2018 Health Insurance Open Enrollment: Game On

Today is November 1, the first day of OPEN ENROLLMENT for Individual & Family 2018 health insurance coverage. This is not going to be my usual Op-Ed or commentary. Things are what they are for now, and I will let the numbers and the available benefits speak for themselves. We can go back to the dialogue once everyone has decided what is in their best interest for the coming year and elected a plan.

Because my phone ― and that of every agent and broker ― specializing in this market ― is going to be ringing off the hook the first few weeks, I am going to provide you some guidance to make this as easy as possible, on all of us.

Please go my quoting and application site. It has just been loaded with all your available plan options. Whether you receive a subsidy and have gone through Healthcare.gov and think you need to – or not ― you should begin here. You can get the quotes; estimate your applicable subsidy; and, seamlessly, enter into Healthcare.gov. Or, if you don’t qualify for or desire a subsidy, you may apply. If you need my assistance, you may save your work. I will see it and can pick up where you left off, to help you finish. You may email me and, if preferring to speak immediately and you cannot reach me on my desk phone, text me on my cell and I will get in touch with you, as soon as possible. If you need me immediately and cannot reach me on my desk phone, text me on my cell and I will get in touch with you, as soon as possible. My cell number is 713-907-7984. I will answer your questions and assist you in completing the process. (The voice-mail on the office line will be checked but, on the cell phone, will remain full.) It will help us both immensely if you review your options before contacting me.

CLICK HERE FOR 2018 HEALTH INSURANCE QUOTES AND PLAN OPTIONS:

https://allplanhealthinsurance.insxcloud.com/my-quote/individual-info

Here are the options I have to assist you from my quoting site:

(CLICK ON IMAGE TO ENLARGE)

Good luck and don’t hesitate to let me assist you with this year’s Open Enrollment!

D. Kenton Henry

Email: Allplanhealthinsurance.com@gmail.com

Office: 281-367-6565

Cell: 713-907-7984

https://allplanhealthinsurance.insxcloud.com/my-quote/individual-info

http://TheWoodlandsTXHealthInsurance.com

https://HealthandMedicareInsurance.com

MEDICARE CHANGES IN 2018 AND HOW THEY MAY AFFECT YOU

By D. Kenton Henry, Editor, Broker, Agent

Each year Medicare recipients and their agents and brokers prepare for upcoming changes in Medicare. This is because all changes have the potential to impact the member’s pocketbook. They may directly affect it or trickle down to the products they use to supplement Medicare.

Here is what we know is changing:

In 2017 you pay:
$1,288 Medicare deductible for each benefit period
• Days 1-60: $0 coinsurance for each benefit period
• Days 61-90: $322 coinsurance per day of each benefit period
• Days 91 and beyond: $644 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)
Beyond lifetime reserve days: all costs

In 2018 you will pay:
$1,316 Medicare deductible for each benefit period
• Days 1-60: $0 coinsurance for each benefit period
• Days 61-90: $329 coinsurance per day of each benefit period
• Days 91 and beyond: $658 coinsurance per each “lifetime reserve day” after day 90 for each benefit period (up to 60 days over your lifetime)
• Beyond lifetime reserve days: all costs

PART B DEDUCTIBLE:
The Medicare Part B deductible is $183 in 2017. It is expected to rise in 2018, but the Center For Medicaid and Medicare Services has not, and is not expected to, release that figure until closer to the end of this calendar year.

PART B PREMIUMS:
COST OF LIVING ADJUSTMENT (COLA), I.e., the Social Security Income Payment Adjustment, numbers for the coming year have not been released as of yet. But it’s widely expected that there will be a COLA of around 2 percent for 2018 (as opposed to 0.3 percent for 2017, and zero percent for 2016). CMS has not yet set Part B premiums for 2018, but it’s likely that premiums will level out for all enrollees (except those with high incomes, who always pay more). This because any necessary rate change will be covered by the COLA. In other words, the increase in Part B premiums will be offset by an increase in income payments for low-income recipients.

For high-income Part B enrollees (income over $85,000 for a single individual, or $170,000 for a married couple), premiums in 2017 range from $187.50/month to $428.60/month, depending on income. They will likely rise again for 2018, but there’s another change coming that will affect some high-income Part B enrollees in 2018. As part of the Medicare payment solution that Congress enacted in 2015 to solve the “doc fix” problem, new income brackets were created to determine Part B premiums for high-income Medicare enrollees, and they’ll take effect in 2018.

The high-income brackets start at $85,001 for a single individual and $170,001 for a married couple. Enrollees with income between $85,001 and $107,000 ($170,001 and $214,000 for a married couple) won’t see any changes to their bracket.
But enrollees with income above those limits might be bumped into a higher bracket in 2018, which means their premiums could jump considerably. The highest bracket (i.e., with the highest Part B premium) will now apply to those with income above $160,000 ($320,000 for a married couple), whereas the highest bracket didn’t apply in 2017 until an enrollee’s income reached $241,000 ($428,000 for a married couple). As with the deductible, Medicare Part B premiums for 2018 have not yet been set, but slightly less wealthy Medicare enrollees will begin paying the highest prices for Medicare Part B in 2018.

Here are Medicare Part B Premiums for 2017 (based on a 2-year look-back to 2015):

If your yearly income in 2015 (for what you pay in 2017) was You pay each month (in 2017)

File individual tax return File joint tax return Married Filing Separately
$85,000 or less $170,000 or less $85,000 or less = $134
above $85,000 up to $107,000 above $170,000 up to $214,000 N/A = $187.50
above $107,000 up to $160,000 above $214,000 up to $320,000 N/A = $267.90
above $160,000 up to $214,000 above $320,000 up to $428,000 N/A = $348.30
above $214,000 above $428,000 above $129,000 = $428.60

PART D PRESCRIPTION DRUG PLANS:
The Part D Annual Deductible is $405 in 2018, up from $400 in 2017
Premiums in the State of Texas, e.g., range from a low of $16.70 to a high of $197.10
* On the positive side, the Affordable Care Act is gradually closing the donut hole -technically known as the Gap – in Medicare Part D. In 2018, enrollees will pay just 35% of the plans cost for brand-name drugs while in the donut hole, and 44% of the cost of generic drugs.

2018 PART D COVERAGE GAP STAGE:
Begins after the total yearly drug cost (including what Your plan has paid and what you have paid) reaches $3,750. After you enter the coverage gap, you pay 35% of the drug cost for covered brand-name drugs and 44% of the drug cost for covered generic drugs until your out-of-pocket costs (not including your premiums) total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap.

2018 Catastrophic Coverage Stage:

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and mail-order) reach $5,000, you pay the greater of:

5% of the cost, or
$3.35 copay for generic drugs (including brand drugs treated as generic) and $8.35 copay for all other drugs.

 

*Tip of the 2018 Part D Open Enrollment Period:
When purchasing your prescription drugs at the pharmacy counter, always ask your pharmacist for the lowest possible cost for your drug through their pharmacy. NBC Today Show did a segment today (10.17.17) in which they revealed that many times your copay for the drug, through your insurance, is higher than the lowest cost from the pharmacy. As the photo at the top of this article depicts, sometimes the difference is quite significant. A pharmacist in Magnolia, Texas, explained that a contractual “Gag” order exists between the pharmacy and the pharmacist (or employee) which prevents the latter from disclosing this to the customer. However, once questioned, the pharmacist or employee must disclose accurate information. If the cash price is lower, by all means, pay the cash price and do not let the purchase go through your insurance.

I will keep followers of my blog apprised of, as yet, unannounced changes in Medicare as they become available. In the meantime, to those of you who are my current clients, I would like to extend a sincere thank you for your business and the confidence you have placed in me.

ASSISTANCE IN IDENTIFYING YOUR LOWEST TOTAL COST PART D DRUG PLAN:

You, and those who would consider my services may email or―for those who feel it a more secure method―may fax a list of your prescription drugs and dosages to my secure fax. (I am the only one with access to it.) I will submit your drug regimen to the quoting system which will identify the plan which covers all your drugs at the lowest total cost for the coming calendar year. The lowest-total-cost is the sum of the plan premium, any applicable deductible, and your drug costs. Whether you elect to go through me to acquire it, is at your discretion.

Please email Kenton at:
allplanhealthinsurance.com@gmail.com
or
Fax to my secure fax at:
281.367.4772

I am processing quote requests in the order received.
Thank you so much for taking the time to stay abreast of these relevant changes affecting, and so important to, Medicare recipients. I know many of you are living on fixed incomes, and keeping your costs for protecting yourself from increases in medical care, and insurance, is of vital importance to you.

 http://TheWoodlandsTXHealthInsurance.com   https://HealthandMedicareInsurance.com

SENATE ACA REPEAL AND REPLACE UP IN THE AIR

Senate’s ACA Repeal and Replace Bill Up In Air

― op-ed by D. Kenton Henry

The passage of the Senate’s Affordable Care Act repeal and replace bill, prior to their scheduled July 4th recess, is as up in the air as the fireworks will be coinciding with that illustrious date. With five Republican and additional Democrat senators currently opposed, its passage appears tenuous at best. This, in spite of President Trump’s expressed confidence it will happen.

As a medical insurance broker the past 30 years, I have certainly have an opinion on, and a vested interest in, the passage (or failure) of the bill. The reality is, the Democrats own the current Patient and Protection Affordable Care Act (PPACA). Not one Republican voted for it. Therefore (if repeal fails), come 2018, it will be the Democrat’s law which, I believe, will result in an even greater increase in health insurance premiums we have already seen skyrocket since the Act’s passage. And be certain―we will see an even greater exodus of insurance carriers from the marketplace, leaving some counties―and possibly states―with only one carrier. Or, possibly, none. In which case, Trump and the Republicans can continue to tell the Democrats, “We told you so!”.

The problem for the Republicans is, they were elected on a platform of repeal and replace. As such, there are two ways Republicans can fail the people. The first is by not fulfilling that promise. The second―and quite possibly the larger failure― is to pass something which turns out to be an equal or greater debacle than the PPACA itself. As much as I want to see the Act replaced with something better, upon analysis, I find myself largely in agreement with Senator Rand Paul. This bill almost resembles Obamacare more than it does not. Not only does it continue subsidies based on income, but it maintains ten of the twelve mandated “essential coverage items” which forced premiums up in the first place! The primary objectives of repeal and replace were to give people more control over the coverage they purchase and reject, and to bring premiums down. To acquire just what they need and reject what they don’t, all at a lower cost. As it stands today, the Senate bill cannot accomplish either because the remaining forced mandates will force insurance companies to keep premiums high while rationalizing the subsidies allow enough people to pay them using “other people’s money”. When all is said and done, if the bill passes as is, those who don’t qualify for a subsidy will feel angry and betrayed and our twenty trillion dollar budget deficit will grow at even faster than its current, virtually criminal, rate of escalation. Couple doing away with the individual mandate to purchase and maintain coverage with allowing people to purchase it anytime of the year―in spite of the state of their health―and you have a recipe for absolute failure. Many will refrain from purchasing until they receive a dread diagnosis, then purchase the insurance to force the loss of huge medical claims on someone else! I.e., the insurance companies and those responsible insured members who pay their own premiums. If passed without restrictions on when insurance may be purchased (Open vs. Closed Enrollment), I predict this replacement will fail more quickly than Obamacare has failed.

Who will be the major losers if this bill passes as is? Those individuals who must pay their own premiums; the American taxpayer; and―when the healthy drop coverage because they are no longer forced by law to purchase it―me. Who are the major winners? Employers who will see the mandate to provide coverage for groups of 50 plus dropped, creating an incentive to hire; Medical Device companies who will see taxes on their products repealed, encouraging innovation; those individuals and families who have someone else paying all, or the majority, of their premium; and the insurance companies who continue to be subsidized and receive even greater premiums (subsidized or not) for somewhat diminished coverage. And―in the case of where a broker’s compensation is based on a percentage of premium―me.

Who knows how this will ultimately shake out. All I know is, whatever the result, it will be a mixed bag depending on your position in the equation. Stay tuned and―regardless the result―contact me at 281-267-6565. Whatever your options, unless agents and brokers fall on the chopping block, I intend to be here to assist you identifying and obtaining the option most beneficial to your physical and financial health.

https://healthandmedicareinsurance.com

http://thewoodlandstxhealthinsurance.com

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FEATURED ARTICLE:

Senate health-care draft repeals Obamacare taxes, provides bigger subsidies for low-income Americans than House bill

By Paige Winfield Cunningham By Paige Winfield Cunningham June 21

Senate leaders on Wednesday were putting the final touches on legislation that would reshape a big piece of the U.S. health-care system by dramatically rolling back Medicaid while easing the impact on Americans who stand to lose coverage under a new bill.

A discussion draft circulating Wednesday afternoon among aides and lobbyists would roll back the Affordable Care Act’s taxes, phase down its Medicaid expansion, rejigger its subsidies, give states wider latitude in opting out of its regulations and eliminate federal funding for Planned Parenthood.

The bill largely mirrors the House measure that narrowly passed last month but with some significant changes aimed at pleasing moderates. While the House legislation tied federal insurance subsidies to age, the Senate bill would link them to income, as the ACA does. The Senate proposal cuts off Medicaid expansion more gradually than the House bill,\ but would enact deeper long-term cuts to the health-care program for low-income Americans. It also removes language restricting federally subsidized health plans from covering abortions, which may have run afoul of complex budget rules.

Senate Majority Leader Mitch McConnell (R-Ky.) intends to present the draft to wary GOP senators at a meeting Thursday morning. McConnell has vowed to hold a vote before senators go home for the July 4 recess, but he is still seeking the 50 votes necessary to pass the major legislation under arcane budget rules. A handful of senators, from conservatives to moderates, are by no means persuaded that they can vote for the emerging measure.

Aides stress that the GOP plan is likely to undergo more changes to garner the 50 votes Republicans need to pass it. Moderate senators are concerned about cutting off coverage too quickly for those who gained it under the ACA, also known as Obamacare, while conservatives don’t want to leave big parts of the ACA in place.

As a nod to conservatives, the Senate bill would give states more leeway in opting out of the ACA’s insurance regulations through expanding the use of so-called “1332” waivers already embedded within the law, according to the draft proposal. States could use the waivers to make federal subsidies available even off the marketplaces — but they couldn’t go so far as to lift ACA protections for patients with preexisting conditions.

But it may prove trickier to get moderates on board. Senate leaders are hoping the big draw for them lies in the bill’s more generous income-based approach to insurance subsidies, which closely mirror the subsidies offered under Obamacare.

Subsidies are available to Americans earning between 100 percent and 400 percent of the federal poverty level. Starting in 2020, under the Senate bill, this assistance would be capped for those earning up to 350 percent — but anyone below that line could get the subsidies if they’re not eligible for Medicaid.

The subsidies would also mirror the ACA in that they would be pegged to a benchmark insurance plan each year, ensuring that the assistance grows enough to keep coverage affordable for customers.

The Senate bill would also keep the ACA’s Medicaid expansion around for longer, gradually phasing it out over three years, starting in 2021.

Despite these shifts, moderates are likely to be turned off by how the bill cuts Medicaid more deeply than the House version. But the biggest cuts wouldn’t take effect for seven years, a time frame that could be more politically palatable for members like Sens. Rob Portman (R-Ohio) and Shelley Moore Capito (R-W.Va.).

Under the Senate draft, federal Medicaid spending would remain as is for three years. Then in 2021 it would be transformed from an open-ended entitlement to a system based on per capita enrollment. Starting in 2025, the measure would tie federal spending on the program to an even slower growth index, which in turn could prompt states to reduce the size of their Medicaid programs.

In a move that is likely to please conservatives, the draft also proposes repealing all of the ACA taxes except for its so-called “Cadillac tax” on high-cost health plans in language similar to the House version. Senators had previously toyed with the idea of keeping some of the ACA’s taxes.

The Senate bill would also provide funding in 2018 and 2019 for extra Obamacare subsidies to insurers to cover the cost-sharing discounts they’re required to give the lowest-income patients. Insurers have been deeply concerned over whether the subsidies will continue, as the Trump administration has refused to say whether it will keep funding them in the long run.

The House had a difficult time passing its own measure after a roller-coaster attempt, with the first version being pulled before reaching the floor after House Speaker Paul D. Ryan (R-Wis.) determined he did not have the votes. House Republicans went back to the drawing board and passed their own measure — which would more quickly kill Medicaid expansion and provide less-generous federal subsidies — on May 4.

Even if the Senate measure does pass the upper chamber, it will still have to pass muster with the more conservative House before any legislation could be enacted.

Juliet Eilperin and Amy Goldstein contributed to this report.

ON THE STATE OF OBAMACARE EXCHANGES AS 2017 OPEN ENROLLMENT APPROACHES

By D. Kenton Henry

As a health insurance broker the last thirty years, I have a vested interest in the state of the industry, and especially so since the Affordable Care Act (ACA) , commonly referred to as Obamacare, was passed in March of 2010. It has been a turbulent ride as I and my clients have struggled to adapt to each phase of the law’s implementation. This has been especially true, the previous three years, as I prepared―and now prepare again―for “Open Enrollment” (OE). OE is the period during which the Department of Health and Human Services allows people to acquire individual and family health insurance for the coming year. This year, it is scheduled to run from November the 1st through January 31st. I say “scheduled”, because they typically extend it in an effort to give people more time to enroll. And, apparently, the Department needs to give people as much time as possible because the latest numbers indicate Obamacare enrollment has fallen significantly short of expectations. (Refer to our feature article from The Washington Post below.)  As it explains, enrollment in the exchanges is less than half initially predicted. The success of the exchanges was predicated on the young and healthy enrolling in numbers sufficient to offset the sick and elderly who would naturally submit more and higher claims to the insuring companies. The young and healthy have largely declined enrolling―presumably and primarily because, well―they’re young and healthy. Had they enrolled, the theory was they would have diluted the claims (losses) with positive (no losses) premium dollars. Additional factors are that, unless someone qualifies for a subsidy, the premiums are high and, for the most part, going higher. The only cases where premiums seem to have gone down are where the insured members are forced into Health Maintenance Organization (HMO) plans where they find their providers and treatment rationed. Furthermore, the penalties (“Shared Responsibility Tax”) for not having insurance, relative to the premiums for having it, are so small as to be largely ignored. Yes, the penalties are increasing but not in proportion to the premiums. And word is, the premiums are only going higher in 2017.

*(CLICK ON THE GRAPHIC TO ENLARGE STATE BY STATE PROJECTED 2017 PREMIUM INCREASES.)

PREMIUM STATS 2017

As our feature article from the Wall Street Journal ( posted below) describes ―another factor detrimental to the success of the Act and the exchanges is decreasing competition among carriers. In spite of the high premiums they charge, insurers are experiencing losses too great to allow them to remain in the marketplace. As a result, they are dropping out in ever increasing numbers. These losses result, in part, because the government itself has cut the subsidies they originally promised insurance companies in order to offset the losses they anticipated. Obviously, companies have less money to pay the higher than expected claims they are experiencing. A Kaiser Family Foundation study, cited in the WSJ article, indicates exchange shoppers may have only one insurance company to choose from in 31% of the nation’s counties and the possibility of only two in another 31%. While many are quick to blame the “greedy” insurance companies, this editor feels the need to point out the reality that insurance companies are not charities. And even charities must operate in the black if they are to remain in existence. It is my opinion that only the government feels it is entitled to operate at a loss and, additionally, that, that is acceptable. Of course, when your are operating entirely with other people’s money―that is a much easier thing to do.

I will now put down my keyboard and go back to studying, testing and certifying to offer and provide the new Obamacare and Medicare related plans to both my clients and prospective clients for 2017. It amounts to an investment of many hours in order to remain informed and credible in an extremely complicated market. As in 2016, one key hurdle for those purchasing 2017 individual and family coverage will be to deal with the inability to find their doctors, and even their hospitals, in the HMO networks. I have developed a strategy for coping with this which I have utilized for myself. While it does not entirely eliminate the inconvenience of the aforementioned problem, it does soften the blow and in some cases―from a purely monetary standpoint―offset the loss in dollars a total and ideal solution would have cost.  Please call me at 281.367.6565 to discuss this and other strategies designed to minimize the difficulties and accompanying stress of identifying and acquiring 2017 health insurance.

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FEATURE ARTICLES

Wall Street Journal

Health Insurers’ Pullback Threatens to Create Monopolies

Analysis suggests ACA exchanges are likely to offer just one coverage option in 31% of U.S. counties

By Anna Wilde Mathews and Stephanie Armour

Updated Aug. 28, 2016 7:47 p.m. ET

Nearly a third of the nation’s counties look likely to have just a single insurer offering health plans on the Affordable Care Act’s exchanges next year, according to a new analysis, an industry pullback that adds to the challenges facing the law.

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THE WASHINGTON POST

Business

Health-care exchange sign-ups fall far short of forecasts

By Carolyn Y. Johnson

Business

August 27 at 8:10 p.m.

Enrollment in the insurance exchanges for President Obama’s signature health-care law is less than half the initial forecast, pushing several major insurance companies to stop offering health plans in certain markets because of significant financial losses.

As a result, the administration’s promise of a menu of health-plan choices has been replaced by a grim, though preliminary, forecast: Next year, more than 1 in 4 counties are at risk of having a single insurer on its exchange, said Cynthia Cox, who studies health reform for the Kaiser Family Foundation.

The debate over how perilous the predicament is for the Affordable Care Act, commonly called Obamacare, is nearly as partisan as the divide over the law itself. But at the root of the problem is this: The success of the law depends fundamentally on the exchanges being profitable for insurers — and that requires more people to sign up.

In February 2013, the Congressional Budget Office predicted that 24 million people would buy health coverage through the federally and state-operated online exchanges by this year. Just 11.1 million people were signed up as of late March.

Exchanges are marketplaces where people who do not receive health benefits through a job can buy private insurance, often with government subsidies.

Aetna, the nation’s third-largest health insurer, announced that it will pull back from Obamacare exchanges citing losses of more than $430 million since January 2014. (Daron Taylor/The Washington Post)

Aetna, the nation’s third-largest health insurer, announced that it will pull back from Obamacare exchanges citing losses of more than $430 million since January 2014. Aetna, the nation’s third-largest health insurer, announced that it will pull back from Obamacare exchanges citing losses of more than $430 million since 2014. (Daron Taylor/The Washington Post)

“Enrollment is key, first and foremost,” said Sara R. Collins, a vice president at the Commonwealth Fund, a nonpartisan foundation that funds health-care research. “They have to have this critical mass of people so that, by the law of averages, you’re going to get a mix of healthy and less healthy people.”

A big reason the CBO projections were so far off is that the agency overestimated how many people would lose insurance through their employers, which would force them into the exchanges. But there have been challenges getting the uninsured to sign up, too.

The law requires every American to get health coverage or pay a penalty, but the penalty hasn’t been high enough to persuade many Americans to buy into the health plans. Even those who qualify for subsidized premiums sometimes balk at the high deductibles on some plans.

And people who do outreach to the uninsured say the enrollment process itself has been more complex and confusing than Obama’s initial comparison to buying a plane ticket.

“This exchange will allow you to ‘one-stop’ shop for a health-care plan, compare benefits and prices, and choose a plan that’s best for you and your family,” Obama said in a speech in 2009. “You will have your choice of a number of plans that offer a few different packages, but every plan would offer an affordable, basic package.”

In some markets, a shortfall in enrollment is testing insurers’ ability to balance the medical claims they pay out with income from premiums. In an announcement curtailing its involvement in the exchanges this month, Aetna cited financial losses traced to too many sick people signing up for care and not enough healthy ones.

The health-care law has been a political lightning rod from the beginning, and Republican legislators have used insurance companies’ withdrawals from the exchanges to reignite calls for the law’s repeal.

Kaiser tracks public data on insurer participation in the exchanges to project how many options counties will have, but the numbers are not final. This year, exchanges in about 7 percent of counties had just one insurer. Earlier this month, Aetna announced that it will pull out of 11 of the 15 states where it offers coverage on the health-care exchanges. Humana made a similar decision weeks earlier, planning to exit several states. And last spring, UnitedHealth Group said it would remain in three or fewer exchanges next year.

Obama has used the health-care law’s challenges to issue a new call for a public insurance option.

“Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited,” he wrote in an essay published in the Journal of the American Medical Association. “Adding a public plan in such areas would strengthen the Marketplace approach, giving consumers more affordable options while also creating savings for the federal government.”

Chicago resident Eva Saur, 32, is exactly the kind of healthy person insurers would like to have on their rolls. Saur hasn’t had coverage in nearly a decade, but she takes good care of her health. For the handful of times she’s been sick, a walk-in clinic at a pharmacy has been sufficient.

“I was raised — not against the system — but we had a doctor who would prescribe us herbs before a prescription” medication, Saur said. “For me, monetarily, it makes way more sense to do this.”

Saur’s tax penalty for being uninsured was a bit more than $600 last year, while the cheapest health plan she examined cost about as much for three months in premiums — and came with a $7,000 deductible.

The penalty for not signing up is increasing. Still, some policy experts insist it is not enough motivation to buy insurance.

“It was basically no stick at all. This is the classic case of where Johnny marked crayon on the wall, his mother said, ‘Don’t do that,’ and then slapped his hand a day later,” said Joseph Antos, a resident fellow at the American Enterprise Institute. “The connection between the offense and the penalty is a little remote.”

The health-care law has had unequivocal successes. In some areas, lots of insurers compete on the exchanges, which helps keep premiums low. In Cleveland and Los Angeles, the average premium for a benchmark health plan actually declined in 2016. The number of uninsured Americans continues to shrink, hitting 9.1 percent last year — the lowest level ever.

The average premium for the people who receive tax credits – 85 percent of the people signed up through the exchanges — is just $106 per month. People who qualify for the income-based tax credits are largely sheltered from premium increases.

The first people to sign up for insurance through the exchanges were expected to be those with chronic diseases and high medical costs. Because insurers could no longer discriminate against those people, the law built in three mechanisms for the government to redistribute money from plans with healthier patients to those with sicker ones. Two of those programs expire at the end of the year. The third, called the “risk adjustment” program, transferred $4.6 billion between insurers in 2014.

Critics say there’s a fundamental problem with the system, and the risk-adjustment program needs to be fixed. But supporters of the law argue that the problem is temporary, the natural evolution of a nascent free-market system. Some of the first companies to enter the market made bad bets on how healthy customers would be, resulting in unprofitable health plans. Proponents say it’s natural for new entrants to replace them, with better information and more competitive plans.

Cigna, for example, has said it has filed to enter exchanges in three new states next year.

“There’s no bottleneck, this is just the natural growth pains of a new market,” said Jonathan Gruber, an economist at the Massachusetts Institute of Technology. “What happened is they set up this new market where insurers didn’t have experience; insurers made an estimate as to what people would cost and their estimate turned out to be too low.”

Supporters point to a recent government analysis that suggests the “risk pool” — the number of high-cost sick customers relative to healthy ones — is not worsening and could even be improving. Medical costs per enrollee in the marketplaces fell by 0.1 percent in 2015, while medical costs for people in the broader health-insurance market grew by at least 3 percent. In states with strong enrollment growth, there were greater reductions in members’ costs.

Everyone agrees that more healthy people need to sign up.

In June, the Obama administration unveiled its plan to target younger and healthier adults, including direct outreach to individuals and families who paid the penalty. It also released new guidance, encouraging insurance companies to communicate more with young adults being kicked off their family’s plan when they turn 26 years old.

Even older adults are taking their chances without health-care coverage.

Donte Fitzhugh, 55, of Charlotte was laid off last year from a job as a call-center operations manager. COBRA, which allows former workers to extend their employer-provided health insurance if they pay the full premium, was expensive, and Fitzhugh didn’t sign up for the exchanges for very human reasons: He figured he’d find a job faster than he did. He thought every penny counted when he was unemployed. He didn’t have major health problems, and he got a coupon to help cover the costs of his hypertension medicine.

As the window to sign up for health insurance passed without a new job, he kept procrastinating. Although health insurance from a new job will begin in October, he faces a penalty that will cost him hundreds of dollars.

“I believe in Obamacare. As an American, it’s my responsibility to have health insurance,” Fitzhugh said. “Since I didn’t have it, it’s going to impact me financially.”

Such are the barriers to insurance: Remaining uninsured can be more attractive or just easier than signing up to pay hundreds of dollars a month for something that many people don’t think they need.

Judy Robinson, a health insurance support specialist at the Charlottesville Free Clinic, has counseled hundreds of patients who are eligible for subsidized insurance on the exchanges but ultimately decide not to sign up. She said the subsidized insurance on the marketplace tends to be a good deal for those who make between 100 and 150 percent of the poverty level. But those who make more often are faced with large deductibles that don’t seem like a good deal to many people.

Beyond the sticker price, she said it can require a lot of paperwork to demonstrate the annual income required to qualify for tax credits if people are juggling multiple part-time jobs. And sometimes, people are simply mistrustful.

“There’s a lot of people that live sort of off the grid, sort of semi-off the grid and they just don’t go to the doctor,” Robinson said. “The hospital is the place where you go to die, and doctors are just going to try and make you do procedures and get money out of you. That’s how they think.”

There are also those who want insurance but are struggling — and find themselves trapped by the high cost of health care.

Donna Privigyi, 49, of Charlottesville has looked into insurance through the exchanges a few times. But over the past few years, much of her modest child-care salary and effort went toward trying to help support her adult son, Mark, who hadn’t been the same since the death of his younger brother. Donna was focused on trying to support her son. Health insurance — even rent — was an afterthought.

“With supporting my son, it didn’t matter,” Privigyi said. “I was just like, I can barely get by, just juggling the bills and taking care of him.”

Late last year, Mark died of a drug overdose, and Privigyi — consumed by grief — wasn’t thinking about insurance when the window to sign up opened and closed.

Then, in June, she got appendicitis. Her bills from two hospitals were $33,000.

The argument for having health insurance is the pile of bills she has been collecting — now with late fees added. The obstacle to getting health insurance is that same stack of bills.

“It’s such a gamble, you know, until I figure out what to do with these medical bills,” Privigyi said. “They’re just adding on late fees. How can I even afford to sign up?”

Juliet Eilperin contributed to this report.

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MEDICARE RECIPIENTS DODGE A BULLET WHILE OBAMACARE INSUREDS PREPARE TO TAKE ONE!

By D. Kenton Henry

Perhaps a storm would be a better analogy but 2016 will deliver something more than a mild tropical depression to the coast of the “Individual and Family” health insurance market. At the same―the Cat 3 (minimum) hurricane projected to slam the Senior market of Medicare recipients appears to have been diverted. For now.

As we enter the third year of enrollment in health insurance plans compliant with the Affordable Care Act (ACA) the “Affordable” aspect of care or―more accurately―the cost of protecting oneself from the cost of health care―seems elusive and more and more a case of misrepresentation. As I have said many times in the past, if you qualify for a subsidy of your health insurance premiums you may find your options affordable. However, depending on where you live, you will surely be upset with the increasing cost of health insurance. 70% of all Obamacare members are enrolled in a Silver Plan. The Department of Health and Human Services (DHS), which oversees enforces the Act and oversees the health insurance industry, has designated the second lowest cost Silver Plan of any insurance company to be the default plan one must select in order to maximize the benefit of any subsidy. This could include a reduction in not only one’s premium but their deductibles and co-pays. As Fox News and the Washington Post report (see featured article below) the cost of these plans will rise by a national average of 7.5%. States such as Oklahoma will see an increase of 37.5%!

ACA ENROLLMENT 2016 2

In some states it is much worse.

ACA ENROLLMENT 2016 1

To add insult to injury many insurance companies, such as BlueCross BlueShield of Texas, have taken such losses―in spite of skyrocketing premiums―they have announced they are eliminating the Preferred Provider Organization (PPO) network option for their plans and member benefit. The only option will be to select a Health Maintenance Organization (HMO) network option wherein the company can ration your providers and treatment. While the young or otherwise very healthy may find this option acceptable, those of us who are older or dealing with existing illnesses or injuries are certain to be upset by this development. The insurance companies seem to be in agreement on the viability of PPOs and explain any premium increase necessary to assure they even break even on a PPO policy would be beyond the increase limit set by Obamacare. As such, it would therefore not be approved by their state insurance commissioner. So the question remains: what will your personal network and benefit options be for 2016 and what will they cost?

Virtually all insurance companies are keeping the answers close to their vest until this Sunday, November 1, the first day of OPEN ENROLLMENT wherein one may choose a health insurance plan for 2016. Enrollment will remain open until January 31st. Those without a plan at that time will be locked out for the remainder of the year and will pay a penalty equal to the higher of two amounts:

2.5% of your yearly household income (Only the amount of income above the tax filing threshold, about $10,150 for an individual in 2014, is used to calculate the penalty.) The maximum penalty is the national average premium for a Bronze plan

$695 per person ($347.50 per child under 18) The maximum penalty per family using this method is $2,085.

A banner follows which, as of Sunday, November 1st, you may click on and by simply entering your birth date, zip code and tobacco usage, obtain ALL your health insurance options from each and every insurance company issuing 2016 coverage in your state. It will also allow you to calculate what subsidy, if any, and enable you (if you choose) to log directly into the federal marketplace to acquire it and your insurance plan. If you have questions, as you most surely will, do not hesitate to contact me via my contact information via the link or below.

CLICK ON THIS BANNER TO OBTAIN 2016 HEALTH INSURANCE QUOTES:

Relative to Medicare recipients, it would appear a planned increase in the 2016 Medicare Part B premium and deductible has been taken off the table for the time being. The increase would have resulted in a huge spike in what higher income recipients and new enrollees in Part B Out-Patient coverage would pay in premium. The proposed premium increase would have been as presented here:

Income Limits, Medicare Part B Premiums for 2016

Single Married 2015 2016 Held Harmless 2016 Not Held Harmless
$85,000 or less $170,000 or less $104.90 $104.90 $159.30
$85,001 to $107,000 $170,001 to $214,000 $146.90 $223.00
$107,001 to $160,000 $214,001 to $320,000 $209.80 $318.60
$160,001 to $214,000 $320,001 to $428,000 $272.70 $414.20
Above $214,000 Above $428,000 $335.70 $509.80

The threat and legislation which averted this is described in detail in The Fiscal Times article below. As of today, it is still unclear to this editor whether the increase in the calendar year deductible has also been averted.

KENTON AT CAPITOL 2 (2)

Editor, Broker, Agent ― D. Kenton Henry

Office: 281.367.6565

Cell (call or text): 713.907.7984

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FEATURED ARTICLES:

Health & Science

THE WASHINGTON POST

26 October 2015

2016 Affordable Care Act insurance rates are climbing

By Amy Goldstein October 26

The prices for a popular and important group of health plans sold through the federal insurance exchange will climb by an average of 7.5 percent for the coming year, a jump nearly four times bigger than a year ago, according to new government figures.

The rate increase for 2016 compares with average growth of 2 percent, from 2014 to this year, in the monthly premiums for a level of coverage that serves as the benchmark for federal subsidies that help most consumers buying coverage under the Affordable Care Act.

A “snapshot” of insurance rates, released Monday by the Department of Health and Human Services, also shows that the rate increases for next year vary substantially around the country. Although there are exceptions, more populous states and metropolitan areas tend to have more modest premium increases for the coming year than smaller areas. 

The changes for next year have a wide range — from premium increases averaging 35 percent in Oklahoma and Montana to a decrease of nearly 13 percent in Indiana.

The analysis is based on hundreds of health plans sold in local markets within 37 states that use HealthCare.gov, the federal online insurance marketplace. It excludes plans in other states that have created separate ACA insurance marketplaces. The rates reflect the prices of the second-least expensive health plan in each market for 2016 in a tier of coverage known as silver. ACA health plans are divided into four tiers, all named for metals, depending on the amount of customers’ care that they cover. Silver plans have proven by far the most popular. Officials at HHS issued the analysis as less than a week remains before the start on Nov. 1 of a third open-enrollment season for Americans eligible to sign up for health plans under the insurance marketplaces created by the 2010 health-care law. The exchanges are intended for people who cannot get affordable health benefits through a job.

In their analysis, federal officials contend that the health plans sold through the exchanges will be affordable to people willing to shop for the best rates. The cost to consumers, HHS officials emphasize, is cushioned by the fact that nearly nine in 10 are eligible for tax credits.

Taking the subsidies into account, nearly four in five people who already have gotten insurance through these marketplaces will have access for 2016 to a health plan for which they could pay no more than $100 in monthly premiums, the analysis found. The analysis does not address other costs to consumers, such as co-payments and deductibles, which tend to be more expensive in ACA health plans than in employer-based health benefits.

The figures in the analysis reinforce a theme that Obama administration officials introduced last year and have revived as the third sign-up period approaches: the usefulness of researching the best and most affordable coverage, even if it means switching insurance from year to year. “If consumers come back to the Marketplace and shop, they may be able to find a plan that saves them money and meets their health needs,” Kevin Counihan, the HHS official who oversees the health exchanges, said in a statement.

The new figures show that existing customers who went back last fall to HealthCare.gov and picked a different plan at the same level of coverage saved an average of nearly $400 in premiums over the course of this year. Slightly fewer than one-third of those who bought such coverage for a second time switched health plans, according to the analysis. During this open enrollment, Obama administration officials are striving both to attract existing customers again and to ferret out Americans eligible for the exchanges who remain uninsured even though the law requires them to have coverage. Although many consumers can be largely shielded from rate jumps through subsidies and shopping around, the increases ratchet up the government’s expenditures on the tax credits that the law provides, health policy analysts point out.

Analysts have expected that premiums for the coming year would grow more rapidly than they did for 2015. “This is the first year that insurers actually have a full year of experience with how much care people use,” said Larry Levitt, senior vice president of the Kaiser Family Foundation, a health policy organization. “In the first two years of the program, insurers were essentially guessing.” In addition, Caroline Pearson, senior vice president at Avalere, a health-care consulting firm, said that, as some health plans have attracted a significant share of customers, “the need to price really low diminishes a little bit.” Clare Krusing, a spokeswoman for America’s Health Insurance Plans, the industry’s main trade group, said that “averages don’t tell the whole story” and that insurance rates hinge on “location and the cost of providing care to individuals in particular markets.” In particular, Krusing said, last year was “a record-breaking year for prescription drug prices. That trend is likely to continue.”

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Seniors Exhale as Congress Blocks Huge Medicare Increase

By Eric Pianin October 27, 2015 3:17 PM

Responding to pressure from seniors’ and labor groups as the 2016 campaign season heats up, congressional leaders and the White House have blocked a huge, 50 percent increase in the Medicare Part B premium for nearly one third of the 50 million elderly Americans who depend on the program for health services.

The bipartisan solution will block all but a tiny fraction of the premium increase. It is contained in the two-year budget and debt ceiling bill negotiated by House Speaker John Boehner (R-OH), House Minority Leader Nancy Pelosi (D-CA) and the White House and that awaits ratification by the two chambers – likely by the end of this week.

Related: Millions Facing a Hefty Increase in Medicare Premiums in 2016

The threatened sharp premium increase – reported back in August by The Fiscal Times – was triggered by a quirk in federal law that penalizes wealthier Medicare beneficiaries, newcomers to the program and lower income Americans with complicated chronic health problems. It kick in any time the Social Security Administration fails to approve an annual cost-of-living adjustment – as will be the case next year.

Medicare Part B and the Social Security trust fund are interconnected, and most seniors on Medicare have their monthly premiums deducted from their Social Security checks. Because the federal law “holds harmless” about 70 percent of Medicare recipients from premium increases to cover unexpected increases in healthcare costs, the remaining 30 percent of Medicare Part B beneficiaries suffer the consequences by being made to pay higher premiums.

Without intervention by Congress, roughly 15 million seniors and chronically ill people currently claiming both Medicare and Medicaid coverage would have seen their premiums increase from $104.90 per month to $159.30 for individuals, according to Medicare actuaries. The actuaries also predicted an increase in the annual deductible for Part B of Medicare, from $147 in 2015 to $223 next year.

Related: Social Security Ruling Drives Up Medicare Costs for Millions

Estimates of the cost of legislation to blunt or block a premium increase have ranged from $7.5 billion to $10 billion. Under the budget agreement unveiled late last night, that cost will be covered by a loan of general revenue from the U.S. Treasury to the Supplemental Medical Insurance Trust Fund.

In order to repay that loan, the 15 million people who are not subject to the “hold harmless” protection will be required to pay an additional $3 a month in premiums – a token amount — until the loan is repaid years from now, according to a House budget document describing the deal. Medicare beneficiaries who currently pay higher income-related premiums would pay more than $3, based on their income levels.

If there is no Social Security cost of living adjustment increase for 2017, this provision will apply again.

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MEDICARE PREMIUM AND DEDUCTIBLE INCREASES AND BLUECROSS PPO ELIMINATION SLATED FOR 2016!

cropped-the-medplus-messenger2.jpg

By D. Kenton Henry

Clients and Friends of Kenton Henry and ALL PLAN MED QUOTE,

It is that time again. We are approaching the end of the calendar year and I write to thank you for your business and for the trust you placed in me to represent your health insurance needs to the best of my ability. This month marks my 29th year in the industry and that would not be possible without you.

Because there are so many changes coming your way-not only for Medicare recipients but for my Under Age 65 clients-following me here will be the easiest way to be informed of vital information affecting your coverage as it becomes available to me. This is your one source for the good, the bad and the ugly of the Medical insurance market. I will be posting the good part later when I determine what that is. Happy New Year.

BREAKING NEWS FOR MEDICARE RECIPIENTS: On Thursday, October 15, the Social Security Administration announced that there will be no cost of living adjustment (COLA) for 2016. At the same time, the Medicare Part B Premium and deductible is expected to increase significantly for some people next year. The Part B basic premium is expected to go from $104.90 to $159.30 per month Additionally, the Medicare Part B calendar year deductible is slated to also increase from $147 to $223! This latter increase would affect approximately the entire Medicare population of 17 million and will in turn trigger premium increases from the supplemental insurances such as Medicare Supplement and Medicare Advantage which pay that deductible for the insured person! Together, these increases could cause people to drop their Medicare Part B insurance resulting loss of coverage for doctors visits, diagnostic testing, lab work and out-patient surgeries. For more details and information on just who this affects please watch this video of a FOX NEWS LIVE report by Martha MacCallum video I recorded just today:

MEDICARE PREMIUM INCREASE 2016

https://youtu.be/9DVGiEa074E

  • Additionally, if you are Part D Prescription Drug Plan client of mine (or not) email me a list of your current prescription drug regimen (drug and dosage) and I will scan the market to identify your lowest total of pocket cost plan and make my recommendation. allplanhealthinsurance.com@gmail.com

UNDER AGE 65 INDIVIDUAL AND FAMILY NEWS:

Most relevant at this time for individuals and families under the age of 65 is the elimination of BlueCross BlueShield of Texas’s “Individual and Family” Blue Choice PPO network which over 370,000, insured members (including myself) utilize. I informed all my clients (sharing this coverage) in a letter mailed via the US Postal Service just a few days ago. I also addressed this issue in my latest blog post entitled “BlueCross BlueShield of Texas Tells Clients ‘Say GoodBye To Your PPO Plan’”. (The more sarcastic side of me considered entitling it, “Take A Bite Of This Sandwich” but my more professional self intervened.) In the letter and post, I informed those who have HMO coverage their policy would not be affected other than an anticipated rate increase. It turns out that is not the case as I was just informed that many who have HMO coverage will also have to select another version. And so it seems that, with my assistance, many of you will be seeking alternative coverage for 2016.

This begs the question: What will our options be with other insurance companies? Unfortunately, like BlueCross, most companies are yet to reveal the details of their policies. Within the next few days, I hope to have a quoting link available to you from which-in the very near future-you will be able to obtain all your 2016 options, subsidy or no subsidy, on or off the Federal Marketplace otherwise known as Healthcare.gov. Regardless, I will be introduced to these changes over the remainder of October and these, along with the quoting link, will be posted on my blog in real time. Rest assuredwhatever your best options are for 2016I will have them. And you will be able to elect them with the beginning of OPEN ENROLLMENT (OE) November 1st―through the end January 31st.

Do not hesitate to call me as we prepare for these changes. And to assure you will be informed of the latest information relative to your coverage – please click “follow” on my blog as I post all coverage changes and preview the options you will have.

If you are currently a client—thanks once again for your business. It is greatly appreciated  as will readership of healthandmedicareinsurance.com!

Sincerely,

BUSINESS PHOTO FINAL FOR BLOG 10 15 2015

Kenton Henry  Blog Administrator, Broker, Agent

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BlueCross BlueShield of Texas Tells Clients “Say Good-Bye To Your PPO Plan”

By D. Kenton Henry

Don’t worry. This doesn’t apply to you if you have coverage through an employer’s group plan. But if you (like myself) are one of 370,000 insured members with an individual or family health insurance plan―be prepared to choose your provider from a different menu. And rest assured it will be portion controlled.

BlueCross will continue to offer Health Maintenance Organization (HMO) Plans where you must elect and utilize a provider within their HMO network or you will have no coverage whatsoever. This is where rationing begins. With your provider. You can expect the number of doctors and hospitals to be significantly limited relative to the selection currently available to you in the Preferred Provider Organization (PPO) network where you may go in or out of the network at your discretion and still be covered. Although details are yet to be unveiled, these HMO plans will most likely require you to select a “Primary Care Physician” with whom all medical care must be initiated. If so, you will have to obtain a referral from that primary care provider in order to see a specialist. And that is where rationing of care continues. With your treatment. HMO providers have contractually agreed to accept a lower payment in return for providing you treatment in the first place. Referring you (away) to a specialist results in a total loss of payment.

BlueCross explains they paid $400,000,000 more in claims then they collected in premium from their PPO members in 2014. And they add (exclamation point mine) “that is unsustainable!” Their rationale is―the insurance company will be better able to “manage” the care we members receive and what we are charged for care, helping to reduce health insurance premiums. Those currently enrolled in a “grandfathered” (written prior to the March 2010 passage of the Affordable Care Act) plan or HMO network policy will be happy to know you will probably be able to maintain your coverage option (deductible, co-pays) into 2016, assuming the premium remains affordable. Those, like myself, who want total discretion as to our providers are certain to be disappointed.

This begs the question: What will our options be with other insurance companies? Unfortunately, like BlueCross, most companies are yet to reveal the details of their policies. I will be introduced to these changes over the remainder of October and―rest assuredwhatever your best options are for 2016―I will have them. And you will be able to elect them with the beginning of OPEN ENROLLMENT (OE) November 1st―through the end January 31st. If you involve me, I will take into consideration your providers and do my best to find an affordable plan which allows you to continue to utilize them. If this entails you qualifying for and needing a premium subsidy from Healthcare.govI will assist you in navigating that process and serve as an advocate in your behalf. As I have done for 29 years this month, my objective is to ensure you obtain and maintain your best possible health care coverage at the lowest cost. Even in this age of increasing insurance premiums and less provider options.

Please refer to the featured article below and, lastly, to the Questions And Answers at the end of today’s post. Additionally, do not hesitate to call me or email me in order to prepare for these coming changes.

D. Kenton Henry (Editor, Agent, Broker)

AllPlanHealthInsurance.com

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Cell: 713.907.7984

Email: Allplanhealthinsurance.com@gmail.com

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Blue Cross to drop PPO plan covering 367,000 Texans

SAN ANTNIOEXPRESS NEWS

By Peggy O’Hare

July 27, 2015 Updated: July 27, 2015 8:34pm

Blue Cross Blue Shield of Texas is eliminating in 2016 its…

Health insurance carrier Blue Cross Blue Shield of Texas next year will eliminate a PPO health plan that 367,000 consumers statewide now depend on for health benefits.

The company’s decision to drop its Blue Choice PPO plan will affect only customers in the individual market — not those covered by Blue Cross PPO group plans through their employers. About 148,000 consumers whose PPO plans were grandfathered in 2010 also won’t be affected.

The change is being made because the insurance company paid out $400 million more in claims than it collected in premiums for its Blue Choice PPO product in 2014.

“We felt like the PPO was not going to be a sustainable option,” said Dr. Dan McCoy, chief medical officer and divisional senior vice president for Blue Cross Blue Shield of Texas.

The move will not interrupt customers’ coverage before the end of the year.

The insurance carrier expects to offer another product when open enrollment for 2016 begins Nov. 1 in the individual market. No details on that new product were available Monday since it still is awaiting federal approval. Consumers won’t be able to view and compare their options on the federal exchange until Oct. 10, the company said.

“A new product has been filed that we believe will give you a flexible choice for your clients,” Blue Cross Blue Shield of Texas said in a communication to insurance brokers last week. “We will be able to share information about that product if and when it is approved by the Centers for Medicare & Medicaid Services closer to open enrollment.”

The carrier has not yet started sending notices to customers affected by the change, aside from posting a general notice on its website, a spokeswoman said. However, they should receive notices by early October.

Only a small fraction of the carrier’s total 5.5 million customers in Texas are covered by individual Blue Choice PPO plans, but the product has proven popular with consumers who want flexibility on which doctors they can visit.

Loretta Camp, an independent health insurance agent at Davidson Camp Insurance Services and a member of the San Antonio Association of Health Underwriters, said she is bracing for a flood of questions from consumers.

“We pretty much expected there to be just a huge amount of feedback,” Camp said of Blue Cross’ announcement, “and we’ve gotten hardly any. I don’t think people have really grasped what that means.

“It‘s a huge impact to my client base,” Camp said, noting that 88 percent of her customers buying health plans for themselves or their families inside or outside the federal exchange selected PPOs — preferred provider organization plans that allow consumers greater freedom on which doctors to visit.

Customers with PPOs pay lower rates if they use doctors or hospitals considered to be “in network” and incur additional costs if they see providers “out of network.”

Such plans are generally pricier than the more restrictive HMOs — health maintenance organization plans that only cover care from doctors and hospitals “in network” and won’t cover services outside the network at all unless it’s an emergency.

“We have a number of clients that moved … to a PPO plan because they were having difficulty finding providers that would take the HMO plans,” Camp said.

In its communication to brokers last week, Blue Cross acknowledged there will be some physicians and providers no longer considered “in network” as a result of individual Blue Choice PPO plans being discontinued.

“The number of providers not in network due to the discontinuance may be greater in 2016,” said the notice to brokers. “We have ensured that we have an adequate network to provide the physicians and hospitals needed to serve our retail members in each market, and we continue to have discussions with additional providers.”

Keeping the individual PPO plans intact and raising the price would have forced the insurance company to raise everyone’s rates in the individual market.

Under the Affordable Care Act, “individual business is rated using a single risk pool, meaning all individual plans had to be looked at together,” the carrier said in its notice to brokers last week.

Like most carriers, Blue Cross was venturing into uncertain territory when the Affordable Care Act made health insurance available to everyone beginning in 2014, McCoy said.

“This is really a new era in American insurance,” McCoy said Monday. “And clearly we entered this marketplace with not a lot of information.”

That meant serving a large number of new customers and complying with the new federal law. “This was a group of people, many of which had never had health insurance before,” McCoy said of the new beneficiaries, “coupled with the Affordable Care Act that contained a lot of new provisions and additions to care.”

“You combine that with the fact that health care costs in the United States have continued to grow. So clearly the premiums were not enough to make up for the health care expenditures that occurred.”

Blue Cross officials sidestepped questions Monday about whether it will continue selling its Blue Advantage HMO plans in the individual market in Texas next year. The company also declined to say how many consumers now now covered by Blue Advantage HMO plans, calling that proprietary information.

However, the federal HealthCare.gov website shows the carrier requested a rate increase of almost 20 percent for its Blue Advantage HMO plans in 2016. That proposal is still under review by the Centers for Medicare & Medicaid Services. Blue Cross officials wouldn’t comment.

Blue Cross Blue Shield of Texas noted it was the only insurance carrier to offer a PPO product in all 254 counties in Texas during the first two years of open enrollment in 2014 and 2015. Company officials said they will continue to offer other options in all 254 counties both inside and outside of the marketplace.

pohare@express-news.net

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QUESTIONS AND ANSWERS:

What to Expect for Open Enrollment for 2016 Plans

Jul. 23, 2015

We’re getting ready for Open Enrollment for 2016. Blue Cross and Blue Shield of Texas (BCBSTX) will offer individual coverage options in every market in the state, both on and off the exchange. If you have an individual health plan or are looking to buy one in 2016, here are some of the changes you need to know.

When is Open Enrollment?

Open Enrollment for individuals runs from November 1, 2015 through January 31, 2016. If you are looking to buy your own health insurance plan for 2016, you can do so during this time.

If you already have health insurance, this is also the time you can:

  • Look at other plan choices
  • Compare plans and prices
  • See if you can get financial help

You’ll be able to see what plans will be available starting in October, when the “window shopping” period begins. This will give you time to weigh your options, ask questions and decide what will work best for you – before it’s time to sign up.

What will be different for individual plans in 2016?

There are some changes in the plans we intend to offer in the individual market in 2016. We won’t be offering PPO insurance plans in the individual, retail market. However, we intend to continue to offer HMO plans. This change does not affect our employer group customers or the grandfathered PPO individual plan members.

Why is Blue Choice PPO going away?

BCBSTX was the only insurer to offer an individual PPO insurance plan across the state to individuals in 2014 and 2015. Since the Affordable Care Act began, the market has changed. We found that the individual PPO plan was no longer sustainable at the cost it was being offered. Because we want to make sure that our plans are affordable, we decided to not offer individual PPO plans in 2016.

Why couldn’t you just keep offering the individual PPO plans and raise the rate for them?

The law requires that we set our individual plan rates based on all of our individual members’ claims history. This means that if the costs of one plan are high, it will raise the rates of all other plans, not just the high-cost plan. If we kept the Blue Choice PPO, this would have raised the rates so much for all our other plans that most people wouldn’t be able to afford them. By dropping the PPO, we can still offer our other plans at reasonable rates.

I have a PPO plan. What will this mean for me?

If you have an employer group PPO plan, this will not affect you. If you enrolled in the individual Blue Choice PPO plan last year, you won’t be able to keep your PPO plan in 2016. We’re sharing this information well in advance of the required notification date so that you have plenty of time to research the plan options that best suit your needs. We will work with you and your doctors to lessen the impact of this change to your ongoing care.

My Blue Choice PPO plan is “grandfathered.” Is it being discontinued too?

No. If you have a grandfathered individual PPO plan, it will still be available in 2016. Grandfathered individual plans are plans that existed on March 23, 2010, when the Affordable Care Act became law. If you don’t know if your plan is grandfathered, check your plan details or call the customer service number on the back of your BCBSTX member ID card.

Will I be able to keep my doctor and/or hospital if I switch plans?

Currently, we have two provider networks for our individual plans: Blue Choice PPO and Blue Advantage HMO. Some providers are only in the Blue Choice network, and some of them have decided not to join the Blue Advantage HMO network in 2016. So, with the Blue Choice PPO individual plans going away, these providers will no longer be an in-network option for most of our individual members. If you have a grandfathered plan, you will still have access to the Blue Choice network.

If your doctor is not in the Blue Advantage network, we will work with you and your doctor to lessen the impact of this change to your ongoing care.

When can I see 2016 plan details and rates?

Individual plan details and rates will be available in October 2015. Open Enrollment begins November 1, 2015

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