office.

Democrats, in particular, would take a public hammering as the traditional boosters of Obamacare. Republicans would undoubtedly attempt to shred them over any attempt to escape coverage by it, unless Boehner and Senate Minority Leader Mitch McConnell (R-Ky.) give Democrats cover by backing it.
There is concern in some quarters that the provision requiring lawmakers and staffers to join the exchanges, if it isn’t revised, could lead to a “brain drain” on Capitol Hill, as several sources close to the talks put it.
The problem stems from whether members and aides set to enter the exchanges would have their health insurance premiums subsidized by their employer — in this case, the federal government. If not, aides and lawmakers in both parties fear that staffers — especially low-paid junior aides — could be hit with thousands of dollars in new health care costs, prompting them to seek jobs elsewhere. Older, more senior staffers could also retire or jump to the private sector rather than face a big financial penalty.
Plus, lawmakers — especially those with long careers in public service and smaller bank accounts — are also concerned about the hit to their own wallets.
House Minority Whip Steny Hoyer (D-Md.) is worried about the provision. The No. 2 House Democrat has personally raised the issue with Boehner and other party leaders, sources said.
“Mr. Hoyer is looking at this policy, like all other policies in the Affordable Care Act, to ensure they’re being implemented in a way that’s workable for everyone, including members and staff,” said Katie Grant, Hoyer’s communications director.
Several proposals have been submitted to the Office of Personnel Management, which will administer the benefits. One proposal exempts lawmakers and aides; the other exempts aides alone.
When asked about the high-level bipartisan talks, Michael Steel, a Boehner spokesman, said: “The speaker’s objective is to spare the entire country from the ravages of the president’s health care law. He is approached daily by American citizens, including members of Congress and staff, who want to be freed from its mandates. If the speaker has the opportunity to save anyone from Obamacare, he will.”
Reid’s office declined to comment about the bipartisan talks.
However, the idea of exempting lawmakers and aides from the exchanges has its detractors, including Rep. Henry Waxman (D-Calif.), a key Obamacare architect. Waxman thinks there is confusion about the content of the law. The Affordable Care Act, he said, mandates that the federal government will still subsidize and provide health plans obtained in the exchange. There will be no additional cost to lawmakers and Hill aides, he contends.