Your Employee Benefits

How to make the most of your health care dollars | BenefitsPro

2012-01-30T10:51:00.000-08:00

How to make the most of your health care dollars | BenefitsPro

House GOP to draft bill replacing PPACA | BenefitsPro

2012-01-30T08:13:00.000-08:00

House GOP to draft bill replacing PPACA | BenefitsPro

User-friendly health plan summaries at risk | BenefitsPro

2012-01-30T08:10:00.000-08:00

User-friendly health plan summaries at risk | BenefitsPro

More Americans lack health coverage | BenefitsPro

2012-01-25T12:19:00.000-08:00

More Americans lack health coverage | BenefitsPro

Selecting the Right LTCI Policy For You:

2012-01-24T12:55:00.001-08:00

First and foremost, in order to qualify for a LTCI policy, the applicant must be reasonably healthy both physically and mentally at the time of application. The rate an agent quotes you may not be the rate you ultimately receive because the insurance company will medically underwrite your application and may find some adverse information in your medical records that cause the carrier to consider you a higher risk.
Even though you may have been turned down by one LTC insurer, another company offering similar coverage may approve your application because it has more lenient underwriting guidelines that will make you an acceptable risk.
Carefully study the policy’s criteria for determining when a policyholder becomes eligible for benefits (often referred to as benefit triggers) after satisfying the waiting (elimination) period. More liberal benefit triggers can be an advantage to the consumer.
The better LTCI policies offer greater flexibility as to where and what kind of care is provided and therefore cover more options:
- Assisted Living Facilities
- Durable Medical Equipment
- Nursing Home Facility
- Home Modifications
- Adult Day CareHospice Services (not covered by Medicare)
- Respite Care while a caregiver (including a spouse or relative) takes a vacation.
- Home Health and Personal Care including meal preparation, chore services, light housekeeping, medicine monitoring, assistance with Activities of Daily Living.
Have a clear understanding of how the insurance company credits days toward satisfying the policy's elimination period, the time between the qualifying event and when benefits actually commence. Under the Calendar Days Method, every day of the week counts toward the elimination period even though no services are provided on some days. With the Days of Service Method, only days you actually receive covered services are counted toward this waiting period.
Even though the Compounded Inflation Rider (usually 5%) can significantly increase the premium, it is strongly recommended that this option be selected, especially for younger applicants (say under 65 or 70), as opposed to no adjustment for inflation or the less expensive Simple Inflation Rider. On average, long-term care services are escalating at a rate of 5% compounded per year.
Consider a policy that has a longer Elimination Period to help lower premiums. One suggestion might be a waiting period of between 45 to100 days since there is a possibility that Medicare (for those age 65 and over) may cover some portion of this waiting period for medically-necessary services performed at home or in a rehabilitation or nursing facility.
Consider a LTCI policy with a 3 to 5 year benefit period since the premiums are less than policies with 7 year or lifetime benefit periods. The average length of stay in a nursing home for persons 65 and older is about 3 years.
Benefits are usually paid out under one of three different approaches:
- Expense-Incurred Method – the most common payment arrangement; benefits are paid to either the policyholder or the provider when a covered expense for an eligible service is incurred once the elimination period has been satisfied.
- Indemnity Method – Once the insurance company has determined you are eligible for benefits and the elimination period has been satisfied, benefits are paid to the policy-holder on a daily, weekly or monthly basis while receiving long-term care services regardless of the actual cost of those specific services rendered until the up lifetime limit has been met.
- Disability Method – The policyholder is only required to meet the benefit eligibility criteria; once satisfied, you receive the full daily benefit even if you are not receiving any services on a particular day.
The better policies often include:
- Guaranteed Renewable provision so long as payments are made within the grace period.
- A Bed Reservation Benefit to set aside your bed in a nursing home or other facility while you are being treated in a hospital or rehabilitation unit.
- A generous (60 days +) Grace Period if premiums are late and written notification to alert your designated next-of-kin or friend of the delinquency.
- A Respite Period of up to 14 or 21 days (consecutive or non-consecutive) to enable your care-giver (even a family member) time off for a vacation.
- Payment for services to an Independent Care-Giver who is not associated with a private or public homecare agency.
- Care-Giver Training to instruct a family member or friend to provide long-term care assistance to the policyholder living at home or returning from a care facility.
- A substantial (up to 30% or even 40%) discount on each policy when two applicants living together (husband/wife, domestic partners, siblings) apply to the same insurer and are approved at the same time. Some companies give a lesser discount to the approved policyholder even though the spouse/partner who applied at the same time is turned down.
- International Coverage if residing or traveling in a foreign country, usually with limits on the amount or length of benefits to encourage return to the U.S.
If financially feasible, the policyholder is well advised to pay the premium on an annual basis to realize greater premium savings. Insurance companies often charge a significant interest surcharge for monthly and quarterly modal payments.
Marketed under different names, a Share(d) Care, Shared Benefit or Joint Benefit Coverage Rider for couples (spouses, two partners or related adults) may give a couple/partners piece of mind in knowing that if one partner uses up all of his/her benefits, that infirmed policyholder has access to the benefits of the healthy partner. Were the second set of benefits to also be exhausted, the policy usually allows the healthy partner to have his/her original benefits reinstated.
The abilty to assign a younger relative or friend as a second person to be notified by the insurance company should the premium payment not be received within 30 to 45 days of the due date. The backup assignee is then able to contact the insured to make arrangements for paying the delinquent payment and to assess the reason for the delay in payment. If the the policy is canceled for lack of timely payment and the insured is determined to have a cognitive impairment, the contract should provide for the carrier to reinstate the policy without penalty or limitation.

* The Activities of Daily Living criteria used as a measure to determine one’s need for long-term care services are: eating, dressing, toileting, transferring from lying to sitting and sitting to standing position, continence, and bathing. Cognitive impairment is another criterion that can trigger eligibility for benefits. Policies may require hands-on assistance, making it harder to qualify for benefits when compared to the less-restrictive stand-by assistance or verbal coaching.

Even With Insurance, Unemployed Have Worse Health Outcomes - Health News - Health.com

2012-01-24T12:36:00.000-08:00

Even With Insurance, Unemployed Have Worse Health Outcomes - Health News - Health.com

Transparency in 2012 health care | BenefitsPro

2012-01-19T12:41:00.000-08:00

Transparency in 2012 health care | BenefitsPro

Top 5 changes to 401(k) market in 2012 | BenefitsPro

2012-01-19T12:38:00.000-08:00

Top 5 changes to 401(k) market in 2012 | BenefitsPro

Another Roadblock to Obamacare in Missouri « CBS St. Louis

2012-01-18T10:50:00.000-08:00

Another Roadblock to Obamacare in Missouri « CBS St. Louis

Dental plans encourage better overall health | BenefitsPro

2012-01-16T08:29:00.000-08:00

Dental plans encourage better overall health | BenefitsPro

Average premiums jumped almost 10 percent this year | BenefitsPro

2011-11-04T06:35:00.000-07:00

Average premiums jumped almost 10 percent this year | BenefitsPro

Federal long-term care insurance program terminated

2011-10-28T13:25:00.000-07:00

October 27, 2011

On October 14, Health and Human Services Secretary Kathleen Sebelius sent a letter to congressional leaders about the CLASS Act – the federal long-term care insurance enacted as part of the health care reform law. Citing concerns over the solvency of the program, the HHS secretary suspended implementation of the program. However, it is important to note that the program has not been repealed.

Grandfathering Q&A for New Healrthcare Reform

2011-10-26T08:15:00.000-07:00

Qualification
What qualifies as a grandfathered plan?

A “Grandfathered Health Plan” is defined as a group health plan or health insurance coverage in which an individual was enrolled on March 23, 2010, regardless of whether the individual later renews coverage. Grandfathered plans are required to meet some, but not all, of the reforms contained in the Affordable Care Act.
The Act allows for family members to be added to a current plan and for new employees (including new enrollees subject to certain anti-abuse rules) to be enrolled in a grandfathered plan.
Beyond this, interim regulations detail what it means to be grandfathered and what benefit changes grandfathered plans can make and still retain their grandfathered status.

Application of rules to grandfathered plans
Which health care reform provisions apply to grandfathered plans?
Grandfathered plans will be required to meet some, but not all of the reforms.
Must grandfathered plans provide internal/external reviews under the Act?
Grandfathered plans are not required to comply with the Act’s internal and external review mandate — although plans may voluntarily comply without losing grandfathered status.
Disqualification
What disqualifies a grandfathered plan?
Can you conform benefits to reflect new state and federal laws without loss of grandfathered status?
Generally, a plan will lose grandfathered status if any of the following changes are made after March 23, 2010.* These rules apply separately to each “benefit package” offered by an employer:

A significant cut or reduction in benefits by eliminating all or substantially all of the benefits to diagnose or treat a condition, or any necessary element to diagnose or treat a condition.
Raising coinsurance charges
Significantly raising fixed cost-sharing (i.e., deductibles and out-of-pocket limits) by more than medical inflation (as measured from March 23, 2010) plus 15 percentage points
Significantly raising copayment charges by more than the greater of: (i) medical inflation (as measured from March 23, 2010) plus 15 percentage points or (ii) $5 (adjusted for medical inflation)
Significantly lowering the rate of employer contributions by 5 percentage points for any coverage tier
Adding or tightening an annual limit (with one exception)
Reclassifying employees so that the reclassified employees are eligible for a different plan (even if it’s a grandfathered plan), without a bona fide employment reason
Failing to continuously maintain at least one covered individual (not necessarily the same individual)

HHS may issue additional guidance on what other changes may defeat grandfathered status in the future.
Note: To maintain grandfathered status, a notice must be placed in plan materials provided to a participant or beneficiary explaining the grandfathered status of the plan or coverage.
For coverage that was in effect on March 23, 2010, an amendment to interim final rules released on November 15, 2010 clarifies that employers can change health insurance coverage effective on or after November 15, 2010 (i.e., enter into a new policy, certificate, or contract of insurance) without losing grandfathered status as long as other changes are not made that cause the loss of grandfathered status. Plans entering into a new policy, certificate, or contract of insurance with a new issuer must provide documentation of plan terms to the new carrier, as detailed in the amended rule. The rules for individual market were not modified, meaning a change in carrier in the individual market would result in the loss of grandfathered status.
Maintaining grandfathered status
How does a plan maintain grandfathered status?
The regulations also provide guidance on changes which are generally acceptable and will not normally affect a plan’s grandfathered status as long as the other invalidating changes are not made. Generally, if any of the changes listed below were made to a plan after March 23, 2010, they will not, by themselves, cause a plan to lose grandfathered status:

Changes to third-party administrators or insurers in the group market
Changing premiums
Changes to comply with state or federal law, including voluntary changes to implement ACA
Agreeing to binding renewals before March 23, 2010, effective on or after March 23, 2010
Allowing new employees or new enrollees who are not new employees and their dependents to enroll (subject to certain anti-abuse rules)
Allowing new dependents of current subscribers to enroll.

In general, routine changes in provider networks and drug formularies should not defeat grandfathered status.

Health plans and HSAs: Two essential parts to one benefits package | BenefitsPro

2011-10-04T07:42:00.000-07:00

Health plans and HSAs: Two essential parts to one benefits package | BenefitsPro

How to Beat Rising Health Insurance Premiums - NASDAQ.com

2011-10-04T07:38:00.000-07:00

How to Beat Rising Health Insurance Premiums - NASDAQ.com

AMA may no longer prescribe ObamaCare as right medicine

2011-07-27T13:16:00.000-07:00

AMA may no longer prescribe ObamaCare as right medicine

Company offers LTC insurance to high-risk, high-need consumers

2011-07-27T13:09:00.000-07:00

Company offers LTC insurance to high-risk, high-need consumers

21 Workplace Benefits That Are Rapidly Disappearing - US News and World Report

2011-07-26T11:35:00.000-07:00

21 Workplace Benefits That Are Rapidly Disappearing - US News and World Report

Towers Watson and National Business Group on Health Release Annual Employer Survey on Health Purchasing Decisions

2011-03-24T09:41:00.001-07:00

Towers Watson and the National Business Group on Health recently released their 16th annual employer survey on health purchasing decisions, a survey based on 588 employers, representing 9.2 million full-time employees across all major industry sectors, and conducted between November 2010 and January 2011.

The survey found that average total health care costs per active employee amounted to $10,387 in 2010, and that this amount is expected to rise to $11,176 per employee in 2011. Both employees and employers will bear the additional cost burden; employees’ share of total premium is expected to increase from an average of 22.9% in 2010 to 23.8% in 2011. To control spending growth, many employers have implemented new tactics in 2011, including rewarding employees for enrollment in healthy lifestyle activities and participating in community-based pilot programs, such as patient-centered medical homes. Survey data indicates that employers’ interest in quality and wellness initiatives is expected to continue into 2012.

Survey responses also indicate that emerging health reform requirements are causing significant changes in employers’ operations. When asked about changes due to the health care reform law, 81% responded that health reform has increased the administrative burden on their HR departments, 11% stated that health reform has decreased their ability to offer competitive pay increases, and 23% stated that they are less committed to offer health care benefits to retirees.

Salary-based Premiums Catching On

2011-02-23T08:41:00.000-08:00

Think everyone at all companies pays the same share of health insurance premiums regardless of how much they make? That’s not always the case. In some companies, higher-paid workers are required to pay a larger share of the premium than those who earn less.
Although the practice isn't widespread, it could become more common because of health care reform. Effective in 2014, companies will pay a penalty if their employees seek a federal subsidy to buy outside health insurance because the cost of employer coverage exceeds a certain percentage of the employees’ income.
Companies have switched to salary-based premiums partly to help lower-paid employees keep up with rising premiums. Employers also want workers to join the company health plan so they will seek medical care when they need it and won’t miss work because of health-related issues.
Some employers have tied premiums to salaries for as long as 10 years. BCBSNE started the practice seven years ago, and 1,300 employees participate in the company's health plan.
Some experts like basing premiums on salary because it helps lower-paid employees afford coverage. Those experts also say some higher-paid workers might resent paying a bigger share. BCBSNE has not heard any complaints. Varying the share employees pay is similar to an employer paying some workers more and some less based on their position.
Information from Omaha World-Herald, 2/9/11.

List of pros and cons concerning health care - The Famuan - Opinions

2011-02-02T09:39:00.000-08:00

List of pros and cons concerning health care - The Famuan - Opinions

Virginia Federal Judge Rules Individual Mandate Unconstitutional

2011-01-20T09:12:00.000-08:00

December 13, 2010

Appeal to Supreme Court Likely
On Dec. 13, 2010, a Virginia federal judge declared the “individual mandate” of the Patient Protection and
Affordable Care Act (PPACA) unconstitutional, ruling that the government cannot require Americans to
purchase health insurance starting in 2014. The case is expected to be heard by the Supreme Court, a
sentiment echoed by the ruling judge. "…this will certainly not be the final word,” said U.S. District Judge
Henry Hudson.
This is the first federal district court decision against the individual mandate. Two earlier decisions in Virginia
and Michigan found the mandate constitutional. Other cases are pending including one in Florida filed by
20 states. Several other lawsuits have been dismissed.
Incoming House Majority Leader Eric Cantor, R-Virginia, has urged President Obama and Attorney General
Eric Holder to request that the Supreme Court hear the appeal directly, bypassing the appellate court.
Under the PPACA, starting in 2014, individuals must be enrolled in a health insurance plan that meets basic
minimum standards. Health care exchanges, also starting in 2014, will provide a new insurance marketplace
where individuals and small businesses can buy qualified health benefit plans.
As the individual mandate is not effective until 2014, the Dec. 13 Virginia ruling has no immediate impact.

Building your Small Business Brand — Be Emotional! | Small Business Conversations by Network Solutions

2010-12-28T13:19:00.000-08:00

Building your Small Business Brand — Be Emotional! | Small Business Conversations by Network Solutions

We will have to get more creative with our Health insurance in 2011

2010-12-28T13:03:00.000-08:00

With all the changes coming at us from Health Care Reform we cannot do business as usual in 2011. When it comes to Employee Benefits we have to be willing to get out of the box and try new ways to cut costs and
to get our employees more involved in their health care expenditures and their lifestyles.

Change will not be easy but will probably pay big dividends down the road.

Report on small business in Missouri and their challenges

2010-12-28T10:36:00.001-08:00

The report, which the authors claim is the first of its kind, draws an interesting portrait of small business in Missouri:

Half of all Missourians work for a small business. Nationwide, small businesses create 60 to 80 percent of net new jobs.
Less of 4 percent of Missouri’s businesses qualify as “cheetahs,” but those 6,252 businesses added 130,000 jobs during the five years covered by the study. The Kansas City area was home to 18.52 percent of those companies, which account for about one of every 13 jobs in the region, slightly higher than the statewide average.
About one-sixth of the firms were in construction, and it’s worth pointing out that construction is one of the areas hardest hit by the economic downturn that was hitting with full force just at the time the report was issued. More than one cheetah in 10 is a retailer, and other major groups are “professional, scientific and technical services,” wholesalers and administrative and support services.
These entrepreneurs say Missouri is a pretty good place to do business – 78 percent said state policies have not been a barrier to their success – but they’d always like to have fewer regulations.

“The top issues that Missouri’s fastest growing firms are faced with due to their rapid growth include: finding and retaining qualified workers, increased administrative duties, higher healthcare costs and payroll, and higher office costs and cash flow,” the report says, adding later, “Half of Cheetah respondents indicated that government could best assist them via regulatory reform, changing the business tax structure, and reducing the costs for health care and energy.”

Blue Cross of Texas joins the rest of the insurance carriers

2010-12-23T07:18:00.000-08:00

Individual Primary Cancelled Under 19 Coverage Options

We want you to be aware of a recent decision regarding dependents under the age of 19 on Individual/family policies. Effective immediately, cancellation of coverage by the primary policyholder will result in cancellation of any dependents under the age of 19 on the policy. Blue Cross and Blue Shield of Texas (BCBSTX) does not offer a policy for primary insured policyholders under the age of 19 at this time.

There are two exceptions to this situation:

In instances where the primary policyholder dies, BCBSTX allows their dependent under the age of 19 to become the primary policyholder. If there is more than one dependent under age 19 on the policy, the oldest dependent becomes the primary policyholder.
In the event of a divorce, BCBSTX will allow a spouse under the age of 19 to move to their own policy as a primary policyholder.

Did you know: Diabetes cost could double or triple by 2050?

2010-12-10T13:17:00.001-08:00

According to an October 2010 report released by the Centers for Disease Control and published in Population Health Metrics, the annual cost of diabetes in the United States is $174 billion, $116 billion of which is in direct medical costs. That figure is expected to double or triple by 2050, with one in every three Americans suffering from the disease.

Medical Loss Ratio (MLR) Interim Final Regulations Announced

2010-11-23T08:17:00.001-08:00

CIGNA Perspective on the Ruling
At CIGNA, we continue to support the objectives of health care reform. We expected these interim final regulations. CIGNA is less impacted by MLR than our competitors because we are more diversified and a smaller percentage of our business is insured.

We fully embrace the goals of improving the quality of health care and providing transparency in an effort to reduce health care costs. We look forward to working collaboratively with national leaders to improve the quality and cost of health care.

CIGNA will continue advocating on behalf of our clients, benefit advisor partners and customers. We also encourage your voices to be heard. Please contact your CIGNA sales representative if we can assist.

On November 22, 2010, the Departments of Treasury, Labor, and Health and Human Services jointly announced Interim Final Regulations for the Patient Protection and Affordable Care Act’s (PPACA) Medical Loss Ratio (MLR) provision.
The provision states that beginning in 2011, insurers and HMOs must annually calculate their MLR and provide rebates to policyholders if their MLR (percent of premium revenue spent on claims/medical care) is less than 85 percent for large groups and 80 percent for small groups or individuals.
MLR applies to insured plans only, regardless of grandfathered status.
Largely, the regulations are consistent with recent recommendations from the National Association of Insurance Commissioners (NAIC).
General highlights of the regulations include:

MLR rebates will be sent to policyholders, which include employers or employee organizations as well as individual plan policyholders.

Insurers may distribute rebates to employers; in turn, employers would need to issue rebates to employees, based on employee contributions.

Policyholders are potentially eligible for a rebate determined on a “block” basis. The “block” is defined by:

Organization size (individual; small or large employer group)
Legal entity issuing coverage
State of issuance
Limited medical and expatriate international plans handled separately

Small group is defined as 2-50 employees – unless a state defines it differently – until at least 2016.
For the 2011 reporting year, issuers of limited medical (“mini-med”) and expatriate international plans are subject to separate calculation rules.

The plan’s numerator of the total claims incurred and expenditures for activities that improve health care quality would be multiplied by two.
Carriers will be required to complete additional quarterly reporting through 2011.
After reviewing this additional reporting, these adjustments will be revisited by the Secretary for 2012 and beyond.

Broker commissions will be included in the MLR calculation.
Non-U.S. insurance companies do not file MLR.

Next Steps
These are Interim Final Regulations from the Department of Health and Human Services (HHS). There will be a 60-day comment period. Final regulations may differ. As additional clarification is made available whether through rule-making or otherwise, we’ll share updates.

Health Insurance Costs Up 6 Percent, Survey Finds

2010-11-12T07:41:00.000-08:00

By Maggie Fox, Health and Science Editor
WASHINGTON, Nov 11 (Reuters) – Healthcare costs for people insured through an employer rose 6.3 percent for the year ended June 30, according to a new Thomson Reuters (TRI.N) index released on Thursday.
It found spending for hospital care rose especially fast — 8.2 percent, compared to a 5.5 percent rise for physician services and a 3.4 percent increase in drug costs.
“Overall, we estimate the per capita healthcare spending for those covered by private insurance is increasing at a rate of 6.3 percent annually in the 2nd quarter of 2010,” reads the report, available here
“It is growing well above the rate of inflation,” said Gary Pickens, chief research officer at the Thomson Reuters Center for Healthcare Analytics.
Thomson Reuters, parent company of Reuters, used data gathered from hospitals, insurers and other clients to gather the information, which it said represents more than 12 million employees and their dependents.
Pickens and colleagues created an index. “These are based on spending estimates that we don’t expose in this report,” Pickens said in a telephone interview.
The index is calibrated to 100 in 2002. Based on this, total health spending by people covered by employer insurance was 53 percent higher at the end of June 2009 than in 2002, and 62 percent higher in June 2010, an additional increase of 6.3 percent.
“Those changes compound and build up quickly,” Pickens said. “That’s why all the talk around the healthcare reform debate had to do with bending the cost curve. It’s very real.”
WORKPLACE BENEFIT
About 60 percent of Americans under 65 get health insurance through an employer — about 157 million adults. Health insurers include WellPoint (WLP.N), Aetna Inc (AET.N), Cigna Corp (CI.N), Humana Inc (HUM.N), UnitedHealth Group Inc (UNH.N), Health Net Inc (HNT.N), Amerigroup Corp (AGP.N) and the Blue Cross Blue Shield network.
Roughly 45 million people 65 and older have coverage through the nation’s Medicare program for the elderly and disabled.
Another 47 million lack insurance, and on Tuesday the U.S. Centers for Disease Control and Prevention estimated that 59 million Americans had no insurance for at least some of the beginning of 2010. [ID:nN09122635]
Healthcare reform was the signature policy for President Barack Obama, but polls show many Americans are unhappy with the bill signed into law in March. Republicans who will take control of the House of Representatives in January have promised to do whatever they can to block its implementation
Pickens said his team is working to break down details but the data covers three main areas — spending in hospitals, on doctor services and on prescription drugs.
Drug spending was the surprise area. “Some categories (of prescription drugs) are growing very rapidly,” Pickens said — for instance, biologics such as targeted drugs for cancer.
He believes the wide availability of cheap generics, especially those offered free or for $4 per refill by retail pharmacies, may be keeping prices from growing too fast.
The report notes that per capita spending inflation for prescription drugs increased dramatically until 2002 but the rate of increase has fallen since 2004.
Consultants PricewaterhouseCoopers LLP and Hewitt Associates both predict U.S. employers will pay nearly 9 percent more for health care costs for their workers in 2011, with Hewitt projecting that the average healthcare cost per employee will rise to $9,821 in 2011, up from $9,028 in 2010.
Hewitt says employees will pay $2,209, or 22.5 percent of the total premium, up 12.4 percent from 2010.

How the 2010 changes in health care reform may impact you

2010-11-11T07:44:00.001-08:00

How the 2010 changes may impact you
We are now focused on helping all of our constituents navigate through the changing health care landscape and prepare for the future. We have developed a piece to describe of some of the 2010 changes and their anticipated impact.
We hope this is helpful information pertaining to health care reform and its impact. Our next topic in the series will profile impacted benefits.

New easy to follow timeline of health care reform

2010-11-11T07:36:00.000-08:00

Timeline
The new health care reform will expand the availability of health care coverage to millions of Americans. While some of the measures of the new health care reform will be implemented this year, many do not take effect until 2014 and some extend out to 2020. We have created a high-level overview of the timeline to showcase key milestones of the measures. It is important to note that many of these reforms and their effective dates are subject to the rules and regulations process both at the state and federal levels — which could alter the intended timing of implementation.

Health Care “Blue Book” to Reduce In-network Variance (7% to 14%Savings on In-Network Claims )

2010-10-25T12:12:00.000-07:00

-Expose the degree in-network price variance that exists

-Disclose that poor quality providers are part of the network

•Members and /or CSR’s enter the diagnosis on-line and are shown the expected cost for each component provider i.e.(hospital, surgeon, anesthesiologist, etc).

•In-network cost variance can be as high as 500% for the same services

•Carriers have performed poorly w.r.t providing members with meaningful cost and quality data. True transparency would:

•Side-by-side provider cost rankings (green , yellow , orange, red) are shown by provider name along with contact information thereby allowing the participant to value shop immediately.

•Employer’s provider quality metrics can be added in

•Via plan design, members can be incentivized to use the “green” providers thereby minimizing the in-network variance to the plan overall.

• Average claims savings is 7% to 14% with proper member incentives.

A simple value proposition: same injury, two very different paths

Lets take a real example from the data. A parent is playing soccer with their child in the front yard, falls down and injures their knee. There are two care paths with similar outcomes, but very different costs:

Orthopedic visit $ 105 Orthopedic visit $ 105

Knee MRI $ 2,500 Knee MRI $ 507

ACL Surgery $ 10,000 ACL Surgery $ 2,691

Total Cost $ 12,605 Total Cost $3,303
Lower cost, same or better clinical outcomes

Low back pain: When are imaging tests needed?

2010-10-22T10:35:00.001-07:00

By Tanise Edwards, M.D.

For many people, low back pain is a sore subject. It occurs quite commonly — nearly everyone develops it at some point in life.

In fact, you may have back pain right now. And, maybe, you're wondering whether an imaging test — such as an MRI or X-ray — could uncover what's causing your pain.

But, before you ask your health care provider about testing, there's some important information you should know:

Your symptoms will likely improve with time. Low back pain usually goes away without treatment. Typically, that's in a matter of days. And, until then, over-the-counter pain relievers may ease discomfort. (See the sidebar for signs of back pain that could be serious.)

It's usually best to stay active. You might be tempted to lie in bed. But, studies have found that too much time lying down can actually slow recovery.

Imaging tests aren't without some risk. Health care providers must weigh the need for testing with the potential downsides. For one, test results may not always pinpoint the source of pain. And, sometimes they may be misleading. This can result in treatments that aren't needed. But, there are other issues to consider. Some tests — such as X-rays and CT scans — use radiation. The levels are considered safe. But, it's still best to avoid unnecessary exposure. And, of course, there's the out-of-pocket cost you may have to cover.

When pain lingers
The best way to get to the bottom of back pain that won't go away — or interferes with daily activities — is to work closely with your health care provider. He or she may do a physical exam and go over your symptoms. This is often how back problems are diagnosed.

Your health care provider may decide that an imaging test would be beneficial if your pain persists. Or, he or she may order one if a serious cause is suspected, such as nerve damage, infection or a tumor, for example. Common imaging tests used to diagnose back pain include:

X-rays. Standard X-rays primarily show bones. They're often used to look for broken or injured vertebrae and spine deformities.
Magnetic resonance imaging (MRI). MRI scans soft tissue and bones. These images can help reveal if back pain is triggered by a serious condition, such as disk disease.
Computed tomography (CT). This test creates three-dimensional images using X-rays. It focuses mainly on bones. But, it can also show soft tissue and help diagnose conditions such as a ruptured disk.

Your health care provider is the best resource when it comes to back woes. Together, you can develop a plan to ease your pain — and keep it from returning. For example, your doctor may advise that you lose excess weight, get more exercise and work on your posture.

Dr. Tanise Edwards is board-certified in emergency medicine. She is a medical consultant for OptumHealth, reviewing guidelines and consumer health publications. Before joining OptumHealth, she practiced emergency and urgent care medicine. She is the co-editor of Urgent Care Medicine (McGraw-Hill) and is on the editorial board of The Journal of Urgent Care Medicine.

New cost cutter for Company Health Plans

2010-10-21T14:11:00.000-07:00

Surgery Benefit Manager - Avg savings $7,700 / Patient

30% of all health care plan costs relate to surgical procedures:

• Cost control services like Pre-Cert, Case Management, Disease Management, etc. are already in place, Yet an estimated 25% of all surgeries still are unnecessary –just like 25 years ago.

• SBM program engages members on-line to learn more about various treatment options to full surgery e.g. minimally invasive surgery, physical therapy, etc) that are to be discussed with the prescribing physician.

• Significant savings occur, as over 20% of the SBM program participants choose a more conservative treatment option

•About 8% of all surgical costs are due to complications which SBM can minimize

•Average savings of $7,700 per participant

•Program can be offered as an additional benefit to the employees,

•Can be easily implemented off-cycle with as little as 60 days lead time.

Savings materialize within 90 days after communication of the program

Contact us to receive more information

2,000 health plans approved for early retiree program; reporting in the works

2010-09-10T12:21:00.000-07:00

Last week, the Department of Health and Human Services (HHS) announced the first round of nearly 2,000 companies and other organizations approved for the Early Retiree Reinsurance Program. This is a federal program that was created as part of the health care reform law. The program reimburses employer-sponsored health plans for part of the cost of health benefits for early retirees and their spouses, surviving spouses and dependents. "Early retirees" are people 55 and older who are no longer active employees and are not eligible for Medicare.
This program went into effect June 23, 2010. Accepted companies and other organizations will receive payments retroactive to that date. The program ends on January 1, 2014, or when the $5 billion allocated to the fund runs out. At that time, early retirees should be able to find coverage through the health insurance exchange (another provision of the health care reform law).
See the full list of companies and other organizations approved, including several of our clients.

Getting to the bottom of your health care costs

2010-09-10T12:16:00.000-07:00

Did you know: Medical errors cost the United States $19.5 billion in 2008?

Medical errors and the problems they cause cost the U.S. economy $19.5 billion in 2008, said the Society of Actuaries in its June 2010 study, The Economic Measurement of Medical Errors. Bed sores - considered to be the result of an error - produced the largest annual error cost at almost $3.9 billion, followed by post-op infections at $3.7 billion, device complications at $1.1 billion, complications from failed spinal surgery at $1.1 billion and hemorrhages at $960 million. The study is based on insurance claims data. The study was conducted by Milliman, an actuarial and consulting firm.

Regulations on Grandfathered Health Insurance Plans

2010-08-12T08:31:00.000-07:00

June 21, 2010

The Affordable Care Act (ACA) provides that certain group health plans that were in existence on March 23, 2010 when the healthcare reform law was enacted are not subject to all of the insurance reforms including in the Act. These plans are referred to as grandfathered health plans. The ACA balances the objective of preserving the ability of individuals to maintain their existing coverage with the goals of ensuring access to affordable essential coverage and improving the quality of coverage by guaranteeing that an individual may maintain the coverage in which he or she was enrolled on March 23, 2010. This is achieved by providing that various requirements of the insurance reforms do not apply to such plans or coverage, even if the coverage is renewed after March 23, 2010. However, to ensure access to coverage with certain particularly significant protections, the ACA requires grandfathered health plans to comply with a subset of the ACA's health reform provisions.
Definition of grandfathered health plan coverage. Under the statute and interim final regulations issued jointly by DOL (29 CFR Sec. 2590.715-1251), HHS (45 CFR Sec. 147.140), and IRS (26 CFR Sec. 54.9815-1251T), a group health plan or group or individual health insurance coverage is a grandfathered health plan for individuals enrolled on March 23, 2010. The regulations provide that a group health plan or group health insurance coverage does not cease to be grandfathered health plan coverage because one or more (or even all) individuals enrolled on March 23, 2010, cease to be covered, provided that the plan or group health insurance coverage has continuously covered someone since March 23, 2010, (not necessarily the same person, but at all times at least one person). The determination of grandfathered status is made separately for each benefit package made available under a group health plan or health insurance coverage. However, if an employer enters into an entirely new policy, certificate, or contract of insurance after March 23, 2010, that new policy, certificate, or contract of insurance is not a grandfathered health plan for the individuals in the group health plan. Any policies sold to a new entity after March 23, 2010, will not be a grandfathered health plan even if the health insurance product sold was offered before March 23, 2010.
Reporting and disclosure requirements. To maintain status as a grandfathered health plan, a plan or health insurance coverage must:

Include a statement, in any plan materials provided to participants or beneficiaries describing the benefits provided under the plan or health insurance coverage, that the plan or health insurance coverage believes that it is a grandfathered health plan within the meaning of section 1251 of the Affordable Care Act; and

Provide contact information for questions and complaints.

The interim final regulations include the following model language that can be used to satisfy this disclosure requirement:

This [group health plan or health insurance issuer] believes this [plan or coverage] is a "grandfathered health plan" under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your [plan or policy] may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at [insert contact information]. [For ERISA plans, insert: You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.] [For individual market 93 policies and nonfederal governmental plans, insert: You may also contact the U.S. Department of Health and Human Services at www.healthreform.gov.]

Recordkeeping requirements. To maintain status as a grandfathered health plan, a plan must also maintain records documenting the terms of the plan or health insurance coverage that were in effect on March 23, 2010, and any other documents necessary to verify, explain, or clarify its status as a grandfathered health plan. Such documents could include intervening and current plan documents, health insurance policies, certificates or contracts of insurance, summary plan descriptions, documentation of premiums or the cost of coverage, and documentation of required employee contribution rates. The records must be available for examination by participants, beneficiaries, or state or federal agency officials to verify the status of the plan as a grandfathered health plan. The plan or issuer must maintain the records and make them available for examination for as long as the plan takes the position that it is a grandfathered health plan.
Preventing abuse. A group health plan that provided coverage on March 23, 2010, generally is also a grandfathered health plan with respect to new employees (whether newly hired or newly enrolled) and their families who enroll in the grandfathered health plan after March 23, 2010. Any health insurance coverage provided under the group health plan in which an individual was enrolled on March 23, 2010, is also a grandfathered health plan. To prevent abuse, the regulations provide that if the principal purpose of a merger, acquisition, or similar business restructuring is to cover new individuals under a grandfathered health plan, the plan ceases to be a grandfathered health plan. The goal of this rule is to prevent grandfather status from being bought and sold as a commodity in commercial transactions.
The regulations also contain a second anti-abuse rule designed to prevent a plan or issuer from circumventing the limits on changes that cause a plan or health insurance coverage to cease to be a grandfathered health plan. In a situation where employees who previously were covered by a grandfathered health plan are transferred to another grandfathered health plan and the resulting change in coverage that would result in loss of grandfathered status if those changes were made directly to the plan from which the employees were transferred, the new plan will lose its grandfathered status.
Coverage requirements. A grandfathered health plan must continue to comply with the statutory requirements that applied prior to the changes enacted by the ACA, except to the extent supplanted by changes made by the ACA including the HIPAA portability and nondiscrimination requirements, the GINA requirements, the mental health parity provisions, the Newborns’ and Mothers’ Health Protection Act, the Women’s Health and Cancer Rights Act, and Michelle’s Law. The ACA provisions that apply to grandfathered plans include:

The prohibition of preexisting condition exclusion or other discrimination based on health status

The prohibition on excessive waiting periods

The prohibition on lifetime limits and the restriction and later prohibition on annual limits

The prohibition on rescissions

The extension of dependent coverage until age 26

The development and utilization of uniform explanation of coverage documents and standardized definitions

The bringing down of the cost of healthcare coverage (for insured coverage)

Plan changes that result in loss of grandfather status. The regulations, set rules for determining when changes to the terms of a plan or health insurance coverage cause the plan or coverage to cease to be a grandfathered health plan.
Benefit reductions. The elimination of all or substantially all benefits to diagnose or treat a particular condition causes a plan or health insurance coverage to cease to be a grandfathered plan. For example, if a plan eliminates all benefits for cystic fibrosis, the plan ceases to be a grandfathered health plan even though this condition may affect relatively few covered individuals. The elimination of benefits for any necessary element to diagnose or treat a condition is considered the elimination of all or substantially all benefits to diagnose or treat that condition. For example, if a plan provides benefits for a particular mental health condition, the treatment for which is a combination of counseling and prescription drugs, and subsequently eliminates benefits for counseling, the plan is treated as having eliminated all or substantially all benefits for the condition.
Increases in percentage cost-sharing requirements. Any increase in a percentage cost-sharing requirement (such as coinsurance) causes a plan to cease to be a grandfathered health plan.
Increases in fixed-amount cost-sharing requirements. Fixed-amount cost-sharing requirements include, for example, a $500 deductible, a $30 copayment, or a $2,500 out-of-pocket limit. For fixed-amount cost-sharing requirements other than copayments, a plan ceases to be a grandfathered health plan if there is an increase, since March 23, 2010, that is greater than the maximum percentage increase. The maximum percentage increase is defined as medical inflation (from March 23, 2010) plus 15 percentage points. For this purpose, medical inflation is defined by reference to the overall medical care component of the Consumer Price Index for All Urban Consumers, unadjusted (CPI), published by the Department of Labor.
For fixed-amount copayments, a plan ceases to be a grandfathered health plan if there is an increase since March 23, 2010, in the copayment that exceeds the greater of (A) the maximum percentage increase or (B) $5.00 increased by medical inflation.
Decreases in employer contribution rates. If the contribution rate is based on the cost of coverage, a group health plan ceases to be a grandfathered health plan if the employer decreases its contribution rate towards the cost of any tier of coverage for any class of similarly situated individuals by more than 5 percentage points below the contribution rate on March 23, 2010. For this purpose, contribution rate is defined as the amount of contributions made by an employer to the total cost of coverage, expressed as a percentage. The total cost of coverage is determined in the same way as the applicable premium is calculated for COBRA purposes. In the case of a self-insured plan, contributions by an employer are calculated by subtracting the employee contributions towards the total cost of coverage from the total cost of coverage.
If the contribution rate is based on a formula, such as hours worked or tons of coal mined, a group health plan coverage ceases to be a grandfathered health plan if the employer decreases its contribution rate towards the cost of any tier of coverage for any class of similarly situated individuals by more than 5 percent below the contribution rate on March 23, 2010.
The imposition of a new or modified annual limit. A plan that did not impose an overall annual or lifetime limit on the dollar value of all benefits ceases to be a grandfathered health plan if the plan an overall annual limit on the dollar value of benefits. A plan that, on March 23, 2010, imposed an overall lifetime limit on the dollar value of all benefits but no overall annual limit on the dollar value of all benefits ceases to be a grandfathered health plan if the plan adopts an overall annual limit at a dollar value that is lower than the dollar value of the lifetime limit on March 23, 2010. A plan that, on March 23, 2010, imposed an overall annual limit on the dollar value of all benefits ceases to be a grandfathered health plan if the plan decreases the dollar value of the annual limit regardless of whether the plan or health insurance coverage also imposed an overall lifetime limit on March 23, 2010.
Changes that do not result in the loss of grandfathered status. Changes other than the changes described above will not cause a plan to cease to be a grandfathered health plan. Examples include changes to premiums, changes to comply with federal or state legal requirements, changes to voluntarily comply with provisions of the ACA, and changes in third party administrators.
Transitional rules. The regulations provide transitional rules for plans that made changes after the enactment of the ACA on March 23, 2010, pursuant to a legally binding contract entered into prior to enactment, made changes to the terms of health insurance coverage pursuant to a filing before March 23, 2010, with a state insurance department, or made changes pursuant to written amendments to a plan that were adopted prior to March 23, 2010. If a plan or issuer made changes in any of these situations, the changes are deemed to be part of the plan terms on March 23, 2010, even though they were not then effective and are not taken into account in considering whether the plan or health insurance coverage remains a grandfathered health plan.
Because status as a grandfathered health plan is determined in relation to coverage on March 23, 2010, the date of enactment of the ACA, the DOL, HHS, and IRS will take into account good-faith efforts to comply with a reasonable interpretation of the statutory requirements. The agencies may disregard changes to plan and policy terms adopted before June 14, 2010, when the regulations were made public, that only modestly exceed those changes that would result in the loss of grandfathered status.
In addition, the regulations provide employers with a grace period within which to revoke or modify any changes adopted prior to June 14, 2010. Thus, grandfathered status is preserved if the changes are revoked, and the plan is modified to bring it within the limits for retaining grandfather status, effective as of the first day of the first plan year beginning on or after September 23, 2010.
For purposes of the grace period and of the reasonable good-faith standard, changes will be considered to have been adopted before June 14, 2010, if the changes are effective:

Before June 14, 2010,

On or after June 14, 2010, pursuant to a legally binding contract entered into before that date,

On or after June 14, 2010, pursuant to a filing before that date with a state insurance department, or

On or after that date pursuant to written amendments to a plan that were adopted before that date.

Although the three agencies have determined that the changes specified in the interim final regulations would cause a group health plan or health insurance coverage to cease to be a grandfathered health plan, they are inviting comments on whether this list of changes is appropriate and what other changes, if any, should be added to this list. Specifically, the agencies are looking for opinions on whether and of the following changes should result in cessation of grandfathered health plan status

Changes to plan structure (such as switching from a health reimbursement arrangement to major medical coverage or from an insured product to a self-insured product);

Changes in a network plan’s provider network, and if so, what magnitude of changes would have to be made;

Changes to a prescription drug formulary, and if so, what magnitude of changes would have to be made; or

Any other substantial change to the overall benefit design.

In addition, the agencies are looking for comments on the specific standards included in these interim final regulations on benefits, cost sharing, and employer contributions and specifically on whether these standards should be drawn differently because the changes made by the ACA may alter plan or issuer practices in the next several years.
Any new standards that are more restrictive than the interim final regulations will only apply prospectively. In addition, the agencies may issue administrative guidance other than in the form of regulations to clarify or interpret the rules contained in the interim final regulations.

Those crazy health insurance companies and their profits

2010-07-09T18:00:00.000-07:00

Getting to the bottom of health care costs

Did you know: Only three cents of every premium dollar is profit?

On average, 87 cents of every premium dollar you pay is spent covering medical care and services that members receive like doctor visits, hospital costs, prescription drugs and more according to a PriceWaterhouseCoopers medical cost trend report for 2009. Another 10 cents funds services we provide like claims processing, enrollment and billing and provider credentialing. That leaves 3 cents of every premium dollar for profits. Kaiser Health news has reported that the combined annual profits of the top 10 health insurers are equal to just two days work of national health care expenditures or just 0.5% of the estimated $2.5 trillion the nation spent on health care in 2009.

Sisters of Mercy sells health plan unit to Coventry Health Care

2010-07-01T12:02:00.000-07:00

Sisters of Mercy sells health plan unit to Coventry Health Care

New Healthcare reform 2010 - Released June 22, 2010

2010-06-24T12:55:00.000-07:00

HHS Releases Final Interim Guidance on Several PPACA Provisions

Would you like more information on Grandfathering? This informational flyer summarizes the interim final regulations published by the government on June 17, 2010. Click here.

Don’t forget to visit our Health Care Reform site at www.informedonreform.com

On June 22, 2010, the Departments of Health & Human Services, Labor, and Treasury issued new regulations that better define the following PPACA provisions:

No Pre-Existing Condition Exclusions for Anyone Under Age 19
No Arbitrary Rescissions of Insurance Coverage
No Lifetime Dollar Limits on Coverage
Restricted Annual Dollar Limits on Coverage
Broader Doctor Choice
No Higher Out-of-Network Cost-Share for Emergency Department Services

These are labeled as interim final rules (IFRs), which means final rules may differ. As clarification continues to be provided through the federal government’s rule-making process, we’ll share that information with you. Please continue to look out for e-mail Alerts and information on our Health Care Reform website on these important subjects.

All provisions are effective on the first plan anniversary on or after 9/23/2010

No Pre-Existing Condition Exclusions for Anyone Under Age 19
Plans are prohibited from denying coverage to anyone under the age of 19 based on a pre-existing condition. This ban includes both benefit limitations and coverage denials. These policies apply to all individual market and group health insurance plans. The requirement will be extended to all ages starting in 2014. Grandfathered individual plans are exempt from this requirement.
No Arbitrary Rescissions of Insurance Coverage
Insurers and plans will be prohibited from rescinding coverage – for individuals or groups of people – except in cases involving fraud or an intentional misrepresentation of material facts.
No Lifetime Dollar Limits on Coverage
Insurers and employers are prohibited from imposing lifetime dollar limits in all health plans and insurance policies issued or renewed on or after September 23, 2010.
Restricted Annual Dollar Limits on Coverage
The rules will phase out the use of annual dollar limits on “essential health benefits” over the next three years until 2014 when the Affordable Care Act bans them for most plans. The limits can only apply to essential health benefits; however, the rule does not provide any further detail on the definition of “essential health benefits” beyond that provided in the law.

Plans issued or renewed beginning September 23, 2010, will be allowed to set annual limits no lower than $750,000
Beginning September 23, 2011, minimum limit will be raised to $1.25 million
Beginning September 23, 2012, minimum limit will be raised to $2 million
Beginning January 1, 2014, all annual dollar limits on coverage of essential health benefits will be prohibited

These limits apply to all employer plans and all new individual market plans. It does not apply to grandfathered individual plans.
Waiver Process/Special Consideration:
The IFRs indicate that the Health & Human Services Secretary will design a process by which employers and insurers may apply for a waiver to delay complying with the restricted annual dollar limit rules if compliance would cause a significant loss of coverage or increase in premiums. The IFRs indicate that limited medical plans (such as CIGNA Voluntary) are one example of the type of plan that may apply for a waiver. We await details from the Secretary about the waiver application process.
The waiver for special circumstances reflects the Administration’s desire to work with the industry to minimize disruption during the transition period from now to 2014, and is a direct result of CIGNA's efforts to work with the Administration on the implementation of the Patient Protection and Affordable Care Act, and of the letters that many Limited Medical clients wrote to Congress and HHS.
Broader Doctor Choice
Health plan members are free to designate any available participating primary care physician (PCP) as their provider (e.g., pediatricians for children). Also, plans cannot require a referral for OB-GYN care.
These policies apply to all individual market and group health insurance plans except those that are grandfathered.
No Higher Out-of-Network Cost-Share for Emergency Department Services
Health plans and insurers will not be able to charge higher cost-sharing (copays or coinsurance) or require prior authorization for emergency services that are obtained out of a plan’s network. This policy applies to all individual market and group health plans except those that are grandfathered.

Mental Health Parity has an immediate impact

2010-06-10T06:53:00.000-07:00

The Mental Health Parity and Addiction Equity Act (MHP) is creating a significant and immediate impact on employer groups with more than 50 total employees. With this legislation, group health plans that provide mental health and/or substance use disorder benefits cannot apply "financial requirements" or "treatment limits" that are more restrictive than the "predominant" financial requirement or treatment limit that applies to "substantially all" medical/surgical benefits. We are working to ensure the health plans we offer fully comply with the provisions contained in MHP.

The Early Retiree Reinsurance Program helps employers provide coverage to retirees

2010-06-10T06:51:00.001-07:00

The recently passed Patient Protection and Affordable Care Act includes an early retiree reinsurance program available to groups that provide medical coverage to early retirees and their spouses, surviving spouses and dependents. This temporary program will provide $5 billion to help employers to continue to provide coverage to retirees ages 55 to 64.
The program provides for reimbursement of an early retiree's (and covered dependents') health care claims in an amount equal to 80% of the costs between $15,000 and $90,000. The employer is then expected to use the reimbursement to help lower health care costs (such as premium contributions, copays and deductibles) for participating enrollees.
This program is expected to be effective from June 1, 2010, to January 1, 2014. After January 1, 2014, retirees will have additional coverage options through the health insurance exchanges and federal subsidies for coverage.
Both self-insured and fully insured employer groups that offer early retiree coverage can apply, including plans sponsored by private entities, state and local governments, nonprofits, religious entities, unions, and other employers. To participate in the program, employers must first submit applications to the Department of Health and Human Services, which is expected to make the application available in the coming weeks. We'll share a link to the application when it becomes available.

Rescission Practises with Health Insurance companies

2010-05-07T07:15:00.000-07:00

May 5, 2010

BCBSTX Responds to Capitol Hill Request to Change
Rescission Practices

Responding to a request from Capitol Hill that insurers end the
practice of rescinding member coverage except in cases of
fraud or material misrepresentation, Health Care Service
Corporation, which operates in Texas as Blue Cross and Blue
Shield of Texas (BCBSTX), outlined the company’s standard
practice already in place that individual policies are rescinded
only in the case of fraud or material misrepresentation.

The request from Congress was made in a letter signed by
several House Committee Chairs and released publicly. In their
request, the Chairs also asked that insurance companies
institute an independent third-party review whenever a policy
is to be rescinded or canceled. BCBSTX is actively working to
implement a third-party review process as soon as possible.

To help you answer customer questions, we have created the
following FAQs. Please contact your BCBSTX account
representative if you have additional questions.

Q: What is rescission?
A: Rescission allows health insurers the right to revoke
coverage for individuals who have fraudulently or intentionally
misrepresented information pertinent to the terms of their policy.
When we offer coverage, we do so based on our understanding
of the individual’s situation – if that has been intentionally
misstated, we have the right to rescind the policy. An analogy
might be, if someone signs a contract to buy a house, but the
inspection shows the house has problems that hadn’t been
disclosed, then the contract is null
and void.

Q: How frequent are rescissions?
A: They are rare – a recent National Association of Insurance
Commissioners study shows they occur in approximately
one-tenth of one percent of individual market policies each year.

Q: What are the PPACA requirements around
rescissions, and how is the federal government
implementing them?
A: Effective Sept. 23, 2010, the Patient Protection and
Affordable Care Act of 2010 (PPACA) prohibits health plans
from rescinding coverage of an enrollee, except in instances
where the individual has acted fraudulently or intentionally
\misrepresented a material fact. Prior notice must be provided
in the event of such a cancellation.
However, leaders in the House of Representatives have
requested an earlier implementation, and also requested an
independent third-
party review of such cancellations, which is not required under
PPACA.

Q: What impact does this PPACA provision and the
House request have on BCBSTX operations?
A: BCBSTX’s current policy is to rescind coverage only in
cases of fraud or intentional material misrepresentation – we are
operating according to that provision. While not a mandate, we
are currently working toward a date when we will provide third-
party review of such rescissions.

Q: What is the timeframe for notice to the member?
A: Health and Human Services (HHS) has not yet defined that.
We will comply with the timing requirements once they are
finalized.

Q: What is the timeframe and scope for the external
review?
A: We will implement a third-party external review process as
soon as possible. Since third-party external reviews are not
required under PPACA, there is not a specific date that such
reviews must begin.

Q: If a member has previously had his/her coverage
rescinded, does the PPACA provision allow them to have
that rescission overturned?
A: Because BCBSTX’s policy has been to rescind coverage
only in cases of fraud or intentional material misrepresentation,
there would be no change in that rescission.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.

FAQ - New Healthcare reform 2010

2010-04-15T07:59:00.000-07:00

CLIENT FAQs - Frequently Asked Questions

Are you making changes to any products or processes?
The law is both comprehensive and complex, and we are currently evaluating its impact on both our agents and our customers. We are taking time to fully understand the impacts of this law and are committed to operating in compliance
with all guidelines and regulations. We will continue to identify and monitor any potential impact, make the necessary
product and process changes and communicate this information with our agents and customers, as appropriate.

How will changes to my clients’ policies or benefits be communicated?
Any requirement of the new legislation that would impact your clients’ policies or benefits with us will be communicated in writing and sent to policyholders. If your clients have specific questions about their policy, please have them contact Assurant Health Customer Service directly by calling the number located on their ID card.

Will my clients’ premiums increase as a result of health care reform?
We pride ourselves on providing valuable benefits and services to our customers; however, rate increases do occur. In compliance with the guidelines and requirements of the new health care law required by September 23, 2010, we will modify policyholder benefits accordingly. With these adjustments to policy benefits, it is probable that an increase in premium costs will
occur. We will provide customers with notice before the benefit changes and any resulting premium increases take
effect. Beginning in 2014, premium prices cannot be based on a customer’s gender or health status. Until then, our current premium pricing will apply.

Are there annual or lifetime maximums on coverage under the new law?
Effective September 23, 2010, there are no lifetime maximum limits on coverage. In addition, there will be no annual limits
on group plans. For individual plans, annual limits may be allowed based on what Health and Human Services deems
reasonable. This information is not yet available.

When are my clients able to have their dependents covered until they are 26?
Effective September 23, 2010, the law states that customers will be able to have dependent coverage for their married AND unmarried children up to the age of 26. The requirement is applicable even if the child is not a tax dependent. The law does not specifically include spouses of married children. There is no requirement to cover children of covered dependent children
(i.e., grandchildren).

Under the new law, do pre‐existing conditions no longer matter?
Effective September 23, 2010, insurance companies cannot limit coverage for children on individual or group policies with pre‐existing medical conditions. For adults with individual policies, this provision goes into effect in 2014.

Under health care reform, what happens to rescission?
Effective September 23, 2010, rescissions will occur only in cases of customer fraud or intentional misrepresentation.

Is it true that anyone who applies for coverage will be issued coverage?
Under the Guarantee Issue provision, effective in 2014, anyone who applies for coverage must be issued coverage.

How will this new law affect my clients with MSAs/HSAs?
At this point, the only change we are aware of is the tax penalty increase from 10 percent to 20 percent for “non‐qualified”
expense withdrawals. This is effective beginning in 2011.

2010-03-11T08:20:00.000-08:00

"Introducing Quicken Health Expense TrackerSM

Quicken Health Expense Tracker
Pay in seconds, fact-check in minutes — save yourself hours.

As a UnitedHealthcare member, you now have access to Quicken Health Expense Tracker, a new Web-based tool that will help you understand and pay your family’s health care expenses.

This new online tool puts the facts at your fingertips, so you know if your “amount due” is correct — and why. From full explanations of the terms, to break-downs of the math, you'll see it all. And you can pay most of your doctors in a matter of clicks.

Click it. Read it. Act on it.
When a new claim is processed, Quicken Health Expense Tracker breaks it down, showing you what you owe and why. It will help you understand exactly how each claim was calculated within the terms of your medical plan. With this tool, you will be able to see how much your medical plan is paying, what part of the visit went to fulfill a deductible or co-pay, and what — if anything — you should pay.

It’s health care paperwork without the paper — or the work
With Quicken Health Expense Tracker you can stay on top of your health care costs like never before — right from your computer, anywhere you have Internet access. Say goodbye to the hassle of phone calls, and searching through paperwork.

Just log on to your myuhc.com® home page, sign up for Quicken Health Expense Tracker, and it will automatically load up to 18 months of your family’s claims history with UnitedHealthcare. And, new claims will continue to be automatically added for as long as you have a UnitedHealthcare health plan.

So if you ever wondered if your bill was correct — or you want to pay it at your convenience — Quicken Health Expense Tracker is right for you."

2010-03-04T07:21:00.000-08:00

"Stress and back pain: What's the connection?

We all have stress from everyday life, and it's not always harmful. It can give us a burst of energy or help us focus on important tasks. But, poorly managed stress can cause problems such as back pain.

'When you're tense, anxious, fearful or angry, your back, shoulder and neck muscles contract,' says Norman Marcus, M.D., director of muscle pain research at the NYU School of Medicine. Eventually, that can lead to pain severe enough to affect daily activities.

You can't escape stress as easily as you can avoid other back pain risks, such as heavy lifting. But, there are steps you can take to help cope with — or avoid — the pain.

Move away from pain
One strategy for relieving stress and back pain is regular exercise. Check with your doctor first, and then try activities that make you break a sweat. Exercise — such as jogging, swimming and bicycling — can release muscular tension and lower your stress level.

Eating right (see the sidebar 'Avoid the pitfalls of stress') and regularly getting enough sleep can help reduce stress and may help to prevent back problems, too.

If you have to sit for long periods, keep your head and shoulders erect. Also, take breaks by standing, moving around and stretching. Your workstation should be comfortable. Make sure your chair supports your lower back and that your working surface is at the proper height so you don't have to lean forward.

Remember to take time for yourself as much as possible. Read a good book, listen to your favorite music or watch a funny show — laughter can be good medicine."

I knew chocolate was good for you - it tastes too good.

2010-02-11T08:25:00.001-08:00

Click here for A touch of dark chocolate can benefit the heart.docx

Eat more chocolate and live longer.

Don't let your budget effect your health

2010-02-10T08:23:00.001-08:00

Click here for Don't let your budget effect your health.pdf

If your financial picture is not real healthy - don't let that effect your healthy lifestyle.

2010-02-10T07:31:00.000-08:00

"Feeling strapped? Don’t let financial stress hurt your health

Perhaps you or your partner is out of work or your investments have lost value. Maybe you just wish money wasn’t so tight every month. If times have been tough on your pocketbook and portfolio, you’re not alone. The signs of economic trouble are everywhere. However, it’s important to take steps to keep these hardships from undermining your physical and emotional well-being.

Signs of the times
The fact is that living with too much financial pressure can raise stress to unsafe levels. And, ongoing stress may lead to issues such as:

* Depression
* Anxiety
* Substance abuse
* Compulsive behaviors, such as eating disorders, excessive gambling or overspending

The effects of stress don’t stop with emotions and behavior. Some experts suggest that if stress isn’t managed, it can even lead to serious physical conditions, such as heart disease and obesity.

Stress makes itself known differently from person to person. It’s important to pay attention to how you’re feeling and behaving in order to look for clues about your stress level. It may be too high if you:

* Feel unusually sad or cry a lot
* Are excessively anxious
* Have trouble sleeping
* Feel tired all the time
* Are irritable or angry
* Drink more alcohol than usual

Of course, eventually, the nation’s economy will improve. In the meantime, there are steps you can take to help get a handle on your personal finances and your stress.

Invest in a plan
For starters, try not to give in to the gloomy, negative hype in the news. Focus on what you can do to control your situation and become more competent when it comes to money. For example:

* Take a good look at your finances, even if it hurts. Think of ways you and your family can reduce expenses. It can start with something as simple as eating more meals at home or carpooling to work. If you smoke, this may be the motivation to quit that you’ve been looking for. Evaluate all the ways you spend money. Little things can add up. There may be some that you could get by without.
* Make a plan to manage your money. Perhaps, you’ve decided to pay down some credit cards or save a little more money every month. Write down specific strategies to reduce and save. Then, commit to a plan and review it regularly.
* Empower yourself. Look for opportunities to grow financially and personally. Consider talking with your employer about taking a course to improve your job skills. Or, contact a financial planner to learn how to better manage your finances. You may be able to find affordable financial guidance through government agencies and community organizations. You may want to start in the government services section of your phone book.

Create your stress defense
You can also protect against ongoing stress. It’s not always easy to make time, especially when so many responsibilities may demand your attention. But, it’s worth it. When you take care of your own needs you’re better able to care for your family’s needs, too. Consider these everyday steps:

* Be active. Playing sports or just taking a walk can reduce stress. If you’re generally healthy, aim to get at least 2.5 hours a week of moderate-intensity aerobic activity. At least two days a week, work in some muscle-strengthening activity at a moderate intensity or higher. Just be sure to check with your doctor before significantly increasing your level of physical activity.
* Make time for yourself. Read a good book or listen to your
favorite music.
* Eat healthfully. Stress may trigger some people to reach for junk food or turn to other unhealthful eating habits. Stick with nutritious foods, such as fruit, vegetables, whole grains and fat-free dairy products.
* Get enough sleep. Adults need seven to nine hours. If you’re having trouble sleeping, make some changes to your sleeping habits. For instance, try going to bed at the same time each night, and get up at the same time each morning.
* Avoid unhealthful behaviors. For example, some people use smoking or drinking too much alcohol to cope with stress. Talk with your doctor if you need help quitting."

2010-02-10T07:30:00.000-08:00

"Get to the heart of
metabolic syndrome

Metabolic syndrome — a combination of risk factors that are linked to being inactive, overweight and obese — is becoming increasingly common in the United States. In fact, almost 25 percent of adults have it. People with metabolic syndrome are twice as likely to develop heart disease compared with those who don’t. They’re also five times more likely to develop diabetes.

Know your factors
Metabolic syndrome may be diagnosed if you have at least three of the following risk factors:

* A large waist — 35 inches or more for women and 40 inches or more for men.
* A triglyceride level of 150 mg/dL or higher.
* A low HDL, or “good” cholesterol, level — less than 40 mg/dL for men and less than 50 mg/dL for women.
* Higher than normal blood pressure — 130/85 mmHg or higher. However, if only one of your two blood pressure numbers is high, it’s still a risk factor of metabolic syndrome.
* Higher than normal fasting blood glucose level — 100 mg/dL
or higher.

The more risk factors you have, the greater your chance of developing heart disease or diabetes or having a stroke.

Risk management
If you have metabolic syndrome, treatment — such as making lifestyle changes — can help reduce your risk of heart disease and diabetes. If you already have one or both of these conditions, lifestyle changes also may help you prevent or delay complications, such as heart attack and stroke.

To get started, talk with your doctor. He or she may suggest that you:

Shed excess weight. If you’re overweight, dropping those extra pounds can make a big difference to your health. Being overweight puts stress on your heart and increases your risk of heart disease. Losing even 7 to 10 percent of your weight can bring health benefits. If you weigh 250 pounds, for example, that’s about 18 to 25 pounds.

Choose a healthful diet. Eating healthful foods not only will help you lose weight, but it may help you lower your cholesterol, too. Choose foods high in soluble fiber and low in fat, such as fruits, vegetables and whole grains.

Step it up. Be sure to talk with your doctor before beginning a new exercise program or significantly increasing your level of physical activity. Your doctor may prescribe an exercise program that’s designed just for you.

In general, people with metabolic syndrome should maintain a moderate level of activity — such as brisk walking — for at least 30 minutes, at least five days a week. It’s fine to break it up into chunks of 10 minutes or more to get to your total. Talk with your doctor about working up to 60 minutes a day, every day of the week.

Quit smoking. It’s harmful to your heart. It also raises triglyceride levels and lowers HDL cholesterol.

In some cases, your doctor may also prescribe medicines to control individual risk factors, such as high blood pressure.

Steps to prevention
A healthful lifestyle is vital if you have metabolic syndrome. And, even if you only have one risk factor, such as high blood pressure, it’s important to take steps to control it. Healthful lifestyle changes may help prevent metabolic syndrome."

New Government research on mammographys

2010-02-02T07:39:00.000-08:00

"Panel: Screening Mammogram Guidelines Change
U.S. Preventive Services Task Force Recommends Routine Mammography Screening Every 2 Years

By Salynn Boyles
WebMD Medical News Reviewed by Louise Chang, MD

Nov. 16, 2009 – A government appointed expert panel is calling for huge changes in breast cancer screening in the United States, but a leading cancer group is highly critical of the move.

In newly revised guidelines, the U.S. Preventive Services Task Force (USPSTF) now recommends against routine mammography screening for average-risk women in their 40s.

USPSTF also says women between the ages of 50 and 74 should have mammogram screenings every two years instead of every year.

Routine screening is not recommended for women older than 74.

In addition, the government task force:

Concluded women and their doctors should base the decision to start mammography before age 50 on the woman’s individual risks and preferences.
Recommends against breast self-exams based on findings from two large studies showing the practice to have no value.
Concluded more evidence is needed to determine if clinical breast exams performed by trained medical professionals are useful.
Concluded more research is needed before recommendations for or against mammography screening after age 74 can be made.
Concluded there is not enough evidence to know if the newer digital mammography or MRI are superior to traditional film mammography.

ACS Does Not Support Changes

The dramatically revised guidelines were based on a comprehensive analysis of the research exploring the benefits and risks of breast cancer screening and a risk-benefit model commissioned by USPSTF.

Task force vice-chairwoman Diana B. Petitti, MD, MPH, says the new recommendations do not mean average-risk women younger than 50 and older than 74 should never be screened.

Rather, they are meant to foster discussion between these women and their doctors about the risks vs. benefits of routine screening.

Potential risks include anxiety, unnecessary biopsy, and unnecessary treatment of cancers that would never become life threatening.

'A woman who still wants to be screened after having the conversation with her clinician and considering the balance of benefits and harms should absolutely be screened,' Pettiti tells WebMD.

The American Cancer Society will continue to recommend annual routine mammography screening for all healthy women age 40 and over, ACS Chief Medical Officer Otis Brawley, MD, confirmed in a statement issued today.

'This is one screening test I recommend unequivocally, and would recommend to any woman 40 and over, be she a patient, a stranger, or a family member,' he notes.

Mammography Screening Every 2 Years

All agree that annual mammography screenings save lives.

But based on the research analysis and risk-assessment model, the task force concluded the harms of telling women to have a mammogram every year starting at age 40 outweigh the benefits.

According to the newly published research analysis:

1,904 women between the ages of 39 and 49 would need to be invited for screening to have one breast cancer death prevented.
1,339 women between the ages of 50 and 59 would need to be invited for screening to prevent one death.
377 women between the ages of 60 and 69 would need to be invited for screening to prevent one death.
According to the risk-assessment model, about 60% more false-positive results could be expected for every 1,000 mammograms performed when screening is started at age 40 instead of 50.

Jeanne S. Mandelblatt, MD, MPH, of Georgetown Lombardi Comprehensive Cancer Center led the research team that developed the model.

The team concluded that mammogram screening every two years achieves most of the benefits of annual screening with far fewer false-positives and other negative outcomes.

'Mammogram screening clearly has benefits, but there are potential risks as well,' she tells WebMD. 'Women need to discuss their own individual balance of risks and benefits with their health care providers.'

Brawley: ‘Women Want Mammograms’

The American Cancer Society’s Brawley says surveys show women understand the limitations of mammography but still place a high value on breast cancer screening.

“With its new recommendations, the USPSTF is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them,” he notes.

In 2003, an ACS expert panel reviewed much of the same research as the USPSTF panel but came to very different conclusions about who should be screened and how often, ACS volunteer president Elizabeth T.H. Fontham, MD, tells WebMD.

She worries the competing recommendations will confuse women and keep those who most need mammograms from getting them.

“It would be a terrible thing if women conclude that mammography screening is not useful,” she says. “One thing we know for sure is that mammography saves lives. That is true for women in their 40s, for women 75 and older, and for all women in between.”

Fox Chase Cancer Center Director of Mammography Kathryn Evers, MD, tells WebMD she will continue to recommend annual screening to her patients in their 40s and to healthy patients who are 75 and older.

She is concerned that health insurance providers may deny coverage for routine mammogram screening to average-risk women younger than 50 and older than 74, based on the new USPTF recommendations.

“Mammography is not a perfect tool, but it saves lives,” she says. “Right now it is the best tool we have to prevent deaths from breast cancer, and women want their insurance to pay for it.”

In a joint statement emailed to WebMD, the American College of Radiology (ACR) and the Society of Breast Imaging say the new guidelines could cost women's lives.

Calling the guidelines a 'cost-cutting' measure, the ACR states that 'two decades of decline in breast cancer mortality could be reversed and countless American women may die needlessly from breast cancer each year.'

In the statement, Carol H. Lee, MD, chairwoman of the ACR's Breast Imaging Commission, calls the USPSTF recommendations 'unfounded.' Lee adds, 'Mammography is not a perfect test, but it has unquestionably been shown to save lives -- including in women aged 40-49.'"