Transparency & Technology: A Winning Combination for Brokers
“Employers today are faced with an overwhelming amount of decisions when it comes to health care. However, the end goal always remains the same – to provide the best, most affordable options to employees.
But it’s nearly impossible for these owners to comb through the complicated benefits, HR, and compliance landscape…without some help.
Group Health Solutions, the benefits company of SDL + GHS, is an employee benefits agency in New York helping clients navigate the complex world of group and individual health insurance. They’re also a PrimePay Broker Concierge partner.
As managing director (with a specialty in group benefits) Rob Bujan explains, technology and transparency have been key players in their quest to make clients’ lives easier. Here’s how.
The right fit.
You get a great referral from a client who you’ve done business with for years. It has the potential for being a huge deal in your book of business and you’re excited about the opportunity. But, after meeting with the business owner, you realize that what you offer might not actually align with their goals as beautifully as you imagined. Disappointment ensues. Sound familiar?
Instead of trying to come up with a customized plan and make something work that really shouldn’t, GHS leads with transparency.
“Not everybody is going to be a great fit for every broker and not every broker is going to be a great fit for every client. And we’re pretty up front and honest about that. If we’re doing an evaluation on a client and we just feel that there’s really nothing that we can bring to the table, we’ll typically say, ‘Give us five minutes. Let us explain our technology and if this is something that you think that would benefit you, then let’s continue the conversation.’ We’re just not going through an arduous sales process just to get a client on the books,” explained Bujan.
Bujan has been in the employee benefits industry for over 25 years and truly believes in this code of ethics. He understands that people are very concerned about what’s going to happen with the hot button issues of health care, mergers, the individual market, Medicare/Medicaid, etc. And though commissions have been gutted over the last 10 years, he still takes it upon himself to do all that he can to take that fear away from clients.
“We give back to the community and often provide services for individuals who need to get enrolled on Medicaid and or need guidance in the individual market. It’s not just about making money; we should really be a good corporate neighbor. We’re an expert for a reason and there’s times that we need to be able to give that expertise to our community or to our clients without expecting anything back from it,” said Bujan.
Transparency is such an important factor of a healthy business relationship. Strong relationships are built on trust and the key to gaining that trust is transparency. Proactive, honest communication will lead to better results.
In what ways have you practiced transparency at your agency?
Technology for everyone.
“No, I don’t want to have more time to focus on my work,” – said no one ever.
GHS sells themselves as a technology-driven organization with a depth of knowledge of benefits that can help solve common HR problems.
“Thanks to our technology, we have the ability to assess an employer’s need and fix their pain points of having too much to do and not enough time,” said Bujan.
Having the right tools in place to streamline processes is a necessary first step in easing your clients’ worries. The second (and crucial) step is adding the human element and support to back up that technology.
There are so many benefits to becoming a technology-driven agency. A lot of times, business owners are hesitant to add more options for coverage because of the exhausting (and tricky) paperwork. But Bujan says, “In the last two months, I have three solid examples of how we’ve been able to refocus clients on hiring and employee engagement and benefits and get them in compliance by following up on the paperwork nightmare they’re in.”
Technology can help increase ease of integration with different carriers, streamline communication and open a world full of greater efficiencies for your clients.
How has technology helped your agency?
Bonus: Integration with PrimePay and Employee Navigator.
GHS and PrimePay have been working together for several years.
“We make it easier for clients to have happier employees when we transition them from one of your competitors over to your services,” said Bujan.
And with PrimePay’s recent integration with Employee Navigator, Bujan is excited for the opportunities to come.
“When we started working with Employee Navigator, we needed to really find some more efficiencies with regard to eligibility and employee benefits. Section 125 programs are all complicated, but we felt that PrimePay offered the fix and was able to dig down and make something good happen. We talked to both Employee Navigator and PrimePay and hoped that they would be able to enter a partnership which they now have so we’re really excited about that,” he said.”
CITATION: Fausnaught, R. (2018, January). Transparency & Technology: A Winning Combination for Brokers. Retrieved from: https://primepay.com/blog/transparency-technology-winning-combination-brokers
Social Security, Medicare & Cheese
I remember visiting my grandmother in Texas as a child in the summer and she would have these frozen blocks of government “cheese” in her freezer. Massive blocks – with important looking seals and eagles. She got them to give to neighbors when they were in need.
Apparently – this cheese was part of a larger program with the US Government when stockpiles got so large, they gave it away. It was an entitlement, you didn’t have to pay for the cheese, it was just given to you if you were entitled to it.
This week, as I was listening to the never-ending pundits and politicians talk about the tax bill, one high ranking house leader mentioned that because of the bill, we are going to have to make cuts to entitlement programs, such as Medicare & Social Security. $25B in Medicare cuts. (AARP is not a fan, as you can imagine)
That gave me pause – so I googled entitlement and it brings up three definitions: 1. the fact of having a right to something, 2. the amount to which a person has a right, 3. the belief that tone is inherently deserving of privileges or special treatment.
Let’s start with Social Security – signed into law by President Roosevelt on August 14, 1935, it created a social program to pay retired workers an income after retirement. Taxes were collected starting in 1937 and regular benefits paid out starting in January 1940. Who is eligible for this benefit – anyone who has worked for at least 10 years.
Now on to Medicare – The Medicare Act (Title XVII of the SS Act) was signed into law by President Johnson on July 30, 1965. IT established Medicare, health coverage for the elderly and Medicaid a program for the poor. Workers pay a tax for Medicare. Who is eligible for this benefit – anyone who has worked for at least 10 years. Then you are able to get Part A at no cost (hospital) and you pay a premium for Part B (outpatient or doctor services) – based on your income.
A couple who both make $44,000 in 2012 dollars who turned 65 in 2010 would have paid $722,000 into Social Security and Medicare.
So if we apply the facts of these two programs to the definition of entitlement, I guess I can make a case that under definition 1 & 2 – someone would have the right to something – that they paid for their whole life – so if this was why it was an entitlement, I guess home ownership or automobiles are entitlements too.
Now, let’s look at 3 – the belief that you are deserving of special treatment – that doesn’t hold water – one pays into this program and you have to meet certain criteria in order to be eligible for the benefits, i.e. working 10 years. I don’t think that I would define work as a special treatment.
So – in a nutshell:
- Cheese = OK, an entitlement
- Healthcare for seniors or children and retirement benefits = money out of hard-working Americans’ pockets, not an entitlement.
$25B in cuts is a lot of cheese, isn’t it?
P.S. – And I use the term “cheese” loosely.
CBO Releases Updated Score of AHCA – 51 Million to Be Uninsured, Government Savings of $119 Billion
CBO Releases Updated Score of AHCA – 51 Million to Be Uninsured, Government Savings of $119 Billion
May 26, 2017
The Congressional Budget Office (CBO) released their highly anticipated updated report on the American Health Care Act (AHCA) on Wednesday, showing that the bill would save the government $119 billion and that an additional 23 million would be uninsured to bring a total of 51 million Americans without insurance. This amounts to a net increase of 3 million additional uninsured from before the ACA was signed into law, when 48 million didn’t have coverage. The previous score released in March projected that the bill would save the government $150 billion (revised down from an initial savings of $337 billion) and would lead to 24 million newly uninsured. The CBO is the nonpartisan group tasked with determining the cost of legislation to the federal government, both in a loss of revenue and increase in spending.
The updated report was necessitated by the adoption of several amendments to the AHCA from the last time the bill had been scored. The most prominent of these was the amendment offered by Representative Tom MacArthur (R-NJ) to allow states to receive a waiver to opt out of the ACA’s essential health benefits and age and community rating provisions. These waivers would be contingent on reducing average premiums, increasing enrollment, stabilizing the market, stabilizing premiums for individuals with pre-existing conditions, or increasing the choice of health plans. In turn, states could propose one of the following:
Increase the state’s age-rating bands. The state must specify a higher age-rating band, generally defaulted at 5:1 under other sections of the AHCA, although states could opt for higher ratios.
Establish state-based requirements for essential health benefits (EHBs) in the individual and small group markets beginning in 2020. The state must precisely specify both the benefit categories and the specific benefits within the categories. This could include overriding the ACA’s prohibitions of lifetime and annual limits and cap on out-of-pocket expenditures, which could also be applied to large group and self-insured employer plans.
Permit insurers to price policies based on health status. This substitutes the AHCA’s original continuous coverage incentive’s late-enrollment penalty to allow insurers to charge higher premiums for consumers who do not maintain continuous coverage (defined as a lapse of 63 days+ over 12 months). It is important to note that the amendment would not allow states to automatically rate up consumers with pre-existing conditions. The amendment only allows for insurers to underwrite consumers with pre-existing conditions if they do not have continuous coverage in states where a waiver has met all conditions to be approved.
Waivers may be approved for a period of up to 10 years, providing they continue to meet the conditions of the waiver, and any waiver submitted by a state would be automatically approved if they are not notified of a denial within 60-days of submission. Waivers that seek to permit health status underwriting would also be contingent on the state providing financial assistance to high-risk individuals to obtain individual market coverage, providing incentives to appropriate entities to help stabilize premiums, and participating in the “Federal Invisible Risk Sharing Program,” which includes $15 billion in federal funding between 2018 and 2026 as a reinsurance mechanism to reimburse insurers for high-cost plan enrollees.
The invisible risk sharing funding was joined by two additional high-risk funding pools to bring a total of $138 billion in the amended bill overall. The original bill included $100 billion over 10 years for the Patient and State Stability Fund, and in addition to the $15 billion in invisible risk sharing, the two other amendments passed since the bill was initially considered in March include $15 billion for funding for maternity, mental health, and substance abuse care, and $8 billion specifically added for additional high-risk pool funding as a result of the MacArthur Amendment. The CBO report cautions that this funding would have a small effect and not be sufficient to reduce large increases for high-cost enrollees. For comparison, the report notes that the ACA’s pre-existing condition insurance pool covered 100,000 enrollees at a cost of $2.5 billion over two years. Further, the Patient and State Stability Fund would require significant funding by states in the out-years; states would initially only be required to provide 7% of matching funds, but this would grow to 50% required by 2026.
With these amendments and the increased state flexibility for how the AHCA would now be implemented at the state level, the CBO performed an extensive analysis of the impact of the legislation. Overall, the CBO found that it would result in a net savings to the federal government of $119 billion, a result of $1.1 trillion in reduced spending over 10 years while revenues would be reduced by $992 billion. The bulk of the reduced spending, $834 billion, comes from repealing the ACA’s Medicaid expansion and another $236 billion comes from replacing the current advanced premium tax credits ($665 billion) with less generous tax credits in the AHCA ($375 billion).
The reduced revenue is largely due to repealing the majority of the ACA’s taxes (a loss of $664 billion in revenue), of which $275 billion would come from eliminating the net investment tax, $145 billion from the health insurance tax (HIT), and additional lost revenue from taxes unrelated to health coverage proposals. The CBO also projects that delaying the Cadillac/excise tax until fiscal year (FY) 2025, as written in the AHCA, would cost the federal government $49 billion in lost revenue. Revenue would further be reduced by effectively eliminating the ACA’s individual and employer mandates by reducing those penalties to $0, although they would still statutorily exist. The employer mandate makes up most of this at $171 billion, while individual penalties would result in $38 billion in lost revenue.
The biggest cause of the increase in the uninsured rate is due to the elimination of these penalties. As with the previous report, the new report estimates that 14 million Americans would become newly uninsured next year under the AHCA, gradually increasing to 23 million for a total of 51 uninsured by 2026. The AHCA as amended would not result in as many individuals losing employer-sponsored insurance (ESI) as previously estimated. The CBO projects that there would be 1 million fewer people enrolled in ESI in 2020 (compared to 2 million in the previous estimate) and by 2026 there would be 3 million fewer enrolled in ESI, compared to 7 million as previously projected. The revised estimates are largely due to individual health insurance being far less comprehensive and individuals opting to enroll in employer coverage instead to avoid higher out-of-pocket expenses.
The employer-based market currently enrolls more than 175 million Americans in health insurance coverage and NAHU strongly supports measures to maintain this system. As with the previous CBO report, NAHU remains concerned about the impact of the AHCA on ESI. The new report reiterates the previous assumption, which projected a gradual erosion of ESI, stating that over time, some employers would decline to offer insurance to their employees due to the loss of the mandate penalties and because the AHCA’s tax credits would be available to a broader group of individuals than those under the ACA. It expects that both employers and employees would decide against coverage, with some employers opting to drop coverage as employees would be eligible for tax credits, and some individuals who are offered ESI choosing not to enroll given the absence of tax penalties for being uninsured. Notably, previous CBO reports similarly expected that the ACA would result in a drop in employer-based coverage, a projection that has not materialized.
The report notes that premiums would generally be lower in the individual market because the health plans would be less comprehensive and cover fewer benefits and a smaller share of healthcare costs for the consumer. Additionally, there would be considerable cost-shifting on enrollees with significantly more out-of-pocket expenses, particularly those enrollees who use services that are no longer covered by plans, who would see substantial increases in out-of-pocket expenses. The CBO projects that consumers in this situation, such as those who require expensive prescription drugs no longer covered by health plans, could have increases of thousands of dollars in out-of-pocket expenses each year. Some consumers may choose to purchase policies with riders for specific conditions for this reason, particularly for maternity coverage.
The report notes that while premiums would generally go down for individual market insurance, net premiums after factoring for tax credits would range considerably depending on the particular consumer. Older people with lower incomes would see dramatic increases in their net premiums, while younger people with lower incomes would see little change, and people with higher incomes would see their net premiums reduced as they could access tax credits previously unavailable to them. And while overall more individuals will be able to access the tax credits under the AHCA, those subsides are far less generous than those under the ACA. The report illustrates the effect on a 64-year-old at 175% of the poverty level; under current law with a $15,300 premium, they would have a tax credit of $13,600 and a net premium of $1,700; under the AHCA’s flat tax credits, they would only be eligible for a tax credit of $4,900 and with an adjusted premium of $21,000, they would face a net cost of $16,100 in premiums alone—nearly ten-fold over the ACA and roughly 60% of their total annual income on health insurance premiums alone.
Additionally, some individuals may be able to purchase policies that would have no net cost to them, as the existence of a baseline level of tax credits could encourage some insurers to offer skinny plans at the value of the tax credit. However, the CBO cautions that these plans would effectively not provide enough financial protection in the event of catastrophic care needs to legitimately be considered insurance.
The CBO effectively made three separate estimates based on how states could respond to the AHCA as passed with the MacArthur Amendment. The first is the group of states that choose not to apply for waivers, which cover roughly half of the population, and would likely be among the seven states that prohibited medical underwriting before the ACA. The second is those that apply for limited waivers, which cover a third of the population, and would be likely be among the 11 states that had limitations on medical underwriting. And the third is states that apply for waivers to significantly modify EHBs and community rating rules, which cover a sixth of the population, and are among the 32 states that had no limitations on medical underwriting. States with lower premiums would generally fall with those that eliminate one or more EHB categories that were not typically available prior to the ACA.
The AHCA would bring needed stability for much of the country’s health insurance markets; however, states that choose to pursue the waivers created under the MacArthur Amendment would conversely become more destabilized. The states that opt for waivers to allow for medical underwriting or to modify their EHBs to eliminate the ACA’s ban on annual and lifetime limits would lead to significant increases in expenses for some consumers. The CBO notes that many of these individuals with pre-existing conditions could face markets where coverage would be either prohibitively expensive or they might not be able to purchase coverage at all. Additionally, many consumers move in and out of the individual market as access to insurance changes and many of these could fail to meet the continuous coverage requirement. As healthier consumers move to medically underwritten plans, the community-rated plans will become increasingly filled with less healthy consumers, and therefore become increasingly more destabilized.
The updated CBO report marks an important milestone for the AHCA. Republicans tasked themselves with coming up with a reconciliation bill that would reduce the deficit by a minimum of $2 billion over 10 years. After passing the AHCA as amended without an updated score, the House had initially delayed sending it over to the Senate to ensure that it would meet the benchmarks laid out in the reconciliation instructions. Had the CBO report indicated that the bill didn’t meet these requirements, the House would have had to once again vote on an updated bill that would meet them. And had the bill already been enrolled by the Senate with a score that didn’t meet the requirements, they would no longer have been able to use the FY 2017 reconciliation vehicle for healthcare and either would have had to use the FY 2018 reconciliation vehicle they planned for tax reform, or wait until next year to try again. Because the new score by the CBO meets the requirement by projecting a net savings of $119 billion, the bill can now be enrolled with the Senate and they can formally begin deliberations on their version of health reform.
The American Health Care Act (AHCA) Passes the U.S. House
From CIGNA Informed on Reform
Today the U.S. House of Representatives passed an amended version of the American Health Care Act (AHCA) by a vote of 217-213. House Republicans crafted the AHCA as a budget reconciliation bill to repeal parts of the Affordable Care Act (ACA). The bill was previously debated on the House floor, but pulled before a full vote on March 24. Since that time, several amendments were added to the bill, paving the way for Republican leadership to reintroduce the bill for a successful vote.
Passage of the bill in the House marks a milestone in the Republican efforts to repeal and replace the ACA; however, the bill will face new challenges in the Senate. Here’s what we currently know — and don’t know — about the next steps to help you stay informed.
What’s Next: AHCA Moves to the U.S. Senate
Without bi-partisan support, Congressional Republicans cannot fully repeal the ACA in one action. By using the budget reconciliation process, only a simple majority (51 votes) is needed for passage in the Senate — and there are 52 Republican senators. Even with a Republican majority, the bill faces an unclear path forward.
The Republican leadership in the Senate will first need to decide if they want to consider and amend the House bill, or substitute their own version of a reconciliation bill, which may contain parts of the House bill.
Additionally, the Senate must follow procedural rules that don’t apply in the House. Under Senate reconciliation rules, the nonpartisan Senate Parliamentarian must first review and confirm the bill and any amendments comply with the rules for reconciliation, known as the Byrd Rule. For example, insurance market reforms that are currently in the AHCA may not be allowable under the Byrd Rule, if it is determined they don’t have direct spending impact.
The Parliamentarian’s analysis requires a Congressional Budget Office (CBO) score (cost estimate). While the CBO scored an earlier version of the AHCA, the recent amendments require the CBO to update its cost estimate, meaning it could be a few weeks before the Senate can bring a bill to the floor for debate and an eventual vote.
Identical versions of the bill must pass both chambers before being signed by the President and becoming law. If the Senate passes a bill that isn’t identical to what the House passed, there are two paths forward: 1) the House could pass the Senate bill and send it to the President; or 2) a bicameral conference committee can meet to negotiate a new compromise bill. That negotiated bill would then have to be passed by both chambers, before sending it to the President for signature. It is unclear which option might be used in this instance.
Timing is unclear for these next steps to occur, but there continues to be support from the Administration to move forward with repeal and replace of the ACA this year.
Reminder: ACA Compliance is Required Until Official Guidance Otherwise
As a reminder, ACA compliance is required until official guidance to the contrary is issued. The House passage of the AHCA is the first of several required steps before any official changes are enacted. For a customized timeline and more information about ongoing annual responsibilities and applicable employer deadlines under the ACA, visit YourACARoadmap.com.
To stay up to date on the evolving state of health care reform, visit www.InformedOnReform.com, including the new Repeal and Replace Update webpage. This page offers a snapshot of the latest regulatory and legislative activity.
Final Regulations Issued for Individual Market Stabilization
Final Regulations Issued for Individual Market Stabilization
From NAHU April 14, 2017
Yesterday, the Centers for Medicare and Medicaid Services (CMS) released the final market stability rule. The 139-page rule was largely unchanged from the proposal that was released in February and which NAHU submitted comments on in March. As proposed, the 2018 open enrollment period (OEP) will run from November 1, 2017, through December 15, 2017, which CMS has specifically designed to overlap with Medicare and most employer plan enrollments, even though NAHU has repeatedly noted the burden this places on agents. The rule also finalizes tighter restrictions on special enrollment period (SEP) eligibility, applies a more rigorous test for uses of the exceptional circumstances SEPs, and will now require these to be verified by supporting documentation.
Additionally, the final rule changes the actuarial value standard to allow a variation from -4 to +2 percentage points (except for bronze plans, which can vary -4 to +5 percentage points) and finalizes the proposal to rely on states for network adequacy reviews. It will reverse earlier guidance on the Essential Community Providers threshold requirement, and will now require that the network includes at least 20% as participating practitioners as it was for the 2014 plan year that was then increased to 30% for 2015. Finally, the rule will not impose continuous coverage requirements, such as imposing a 90-day waiting period, late enrollment penalty, or requiring 6-12 months of prior coverage; however, CMS will explore other policies to promote continuous coverage.
Notably, the rule did not address two critical issues that could have the greatest impact on the overall stability of the marketplace: whether the administration plans to fund the cost-sharing reduction (CSR) payment program, and whether the administration will enforce the individual mandate. However, neither of those provisions were included in the proposed rule.
Change the 2018 OEP from November 1, 2017-January 31, 2018, to November 1-December 15, 2017.
Noted issues with the overlap of the proposed OEP with the Medicare annual enrollment period and the OEP for many employer-sponsored plans that operate on a calendar-year basis.
Requested that in future years there should be three distinct open-enrollment windows.
Requested that state-based exchanges and all off-exchange individual-market issuers be required to align with the federal individual-market open-enrollment dates.
No change from proposal; the OEP will run from November 1, 2017, through December 15, 2017.
CMS noted that this was purposely done to more closely align with Medicare and the private market.
State-based exchanges (SBEs) that can’t meet the new OEP will be allowed to supplement with a special enrollment period as a transitional measure.
All new marketplace consumers during a SEP must complete expanded pre-enrollment verification. Applications would be “pended” and not released to the issuer until eligibility is confirmed. Consumers would have 30 days to provide documentation.
Supported the proposal to require appropriate documentation prior to the effectuation of coverage and the proposed 30-day timeframe for document submission.
Requested better verification standards on involuntary loss of eligibility for minimum essential coverage (MEC), such as if an individual who previously had access to group coverage through an employer but chose not to enroll, and then lost such eligibility mid-year due to a discontinuation of the employer group plan.
No changes from proposal; consumers will have 30 days from the date of qualified health plan (QHP) selection to provide documentation; enrollment will be delayed or “pended” until verification of eligibility is completed.
100% of new consumers enrolling in marketplace coverage through SEPs will need to complete pre-enrollment verification.
Will not require SBEs to conduct pre-enrollment verification, but recommend that SBEs that do not currently conduct pre-enrollment verification follow this approach.
Will begin pre-enrollment verification for SEPs in June 2017.
Tightening of SEP eligibility requirements relative to people who have a previous history of nonpayment of premiums, documentation of a move, and gaining a SEP for a marriage.
Requested that CMS change the 90-day grace period for recipients of advanced premium tax credits (APTCs) to make past-due premium payments prior to their insurance being terminated to 30 days to reflect exiting state policies for other coverage, and to prevent the risk-pool instability that results when individuals sign up for coverage, receive care and incur claims but do not ultimately make premium payments.
Suggested clarification that all special-circumstance cases are to be routed through the appeals process, including individuals who cannot obtain official documentation and individuals whose ability to obtain the documents eclipsed the 30 days allowed by the proposed rule.
Noted that the additional verification criteria of newly married couples is a different verification standard than what is used in the private individual market or employer-sponsored plans and requested consistency across markets.
Does not address changing the grace period from 90-days to 30-days.
Allows issuers to reject an enrollment for a record of termination due to non-payment of premiums by the individual, unless the individual fulfills obligations for premiums due for previous coverage.
Allows issuers to apply a premium payment to an individual’s past debt owed for coverage within the prior 12 months before applying the payment toward a new enrollment.
Verification criteria for newly married couples will be more stringent for exchange coverage because of the differences in the markets and the impacts on the risk pool warrant an approach in the individual market that diverges from long-standing rules and norms in the group market.
Medical Loss Ratio (not addressed in the proposed rule).
Requested that CMS allow for health insurance agent and broker commissions, as well as issuer fraud-prevention measures, be exempted from an issuer’s MLR calculation.
Not addressed in the final rule.
Age-Rating Bands (not addressed in the proposed rule).
Requested administrative action to expand the current age rating bands of 3:1 in the individual and small-group markets.
Requested CMS to rescind planned changes to the age rating rules for children age 15 and older finalized in the Notice of Benefit and Payment Parameters for 2018 and instead maintain the existing age-rating structure for children.
Requested that CMS grant state-based age-rating variations to allow for the return of small-group composite rates and more state-based variations.
Not addressed in the final rule.
Grandmothered Plans (not addressed in the proposed rule).
Recommended that CMS formally state that the federal transition policy will remain in effect until further notice and will not be rescinded until ACA statutory improvements are signed into law and can be fully implemented.
Not addressed in the final rule although guidance was released from CMS granting states the ability to determine whether to allow grandmothered plans through 2018.
NAHU Washington Update
Pulling the plug on Healthcare in the US – Dissecting the Regular Facts from the Alternative Facts
With all cards on the table, is this Pay or Play 2.0?
Where do we stand now?
New changes in the last 24 hours were made among them:
1. Repeal the 10 essential health benefits mandate (Conservative Caucus)
2. Add an addition $15B into a flexibility fund (for states to manage Medicaid) (Coverage Caucus – side note here – Senator Cassidy R-LA – who worked with Senator Collins R-ME on a separate bill is heading the coverage caucus as they are working to keep coverage in the Medicaid programs)
3. Keep the .9% Medicare tax for high-income earners making over $200,000 filing single for six more years – this would be to keep bringing in new revenue (This was originally in the bill to sunset as of 2018, then adjusted to sunset this year but looks to be sunsetted in 6 years)
What else did I miss?
Earlier this week, additional changes were made to the bill as it was attempted to garner enough votes to pass on the floor of the House. Most of these are changes in implementation dates to appeal to different parts of the House GOP.
1. Moving the repeal of the Tanning & Medical Device tax from 2018 to 2017
2. Moving the repeal of the business tax cap for executives in health insurance companies from 2018 to 2017
3. Sunset new Medicaid expansion for states that have not expanded from 2020 to 2017 (Kansas is currently trying to expand Medicaid as we speak)
4. NY Representatives add an amendment to move $2.3B Medicaid costs from local (county – excluding large metropolises like NYC) to the State Budget
5. Lower the medical expense deduction from 7.5% under the original bill now to a new low of 5.8% and to move up implementation from 2018 to 2017
6. Delay Cadillac tax from 2025 now pushed out to 2026
7. Repeal the maximums and over the counter medication bans on Flexible Spending Accounts from 2018 to 2017
8. Increase the HSA limits to maximum out of pocket costs from 2018 to 2017
What does this all mean? Well, to be absolutely frank – not much, if they don’t have the votes today. What does it mean in the future, though, EVERYTHING.
I don’t think you will find someone who doesn’t think we have work to do on the ACA. I am the first to say it. I also think that we have to get a bi-partisan committee to work together with consumer groups; AARP; AHIP; AHA; AMA and the healthcare consulting (i.e. the broker) community. We are in the battle on a daily basis. We know what can work and what should work and this needs to be done right and it needs to be done soon.
There are good ideas out there and we have to approach this on a more macro level and look at the outside forces that are affecting the current delivery system, i.e. lowering the cost of pharmaceuticals by introducing competition; providing incentives for smaller companies to do more development on generic alternatives; banning pharmaceutical companies from shelving generic patents when they become available; more efficient medical record data sharing; cutting out redundancy; providing affordable medical malpractice insurance programs to incent OBGYNs and other speciality providers who want to provide care but can’t afford the malpractice premiums; identifying high-cost chronic conditions and look at possibly pooling them into a national program such as Medicare, as we do with End Stage Renal Disease; providing TRANSPARENCY to the consumer by giving them the means to shop for a procedure with outcomes and cost as easily as they can today with houses; technology and cars; getting more funding and education to fight the opioid epidemic.
We cannot continue to kick the can down the road, adjust the programs to suit a small group of interest. The health of this country is at stake; the health of its citizens are at stake and millions of jobs are at stake. We need to pull this out of the halls of Congress and get the experts, who manage this, at the table now before it is too late.
There are solutions, there is a way – but we have to do this together with experts and support it as a country. This is one thing neither party should own but every party should want to see succeed.
You think you are going to touch my MOTHER’S Original Medicare? Have you met my Mom? Didn’t think so. . . .
You think you are going to touch my MOTHER’S Original Medicare? Have you met my Mom? Didn’t think so. . . .
Posted: 05 Feb 2017 04:14 PM PST
Original Medicare, as I introduced it in my post Turning Alternative Facts to Actual Facts, was rolled out in 1965. We have Part A for hospital coverage, Part B for outpatient and doctor care. Most Medicare participants also choose to enroll in either a supplement plan that will supplement (no insurance carrier network – but the doctors/hospitals have to accept Original Medicare). The supplement will cover the gaps in coinsurance (percentage of coverage by Medicare versus what you would be responsible for) & deductibles (first dollar costs that you are responsible for) or a Medicare Advantage Plan, where the insurance carrier will take on the risk and you are normally going to navigate within a local or regional network, sometimes with coverage for doctor’s who do not participate in the network. You would normally have copays if you are staying within the network.
Paul Ryan, R-WI & the Speaker of the House, has a proposition on the table to change Original Medicare. He has put forth a plan to privatize Original Medicare. Speaker Ryan would replace the current program with vouchers. It’s interesting to see how everyone is all about these ‘vouchers’ to replace what we have today. The healthcare industry, as you can tell, from my previous posts – it not easy to navigate. It takes someone with the time and background to really figure out how to make the system work for them. So, instead of providing more ease of use, it seems the answer is the voucher and making seniors, in this case, more participatory in their healthcare process. Why do you need to upend a system that has worked for seniors and replace it with a privatized program?
The answer that we are given is that Medicare is on its last legs. It is on life-support and we have to do something before it collapses and leaves Granny Nan & PePa out in the cold.
Quick reality check. Medicare’ has IMPROVED in the last couple of years, not gotten worse. As a matter of fact, it is funded through 2029 and 79% funded through 2040, which can be made up without privatization. Medicare Trustees Report (page 29).
Medicare is one of the programs that will find a hard time getting approval to change it, under the current Administration. It is also NOT tied to the ACA issues. Remember, Medicare has been around since 1965. The current Administration ran on a platform promising not to touch Medicare.
One might argue that Medicare is an entitlement but I disagree. An entitlement is the having a right to something or the believe that one is inherently deserving of privileges or special treatment. We all pay into Medicare while we work and once we retire, we have to pay into Part B Premiums. 2017 Part B Premiums.
Seniors have a very strong voice and membership association, in AARP (American Association of Retired Persons). They are 38M members strong and they have the resources to fire up their base. And let me tell you, don’t screw around with their healthcare, golf tee time or cruise ship schedule. Trust me, my mom would be the first to tell me that! So, let’s not pull Part A & B away from our loved ones, let’s find ways to enhance the program to make it easier to gain access to incentives for better outcomes within the healthcare delivery system.
Senate Republican Leaders Vow to Begin Repeal of Health Law Next Month
THE NEW YORK TIMES
By ROBERT PEAR
DEC. 6, 2016
WASHINGTON — Senate Republican leaders, after meeting with Vice President-elect Mike Pence, said on Tuesday that they would move immediately next month to start repealing the Affordable Care Act, despite qualms among some of their members.
“The Obamacare repeal resolution will be the first item up in the new year,” said Senator Mitch McConnell, Republican of Kentucky and majority leader.
Republicans have not fleshed out a plan to replace the 2010 health care law, President Obama’s signature legislative achievement. But on Tuesday they laid out their principles for a replacement plan and said they would try to minimize disruption for the 20 million people who have gained coverage under the law.
Senate Republican leaders appeared to agree with House Republican leaders on a “repeal and delay” strategy, which could keep parts of the health law in place for several years, as Congress works with the administration of Donald J. Trump to devise a replacement.
The Senate Republican strategy would start the repeal process in early January and could defer the effective date for several years, but not all party members were on board.
“They have to be done together,” said Senator John McCain, Republican of Arizona, referring to efforts to repeal and replace the health law. “We don’t want to have people left out.”
Democrats vowed to fight for preservation of the health law, on which public opinion has been deeply divided for six years.
“Bring it on!” Senator Chuck Schumer of New York, the next Democratic leader, said to Republicans. “Just repealing Obamacare, even though they have nothing to put in its place, and saying they’ll do it sometime down the road will cause huge calamity from one end of America to the other.”
Many health policy experts say the law has been beneficial. But Senator John Thune of South Dakota, the No. 3 Senate Republican, said: “It’s well documented, everybody agrees, both Republicans and Democrats, that Obamacare has serious problems. I would say it’s been a failure, and I think the American people agree.”
After repealing the law, Mr. Thune said, Republicans will proceed step by step to develop a replacement, built around four principles: States, not the federal government, should have the primary responsibility for health policy. Patients and doctors should be “in control.” There should be more competition among health plans, so consumers would have more choices. And small businesses should have more discretion and flexibility to configure health benefits for their employees.
After their lunch on Tuesday with Mr. Pence, many Senate Republicans were energized. After the inauguration of Mr. Trump, the schedule will be “very aggressive,” said Senator Michael Rounds, Republican of South Dakota.
But other Republican senators were still mulling their strategy.
Senator Bob Corker, Republican of Tennessee, suggested that it might make sense to repeal and replace the heath law at the same time, and that there could be pitfalls in deferring a replacement for several years.
“People are trying to figure out the best route,” Mr. Corker said. “It’s not really repeal if it’s still in place for three years.”
Senator John Barrasso of Wyoming, a member of the Senate Republican leadership, said Congress would need time to develop a replacement.
“Health care has been driven into the ditch by President Obama and this health care law,” Mr. Barrasso said. “It will take time to get the cart out of the ditch.”
Senator Susan Collins, Republican of Maine, said she supported efforts to repeal and replace the health law, but not Republican efforts to cut off federal funds for Planned Parenthood clinics. Last December, she voted against a budget bill that would have repealed major provisions of the health law because it would also have terminated funds for Planned Parenthood.
“Under the incoming administration, Republicans and Democrats will have a new opportunity to fix Obamacare, and there is a lot to fix,” Ms. Collins said on Tuesday, noting that premiums for health plans on the exchange in her state were increasing an average of 22 percent next year.
Medicare Part D Disclosure Model Notices & CMS Disclosure Instructions – Required notice 10/15/16
Medicare Part D Disclosure Model Notices & CMS Disclosure Instructions – Required notice 10/15/16
The Medicare Modernization Act (MMA) requires employers whose policies include prescription drug coverage to provide a written disclosure notice to all Medicare eligible policyholders of whether such coverage is creditable. Creditable coverage means that the coverage is expected to pay, on average, as much as the standard Medicare prescription drug coverage.
This disclosure must be provided prior to October 15th, 2016 (and at various times as stated in the regulations) to:
- – Medicare eligible active working individuals and their dependents (including a Medicare eligible individual when he or she joins the plan);
- – Medicare eligible COBRA individuals and their dependents;
- – Medicare eligible disabled individuals covered under an employer’s prescription drug plan; and
- – Any retirees and their dependents.
Please see the attached Model notices available for distribution.
Additional Disclosure Requirements
Under the law, employers must also complete an online disclosure to CMS to report the creditable coverage status of their prescription drug plan at certain intervals.
The disclosure submission process is composed of the following steps to complete the online Creditable Coverage Disclosure Form available via the following link:
Disclosure to CMS Instructions:
Step 1 -Enter the Disclosure Information
Step 2 -Verify and Submit Disclosure Information, and
Step 3 -Receive Submission Confirmation
Please see the attached ‘Disclosure to CMS Instructions’ for further information on completing the online Creditable Coverage Disclosure form.